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Résumé

La recherche en santé mentale
et la domination culturelle :
la construction sociale de la connaissance
à des Ž ns de développement international
Sonya L. Jakubec et Marie Campbell
Ce travail ethnographique institutionnel s’appuie sur l’expérience de la première
auteure en tant qu’intervenante en développement international, éducatrice et
infir mière en santé mentale communautaire en Afrique occidentale, pour
illustrer comment la recherche ofŽ cielle et les politiques portant sur les services
de santé mentale re ètent la domination occidentale sur le plan académique,
corporatif, économique et culturel. S’appuyant sur une analyse textuelle critique
d’un questionnaire utilisé dans le cadre de demandes de subvention adressées à
des agences d’aide internationale et de prêts, les auteures démontrent comment
les processus ofŽ ciels privilégient les politiques et les approches de recherche
occidentales et supplantent les perspectives locales. Pour être efŽ caces dans leur
travail de développement en Afrique, les inŽ rmières, les chercheurs et les décisionnaires doivent apprendre à reconnaître les attitudes de domination subtiles
inhérentes aux approches occidentales. Les auteurs proposent que la recherche
internationale et les politiques de développement international mettent en
priorité la compréhension des connaissances locales plutôt qu’une approche
privilégiant des cadres d’interprétation complexes et généraux.
Mots clés : santé mentale internationale, domination culturelle, ethnographie
institutionnelle

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Mental Health Research and Cultural
Dominance:The Social Construction
of Knowledge for International
Development
Sonya L. Jakubec and Marie Campbell
This institutional ethnographic work uses the Ž rst author’s experience as an
international development worker, educator, and community mental health
nurse in West Africa to illustrate how ofŽ cial research and policy on mental
health services re ect Western academic, corporate, economic, and cultural
dominance. Focusing on a cr itical textual analysis of a survey intended to
support funding applications to international aid/lending agencies, the authors
show how ofŽ cial processes privilege Western policies/research approaches and
subordinate local perspectives. If nurses, researchers, and policy-makers are to be
effective in carrying out development work in Africa, they must learn to appreciate the subtle exertion of dominance inherent in Western approaches. The
authors propose that understanding local knowledge be foregrounded rather
than backgrounded to the complex global interpretive frames for international
research and international development policy.
Keywords: international mental health, cultural dominance, institutional ethnography

Introduction
The question of ruling practices that masquerade as development is very
difŽ cult to pry apart from the ideology of caring that motivates nurses.
Those who experience it can feel the contradictions. (Campbell &
Gregor, 2002, p. 126)

This institutional ethnographic work questions the assumed beneŽ ts of
development work in cross-cultural research. It uses the Ž rst author’s
experiences as a development worker, educator, and mental health nurse
in West Africa to demonstrate that ofŽ cial research and policy regarding
mental health services in developing countries are part of Western cultural dominance.As such, the analysis should serve to further our understanding of the increasingly vocal resistance to international development
that sometimes appears to be a generalized critique of globalization. A
careful textual analysis of a survey developed by the World Health
Organization provides the basis for the argument that ofŽ cial knowledge
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about mental health in The Gambia,West Africa, privileges Western ideas
and practices.An analytic focus on knowledge is central to this argument.
The knowledge generated by surveys such as that of the WHO is crucial
to the development and management of mental health intervention programs in developing countries.Yet the knowledge generated and the
treatment based on that knowledge are shaped by ideas and interests that
are not those of the people they are designed to help.
The analysis was conducted by the Ž rst author as part of her master’s
of nursing thesis (Jakubec, 2001). The second author supervised the
research and helped to develop the conceptual framework for the paper.
For clarity, the Ž rst author’s voice will be used throughout. In the thesis
research, I (Sonya Jakubec) analyzed my own work in The Gambia to
illustrate the contradictory nature of development work in general and
mental health nursing in developing countries in particular. On the one
hand, mental health patients in The Gambia needed help, and as an experienced Canadian mental health nurse I felt that I had much to contribute to the mental health team. On the other hand, I saw a different
picture emerg ing. What is analyzed is the “help” offered by a wellmeaning nurse as part of a “world mental health” framework that carries
certain cultural implications.
Background
Between 1996 and 1998 I served as technical advisor to a community
mental health team in The Gambia, having been recruited by a British
non-governmental international development agency. My responsibility
was essentially to assist in building a community health program in this
impoverished country.Through orientation programs, I was trained to
adapt my skills and knowledge to new, resource-poor settings as well as
to customs, ethics, and values speciŽ c to The Gambia. I brought with me,
as would any Canadian nurse, a respect for the cultural practices of the
country in which I would be living and for the views of the four
Gambian nurses with whom I would be working. I learned to be attentive to predominant local beliefs and traditional healing methods, which
included a belief in spiritual disease causation, extensive family involvement in care, and treatment by healers known as marabouts.The Gambian
nurses were Western-trained and moved comfortably between Western
and traditional beliefs surrounding mental health.The team’s work practices had been shaped in the context of diverse belief systems, values, and
practices.The population served by the team comprised Ž ve main ethnic
groups. Most patients approached traditional healers Ž rst in their pursuit
of treatment for mental health problems. In order to function effectively
in this setting, I took local language lessons, participated in an extensive
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in-country cultural training program, and attended local ceremonies and
other events. I also closely observed and tried to learn from my colleagues and the Gambians who I befriended and with whom I resided.
This process of observation, questioning, and immersion was, for me, an
important means of understanding nuances, taboos, and cultural mores,
and of supervising nursing staff, teaching, and offering clinical guidance
to colleagues in an appropriate way.
As I approached the end of my 2 years in The Gambia I began to
look for base or long-term funding to help sustain the work of my team.
The team had worked hard and accomplished much: the mental health
program was growing and was seen as a successful health resource in the
country. But I was aware that, as an outsider, I had access to resources that
my Gambian colleagues did not. Included in the advice I received on
attempting to secure continued funding was a strong suggestion that I
collect “better data” on the need for the service being offered, in terms
of both the clients and their treatment. I was directed to the Gambian
national ofŽ ce of the WHO, where, after some consultation, it was suggested that I begin to collect data on mental health.The Pathways Study
material was put in my hands, and I eventually sought and received
Canadian government funding to conduct a study.After completing one
term of a master’s program at the University of Victoria, I returned to
The Gambia in 1999 and conducted the study as a member of a large
team of mental health workers.The Pathways Study consisted of a questionnaire administered during routine “encounters” with new patients
over a 1-month period.There are several pages on the patient’s history of
being examined, diagnosed, and treated over the course of an illness or
series of illnesses up to the point of the present encounter with the psychiatric system. This paper does not report the Ž ndings of the Pathways
Study nor critique the questionnaire itself. Rather, it concerns the construction of knowledge through the Pathways Study.
Institutional Ethnography
Institutional ethnography is an approach to studying everyday life in
which the analyst looks at “how things are organized.” It draws on
Dorothy Smith’s (1990a, 1990b, 1999, 2002) theory of the social organization of knowledge, in which “experience” is the starting place for an
inquiry. Something that is experienced by an actual person in an actual
setting is examined in order to discover the forms of social organization
that constitute it as it is known and responded to by insiders (Campbell,
1998). The notion of “standpoint” is central to Smith’s institutional
ethnography. Knowing and knowledge, Smith claims, are always located
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cates” a problematic from a particular standpoint. Smith’s interest in
developing a methodology for social analysis that attends to a particular
standpoint emerged from her (feminist) concerns about men’s views
being taken as normative (Smith, 1987). Smith and other feminists have
suggested that the subordination of women originates in just such “invisible” knowledge practices.This view has strong appeal for nurses whose
experiential knowledge lacks professional authority. It can also be useful
in analyzing the troublesome issues of post-colonial development work.
Smith takes Foucault’s (1984) view that knowledge and power are linked.
Smith’s commitment to social equality brings to her scholarly research a
theorized interest in identifying the role of power in the knowledge
practices that permeate everyday life. She argues that people’s lives are
ruled, at least in industrialized societies, by the textual coordination of
action (Smith, 1990b). In institutional ethnography, the goal is to determine empirically how that kind of rule is organized and how all of those
involved (both the ruled and the rulers) make it function.This analytic
interest points researchers towards textual analysis and text-based or
mediated practices.
Institutional ethnography was the methodology of choice for my
investigation, because it offered a way of analyzing the Pathways Study
texts, the use of which became a condition for securing further support
from aid/lending agencies.The whole scenario surrounding the Pathways
Study had been puzzling me.That is to say, it was not immediately clear
to me why any new account of the work of my mental health team was
necessary given that information on our work in The Gambia had
already been collected. Smith’s writings on the social organization of
knowledge offer some insight. She explains that texts function as part of
the social relations of any setting and serve to unite people in coordinated action. Such a conceptual framework seemed useful for my
attempts to understand the contradictions and conundrums I saw in the
demand for “better data.” It offered me a way of treating the Pathways
Study as a step in the textual organization of “getting mental health work
done.”
An institutional ethnographic inquiry is framed, not around a hypothesis, but around a problematic “in the everyday world” (Smith, 1987).The
underlying belief about social reality (ontology) is that people “enact”
social life; thus a social inquiry must be framed in such a way as to
capture accounts of what people do (Campbell & Gregor, 2002, pp.
90–91). All research strategies are approaches to the analysis of data, but
they do so in different ways.The institutional ethnographer focuses on
how people’s actions, lives, and experiences are socially organized. Smith’s
(1987) concept of social relations is central to such inquiry. Social
relations is an ontological notion about social life whereby people act
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knowledgeably as they conduct their lives and are therefore participants
in weaving their personal actions into the social fabric.The goal of the
institutional ethnographer is to explicate how people’s actions are socially
organized and put together to result in what is observed and recounted.
Informants understand the meaning of their everyday experiences but do
not have a Ž rm grasp of the social organization of these experiences. My
explication draws what is missing in people’s stories, or in observational
data, into the analysis. Ethnographic data provide clues to connections
between everyday life and its social organization.The institutional ethnographer follows these outwards to their source.This is how the notion of
social relations as organizing the setting becomes a methodological tool.
The research questions were: How does the Pathways Study work? What are
its governing social relations? What does it accomplish? Treating the Pathways
Study as governed by social relations serves both to identify the impetus
for and implementation of the Pathways Study and to determine how,
on the basis of the study itself and the knowledge it generates, a continuing coordinated action occurs.The data of analysis were the study itself
— its texts and their origins in various discourses — and the methods I
used in conducting the original study.
Data
Institutional ethnography’s focus on the social organization of everyday
life calls for two levels of data (Campbell & Gregor, 2002, p. 60).The Ž rst
is ethnographic, in the anthropological sense, and may include interviews
or, as with this inquiry, participant observation. My work as a technical
advisor included experiential involvement in everyday mental health
work, with colleagues and patients, in The Gambia.This experience was
my means of studying the organization of the everyday work of mental
health nurses in The Gambia. My accounts were supplemented by entries
in a journal that I kept on my experiences as a practising nurse and
development worker, photographs and slides documenting the workings
of the team, and letters that I had sent to colleagues, friends, and family
members in Canada.
The second level of data consisted of the Pathways Study documents,
the actual survey instruments, and several of the completed questionnaires.The inquiry also entailed a search of the literature on the Pathways
Study — its origins and various applications — and a search of the
development literature.
Analysis
As the mental health team “activated” the text of the Pathways Study in
The Gambia, we participated in its social relations. Smith explains that
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texts carry social organization across the experiential boundaries of settings.The activation of the survey form brings its organization into the
local setting. For Smith, “texts speak in the absence of speakers” (1990b,
p. 211).As we nurses activated the text, we began to relate to our patients
through the form.This section of the paper analyzes this process, using the
text as data explicated through institutional ethnography.
Organizing and “Encountering” Patients:
Not So “Routine” Information
At the top of the Ž rst page of the Pathways Study is the title “Encounter
Form,” followed by several lines of instructions to guide the interviewer’s
“encounter” with the patient. Health workers are instructed to carry out
their “usual full clinical assessm ent, with particular attention to the
sequence in which symptoms were developed” (WHO, MNH/NAT/
87.1).
The basic data to be collected (see Figure 1) were the name of the
facility at which the patient was seen, the name of the nurse who Ž lled
in the form, the date, the patient’s initials, the date when the patient was
Ž rst seen by any mental health service, the date when symptoms Ž rst
appeared, the time elapsed since the symptoms Ž rst appeared, and the
diagnosis (translated into the language of the International ClassiŽ cation
of Diseases-10, or ICD-10; World Health Organization, 1993). Other
data to be collected were the name of the person who Ž rst saw the
patient, how that contact was initiated, the symptoms that caused the
patient to seek help, and any speciŽ c treatment. This process was to be
repeated for any and all other referrals described by the patient.
Activating the Encounter Form
My experiential account indicates that as the text was activated it began
to demonstrate cultural domination. I begin by arguing that the “usual
full clinical assessment” conducted by my mental health team could be
described as anything but routine but transferring these assessments to
the Encounter Form began to make them so.
As The Gambia’s only community mental health service, the team
had to journey to remote areas of the country in what were called treks.
Just getting there was an adventure, owing to the rugged terrain, lack of
secure supplies of fuel, and other factors. As we travelled throughout the
country, we would see both registered patients and their relatives, brought
along as new consultations. Sometimes the queue would comprise hundreds of people, while others would wait outside seeking the shade of
trees. Still others would be seen along the way at the compound of the
local marabout.The team functioned in an informal manner.We would
visit people in their homes or, in the case of the smaller health centres, at
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Excerpt from a Completed Encounter Form
1. BASIC INFORMATION
1.1) Name of facility at which the form is Ž lled in: CMHT ofŽ ce
1.2) Form Ž lled in by: MA
1.2) Date: 31 May 1999
1.4) Patient’s initial: MJ
1.5) Date Ž rst seen by mental health services: 31 May 1999
1a.) What was the Ž rst symptom developed by the patient?:
Isolative, loss of appetite
1b.) How long ago? (number of months): 3 years
1c.) State diagnosis: Schizophrenia + speciŽ c ICD-10 classiŽ cation number XXXX
(WHO, MNH/NAT/87.1)

tables set up outdoors under a gazebo. Occasionally we would make an
initial or follow-up assessment at the riverside, at the roadside, or in a
store.
As with all interactions in The Gambia, every conversation with a
patient, family member, or member of the health centre staff began with
an exchange of greetings, ritual questions/answers, and blessings/prayers.
The Gambia being a small country, the Gambian nurses on the team
would often run into extended family members or acquaintances.As we
moved about the countryside, the team members would chat with
various people, from the patients with mental illnesses, to their relatives
and friends, to village leaders and rural health workers, thereby establishing personal connections. An interview might be brief, but it would be
Ž lled with laughter, village news, or the stories of the people or families
being assessed, often shared over food, which was almost always offered
to us at some point in the journey. Rarely would the mental health team
consult with a patient alone.The entire family might be present if the
assessment took place in a home.Visits to the local healer, where perspectives and treatment strategies would be shared with the marabout,
were an opportunity to engage in the kind of informal education in
which the team specialized. Often the cause of a disorder would be interpreted as personal or social distress, misfortune, loss, or extreme poverty,
possibly connected to what was referred to as a juru, or curse. The
marabout would offer charms, prayers, or spiritual healing for the manifestations of the curse.
The Pathways Study transformed the team’s way of conducting
routine assessments.The questionnaire served as a template for our interactions, with the nurses interviewing people in order to get speciŽ c
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answers and interpreting their comments in terms of the survey categories. With the increased emphasis on diagnosis came an increased
emphasis on “appropriate” treatment — that is,Western psychiatric treatment.
I noticed that my colleagues seemed to enjoy working with the questionnaire.As suggested in the instructions, it was easy to implement, eliminating some of the conversation and informal interactions in the interview process. I sensed that the Gambian nurses found that using the
structured, standardized tool and writing down their Ž ndings enhanced
their “professionalism.”The survey structure also facilitated the team’s
control over the queues. One day I was surprised to hear one of my colleagues shout “Next!” as he processed the patients.This struck me as a
complete departure from the usual conversational approach whereby
patients were treated as members of families and communities.
It was not just the style of interaction that changed.The questionnaire
itself altered basic understandings of mental health and proper treatment.
It required the interviewer to interpret people’s stories in terms of psychiatric and Western medical notions of causation and treatment. One
woman’s first symptoms, as told to a marabout, are recorded on the
Encounter Form as “meditates a lot, withdrawn, thinking too much (not
able to bear children).”After several months her symptoms worsened, to
include “tearfulness, insomnia and loss of appetite.”When the woman
approached the community mental health team she was given a diagnosis of “depression” and prescribed medical treatment.The actual availability of such prescribed medical treatment would vary.The Gambian state
supplemented what medications could be obtained through the WHO
drug programs, and occasionally well-intentioned donors would send
supplies of psychiatric drugs that were made available as a one-time-only
gift. However, a chronic shortage of medications did not affect the team’s
evolving understanding of the “best way” to treat patients.
The Encounter Form required that local needs and mental conditions
be reported in institutional language.To complete each survey, the team
would take an observed case (already worked up through the questions
of the trained mental health nurse), interpret the symptoms based on
Western notions of causation, and make a diagnosis.This activation of the
text would, as in the above example, translate a person’s suffering into
“depression,” a condition to be treated pharmaceutically.
Pathways Texts as Elements of Social Organization
My text analysis also explicates the relation between the survey text that
we used in The Gambia and a number of mental health and international
development discourses, reinforcing my argument that the Pathways
Study is a form of cultural dominance. The theory of institutional
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ethnography tells me that texts “carry” and establish certain relations
among the people who read and use them. My inquiry was directed at
the trans-local relations being organized in The Gambia through our participation in the Pathways Study.
In practice I acted as a member of the team, completing Encounter
Forms according to the instructions. However, as Smith points out,“the
everyday world is not fully understood within its own scope.The everyday world is organized by social relations not fully apparent in it” (1987,
p. 92). People make sense of texts in the context of their social situation
(McCoy, 1995), consciously and unconsciously interpreting and giving
meaning to texts from external settings and drawing them into their
own, everyday worlds.1 Smith (2002) further explains:
Texts as read and written in the everyday actuality of people’s work coordinate what people are doing in one local setting with work done by
others elsewhere or at different times… Not everybody reads a given
text in the same way, but for every site into which a given text is inserted
one side of the text-reader conversation is Ž xed and unchanging from
site to site to site. (p. 34)

When people engage competently with texts such as surveys and
other data-collection tools, they use the resources of the text itself to
determine how it is intended to be read.Thus informed, they are able to
understand and follow the instructions as well as the unwritten rules.The
practitioner’s competency with the text’s words and symbols makes possible the application of some of the text’s meanings to the local setting.
In terms of my research, this meant investigating the discourses whose
meanings are (or will be) drawn into the local setting through the various
ways that the Pathways Study and its Ž ndings are (or will be) activated.
This text-reader conversation begins with the Encounter Form, my analytic entry into the social organization of the Pathways Study.To read the
text analytically is to search for clues to its discursive origins. I need to
know what extra-local messages are carried into my work setting.These
connections lead to a fuller understanding of what the Pathways Study is
doing in Africa and elsewhere.
The Encounter Form provides a number of textual clues to its discursive antecedents. Initials in its top left corner inform the reader of its
origins.A referencing code,“MNH,” makes an authoritative connection
between the form and WHO research guidelines and protocols. I knew
from my initial contact with the WHO’s Gambia ofŽ ce that MNH refers
to a group of studies within the WHO’s mental health division.The title
1 This kind of text-reader conversation in institutional ethnography draws on Smith’s

(1999) engagement with Russian language theorists such as Bakhtin (1981) and Volosinov
(1983).

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MNH/NAT/87.1 ties the Pathways Study to the WHO libraries in
Geneva that distribute the documents through its various national ofŽ ces
(in this case, in the capital city of The Gambia). Thus, I identiŽ ed the
deŽ nitive link not just between the Gambian national ofŽ ce and the
Pathways Study, but also to its initiators, Gater, Almeida, Sousa, and
Barrientos (1991), and other discussants of the Pathways Study. Gater and
his associates in the Mental Illness Research Unit at the University of
Manchester report their research in an influential article, “WHO
Activities Aimed at Improving the Quality of Mental Illness Care” (1991,
p. 761). Their work in initiating the Pathways Study is vital to how the
survey is to be read. It establishes the WHO’s methodology for improving
mental health as expressed in the survey and other documents.
The reference to “Annex 1” at the top right corner of the Encounter
Form is another indication of how the Pathway Study Ž ts within the
WHO’s other studies. It identiŽ es the Encounter Form as an annex of a
report that outlines a whole program of research, including the goals,
required resources, protocols, methods, and analyses of the various studies,
thus showing that the documents can, in combination, build a clear
understanding of mental health circumstances, training needs, and so on.
The chief aim of the Pathways Study, according to an introductory document, is “to describe the pathways which patients with mental illness
take in each centre” (WHO, MHN/NAT/87.1) This introductory document reveals other aims and discourses of Pathways research (see
Figure 2). Quick referral to a specialist psychiatric service is particularly
important. Concern about delays in getting patients to Western psychiatric care is Gater’s motivation for initiating the Pathways Study —
“appropriate help…as soon as possible after the beginning of patient’s
contact with services” (Gater et al., 1991, p. 762). All Pathways research, it
should be noted, assumes the beneŽ ts to patients of a quick referral from
the time of initial contact with a service provider, whether a general
practitioner in Manchester or a local healer in a developing country.This
assumption is implicit in the research as a feature of the dominant
medical discourse of psychiatry in which Gater’s work is rooted.
Pathways Survey and the Construction of “Delay”
A typical completed Encounter Form concerns a patient with one or
more symptoms (such as sleeplessness or illusions) who had sought help
from a practitioner — often a local healer who provided a charm or a
herbal remedy — several months or even years previously.To properly
read the Pathways data on “referrals,” one must be familiar with Gater et
al.’s (1991) perspective on “delays” as manifested in the questionnaire.The
questionnaire constructs a patient’s story as a sequence of help-seeking.
A proper reading (and activation) makes note of the length of time it
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Aims of the Pathways Study
For a variety of practical reasons it [the survey] begins with patients coming
to mental illness services with new illnesses, and it aims to answer questions
such as the following:
Pathways of care:
What paths do people with mental illnesses follow in the course of their
search for help?
How long does it take to pass the various nodes in the path?
And which symptoms hasten the process of referral to a specialist psychiatric
service?
(WHO, MNH/NAT/87.1; italics added)

took the patient to reach some form of Western psychiatric assessment
(presumably, the encounter during which the questionnaire is completed).The categories and the instructions to the interviewer construct
each case in terms of the survey’s meanings. Implicit in the text are connections to the authorizing organizations and their discourse. Only when
the concept of “delay” is seen as developed by Gater et al. can the
Encounter Form be read in this way.
Gater’s research establishes a connection between local and extra-local
sites, between efŽ cient referral to Western treatment and efŽ cient service
— those who seek help from local healers are likely to experience delays
in accessing “appropriate” care. Once patients’ involvement with local
healers is understood, Gater et al. (1991) suggest, a variety of ways of
“hastening referrals” (p. 773) become possible.They recommend training
in recognizing psychiatric symptoms. Recall that in implementing the
Pathways Study I observed some negative effects of “hastening referrals”
in this manner. As my team became orientated to the Encounter Form,
whereby each symptom must Ž t into a diagnostic category, they stopped
paying careful attention to the patient’s account and began associating
symptoms with a diagnosis.While the sort of clinical training suggested
by the Pathways Study can be beneŽ cial, it can also give rise to difŽ culties. Once the focus is on delay in access to Western treatment, the practitioner-patient interview becomes based on efŽ ciency.This reliance on
Western science to diagnose a condition and prescribe the most “effective” or “helpful” treatment sits in contradiction to the lack of medical
resources in many developing countries — potentially, however, creating
new markets for Western corporations. Underlying such interventions is
the danger that traditional approaches will be subordinated, displaced, and
discredited.
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Delays and “Development”
How can this happen in the context of international development, which
would seem to have a philosophy entirely different from that of business?
My text-reader conversation offers some insights. Reading a mental
health text to determine its social relations leads one to question the
research interest in what international health experts call “the burden of
disease.”This concern Ž ts with the World Bank’s interest in efŽ ciency and
productivity as laid out in the report Highly Indebted Poor Countries
(World Bank, 2002). Desjarlais, Eisenberg, Good, and Kleinman (1995)
describe the connection among health, health care, and productivity: the
burden of prolonged illness, in terms of loss of productivity, on individuals and families is considered to be one of the most signiŽ cant health and
social problems internationally.The increasing interest in promoting and
studying the pathways that patients take in accessing appropriate psychiatric care is expected to have an economic pay-off (Gater et al., 1991;
Sartorious & Harding, 1987; Sartorious et al., 1993).
The World Bank, through its Mental Health Policy Department,
closely monitors the Ž nancing of mental health services. It issues mental
health “do’s and don’ts” for both donors and countries seeking loans or
other forms of funding (World Bank, 2001). For instance, the information collected via the Pathways Study is intended to assist the Gambian
government. In 1999 The Gambia was preparing a Five-Year Health
Action Plan to obtain training resources from the WHO and to obtain
aid from international funding/lending bodies such as the World Bank
and the International Monetary Fund. Marten de Vries, Secretary
General of the World Federation for Mental Health, has cited the role of
“productivity, work, and the ‘disability adjusted life years’ lost through the
‘burden of disease,’ with managing the scourge of depression” (de Vries,
2001).This helps to explain the rationale of hastening psychiatric referrals in order to promote productivity.The Pathways Study is part of what
I view as the “world mental health” framework (Jakubec, 2001, p. 7),
whose purpose is to support the economic development and productivity of “under-productive” nations — nations that are increasingly plagued
by illnesses that rob individuals of the ability to participate in the market
economy. In developing countries such as The Gambia, according to this
discursive framework, mental illness must be treated efŽ ciently and
appropriately in order to support development. Development is guided
and supported by aid and lending agencies that, while “helping,” also
have a distinct view of how such development should proceed. All of
these activities, and their textual representations, I suggest, are the basis of
a new form of colonization through development, international aid, and
tied trade.
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Mental Health Research and International Development

Explicating Everyday Practices of Dominance
“Why do they hate us?” (Davis, 2002). Events in the past year have
prompted North Americans to re ect on this question. I suggest that
nurses who are involved in international development are implicated in
some of the practices of dominance that arouse hatred internationally. I
have analyzed common research tools to illustrate that their texts have
colonizing implications. Mental illness is a problem that people in developing countries need help in overcoming. Sometimes the products of
Western research and development will be the solution. Clearly, however,
the mental anguish faced by people living in abject poverty cannot
always be explained by psychiatry nor properly treated with pharmaceuticals. Methods of knowing that interpret local conditions in terms of
psychiatric categories are part of the problem.The results of my analysis
suggest that we can best understand the colonizing implications of this
kind of interpretation of people’s experiences by Ž rst acknowledging our
own complicity in the process.This analytic agenda aims to recover an
account of what is occurring in everyday practice — behind the slogans
— in the developing world and elsewhere.This kind of analysis can contribute to a new way of thinking and to ways of working that actually
address people’s needs.
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Authors’ Note
Collection of the data on which this analysis was conducted was made
possible by a Professional Research Award generously granted to the Ž rst
author by the Canadian International Development Agency through the
Canadian Bureau for International Education.We are indebted to our
colleagues in The Gambia for that initial work, as well as to Drs. Colleen
Varcoe and Jane Milliken at the University of Victoria for their guidance
in the thesis preparation.Also, we are grateful to the Journal’s anonymous
reviewers for their comments, which have helped us to improve the
paper.
Correspondence may be sent to Sonya Jakubec, School of Nursing,
Okanagan University College, 3333 College Way, Kelowna, British
Columbia V1V 1V7 Canada. E-mail: sjakubec@ouc.bc.ca
Sonya L. Jakubec, RN, MN, is Assistant Professor, School of Nursing, Okanagan
University College, Kelowna, British Columbia, Canada, and a PhD student in the
Faculty of Nursing, University of Calgary, Alberta, Canada. Marie Campbell, PhD, is
Professor Emeritus, Faculty of Human and Social Development, University of Victoria,
British Columbia.
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