Globalising Disorders: Encounters with Psychiatry in India China Mills A thesis submitted in partial fulfilment of the requirements of the Manchester Metropolitan University for the Degree of Doctor of Philosophy Education and Social Research Institute Manchester Metropolitan University 2012 2 Globalising Disorders: Encounters with Psychiatry in India This is a thesis on Global Mental Health, on what it means for mental health to be ‘global’. It is a thesis about encounters; about research encounters, about psychiatry’s encounters with the global South, about colonial encounters. It’s about crises both individual and global, and the poltical rationales at work in the mediation of these crises. It’s about becoming and unbecoming psychiatric subjects, it’s about psychiatrization, about psychiatry’s creep out of asylums and across borders, into everyday life, globally. 2 Abstract Amid calls from the World Health Organization (WHO) and Global Mental Health to ‘scale up’ psychiatric treatments, globally, there are other calls (sometimes from those who have received those treatments), to abolish psychiatric diagnostic systems and to acknowledge the harm caused by some medications. This thesis elaborates a space for these arguments to encounter and to be encountered by each other. This is a thesis about encounters; about psychiatry’s encounters with the global South; about research encounters in India with mental health Non-Governmental Organisations (NGOs); and about colonial encounters more generally. Drawing on analysis of interviews and visits to a range of mental health support provision in India, this thesis traces some conceptual and material mechanisms by which psychiatry travels - across borders - into increasing domains of everyday experience, and across geographical borders, into low and middle-income countries. It explores the claims of Global Mental Health, ‘to make mental health for all a reality’, as being particular mechanisms of psychiatrization - ones that may employ similar codifications to those of colonial discourse. Global Mental Health and WHO mental health policy often mobilise psychiatric interventions in response to a ‘crisis’ or an ‘emergency’ in mental health, globally. Yet while this current incitement suggests an abnormal deviation from a normal order, mental illness may also be read as a ‘normal’ reaction to the (dis)order of globalisation. Nevertheless, in making the claim that mental health problems, such as Depression, are a ‘normal’ response to inequitable market relations in the global South, may also be normative, as it glosses over a simultaneous globalisation; that of bio-psychiatric explanations of distress. Thus, while Global Mental Health marks an explicit making political of psychiatry through its conceptualisation of mental health as key to an agenda of international development, it simultaneously disavows psychiatry as political through its universal application of psychiatric technologies. To claim the universality of psychiatric diagnoses is different from making the claim that distress, manifest in myriad forms, is universal. This is because psychiatric frameworks are mediators of that distress, they provide but one way of understanding yet they are often framed as being the ‘truth’, globally. 3 Reading Global Mental Health psychopolitically, then, enables an engagement with the double process through which conditions of inequality and alienation may become internalised –how inequality may come to play on the body, to be made flesh. This move occurs alongside another process that reads the mechanisms by which socio- economic crisis comes to be rearticulated and reconfigured as individual crisis, as mental illness. To read Global Mental Health as a colonial discourse is to trace how particular knowledge is mobilised in the creation of a space for psychiatric ‘subject peoples’, a global space. This research traces some of these ‘on the ground’, often powerful, techniques of recruiting subjects and fixing them. It also interrogates the knowledge base of Global Mental Health to create a space to read this alongside alternative ways of knowing; specifically psychiatric user/survivor and critical psychiatry critiques. This works to explore how psychiatry encounters difference (both within the global North and South), and to (re)think how Global Mental Health might be encountered differently. This thesis thus explores how the colonial relation is mobilised within psychiatric treatment in order to think through how the violence of colonialism may enable a re- thinking of contemporary forms of psychiatric treatment as being violent, the violence of psychiatrization - violence in the name of ‘treatment’. Using the post-colonial theory of Frantz Fanon, Ashis Nandy and Homi Bhabha, as conceptual tools, alongside research encounters (interviews, ethnographic field work, policy documents) in India, enables exploration of how psychiatrization may allow relationships of domination and resistance to continue after formal colonialism has ended. It also enables engagement with how strategies of resistance to colonialism may be read alongside and used to illuminate resistance to psychiatry – resistance that may be secret, sly, covered up. This research concludes by attending to emerging counter-hegemonic ways of knowing distress, epistemologies of the South, in order to creatively re-think the work of Global Mental Health and psychiatry in countries of the global South. To imagine a global mental health that attends to the heterogeneity and complexity of local, indigenous ways of knowing distress, that rethinks issues of consent – specifically around the use of psychiatric terminology and the provision of non-medical (and non-‘western’) spaces 4 of healing, and that recognises psychiatry as one of many approaches, questioning whether it can, or should, be global. 5 6 TABLE OF CONTENTS Acknowledgements……………………………………………………………11 Preface…………………………………..…………………………………………..15 Chapter One De-familiarising Global Mental Health: a methodology of Encounters A Chapter on encounters, psychiatry’s encounters with the global South, my encounters with methodology, on the identity of a woman spoken in foreign terms, on making the familiar strange, on writing messily, on psychopolitics ….17 Chapter Two Sublation and the Brain: Burdens, Markets, Gaps: A chapter on illness, distress and disability, on what counts as evidence, on mental illness as a burden, and on burdens as markets, on universals and synthesis and sublation, on gaps, and on asking questions about gaps, like, ‘is there a gap?’, ‘a gap between what and what’? ...59 Chapter Three Special Treatment, Special Rights: Children who can’t refuse A chapter on children who can’t refuse and who are not believed, children as limit figures, on ‘normal’ childhoods and global childhoods, on children as the ‘future’ and as a ‘target’, on who’s lives are worth living, and who’s lives are ‘bare’, on what counts as ‘treatment’ and what counts as violence. …109 Chapter Four Normal violence: Violence with a Civilising Mission A chapter on the adult/child and the north/south; on the figure of the child-like and the primitive; on when we do and do not feel horror, on constructions of crisis and 7 emergency – both individual and national, on violence that we see as normal, natural, necessary, banal and bureaucratic, on violence with a civilising mission. …137 Chapter Five ‘Harvesting Despair’ – Writing Suicide Notes to the State A chapter on pesticides and suicides, on global markets and cotton prices, on suicide notes written to the Government, on patenting drugs, on recognition and inoculation, and on the messiness of Neoliberalism. …159 Chapter Six Educating, Marketing, Mongering; Making Mental Health a Reality for All A chapter on the ‘making up’ of psychiatric ‘subject peoples’, on eliciting, fostering and promoting, on the blurry boundaries between educating and marketing, on different types of literacy – mental health, colonial, and emotional, on the global mongering of disease, on ‘native madness,’ and on whether mental illness exists. …179 Chapter Seven The Turn / The Look: Interpellating the Mad Colonial Subject A chapter on abrading, objectifying, crushing, on psychiatrization, on hailing and recruiting, recruiting them all, a way of forming subjects that almost always gets its (wo)man, about a look, and a turn, a doubling, the formulas and figures of interpellation – from behind, from above, face to face, about a psychiatrist squatting down on the street. Who will occupy the space of Global Mental Health, and how will ‘they’ come into being? …209 8 Chapter Eight Oozing Bodies; Visibly Invisible A chapter on oozing, defecating, leaking, on the disruption of boundaries, on the pleasure of seeing, and on remaining invisible, on psychiatry’s fantasies, and on touch – the touch of medication, the touch of hands, the touch of skin - the ‘border that feels’. …243 Chapter Nine Sly Normality: Between Quiescence and Revolt A chapter on fading, being faint, as feint, on making oneself invisible, on camouflage and blending, on a secret terrain of resistance, resistance that is hidden, that leaves few traces and covers its tracks, on pills hidden under tongues, on being sly, and on pretending – pretending to be sane, pretending to be insane, on sly normality – as seduction, symptom and subversion …265 Chapter Ten Decolonising Global Mental Health: mapping dissent / (en)countering epistemicide A Chapter on repetitions and on mapping alternatives, on anxiety and repetitions (successful