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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 2Globalising 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 ps ychiatry’s creep out of asylums and across borders, into everyday life, globally. 2Abstract 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. 3Reading 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 socioeconomic 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 rethinking 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 4of healing, and that recognises psychiatry as one of many approaches, questioning whether it can, or should, be global. <ul style="display: flex;"><li style="flex:1">5</li><li style="flex:1">6</li></ul>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 ….1 7 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 believ ed, 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. …1 09 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 7emergency – 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? …2 09 8Chapter 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 and failed), on Fanon and the psychopathology of colonialism, on Nandy and a language that makes no-sense, a chapter to end on. … 305 Bibliography……………………..349 Appendices (one to nine)………379-399 <ul style="display: flex;"><li style="flex:1">9</li><li style="flex:1">10 </li></ul>Acknowledgements and Thanks This thesis is in many ways the product of a collective (re)thinking of issues around psychiatrization, colonisation, violence and alternatives – a search for other ways of knowing. While I may be the author, my writing is haunted by many voices - whispering throughout. In India, so many people offered me their time and their kindness. I want to say thank you to the people I met, and who met with me - many of them surprise encounters - who gave me their time to chat, who invited me for dinners, who whizzed me round on scooters and motorbikes, and who told me where I could get a strong coffee. The people who translated my workshops so beautifully and showed me round their organisations, their homes, their lives. To the organisations that let me visit and took me in, I hope they think this is a fair representation of their work, even though we didn’t always agree. Particularly I would like to thank the staff at Bapu Trust, Iswar Sankalpa, The Banyan, the Schizophrenia Awareness Association, and the Shraddha Foundation. I owe a great debt to Bhargavi Davar and Sarbani Das Roy - you both scare me a bit, not least because your dedication and your kindness is overwhelming. And thank you to; Reshma Val and Lavanya Seshasayee – for surviving and sharing your stories; to Yogita Kulkarni for your lovely way of explaining things, your patience is endless; to Sonia Soans - for Koshy’s and for potatoes that smile – a wonderful introduction to Bangalore. And for getting me into NIMHANS and getting me out. To Ranjita Biswas, Diptarup Chowdrey, Kimberley Lacroix and Sabah Siddiqui. Thank you to Anup Dhar and those who made it possible for me to share my work at Ambedkar University Delhi - where discussion rendered me literally speechless due to the wonderful suggestions of the participants and a simultaneous throat infection. And to those who let me share my work at the Indian Association of Women’s Studies Conference in Wardha, 2011; and at CSCS, in Bangalore. So many conversations, stolen moments, haunt this work – my memory doesn’t do them juistce, but thank you to; all those who make up the wonderful discussions at the Asylum North-West Collective, the Discourse Unit, and the Education and Social 11 Research Institute. And particularly, thank you to, Ian Parker, Dan Goodley, Shaun Grech, Donna Reeve, Dean Smith and Helen Spandler. Thankfully, I shared the struggle this journey has sometimes been with a few others on the same journey - Hannah Berry, Steve Graby, Anat Greenstein, Jen Slater, and Jemma Tosh. A struggle shared over cheap food in pubs, and often many many pints. And thank you to the Education and Social Research Institute for funding me, and giving me the space for my thesis change; and to John Schostak, for believing in it. For much of the time while writing this thesis I have had no fixed place to live, I became a ‘house sitter’, and it has been wonderful, unsettling and means I now immediately feel at home in other people’s houses, and never at home in my own. A variety of homes, then, have provided the setting for writing this thesis, endless cups of coffee from other people’s mugs have given me the energy and the shakes, and Laurie Anderson and Radiohead (played on other people’s stereos) have provided the soundtrack. For those who trusted me with their homes (or let me live with them) – a million thanks. Some people deserve a special mention – for more reasons than I could ever say; The O’Hanrahans, and especially Elaine and Sean, my Mancunian family, for so much love. My dads - Paul and Mimmo, for delicious dinners in chilly surroundings, for living the way that makes you happy. Julie Downs and Becky Harper, for showing me what bravery is, and courage. For showing me other ways of understanding. Michael Toth, for your ever-lasting friendship and your gravity defying hair. Jen, for your company, your mutual love of port and for the sanctuary of your flat. David, for interrupting me, for making me laugh, and for teaching me how to build a good den. 12 There are three people in particular for whom thank you is simply not enough. Erica Burman - how can I express what having you as a supervisor - so much more than a supervisor - has been like? Your support and belief have left me speechless. Jane – for everything. Not least for being a wonderful mum. Liam – I couldn’t have written this without you, and I have struggled to finish it without you. You have been my harshest critic and the most wonderful companion - I hope we will travel together again in the future. 13 This thesis is dedicated to the memories of Marion and Arthur - my Grandparents – for stories and butterfly buns, and well kept secrets - for everything And to, Bhargavi Davar and Sarbani Das Roy – for believing that another world is possible, and for doing something about it 14 Preface Not so very long ago, the earth numbered seven billion inhabitants; 450 million of them developed a mental illness every year;1 and 290,500 of them were psychiatrists.2 The latter had the Word; the others had the use of it.3 1 WHO (2001). Mental Health: A Call for Action by World Health Ministers. Ministerial Round Tables, 54th World Health Assembly. WHO, Geneva. 2 Based on Mental Health Atlas (2005) estimates of 4.15 psychiatrists per 100 000 [online<a href="/goto?url=http://www.who.int/mediacentre/news/notes/2005/np21/en/" target="_blank">] </a><a href="/goto?url=http://www.who.int/mediacentre/news/notes/2005/np21/en/" target="_blank">http://www.who.int/mediacentre/news/notes/2005/np21/en/ </a>(Accessed 2.8.2012); and on world population being approx. just over 7 billion, according to the UN Department of Economic and Social Affairs [online] <a href="/goto?url=http://esa.un.org/unpd/wpp/index.htm" target="_blank">http://esa.un.org/unpd/wpp/index.htm </a>(Accessed 2.8.2012). 3 This is a reworking of Sartre’s (1963) preface to Frantz Fanon’s ‘Wretched of the Earth’ (Penguin Books). The original reads, ‘NOT so very long ago, the earth numbered two thousand million inhabitants: five hundred million men, and one thousand five hundred million natives. The former had the Word; the others had the use of it’ (Sartre, 1963:7). <ul style="display: flex;"><li style="flex:1">15 </li><li style="flex:1">16 </li></ul>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 Encountering the ‘psychiatric patient’ - Story Number one (one way of telling the story) At the Banyan, a Non-Governmental Organization (NGO) that works with and houses people with mental health problems, in Chennai, India, the staff began asking Meesha4 (a woman with a Schizophrenia diagnosis who lives at the centre) some questions. They asked her about her family. She told them, in Tamil (a South Indian language), that her mother had heard voices, like she does, and had been a ‘psychiatric patient’. Meesha said those two words, ‘psychiatric patient’ in English. That was the only English she spoke that day. When the staff asked her if she was a ’psychiatric patient’, she said ‘No’, because ‘psychiatric patients’ had wild unbrushed hair – unlike her. ‘If you’re not a psychiatric patient’ the staff said, in Tamil, ‘why do you take medication? ‘To be cured’, Meesha replied, ‘to be cured of The Banyan’. [Field notes, January 10th, 2011].5 Meesha’s words, without her ever knowing it, illuminate many of the concerns, the messy spaces of this thesis. I want to draw upon Meesha’s words as lens. Lens 1: ‘psychiatric patient’ What does it mean that Meesha, who speaks only Tamil, said the words ‘psychiatric patient’ in English? In those two words, spoken in a foreign language, it is possible to hear echoes of psychiatry’s colonial history, brought to India in the form of asylums built by the East India Company in the late 18th Century (Ernst, 1997). It is possible to glimpse the multiple translations at work within psychiatry; the translation of experiences and local idioms of distress into psychiatric categories, into English – into different languages. Her words show that here, when we speak and write of mental distress (or ‘mental illness’), what we call ‘it’ matters, language matters. Her words call on us to grasp the hegemony of ‘western’ psychiatry, a psychiatry developed in specific 4 Names have been changed throughout to ensure confidentiality, except where stated, and where permission was given. 5 These notes are taken from a workshop that I facilitated at the Banyan, on January 10th 2011. I do not speak Tamil, and thus Meesha’s words were translated for me by the staff. 18 High-Income Countries (HICs) of the global North (yet always haunted by their colonial intertwinings). Her words hint at psychiatry itself as colonial, as enacting a colonial relation through its multiple translations, a colonisation of the mind (Thiong’o, 1981). Finally, Meesha’s words are suggestive of the globalisation of psychiatry, how psychiatric ways of understanding distress, health, illness - what it means to be a person - ‘travel’ across the globe. Her words even hint at one of the ways that psychiatry may travel, through the work of NGOs like the Banyan. Lens 2: ‘To be cured’, Meesha replied, ‘to be cured of The Banyan’. And so Meesha said that she needed to be ‘cured’, but for her the ‘problem’ that required a cure was the place that claimed to be ‘treating’ her of the thing that they ‘knew’ she had but she said she didn’t have – a ‘mental illness’ called Schizophrenia. Meesha’s words locate the ‘problem’ in need of ‘cure’ in the social world, in the environment, in psychiatric interventions. The psychiatrists who have intervened in Meesha’s life think that the ‘problem’ lies inside Meesha, in her brain, in her biochemicals. In her understanding, Meesha takes psychiatric medications in order to get out of the Banyan, the very place that provides her with that medication. For the staff, Meesha takes medication because she has Schizophrenia, a diagnosis made by The Banyan. What does it mean to take psychiatric medication to be ‘cured’ of psychiatry? How do psychiatric medications broker subjectivity? If some of those subjected to psychiatry want to be ‘cured’ of it, then what role should psychiatry play in responding to people’s distress, in the global South and North? Meesha’s words also happen to be the only words spoken in this thesis by someone who receives psychiatric interventions within an Indian NGO; people who are often referred to as the ‘destitute mentally ill’. Encountering Global Mental Health, ‘scaling up’ This thesis was initially supposed to be something very different. But one day, when I was in Kolkata doing research with a mental health NGO for my PhD, I encountered three words - ‘Global Mental Health’ - and lots of things changed. This was a surprise encounter, a seminar I heard about only half an hour before it was due to take place

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