The Silent Subjects of Mental Illness in India

The kind of silence I wish to discuss permeates everyday life: mental health, particularly in developing countries. Having done previous research^[1] on development and humanitarian organisations’ lack of critical engagement with psychosocial emergencies and cross-cultural psychiatry, I find problematic the kinds of commitment — or perhaps the lack thereof — international development organisations make in regards to mental wellbeing. A multitude of problems face international development organizations and their approach to dealing with mental health issues. In particular there is a threefold problematic around silence: mental health has been deemphasized and thus silenced in the development discourse^[2], problems arise diagnosing personality and behavioural disorders across different cultural contexts, and the silencing and marginalization of individuals suffering from mental illness by everyday cultural practices. Drawing on a case study recently done in South India, this essay seeks to argue that a focus on illness narrative, borrowing a few ideas from the radical democratic theories of Mouffe and Laclau, can help combat the second and third types of silence mentioned above. The approach is firmly rooted in medical/psychological anthropology and mostly seeks to highlight what is an increasingly prevalent problem not just in the global north but also the global south—both how we discuss issues pertaining to mental health, and the ways in which we decide what is (ir)relevant in both mental health and development discourses.

Mental Health in Cross-Cultural Settings

Making accurate diagnoses under different cultural backgrounds is a problem mental health practitioners need to resolve. Gananath Obeyesekere’s^[3] foray into Sri Lankan Thevarada Buddhism exemplifies the problem: Obeyesekere took a group of American psychiatrists to a Thevarada temple in Sri Lanka. During their visit, the Americans talked to some of the Buddhist monks, who were meditating in front of fecal matter, and express ideas one would associate with depression: loss of material pleasure and desires, no explanations of aspirations, and a sense of apathy and detachment from everyday life. Based on such discussions, the psychiatrists panicked and diagnosed everyone in the temple with depression. However, Buddhist ontology revolves around the transient nature of life; since nothing will last forever, one must refrain from becoming attached to all material objects on Earth to minimise pain and suffering from the loss they experience. Through meditating in front of faeces, the Thevarada Buddhist comes to find their bodily senses to be repulsive, and gradually detaches themself away from them. Obeyesekere punctuates the importance of cultural backgrounds by asking the following rhetorical question: could anyone imagine a depressed Anglo-Saxon American meditating in front of faeces?

Obeyesekere however fails to consider the possibility that the Buddhist monks could be experiencing genuine distress affecting their mental wellbeing not related to depression, a distress that would be silenced by the rash conflation of Buddhism and depression like symptoms. For an example in which socio-cultural constructions override an individual’s psychological distress, consider the Havik Brahmin women in Karnataka. In Havik Brahmin society, women serving food late or cold to guests signified displeasure with their in-laws, as well as communicating general discomfort; from an early age, women are taught to suppress their feelings, and this was one of the only ways they could openly express discomfort and anger.^[4] The women’s resentment triggered psychological distress, which in turn affected their eating and sleeping patterns and concentration, leading to a visit to an Ayurveda practitioner. Since Ayurveda explained good health through bodily fluid cycles, women frequently relied on its solutions for menstruation and leukorrhea problems. However, this is a misinterpretation of the real reason why the Havik Brahmin women visit Ayurveda practitioners. As women in Havik Brahmin households were subordinates, they were forbidden from leaving the house except to attend weddings and certain religious ceremonies at the local temple, and were not allowed to remarry or maintain contact with her own family after marriage. This meant nonexistent opportunities to have a social support network outside their homes, let alone have friends or talk to non-family members, leaving an Ayurvedic consultation as one of few opportunities to express distress^[5]. Thus psychological distress becomes masked as a menstruation or leukorrhea problem; not enough attention/analysis to the cultural contexts produced a misdiagnosis.

Although cultural practices help contextualise and explain a person’s behaviour or personality, they can just as easily mask abnormal phenomena or discomfort under the very premises being used to rationalise said person’s actions. To Thevarada Buddhists, meditating in front of faecal matter is considered normal, given their religious system’s ontological reasoning. Faeces serve the purpose of reminding Thevarada practitioners the fleeting nature of existence, not to mention the disgust and pain one experiences when utilising the five physical senses. For Havik Brahmin women, their only avenue to express psychological distress or even talk to anyone outside of their families was at consultations with Ayurveda practitioners; this was however only possible if they had problems in their bodily fluid cycles, such as leukorrhea or fluctuating menstruation cycles. The important point here is that the somatic complaints provided by the Havik Brahmin women in fact represented their psychological distress from being socially isolated, silenced and mistreated by their families; a culturally uninformed reading of the situation would have dismissed this instance as routine bodily malfunctioning. What looks like ‘normal’ behaviour to some might in fact be ‘abnormal’ to everyone else; the distinctions between the normal and the pathological are not always as clear-cut as they seem.

Essentially, the argument here is that disease categories can only explain so much, especially when it comes to more ‘ambiguous’ categories such as depression that have significant overlaps with everyday emotions, or in non-Anglo/European countries that have different socio-cultural customs and rationale. The Diagnostic and Statistics Manual^[6] — the Holy Grail of modern psychology and psychiatry — states that when people suffer from a loss of motivation, pleasure from material or emotional things and fatigue for two weeks, they are suspect of having a major depressive episode. But what if I experienced such symptoms for a marginally shorter/greater time, such as ten days? What if some of the symptoms were only present on certain days? While such terms are important to be able to explain their chief complaints to a professional and for them to start preparing a treatment plan, one person’s experience of depression or schizophrenia is not likely to be the same as another’s, especially in cross-cultural situations. So when professionals only prioritise the features of illness that they can identify and ignore the rest of the patient’s illness narrative, the patients become silenced by medical paternalism. This is not to say that disease categories are fictitious; they are needed, but should be adjusted accordingly based on the sample population.

If psychiatrists completely dismiss their patients’ accounts of sickness during consultations, patients’ needs are silenced and individual-specific nuances and illness experiences are smoothed over. This is shown in the two examples from Nichter and Obeyesekere: both biomedical and socio-cultural constructions have the potential to omit and/or generalise subjective experience. The social psychologist Jerome Bruner^[7] argues that life is arranged, and subsequently lived, as narratives: given the unstructured chaos that is everyday life, people create and structure meaning into their actions and thoughts by establishing a clear plot with a beginning, middle, and an end. Illness are no exceptions to the rule, as people attempt to make sense of disruptions — that is, the illness they have contracted — happening in their lives by constructing narratives that link their past lives, their illnesses, and their future projections together to produce a sense of continuity and coherence^[8]. It is important to find from these narratives what is at stake^[9] for the patient if they do not recover, and the kinds of metaphors they use to describe their distress so that treatment is structured around the patient’s experiences of their illness. Both biomedical and socio-cultural constructs can silence the individual’s illness experience, which is ultimately what needs to take precedence when working with clients on an individual basis.

The Silenced Individual with Mental Illness(es) in India

Language is a barrier when it comes to creating a pan-India mental health association, let alone to communicate illness categories between one another. Most West, East and North Indian states speak languages that have close linguistic connections with Hindi, as they are Indo-Aryan languages stemming from Sanskrit, and some languages also share the Devanagari script. In contrast, the five South Indian states that speak Dravidian languages — Telangana and Andhra Pradesh (Telugu), Karnataka (Kannada), Kerala (Malayalam), and Tamil Nadu (Tamil) — do not have the same kinds of linguistic familiarity and connectedness with their northern counterparts. Furthermore, literacy levels in India also fluctuate greatly: in 2011, Kerala’s literacy rate was 93.9%, which was the highest among Indian States and Union Territories; in contrast, the lowest literacy rate was in Bihar at 63.8%^[10]. Another thing to consider is that in some Indian languages, certain mental illness categories do not exist. For example, in Konkani — the official language of Goa — there is no equivalent term for “dementia” or “depression.”^[11] Finding a common language, let alone being able to express one’s complaints and experiences comfortably, becomes a problem when attempting to mobilise mental health NGOs, service users and professionals together. This is an example of how, even within a culture, there remain difficulties regarding approaching mental health and giving persons with mental illnesses a voice.

Although this is gradually changing in some urban centres, India’s history of being a sociocentric society means that the family’s preferences are prioritised over those of the individual, marking a contrast to egocentric societies such as Anglo/European countries, where the individual is the primary unit of social organisation^[12]. The participants in a research project I conducted in a psychosocial rehabilitation centre in Bangalore all told me that previous decisions made regarding their psychiatric medications had little or none of their input, except for one or two psychiatrists responding to their complaints regarding side effects. Furthermore, persons with mental illnesses are silenced by their own families, who in turn remain silent when asked by others about “that family member,” lest their reputation be damaged. To use a cliché here: the silence truly is deafeningly for Indians with mental illnesses who are left abandoned in various religious asylums and government hospitals across the country, or even on the streets; and yet that puts them in the lucky/fortunate minority who are rich enough to seek private mental health services such as psychiatric rehabilitation centres. Those who are unable to afford such facilitiesare sent to government hospitals, which are inadequately equipped and outdated: people are not given enough support to endure electroconvulsive therapy (ECT), still the preferred treatment method among Indian mental health hospitals due to budget constraints^[13]. Or worse, people are sent to religious asylums where they are chained and whipped, similar to the institution that burned down in Erwadi^[14] 14 years ago, where 27 patients could not escape and subsequently died.

This is where a radical democratic approach towards establishing an All-India association for persons with mental illnesses could be useful. To grossly bastardise Laclau and Mouffe’s^[15] premises of radical democracy: differences are what makes us unique, and should therefore be accepted and incorporated into an overarching democratic movement. Applying this to the Indian mental health policy context: medical pluralism is widely practised by families of persons with mental illnesses. They will try various methods from the supernatural, biomedical and Ayurvedic, and decide upon the method they deem to be the most “effective”: follow-up interviews conducted with patients after undergoing treatment of their choice indicated improvement, or at least the interviewees thought there was positive change^[16]. Despite the lack of awareness about schizophrenia as a disease category among urban Indians, research conducted in Chennai and my research in Bangalore revealed that schizophrenia patients’ families and the patients themselves had established plausible causalities behind the onset of their illness, such as psychosocial stress or heredity^[17]. This potentially explains the oft-cited World Health Organisation^[18] study and its subsequent follow-up project^[19], whose primary finding was that schizophrenia patients in developing countries had better treatment outcomes than their counterparts in developed countries. Working with the patient’s metaphors and ways of understanding their illness by offering different systems of healing and finding an ideal ‘fit’ seems to be effective. Differences are important, and they must be highlighted and accepted by practitioners, service users and advocacy groups.

Applying this concept to mental illness advocacy work is not too far a stretch. Andrew Solomon spent eleven years observing and interviewing children and their families with deafness, schizophrenia, Down syndrome, prodigies, and other ‘abnormal’ conditions, and arrived at a similar conclusion of embracing the similar yet different struggles each family endures daily.^[20] Instead of conflating various behavioural disorders under the term “mental illness,” perhaps it is now time we also start explicitly acknowledging these disorders separately using their diagnostic terms. Schizophrenia, bipolar disorder and substance abuse can have similar symptoms and causes, but are ultimately different disease categories. By continuing to mention the aforementioned terms under “mental illnesses,” we are silencing the nuances of each disease category that needs to be addressed. This is not to say “mental illness” as an umbrella term should be discarded: mental healthcare providers and users can still work together to lobby for causes that all persons with mental illnesses have in common, such as a lack of government support in receiving adequate treatment or having their legal rights recognised. However, depression and schizophrenia are two very different illnesses, and treating them as if they were similar by lumping them together under the term ‘mental illness’ is problematic. Mental health activists and caregivers — both professionals and kin — understand and have empathy for each other’s challenges and problems, and therefore should work together for a better India for persons with mental illnesses.

Conclusion

Diagnosing mental illnesses is at once easy and difficult. It is ‘easy’ to identify delusions when they involve statements such as “ASIO planted a chip inside my head.” The hard part is trying to convince the client that their beliefs are wrong, and they need to be changed. By working with, not against, this metaphor of the chip implant, the patient is likely to understand why he/she is being asked to undergo certain kinds of treatment. Radical democratic theory helps bring patients’ illness narrative to the forefront of clinical diagnosis, while maintaining the diversity of subjective narratives within distinct cultural contexts. Radical democracy also guides and brings various mental healthcare providers and users together to lobby for causes that affect all persons with mental illnesses. Despite a lack of psychoeducation among urban Indians, many of them are capable of making plausible connections between precipitating factors of an illness and its onset. To continue ignoring the patient and his/her family’s viewpoints, as layman as they seem to the medical professional, is problematic because their subjective experiences are being silenced in favour of biomedical or sociocultural models of explanation. While these two models certainly have significant explanatory power, they can equally be tyrannical in silencing and overriding the individual’s subjective experiences of illness. The ways in which we discuss and omit these issues – and their details – matter, and these are the kinds of concerns that international development organisations must take heed, if and when they start addressing mental health and illness as a serious topic in the development discourse.