Decolonization is a broad term referring to attempting to undo or rectify the consequences of colonialism. The repercussions of colonialism are widespread, influencing many, if not all, facets of life in countries of the Global South. As a result, there are numerous possible strategies to accomplish the goal of decolonization across various disciplines. In mental health disciplines, discussions about decolonization are "en vogue” in academia. Yet despite an abundance of research, translating this knowledge into settings of clinical practice remains a challenge in the Global South. The question of “where do we go now?” in the process of actualizing decolonization emerges in both primary health care and specialized psychotherapeutic settings.

While other social science disciplines have made efforts to decolonize for over five decades, clinical psychology and psychiatry lag behind on systematically raising questions about decolonization. In fact, earlier scholars calling for decolonization in psychiatry, such as psychiatrist and political philosopher Franz Fanon, were often disregarded or left out of the discipline’s mainstream discourses until the past decade or two. The works of both Fanon and more modern-day scholars who have raised similar questions have been used and celebrated in other social science disciplines, but not in ours. Although the disciplines of psychiatry and clinical psychology have not yet had their decolonization moment in which colonial and capitalist origins are acknowledged and accounted for in the mainstream narrative of their histories, there have been loud voices both from within and outside working towards change for decades.

Broad advice on decolonization for institutions and disciplines as a whole is becoming more available, yet we mostly find ourselves lost in terms of individual practice in the Global South. The main points raised in the existing literature around decolonizing psychiatry and clinical psychology include:

Tools for oppression and suffering

Psychiatry and psychology have historically been used as tools to colonize non-Western cultures by pathologizing their cultural variations and their experiences of distress. The imposition of Western theoretical frameworks in the Global South has marginalized alternative perspectives and knowledge systems. Decolonizing mental health involves recognizing and challenging the legacy of colonialism, imperialism, and systemic oppression. It requires addressing key issues such as the over-representation of Western psychiatric knowledge and the under-representation of non-Western models of local knowledge ; the need for culturally-sensitive or context-specific approaches to diagnosis and treatment; and the importance of acknowledging and addressing the socioeconomic and historical determinants of mental health. It also stresses the need to formally incorporate decolonization into psychiatric and psychological education and training to ensure more inclusive and relevant diagnostic concepts and interventions.

Addressing unbalanced power dynamics

The issue of power dynamics and privilege has been constantly brought up in literature addressing decolonization, with authors calling for greater self-reflection and awareness of one's own positionality and biases. This includes acknowledging and challenging the ways in which privilege can shape research and clinical practice while working towards more just approaches to mental health. It also involves recognizing and challenging the underlying power structures that continue to pathologize certain communities and their experiences. This requires cultural humility: incorporating diverse cultural knowledge systems, idioms, and norms into theory and practice and approaching mental health from a more collaborative stance.

Where do we go now?

As a young clinician and researcher from North Africa, I still somehow find myself posing this question—and I know that I am not alone. What do I do inside and outside the therapy room? To answer these questions, over the initial five years of my practice, I have begun collecting and stitching together a list of actionable steps from literature and advice from senior practitioners. I share them here as an effort to reach out to colleagues to connect, discuss, and raise these questions that will bring us closer to decolonizing practice.

1. Increase awareness: Mental health professionals (MHPs) tend to believe that clinical knowledge and training are enough. Unfortunately, they are not. We need to become aware of our own biases and how colonization has directly or indirectly influenced our work and the paradigm in which we view and understand mental health. Most clinicians in the region are trained in the biomedical model and in treatment modalities based on Western psychiatric nosology. We should educate ourselves about culture, social theory, the history of colonization, and its impact on mental health and wellness. We need to be aware of our own biases for or against local cultural frameworks. Hidden biases have no place in good reflexive practice.
2. Emphasize cultural humility: MHPs in the Global South are trained to believe that “modern” medicine requires a clear separation of cultural knowledge and clinical practice. This method of practice is anachronistic and reflects colonial baggage, as the line cannot be drawn in such an artificial way—knowledge and practice are interconnected. In reality, the burden lies on MHPs in the Global South to act as arbiters who need to transform cultural information and concepts provided in illness narratives of patients to “objective” information in medical charts. Clinicians should prioritize learning from patients and approach therapy with humility. In the case of the Global South, as insiders who mostly share the same cultural backgrounds as our patients, it is a process of re-learning. We should not shy away from incorporating cultural practices that are meaningful to our patients when appropriate.
3. Challenge Western paradigms: Most MHPs use “universal” diagnostic and clinical guidelines such as the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and International Statistical Classification of Diseases and Related Health Problems (ICD-11) in practice. At the moment this is inevitable, yet we should not shy away from challenging these Western frameworks when needed. This may involve re-evaluating the presence or variations of symptom presentations and meanings, as well as more broadly questioning the dominant models around individual mental health. When we find that these Western frameworks prioritize other cultural and socioeconomic contexts, we should not take them for granted.
   
4. Do not reinvent the wheel: Despite being vigilant and open to questioning, we need to accept what works in Western approaches and accept transcultural “commonalities” of mental distress just as we accept its variations. We then need to move to thinking of how to adapt elements that seem to be applicable to our own contexts in culturally appropriate and sensitive ways to the people being served. Doing this will allow us to have a wider and more effective clinical toolbox.
5. Create a village: The phrase “it takes a village” applies beyond child-rearing. Seek out opportunities to discuss and explore questions with colleagues who share similar concerns and discomfort in our practice. We do not have to be alone; experienced clinicians who have grappled with similar issues over the years are always a source of valuable insights. We often trust evidence over clinical experience, and while that is crucial for ethical clinical practice, it is important to seek others' input to be able to identify new evidence if needed.
6. Decolonize research: To identify new evidence, we need to stay in touch with the world of research. Research is not just for academics. In fact, in the Global South, questions will mostly be derived from our practice. We should consider the ways in which research in mental health has been used to reinforce colonial power structures. Now we should do the opposite: put research that is participatory, bottom-up, and derived from lived experience in our practices into systematic inquiry.
7. Collaborate with communities: When and if possible, we should collaborate with community members to develop culturally appropriate interventions and services. The individual psychotherapy room is not the only place for healing. This collaboration can also involve working with community members to develop social support networks and working to address the social and political factors that contribute to both distress and healing within communities. This will take a conscious effort, as it might not be a part of usual mental health practice. At times collaboration will not be possible due to unavailable resources or sociopolitical conditions. Nonetheless, it should be attempted when possible.
8. Widen the lens: Understanding mental health within a broader socio-political context, including the impact of globalization and neoliberalism, is crucial. The role of mental health professionals includes being aware of disparities causing distress and supporting collective efforts for social justice. This may entail acknowledging that we are now a part of the “well-being industry.” We need to be conscious of whose agenda we are serving. The therapy room does not exist in a vacuum; bringing structural competence and understanding into the therapy setting is critical.

As I conclude and come back to my question “Where do we go now?” in mental health care, I find that there are two levels to address. At the macro-level of global and institutional efforts of decolonization, we need to stop recycling arguments and start implementing the recommendations that have already been made to enact deep decolonization on a broad scale in mental health systems of the Global South. Current efforts to step outside of “Western” frames are already promising. We need to look at how to expedite and augment them systematically in our countries.

These efforts also need to be made at the micro-level of individual clinical practice in the Global South and of those serving diverse populations. This includes acting within primary health care (when applicable), referral pathways, and specialized MHPs. We are fortunate to exist in an era where psychiatry and clinical psychology are increasingly receptive to such efforts. Subfields such as cultural clinical psychology and transcultural psychiatry have become well-established, creating ample space to pose pertinent questions and delve deeper into decolonization scholarship and programming. Our predecessors were not as fortunate, and questions pertaining to decolonization were historically limited to the realm of “critical theory.” Today, we can put forward these questions in clinical science and endeavor to find meaningful answers.

I hope that we will see more literature and actionable guidelines targeting clinicians in the Global South as well as instituting a formal body of knowledge within our training. Decolonization tools need to be given to those on the ground so that the concept ceases to be an academic debate or limited to clinical settings of minorities in well-resourced countries of the Global North to enhance access to and quality of care. The billions of people living in and originating from the Global South need us to use all available resources to enhance the quality and appropriateness of their care.

About the author

Nadine Hosny, MSc, is a psychotherapist and doctoral researcher at the Cultural Clinical Psychology Lab at the Institute of Psychology, University of Lausanne, Switzerland. She studies cultural concepts of distress, complex trauma, and the development of culturally congruent interventions. She is also an affiliate researcher in the Department of Psychology at the American University in Cairo and in the Department of Public Health at the University of California, Davis.

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