Impact statement

Efforts to make mental health care more inclusive have helped expand access to services and increase attention to cultural and social differences. However, inclusion alone may not address the conditions that cause people and communities to be excluded in the first place. This article invites researchers, practitioners, policymakers, and organizations working in global mental health to look beyond the question of how to include people within existing systems and to consider whether those systems themselves need to change. This shift has practical implications. Communities should not only be invited to participate in programs or services whose priorities have already been decided. They should have meaningful opportunities to shape how mental health problems are understood, what forms of support are considered appropriate, and how interventions are designed and evaluated. Similarly, improving access to care should go alongside attention to poverty, displacement, discrimination, unequal access to resources, and other conditions that affect mental health and well-being. Viewing inclusion through the lens of justice can therefore help global mental health move toward approaches in which different forms of knowledge and lived experience do not simply fit into existing systems, but contribute to changing them.

The limits of inclusion: Managing difference, preserving the norm

Mainstream approaches to inclusion, particularly within global mental health and related educational and psychological fields, have often emphasized the development of individual competencies as the primary means of engaging with diversity. Within global mental health, this orientation is reflected in efforts to expand access to care, strengthen participation, and promote culturally responsive services (Patel et al., Reference Patel, Saxena, Lund, Kohrt, Kieling, Sunkel, Kola, Chang, Charlson, O’Neill and Herrman2023). These developments have represented important advances. Yet they are frequently accompanied by an emphasis on individual adaptation and professional competence, while the institutional and epistemic conditions that shape exclusion receive comparatively less attention. For example, culturally adapted interventions may modify language, examples, or modes of delivery without questioning the diagnostic assumptions, institutional priorities, or definitions of legitimate knowledge on which they are based. Adaptation may therefore improve accessibility without necessarily redistributing the power to define problems or appropriate responses. Concepts such as intercultural sensitivity, cultural competence, and adaptability (Deardorff, Reference Deardorff2006; Bennett, Reference Bennett and Kim2017) reflect this orientation by framing inclusion primarily as the acquisition of skills that enable individuals and professionals to navigate diversity more effectively. While these approaches offer important practical resources, they also risk relocating responsibility for inclusion onto individuals rather than onto the systems that generate exclusion. Structural conditions – including institutional racism, economic precarity, historical marginalization, and unequal distributions of power and resources – can consequently become backgrounded, while inequality is reframed as a challenge to be managed rather than transformed (Crenshaw, Reference Crenshaw1989; Collins, Reference Collins2000).

Within global mental health, this tension becomes particularly evident when efforts to improve access are not accompanied by critical attention to the structural determinants of mental health, including poverty, discrimination, forced displacement, and unequal access to resources (Fiscone, Reference Fiscone2026). Expanding services is undoubtedly essential, yet access alone cannot transform the conditions through which distress and exclusion are produced. This is especially visible in humanitarian and displacement settings, where psychological support often responds to suffering that is inseparable from violence, material deprivation, legal insecurity, and disrupted social worlds (Silove et al., Reference Silove, Ventevogel and Rees2017). In these contexts, interventions may alleviate immediate distress while leaving the political and material production of that distress beyond their scope (Afifi et al., Reference Afifi, Nakkash, Hammad, Hajj, Makhoul, Abdulrahim, Mahfoud and Kanj2025). Consequently, inclusion and access become less a process of institutional transformation than one of managing difference within existing systems. The underlying assumption is that these systems require adjustment rather than fundamental change. The norm therefore remains intact, while those positioned as “other” are expected to move closer to it, and access becomes conditional upon alignment with dominant expectations (Ahmed, Reference Ahmed2012).

Comparable dynamics can be observed across global mental health, education, and developmental support. Practitioners are encouraged to develop cultural competence, adapt interventions, and create more welcoming environments. These efforts are valuable and often necessary, yet they remain limited when the institutional, political, and epistemic conditions through which exclusion is produced are left unexamined. Inclusion, in this sense, risks functioning as a strategy for accommodating difference rather than transforming the structures that define it.

The question, then, is not simply how to include, but what inclusion does.

Inclusion as a practice of power

To understand the ambivalence of inclusion, it is necessary to situate it within broader frameworks of power. Critical and decolonial perspectives remind us that concepts are never neutral; they are embedded within historical, political, and epistemological contexts (Foucault, Reference Foucault1972; Mignolo, Reference Mignolo2011). Inclusion must therefore be examined in relation to the systems of power through which it operates and acquires meaning. Accordingly, it can be understood as a regulatory mechanism that defines the conditions of belonging (Ahmed, Reference Ahmed2012). By establishing who belongs and under what terms, it contributes to the production of normative boundaries. Those who are included are often required to conform, at least partially, to dominant expectations – whether in terms of language, behavior, values, or forms of knowledge. Inclusion thus does not simply expand access and participation, but actively shapes the terms on which belonging is granted, producing forms of conditional recognition that remain dependent on alignment with dominant norms (Foucault, Reference Foucault1972).

This process does not rely solely on overt exclusion, but operates through more subtle forms of normalization. Difference is acknowledged, but within limits. Cultural diversity may be celebrated, yet only insofar as it remains compatible with existing institutional frameworks. When difference challenges these frameworks, it risks being problematized or rendered invisible. In this sense, inclusion operates not only through recognition, but also through containment, regulating the extent to which difference can disrupt established orders (Ahmed, Reference Ahmed2012). From a decolonial perspective, these dynamics reflect the persistence of epistemic hierarchies (Mignolo, Reference Mignolo2011). Western models of knowledge and practice continue to define what counts as valid, legitimate, and desirable, often positioning themselves as universal while marginalizing other epistemologies (Said, Reference Said1978). Alternative ways of knowing and being are frequently incorporated selectively, translated into dominant frameworks, or excluded altogether, reinforcing asymmetries in whose knowledge is recognized and whose is rendered invisible.

These dynamics are particularly relevant to global mental health, where questions of whose knowledge counts, whose expertise is privileged, and whose experiences are recognized have become increasingly central to debates on research, policy, and practice (Bemme, Reference Bemme2023). They become visible, for example, when communities are invited to participate in programs whose diagnostic categories, research questions, outcome measures, and intervention priorities have already been defined elsewhere. Participation may then shape how interventions are implemented without extending to the authority to influence the epistemological assumptions on which they are based. Comparable patterns can be observed across applied domains, including education and developmental support, where institutional practices translate abstract principles of inclusion into standardized procedures that often reproduce normative assumptions (Marinus, Reference Marinus2026). Within global mental health, these dynamics are reinforced through the global circulation of diagnostic categories, intervention models, and evidence-based practices. Such models have contributed substantially to expanding access to care and providing valuable resources across diverse contexts (Patel et al., Reference Patel, Saxena, Lund, Thornicroft, Baingana, Bolton, Chisholm, Collins, Cooper, Eaton, Herrman, Herzallah, Huang, Jordans, Kleinman, Medina-Mora, Morgan, Niaz, Omigbodun, Prince, Rahman, Saraceno, Sarkar, De Silva, Singh, Stein, Sunkel and Unützer2018). At the same time, when socio-political histories and locally grounded forms of knowledge are treated primarily as contextual variables rather than as constitutive dimensions of suffering and care, these approaches may reinforce existing epistemic hierarchies rather than opening space for alternative understandings (Summerfield, Reference Summerfield2008; Mills, Reference Mills2014).

In this context, inclusion may function less as a transformative process and more as a form of assimilation – albeit a softer and more benevolent one. Rather than questioning existing institutional and epistemic arrangements, inclusion may unintentionally facilitate participation on terms that remain largely defined by dominant systems of knowledge and practice.

From inclusion to justice: Rethinking the premises of inclusion

If inclusion, as currently conceptualized, risks reproducing asymmetrical relations of power, the challenge is not simply to improve its implementation, but to reconsider its underlying premises. Within dominant frameworks, inclusion is typically presented as a corrective response to exclusion: individuals or groups identified as marginalized are supported in accessing, participating in, or adapting to existing systems. Although this may mitigate some forms of disadvantage, it leaves largely unquestioned the structures that produce marginality in the first place (Fraser, Reference Fraser2008). As a result, inclusion often addresses the consequences of inequality without challenging its underlying conditions, allowing existing hierarchies to persist in more inclusive forms (Ahmed, Reference Ahmed2012).

A different perspective requires shifting from inclusion as incorporation toward justice as structural transformation. Rather than asking how individuals can better fit existing systems, the more fundamental questions become:

From this perspective, inclusion is not a neutral principle but a practice embedded in relations of power that shape recognition, legitimacy, and belonging. It presupposes a boundary between those who belong and those who must be included. Unless this boundary itself becomes open to critique, inclusion risks reproducing the distinctions it seeks to overcome (Foucault, Reference Foucault1972).

A justice-oriented approach therefore shifts attention from individuals to institutions, policies, and epistemological frameworks. Rather than improving participation within existing arrangements, it asks how those arrangements themselves might become accountable to the diversity of lived experiences they seek to serve. In global mental health, this involves opening the definition of priorities, research questions, intervention aims, and evaluation criteria to shared deliberation rather than inviting participation only after these have already been established. It also requires greater attention to how resources, institutional authority, authorship, and decision-making power are distributed. Justice, in this sense, cannot be reduced to expanding access. It requires creating conditions in which diverse forms of knowledge and experience are able to reshape the institutions, practices, and assumptions through which care is organized. This resonates with traditions that understand well-being as inseparable from social justice and structural transformation (Freire, Reference Freire1970; Martín-Baró, Reference Martín-Baró1998).

The practical implications in the field of global mental health are substantial. Efforts to expand access remain essential, but they must be accompanied by critical reflection on the models being disseminated and the assumptions they carry (Mills, Reference Mills2014). What a justice-oriented approach requires will inevitably differ across contexts. In established health systems, structural transformation may concern institutional access, migration status, language, or professional hierarchies. In humanitarian and conflict-affected settings, it may additionally require engaging with displacement, insecurity, material deprivation, and the relationship between psychosocial suffering and political violence. Justice therefore cannot be reduced to a universally transferable model, but must remain attentive to the historical and structural conditions through which exclusion is produced (Fiscone, Reference Fiscone2026).

Toward justice-oriented practice in global mental health

In practice, the limitations of inclusion become apparent in the persistent tension between professionals’ commitment to participation and care and the institutional conditions that continue to produce exclusion. Across global mental health and related fields, interventions may expand access and respond to immediate needs, yet often have limited capacity to transform the structural arrangements through which inequality is reproduced (Ahmed, Reference Ahmed2012).

Importantly, these tensions also create opportunities for transformation. In many contexts, practitioners move beyond procedural understandings of inclusion by developing more collaborative and dialogical forms of practice. Mutual learning, shared decision-making, and the redefinition of professional roles allow difference to become a source of institutional learning rather than simply an object of accommodation. Such practices resonate with traditions emphasizing reflexivity, co-construction, and agency (Freire, Reference Freire1970).

From a justice-oriented perspective, however, these concepts require more than rhetorical commitment. Reflexivity involves critically examining how professional authority, institutional location, funding arrangements, and dominant knowledge systems shape both the questions that are asked and the responses considered legitimate (Farr et al., Reference Farr, Davies, Andrews, Bagnall, Brangan and Davies2021). Co-construction refers to genuinely shared processes through which communities participate in defining priorities, producing knowledge, designing interventions, and interpreting outcomes, rather than being consulted after key decisions have already been made (Fiscone, Reference Fiscone2026). Agency similarly extends beyond participation alone. It requires that individuals and communities retain meaningful influence over decisions, possess the possibility of contesting dominant understandings, and contribute actively to transforming the systems intended to support them (Hammou, Reference Hammou2025).

However, these practices are not inherently transformative. For instance, co-production itself can become procedural when institutions retain control over agendas, resources, and decision-making. A justice-oriented approach therefore requires attention not only to whether participation occurs, but also to how power is shared and what institutional consequences follow from that participation. For global mental health, this means understanding justice not as an outcome that follows inclusion, but as the principle through which research, policy, and practice are conceived from the outset.

Conclusion: Beyond inclusion as a corrective framework

This paper began with a simple yet unsettling question:

Rather than treating inclusion as an unquestioned solution, this paper has approached it as a concept requiring critical examination. The analysis has argued that inclusion, as commonly framed, rests on assumptions that often remain implicit. It presupposes a normative center, positions certain groups as “in need” of inclusion, and tends to privilege adaptation over transformation. While inclusion may mitigate some forms of exclusion, it does not necessarily address the conditions that produce inequality (Ahmed, Reference Ahmed2012). In this sense, it risks functioning as a corrective response to inequality rather than as a means of transforming the structures that sustain it.

Reframing inclusion therefore requires a shift in perspective. Rather than asking how individuals can be included more effectively, attention must turn to the structures, norms, and epistemologies that define the structural, relational, and political dimensions of power shape underlying inclusion and exclusion. This means moving beyond inclusion as a compensatory mechanism toward justice understood as structural transformation, requiring not only institutional change but also a reconfiguration of the assumptions underpinning dominant approaches to care, education, and participation (Fraser, Reference Fraser2008).

Within global mental health, this reorientation has important implications. Expanding access to care and improving participation remain essential achievements, but they are not sufficient on their own. A justice-oriented approach requires engaging with the structural and historical dimensions of inequality, including those related to migration, power, and the global circulation of knowledge (Mills, Reference Mills2014; Patel et al., Reference Patel, Saxena, Lund, Thornicroft, Baingana, Bolton, Chisholm, Collins, Cooper, Eaton, Herrman, Herzallah, Huang, Jordans, Kleinman, Medina-Mora, Morgan, Niaz, Omigbodun, Prince, Rahman, Saraceno, Sarkar, De Silva, Singh, Stein, Sunkel and Unützer2018). Across the diverse contexts considered in this Perspective, practitioners and researchers often work at the intersection of care and structural constraint, responding to immediate needs while having limited capacity to transform the systems through which exclusion is reproduced. This highlights both the possibilities and the limits of inclusion when broader institutional and political conditions remain unchanged.

Moving beyond inclusion does not mean abandoning it. Rather, it means situating inclusion within a broader project of transformation that seeks to reconfigure the conditions producing marginalization in the first place. Such a project requires greater reflexivity regarding the assumptions shaping research and practice, more equitable forms of knowledge production, and stronger partnerships with the communities whose experiences are too often positioned as objects rather than sources of knowledge (Farr et al., Reference Farr, Davies, Andrews, Bagnall, Brangan and Davies2021). Because these conditions differ across health systems, communities, and humanitarian settings, justice-oriented practice cannot take the form of a universal model (Martín-Baró, Reference Martín-Baró1998). Instead, it must emerge through historically and politically situated processes of reflection, negotiation, and shared decision-making.

Ultimately, the goal is not to perfect inclusion, but to render it less necessary by transforming the conditions that make it required. For global mental health, this means recognizing justice not as an additional objective alongside inclusion, but as the framework through which research, policy, and practice are conceived. In this sense, rethinking inclusion is not simply an academic exercise, but a political and ethical imperative that calls for a reimagining of belonging, participation, and justice in a deeply unequal world.