1. Introduction
From the late-1990s and into the first two decades of the 21st century, policy makers and non-governmental organisations (NGOs) at local, national, European and global level pushed mental health as a responsibility of the European Union (EU). Pressures from these actors and from inside EU institutions including the Commission of the European Union and the Council of European Ministers led to the establishment of ‘soft law’ instruments to monitor, evaluate and compare mental health and mental ill-health in EU Member States. These instruments also funded programmes, projects and analysis regarding mental health across Europe, even as EU Member States opposed some of these actions (Wahlbeck, Reference Wahlbeck2011).
In short, a system of European Union mental health governance (EUMHG) emerged. EUMHG assembled legislators, mental health care providers, academic and policy experts, NGOs, and patients and families in a broad range of activities and projects. Yet, EU activities regarding mental health have received scant scholarly attention. Nearly a decade ago, scholars of public mental health critiqued the internal political dynamics and direction EUMHG took following the 2008 release of the EU Pact for Mental Health and Well-Being (Wahlbeck, Reference Wahlbeck2011), and others highlighted the potential for EUMHG to invigorate state research funding for psychiatry in Europe (Fears and Höschle, Reference Fears and Höschle2011). Since that time, little research has been published regarding EU mental health activities. Flear (Reference Flear2015) has offered a governmentality-inspired analysis of EU public health governance in the areas of cancer, HIV/AIDS and pandemic planning, whose spirit of critical scepticism about science and technology and whose questions of citizen participation are worthy of emulation in the case of EUMHG. This is particularly true since EU soft law has been touted for enhancing EU legitimacy (Warwick, Reference Warwick2005), for opening accessibility to activists (Borrás and Greve, Reference Borrás and Greve2004) and in the area of health, for providing opportunities for activist resistance to market orientated practices (Fierlbeck, Reference Fierlbeck2014). But Flear's analysis, grounded in legal and regulation scholarship, lacks an explicitly global dimension. Specifically, it lacks a focus on the transnational and international organisational origins and pathways of the practices and discourses of EU governance, and thus overlooks obstacles to citizen participation that emerged in EUMHG, and that likely characterise other EU governance processes.
Through analysis of EUMHG as a case of EU governance, this paper attempts to fill gaps in our understanding of EU health policy more generally, and to highlight the need to attend to global dynamics in studies of EU governance. It does so by outlining the discourses and practices that structured political relations within EUMHG, and attending to any openings for citizen participation. To do so, it adopts the approach of global governmentality, and applies the method of discourse analysis to EU documents, programme descriptions of EU-funded projects and grey literature. It also uses the method of participant observation to the 2018 February meeting of the Third EU Compass Forum on Mental Health and Well-being, which met in February 2018 in Luxembourg.
The paper adopts a global governmentality approach because this scholarship, which is the most recent iteration of global governance analysis (Bueger, Reference Bueger2017), has proved useful for understanding processes of supranational governance in multiple issue-areas, such as international population policy and landmine governance (Sending and Neumann, Reference Sending and Neumann2006), global environmental governance (Goldman, Reference Goldman2005) and community forest management (Li, Reference Li2007). The approach also has been applied to the practices and discourses of global-level mental health governance (Edquist, Reference Edquist2008). This approach encourages examination of the practices and discourses of governance. Its application to EUMHG reveals that key EUMHG practices, also found in many other EU governance areas, have their origins in post-War economic and business practices, which travelled across borders and were refined in the era of New Public Management (NPM) theory. The practices included the use of indicators or benchmarks, partnerships (between public and private sectors) (Simonet, Reference Simonet2008) and the pursuit of good practices or best practices, among others. The practices worked their way into EU governance slowly, but were embraced en masse in the 2000 Lisbon endorsement of the Open Method of Coordination (OMC). Yet, the practices' origins and development in business management practices and theory dispose them to reinforce larger EU policy goals of market-optimisation (Flear, Reference Flear2015). Meanwhile, risk-management practices took hold in psychiatry and travelled via international institutions and transnational collaboration to reshape concepts of the role of psychiatric professionals in mental health care towards obligations to assess risk and away from diagnosis, care, control or patient integration. NGO activities within, and any citizen input into, EUMHG would have had to at least acknowledge and deliberately avoid, if not work within the limits of, these practices.
Regarding the political relations constructed through and by EUMHG, the paper presents two findings. One, the discourses of de-institutionalisation (DI) and community mental health (CMH) played central roles in EUMHG and to some extent their redefinitions shifted EUMHG from its original public-health emphasis to a focus on prevention of mental disorders and the burdens they pose to Member States. These reconstructions not only aligned more closely with EU market-optimisation goals (Flear, Reference Flear2015) as well as Member States' post-2010 austerity practices (Wahlbeck, Reference Wahlbeck2011), but also moved EUMHG from ‘There is no health without mental health’ to community-based service-provision focused on specific mental disorders, with an eye to the burden they posed for EU Member States. Meanwhile, as with other EU policies, opportunities for citizen participation in EUMHG were narrow.
The second finding, anticipated by other applications of a global governmentality approach, is that by taking up EUMHG discourses, the identities of mental health-oriented NGOs were transformed. This was because the NGOs were able to partner with EU institutional actors. By so doing, and by taking up the discourses of DI and CMH for their own purposes, NGOs became both objects and subjects of government (Sending and Neumann, Reference Sending and Neumann2006: 652). This was in part because the EU institutions developing EUMHG were more accessible to NGOs than to everyday citizens. Contrary to Flear's (Reference Flear2015) more hopeful conclusions, this finding renders it doubtful that citizens could meaningfully reframe EUMHG. Rather, citizens usually were positioned outside governance, and their participation was heavily conditioned if not discouraged through bureaucratic obscurity and the discourses and practices of EUMHG. NGOs served as proxies for them, even as NGOs' own position was compromised. To provide less compromised input, NGOs and citizens will need vigilant protection in any future EUMHG.
A few qualifications are in order. This paper does not intend to say that EUMHG became a dominant process in Member States' mental health approaches. It is keenly aware that EU Member States operate widely different health care and mental health systems, and that EU-level influence, even at its most precise or demanding as it may have been in EUMHG's last phase [under the European Framework for Action on Mental Health and Wellbeing (2016–2018)], was experienced differently depending on the Member State in question and the means, abilities and will it had to carry out EUMHG practices. The paper also does not provide an overall assessment of the level of pressure EUMHG places on Member States, because its primary focus is not on EUMHG's effects on member state mental health policy. Its purpose instead is to understand how EUMHG operated, what discourses and practices constituted it, and what kind of citizen participation it encouraged.
Because discourse-oriented analysis encourages reconstructing the history of a policy area (Green, Reference Green and Green2002), the paper starts with a brief history of EUMHG. Then it conducts a global governmentality analysis of EUMHG by tracing how EUMHG practices structured political relations among interested parties, including NGOs, citizens and EU institutions. This section illustrates these practices' transnational ties to NPM theory and to the rise of ‘risk-thinking’ in psychiatry. It also discusses the ways in which these practices make NGOs both subjects and objects of government. The paper then outlines the discourses adopted throughout the history of EUMHG including DI, CMH, and the burden of disease. The focus is on these discourses because they establish the general position of mental health relative to citizens and institutions, e.g. as a public health goal or a burden to EU Member States. Subsequent is a discussion of citizens' role in these processes. The conclusion reviews these findings and discusses the uncertain future of EUMHG.
2. History of EUMHG
The history of EUMHG is quite short, relative even to other EU health governance areas. While health on the job has been an EU concern since 1978, and the Commission of the European Union initiated its first public health Community Action Programme in 1995, mental health officially became a concern of the EU in 1998, when the Council passed a Resolution on the Promotion of Mental Health (Commission of the European Communities, 2005), based on Article 152 of the Amsterdam Treaty (signed 1997; entered in force in 1999). In 1999, the World Health Organization (WHO) and the Commission held a joint meeting on mental health, whose declaration, ‘There is no health without mental health’ signalled a public health approach to mental health. (World Health Organization, 1999) In 2001, the European Commission established a Forum on Mental Health, which provided opportunity for discussion among various non-state European interests including health care professionals, patient and consumer organisations, insurers and pharmaceutical interests (Global Alliance of Mental Illness Advocacy Networks, 2007). Not unexpectedly, there is no evidence of direct citizen participation in the Forum; it would have had to been filtered through these organisations or through citizens' roles as patients or consumers.
In 2005 the Commission released a Green Paper on ‘an EU-strategy on mental health’ (Commission of the European Communities, 2005) and European member-states of WHO published their Declaration and Action Plan on Mental Health (WHO European Ministerial Conference on Mental Health, 2005). In 2008 the Commission convened a High-Level Conference (a group of independent experts) on Mental Health and Well-Being, whose Pact for Mental Health and Well-Being identified five priority areas for EU action, including prevention of depression and suicide, mental health in youth and education, mental health in workplace settings, mental health of older people and combating stigma and social exclusion (EU High-Level Conference on Mental Health and Well-Being, 2008). The Pact therefore marked a step away from the public-health emphasis of the 1999 WHO/Commission Conference and Report, towards a focus on specific mental disorders. Following this Conference, the Member States agreed to a Joint Action Mental health and Well-being. The Action established national working groups in each state and multi-country working groups at EU level, and aimed to analyse and build capacity and commitment at national level for mental health action, and to ‘map’ knowledge and best practices at EU level (Commission of the European Communities, Directorate-General of Consumers, Health and Food, 2013). The Joint Action resulted in the European Framework for Action on Mental Health and Wellbeing (2016–2018)Footnote 1 (EU Joint Action on Mental Health and Wellbeing, 2016). The last element of EUMHG was a programme to assist member states in implementing the Joint Action, the 2016–2018 EU Compass for Action on Mental Health and Well-being (EU-COMPASS). This programme aimed to communicate the Joint Action's priorities to member states through a series of ‘multi-sectoral awareness raising workshops with a focus on investing in Europe's mental capital’ in every member state (EU Compass Consortium, 2018), via annual transnational, multi-stakeholder conferences and a Web-based portal for best-practice sharing. Citizen participation would have been assumed to occur via states (Alemanno, Reference Alemanno2018).
As the next section illustrates, from its beginning, EUMHG was constituted by the practices of benchmarking/indicators, partnership, best practices, and risk-thinking. While the first three practices frequently are presented as elements of soft law practices such as the OMC, it bears remembering that they operated at EU level long before OMC, and that they were borne of managerial practices of the private sector. The practices' transnational ties to NPM theory disposed them to complement market optimisation goals. Additionally, their ties to psychiatric risk assessment practices disposed them to approach mental ill health as an issue of risk.
3. Practices of EUMHG
EU mental health governance's grounding in soft law derives in part from its emerging at the same time as the OMC, a collection of practices that the EU formally embraced at the 2000 meeting of the Council of European Ministers in Lisbon, although it had adopted some of the soft law practices constituting OMC long before (Dale, Reference Dale, Larner and Walters2004). The EU is unusual if not unique in its purposeful and overt pursuit of soft law mechanisms (Greer and Vanhercke, Reference Greer, Vanhercke, Mossialos, Permanand, Baeten and Hervey2010) and the EU consistently has adopted them in its health initiatives (European Parliamentary Research Service, 2014). Since the financial crisis of 2008–2011, these practices have seen critique and refinement by the Commission (Fierlbeck, Reference Fierlbeck2014). The central soft law practices of EUMHG reflect those adopted in EU public health governance (Flear, Reference Flear2015), including the use of indicators including benchmarks, the pursuit of ‘partnerships’ usually between state and private or non-state actors, and the pursuit of good or best practices. These practices have a transnational history and their enactment in EUMHG also was transnational.
The use of benchmarks and best practices emerged from post-War economic activities, particularly the operations of transnational corporations. As originally conceived in post-War private corporate management, best practices were the production forms practiced by the most competitive firm in a given industry or sector, and benchmarking was the establishment of quantifiable criteria for gauging firm performance towards continuous improvement (Sklair, Reference Sklair2001). Over time, these practices changed business operations profoundly (Sklair, Reference Sklair2001), for example by initiating the practice of Total Quality Management and other quality-assurance processes in industry and consumer services (Flynn, Reference Flynn2002). Best practices eventually shaped European states' public policy, including health policy. For example, by 2002, best practices and benchmarking had worked their way into the British National Health System (Flynn, Reference Flynn2002), while UK local government saw the advent of the ‘best value initiative’ (McAdam and O'Neill, Reference McAdam and O'Neill2002).
These practices also were shaped by transnational scholarly analysis, as embodied for example in the theory of NPM (Simonet, Reference Simonet2008). NPM advocated the use of best practices to advance “principles of customer-driven, value-focused, entrepreneurial, market-oriented government” (Overman and Boyd, Reference Overman and Boyd1994). Similarly, NPM encouraged the practice of ‘partnerships’, that is, shifting public policy from direct ministerial control and accountability to private, quasi-private, and government agencies (Chandler, Reference Chandler and Chandler2014) on the grounds that “the managerial methods and ethos of the private sector could be profitably introduced into the public sectors” (Kingdom, Reference Kingdom and Chandler2014). In other words, these practices were part of a political strategy to dismantle state services and move them to the most efficient and competitive arenas. While taking up these practices does not automatically challenge the universal-coverage premises of state insurance or hybrid health care systems, it does call into question state mental health systems' efficiency and return on investment – concerns that can privilege market functioning over mental health as a public concern.
Best practices and benchmarking have figured in another practice found in EUMHG, which Rose (Reference Rose1998) calls risk-thinking. Risk-thinking is part of a sea-change in psychiatry wherein risk assessment, prediction, and management became central to the “new logics of ‘community psychiatry’” (Rose, Reference Rose1998: 177). In this practice, psychiatric professionals find themselves under an obligation to manage risk, a position that challenges the preeminence of the psychiatrist in mental health care and transforms the act of diagnosis into an exercise involving multiple professionals, whose judgement is called upon to assess a person's situation not in terms of a case history or case conference, but rather in terms of risk factors. These can include “not taking medication, previous records of violent or aggressive behaviour, use of alcohol or illegal drugs, relations with other individuals, age, social isolation, place of residence, and self-neglect” (Rose, Reference Rose1998: 186, citing Camden and Islington Community Health Services Trust, 1994). While critical sociological analysis identifies risk assessment as a key element of new regimes of social control, the more important concerns for this paper are that risk-thinking formed a practice that influenced EUMHG, and that citizen participation is highly limited in such a context, and would be oriented as much towards protecting ‘the community’ from risky individuals as it would towards engaging political representatives about the best way to care for persons struggling from mental distress.
Best practices shaped EUMHG early on. For example, the 2005 Green Paper on Mental Health invited civil society actors to ‘consult’ on the Paper as well as ‘identify best practice for promoting the social inclusion and protecting the rights of people with mental ill health and disability’. The Paper also proposed an EU Platform on Mental Health that would “identify best practice for promoting the social inclusion of people with mental ill health and disability and for protecting their fundamental rights and dignity” (Commission of the European Communities, 2005: 5, 13). The 2016 Joint Action's primary contribution was a map of best practices in mental health across Europe, and a primary outcome of EU COMPASS (2016–2018) was a database of best practices.
Benchmarks and other indicators also figured repeatedly in EUMHG. One objective identified by the 2005 Green Paper was to establish ‘targets, benchmarks, timelines for action and a mechanism to monitor implementation’ of an action plan on mental health (Commission of the European Communities, 2005: 13). Similar types of indicators also shape the 2016 Framework for Action, which links directly to WHO-Europe's 2013–2020 comprehensive goal that “80% of countries will be routinely collecting and reporting at least a core set of mental health indicators every two years through their national health and social information systems” (EU Joint Action on Mental Health and Wellbeing, 2016: 3). And as discussed below, state CMH Centres (CMHCs) became indicators the quality of European states' mental health care systems.
These practices structured the projects of EUMHG, as well as the identities of the NGOs working through them. For example, a 2007 EU-sponsored project, ‘European Mental Health Promotion Implementation’, aimed to share ‘models of good practice on mental health promotion and prevention of mental ill-health’ among its ‘partners’ (European Public Health Alliance, 2007). Its role as ‘partner’ within EUMHG meant it was not just advocating on behalf of EU citizens concerned with mental health: it was helping spread the discourses and practices of EUMHG. This NGO also observed that its earlier (1994) partnership with the Commission had provided ‘powerful impetus’ to its status (European Public Health Alliance, 2007). Another NGO's participation in the 2001 EU Forum on Mental Health enabled it to identify itself as a ‘key decision-maker’ (Global Alliance of Mental Illness Advocacy Networks, 2007). And in 2007 a third NGO called the Green Paper's consultation process “a golden opportunity for influencing the discussion of mental health issues at European level” (Mental Health Europe, 2007).
Partnership and consultation practices within EUMHG constructed NGOs as legitimate civil-society actors in European health, and structured their relations within EUMHG. NGOs became not only advocates for EU action on mental health, but were also transnational conduits of EU governance. This reflects a central insight of global governmentality studies, namely, that in processes of global governmentality, NGOs act as both subjects and objects of government, extending rather than counteracting the power of the state (Sending and Neumann, Reference Sending and Neumann2006). As Sending and Neumann observe, a global governmentality perspective that focuses on the sociopolitical functions of governance reveals how “the self-association and political will-formation characteristic of civil society and nonstate actors do not stand in opposition to the political power of the state, but is a most central feature of how power, understood as government, operates in late modern society” (p. 652). This finding is reinforced by the fact that EU public consultations tend to be ‘top-down exercises’ involving only a few actors and disconnected from daily decision making (Alemanno, Reference Alemanno2018). It is also reinforced by research suggesting that NGOs wishing to influence EU governance processes must build ‘clientelist’ relations with representatives at the Commission or other EU institutions (Grugel and Iusmen, Reference Grugel and Iusmen2013).
To be sure, global governmentality studies also indicate that NGOs can reconstitute international organisations' identities (Park, Reference Park2004). This implies that NGOs may have possessed the capabilities to reframe EUMHG. Perhaps citizens too can engage in a more robust, republican form of citizenship within EUMHG such as that envisioned by Flear (Reference Flear2015). But the practices outlined above put serious strictures on the content and direction of citizen participation, if EUMHG ever were to be revived. As Alemanno (Reference Alemanno2018) observes, current EU participatory mechanisms were not designed for broad citizen participation, but rather for ‘receivin[g] public input through functional intermediaries’ including NGOs (p. 2).
NGOs operating within EUMHG were constrained by the practices outlined above. Not surprisingly, NGOs were encouraged to take up the practices of risk assessment (in the form of best practices and indicators); after all, mental health professionals' participation in risk-thinking regimes becomes ‘a necessary condition of their claim to expertise’ (Rose, Reference Rose1998: 190). Nonetheless, risk-thinking did not always permeate EUMHG or the NGOs operating within it. When EUMHG discourse retained terms like ‘community mental health’, the meaning of those terms shifted, but at least one non-state project sponsored by the Commission was able to maintain a focus on psychiatric obligations of care and integration and avoid risk-management obligations to evaluate and minimise risk. Nonetheless, NGOs worked within a context in which these transnational practices shaped EUMHG. Given the scientific and medical bona fides of these discourses, NGOs would have found it difficult to resist their influence. And given NGOs' de facto role as proxies for citizen participants in EU governance, we would have to say that citizen input faced similar constraints, in addition to the constraints to citizen participation in EU governance more generally.
4. The transnational discourses and discursive practices of EUMHG
EU mental health governance was shaped by discourses of mental health care that transcend state boundaries and have shaped the sciences and politics of mental health and mental illness in Europe for over 150 years. [See e.g. studies of mental health care in France (Coldefy and Curtis, Reference Coldefy and Curtis2010), Italy (Babini, Reference Babini2014; Ventriglio, Reference Ventriglio2016) and Italy/UK (Jones, Reference Jones2000, Reference Jones2001).] Over this time, psychiatry emerged as a distinct scientific discipline and advanced different models of mental pathology (Drake et al., Reference Drake, Green, Mueser and Goldman2003). Psychiatry also advanced different ‘ideologies’ of care, (Drake et al., Reference Drake, Green, Mueser and Goldman2003) – i.e. discourses – including DI and CMH. DI and CMH deserve especial attention in the study of EUMHG because they shaped EUMHG's approach to the relative positions of citizens, institutions, the state, and the EU in questions of mental health. That is, within EUMHG, these discourses were taken up at various times and in multiple formats, to answer the questions, Is mental health a public health concern, or is mental ill health a burden to EU societies and Member States? And, What does a diagnosis obligate the mental health professional to do – care for the person, or protect the community? It behooves us to understand these discourses' transnational constructions.
4.1 De-institutionalisation and community mental health
DI discourse emerged with the rise of new antipsychotic pharmaceutical treatments in the 1950s. In the United States, DI was envisioned as a means of removing long-term psychiatric patients from obsolete custodial mental hospitals, and aiding their transition into communities through social and psychiatric support systems. In this sense, it was a ‘radical’ policy and part of a larger vision of health (Grob, Reference Grob1995). In Europe, DI was similarly radical. In Italy, for example,
The DI paradigm means … much more than the closure of psychiatric hospitals. It is a social and political construct designed to reformulate relations between individuals and the society, balancing power relationships in favour of the vulnerable subject. It implies an attitude of constant awareness of the iatrogenic, destructive, and dehumanising effects of heavy institutional interventions and a continuous effort to minimise them. For this reason, any DI-based programme is necessarily a political programme (Fioritti, Reference Fioritti2018: 4).
The political programme of DI was embodied in the discourse of CMH. However, CMH has shifted emphasis over time, from symptom control (in the 1970s), to rehabilitation (1980s), to recovery (1990s) (Drake et al., Reference Drake, Green, Mueser and Goldman2003). The most current element of CMH emphasises both recovery and ‘resilience’ (Harper and Speed, Reference Harper and Speed2012). CMH has transnational origins and continues to be constructed via transnational processes and global institutionalisation. The transnational collaboration of psychiatrists (Coldefy and Curtis, Reference Coldefy and Curtis2010) including prominent mental health experts in Italy (Fioritti, Reference Fioritti2018), and the activities of the WHO have facilitated CMH's global spread. In fact, WHO's 2001 World Health Report, ‘Mental health: New understanding, new hope’, which outlined a vision for giving ‘care in the community’ and took up the CMH discourse, played a ‘foundational’ role in global mental health governance (Wahlberg and Rose, Reference Wahlberg and Rose2015). WHO activities including the activities of WHO-Europe strongly influenced the shape and scope of EUMHG.
In the United States, the combination of DI and CMH discourses spurred the creation of CMHCs in a decentralised system of care that would provide integrated and continuous services to persons who previously had lived in institutional hospitals (Grob, Reference Grob1995). The United States took up the practice of CMHCs in the 1970s, but political elites soon embraced NPM practices and ushered in market-oriented policies that led to the under-funding of CMHCs. US CMHCs thus were unable to assume the burdens previously shouldered by state hospitals, leading to the ‘paradoxical’ situation in which CMHCs proliferated while the most vulnerable persons whose liberation from institutions had originally been sought were neglected. CMHCs ended up meeting the needs of individuals with emotional and personal problems, including more affluent professionals (Grob, Reference Grob1995).
In the United States, the political decisions encouraged by policy elites and by concepts of NPM helped strip CMH and CMHCs of their potentially transformative character. European CMHCs will fare differently depending on health care and insurance systems, which vary greatly across states. However, it seems that in a context of practices of risk-thinking, in which individuals are classified in terms of their riskiness to the community as well as themselves (Rose, Reference Rose1998: 185), professionals and NGOs will have to intentionally pursue CMHCs' transformative character, lest they balance power relationships in favour of the vulnerable community, rather than the ‘vulnerable subject’ (Fioritti, Reference Fioritti2018).
Interestingly, this may have been possible within EUMHG. By the time EUMHG emerged, CMH had become permeated with the transnational practices of risk thinking, benchmarking, and best practices that have helped define what counts as expertise in mental health care. It is therefore unsurprising that the South-Eastern Europe Mental Health Project (2002–2008), funded in part by the Commission, established ‘multidisciplinary pilot’ CMHCs in nine Southeast European states by 2012 (Priebe et al., Reference Priebe, Matanov, Demi, Blagovcanin Simic, Jovanovic, Gajic, Radoni, Bajraktarov, Boderscova, Konatar, Nica and Muijen2012), that the Project presented its CMHCs as models of best practice (South-Eastern Europe Health Network, 2008), and that the Commission published the Project's 2008 presentation on its Web site, thereby providing a model of mental-health governance for other states to emulate. By 2018, Commission-sponsored research was analysing Member States in terms of their ‘mixes’ of CMH institutions and other forms of care (Killaspy et al., Reference Killaspy, McPherson, Samele, Keet and Caldas de Almeida2018).
Yet, one report presented at an EUMHG event indicates that risk-thinking may have been avoided via EUMHG understandings of CMH. The report, presented at the 2018 Third EU Compass Forum on mental health governance in Luxembourg, critiqued Bulgaria and other former Soviet-satellite states for lacking recorded data on CMH activities such as “follow-up, active searching, prevention of crises and relapses, psychosocial integration and resocialization of patients” (Nakov and Hinkov, Reference Nakov and Hinkov2018). Notably, these data do not reflect the data encouraged by risk-thinking, which entails an ‘obligation to assess, evaluate and minimize risk’; instead, the requested data reflect more traditional psychiatric and mental health care practices, such as ‘the obligation to care and control, or to diagnose and cure, or to befriend and reintegrate’ (Rose, Reference Rose1998: 186). Whether this means that citizens participation was less constrained within EUMHG is unclear.
4.2 The burden of disease
The burden of disease discourse deserves attention because, as a derivative of risk-thinking practices, it shifts emphasis away from mental health as a public-health concern, and it did figure in EUMHG. The burden of disease is a concept that emerged in 1980s epidemiology. It was spurred by research done at the World Bank, where the method of calculating disease burden, the disability adjusted life years (DALYs), was developed. ‘Disease burden’ epidemiology was applied to mental disorder, in a shift from studying the distribution to the impact of mental ill health on social systems. Disease-burden discourse encourages the practices of quantifying ‘the experience of living with mental disease’ and estimating ‘the costs – to individuals, families and society – of mental disorders and in particular of depression’ (Wahlberg and Rose, Reference Wahlberg and Rose2015: 78–81). Thus, disease-burden discourse is a form of risk-thinking, as well as an indicator. This discourse encourages prioritising risk and, in general EU health policy, it reinforced the economic optimisation goals of the EU (Flear, Reference Flear2015).
Disease-burden discourse appears throughout EUMHG. The discourse was enshrined in the WHO 2001 paper ‘Mental health: New understanding, new hope’, which presented mental ill health as hugely costly while mental health care was deeply under-funded (Wahlberg and Rose, Reference Wahlberg and Rose2015). As noted above, this paper influenced EUMHG at its inception. The 2005 Green Paper echoed that theme with its observation that “mental ill health imposes manifold costs, losses and burdens on citizens and societal systems” (Commission of the European Communities, 2005: 6). An EU COMPASS publication opened with a similar statement: “Mental disorders place a tremendous burden on the well-being and health of European citizens. They are a leading contributor to the burden of disease (DALYs) in the European Union, and approximately 38.2% of EU citizens across all age groups are affected by a mental disorder each year” (Walters, et al., Reference Walters, Heerink, Steenhuis and Petrea2016: 5). The Commission embraced the discourse via its Executive Agency for Health and Consumers, which conducted extensive research to contribute to the WHO/Harvard University World Mental Health Surveys Initiative, whose primary aim is to build on the WHO Global Burden of Disease Study by promoting public health initiatives aimed at addressing the global burden of mental disorders (EU WMH The EU Contribution to the World Mental Health Surveys Initiative, 2009–2011). By encouraging the measurement of trends in specific mental disorders and emphasising the dangers they pose to society, disease-burden discourse introduced another way in which EUMHG contravened the public-health spirit in which had been originally conceived.
Disease-burden discourse poses a high obstacle to citizens' meaningfully reframing EUMHG. After all, within its confines, citizens embody the risk: they are the bodies, they are the minds, whose existence and possible ill health poses a burden to states. The prospect for meaningful citizen input seems quite limited while EUMHG employs and is constituted by this discourse.
Space limitations prevent analysis of Member States' varying experiences of DI, CMH, CMHC and disease-burden discourses and discursive practices, so it is not possible to explore the nuanced meanings they acquire in more local settings. What is notable is that they have been constructed through transnational professional and scientific networks. Indeed, one finding of this paper is that the discourses and practices came to operate within EUMHG as a ‘dominant economic semiotic system’ (Bogard, Reference Bogard1998: 72) – that is, an economy of discourses and practices that ‘define what counts as common sense’ (Bueger and Gadinger, Reference Bueger and Gadinger2018: 38). This dynamic of global governmentality has been observed in other areas of global governance, such as the ‘green neoliberalist’ practices exercised at the World Bank: in that case, an international organisation enlisted international experts to develop indicators to measure state performance on an issue, NGOs took up the measurements as a means of applying their own knowledge to the issue and helped contribute to the spread of a particular economy of discourses and practices that became the common-sense way of discussing the issue (Goldman, Reference Goldman2005). The above analysis presents a similar chain of events in the case of EUMHG (Goldman, Reference Goldman2005).
5. Discussion: citizens, NGOs and the limitations posed by discourses
This paper has argued that the global dimension of EUMHG discourses and the ways in which they are shaped by EUMHG practices call into question the extent to which citizens can reframe EU governance as Flear (Reference Flear2015) envisions in EU public health. EUMHG discourses had been defined through transnational debate within professional and expert networks, in forums at international organisations, or through those organisations' sponsorship of expert study and opinion. Contention over meaning was not confined to EU borders, and instantiations of these discourses as policy practices in different states helped shape and reshape their meaning. To a certain extent, EUMHG reflected these changes during its brief existence: it shifted from the language of ‘There is no health without mental health’ to practices of community-based service-provision focused on specific mental disorders, with an eye to the burden they posed for EU Member States.
Throughout the life of EUMHG, NGOs played a crucial role in contributing ideas, effort, personnel and expertise to EUMHG. They also served as proxies for public input. Yet, not unexpectedly from a global governmentality perspective, they also became entities through which rule is exercised, in addition to acting as a check on the power of Member States. Their input was shaped in part by EUMHG's content and direction, and they continued to participate in and build EUMHG despite the wide shifts in EUMHG focus from a public health definition of mental health to prioritising risk and thus reinforcing the economic optimisation goals of the EU, and to practices of community-based service-provision focused on specific mental disorders, albeit while pursuing more traditional obligations of mental health professionals. NGOs' persistent participation in EUMHG despite these shifts may be explained in part by observing that since the 1990s, many NGOs have operated under the NPM practices outlined above (Edwards and Hulme, Reference Edwards, Hulme, Edwards and Hulme1996). Moreover, evidence suggests that NGOs must build close, even ‘clientelist’, relations with representatives at the Commission or another EU institution in order to shift the meanings of EU governance processes (Grugel and Iusmen, Reference Grugel and Iusmen2013).
Of course, there are many types of NGOs, some more reformist than others. In any case, NGOs are not citizens, and the EU's consistent consultation of NGOs as a proxy for direct citizen participation is a key concern of analysts of EU participatory politics. The case of EUMHG thus brings us to core questions about the democratic deficit in the EU, which has struggled with citizen participation from its beginning. As Alemanno (Reference Alemanno2018) argues, “Owing to its very genetic code, the union has been suspicious toward any expression of popular sovereignty. This atavistic hostility toward citizens’ input explains why the EU is particularly vulnerable to political actors speaking on behalf of the people as a whole” (p. 2). If our concern is the extent to which citizens were able to participate in, and possibly reshape, the direction and content of EUMHG, a key finding of this paper is that at best, citizens had input via NGOs. NGOs certainly can have a valid voice in governance processes, particularly if they are accountable to those whose lives are affected by the matter in discussion, have experience in the issue-area, and are held to standards of expertise such as peer review (Bendell, Reference Bendell2006). In mental health policymaking, NGOs may be a necessary alternative to citizen input because some citizens may not be able to give voice to their own concerns. Yet, citizens themselves also need a direct voice in policy-making that affects them, and NGOs cannot always substitute for them. Indeed, at its worst, consultation of NGOs could be interpreted as an end-run around robust republican participation (Bendell, Reference Bendell2006). While the EU has created new tools for citizen participation in the past decade, they tend to be little known, not fit for their dedicated purposes, and disconnected from the decision-making processes they were intended to inform. Thus, they ultimately serve as an exercise in legitimising existing policy approaches (Alemanno, Reference Alemanno2018). Citizens will need to work more directly with their political representatives, and political representatives will need to work more directly on mental health, if this situation is to change.
A main finding of this paper is that at best, citizens participated in EUMHG via NGOs. Given NGOs' complex relation to EU governmentality, their ability to participate in citizens' stead (they do not claim to ‘represent’ citizens) (Edwards and Hulme, Reference Edwards, Hulme, Edwards and Hulme1996) is compromised, depending on the NGO in question. To the extent that NGOs find it necessary to build clientelist relations with EU institutional actors to reorient the EU agenda, then what hope can we hold that EU citizens will do so, when their frequent position within governmentality processes is to be ‘governed at a distance’? (Larner and Le Heron, Reference Larner, Le Heron, Larner and Walters2004). It is true that within the discourses and practices of governmentality, “government and resistance articulate, mingle and hybridize, so that resistance cannot readily be thought of as external to rule” (O'Malley, Reference O'Malley1995: 310). EUMHG may be a case in point. But the list of obstacles to informed yet politically effective and aware citizen input is imposing: EU public health governance had already limited citizen participation to avoid disrupting “the broader programmatic priorities and normative orientation of EU governance” (Flear, Reference Flear2015: 275). Practices such as benchmarks, best practices and risk-thinking disposed EUMHG to encourage professional participation in regimes that conceived of communities as sites of potential danger. The discourses of DI and CMH shifted meaning through the input and knowledge of global experts. Research at international institutions birthed the concept of the disease burden. Knowing these challenges as well as finding ways around them will require citizens to work with NGOs without falling into an ‘end run’ around citizens' input. This is a tall order, though it may not be impossible, even though EUMHG's discourses and practices likely will persist at global level and in professional and policy arenas, though their meanings will shift. Still, it may be that other practices within EUMHG will emerge or become more prominent, such as peer counselling (Samen Sterk Zonder Stigma, 2018) alongside best practices, benchmarking and CMH. The rise of ‘e-health’ practices built on Web-based platforms is already occurring, although these practices have been built on infrastructures oriented towards market optimisation. Future mental health policies in the EU, if not at the EU level, will require vigilance on the part of NGOs and citizens if they are to avoid merely being governed ‘at a distance’.
6. Conclusion
At a theoretical level, this paper has suggested that EU mental health governance operated within and contributed to the spread of a ‘dominant economic semiotic system’ that had been formed through transnational and global processes. The system of discourses and practices defined what counted as ‘common sense’ within EUMHG. Common sense mental health care, according to this system, involved states and non-state actors to practice benchmarking, search for and promote best practices, pursue DI and create CMHCs, and pursue CMH. The ultimate impetus within EUMHG, after a shift in direction in the early 2010s, rendered mental (ill) health a problem and even a risk to be treated in community settings, rather than an essential element of public health. NGOs played a key but compromised role within EUMHG, as they have in other areas of global governance: they acted not just as policy advocates reflecting the concerns of citizens, but also as transnational conduits of EU governance. Robust republican citizen participation in mental health in Europe may have to occur through other means. Even then, the discursive space is fraught.
