Abstract

This article presents a critical reflection on the conceptual perspectives in mental health, in the quest for new meanings for this concept and its implications in the context of achieving peace in Colombia. For this, an integrative review of the literature was conducted in seven bibliographic databases and search engines. As a result, five conceptual perspectives of mental health were identified: 1) biomedical and behavioral; 2) wellbeing and its potential; 3) cultural; 4) psychosocial; and 5) based on social determination, the epistemological foundations, contributions, criticisms, and limitations of which are described in each case. Finding more pertinence in the proposal of mental health from collective health/social medicine rather than from the classic public health for achieving peace in Colombia, a comprehensive view of mental health that takes into account its socio-cultural relevance from a critical and socio-­historical position is proposed.

Key words
Mental health; Public health; Collective health/social medicine; Armed conflict; Peace

Introduction

The review on mental health in situations of armed conflict/peace-building shows how the study of them has primarily focused on armed conflict and less on peace-building, with a morbicentric perspective that takes no account of the collective and political connotation of mental health or its relationship with the overcoming of inequities and social injustices as causes of armed conflict. With a central interest in the concept of mental health in peace-building processes the starting point is recognising that political violence and in it, the quest for peace, has been a matter of public health concern, as reflected by the creation of the World Health Organization (WHO) which, motivated by the effects of world wars, evidenced the mental dimension of health¹1 Organización Mundial de la Salud (OMS). Official Records of the World Health Organization, N°2. Proceedings and final acts of the International Health Conference. New York: OMS; 1946.. Subsequently, in transitional justice processes²2 Pham PN, Vinck P, Weinstein HM. Human rights, transitional justice, public health and social reconstruction. Social Science Med 2010; 70(1):98-105. special importance has been given to recovery after trauma, forgiveness, reconciliation, human rights and the fight against impunity, measures linked to the achievement of improved health and peace.

Since the mid-twentieth century, guerrillas arose in Latin America in response to dictatorships and social injustices, which in the case of Colombia have led to protracted, changing and complex armed conflict³3 Centro Nacional de Memoria Histórica. ¡Basta ya! Colombia: memorias de guerra y dignidad. Informe General Grupo de Memoria Histórica. Santafé de Bogotá: CNMH; 2013., whose figures record 8,632,032 victims⁴4 Unidad para las víctimas República de Colombia. Registro Único de Víctimas [Internet]. [consultado 2018 Fev 26]. Disponible en: https://rni.unidadvictimas.gov.co/RUV
https://rni.unidadvictimas.gov.co/RUV... with its counterpart in damage to community structures, destruction of the social fabric and increasing inequity³3 Centro Nacional de Memoria Histórica. ¡Basta ya! Colombia: memorias de guerra y dignidad. Informe General Grupo de Memoria Histórica. Santafé de Bogotá: CNMH; 2013.. At the same time, 59,761 people have been demobilised from illegal armed groups⁵5 Agencia para la Reincorporación y la Normalización República de Colombia. La reintegración en Colombia [Internet]. Bogotá: ARN; 2017. [consultado 2018 Fev 26]. Disponible en: http://www.reintegracion.gov.co/es/la-reintegracion/Paginas/cifras.aspx
http://www.reintegracion.gov.co/es/la-re... ; while 77 social leaders have been killed 15 months after the start of the implementation of the agreements with the Revolutionary Armed Forces of Colombia - People’s Army⁶6 ¡Pacifista!. Estos son los 77 líderes sociales asesinados desde el inicio de la implementación [Internet]. [consultado 2018 Fev 26]. Disponible en: http://pacifista.co/lideres-sociales-asesinados-inicio-implementacion/
http://pacifista.co/lideres-sociales-ase... and a year after the beginning of a negotiation process with the National Liberation Army⁷7 Alto comisionado para la Paz, República de Colombia. Procesos y acuerdos de paz [Internet]. [consultado 2018 Fev 26]. Disponible en: http://www.altocomisionadoparalapaz.gov.co/Paginas/inicio.aspx
http://www.altocomisionadoparalapaz.gov.... . These agreements with two of the country’s oldest guerrillas enliven the debate on peace-building, whether it starts with the post-agreement or is constituted by the efforts that took place in the midst of armed conflict⁸8 Lederach JP. Construyendo la paz: reconciliación sostenible en sociedades divididas. 2ª ed. Bogotá: Justapaz, CRS, PNUD; 2007. and whether or not it takes social inequality into account.

For Castillejo “there is no peace without justice”⁹9 Castillejo A. La Imaginación Social del Futuro: reflexiones sobre Colombia y el prospecto de una Comisión de Verdad. Buenos Aires: Consejo Latinoamericano de Ciencias Sociales; 2015.(p.84); in this logic peace-building implies inter-sectoral work that includes the health sector in the pursuit of social justice, the strengthening of social ties, the return to the causes of conflict, the claiming of rights historically violated and participatory democracy. In this case, peace has been understood as “positive” and “imperfect”, beyond the absence of direct violence, it emphasises the presence of social justice, requires an equitable distribution of power and resources, understands the potential of conflict as a driver for transformation and insists on its peaceful resolution¹⁰10 Zapata-Cancelado ML. Construcción de paz y transformación de conflictos en Programa de Iniciativas Universitarias para la Paz y la Convivencia. Bogotá: Universidad Nacional; 2010., is not absolute and perfect¹¹11 Muñoz FA, Martínez ML. El re-conocimiento de la paz en la historia. En: Muñoz FA, Martínez ML, editores. Historia de La Paz. Tiempos, Espacios Y Actores. Granada: Editorial Universidad de Granada; 2000. p.15-50., is not manifestly present but co-exists with conflict and with several alternatives, violent or not, to regulate it.

In this scenario the violence in Colombia has been considered a public health problem¹²12 Franco S, Suárez C, Naranjo C, Báez L, Rozo P. The effects of the armed conflict on the life and health in Colombia. Cien Saude Colet 2006; 11(2):349-361. in which mental health has been studied more based on the neurophysiologic, genetic and behavioural mechanisms of mental disorders than based on the community¹³13 Restrepo-Espinosa MH. Biopolítica: elementos para un análisis crítico sobre la salud mental pública en la Colombia contemporánea. Rev Gerenc Polit Salud 2012; 11(23):39-55., and in disconnection with the country’s socio-historical reality¹⁴14 Urrego-Mendoza Z. Reflexiones en torno al análisis de la situación de salud mental en Colombia, 1974-2004. Rev Col Psiqui 2007; 2(0034-7450):307-319.. This is despite having implicated it in its expression of positive mental health, for example with the individual and collective resistances as affirmative opposition¹⁵15 Arias-López BE. La potencia de la noción de resistencia para el campo de la salud mental: Un estudio de caso sobre la vida campesina en el conflicto armado colombiano. Salud Colect 2014; 10(2):201-211..

Mental health moves within a fuzzy and ambiguous concept, which only offers a biased orientation, according to the perspective assumed and with the impossibility of defining it, given its established nature (social, relational and cultural). The deconstruction of the concept of mental health in peace-building contexts allows us to move from a scattered and confused conceptual overview with broad limits, to another with more clarity, not to a single concept of mental health, but to better clarity on elements for decision-making in this field. In fact, faced with the many forms and inconsistencies in the approach to mental health, this article aims to provide a critical reflection of its conceptualisation, in search of new meanings and their potential practical implications in the context of peace-building.

We present an overview of the major epistemological perspectives on mental health in peace-building processes: biomedical and behavioural, wellness and potentials, cultural, psychosocial and social determination. However, we are not looking for a single concept of mental health, but we are inviting the confluence of conceptual perspectives and starting from recognising its expression in the individual and the collective, in critical reflection and politics and the need to contemplate the cultural and socio-historical conditions to which it relates.

Methods

A comprehensive literature review was conducted, whose purpose is to summarise the findings on a topic of interest, in a systematic, orderly and complete manner, allows for the inclusion of studies of various designs for understanding the phenomenon of interest, combines data from the theoretical and empirical literature and incorporates a wide range of purposes, including the review of concepts, theories or methodologies, and highlights the interpretation given by the author on the findings¹⁶16 Souza MT, Silva MD, Carvalho R. Revisão integrativa: o que é e como fazer. Einstein 2010; 18(1):102-106..

The question that guided the search and analysis was “what are the conceptual perspectives of mental health services in peace-building academic output?” The main themes were: “armed conflict”, “peace-building”, “mental health” and “community experiences”. It should be clarified that the blurred lines between war and peace led to taking account of the “armed conflict/peace-building” relationship. 20 combinations of descriptors were created using thesauri -18 yielded information - six with DecS terms, two with MesH terms and 12 with Unesco terms, for a search in seven bibliographic databases and search engines: Blackwell Reference Online, DOAJ (Directory of Open Access Journals), Hapi Online, Lilacs, Scielo, Science direct and Google Scholar.

The inclusion criteria were: article or book chapter documents (review and research), language (English, Spanish and Portuguese), period (1986-2016), accessibility, quality (clarity and conceptual and methodological consistency) and thematic relevance. These criteria were implemented progressively, as can be seen in Figure 1, to the 680 initial documents until 128 were obtained, and a further 365 texts were identified from the references, for a total of 493. Of these 118 were selected which satisfied the thematic relevance according to the summary, were available and were not repeated, of which 69 were obtained after having been classified and prioritised according to conceptual and methodological consistency, descriptive vivacity and analytical precision¹⁷17 Sandelowski M, Docherty S, Emden C. Qualitative metasynthesis: Issues and techniques. Nursing Health 1997; 20(4):365-371.; 42 texts were selected for writing the article and, in the end, 31 were cited.

The documents were recorded in a matrix with their bibliographic reference, concept of mental health, origin of the concept, epistemological position, basic disciplines; centre of the proposal and criticisms; which facilitated the categorisation of the material. Inductive analysis was carried out on their specific content until categories were identified. The central categories on perspectives on mental health: biomedical and behavioural, wellness and potentials, cultural, psychosocial and social determination were reached from the “centre of the proposal” and its confluence with other sub-categories such as the “concept of mental health” and “epistemological position”.

Results

The literature search on the concept of mental health yielded three publications of reviews related to this objective, which are taken as a theoretical framework given their conceptual contribution, the first “New concepts in mental health” [Nouveaux concepts in sante mentale] by Castel¹⁸18 Castel R. Nouveaux concepts en santé mentale. Social Science Med 1986; 22(2):113-284., the second “Concepts of health in contemporary discourses of scientific reference” [Conceitos de saúde em discursos contemporâneos de referência científica] by Coelho & Almeida Filho¹⁹19 Coelho M, Almeida Filho N. Conceitos de saúde em discursos contemporâneos de referência científica. Hist Cien Saude-Manguinhos 2002; 9(2):315-333. and the third “Concepts of mental health services in the field of public health” [Concepciones de salud mental en el campo de la salud pública] by Restrepo & Jaramillo²⁰20 Restrepo D, Jaramillo JC. Concepciones de salud mental en el campo de la salud pública. Rev Fac Nac Salud Publica 2012; 30(2):202-211.. All coincide in their interest in tracing the concepts of mental health and converge in a similar classification on the basis of the dominant discourses proposed by Coelho & Almeida Filho¹⁹19 Coelho M, Almeida Filho N. Conceitos de saúde em discursos contemporâneos de referência científica. Hist Cien Saude-Manguinhos 2002; 9(2):315-333., reviews that constitute a starting point for the proposal presented below based on the results of our review, with the background summarised in Chart 1.

For functionalist sociology, the first dominant discourse proposed by Coelho & Almeida Filho¹⁹19 Coelho M, Almeida Filho N. Conceitos de saúde em discursos contemporâneos de referência científica. Hist Cien Saude-Manguinhos 2002; 9(2):315-333., the main objective of any life science is to explain and differentiate normal-pathological states; in order to classify people as normal or abnormal. This model takes mental illness as somatic and hereditary and seeks to bring an end to pathological dysfunctions¹⁸18 Castel R. Nouveaux concepts en santé mentale. Social Science Med 1986; 22(2):113-284. through drug or behavioural prescriptions²⁰20 Restrepo D, Jaramillo JC. Concepciones de salud mental en el campo de la salud pública. Rev Fac Nac Salud Publica 2012; 30(2):202-211..

In turn, the social model proposed by Castel¹⁸18 Castel R. Nouveaux concepts en santé mentale. Social Science Med 1986; 22(2):113-284. highlights the social and political dimensions of mental health; thus, the psychiatrist as an agent of social change works to improve the living conditions of the community; while the theory of signs, meanings and practices advocates a singular, inter-subjective, historical and established concept of mental health¹⁹19 Coelho M, Almeida Filho N. Conceitos de saúde em discursos contemporâneos de referência científica. Hist Cien Saude-Manguinhos 2002; 9(2):315-333..

It is interesting to see how these models and concepts of health have not been sequential, but they overlap and blend²⁰20 Restrepo D, Jaramillo JC. Concepciones de salud mental en el campo de la salud pública. Rev Fac Nac Salud Publica 2012; 30(2):202-211.; within them the social perspectives of health only began to take hold in the late 20th century with interpretative anthropology and medical epistemology¹⁹19 Coelho M, Almeida Filho N. Conceitos de saúde em discursos contemporâneos de referência científica. Hist Cien Saude-Manguinhos 2002; 9(2):315-333. and in coherence with these, the socio-economic concept of mental health, based on human rights and development²⁰20 Restrepo D, Jaramillo JC. Concepciones de salud mental en el campo de la salud pública. Rev Fac Nac Salud Publica 2012; 30(2):202-211.. These propose an established and critical concept of health that may be relevant for understanding and social transformation in Colombia.

Below Chart 2 presents the documents analysed according to the perspective on mental health and subsequently describes the perspectives identified in the same, in order to relate them to peace-building, such as: biomedical and behavioural, wellness and potentials, cultural, psychosocial and social determination.

Epistemological perspectives on mental health

Biomedical and behavioural perspective

It is based on the functionalist sociology of Durkheim in his work “The rules of the Sociological Method” [As regras do método sociológico] as is cited in Coelho & Almeida Filho¹⁹19 Coelho M, Almeida Filho N. Conceitos de saúde em discursos contemporâneos de referência científica. Hist Cien Saude-Manguinhos 2002; 9(2):315-333., considering that any life science should focus on the operation, the regularities and rules of society; on mental health in the normal and pathological, functional and dysfunctional, on the role and status of the sick in society and combined with the organicist tradition of the 19th century, with pharmacological treatment and neuroscience¹⁸18 Castel R. Nouveaux concepts en santé mentale. Social Science Med 1986; 22(2):113-284., with which relevance is given to Post-Traumatic Stress Disorder (PTSD), and with risk and protective factors and health systems.

In Colombia, methodological and conceptual efforts have been made from this perspective to gain further insight into the causes, consequences, and the response to mental disorders associated with armed conflict, for example the concept of historical trauma, an alternative diagnosis to PTSD that contemplates the collective and cultural impact and the transgenerational transmission of trauma²¹21 Borda JP, Carrillo JO, Garzón DF, Ramírez MP, Rodríguez N. Trauma histórico. Revisión sistemática de un abordaje diferente al conflicto armado. Rev Col Psiqui 2015; 44(1):41-49.. However, these proposals are still focused on particular features of the trauma and on the health system as a social response.

This perspective has received criticism that acts to clarify the current situation in Colombia, because, as has been reported from the experience of Guatemala²²22 Foxen P. Local narratives of distress and resilience: Lessons in psychosocial well-being among the k'iche' Maya in postwar Guatemala. J Lat Am Caribb Anthropol 2010; 15(1):66-89. this entails a pathologising perspective and focuses on individual effects of war. In addition, the PTSD diagnosis has excessively extended the scope of emotional reactions, ignoring social suffering, asserting a medical stance to a social problem²³23 Jansen S, White R, Hogwood J, Jansen A, Gishoma D, Mukamana D, Richters A. The "treatment gap" in global mental health reconsidered: Sociotherapy for collective trauma in Rwanda. Eur J Psychotraumatol 2015; 6(10):1-6. and limits itself to access to health services, while the problems of inequity and violence demand social justice. However, the hegemony of this proposal continues²⁴24 Arias López BE. Salud mental y violencia política. Atender al enfermo psiquiátrico o reconocer al sujeto de la micropolítica. Rev Col Psiqui 2013; 42(3):276-282..

Perspective of wellness and potentials

There are a number of proposals that share a mental health perspective centred on wellness and human potentials: positive mental health, wellness and resilience. These emphases coincide with the approach of the WHO which, in its report on mental health promotion in 2005²⁵25 Herrman H, Saxena S, Moodie R. Promoting mental health. Concepts, emerging evidence, practice. Geneva: WHO; 2005., speaks of positive mental health from its concept of wellness with positive affect, personality trait and resilience.

In this sense, Marie Jahoda proposed “positive mental health” as a model based on happiness and wellness which, regardless of the mental disorder, is reflected in self-realisation, one’s own potential, the feeling of control over the environment and capacity for autonomy, contributions that were recaptured and reoriented by positive psychology and resilience from 1970²⁶26 Muñoz CO, Restrepo D. Construcción del concepto de salud mental positiva: revisión sistemática. Rev Panam Salud Pública 2016; 39(5):166-173..

Resilience had its origin in the 1960s’ when some researchers (Emmy Werner, Norma Garmezy) observed positive outcomes in abandoned children²⁷27 Rutter M. Resilience as a dynamic concept. Dev Psychopathol 2012; 24(2):335-344.. Explanations that were advanced until resilience was considered as a biopsychosocial process²⁸28 Davydov DM, Stewart R, Ritchie K, Chaudieu I. Resilience and mental health. Clin Psychol Rev 2010; 30(5):479-495. featuring the ability to overcome adversity by means of adaptive systems for harm reduction and the protection of life.

From positive psychology, Vasquez²⁹29 Vásquez Valverde C. La ciencia del Bienestar psicológico. In: Vázquez C, Torres GH. La ciencia del bienestar: Fundamentos de una psicología positiva. Madrid: Alianza Editorial; 2009. p. 13-46. recounts the evolution of happiness and wellness, their philosophical roots, with the hedonism of Epicurus (subjective well-being) and Aristotle’s eudaimonia (psychological well-being). For subjective wellness the purpose of life is to experience the greatest possible amount of pleasure and happiness, the sum of pleasant moments, and psychological wellness studies the realisation of human potential in coherence with one’s own values. A single study was found based on subjective wellness in a context of armed conflict, with children from Palestine³⁰30 Veronese G, Pepe A, Jaradah A, Al Muranak F, Hamdouna H. Modelling life satisfaction and adjustment to trauma in children exposed to ongoing military violence: An exploratory study in Palestine. Child Abuse Negl 2017; 63:61-72..

The biomedical and behavioural perspective and the perspective of wellness and potentials have been criticised for their functionalist and individualistic view and the fact that they do not explain a critical analysis of armed conflict³¹31 Blue S, Shove E, Carmona C, Kelly MP. Theories of practice and public health: understanding (un)healthy practices. Crit Public Health 2014; 1596:1-15., in addition to the ideological position of the perspective of wellness and potentials that preaches the search for an unattainable happiness from an alienating standpoint. In addition, there is criticism of resilience as a biopolitical mechanism that promotes the expansion of uncertainty and anticipatory response logics, leading to the classification of resilient or vulnerable, where vulnerability is seen as an ontological matter, therefore, living in the midst of danger is something socially inevitable and suffering is something that must be addressed as socially expected according to neo-liberal markers³²32 Evans B, Reid J. Una vida en resiliencia. El arte de vivir en peligro. 1ª ed en español. México: Fondo de Cultura Económica; 2016..

Some authors have sought the complementarity of the perspective of wellness and potentials with the biomedical and behavioural perspective, as two parallel continua³³33 Westerhof GJ, Keyes CLM. Mental illness and mental health: The two continua model across the lifespan. J Adult Develop 2010; 17(2):110-119., or from ecological studies of resilience²⁸28 Davydov DM, Stewart R, Ritchie K, Chaudieu I. Resilience and mental health. Clin Psychol Rev 2010; 30(5):479-495.. However, there are still criticisms of its individualistic and functionalist position, which it shares with classic public health, in addition to ethical questioning of resilience.

Cultural perspective

In the review by Coelho & Almeida Filho¹⁹19 Coelho M, Almeida Filho N. Conceitos de saúde em discursos contemporâneos de referência científica. Hist Cien Saude-Manguinhos 2002; 9(2):315-333. on interpretative anthropology, the work of Kleinman stands out, who inaugurated transcultural psychiatry with a criticism of the assumptions of the universality of cultural health-disease patterns. In it doctors, healers, patients and families have different explanatory models of the disease. In the same review, Bibeau & Corin stand out with their theory of the systems of signs, meanings and practices, pose the need to consider the socio-economic, political and historical context of the health-disease processes and overcome the duality of culture and society, and introduce popular semiology into the concept of health, a form of symbolic and collective construction of subjectivity. This proposal recalls the intersubjective and dialogical dimension and the human being as an inhabitant in the world:

[...] Gadamer would speak here of a fusion of the horizons of understanding, which is nothing other than embracing others’ perspectives, entering into dialogue with the other, be it a person, a town, a text³⁴34 Jáuregui I. Cuestiones epistemológicas en Antropología [Internet]. 2001 [consultado 2017 Out 6]. Disponible en: https://www.ugr.es/~pwlac/G17_16Inmaculada_Jauregui_Balenciaga.html
https://www.ugr.es/~pwlac/G17_16Inmacula... .

From this more established position Kleinman³⁵35 Kleinman A. Experience and Its Moral Modes: Culture, Human Conditions, and Disorder. California: Stanford University; 1998. and Drozdek³⁶36 Drozdek B. If You Want to Go Fast Go Alone, If You Want to Go Far Go Together On Context-Sensitive Group Treatment of Asylum Seekers and Refugees Traumatized by War and Terror. Ipskamp Drukkers, Enschede, The Netherlands; 2013. question the individual and pharmacological approach to trauma, the first also questions not taking into account the moral and political implications of social suffering and emphasizes its social sources, its relationship with inequity and intersubjective and cultural nature and the second proposes an integrative contextual model for the study of the impact of traumatic experiences, which contemplates the experiential value and the cultural context of the victims.

One of the publications found in Colombia from this perspective “Language, subjectivity and experiences of violence” [Lenguaje, subjetividad y experiencias de violencia] on memory and suffering, states that the emotional expression of suffering also speaks about the actions of others and therefore has moral content and potential as a political instrument³⁷37 Jimeno M. Lenguaje, subjetividad y experiencias de violencia. ANTÍPODA 2007; 5:169-190..

Although this perspective is in itself a strength for cultural relevance in the understanding and care of mental health problems in the context of the peace-building and cultural diversity in Colombia, it barely hints at its direct relationship with mental health.

Psychosocial perspective

The psychosocial perspective has its antecedents in the 18th century, with the study of individual trauma focused on organic damage²⁴24 Arias López BE. Salud mental y violencia política. Atender al enfermo psiquiátrico o reconocer al sujeto de la micropolítica. Rev Col Psiqui 2013; 42(3):276-282., and named by Freud as traumatic neurosis due to its psychic causes between the 19th and 20th centuries. It was later named war neurosis, with clear real causes and, later, post-traumatic stress syndrome as a psychiatric category. Throughout the 20th century, in the context of humanitarian aid and political, pacifist and feminist movements the psychosocial perspective arises, as a rejection and criticism of PTSD³⁸38 Rebolledo O, Rondón L. Reflexiones y aproximaciones al trabajo psicosocial, Rev Estudios Sociales 2010; 36:15-18., linked to solidarity and social activism³⁹39 Castaño BL, Jaramillo LE, Summerfield D. Violencia política y trabajo psicosocial. Aportes al debate. Santa Fe de Bogotá: Corporación AVRE; 1998..

On the other hand, Martín-Baró⁴⁰40 Martín-Baró I. Guerra y Salud Mental. Rev Psicología El Salvador 1990; IX(35):71-88. proposed the term psychosocial trauma indicating the impairment of social relations due to the armed conflict of a historic, dialectical and subjective nature⁴¹41 Lykes MB. Terror, silencing, and children: International multidisciplinary collaboration with Guatemalan Maya communities. Soc Sci Med 1994; 38(4):543-552. as critical to biomedical, standardised²⁴24 Arias López BE. Salud mental y violencia política. Atender al enfermo psiquiátrico o reconocer al sujeto de la micropolítica. Rev Col Psiqui 2013; 42(3):276-282., individual, psychological and decontextualised processes. It should be emphasised that the production of Colombian scientific literature on this perspective implies two trends: social psychology and ethics and human rights.

For Villa-Gómez⁴²42 Villa-Gómez JD. La acción y el enfoque psicosocial de la intervención en contextos sociales ¿podemos pasar de la moda a la precisión teórica, epistemológica y metodológica? El Ágora USB 2012; 12(2):349-365. the psychosocial perspective is a proposal with emphasis on social psychology, whose epistemological bases are socio-constructionism and the systemic-constructionist approach⁴³43 Carmona J. ¿QUÉ ES LO PSICOSOCIAL? Una urdimbre transdisciplinar con cinco madejas. Complejidad 2013; 19(19):1-15.

44 Camacho MAM, Moncayo JE. Abordaje Psicosocial: Consideraciones conceptuales y alternativas de análisis en el escenario de atención a víctimas del conflicto armado. En: Quevedo JEM, Gómez AD, editores. Psicología Social Crítica E Intervención Psicosocial: reflexiones y experiencias de investigacíon. Universidad de San Buenaventura Cali: Ascofapsi; 2015. p.37-56.^-4545 Albarracín MNB. Trabajo social en contextos de violencia política. Trabajo Social 2005; 7:9-20. in which the interaction and feedback of theories with social contexts take relevance and are combined with multiple theoretical proposals, for example, symbolic interactionism, systems theory, psychoanalytic theory⁴³43 Carmona J. ¿QUÉ ES LO PSICOSOCIAL? Una urdimbre transdisciplinar con cinco madejas. Complejidad 2013; 19(19):1-15., the cultural-historical perspective and community-social psychology⁴⁴44 Camacho MAM, Moncayo JE. Abordaje Psicosocial: Consideraciones conceptuales y alternativas de análisis en el escenario de atención a víctimas del conflicto armado. En: Quevedo JEM, Gómez AD, editores. Psicología Social Crítica E Intervención Psicosocial: reflexiones y experiencias de investigacíon. Universidad de San Buenaventura Cali: Ascofapsi; 2015. p.37-56., framed in the critical paradigm and in a dialectic perspective. The trend based on ethics and human rights believes that the roots of the term “psychosocial” should be investigated due to the ethical value of human rights in war³⁸38 Rebolledo O, Rondón L. Reflexiones y aproximaciones al trabajo psicosocial, Rev Estudios Sociales 2010; 36:15-18..

The most visible agreements among the authors are in naming psychosocial as an approach or perspective²⁴24 Arias López BE. Salud mental y violencia política. Atender al enfermo psiquiátrico o reconocer al sujeto de la micropolítica. Rev Col Psiqui 2013; 42(3):276-282.^,4242 Villa-Gómez JD. La acción y el enfoque psicosocial de la intervención en contextos sociales ¿podemos pasar de la moda a la precisión teórica, epistemológica y metodológica? El Ágora USB 2012; 12(2):349-365.^,4343 Carmona J. ¿QUÉ ES LO PSICOSOCIAL? Una urdimbre transdisciplinar con cinco madejas. Complejidad 2013; 19(19):1-15. for the analysis of human behaviour in socially defined situations or as a practice of social intervention⁴⁴44 Camacho MAM, Moncayo JE. Abordaje Psicosocial: Consideraciones conceptuales y alternativas de análisis en el escenario de atención a víctimas del conflicto armado. En: Quevedo JEM, Gómez AD, editores. Psicología Social Crítica E Intervención Psicosocial: reflexiones y experiencias de investigacíon. Universidad de San Buenaventura Cali: Ascofapsi; 2015. p.37-56., as well as in the relationship between the individual and society in a dialectical continuity, its implications on the subjective, ethical considerations in relation to solidarity, the restoration of violated rights, the capacity for agency of people affected by armed conflict and the depathologisation of suffering³⁸38 Rebolledo O, Rondón L. Reflexiones y aproximaciones al trabajo psicosocial, Rev Estudios Sociales 2010; 36:15-18.^,4545 Albarracín MNB. Trabajo social en contextos de violencia política. Trabajo Social 2005; 7:9-20.. On the other hand there is a marked variety in the political position, ranging from what is not expressed to micropolitics as in the case of resistance¹⁵15 Arias-López BE. La potencia de la noción de resistencia para el campo de la salud mental: Un estudio de caso sobre la vida campesina en el conflicto armado colombiano. Salud Colect 2014; 10(2):201-211.^,3939 Castaño BL, Jaramillo LE, Summerfield D. Violencia política y trabajo psicosocial. Aportes al debate. Santa Fe de Bogotá: Corporación AVRE; 1998. and condemnation in a few publications from El Salvador⁴⁰40 Martín-Baró I. Guerra y Salud Mental. Rev Psicología El Salvador 1990; IX(35):71-88., Guatemala⁴¹41 Lykes MB. Terror, silencing, and children: International multidisciplinary collaboration with Guatemalan Maya communities. Soc Sci Med 1994; 38(4):543-552. and Colombia⁴⁵45 Albarracín MNB. Trabajo social en contextos de violencia política. Trabajo Social 2005; 7:9-20.. As practical elements, it is sought to reduce emotional suffering, satisfy basic needs, reconstruct social networks and boost citizen participation, with a perspective differentiated by gender, life cycle, type, intensity and duration of the violent event, among others⁴⁵45 Albarracín MNB. Trabajo social en contextos de violencia política. Trabajo Social 2005; 7:9-20., as well as a psychosocial support that enables victims to resume the exercise of their rights and recover dignity, the value of the person, that “is not recognised when basic needs (food, shelter, education) are met in a mechanical and impersonal way”⁴⁶46 Beristain CM. Acompañar los procesos con las víctimas. Atención psicosocial en las violaciones de derechos humanos. Colombia: Fondo de Justicia Transicional; 2012.(p.11).

With regard to the relationship of the psychosocial to mental health, Martín-Baró⁴⁰40 Martín-Baró I. Guerra y Salud Mental. Rev Psicología El Salvador 1990; IX(35):71-88. makes direct reference to the psychosocial perspective of mental health, when he says: “mental health is not so much in the abstract operation of an individual organism than in the nature of the social relations...” to distinguish it from psychological wellness. With this exception, the few insinuations about “mental health” reveal its biomedical and behavioural conception, different to psychosocial⁴²42 Villa-Gómez JD. La acción y el enfoque psicosocial de la intervención en contextos sociales ¿podemos pasar de la moda a la precisión teórica, epistemológica y metodológica? El Ágora USB 2012; 12(2):349-365. or as a capacity that is expressed in the community as a product of psychosocial support³⁸38 Rebolledo O, Rondón L. Reflexiones y aproximaciones al trabajo psicosocial, Rev Estudios Sociales 2010; 36:15-18.. This inaccuracy is joined by misrepresentations when an assistive and fragmented nature is maintained in relation to community⁴⁵45 Albarracín MNB. Trabajo social en contextos de violencia política. Trabajo Social 2005; 7:9-20., when emphasis is placed on the “psycho” or “social”⁴¹41 Lykes MB. Terror, silencing, and children: International multidisciplinary collaboration with Guatemalan Maya communities. Soc Sci Med 1994; 38(4):543-552. and when no account is taken of structural inequalities (socio-economic and political)⁴⁷47 Somasundaram D. Collective trauma in northern Sri Lanka: a qualitative psychosocial-ecological study. Int J Ment Health Syst 2007; 1(1):5.. Outside of Latin America less theoretical discussions were found on the psychosocial and more agreement was found on mental health as a mental disorder and psychosocial wellness as its positive expression⁴⁸48 Betancourt TS, Meyers-Ohki SE, Charrow AP, Tol WA. Interventions for Children Affected by War: An Ecological Perspective on Psychosocial Support and Mental Health Care. Harv Rev Psychiatry 2013; 21(2):70-91..

The psychosocial perspective manages to overcome individualism and introduces the relational nature of mental health, however the lack of agreement as to the critical position and as found, with some exceptions in publications coming from Central and South America²⁴24 Arias López BE. Salud mental y violencia política. Atender al enfermo psiquiátrico o reconocer al sujeto de la micropolítica. Rev Col Psiqui 2013; 42(3):276-282.^,4040 Martín-Baró I. Guerra y Salud Mental. Rev Psicología El Salvador 1990; IX(35):71-88.^,4141 Lykes MB. Terror, silencing, and children: International multidisciplinary collaboration with Guatemalan Maya communities. Soc Sci Med 1994; 38(4):543-552., setting aside the determinants of health, let us see it as an incomplete perspective on key aspects such as social inequity, a matter historically linked to the structural violence in Colombia.

Perspective of social determination

Latin American social medicine has been reported as a current of thought and practice⁴⁹49 Iriart C, Waitzkin H, Breilh J, Estrada A, Merhy E. Medicina social latinoamericana: aportes y desafíos. Rev Panam Salud Publica 2002; 12(2):128-136. that was boosted in the 1970s with the support of popular movements against classic public health; it envisages the following as conceptual bases: social class, ideology, health-illness as a dialectical process and social reproduction. This was based on the social medicine movement of the 19th century in Europe, from which the health crisis was understood as an eminently political and social issue⁵⁰50 Almeida Filho N, Silva Paim J. La crisis de la salud pública y el movimiento de la salud colectiva en Latinoamérica. Cuad Med Soc 1999; 75:5-30.. For the study of mental health based on social medicine, it is suggested to return to the subject as the protagonist of the collective relational life and understanding mental health-illness under four interrelated principles: recognising the social, community and political spheres; knowing oneself to be part of the context observed; achieving a complex and dynamic understanding and praxis; understanding mental health as a social production, affected by structural causes⁵¹51 Ruiz LF. La salud mental vista desde la medicina social latinoamericana. Investig Segur Soc Salud 2009; 11:131-142..

At the end of the 1980s, when we spoke of the “public health crisis” and WHO called for reflection on health⁵⁰50 Almeida Filho N, Silva Paim J. La crisis de la salud pública y el movimiento de la salud colectiva en Latinoamérica. Cuad Med Soc 1999; 75:5-30., collective health arose as an ideological movement committed to social transformation, against welfare interventions; which complicates the “promotion-health-disease-care” relationships, conceives complex and contradictory societies in particular historical contexts⁵²52 Almeida Filho N. Modelos de determinação social das doenças crônicas não-transmissíveis. Cien Saude Colet 2004; 9(4):865-884. and highlights the value of the subjective, the conflicts of the subject, their social and political interests and their participation in the construction of history⁵³53 Minayo MCDS. Estrutura e sujeito, determinismo e protagonismo histórico: uma reflexão sobre a práxis da saúde coletiva. Cien Saude Colet 2001; 6(1):7-19.. Thus, social determination of health arises as an alternative to social medicine/collective health for overcoming causalism in public health, taken primarily as a “process or mode of evolution through which objects acquire their properties”⁵⁴54 Breilh J. Las tres "s" de la determinación de la vida y el triángulo de la política (10 tesis hacia una visión crítica de la determinación social de la vida y la salud). En: Nogueira RP, organizador. Determinação social da saúde e reforma sanitária. Rio de Janeiro: CEBES; 2010. p. 87-126., in this case referring to the complex nature of health and its construction in dialectical relation with structural factors (cultural, social, economic, political, historical) beyond theoretical-methodological approaches that address the social determinants of health in a fragmented manner and in isolation, even falling in mechanistic relationships of correlations and associations.

The differentiators of collective health vs social medicine are abandonment of the disease as a central axis in health and its emphasis on the fact that health is built collectively, both in the form that it takes in each society and historic moment and in the possibilities of transforming it⁴⁹49 Iriart C, Waitzkin H, Breilh J, Estrada A, Merhy E. Medicina social latinoamericana: aportes y desafíos. Rev Panam Salud Publica 2002; 12(2):128-136.. In this regard, Almeida-Filho⁵²52 Almeida Filho N. Modelos de determinação social das doenças crônicas não-transmissíveis. Cien Saude Colet 2004; 9(4):865-884. cites several authors: Samaja (1998) that proposes the study not only of the health situation, but also of the representations of health and its determinations, as well as of daily life, which proposes a review in light of the concept of “health practices” of Testa (1997), that operate in a complex and articulated dynamic of signs, meanings and practices (Bibeau & Corin, 1980), which applied to mental health at the micro and macro levels of relationships, gives a historical character and the possibility of transforming reality.

Despite the theoretical contributions on social determination from Brazil and Ecuador, few publications were found on mental health in peace-building contexts with a perspective of social determination; however, it should be noted that in the history of social medicine the study of violence and mental health is valued in the work carried out by Martín-Baró⁴⁰40 Martín-Baró I. Guerra y Salud Mental. Rev Psicología El Salvador 1990; IX(35):71-88.. In Colombia three studies were found: two social medicine studies in Bogotá, such as “Biopolitics: elements for a critical analysis of public mental health in present day Colombia”¹³13 Restrepo-Espinosa MH. Biopolítica: elementos para un análisis crítico sobre la salud mental pública en la Colombia contemporánea. Rev Gerenc Polit Salud 2012; 11(23):39-55. [Biopolítica: elementos para un análisis crítico sobre la salud mental pública en la Colombia contemporánea] and a study of collective health in Antioquia⁵⁵55 Arias LBE. Saberes locales campesinos sobre el alimento: aportes a la soberanía y la salud mental comunitaria. Rev La Universidad Industrial de Santander 2016; 48(2):232-239. “Local farmer knowledge about food: contributions to sovereignty and community mental health” [Saberes locales campesinos sobre el alimento: aportes a la soberanía y la salud mental comunitaria], which highlighted the social and cultural nature of mental health, its political implications in communities that are victims of armed conflict and calls to continue its study in everyday life.

Despite the scant empirical studies from this perspective on mental health in Colombia, their contributions are relevant in collective peace-building processes in view of their conception of health as a collective construction, in which subject, history and the possibilities of social transformation are fundamental; in addition to their openness to contributions from other perspectives. Figure 2 shows an attempt to summarise the perspectives described.

Discussion

Although in Latin America there are alternative ways to understand and place mental health based on comprehensive and critical approaches in the context of violence and armed conflict, the studies referring explicitly to mental health and peace-building are apparently still very novel and scarce. Particularly in Colombia, a key aspect of the concept of mental health is that both the Law on Victims of Domestic Armed Conflict⁵⁶56 República de Colombia. Ley 1448, de 10 de jun de 2011. Por la cual se dictan medidas de atención, asistencia y reparación integral a las víctimas del conflicto armado interno y se dictan otras disposiciones [Internet]. [consultada 2017 Mar 10]. Disponible en: http://wsp.presidencia.gov.co/Normativa/Leyes/Documents/ley144810062011.pdf
http://wsp.presidencia.gov.co/Normativa/... and the National Mental Health Survey, which seeks to respond to social coexistence and mental health needs⁵⁷57 República de Colombia. Ministerio de Salud y Protección Social. Encuesta Nacional de Salud Mental. Tomo I. Bogotá: Ministerio de Salud y Protección Social; 2015., are guided by the biomedical and behavioural perspectives and that of wellness and potentials, in both cases psychosocial is deemed less critical, as a way to forge close relationships; this in spite of the criticism of the functionalist, individualistic, and political stance of these perspectives.

In addition to the importance of progress in theories consistent with collective health/social medicine the proposal for a confluence of perspectives on mental health, mainly psychosocial, cultural and of social determination, which are complementary and not contradictory, is recaptured. A proposal supported by Foucault’s “toolbox” concept, according to which the theory is an instrument that contains a logic of power relationships that have been established around them⁵⁸58 Foucault M. Poderes y estrategias. In Un diálogo sobre el poder y otras conversaciones. Madrid: Alianza Ed; 2000., with practical implications. Some key aspects that might be considered for the study of mental health in Latin America involve: the individual and collective connotation of health, the historical and political conception of the subject and the socio-cultural aspect in mental health.

One of the contributions of Samaja⁵⁹59 Samaja J. Epistemología de la salud. Reproducción social, subjetividad y transdisciplina. Buenos Aires: Lugar Editorial; 2004. to think about the connotation of individual and collective health, starts from recognising speech “not as an instrument external to the speaker, but what constitutes and governs them”; for this author, understanding and mastering the rules of language means to be governed by the rules of the community, in such a way that the actions of the individual organism appear vested in respect of their life together as a family member, a citizen of the state, or a social agent and it is in this collective production where there may be a protagonist⁶⁰60 Torre EHGE, Amarante PDDC. Protagonismo e subjetividade: a construção coletiva no campo da saúde mental. Cien Saude Colet 2001; 6(1):73-85. of its historic action.

With regard to politics and particular socio-historical conditions, Hernández⁶¹61 Hernández M. Desigualdad, inequidad e injusticia en el debate actual en salud: posiciones e implicaciones [Internet]. 2008 [consultada 2017 Mar 10]. Disponible en: http://www.saludcapital.gov.co/Artculos%20Observatorio/Desigualdad,%20inequidad%20e%20injusticia_Mario_Hern%C3%A1ndez.pdf
http://www.saludcapital.gov.co/Artculos%... speaks of a “historical-political subject”, aware of their dignity and of their status as a moral and historical subject, able to criticise and to transform their reality in an “intersubjective” manner, which in turn implies a process of democratisation of social relations. It could be said that critical reflection as a manifestation of mental health in peace-building experiences favours the construction of political subjects and in turn is a form of political exercise.

With regard to cultural differences, Almeida Filho⁵²52 Almeida Filho N. Modelos de determinação social das doenças crônicas não-transmissíveis. Cien Saude Colet 2004; 9(4):865-884. takes the theory of signs, meanings and practices and apply it to mental health, suggesting that in Colombia, a country with a varied ethnic wealth, consideration should be given to cultural diversity in the approach to mental health in communities affected by armed conflict and seeking peace-building.

In addition, to address mental health in peace-building contexts, it is not enough to re-establish relations that facilitate tranquillity, we must seek a return to the causes of conflict, consider the determination of mental health and socio-economic and political inequities that have affected the communities in connection with the armed conflict.

Finally, the panorama presented opens up a range mental health perspectives that deserve their own space for reflection, and from these other branches emerge to continue working on. Some of the issues to expand further work could be on: 1) other proposals of mental health - which do not report empirical studies in contexts of armed conflict/peace-building - based on the notion of “good life” more related to the doxa or practical, intuitive knowledge, than to episteme or formalised, systematic knowledge, susceptible to being studied scientifically⁶²62 Lopera-Echavarría JD. Salud mental y sabiduría práctica. Un intento de integración y aproximación conceptual. Tesis Psicológica 2012; 7(1):60-75. and the theory of capabilities⁶³63 Restrepo-Ochoa DA. La salud y la vida buena: aportes del enfoque de las capacidades de Amartya Sen para el razonamiento ético en salud pública. Cad Saude Publica 2013; 29(12):2371-2382. that beyond potentials takes into account the expansion of freedom as the ethical foundation of health actions, the concept of the person as an agent, the recognition of the internal view of health and development of capabilities as the purpose of public health policies; 2) the trends of those proposals that, from the various perspectives on mental health, place trauma at the centre in situations that break the continuum of life, become incomprehensible and the resources available are limited in their ability to face them, for example PTSD and its emphasis on the individual based on universal parameters; psychosocial trauma, particular and contextualised; historical trauma and its emphasis on transgenerational accumulation and social suffering and its moral, political and cultural implications; 3) the relationship between mental health and politics in peace-building contexts; 4) epistemological understandings of the mental health perspectives identified, its derivations and relationships; 5) the place that a focus on rights could hold in this type of studies.

Conclusions

The psychosocial perspective is very heterogeneous, has functionalist stances, but also constructionist, historical and critical. In Latin America its emphasis is on social practice and ethics and its relationship with the category “mental health” is quite uneven, there are authors that place it exclusively in the biomedical and behavioural perspective, others do not name it, and it was only found that Martín-Baró⁴⁰40 Martín-Baró I. Guerra y Salud Mental. Rev Psicología El Salvador 1990; IX(35):71-88. explicitly equates “mental health” with “the psychosocial”.

In contrast, the cultural perspective is grounded in interpretative anthropology, provides elements to understand mental health in particular socio-cultural conditions, in an interaction between immediate relations, the local and the global, in line with the perspective of social determination in its interest in showing the configuration of health and life in relation to political, social, economic and cultural systems.

Although research on mental health in Colombia based on collective health/social medicine is still incipient, it is important to have clear issues that are proposed as a starting point in their delimitation and argumentation: the expression of mental health is given in the individual and in the collective, critical reflection and the political exercise as an expression of mental health, the need to accommodate cultural differences, and the particular socio-historical conditions in Colombia that lead us to look toward the causes of armed conflict. In this way, we invite the articulated confluence of perspectives with a social purpose, providing a comprehensive vision of mental health, which is relevant socio-culturally and to advance toward the promotion of peaceful, constructive, supportive and dignifying relations.

Acknowledgment

To the Professors Beatriz Elena Arias-López, from the Facultad de Enfermería and Yadira Eugenia Borrero-Ramírez, from the Facultad Nacional de Salud Pública, from the Universidad de Antioquia for guidance and review during the writing process. To the Departamento Administrativo de Ciencia, Tecnología e Innovación (Colciencias) for its financial support to the formation of the author by the Convocatoria Doctorados Nacionales 647 de 2014.

References

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