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Transnational mental-health advocacy in the European Union: Diagnosing and depoliticizing?

Kristin Edquist, Ph.D. Assistant Professor of Government Eastern Washington University Cheney, Washington, USA [email protected]

ABSTRACT This article analyzes non-state mental-health advocacy in the context of increasing European Union (EU) attention to mental health issues. Its central case is the EU-Strategy on Mental Health, a policy outline proposed by the Commission of the EU in 2005. Secondary cases include non-state-initiated as well as state-level programs on mental health in Europe. The article finds that non-state actors have played an important role in bringing mental health issues to the European level, at times bypassing state officials – just as the multi-level governance model suggests can happen. It also finds that while the Strategy's ultimate implementation is uncertain, and the state-level and non-state-initiated programs are not Europe-wide, a mental-health governance process, or assemblage, is developing at the European level. The main purpose of this article is to examine the political dynamics of this assemblage. It finds that non-state advocacy within the assemblage largely reinforces rather than challenges the scientific assumptions and diagnostic criteria at work in EU member state and EU-level policies, thereby contributing to processes in which clients'/patients' health ultimately remains a question of elite scrutiny and judgment rather than societal discussion and reflection. On this view, mental-health advocacy in Europe works on behalf of psychiatric professionals as much as it does those perceived as mentally ill. Indeed, close analysis of the history and political dimensions of diagnostic criteria shows that mentalhealth advocates are contributing to processes that shape European societies' perceptions of what constitutes mental illness, while also privileging certain diagnoses and treatments—even though the assumptions built into any diagnostic taxonomy are contestable and value-laden, just as their procedures are methodologically problematic and uncertain. This dynamic is particularly interesting when discussing transnational advocacy, particularly in Europe, where the concepts of North and South, as well as West and East, hold many politicized meanings. While a formal EU-wide mental-health policy may not materialize anytime soon, current advocacy strategies and their larger context deserve close attention.

Key terms: governance, European Union, mental health policy, assemblage, advocacy

INTRODUCTION The psychological well being of persons is a newer realm of European Union (EU) governance relative to other health issue-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 of the European Union passed a Resolution on the Promotion of Mental Health (Council of the European Union, 1999). Since then, the most significant European-level mental-health initiative has been the Commission's 2005 Green Paper on "an EU-strategy on mental health,” and the awaited but as yet absent White Paper on the same subject (European Commission, 2005). The Green Paper invited all manner of mental-health experts, including public, private, and non-profit professionals, as well as more "grassroots" activists, to participate in a European-level discussion and policymaking process regarding mental health issues. It received broad response from non-state mental health advocates, and indeed its publication provided a window of opportunity for activists to establish mental-health advocacy organizations and networks. This article takes a critical analytic perspective on these activities surrounding mental health. Specifically, it problematizes the activities of mental health advocates in the European Union (EU), using the EU-Strategy on Mental Health as its central case study. It finds that while the Strategy's ultimate implementation is uncertain, and the state-level and non-state-initiated programs are not Europe-wide, we can speak of an assemblage of mental health at the European level, encompassing the activities, initiatives, and overlapping agendas of non-state advocates, state officials, European-level officials, and private capital, in a process of regional-level governance. Further, it finds that non-state advocacy within this European mental-health assemblage reinforces rather than challenges the scientific assumptions and diagnostic criteria of psychiatric professionals that erstwhile has been adopted by many European states, to varying levels of impact.

This finding is significant because it suggests that 1

advocacy on behalf of those persons perceived as mentally ill may encourage a greater rate of diagnosis of mental illness, even though the assumptions built into any diagnostic taxonomy are contestable and value-laden, just as their procedures are methodologically problematic and uncertain (Rob Flynn, 2002). The implications of mental-health policymaking at the European level are that, at best, mentalhealth advocacy in these assemblage processes helps constitute the identities of European citizens as more or less mentally ill; at worst, it limits the ultimate political agency in questions of mental illness— the diagnostic judgment—to elites who also manage the diagnostic criteria. Meanwhile, advocates contribute to processes that reduce non-elites’ agency to either rejecting the “rationalization” of rule or accepting it and thereby rendering themselves “citizen-subjects” (Rob Flynn, 2002) of mental-health governance. That mental-health advocates may encourage elitist rather than grassroots contributions to mental health policy is particularly notable once we note that in Europe, the concepts of North and South, as well as West and East, hold many politicized meanings: North and West are often considered more developed and politically more stable (and democratic); southern states, less developed; eastern states, "transitional."

In this socio-political context, an emerging European-level mental health

assemblage represents a potentially depoliticizing, de-democratizing influence on Europeans’ conceptions of their own and their fellows’ mental acuity, reasoning, and health. The article explores the EU-Strategy on Mental Health because it is the most visible (and first) initiative on mental health issues within the EU structure. The article adopts a critical constructivist method of analysis, including analytic tools from constructivist international relations and critical constructivist comparative politics, namely, the concept of "assemblage" (and the related concept "governmentality") and the conception of policy as a cultural rather than functional variable. This approach is useful for several reasons. First, the concept of assemblage captures the conglomerations or “ensembles” (Stephen J. Collier and Aihwa Ong, 2005:4) of scientific expertise, state policy, 2

international institutions, and other practices employed by state and non-state actors with a “will to improve” (Tanya Murray Li, 2007). Assemblages are sets of processes that frame interventions of a governmental or “improving” kind in a discourse that presumes a particular type of problem and entails a particular set of solutions (see for example Li, 2007; Deborah Wilson Lowry 2004). Second, the concept of governmentality "places the state/polity/society in a larger, and theorized, global-systemic and historical context” (Daniel Green, 2002: 9). Third, the article draws from critical analysis of global governance because of its ability to highlights the ways in which "the politics of global governance leads its participants to think in terms of power as the ability to control others" (Craig Murphy, 2002: xv)—though at the same time, the concept of assemblage allows us to highlight how participants are encouraged to think in terms of the ability to control themselves. On this view, the elements of a European-level mental health assemblage are emerging, pushed in part by mental-health advocates. The problem is that these assemblage processes reinforce and indeed encourage persons and societies to render themselves "governable" (Flynn, 2002) – likely not something that all mental-health advocates wish to encourage. The article begins by delineating the processes of EU mental-health assemblage, highlighting how it is beginning to resemble and yet diverge from current models of governance noted in international relations and EU studies.

It shows that advocacy groups (especially NGOs) have

participated in the policy design process; indeed, the promise of formal EU-level mental health policy prompted some NGOs' founding. The second section examines the principles grounding the EU-Strategy on Mental Health and other mental health policies in Europe. The principles originated as private-sector concepts and though that fact alone does not make them suspect, the principles’ trajectory through and role as a framework for EU policy processes raises questions about advocates' abilities to avoid reinforcing private privilege 3

over social empowerment. Indeed, analysis of EU mental-health principles illustrates official avoidance of policy harmonization across Member States (a characteristic most often noted by EU health-policy analysts, and a claim Europeanization theorists will find intriguing) but also repeated invocation of scientific knowledge and authority and calls for non-state-actor participation and expertise as means of legitimizing state and EU mental-health policies. After outlining the policy instruments and principles within the emerging EU mental-health governance process, the article explores their influence on the broader public's awareness of mental health issues, including what kind of public engagement it may produce. It finds that advocacy in EU mental health assemblage will incorporate citizens in a process of monitoring and assessment, and thereby rendering EU residents and citizens "governable." Additionally, the effects of assemblage will vary by state institutional and cultural context. Yet at the same time, it is likely that the increasingly regional and indeed global process of designing and implementing mental health policy will encourage similar advocacy strategies across European states (including both EU member- and non-memberstates). In the language of sociologists, a sort of isomorphism of advocacy1 will entail. I.

THE BACKGROUND OF EU MENTAL-HEALTH ASSEMBLAGE European Union authorities historically have claimed varying roles in health issues, and only

recently has the EU focused on mental health. While the Commission has spurred programs in various health issue-areas, EU legal authority in mental-health issues is not prominent. While a public-policy perspective might criticize EU law and activities for presenting a confusing array of authorities and priorities, this article highlights a different dynamic at work in EU mental-health governance. Namely, the structure and process of EU mental-health strategies exhibit patterns observed by Rob Flynn in his assessment of "clinical governance," including “a very complex [form] of ‘autonomy’” including

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This is a particular concern of sociological institutionalists.

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“variation in the relationship between medical professions and the state” and a “fluctuating boundary of bureaucratic and managerial control” (2002: 162). Indeed, a close examination of the contributions of non-state actors to Commission proposals on mental health underscores Daniel Green’s (2002: 7) observation that in late-modern policymaking, the state is not merely regulating an autonomous civil society; the two are co-constituted and co-constituting. We need to understand the context in which this assemblage has begun to form. A. Legal competencies in EU mental-health assemblage The EU’s legal competence in public health (though not health services) first was established in the 1992 Maastricht Treaty, which reworded article 3 of the Treaty of the European Community (1957) to read, "the Activities of the Community shall include…a contribution to the attainment of a high level of health protection," and more important, in Title X, Article 129, which declared, "the Community shall contribute towards a high level of human health protection by encouraging co-operation between Member States and, if necessary, lending support to their action," and "Community action shall be directed towards the prevention of diseases, in particular the major health scourges, including drug dependence, by promoting research into their causes and their transmission, as well as health information and education" (Treaty on European Union, 1992). This phrasing became part of Article 152 of the Amsterdam Treaty. On the basis of Article 152, mental health officially became a concern of the EU in 1998. At this time, the Council of the European Union passed a Resolution on the Promotion of Mental Health (Council of the European Union, 1999).

(Resolutions are binding to member states; states can

implement Resolutions in various manners.) A core concern of EU law is to delineate the respective authority of European-level institutions and laws, and state-level institutions and laws. In the formulation currently operating in the area of 5

mental health, EU institutions technically are limited to coordination activities and not to harmonization of member-state laws. For example, the Amsterdam Treaty declares that the Council shall adopt recommendations via qualified majority voting on health issues, including "incentive measures designed to protect and improve human health, excluding any harmonisation of the laws and regulations of the Member States" (Treaty of Amsterdam, 1997, rewording of article 129 of Treaty on European Union). At the same time, of course, states do not make decisions in a vacuum, and indeed, the Amsterdam Treaty entreats them to establish connections with non-state actors in the area of public health: a notable rewording of the Treaty on European Union (Maastricht Treaty) in the Amsterdam Treaty states, "The Community and the Member States shall foster co-operation with third countries and the competent international organisations in the sphere of public health" (Treaty of Amsterdam, 1997: article 129, section 3). B. “Soft law” initiatives in EU mental-health assemblage The Commission of the European Union has been the initiator of the “soft law” (i.e., non-binding official programs) on mental health in Europe. Health on the job has been a Commission (and Council) concern since 1978, and the Commission initiated its first public health Community Action Programme in 1995. Over the years, these Action Programmes have addressed health promotion, health monitoring, AIDS and other communicable diseases, cancer, rare diseases, injury prevention, pollution-related diseases, and drug prevention (Michael Joffe 2004; Scott Greer, 2006: 138; European Commission, 2007). Since the 1999 passage of the Council Resolution on the Promotion of Mental Health, and on the basis of Article 152 of the Amsterdam Treaty (specifically the statement, "a high level of human health protection shall be ensured in the definition and implementation of all Community policies and activities"), the most significant European-level mental-health initiative has been the Commission's 2005 Green Paper on "an EU-strategy on mental health,” and the awaited but as yet absent White Paper on the 6

same subject (European Commission, 2005). The Commission based its proposal on the observation that mental health is increasingly a concern of policymakers, and that "a first priority is to provide effective and high-quality mental health care and treatment services, accessible to those with mental health” problems (European Commission, 2005). The Green Paper could be read as an example of the state-centered, economic nature of the European project generally. This is true, for example, of its opening statement, which says, "The mental health of the European population is a resource for the attainment of some of the EU’s strategic policy objectives, such as to put Europe back on the path to long-term prosperity, to sustain Europe’s commitment to solidarity and social justice, and to bring tangible practical benefits to the quality of life for European citizens" (European Commission, 2005: 3). One could also read it as an attempt to co-opt or "capture" other actors in the EU's strategic web. But it seems more fruitful to read this statement, along with the “hard law” outlined above, as illustrative of the processes of assemblage. In the emerging EU mental-health governance system, European-level and state authorities’ roles vary over time and across programs. Adding to this “complex autonomy” (Flynn 2002: 162) are global-level and transnational non-state actors’ influences: the Green Paper cites the 2005 World Health Organization (WHO) European Ministerial Conference on Mental Health as inspiration for its policy vision. (It notes, however, that it envisions a broader strategy for mental health than that outlined by the WHO, which would include not only medical interventions, but also "a comprehensive approach…covering the provision of treatment and care for individuals…[and] action for the whole population in order to promote mental health, to prevent mental ill health and to address the challenges associated with stigma and human rights" (European Commission, 2005).) This broader approach is recommended because medical intervention "alone cannot address and change social determinants"; indeed, the Commission recommends "health and non-health policy sectors and stakeholders whose decisions impact on the 7

mental health of the population, as well as patient organisations and civil society" participate in the strategy (European Commission, 2005: 5). What has been most notable and interesting, however, is the complex autonomy and constituting and constituted role played by transnational non-state advocates of mental-health policy in Europe. The next section discusses this dynamic role. C. NGO activity within the European mental-health assemblage European non-governmental organisations (NGOs) began advocating seriously for European Union-level attention to health issues in 1991, in anticipation of the single market's completion by 1993. (Prior to 1991, non-governmental “activity on health at the European level was confined to single-issue organisations, such as those working on tobacco control or on cancers" (Joffe, 2004).) Mental-health activism at the European level occurred sporadically during the 1990s, for example, through Commission sponsorship of mental-health projects via the Action Programmes mentioned above. Then the Commission published the 2005 Green Paper proposing an EU-strategy on mental health that would "allow…involvement of a broad range of relevant stakeholders into building solutions" in the policy area.

Accordingly, it launched a debate "with the European institutions, Governments, health

professionals, stakeholders in other sectors, civil society including patient organisations, and the research community about the relevance of mental health for the EU, the need for a strategy at EU-level and its possible priorities" (European Commission, 2005: 3). Prior to the publication of this Green Paper, the Commission had already started working within a multi-actor framework often referred to as the “open method of coordination” and to date, through this framework, Commission funds have helped sponsor several mental-health advocacy groups, including the European Public Health Alliance (EPHA), the European branch of the Global Alliance of Mental Illness Advocacy Networks (GAMIAN-Europe) and other NGOs and industry organizations. These 8

NGOs responded to the Green Paper’s call for “debate.” What is notable about the Commission-NGO relationship is that each constituted and was constituted by those European-level mental-health activities. The Green Paper not only initiated more mental-health policy processes, including processes that linked NGO advocacy networks with medical professionals and university researchers, but also it provided these non-state actors with new impetus and indeed raison d'etre. For instance, the European Public Health Alliance cites Commission funding as a significant contributor to its activities and livelihood. In fact, it traces its history to obtaining Commission funding for a seminar that "attracted a high level audience from the European institutions and from several member states, and gave a powerful impetus to the new organisation” (European Public Health Alliance, 2007). EPHA and GAMIAN-Europe's input then was incorporated into several EU policy publications, including a Commission draft Directive on Data Protection and the 1994 EU Green Paper on Social Policy (European Public Health Alliance, 2007). Additionally, EPHA and GAMIAN-Europe both have been participants in the EU Health Policy Forum since its inception in 2001; the latter notes this prominently in its discussion of News from the European Union.2 Thus, it is not surprising that non-government mental health advocates read the Green Paper on an EU-Strategy on mental health as a window of opportunity for policy influence. The Green Paper states, "Given the diversity between Member States, it is not possible to draw simple conclusions or to propose uniform solutions. However, there is scope for exchange and cooperation between Member States and the opportunity to learn from each other" (European Commission, 2005: 7). Yet at the same

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"GAMIAN-Europe has been a member of this influential Forum since its creation by the European Commission in 2001. It brings together a number of key decision makers including representatives from the Commission’s DG Health & Consumer Protection, DG Enterprise and DG Research, selected pan-European patient groups, a range of healthcare professionals, health insurers, academic bodies, pharmaceutical industries and associations, consumer bodies and public service unions"(Global Alliance of Mental Illness Advocacy Networks, 2007).

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time, the European Public Health Alliance (EPHA3, a not-for-profit umbrella NGO) touts its member organizations' cooperating with the Commission on designing the ultimate mental health strategy, and its Web site congratulates NGOs on their contribution to the strategy, complete with links to those contributions: "Before producing a Strategy (due to be published during the summer 2007), the European Commission has compiled the main elements received from the 234 stakeholders and individuals that responded, (among which NGOs represent nearly half of the respondents). EPHA is pleased to see that most of the elements of its response are reflected in the report" (emphasis added, European Public Health Alliance: 2007). Similarly, the Commission clearly sees civil society as a significant contributor to its ultimate strategy, and values the contributions its members could make. As it claims, "Suggestions developed through the consultation process could identify best practice for promoting the social inclusion and protecting the rights of people with mental ill health and disability" (European Commission, 2005: 12). In this sense, the Commission-NGO relationship in European mental-health governance reflects a central characteristic of governance processes (Green, 2002), namely, that they involve state and nonstate actors respectively constituting and being constituted by each other. What is interesting about the Commission-NGO relationship, however, is that their complex, non-dichotomous relationship exhibits elements of what Flynn (2002) calls a “managerialist” character. What this is and what it means for Europeans’ understandings of mental health, of their own mental health, and of each other, is covered in the following sections. II.

EU

MENTAL-HEALTH

GOVERNANCE:

“MANAGERIALIST”

AND

ENCOURAGING EUROPEANS’ “GOVERNABILITY” The EU and mental-health NGOs exhibit a co-constituting and co-constituted” relationship not

3

The EPHA should not be confused with the EuPHA, which is an Association, not an Alliance.

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only in their visions of each other’s role(s) in mental-health governance, but also in their respective adoption of a standardized professional/diplomatic language. Interestingly, the language exhibits what Flynn (2002) calls a "managerialist" form. For example, the Commission invited EPHA and its member organizations to provide "consultant" feedback on EU policy papers. And the language of total quality management and consumer services pervades the language of the Green Paper. The Commission argued that civil society actors "could identify best practice for promoting the social inclusion and protecting the rights of people with mental ill health and disability." Best practices are mentioned not only in the quote above, but also in reference to a plan for an EU Platform on Mental Health that would "analyse key mental health aspects, identify evidence-based practice, develop recommendations for action, also at Community level, and identify best practice for promoting the social inclusion of people with mental ill health and disability and for protecting their fundamental rights and dignity" (European Commission, 2005: 13). Benchmarks also figure in the Commission's plan, as when it outlines the goals for the "consultation process" it envisions: "One objective is to identify priorities and elements for an action plan on mental health, leading to a set of core actions in health and non-health policies together with targets, benchmarks, timelines for action and a mechanism to monitor implementation"4 (European Commission, 2005: 13). And the Green Paper repeats three times the concern to "add value" to existing policies on mental health (European Commission, 2005: 3, 7, 13). Meanwhile, the EPHA and its constituent organizations use the same language in describing their goals and activities within the context of EU mental health policy. For example, while describing its policy implementation activities, the EPHA notes a project ("European Mental Health Promotion Implementation") whose areas include "partnerships and capacity building" and whose aims include "sharing models of good practice on mental health promotion and prevention of mental ill-health" 4

Notably, the Commission ties its goals to a larger process of mental health policymaking, begun at the global level: " The WHO Mental Health Action Plan for Europe could serve as model, together with the Action Plan “Mental Health Promotion and Mental Disorder Prevention: A Policy for Europe” developed under the EU-Public Health Programme."

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amongst eight European networks and twelve "national partners" (European Public Health Alliance. 2007).

Similary, on its Web page discussing current activities, GAMIAN notes a project called,

"Exchange of good practice between patients groups" (Global Alliance of Mental Illness Advocacy Networks, 2007).

(A seminar within this project included several activities involving EU

representatives, such as a presentation by the Health Counsellor of the German Permanent Representation to the European Union, who "outlined the role and responsibilities of the members of the Council of Europe"; another presentation by a member and a Vice Chairman of the European Parliament Committee on the Environment, Public Health and Food Safety; representatives of the Commission Directorates General on Research and Enterprise—the latter described the Commission’s "Pharmaceutical Forum" to workshop participants—and finally, presentations by representatives of two advocacy groups, the Estonian Mental Health Association, and the Men's Health Forum in the UK ((Global Alliance of Mental Illness Advocacy Networks, 2007). III.

IMPLICATIONS OF THE EU MENTAL-HEALTH ASSEMBLAGE FOR MENTALHEALTH ADVOCACY IN EUROPE Does it matter that the EU and mental health advocates have adopted the same language,

principles, and practices?

To consider this question, we need to understand the origins of these

principles, such as "good" or "best practices" and "benchmarking." Benchmarking and best practices originated in U.S. corporate management philosophy after World War II, when firms adopted the goal of continuous improvement. Benchmarking was the establishment of quantifiable criteria for gauging firm performance toward this end.

Best practices were those production forms practiced by the most

competitive firm in a given industry or sector. Over time, these concepts changed business practices profoundly: for example, the practice of Total Quality Management (TQM) and its derivatives emerge from these concepts (Leslie Sklair, 2001).

They also became the concern of developed state 12

governments (Michael Edwards and David Hulme, 1996; Sklair, 2001).

Flynn notes that these

principles, which are included in what some sociologists call "managerialism," have worked their way into clinical governance, which he sees as "one small part of a long-term programme of reform in the public sector" that "may be seen as the latest phase in the expansion of managerialism." "The genealogy of clinical governance can be traced back to these generic aspects of managerialism, and specifically to ‘total quality management’ and similar approaches to quality assurance in industry and consumer services" (Flynn, 2002). There are at least two different ways to read the implications of a policymaking process that involves benchmarking, good or best practices, and a concern for "value added." One is that this kind of process establishes more horizontal relations between non-state actors, including advocacy networks, and state and supranational governments (Arrowsmith et al., 2004 (citing Borrás and Jacobsson 2003)). Another, and I believe more important implication to these policy principles is that they alter the substance of advocacy and the form mobilization can take. By adopting these principles, advocates engage in a "governmentality" policymaking process that involves “the disciplining and regulation of the population without direct or oppressive intervention” (Flynn, 2002: 163). As Flynn (2002) notes in his analysis of clinical governance processes, the process of governmentality encourages actors “to perceive problems in similar ways and accept a responsibility to seek ways of transforming their positions themselves” (p. 163, quoting Johnson, 1995: 23). We may perceive a governmentality element, then, in the Green Paper, where the Commission invites "all interested citizens, parties, organizations and the European Union institutions to contribute to the preparation of a possible EU-Strategy and an Action Plan on Mental Health by commenting" on the paper (European Commission, 2005: 13). Governmentality processes are also evident in the EPHA's encouraging its member organizations to respond to Commission Papers, and with GAMIAN-Europe's 13

participating in and co-hosting the 2001 EU Health Policy Forum. Indeed, from a critical constructivist position, these advocacy organizations play a crucial role in the governmentality of mental health in the EU. In governmentality processes, "experts play a strategic role in producing knowledge (discourse) and schemes of action (practice)….[P]rofessionals become crucial to the state in its 'exercise of power, systems of technique and instrumentality; of notation, documentation, evaluation, monitoring and calculation', and thus render society governable" (Flynn, 2002, quoting Johnson, 1995: 23).

As such, mental health advocates should watch for a sort of

isomorphism of advocacy (Green, 2002: 24) to develop within the EU context, in which mental-health advocacy takes a similar (and perhaps more acceptable to state and/or EU officials) form over time. Mental health advocates also should watch for a more-governable (not more-agitated) social response. In other words, these principles, and their adoption by both EU officials and European mentalhealth advocacy networks and activists, raise the concern that in the context of EU governance, advocates will construct and mobilize publics by adopting a "rationality of rule" in which advocate (and eventually public) learning is limited. In the area of mental health, it will be limited to building expertise in treatments that either have been ineffective, such as most treatments for eating disorders such as anorexia nervosa and bulimia nervosa, or differently and perhaps worse, to treatments that have contributed to the social conditions conducive of problematic eating patterns in the first place. That is, through EU governance processes that co-constitute both EU officials and mental-health advocates, the advocates run the risk of contributing to processes that render European societies “governable.” They may run this risk in many issue-areas, but this article’s concern is that this is a higher risk in mental health because of the heavy influence of scientific knowledge in this policy area. To be sure, there is some possibility that this "managerial" process can create new forms of statenonstate interaction, and this paper is not meant to sound only alarm bells. Additionally, the approach 14

taken here should not be taken as a sign that the author does not approve of better standards of mental health care, or greater professional accountability to patients (see Flynn, 2002: 156). Yet there are concerns about mental health care in Europe that should be raised while the EU adopts these policy principles. Therefore, in the context of the emerging EU mental-health policy process, advocates of mental health in particular should not overestimate their abilities to change the perceived shortcomings of state mental-health policies by bypassing national governments and targeting supranational officials, or by using the tools of professional and scientific expertise adopted by the Commission itself. Specifically, they should remain watchful not so much of overt moves by EU offices or member-states to "coopt" them, but rather of strong overlap in the language and knowledge they and their government counterparts adopt. Partnership between state and non-state actors is feasible—indeed, it is a core principle within the managerial context of EU policymaking. But advocates should be concerned if partnership itself becomes the end rather than the means to the end of equal and healthier societies, and they should be vigilant of EU soft-law's ability to construct and constrict the substance and results of their advocacy strategies. IV.

STRATEGIC OPTIONS FOR MENTAL-HEALTH ADVOCATES IN EUROPE Thus we can see a tension here for mental health advocates. Specifically, advocates will face

two pressures in policymaking processes in the EU. The first is the pressure to act as "expert" and thus play a part in the process of managerialism or governmentality that appears to be emerging. This is a risky or at least very difficult role for advocates to play because, as we have seen above, it enlists the expert, and the objects of the expert's professional (in our case diagnostic) gaze, in the governmentality process, thereby rendering people "governable" rather than, say, agitated or disruptive.

Such an

outcome surely is contrary to those that at least some feminist advocates would hope for. Additionally, as we shall see below, feminists who adopt this role in EU mental health policy may even contribute to 15

the conditions for mental health problems, such as the eating problems and other behavioral or mental distresses that women disproportionately exhibit (and which are labeled "mental disorders" despite their social components highlighted by EPHA, GAMIAN-Europe, and other mental health advocacy groups, and even by the Commission). The other pressure is for advocates to resist the governmentality process and the practice of managerialism by working from outside the language of consultation, best practices, benchmarking, etc., and by encouraging political instability in the area of mental health. Yet this role flies in the face of at least some advocacy models today, particularly in an era in which NGOs have adopted the "New Policy Agenda" of neoliberal economics and liberal democratic theory (Edwards and Hulme, 1996). CONCLUSION European mental health advocates therefore are situated in a difficult position. One, they work within a process in which they encourage the incorporation of persons into the diagnostic codes. Thus, in the constructivist terms employed throughout this paper, they stand to help "render" those persons "governable" in a particularly personal sense. This is the case because although the diagnostic codes with which they engage are continually in revision, certain assumptions of the ICD as well as the DSM appear to lie beyond revision, including, most important, the assumption that eating problems result from mental disorder inherent in an individual. The second dimension to advocates' position therefore is that despite encouraging a broader, societal view of mental illness, the diagnostic codes with which they engage return the policy focus back to the individual. Individuals are treated for mental disorders, not societies, even though, as the Commission itself puts it, medical intervention "alone cannot address and change social determinants" (European Commission, 2005: 5). (This may reflect a blind spot in many experts' perspectives, because they do not appear to consider their own knowledge as embedded in the social structure whose influence they wish to recognize.) By contrast, advocates in the area of 16

mental health ought to acknowledge the ways in which "scientific knowledge about ourselves…changes how we think of ourselves, the possibilities that are open to us, the kinds of people that we take ourselves and our fellows to be" (Ian Hacking, 1998: 10). Can advocates ally with the European Union on mental health? The answer is, of course, that they may have no choice, insofar as their work provides the glue that brings an assemblage together. As Li (2007) argues, “Assemblage flags agency, the hard work required to draw heterogeneous elements together, forge connections between them and sustain these connections in the face of tension. It invites analysis of how the elements of an assemblage might—or might not—be made to cohere” (p. 264). Arguably, social advocates are crucial to any assemblage: it is in their interests to create assemblages and maintain the processes of assemblage. In this sense, it may be that mental-health advocates will find the assemblage to which they have contributed great amounts of effort and time are either not quite what they had envisioned, or have become (or always were) entirely impenetrable to the kind of practices they hoped to engage in across Europe. The position paper that the advocacy group Mental Health Europe (MHE) published in response to the Green Paper illustrates why advocates must be careful: Namely, because it illustrates the tension they will find in advancing mental-disorder discussion in the European context. The position paper's views are worth close consideration: MHE also notes that medical models of mental health are still dominant in some EU countries and may obscure the social causes and contexts of mental distress. ‘Mental well-being’ is a more useful term to use than ‘mental (ill) health’ as it is something that all European citizens can readily relate to their own lives and experiences. There is an urgent need to improve mental health and well-being for all as well as to improve the quality of life for those experiencing mental illness or distress. (Mental Health Europe, 17

2006) If advocates are to provide a voice for persons who experience mental distress and express their distress through problematic eating patterns or other self-destructive means, they should do as MHE has done with the language of the Commission (and by implication, other official EU actors) and rewrite it. They should also do as MHE has done and emphasize the larger social context in which mental distress can occur. But they will need to do both of these things in a way that does not adopt an expert voice (as embodied in a diagnostic code, for example) if and when that voice stands to minimize the social dimension for the sake of diagnosis. And advocates will need to attend to the anxiety pervading much discussion on mental health. An example of this anxiety is the opening statement by participants in a large, trans-European mental health project, the European Study of the Epidemiology of Mental Disorders (ESEMeD). It states, “Mental disorders are increasingly recognized as a major source of disability in the world. The costs associated with mood and anxiety disorders are very high. Forecasted future increase in the magnitude of mental disorders will most likely be associated with higher costs" (J. Alonso, M.C. Angermeyer, J.P. Lépine. 2004: 5-7).

Setting aside the framing of mental disorder as "disability" (which some

constructivists would certainly challenge (see for example Ray McDermott and Hervé Varenne, 1995: 326),5 the anxiety reflected in this and following statements of ESEMeD reflect Flynn's observations of a "common thread" in analyses of clinical governance, namely, "that at every level of civil society, complexity, fragmentation and uncertainty all place severe pressure on individuals’ and groups’ capacity to collaborate and their willingness to trust others" (2002: 162) In this context, the patient being treated may not necessarily be the mentally distressed person, but rather, those around who feel anxious and look to diagnosis as remedy. European mental-health advocates will need to keep this in mind as they For example, Ray McDermott and Hervé Varenne view "culture as disability", arguing, “Culture is not so much a product of sharing as a product of people hammering each other into shape with the well-structured tools already available. We need to think of culture as this very process of hammering a world.” 5

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employ diagnostic terms, lest they disempower those they aim to empower. Talk of eating disorders or other mental disorders in Europe includes an element of anxiety that will need to be tempered, because under its influence, diagnosis may seem the best, most expedient treatment.

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Works Cited Alonso, J., M.C. Angermeyer, J.P. Lépine. 2004. The European Study of the Epidemiology of Mental Disorders (ESEMeD) project: An epidemiological basis for informing mental health policies in Europe. Acta Psychiatrica Scandinavica, 109 (Suppl. 420). Collier, Stephen J. and Ong, Aihwa (2005) “Global assemblages, anthropological problems.” In Global assemblages: Technology, politics, and ethics as anthropological problems, edited by A. Ong and S.J. Collier, pp. 3-21. Malden, MA: Blackwell Publishing. Council of the European Union. 1999. European Council resolution of 18 November 1999 on the promotion

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lex.europa.eu/LexUriServ/LexUriServ.do?uri=CELEX:32000Y0324 (01):EN:NOT. Accessed 13 June 2007. European Commission. 2005. Green Paper: Improving the mental health of the population. Towards a strategy

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European Public Health Alliance. 2007. "*UPDATED* Promoting mental health at EU level: The Commission consults the civil society." Web page. Retrieved 4 May 2007 from the Web: http://www.epha.org/a/1903. Flynn, Rob. 2002. Clinical governance and governmentality. Health, risk & society, 4, 2 (155-173). Global Alliance of Mental Illness Advocacy Networks. 2007. "GAMIAN Europe: Current activities." Web page. Retrieved 4 May 2007 from the Web: http://www.gamian-europe-history.org/. Global Alliance of Mental Illness Advocacy Networks. 2007. "GAMIAN Europe: News from the European Union." Web page. Retrieved 4 May 2007 from the Web: http://www.gamian-europehistory.org/. Green, Daniel M. (2002) Constructivist comparative politics:

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Constructivism and comparative politics, edited by Daniel M. Green. London: M.E. Sharpe. Greer, Scott L. 2006. Uninvited Europeanization: neofunctionalism and the EU in health policy. Journal of European Public Policy 13, 1: 134–152. Hacking, Ian (1998) Mad travelers: Reflections on the reality of transient mental illnesses. Cambridge, Massachusetts: Harvard University Press. Joffe, Michael. 2004. History of the EPHA. European Public Health Alliance Web site. Retrieved 4 May 2007: http://www.epha.org/a/715. Last modified 6 February 2004. Li, Tania Murray. 2007. Practices of assemblage and community forest management. Economy and Society, 36, 2: 263-293. Lowry, Deborah Wilson (2004) Understanding reproductive technologies as a surveillant assemblage: Revisions of power and technoscience. Sociological perspectives, 47, 4: 357-370. McDermott, Ray, and Varenne, Hervé. 1995. Culture "as" Disability. Anthropology & Education Quarterly, 26, 3: 326. 21

Mental Health Europe. 2006. MHE Position on the EC Green Paper on Mental Health: An EU Strategy on Mental Health and Well Being. Brussels: Mental Health Europe (pp. 2-3). Murphy, Craig M. 2002. Foreword: Why pay attention to global governance? In R. Wilkinson and S. Hughes. 2002. Global governance: Critical perspectives (pp. xiv). London: Routledge. Sklair, Leslie. 2001. The Transnational Capitalist Class. London: Blackwell. Treaty of Amsterdam, 1997: article 129, section 3. Treaty on European Union, 1992.

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