How Global Mental Health Guidelines Produce False Universality

A new article recently published in Transcultural psychiatry written by China Mills of the City University of London examines how global treatment guidelines, such as the World Health Organization’s (WHO’s) Mental Health Gap Action Program (mhGAP), are failing to address finding universality and cross-cultural applicability.

“The mhGAP guidelines are an example of a key techno-scientific object that contributes to producing the universality of mental health. Yet, thematic analysis of interviews with decision makers involved in the design of the Guidelines shows that unlike the public consensus often presented in Global Mental Health, members of the Guidelines Development Group have contrasting and contingent understandings of the nature of universality in relation to mental health. diagnostics and health interventions,” Mills writes. “The universality achieved through the mhGAP guidelines is therefore partial and temporary…this contingent and iterative approach shows the inherently unstable universality of mental health.”

The World Health Organization’s Mental Health Gap Action Program (mhGAP) was established in 2008 to address the “treatment gap” for mental illness in low- and middle-income (LMIC) countries. The program, designed for use by practitioners outside the mental health field, includes a written and electronic treatment guide. The guide itself, which has been adopted by more than 80 countries around the world, draws heavily on evidence-based medicine and a universal understanding of mental disorders.

Unlike other articles and books Mills has written, the most recent report focuses less on whether mental health can truly be made “global” and more on the processes that are working behind the scenes in an attempt to make it “global”. To better understand and elucidate those working to globalize mental health, Mills interviewed the people who helped create the mhGAP guidelines years before.

Between July and December 2018, a total of 19 interviews were conducted, half of them with the original creators of the original mhGAP guidelines, also known as members of the Guideline Development Group (GDG). Participants were primarily interviewed online due to geographic diversity. Each participant was interviewed with a semi-structured interview questionnaire explicitly designed to allow each participant to prioritize the narratives and stories they felt were most important without straying too far from the topic at hand.

Eighteen of the original GDGs were contacted, 12 agreed to participate and nine were interviewed. Mills coded each interview using a thematic analysis framework. Along with the thematic analysis, official documents made public by WHO regarding the production of the mhGAP guidelines were also reviewed and analyzed.

“By focusing on the mundane ‘behind-the-scenes’ interviews and processes in the production of mhGAP guidelines, the findings illuminate insights that may be lacking in both the official documentation process and the consensus presented in the official GMH literature.”

Six cross-strategies used to construct the universal guidelines were found.

  1. Assemble the expertise of professionals in the field.
  2. Create consensus among professionals.
  3. Deciding what counts as evidence and evidence-based medicine.
  4. Understand that cultural relativism is “nihilistic”.
  5. Make sanity technical.
  6. Understand that messy global contexts require guidelines to be messy as well.

Each of the above strategies requires a particular concession from strategists and experts, despite their respective understanding that there are good reasons to be skeptical and critical of a universal tool. Nevertheless, the experts were chosen according to standards that excluded people with lived experience and psychosocial disorders. This exclusion has only further exposed the process of deciding what counts as evidence to be deeply situated and isolated, simultaneously allowing a nuanced understanding of cultural relativism to give way to immediate action and technical precision. Then, when the guidelines fail, it is not the fault of the tool but rather of the context and culture in which it is placed.

Mills notes that the above strategies are necessarily iterative, unstable, and exclusive. She argues:

“The inherently unstable universality of mental health helps focus attention on the conditions and contexts that produce the perception by some within GMH that strategic universality is necessary or desirable, shifting the focus to the work needed to make mental health global.”


Mills, C. (2022). Strategic universality in the development of global guidelines for mental health. Transcultural psychiatry13634615211068605. (Link)

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