Crisis in global mental health research

In the last 3 years, several touchstone commentaries and calls to action have explicitly and attentively outlined a growing crisis in global (mental) health research. In 2020, Lawrence and Hirsch wrote one of many commentaries outlining the persistence of colonial research practices in global health research (Büyüm et al., Reference Büyüm, Kenney, Koris, Mkumba and Raveendran2020; Lawrence and Hirsch, Reference Lawrence and Hirsch2020; Oti and Ncayiyana, Reference Oti and Ncayiyana2021; Khan et al., Reference Khan, Shahzad and Khan2022). They focused on how transnational research partnerships involving randomized controlled trials maintain colonial power imbalances, biases and lack of representation (e.g., composition of study teams, decision-making, authorship). They question the idea of partnership between low- and middle-income countries and high-income countries and if it is ever truly equitable. They suggest three main ways that international research programs can be more equitable: participant experience, expertise, infrastructure and authorship (Lawrence and Hirsch, Reference Lawrence and Hirsch2020). These themes are extended in further calls to action and commentaries. For example, Kronick et al. (Reference Kronick, Jarvis and Kirmayer2021) highlighted three main challenges for global mental health research involving refugee and displaced peoples: the role of refugees as victims, traditional research practice that recreates powerlessness and lack of translation into practice. First, in mental health research, refugees primarily play the role of the subject to be studied and are rarely included as collaborators and partners. This perpetuates colonial power imbalances where the refugee participant is seen as unwell, vulnerable, victimized and lacking agency. In line with that, it has been our experience that professionals and volunteers from the majority society who work with refugees often act as gatekeepers. Many are reluctant to share information about research projects with refugees or advise them against participating out of a concern that answering questions about grief or trauma might be too distressing. While every potential study participant has, of course, the right to decide whether or not they want to be involved in a study, refugees are often not given the opportunity to make this choice for themselves and instead are seen as needing protection.

This is a one-sided conceptualization of refugee health, as refugees are also resilient, strong, resourceful and overcoming (Chung et al., Reference Chung, Meijer, Zonneveld, Al Sawaf, Alajak, Moopen, Rahim, Çiftçi, Alisic, Stellar, Mooren, Sleijpen, Tešanovic, Al Baker, Dali, Papadantonaki, Papakosta, Antink, Charisopoulou, Frens, O’Connor, Taşfiliz and Laceulle2022; Hirad et al., Reference Hirad, Miller, Negash and Lambert2023). ‘Nothing about us, without us’ (Fricker, Reference Fricker2007) advocates for participatory methodologies as a way forward. However, there are real ethical dilemmas that must be considered. There are risks to speaking out and disrupting the status quo; silence is a key strategy for safety and survival for refugee groups (Kronick et al., Reference Kronick, Jarvis and Kirmayer2021). From our recent experience, many participants did not answer questions about the duration of their journey and the concrete status of the asylum application, even though we explained our data handling procedures to them in detail. Kronick et al. (Reference Kronick, Jarvis and Kirmayer2021) suggest careful reflection on the use and purpose of participatory action research. Community-based participatory research (CBPR) places a key emphasis on partnership, research, action and education. Kia-Keating and Juang (Reference Kia-Keating and Juang2022) explain how CBPR commits to partnering with communities, for example, by clearly outlining the benefits and disadvantages of the co-construction of knowledge, prioritizing the development of relationships with stakeholders and choosing research with social or racial justice impact. ‘Helicoptering’ into communities for our own research benefit (i.e., publications, funding) is no longer tolerable. Kia-Keating and Juang (Reference Kia-Keating and Juang2022) ask the question about how can research be more open, inclusive and equitable? Shifting the focus from the individual (i.e., researcher, participant) to collaboration and co-construction of knowledge through CBPR is a key step.

Second, traditional research practice (questionnaire, interview based and online data collection) may be recreating experiences of powerlessness and control that displaced people escaped (Kia-Keating and Juang, Reference Kia-Keating and Juang2022). What is more, these practices might also resemble the experiences of asylum seekers during their asylum procedure, which is often associated with power imbalance, uncertainty and fear. Mental health research methods and questions often decontextualize the individual and emphasize individual-level variables such as symptoms, physiology, genetics and behaviors instead of systemic, cultural or ecological factors (Kia-Keating and Juang, Reference Kia-Keating and Juang2022). Researchers choose the questions, measures and variables, therefore choosing what is prioritized and presented to the world. In academia, the types of research questions (symptoms, markers, quantitative evidence-based) are often driven by funding bodies and structural factors that prioritize certain types of knowledge and research methods. Depending on the cultural group, research questions with a focus on individual symptoms, processes and functioning might be at odds with what participants themselves view as important (Kohrt et al., Reference Kohrt, Rasmussen, Kaiser, Haroz, Maharjan, Mutamba, de Jong and Hinton2014; Killikelly et al., Reference Killikelly, Bauer and Maercker2018). This can also lead to a lack of participation and high dropout rates. This reflects another challenge; relocating the research question in a broader socio-ecological framework instead of at the individual level (Kronick et al., Reference Kronick, Jarvis and Kirmayer2021). Research questions should include sociological and structural processes. For example, a research question about depression in refugee groups could be expanded to include questions about access to support, help-seeking behavior and impairment in family relationships alongside individual depression symptom measures.

Finally, translating research into practice is a significant challenge for all areas of mental health research. In the case of research involving refugees, key questions emerge about who benefits from this research and what are the long-term plans for support and resourcing typically underfunded organizations and programs (Kronick et al., Reference Kronick, Jarvis and Kirmayer2021). Recently, Rivera-Segarra et al. (Reference Rivera-Segarra, Mascayano, Alnasser, van der Ven, Martínez-Alés, Durand-Arias, Moro, Karam, Hernández-Torres, Alarcón, Ramos-Pibernus, Alvarado and Susser2022) challenged the predominant use of Western-centric research methods, ‘evidenced-based practice’ and therapeutic models that are largely developed from a system that historically oppresses and exploits less powerful groups. Most global mental health research, including research on refugees in high-income host countries, is led by White, Western-educated clinicians who benefit economically and professionally, while foundational clinical research studies are mostly conducted on White-educated industrialized rich democratic populations (Henrich et al., Reference Henrich, Heine and Norenzayan2010). Disrupting this current power imbalance in academia means establishing equitable partnerships, but also prioritizing other types of knowledge and mental health practices (epistemic justice). It also means sharing support and resources (pragmatic solidarity), as well as redefining barriers and breaking traditional research norms (sovereign acts) (Rivera-Segarra et al., Reference Rivera-Segarra, Mascayano, Alnasser, van der Ven, Martínez-Alés, Durand-Arias, Moro, Karam, Hernández-Torres, Alarcón, Ramos-Pibernus, Alvarado and Susser2022). Each of these concepts will be discussed in the following sections.