Global Mental Health

Cultural clinical psychology and psychiatry aim to address the mental health needs of diverse communities by integrating attention to cultural differences in knowledge, social institutions, identities, and practices. These differences affect mental health by influencing the causes and mechanisms of psychopathology, shaping illness experience and expression, and guiding processes of coping, adaptation, healing and recovery. Various theoretical models, borrowed from social sciences, have been used to understand the interaction of culture and mental health and the nature of psychiatric disorders. These models reflect the cultural assumptions of psychiatry itself and becoming aware of some of these tacit assumptions is essential to open up a space for intercultural work. In this chapter, we will advance an ecosocial approach to culture in mental health in terms of “culturally responsive care.” This aims to identify crucial dimensions of culture and social context relevant to the lived experience of mental health problems and apply that to understanding to clinical assessment and interventions.

Madness is a major disorder of social ties and a universal problem for all societies. The formation and transformation of local treatments of madness are therefore a major area of study within social and cultural anthropology. In this perspective, “treatment” should be understood on three different levels. First, as treatment of the problem that madness poses to social order; Second, as treatment of an ailment on the basis of a therapeutic system that can call upon specialist knowledge or not (e.g. a classification, an etiology, a pharmacopoeia, etc.) in order to identify the disorder or to determine its nature and to then provide the appropriate intervention; Finally, as moral treatment of people experiencing madness and trying to find a solution to their state of disorder.

"Researchers have tried to determine and verify the effects of violent conflicts on the men- tal health of those affected by focusing on war trauma, posttraumatic stress disorder (PTSD), and other trauma-related disorders. This, in turn, led to the development of differ- ent kinds of theories and aid programs that aim at preventing and treating the conse- quences of violence and mental health. Until now, there is no agreement on the public health value of the concept of PTSD and no agreement on the appropriate type of men- tal-health care. Instead, psychiatrists have engaged in sometimes fierce discussions over the universality of war trauma, PTSD, and other trauma-related disorders. The two most polar positions are those who try to validate PTSD as a universal and cross-culturally valid psychopathological response to traumatic distress which may be cured or ameliorated with (Western) clinical and psychosocial therapeutic measures, and those who argue that the Western discourse on trauma only makes sense in the context of a particular cultural and moral framework and, therefore, becomes problematic in the context of other cultural and social settings. Although these positions seem mutually exclusive, their debates have led to the development of less radical approaches toward war-trauma and PTSD.
The purpose of this literature review is to analyse the discourses on and debates over war- trauma and PTSD in the psychiatric literature in order to establish a better understanding for the diverse conceptualizations, interpretations and proposed healing strategies. More- over, I discuss the cultural construction and conceptualization of war-trauma and PTSD from an anthropological perspective and show how anthropologists contribute to psychi- atric debates so as to ensure more sophisticated diagnoses and healing strategies in cultur- ally diverse contexts."

Anthropology and psychiatry have long shared common intellectual and scientific ground. Both are interested in human beings, the societies within
which they live and their behaviours. A key starting difference between the two is anthropology’s interest in relativism, whereas psychiatry has been interested in universalism. Also, both anthropology and psychiatry
have a long history of common interest in phenomenology and the qualitative dimensions of human experience, as well as a broader comparative and epidemiological approach. Jenkins illustrates the
common ground by emphasizing that both disciplines contribute to the philosophical questions of and experience raised by cultural diversity
in mental illness and healing. Both disciplines also contribute to the practical problems of identifying and treating distress of patients from diverse ethnic, gender, class and religious backgrounds. Psychiatry
focuses on individual biography and pathology, thereby giving it a unique relevance and transformation.Patient narratives thus become of great interest to clinicians and anthropologists. Development of specializations such as medical or clinical anthropology puts medicine in general and psychiatry in particular under a magnifying glass. The nexus between anthropology of emotion and the study of psychopathology looks at normality and abnormality, feeling and emotion, variability of
course and outcome, among others. The article concludes by highlighting the convergence between these two disciplines as a very fertile ground for the burgeoning field of Global Mental Health.

This article traces the rise of military psychological resilience training, focusing on the US Army’s Comprehensive Soldier and Family Fitness program, which seeks to assess and instill resilience in soldiers and their families through techniques developed in the discipline of positive psychology. In maximizing the happiness, optimism, and mental fitness of soldiers, military resilience training has two aims: (1) to produce a fit fighting force capable of winning complex wars, and (2) to cut costs, not by averting war, but by ostensibly reducing the need for costly healthcare through a claim to prevent soldiers’ ‘pessimistic’ responses to war. The architects of military resilience are also exporting this model to the civilian sphere of social security, using their military experiment as ‘proof of concept’ of the scientific validity not only of resilience training, but also of positive psychology more generally. The article thus illustrates that ‘social security’ cannot be held separate from inter/national security, because these domains are, in practice, imbricated. It is argued that resilience is not merely a response to war and austerity, but a means for producing these forms of precarity through a fantasy of indomitability. The article concludes by considering the broader ethics of psychological resilience.

In this chapter, we interrogate some assumptions of Western (Euro-American) psychology to open up a broader conversation about the diversity of human experience in health and illness. Our approach draws from cultural constructivist and critical anthropological perspectives that view notions of self as situated and shaped by local interpretive practices inscribed within and constrained by larger histories and political economic contexts (Kirmayer, 2006). We view notions of self as cultural constructions that reflect collective understandings of experience and behavior. These practices involve embodied experience, modes of discourse, and social contexts or institutions that provide the cultural affordances through which we navigate the world. By laying bare these contexts, we can show some of the building blocks of psychological structure and function, the range of methodologies needed to advance this exploration, and the political constraints that continue to marginalize or silence diverse voices and perspectives.

The introduction of the Cultural Formulation Interview (CFI) in DSM-5 (American Psychiatric Association 2013) is a milestone in the development of cultural psychiatry and, more broadly, of person-centered mental health care. This volume provides detailed elaboration of the rationale, development, and application of the cultural formulation in diverse clinical settings. In this concluding chapter, I consider some directions for the future development of the CFI and of cultural formulation more generally, in terms of theory, research, and practice.

The term ‘‘cultural concepts of distress’’ (CCD) was introduced in DSM-5 to better characterize the broad set of constructs identified in clinical and ethnographic research on cultural variations in distress. The contributions to this issue of Transcultural Psychiatry on cultural concepts of distress show how much work on this topic has evolved and equally what remains to be done. In this Commentary, we take stock of the current state of the field and outline some future directions for research and clinical application.

The autism spectrum disorder (ASD) is increasingly being recognized as a major public health issue which affects approximately 0.5-0.6% of the population. Promoting the general awareness of the disorder, increasing the engagement with the affected individuals and their carers, and understanding the success of penetration of the current clinical recommendations in the target communities, is crucial in driving research as well as policy. The aim of the present work is to investigate if Twitter, as a highly popular platform for information exchange, can be used as a data-mining source which could aid in the aforementioned challenges. Specifically, using a large data set of harvested tweets, we present a series of experiments which examine a range of linguistic and semantic aspects of messages posted by individuals interested in ASD. Our findings, the first of their nature in the published scientific literature, strongly motivate additional research on this topic and present a methodological basis for further work.

Background: The objective of this article is to present an overview of the burden, spectrum of diseases and risk factors for mental illness among subgroups of migrants, namely, immigrants, refugees and individuals with precarious legal status. This expert review summarises some of the implications for primary care services in migrant receiving countries in the global North.
Methods: A broad literature review was conducted on the epidemiology of mental health disorders in migrants and the available evidence on mental health services for this population focusing on key issues for primary care practitioners in high-income countries.
Results: Although most migrants are resilient, migration is associated with an over-representation of mental disorder in specific subpopulations. There is a general consensus that stress-related disorders are more prevalent
among refugee populations of all ages compared to the general population. Relative to refugees, migrants with precarious legal status may be at even higher risk of depression and anxiety disorders. Persistence and severity of psychiatric disorders among migrant populations can be attributed to a combination of factors including severity of trauma exposures during the migration process. Exposure to stressors after resettlement, such as poverty and limited social support, also impacts mental illness. Services for migrants are affected by restricted accessibility and should address cultural and linguistic barriers to and issues in the larger social environment that impact psychosocial functioning.
Conclusion: There is substantial burden of mental illness among some migrant populations. Primary care providers seeking to assist individuals need to be cognizant of language barriers to and challenges of working with interpreters as well as sensitive to cultural and social contexts within the diagnosis and service delivery process. In addition, best practices in screening migrants and providing intervention services for mental disorders need to be sensitive to where individuals and families are in the resettlement trajectory.

Despite exposure to political violence, many Tibetans in the diaspora avoid framing past experience in terms of trauma. Instead, they deploy shared cultural understandings often infused with Buddhist doctrine, to reframe loss, violence and displacement. Drawing on 14 months of ethnographic research in Dharamsala, India conducted in the Tibetan language, this article investigates how Tibetans utilise everyday cultural wisdom framed by lojong (mind-training) teachings to cope with adversity. Here, compassion practices serve to orient members of the diaspora towards recovery even, and perhaps, especially, when they are struggling. In this article, I argue that this cultural form of resilience is better conceived of as a practice of agency than a mental health practice, despite a global interest in adapting meditation and mindfulness for use in clinical settings. This study also challenges theory on structural violence and social suffering, which tends to overemphasise victimhood, bypassing the ordinary (and extraordinary) ways that people find agency.

Multidisciplinary teams (MDTs) are conventionally recommended in mental health
care literature as an important way to offer holistic treatment provision to patients. This
study aims to explore multidisciplinary teamwork in contemporary mental health
settings, particularly what aids and hinders the process of multidisciplinary teamworking,
and the social work contribution in such teams. In order to attain an in-depth
exploration of these phenomena, a single case study design was employed. Within this
design, data were generated through semi-structured interviews and structured
observation of a mental health MDT in Ireland. These data were analysed using
interpretative phenomenological analysis. The research highlights how the concept of
mental illness is contested within this MDT, with the medical model dominant within
an environment of fluid working arrangements. Professional role blurring and
stereotyping were found to impact the division of labour on this team, with role
negotiation found to be an integral part of retaining a professional’s practice identity.
This research raises concerns for social work’s capacity to function within mental
health MDTs in Ireland, and highlights ways in which social work educators might
respond in order to empower Irish social workers to meet the challenges of mental
health multidisciplinary teamworking.

Tracing the historical trajectories of war traumatology in Turkey, this paper develops a genealogy of the recent institutionalization of the diagnostic category of Post-Traumatic Stress Disorder (PTSD) in Turkish military psychiatry and the state’s welfare system. A complex blend of economic, political, and cultural dynamics long prevented trauma from becoming an officially recognized category of military medical diagnosis in Turkey. I argue that the Turkish state’s denial of war trauma in general and PTSD in particular should be read not as a historical lag or a conceptual lack, but as an overdetermined historical specificity that needs to be understood in relation to the particularities of specific military conflicts, welfare and medical institutional histories, and moral and political economies. I show how PTSD has not simply replaced existing local categories of mental illness, but entered into complex relations of mutual symbiosis and competition with them. Shifting the terms of scholarly debates on the globalization of PTSD from the question of cultural difference to the political, moral, economic, and therapeutic work of locally embedded psychiatric categories, this paper contributes to the literatures on political violence, trauma, medicalization, and militarism in Turkey and beyond.

This article makes the case for a new field in International Relations (IR): the Global Politics of Medicine. It argues that significant avenues of research can be opened up by focusing on medicine and the life sciences, in order to both challenge current IR theories, and develop new theoretical and empirical insights in IR. In particular, the article challenges the validity of securitisation theory, and specifically the argument that health has been securitised. Showing instead that medicine and warfare have been imbricated from the nineteenth century as strategies of population, it challenges securitisation theory's ahistoricism and its assumption that social security and international security (and the norm/exception) are analytically divisible. Bringing this into the present through the examples of triage, psychological resilience, and genetic intelligence in counterinsurgency, it traces how warfare and medicine now ambitiously seek to treat populations as sets of individual bodies. Arguing that we cannot retreat to some mythical state of politics ‘prior’ to securitisation, it draws out how the fields of war, health, and medicine are nonetheless highly contested. The article concludes by challenging the fields of Global Health, war, and security studies, but also suggests novel routes for pursuing the study of the Global Politics of Medicine.

Purpose -The purpose of this paper is to produce a comprehensive and tabulated review of the many and scattered papers on public mental health literacy, with particular focus on people's ability to recognise mental illness and beliefs about the treatment. Design/methodology/approach -This was a review and tabula study. Comprehensive tables describe studies: the first looks at the beliefs of three different groups (the general public, students and young people) within developed English-speaking countries, and the second on studies from non-English-speaking countries. Findings -Some illnesses like depression and schizophrenia are well researched and others like anxiety or personality disorders largely ignored. The conclusion considers terminological (the loose use of different terms), theoretical (little or no theoretical models) and methodological (heavy reliance on printed, culture-bound vignettes) issues in the developing area of research. Originality/value -No such review exists and this therefore should be of considerable value to people working in the area.

The Global South:
An Emergent Epistemology

Summary

In this essay, I discuss the sociopolitical notion of the Global South as a bridge between globalization and the Global Mental Health (GMH) movement. A brief history of the Global South reveals that it is wider and deeper than economic and geopolitical notions such as the Third World, the developing world and the Non-Aligned Movement, across a broad swathe of history and culture. I then turn to globalization and its critics, examining critiques of economics, human rights, and problems associated with humanitarian services. A feature of GMH, “the health gap” is contrasted with “the epistemic gap,” a divide between the epistemologies of the North and emergent Southern epistemologies. Three key features of the Global South – conviviality, porosity and syncretism – are discussed with examples from my practice of cultural consultations in child psychiatry and family therapy in Haiti and Brazil.

Keywords: Globalization, the Global South, Global Mental Health (GMH), Southern epistemologies, syncretism, conviviality, porosity

Delivery of effective mental health and psychosocial support programs requires knowledge of existing health systems and socio-cultural context. To respond rapidly to humanitarian emergencies, international organizations often seek to design programs according to international guidelines and mobilize external human resources to manage and deliver programs. Familiarizing international humanitarian practitioners with local culture and contextualizing programs is essential to minimize risk of harm, maximize benefit, and optimize efficient use of resources. Timely literature reviews on traditional health practices, cultural beliefs and attitudes toward mental health and illness, local health care systems and previous experiences with humanitarian interventions can provide international practitioners with crucial background information to improve their capacity to work efficiently and with maximum benefit. In this paper, we draw on experience implementing desk review guidance from the World Health Organization (WHO) and UNHCR, the United Nations Refugee Agency (2012) in four diverse humanitarian crises (earthquakes in Haiti and Nepal; forced displacement among Syrians and Congolese). We discuss critical parameters for the design and implementation of desk reviews, and discuss current challenges and future directions to improve mental health care and psychosocial support in humanitarian emergencies.

This qualitative study explores institutional and community-based mental health services in Albania today. It was carried out in central  and southeastern (Elbasan, Korče, and Tirana) Albania between June 1 and September 1, 2013. Information was collected through 44 semi-structured interviews with mental health professionals, family caregivers, and advocates identified through convenience sampling and online research. 30+ additional hours of participant-observation were completed with psycho-social staff and residents at the Sadik Dinci Psychiatric Hospital in Elbasan, Albania. The comparative cases of de/institutionalization of children and Albania’s elderly population were also explored. Based on data collected, Albania’s low rates of psychiatric institutionalization can be said to reflect the chronic underfunding of the mental health sector and not extensive deinstitutionalization efforts or the successful creation of community-based alternatives to institutional care. Western models of service provision such as the Community Mental Health Center and the Supported Home are only partially implemented. Major challenges related to funding, acceptability, accessibility etc. affect Albania’s vulnerable populations and a trend towards re/institutionalization looms if community-based care cannot be properly supported.

This cultural case study investigates one U.S. psychosocial rehabilitation organization’s (Horizons) attempt to implement the recovery philosophy of the U.S. Recovery Movement and offers lessons from this local attempt that may inform global mental health care reform. Horizons’ ‘‘recovery-oriented’’ initiatives unwit-
tingly mobilized stressful North American discourses of valued citizenship. At times, efforts to ‘‘empower’’ people diagnosed with schizophrenia to become esteemed self- made citizens generated more stressful sociocultural conditions for people whose daily lives were typically remarkably stressful. A recovery-oriented mental health system must account for people diagnosed with schizophrenia’s sensitivity to stress
and offer consumers contextually relevant coping mechanisms. Any attempt to export U.S. mental health care practices to the rest of the world must acknowledge that (1) sociocultural conditions affect schizophrenia outcomes; (2) schizophrenia outcomes are already better in the developing world than in the United States; and (3) much of what leads to ‘‘better’’ outcomes in the developing world may rely on the availability
of locally relevant techniques to address stress.

In the past decade, a large number of studies have been conducted exploring the relationship between gratitude, psychological well-being and happiness. Empirical studies have indicated potential variations in the relationship between gratitude and well-being and few studies have even reported negative association between these constructs. The present study was conducted to examine the relationship between Gratitude, Psychological well-being and Happiness. The study was conducted on a sample of 200 college students. Participants were randomly selected and the sample consisted of both male (n = 67) and female (n = 133). Measures included The Gratitude Questionnaire, Ryff's Psychological Well-being Scale, and The Oxford Happiness Questionnaire (OHQ). Findings suggest that there is a positive association among Gratitude, Psychological well-being, its dimensions and Happiness. Limitation and implications of the present study are discussed. The findings of the present study can lay a ground work for conceptualizing a theoretical model of Gratitude and its estimator variables. Further research can focus on intervention study to improve Gratitude among adolescence population by implementing Gratitude based therapy, and thereby enhancing their Psychological Well-Being.

Keywords: Gratitude, Psychological well-being, Happiness, Intervention, Mental Health

Mental illness is considered a silent epidemic throughoutAfrica due to substantial financial and systemic challenges. In this article, I discuss the infrastructure, psychosocial and socioeconomic contributors to the global mental health disparities in Africa, which include: low priority/lack of clear mental health policy; poor health infrastructure and lack of funding; insufficient number of trained specialists; poor legal protection and lack of equity; lack of evidence-based and culturally aligned assessment and treatment; stigma, discrimination and human rights abuses; and social, environmental and economic vulnerability. I propose extending the biopsychosocial model of clinical and research practice in psychiatry to focus on the socio-cultural-spiritual factors that are the basis of many traditional explanatory models of mental illness in Africa and are also important determinants of illness, health, and wellbeing. Strategies for contextualizing mental health care approaches in Africa include: understanding explanatory and treatment models in Africa; recognizing multidimensional protective factors; strengthening community mental health and exploring parallel health systems; and incorporating global health best practices Implications for making current treatment more culturally responsive and improving mental health systems are discussed.
Keywords: Africa, global mental health, mental illness, health disparities, culture, spirituality

This article analyses some of the emerging problems in the field of social studies at the juncture of the domains of health and science. Building on critical perspectives, namely those hailing from social history, postcolonial studies and collaborative research, it argues for the need to ground investigation on concrete historical forms of social suffering. This implies a multi ‑scale approach which considers: 1) individual suffering and illness experienced in social interactions; 2) the institutionalised expert translations of suf‑ fering into disease; and 3) the political rationales, developed by both local and global stakeholders, which assist in the creation of social environments of health and illness. While illustrations of the theoretical proposals derive mostly from the particular field of mental health, it is argued that their implications may apply to a wider range of themes dealing with health and science issues. The fields of health and science studies, respectively, have vast sets of problems, the exploration of which has developed from various disci‑ plinary and methodological traditions, involving different epistemologies

When most patients visit physicians in a clinic or a hospital, they are asked about their medical history and related medical tests' results which might not exist or might simply have been lost over time. In emergency situations, many patients suffer or sadly die because of lack of pertinent medical information. Patient's Health information (PHI) saved by Electronic Medical Record (EMR) could be accessible only by a hospital using their EMR system. Furthermore, Personal Health Record (PHR) information cannot be solely relied on since it is controlled solely by patients. This paper introduces a novel framework for accessing, sharing, and controlling the medical records for patients and their physicians globally, while patients' PHI are securely stored and their privacy is taken into consideration. Based on the framework, a proof of concept prototype is implemented. Preliminary performance evaluation results indicate the validity and viability of the proposed framework.

This Special Issue includes articles that contribute to (a) the global research base pertaining to the development of infants and toddlers at risk, primarily those who are institutionalized in lower resource countries; (b) interventions in institutions and to promote family alternatives to institutionalization; and (c) attempts to create modern child welfare systems emphasizing family care in entire states and countries. This introduction places these articles into the broader contexts of the literature in these three domains of interest. Across the world, urbanization, migration, armed conflict, epidemics, and famine disrupt families. Add poverty, abuse, neglect, and parental incapacity due to substance abuse and mental health problems, and the result is millions of children without parental care who come under governmental responsibility, often to be reared in institutions, and at risk for long-term developmental deficiencies and problems. Over the last 2 decades and especially recently, national and international governments and nongovernment organizations have increased efforts to help such children, especially those in low-resource countries. Two types of efforts have been made: one to improve the quality of care provided by institutions and the other to minimize the use of institutions and promote family residential care alternatives. The latter effort includes preventing family separations in the first place, reunification of children with birth families, and developing systems of kinship care, foster care, and adoption. This Special Issue of IMHJ is devoted to reports pertaining to issues in the research knowledge base, program practices, and countrywide policies for infants and young children at risk. We attempt in this introduction to place these reports in the broader context of this field, identify their unique contributions, and highlight lessons learned that can contribute to improved care practices and better child welfare systems. RESUMEN: Esta Edición Especial incluye artículos que contribuyen a 1) la base de la investigación global que concierne al desarrollo de niños pequeños e infantes bajo riesgo, primariamente aquellos que se encuentran bajo el cuidado de una institución en países de bajos recursos, 2) las intervenciones en las instituciones y el promover en las familias alternativas a la institucionalización, y 3) tratar de crear sistemas modernos de bienestar infantil que enfaticen el cuidado familiar en estados y países enteros. Esta introducción coloca estos artículos dentro contextos más amplios en las literaturas de estos tres dominios de interés. R ´ ESUM´ E: Ce numéro spécial comprend des articles qui contribuentà 1) une base de recherches globale ayant trait au développement des nourrissons et des jeunes enfantsà risque, surtout ceux qui sont placés en institutions dans des pays n'ayant que de faibles resources, 2) des interventions en institutions et pour promouvoir des alternatives familialesà l'institutionnalisation en orphelinat, et 3) les tentatives pour créer des systèmes modernes de soutienà l'enfance et mettant l'accent sur le soinà la famille dans desétats et des pays entiers. Cette introduction replace ces articles dans les contextes plus grand des recherches dans ces trois domaines d'intérêt. ZUSAMMENFASSUNG: Diese Sonderausgabe enthält Artikel, die einen Beitrag leisten 1) zur globalen Grundlagenforschung in Bezug auf die Entwicklung von gefährdeten Säuglingen und Kleinkindern, vor allem von denjenigen, die in Ländern mit begrenzten Ressourcen institutionalisiert sind, 2) für Interventionen in Institutionen und für die Förderung von Familienalternativen statt Institutionalisierung und 3) die Sonderausgabe versucht moderne Kinderschutzsysteme zu schaffen, indem die Familienpflege in allen Staaten und Ländern betont wird. Diese Einführung setzt die Artikel in den Kontext der zu diesen drei Interessensgebieten vorliegenden Literatur. ABSTRACT: This Special Issue includes articles that contribute to 1) the global research base pertaining to the development of infants and toddlers at risk, primarily those who are institutionalized in lower-resource countries, : 1) 2

This article traces the social life of psychiatric practice in the context of war and postwar societies. It is argued that although psychiatric knowledge and practice is situated and grounded in particular cul- tural, social, and political contexts, it is important to examine how transnational networks situate local systems of meaning in much larger settings. I illustrate this claim by examining discourses and observations concerning health-seeking behaviors of Kosovar Albanian women and ways in which Kosovar health practitioners help them by employing, adapting, and changing the psychiatric tools and lessons learned during (trauma) training provided by international health professionals dur- ing the Yugoslav war and postwar eras. Thereby, I hope to contribute to a better understanding of how local health beliefs and practices are nested in the processes involved in international health policymaking and, thereby, relate to higher level structures such as international political economy, regional history, and development ideology.

The Global South:
An Emergent Epistemology

Summary

In this essay, I discuss the sociopolitical notion of the Global South as a bridge between globalization and the Global Mental Health (GMH) movement. A brief history of the Global South reveals that it is wider and deeper than economic and geopolitical notions such as the Third World, the developing world and the Non-Aligned Movement, across a broad swathe of history and culture. I then turn to globalization and its critics, examining critiques of economics, human rights, and problems associated with humanitarian services. A feature of GMH, “the health gap” is contrasted with “the epistemic gap,” a divide between the epistemologies of the North and emergent Southern epistemologies. Three key features of the Global South – conviviality, porosity and syncretism – are discussed with examples from my practice of cultural consultations in child psychiatry and family therapy in Haiti and Brazil.

Keywords: Globalization, the Global South, Global Mental Health (GMH), Southern epistemologies, syncretism, conviviality, porosity

The finding that expressed emotion is associated with the course of psychiatric disorder has generated a great deal of clinical and research interest in expressed emotion as an important
risk factor. Theoretical elucidation of the construct of expressed emotion has lagged considerably behind this interest, however. The authors contribute to a dialogue on what is inside the "black box'' called expressed emotion. They argue that cross-cultural research can provide an empirical basis for the theoretical grounding of expressed emotion factors. A comparative
approach reveals that the construct of expressed emotion is essentially cultural in nature. The constellation of emotions, auitudes, and behaviors that are indexed by the expressed emotion method represent cross-culturally variable features of family response to an ill relative. Questions surrounding the cultural validity of the construct of expressed emotion, the qualitative dimensions of expressed emotion, and statistically significant cross-cultural variations in expressed
emotion profiles are discussed. Finally, the authors provide an outline of diverse (cultural, psychobiological, social-ecological) features of expressed emotion. Anthropological analysis of expressed emotion reveals that although expressed emotion indexes a Pandora's box of diverse features, culture provides the context of variation through which these factors are most productively analyzed.
(AMJ Psychiatry 1992; 149:9-21)