Decolonizing Global Mental Health
Decolonizing Global Mental Health is a book that maps a strange irony. The World
Health Organization (WHO) and the Movement for Global Mental Health are calling
to ‘scale up’ access to psychological and psychiatric treatments globally, particularly
within the global South. Simultaneously, in the global North, psychiatry and its often
chemical treatments are coming under increased criticism (from both those who take
the medication and those in the position to prescribe it).
The book argues that it is imperative to explore what counts as evidence within
Global Mental Health, and seeks to de-familiarize current ‘Western’ conceptions of
psychology and psychiatry using postcolonial theory. It leads us to wonder whether
we should call for equality in global access to psychiatry, whether everyone should
have the right to a psychotropic citizenship and whether mental health can, or should,
be global. As such, it is ideal reading for undergraduate and postgraduate students,
as well as researchers in the fi elds of critical psychology and psychiatry, social and
health psychology, cultural studies, public health and social work.
China Mills is a researcher at the Oxford Poverty and Human Development
Initiative (OPHI) at the University of Oxford. Her research interests span
interdisciplinary approaches to exploring the interconnections between Global
Mental Health, psychiatry, the pharmaceutical industry and colonialism.
Concepts for Critical Psychology: Disciplinary
Boundaries Re-thought
Series editor: Ian Parker
Developments inside psychology that question the history of the discipline
and the way it functions in society have led many psychologists to look
outside the discipline for new ideas. This series draws on cutting-edge
critiques from just outside psychology in order to complement and question
critical arguments emerging inside. The authors provide new perspectives
on subjectivity from disciplinary debates and cultural phenomena adjacent
to traditional studies of the individual.
The books in the series are useful for advanced-level undergraduate and
postgraduate students, researchers and lecturers in psychology and other
related disciplines such as cultural studies, geography, literary theory,
philosophy, psychotherapy, social work and sociology.
Published Titles:
Surviving Identity
Vulnerability and the psychology of recognition
Kenneth McLaughlin
Psychologisation in Times of Globalisation
Jan De Vos
Social Identity in Question
Construction, subjectivity and critique
Parisa Dashtipour
Cultural Ecstasies
Drugs, gender and the social imaginary
Ilana Mountian
Forthcoming Titles:
Ethics and Psychology
Beyond codes of practice
Calum Neill
Self Research
The intersection of therapy and research
Ian Law
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Decolonizing Global
Mental Health
The psychiatrization of the
majority world
China Mills
First published 2014
by Routledge
27 Church Road, Hove, East Sussex BN3 2FA
and by Routledge
711 Third Avenue, New York, NY 10017
Routledge is an imprint of the Taylor & Francis Group, an informa
business © 2014 China Mills
The right of China Mills to be identifi ed as author of this work has been
asserted by her in accordance with sections 77 and 78 of the Copyright,
Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced or
utilised in any form or by any electronic, mechanical, or other means, now
known or hereafter invented, including photocopying and recording, or in
any information storage or retrieval system, without permission in writing
from the publishers.
Trademark notice: Product or corporate names may be trademarks or
registered trademarks, and are used only for identifi cation and
explanation without intent to infringe.
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library.
Library of Congress Cataloging in Publication Data
Mills, China.
Decolonizing global mental health : the psychiatrization of the majority
world / China Mills.
pages cm. – (Concepts for critical psychology)
1. Mental health policy. 2. Psychiatry, Transcultural. 3. Mental health
services–Standards. 4. World health.
I. Title.
RA790.5.M56 2014
362.19689–dc23 2013022955
ISBN: 978-1-84872-159-3 (hbk)
ISBN: 978-1-84872-160-9 (pbk)
ISBN: 978-0-203-79675-7 (ebk)
Typeset in Times New Roman
by Cenveo Publisher Services
This book is dedicated to the memories of Marion and
Arthur – my Grandparents – for stories and butterfl y
buns, and well kept secrets – for everything.
It is also a warning. To those not (yet) psychiatrized –
beware.
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Contents
Preface xi Acknowledgements xiii
Introduction
De-familiarizing Global Mental Health: A methodology of
encounters 1
1 Making mental health a reality for all 17
2 ‘Harvesting despair’ – Suicide notes to the state and
psychotropics in the post 35
3 Educating, marketing, mongering 51
4 The turn, the look: Interpellating the mad
colonial subject 72
5 ‘Necessary evils’: When torture is treatment and violence is
normal 86
6 Sly normality: Between quiescence and revolt 108 7
Decolonizing Global Mental Health 122
Bibliography 152 Index 171
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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
Notes
1 WHO (2001). Mental Health: A Call for Action by World Health Ministers. Ministerial
Round Tables, 54 th World Health Assembly. WHO, Geneva.
2 Based on Mental Health Atlas (2005) estimates of 4.15 psychiatrists per 100 000 [online]
http://www.who.int/mediacentre/news/notes/2005/np21/en/ (accessed 2.8.2012); and on
world population being approx. 7 billion, according to the UN Department of Economic and
Social Affairs [online] http://esa.un.org/unpd/wpp/index.htm (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 thou
sand million inhabitants: fi ve hundred million men, and one thousand fi ve hundred
million natives. The former had the Word; the others had the use of it’ (Sartre, 1963:7).
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Acknowledgements
This book, born out of anxiety and written against a stain of
psychiatrization, carved like a wound, bears the whispers of so many voices,
of blended sadnesses and joys that coat the inside of my mouth and make
me bite my lip. So many diffi cult conversations, stolen moments, cups of
coffee, dreams of escape, haunt this work, and only some of them are mine.
So many ‘thank you’s’ and ‘I’m sorry’s’. Particularly I would like to thank
the staff at the Bapu Trust, Iswar Sankalpa, and all the NGOs in India who
so kindly gave me their time, and who may well not agree with what I have
written. Thank you to all those who make discussion wonderful, at the
Asylum North-West Collective, the Discourse Unit, and at Ambedkar
University, Delhi.
Thank you to Ian Parker for asking me to write this book and for
believing that I could. Thank you to the Education and Social Research
Institute, at Manchester Metropolitan University, for funding the PhD
research that forms the fragmented body of this book.
Some people deserve a special mention for more reasons than I could
ever say; Bhargavi Davar and Sarbani Das Roy – whose dedication and
kindness are overwhelming – if I hadn’t have met you there would be no
book; the O’Hanrahans − my Mancunian family, and especially Liam; Julie
Downs and Becky Harper, for showing me that other worlds are possible;
David North, Katharine Sharp, Suman Fernando; and thank you to Erica
Burman, for the support and inspiration that has fi lled my thoughts and
notebooks for nearly ten years. And to Jane and Paul, for teaching me to
read and write all those years ago, despite my stubborn resistance – I hope
you think it was worth it.
There is a different thank you also due − to those who defy the ways we are
told to be defi ant, to those who tell stories as if they are not the only story,
to those who continue to dream in their own languages.
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Introduction
De-familiarizing Global
Mental Health
A methodology of encounters
‘Why do you take medication?’ they asked
At a Non-Governmental Organization (NGO) that works with people
diagnosed with mental health problems, in Southern India, the staff
began asking Meesha1 (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 this place’. [Field notes, 10 January
2011]
Meesha’s words, illuminate many of the concerns, the messy spaces that
make up this book, a book that looks, in part, at the mechanisms of ‘making
up’ psychiatrized peoples globally. I want to draw upon Meesha’s words as
lenses.
Lens 1: ‘psychiatric patient’
What does it mean that Meesha, who speaks only Tamil, said the words
‘psy chiatric patient’ in English? In those two words, spoken in a foreign
lan guage, it is possible to hear echoes of psychiatry’s colonial history.
However, while colonial forces brought asylums to many countries of the
global South, now no walls are needed to become a psychiatric subject, as
psychi atry creeps into increasing domains of experience and across
increasing
2 Introduction
geographical borders (Rose, 2006 ). In Meesha’s words 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 hint at psychiatry itself as
being colonial, an alienating process where people come to understand them
selves in foreign terms, a colonization of the mind (Thiong’o, 1981 ). Her
words call on us to grasp the hegemony of ‘Western’ psychiatry, psychiatry
developed in specifi c high-income countries (HICs) of the global North and
exported to the global South. Finally, Meesha’s words are suggestive of the
globalization of psychiatry and how psychiatric ways of understanding dis
tress, health, illness, and ultimately 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.
Lens 2: ‘To be cured’, Meesha replied, ‘to be cured of this place’
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 ill ness’2 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 ‘prob lem’ lies inside Meesha, in her brain, in
her biochemicals. In her under standing, Meesha takes psychiatric
medications in order to get out of the NGO, the very place that provides
her with that medication. For the staff, Meesha takes medication because
she has schizophrenia, a diagnosis made by them.
What does it mean to take psychiatric medication to be ‘cured’ of
psychia try? How do psychiatric medications broker subjectivity? If some
of those subjected to psychiatry want to be ‘cured’ of it, then what role
should psy chiatry play in responding to people’s distress globally?
Scaling up
This question forms the uncomfortable crux of this book; this is an anxious
space, it may not be an easy read. Currently, the World Health Organization
(WHO) and the Movement for Global Mental Health (MGMH) are calling
to ‘scale up’ psychiatric treatments, often specifi cally access to psychiatric
medication, globally, and particularly within the global South. Amid these
calls, others can be heard, from local and global movements of psychi
atrized peoples in the global North and South, and from some critical and
transcultural psychiatrists, to abolish psychiatric diagnostic systems and to
Introduction 3
acknowledge the harm caused by some medications. Both of these calls – to
increase access to psychiatric interventions, and to recognize the harm
caused by such interventions – are often made on the basis of human rights.
This points to a strange irony at work in Global Mental Health (GMH); for,
as psychiatry is being increasingly criticized in many HICs, with some
calling for a paradigm change within psychiatry (Bracken et al., 2012 ) due
to its controversial evidence base (Summerfi eld, 2008 ), there are simultane
ous calls to ‘scale up’ this same psychiatry globally. Thus, alongside
Fernando ( 2011 :22), we might ask, ‘has psychiatry been such a success
here [in HICs] to entitle us to export it all over the world?’ It would seem
not.
In 2001, the World Health Organization (WHO) reported that over ‘450
million people worldwide are estimated to be suffering at any given time
from some kind of mental or brain disorder’ (WHO, 2001b :6), and that
‘14% of the global burden of disease has been attributed to neuropsychiatric
disorders’ due to their ‘chronically disabling nature’ (Prince et al., 2007 :1).
Despite this global ‘burden’ of mental disorders and their growing preva
lence, the World Health Report documents that ‘[m]ore than 40% of coun
tries have no mental health policy and over 30% have no mental health
programme’, meaning that ‘there is no psychiatric care for the majority of
the population’ (WHO, 2001a :3 and xvi). Thus, advocates of GMH call ‘to
scale up the coverage of services for mental disorders in all countries, but
especially in low-income and middle-income countries’ (Lancet Global
Mental Health Group, 2007 :87), where ‘75% of people do not get the mental
health services they need’ (WHO, 2008a , mhGAP launch video). In light of
this, the MGMH was launched, in 2008, ‘to close the treatment gap for
people living with mental disorders worldwide’ (Patel et al., 2011a :88) –
‘the gulf between the huge numbers who need treatment and the small
minority who actually receive it’ (WHO, 2001b :7).
The ‘scientifi c foundation’ of the Movement emerges from a series of
articles published in The Lancet in 2007 and 2011. This evidence has been
used to map the mhGAP guidelines (specifi cally developed to aid treatment
decisions in non-specialised health care settings in LAMICs – see next
chapter) which for Patel et al. ( 2011b :1442), ‘should become the standard
approach for all countries and health sectors’, meaning that ‘irrational and
inappropriate interventions should be discouraged and weeded out’.
Thus, this standard approach to understanding the assumed irrationality
of ‘mental illness’ (an approach developed in the global North) is applied
globally, as a means to ‘weed out’ alternative interventions that judged by
this standard are taken to be ‘irrational’. But who decides what constitutes
irrationality? The MGMH frames distress as an illness like any other, calling
for global equality in access to psychiatric medication. However, there is a
growing body of research from the global North that documents
4 Introduction
the harmful effects of long-term use of psychiatric medication and ques
tions the usefulness of psychiatric models (see Angell, 2011 ; further discus
sion in the following chapter).
This raises a number of concerns: a) about what constitutes the ‘evidence
base of GMH, and who decides what counts as ‘evidence’; b) about the
framing of certain human experiences as psychiatric diagnoses and as ‘ill
nesses’; and c) about increasing access globally to psychiatric medications
that have been found to be harmful. These concerns reframe the terms of
debate around equality between the global South and North, for what are the
ethics of ‘scaling up’ treatments within the global South whose effi cacies
are still hotly debated within the global North? Who sets the agenda for this
global project and what political and economic rationales are tied into this
agenda? Alongside this, there are concerns that the MGMH discredits and
replaces alternative forms of healing that are local, religious or indigenous
(Watters, 2010 ) and many users and survivors of the psychiatric system
argue for the right to access non-medical and non-Western healing spaces,
and to frame their experience as distress and not depoliticize it as ‘illness’
(PANUSP, 2012 ).3
A letter they wouldn’t publish
Much of the critique of the MGMH was summed up in a letter, sent to the
journal Nature , to voice concern about an article it had published document
ing the ‘Grand Challenges in Mental Health’ initiative (Collins et al., 2011
). The letter sought to highlight research priorities in the global ‘scale up’ of
psychiatry, and, more generally, was about the assumptions embedded
within the approaches of GMH (Shukla et al., 2012 :292). This letter came
from activists and practitioners from the global South and North, some of
whom were psychiatric survivors. Nature wouldn’t publish the letter. It was
published elsewhere.
The letter raised some key critiques of GMH that are worth summarizing
here. The fi rst issue raised was that the Delphi panel (a selected group of
researchers nominated by the US National Institute of Mental Health) who
decided on research priorities for GMH did not do so in collaboration with
local communities or user/survivors. Secondly, that the evidence on which
the recommendations are based is questionable and exaggerates the global
prevalence of ‘mental illness’. Thirdly, the focus on the brain and on a
‘global norm for mental health’ overlooks the complexity of lived
experiences (Shukla et al., 2012 :292). Fourthly, indigenous healing and
alternative sources of support are overlooked. Fifthly, funding for mental
health should not come from those with vested interests, such as the
pharmaceutical industry.
Introduction 5
Lastly, the letter refers to the picture of a black child chained to a tree in
Somalia, in the Nature article, suggesting that it implies that human rights
violations are more likely within local and indigenous settings. For me, this
photo, positioned next to a call to increase access to psychiatric medications
in low and middle income countries (LAMICs), conjures an image of psy
chiatric drugs as agents that unshackle, break chains, and enable humane
treatment (compared to the human rights abuses implied here by lack of
psychiatric knowledge and by some indigenous practices). However, as
Shukla et al. ( 2012 :292) point out, in fact ‘[m]ental health service delivery
has involved rights violations across the globe’, and it is often psychiatric
interventions, conceived of as ‘treatment’, that violate human rights. Here
it is not only institutional ‘treatment’ (the chaining, cage beds, electro
convulsive therapy explored in Chapter 5 ) that violate human rights. For
psychiatry, and particularly the scaling up of access to psychotropic medi
cations globally, may enable new kinds of incarceration outside the walls
of psychiatric hospitals – global chemical incarcerations (Fabris, 2011 ).
No answer, no evidence, no test
If psychiatric interventions legitimize involuntary detention and high-dose
medication (and are being scaled up globally) then surely psychiatry’s evi
dence base must be convincing? Yet, in fact, for Summerfi eld ( 2012 :519),
when asked ‘what is a mental disorder?’ psychiatry can provide no answer
and no test. In fact, there is, as yet, ‘no convincing evidence that psychiatric
disorders or symptoms are caused by a chemical imbalance and no evidence
that psychiatric drugs exert their effects by correcting such an imbalance’
(Moncrieff, 2009 :101). While there is no evidence that most ‘mental
illness’ is caused by a chemical imbalance, when impairments are found in
the brain they are often caused by psychiatric medications, with studies into
the long-term effects of many psychiatric drugs showing harm and life-long
disability (Breggin, 2002 ; Whitaker, 2010 ). Thus, many criti
cal psychiatrists are increasingly calling to abolish psychiatric diagnostic
systems, based on evidence that, in summary; ‘psychiatric diagnoses are not
valid … they increase stigma … [they] do not aid treatment decisions [and
they] impose Western beliefs about mental distress on other cultures’
(Timimi, 2011 , online). This has led many to call for a paradigm shift within
psychiatry (Bracken, et al. 2012 .)
That the call to abolish such systems because of increasing evidence of
the harm caused by bio-psychiatry in HICs should come at the same time as
a call to scale up these approaches in LAMICs seems ironic and strange, and
is further compounded by much research that points to the multiple racisms
at work within psychiatry (Fernando, 1988 ). This leads us to
6 Introduction
wonder whose interests are shaping this complicated force fi eld of GMH.
For, as my Granddad used to say, ‘if it’s not broke don’t fi x it’ and I’m
pretty sure in this context he might have added – ‘if it is broken don’t export
it globally’.
That psychiatry is exported to the global South ‘by economic and politi
cal forces allied to western power’ (Fernando, 2010 :113) has led to another
major critique of GMH – that it is colonial, that it is a form of ‘psychiatric
imperialism’. This was a concern raised at a Transcultural Psychiatry
conference on GMH, in Montreal in 2012, where opinions and concerns
‘oscillated between two antagonistic poles’; those who saw GMH as a
public health movement from the ‘bottom up’, and those for whom GMH
works ‘as a top-down, imperial project exporting Western illness categories
and treatments that would ultimately replace diverse cultural environments
for interpreting mental health’ (Bemme and D’Souza, 2012 ).
That GMH is imperial or colonial emerges often within its critiques.
Thomas et al. ( 2005 :27–28) ‘regard the globalisation of biomedical psy
chiatry as a form of neo-colonialism; it involves the imposition of western
values, customs and practices on non-western cultures’. Similarly, for
Summerfi eld ( 2008 ), GMH imposes a Western understanding of person
hood. In 1988, faced with the strange familiarity of psychaitric care in the
cities of South Asia, Marsella and Higginbotham felt that colonial forces
were at work in psychiatric provision. Like Thomas et al. ( 2005 ),
Summerfi eld sees WHO global initaives as rooted in neo-colonial power
relationships and as ‘medical imperialism, similar to the marginalisation of
indigenous knowledge systems in the colonial era’ (Summerfi eld, 2008
:992). To export psychiatry globally is to begin to reframe an enormous
variety in expression of personal and social distress into an illness model,
treatable by drugs. That this approach is ‘developed in an alien culture’
marks, for Fernando ( 2010 :115), a form of psychiatric imperialism that is
‘less obvi ous’ than military domination, ‘but no less powerful and as
destructive to the vast majority of people in the world’.
Even when psychiatry is applied within the countries it originates from it
has been criticized as being colonizing – naming people’s experiences in
alien, and alienating, technical terms that deny personal or social meaning
fulness, labelling people as ‘irrational’ and thus in need of care in their
‘best interests’, and subjecting people to forced ‘treatment’ and
involuntary deten tion (Johnstone, 2000 ; Mills, 2012 ). Furthermore, while
psychiatry may be an agent of colonization, it lays the ground for other
colonizations, for as ‘the interests of psychiatry and the pharmaceutical
industry are becoming ever more tightly-woven’ (Thomas et al., 2005
:23), psychiatry provides the networks for the pharmaceutical ‘industry to
colonise more and more areas of modern life in order to expand the market
for psychotropic drugs’
Introduction 7
(Moncrieff, 2007 :192). In fact, we might wonder if the pharmaceutical
industry has colonized psychiatry.
Encounters and forcefi elds
The point of departure for this book, then, lies in thinking GMH ‘otherwise’
(Lather 2007 :7); both from spaces that are designated ‘other’ (those with
mental health problems and countries of the global South), and from ‘other’
frames of reference. This is to explore how the assumptions embedded
within GMH enable psychiatry to travel across geographical borders, and in
the swallowing of a pill, to travel deep inside populations of the global
South. This research is about encounters; it is a post-colonial reading of
psychia try’s encounters with the global South. It is worth pointing out here
that the global South is not a clear geographical space, it is a ‘metaphor of
exclusion’ (Santos and Álvarez, 2011 ), just as ‘mental illness’ might be
understood to be. Just as the ‘West’, in Nandy’s ( 1997 :170)
conceptualization is more than a temporal entity, it is a ‘psychological
category. The West is now every
where, within the West and outside; in structures and in minds’. ‘Global
South’ is used interchangeably here with ‘majority world’ to retain as a
continual reminder that the ways of knowing distress promulgated by GMH
arise from a minority world-view and yet are ‘scaled up’ to the majority.
One entry point for the book, in mapping the force fi eld of GMH through
a post-colonial lens as a ‘messy, contradictory, fragmented’ space (Swartz,
2012 :537), is to trace how GMH functions as an apparatus – made up of
‘strategies of relations of forces supporting and supported by, types of knowl
edge’ (Foucault, 1980 :196). Or as a global assemblage through which new
types of personhood emerge (Ong and Collier, 2005 ). This is to trace what
knowledge is at work within GMH, the conditions of possibility for this
knowledge to emerge, and how this knowledge operates to make possible
GMH’s call to make ‘mental health a reality for all’ (Patel et al., 2011a :90).
For Foucault ( 1972 :130), this is to trace how the statements of GMH
come to be ‘authorised’, their regulation by sets of practices that work
either to distribute such statements or to restrict their circulation. Different
institu tions thus ‘work to exclude statements which they characterise as
false and they keep in circulation those statements which they characterise
as true’ (Mills, 2003 :58). Here Foucault takes as the object of his analysis
not a sentence but a statement, the taking place of discourse through a
statement’s enunciation, the conditions that make up the operational fi eld
of speaking.
But as this knowledge is exported as a universal standard, a global norm,
what other ways of knowing are lost, or forced to speak in whispers? This
calls for analysis not only of the offi cial statements of GMH and the WHO,
but also of the mechanisms that enable these statements to circulate as
8 Introduction
‘true’, and those that prevent or foreclose other statements from circulating
at all. This is to pay attention to how certain statements and terminology
‘become a way of thinking – a way of life – that threatens to eclipse all other
ways of thinking’ (Murray, 2009 :12). Or, for Segal ( 2005 :116), how ‘the
terms of a discourse constrain not only the outcomes of debate but also what
it is possible to argue at all’. Importantly, this resists a reading of GMH as
simply transposing psychiatric concepts onto countries of the global South,
as though this fl ows only one way, as though people and populations cannot
rework and resist such ideas.
This book is rooted in reading GMH (and its pharma-centric knowledge
base) alongside that which psychiatry disallows, that which is ‘excluded–
repudiated–foreclosed’ (Chakrabarti and Dhar, 2009 :199), that which
speaks a different language to psychiatry and makes its epistemologies
‘shudder’ (Losinsky and Collinson, 1999 :3). In this book, a useful tool to
make GMH ‘shudder’ is to read it through the lens of (post)colonialism.
Global Mental Health as colonial discourse
Psychiatry is a colonial legacy in many parts of the global South (Ernst,
1997 ; Fernando, 2010 ). Yet it is not only a colonial legacy, just as the prefi
x ‘post’ in the putting to work of post-colonial theory does not imply that
colonialism is somehow fi nished and in the past (Loomba, 1998 ).
Postcolonial theory encounters colonialism as ‘a historical legacy of vio
lence and appropriation, carried into the present as a traumatic memory’
(DelVecchio Good, Hyde, Pinto and Good, 2008:6 ), a memory often writ
ten on the body and in minds. But more than memory, the ‘post’ is never
far from the ‘neo’ colonialism of new and continued forms of oppression
(DelVecchio, et al., 2008 ). Therefore, this book seeks to explore how psy
chiatry, through WHO policy and the MGMH, may be one such
mechanism to enable this ‘perpetuated coloniality’ (Grech, 2011 ). Here,
post-colonial ism is used as a conceptual tool to explore relationships of
domination and resistance that continue after formal colonialism has
ended (Van Zyl, 1998 ), and that sometimes continue from within. This
marks a ‘medicalized colo nizing of lands, peoples, bodies, and minds’,
that are are deeply entangled and yet rarely thought about together, and
which call for an understanding of impairment and distress in the context
of the violence of colonization and ‘the conjunct processes of
colonization, racial, gender, class, and ableist oppression as expressions of
empire’ (Roman et al, 2009:19). This is evi dent in the central role played
by asylums in a colonial and capitalist system (Ernst, 1997). Here
psychiatry and colonialism (and a multitude of other oppressions)
interweave not in a sum where one is added to the other and not as discrete
entities that only relate through analogy – but in a knot.
Introduction 9
This is to grapple with a space where while psychiatry is always already
racialized and colonial, it is not an even terrain, and it is experienced differ
ently by different groups (Diamond, 2013). To claim that all those who are
psychiatrized are simultaneously colonized thus marginalizes the realities
of those populations who have experienced both colonization and psychi
atrization (for example, the indigenous and First Nations communities of
many HICs), glossing over how forms of oppression are tethered and inter
woven (Tam, 2013).
One of the key points of departure of this book, then, is the exploration
of how GMH policy could be read as a form of colonial discourse, and how
mental health NGOs that work in the global South may constitute some of
the capillary channels for this discourse to travel. Psychiatry’s journey out
from the global North is made possible at ground level by diagnostic and
classifi catory tools (such as the Diagnostic and Statistical Manual – DSM,
and the International Classifi cation of Diseases – ICD), which are translated
in order to travel across geographical borders. This ‘diagnostic creep’ works
as a form of psychiatrization that frames increasing numbers of experiences,
globally, in psychiatric terms, as concerns for psychiatry (Rose, 2006 :478).
This book, then, traces how we might read GMH and WHO policy as enact
ing colonial relations in potentially multiple ways through psychiatrization.
The ‘minimum conditions’
For such an analysis, Homi Bhabha comes in useful, despite his writing
having been criticized for being esoteric, ‘dense’ and ‘clotted’ (Hook,
2005b :10), and despite my copies of some of his books bearing the multiple
wounds of being thrown across rooms. And yet I always pick them up again.
Here I want to briefl y outline what is meant by colonial discourse, drawing
upon and summarizing Bhabha’s ( 1983 ) ‘minimum conditions and specifi
cations’. Thus, according to Bhabha, colonial discourse:
• Is an apparatus that ‘turns on the recognition and disavowal’ of
difference. • Its ‘strategic function is the creation of a space for a “subject
peoples” through the production of knowledges’.
• In ‘marking out a “subject nation”’ colonial discourse operates as a form
of governmentality, that ‘appropriates, directs and dominates its
various spheres of activity’.
• It ‘produces the colonised as a fi xed reality which is at once an “other”
and yet entirely knowable and visible’.
• Through this knowledge surveillance is exercised, and ‘a complex form
of pleasure/unpleasure is incited’. These forms of knowledge are drawn
upon to authorize colonial discourse.
10 Introduction
• ‘The objective of colonial discourse is to construe the colonised as a pop
ulation of degenerate types on the basis of racial origin, in order to justify
conquest and to establish systems of administration and instruction.’
• It ‘resembles a form of narrative whereby the productivity and circula
tion of subjects and signs are bound in a reformed and recognisable
totality’.
• ‘It employs a system of representation, a regime of truth, that is
structurally similar to Realism’ (Bhabha, 1983 :23).
The chapters of this book interlace and layer in their analysis of how
the psychiatrization at work through GMH and WHO policy may be
conceptu alized within Bhabha’s ( 1983 ) ‘minimum conditions’ above.
This is a colonial discourse analysis of GMH, but in exploring how the
subjectivity of the ‘subject peoples’ of GMH comes to be constituted, how
socio political factors come to be reconfi gured within psychiatric
categories, another analysis is also at work – one that is psychopolitical.
The ‘psychic life of colonial power’
Psychopolitics, an anxious process (Lebeau, 1998 ), marks a constant
shifting between the socio-political and the psychological, a continuous ‘toand fro- movement, whereby the political is continually brought into the
register of the psychological, and the psychological into the political’
(Hook, 2012 :17) – thus, importantly, not dissolving the two or aban
doning one register in favour of the other, but employing a ‘psychology of
critique’ (Hook, 2012 :18). Hook ( 2004b ; 2012 ) further foregrounds a
psychopolitical analysis as falling into three forms: the ‘politicisation of the
psychological’ (Hook, 2004b :85); deploying psychological concepts in
understanding the workings of power; and putting psychological con
cepts to work politically as ‘a means of consolidating resistances to
power’ (Hook, 2012 :18).
All three layers are traversed in this book – interlaced, entangled. The fi
rst layer is mainly worked through in the fi rst half of the book, with a
further interrogation of how certain phenomena come to be understood as
psycho logical, or more specifi cally here, psychiatric, and the rationales
this may serve. The violence of colonial subject formation is juxtaposed
uneasily throughout with the processes by which psychiatric subjects are
formed – thus, speaking of the ‘psychic life of colonial power’ (Hook,
2012 :18) is both a reference to the use of the psychological to explore
work ings of power, but also hints at how the colonial shapes and makes
possible psychic life. The second and third layers of this psychopolitical
project come into play in the second half of the book, putting Frantz
Fanon’s language of
Introduction 11
pathology, of the psychopathology of colonialism, to work on psychiatric
encounters with the global South.
The chapters that make up this book
Throughout this book, psychiatry and colonialism are read alongside each
other, uncomfortably juxtaposed. There is a point to this, because in tracing
how GMH is made a ‘reality for all’, globalizing tropes of ‘brain disease’
and ‘biochemical imbalances’, tropes that reconfi gure violence and treat
ment, a strange space emerges where equality, access and rights begin to
look different. More specifi cally, Chapter 1 maps how particular
knowledge is mobilized in the creation of a global space for psychiatric
‘subject peo ples’ and how these constitute the ‘reality’ that GMH wants to
make for all. This is anxiously juxtaposed with other ways of knowing
health and distress in order to examine the implications of the claims of
GMH. Chapter 2 addresses a central implication of GMH’s within-brain
approach to mental distress as ‘illness’, through the psychiatrization of
farmer suicides in India. Thus, while farmers write suicide notes to the
Government telling of an unliveable life due to agricultural reforms, GMH
calls for increased access amongst farmers to anti-depressants.
Chapter 3 traces the psychiatric ‘subject peoples’ made possible from
the knowledge base of GMH, taking the mechanisms and tools of this ‘on
the ground’ psychiatrization (Rose, 2006 ) of the global South as its entry
point as it brings into being particular categories of personhood, chemically
and globally. Here colonial subject formation will be read alongside psy
chiatric subject formation to highlight the potential ‘identity violence’
(Hook, 2005a :480) at work in psychiatrization. Psychiatrization continues
in Chapter 4 , where the conceptual contours of this ‘making up’ are turned
to through the ‘turn’, exploring two formulations of interpellation, to
address who will occupy the space of GMH, and how ‘they’ might come
into being.
That this coming into being may be violent will form the basis of
Chapter 5 , which explores how the mobilization of particular tropes may
work to enable a violence not usually read as being violent, a ‘normal’
violence – violence that is reconfi gured as ‘essential’ treatment. In Chapter
6 , resistance to colonialism is used as a lens to read resistance to psychiatry
– resistance that is veiled, that is sly, resistance that pretends to be something
else. The fi nal chapter quotes Fanon, against himself, to explore the
implications of psychiatry and GMH as colonial, as alien/ating. For as
psychiatry travels, so do the networks, initiatives and movements that fi ght
against psychiatric hegemony, from alternative frames of reference where
distress may not be an ‘illness’.
12 Introduction
What this book is not
This book is not an extensive overview of GMH and WHO policy. It is an
exploration of particular mobilizations within these policies, a map of some
of the rationales these ways of thinking may align with, and what alternative
frameworks they may hide. It is not a romanticization or glorifi cation of
alternative or ‘traditional’ healing systems, or of survivor-led approaches.
Ultimately, it is a provocation.
Writing messily
Is this book anti-psychiatry? Am I? For me the answer to this involves fi
rstly exploring what one means by psychiatry. I understand psychiatry
broadly as a medical, legal, economic, socio-cultural and political system of
understanding and intervening with those who are distressed or different
that often, but not solely, works on the individual body/brain, through
frameworks of diagnostic categories that frame distress or difference as
pathology, as ‘illness’. Centrally to this book, these understandings and
ways of categorizing people seem increasingly to be applied to individual
bodies within the global ‘body’, and to populations of LAMICs. When I
write bio-psychiatry I am alluding to the ties between psychiatry and the
pharmaceutical industry, the industry that manufactures, markets and
supplies the medications prescribed by psychiatrists.
To write messily about GMH and psychiatry is to move away from
ques tions of being ‘for’ or ‘against’, ‘pro’ or ‘anti’; it is to ask what these
particular frameworks prevent us from seeing, and what alternative ways of
intervening they might foreclose. It is to explore what is meant by
evidence, and what other evidences might mean for the practices of GMH
and psy chiatry. For Nandy ( 1983 :3), the pervasiveness of colonialism,
the ‘ultimate violence which colonialism does to its victims, [is] namely
that it creates a culture in which the ruled are constantly tempted to fi ght
their rulers within the psychological limits set by the latter’. This pressure
to be the obverse of the West thus binds the Indian ‘even more irrevocably
to the West’ (Nandy, 1983 :73). Here, to be ‘anti-psychiatry’ could be
read as being tied to, bound to psychiatry even more tightly. Therefore I
wonder, with Lather ( 2007 :13), ‘how can writing the other not be an act
of continuing colonization?’
Avoiding this temptation means speaking another language, ‘a language
of dissent which would not make sense – and will not try to make any sense
in the capitals of the global knowledge industry’ (Nandy, 1998 :147). Thus,
I want to write messily, not in opposition to or to be ‘anti’ GMH or psy
chiatry, but to use the book itself as a space to encounter GMH differently.
It is also a refusal to meet psychiatry’s criteria for what counts as
Introduction 13
‘evidence’, through the intertwining of the psychopolitical layers that form
the body of the book. This is a body formed, like Hook’s reading of Fanon’s
‘Black Skin/White Masks’, through a ‘traumatic assemblage’, an ‘uneasy
bricolage’, the grating and chafi ng of different styles and texts, a ‘body-in
pieces’ – a text in bits (Hook, 2012 :46).
This is to read and write GMH as Homi Bhabha reads colonialism, and
as he reads the work of Fanon, on a different register, poetically, messily.
In seemingly (yet purposefully) making a ‘category error’, ‘applying
inappro priate reading techniques to the texts of colonialism’, Fanon and
Bhabha are ‘challenging the lifeless statements of colonialism’, invoking
the poetic itself as a form of resistance to colonialism (Huddart, 2006 :9 &
18). However, the statements of WHO policy and GMH, while rarely read
poeti cally, are not ‘lifeless’. In many ways, ‘as the product of relational
practices, but also as productive of social relations, these policies, these
statements are living’ (Hunter, 2008 :507). Just as for Said ( 1978 :94),
‘texts can create not only knowledge but also the very reality they appear
to describe’ – the mental health that GMH is making a reality for all.
This is to change the focus of the analytic gaze onto ‘the relations of
meaning that are internal to the discourses embedded in policies themselves
rather than to seek an objective truth “out there” which the policy documents
then describe’ (Lewis, 2000 :11). It is to trace how policy works performa
tively, how policies ‘travel across time and space’ (Hunter, 2008 :508).
What do GMH and WHO policy do? How might we trace the performativ
ity of these policies, the staking out of a space that is ‘global’, and the
‘making up’ (Hacking, 2006 ) of those who will inhabit that space – global
psychiatric citizens?
This marks a move away (as much as possible) from essences, linearity,
origins, rationality; ‘it rejects the Whole in favour of dissemination and
disorder … it “catches a moving train”’ (Illuminati, 2005 :2; Althusser,
2006 :290–291). Like the moving trains I learned to jump onto while doing
research in India, I want through this research to jump on and off, and in
between, GMH advocacy and the criticisms made against it. Like Fanon’s
refusal ‘to remain within one discourse, and to stick to one approach to its
defi ned problem’ (Huddart, 2006 :20), I want to ‘fold and layer concepts in
ways that are multiple, simultaneous, and in fl ux rather than presenting
them as linear and discreet’ (Lather, 2007 :4).
The text of this book is ‘unwilling to confi ne itself within a single mode
of theorizing’; it is ‘hybrid and impure’, and this ‘formal mix is more than
a choice of style: it also destabilizes any claims to being an authoritative
narrative’ (Huddart, 2006 :20). To write in this way is also to destabilize any
of the claims to authority made by GMH and psychiatry; it refl ects a
commitment to de-familiarizing both the act of writing and researching
14 Introduction
(disrupting what counts as evidence, what makes sense), and that of GMH.
It is the writing of a text that both ‘interrupts itself and gathers up its inter
ruptions into its texture’ (Lather, 2007 :4).
White knowledge
I fi rst heard about GMH while doing research for my PhD in India, and it
is from this research, from my encounters with NGOs in India and their
encounters with people in distress, that this book emerges. I’m not going to
pretend that these encounters, the interviews and fi eld notes that make up
parts of this book, took place in quiet idyllic locations. The recordings are
backed by the hum of ceiling fans churning hot air around the room and
punctuated by car horns, and often my fi eld notes blurred under the stain of
a coffee cup, or a splash of blood when used as a mosquito swot. Writing
this research messily, then, is in part an attempt to situate the encounters that
make up the research, the interviews shouted in the back of a rickshaw as it
came to a screeching halt on a motorway fl yover.
In a methodology of encounters, then, ‘I’ am situated throughout. But
who is this ‘I’ who writes – ‘For whom is the writing being done? In what
circumstances’ (Said, 1983:7)? Who constitutes the ‘I’ and the ‘we’, and
how do these pronouns exclude those being written about (Tuhiwai Smith,
1999 :37)? This is important in this research, which does not claim to be col
laborative and barely contains any voice of those in the global South who
live under the psychiatric categories discussed throughout. For me to
confess now that I’m white and I’m a woman seems to mean everything
and nothing. However, as a white British woman researching in India, I
was often reminded of these categories that I visibly occupy. Indian
friends and colleagues told me I only gained access to certain psychiatric
institutions and psychiatrists in India because I am white. Once inside these
prestigious institutions, those I met told me that what I was talking about
had no application in India because it was ‘white knowledge’. The fact that
I felt troubled by many of my encounters in India is evident in a note I
found scribbled furiously among the tea stains in the back of my fi eldwork
diary:
Today a group of cognitive behavioral therapists and psychiatrists, who
work in an asylum established under colonialism, told me that what I
discussed in my workshop (on the psychiatric survivor movement and
the Hearing Voices movement)4 was ‘white knowledge’ and colo
nial … I feel like India is becoming psychiatrised before my very eyes,
and I’m somehow complicit.5
Introduction 15
Even in opposition to some of the practices I encountered I am painfully
aware of my own complicity in that which I critique. And thus how I, we,
as researchers need to read ourselves into the problem (Parker, 1999 ), grap
pling with the ways that we ‘are inscribed in that which we struggle against’
(Lather, 1991 :20). Here, more than concerns of how to position myself, for
example, as a ‘professional stranger’, or to ‘go native’ (Tedlock, 2001 ),
there emerged a particular problematic of whether to ‘present’ myself as a
psychiatric survivor or not, and how to think through my own anxiety about
GMH. Therefore, like Fanon ( 1952[1986] :86), ‘I have not wished to be
objective. Besides, that would be dishonest: It is not possible for me to be
objective’. For, as Nandy ( 1983 :80) states, in the end, ‘[a]ll interpretations
of India are ultimately autobiographical’.
My grandma and schizophrenia
There are so many ways I could tell the story of the journey that writing and
researching for this book has been, and how it all began. One way to tell it
would begin long before I was born, when my granddad Arthur was in the
British Army in India (before the Second World War). My dad and then I
were brought up on stories of an India that both of us would grow up to
visit; both the same India as in the stories and not the same at all. As my
granddad’s stories continued, long before I would visit India, my grandma,
who wore blouses with gold buttons and earrings that clipped on, went
outside one night with a pair of scissors, to tell the next door neighbours
that she knew they were inserting recording devices that read our minds
through the wall above the phone. I curled up behind the big box where the
Christmas decorations were kept, listening to my Grandma cry with the fear
of being called ‘mad’, because that meant being carried away in a van by
men in white coats. She was wrong. They didn’t wear white coats, and they
didn’t carry her away – we took her in the car. She was diagnosed with
schizophrenia. I was 10. We were all psychiatrized as she was told to swal
low that fi rst pill .
At a similar time, my uncle, who drove an open-backed truck, smoked
weed and chased me around until I was dizzy with joy, rolled up the carpet
in his room to make a tunnel in which he lived to shut out the fl ies that were
making formations and spelling out words, speaking to him. My uncle too
was diagnosed with schizophrenia .
I have lived close to madness for most of my life. While the people in my
family were given diagnoses of schizophrenia, we lived alongside them. I
had conversations with my grandma where many more people than just us
were present, even if I couldn’t see them. Sometimes I wondered if actually
16 Introduction
she could really see something that I couldn’t. The psychiatrists my
grandma encountered did not seem to share this thought .
I have also had periods of what I would now call melancholy, and what
my doctor, when I fi rst tried to tell her, called depression – something for
which she prescribed anti-depressants within the fi rst fi ve minutes of me
telling her, anti-depressants that took many months for me to stop taking
(something I did without telling her). And so, madness was heard in the
background of my childhood like whispers, as psychiatry peeled off the odd
and the distressed in our family and called them schizophrenic. Their psy
chiatrization has left a stain.
Thus, as my grandma took anti-psychotics from a box with a velvet top,
that stood on a desk fi lled with my granddad’s letters from an India where
the British Army were fi ghting to suppress Gandhi, before I was even born
my family’s life was a space entangled with colonialism and psychiatry. A
space where power relations justifi ed through the trope of the ‘irrational’
were played out, quietly, every day, swallowed down with water by my
grandma in the form of a pill.
Notes
1 Names have been changed throughout to ensure confi dentiality, except where
stated and where permission was given.
2 The term ‘mental illness’ saturates the pages of this book. In part this is because
that is the term used by GMH and many NGOs in the global South to describe
distress. Yet in the pages of this book these two words, of which much of the
book argues against using, serve as a critical remainder, they mark an anxiety,
they are words I cannot use, signifi ed by the inverted commas that encase them
throughout. Instead of inverted commas I imagine a line crossing these two
words out throughout.
3 I use the terms ‘user’ and ‘survivor’ here to refer to those who currently ‘use’
psychiatric interventions (often not by choice), and to those who have been psy
chiatrized (through psychiatric categories and/or interventions). I am also refer
ring here to the local and global self-organizing of psychiatrized peoples (and
sometimes those who are not (yet) psychiatrized) into hetrogenous movements
made up of people who are diversly situated in relation to psychiatry and have
different priorities in their struggles, but that share a committment to challenge
psychiatric hegemony in all the areas of life into which it permeates. (See
Diamond, 2013 , for a discussion of the different community constituencies of
survivor/Mad/Anti-psychiatry activism).
4 The Hearing Voices Network is an international network of people who hear
voices (see visions and/or have unusual experiences) who are interested in
alternative ways (that are non-pathologising) of understanding and living with the
experience of hear ing voices. The Network is more broadly part of a ‘hearing
voices movement’, where emphasis is on accepting and making sense of voices,
often seeing them as personally meaningful, and establishing self-help groups and
peer support networks. 5 From my fi eld notes, and reproduced in Kumar and Mills
( 2013 ).
1 Making mental health
a reality for all
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, and on gaps.
‘To make mental health for all a reality’
The Movement for Global Mental Health aims ‘to make mental health for
all a reality’ (Patel et al., 2011a :90). The next few chapters will focus on
three of these words; ‘make’, ‘all’ and ‘reality’. To ‘make’ mental health a
reality alludes to how psychiatry and GMH, to draw upon Hacking ( 2006 ),
work to ‘make up’ people, to make possible particular ways of being a
person: neurochemical selfhoods (Rose, 2003 ), pharmaceutical citizens
(Ecks, 2005 ), and ‘pharmaceutical personalities’ (Martin, 2007 ). It hints at
the potential ‘made-up-ness’ of psychiatric diagnostic categories, for exam
ple, made up by the pharmaceutical industry for profi ts, disorders made up
for drugs, ‘disease mongering’ (Moynihan et al., 2002 ).
‘Making’ mental health a reality also hints at a force – to ‘make’ some
one do something – a force that seems interlaced with psychiatric and
colonial subject formation. For Bhabha, ‘the creation of a space for a
“subject peoples”’ occurs through ‘the production of knowledges’
(Bhabha, 1983 :23); thus before we ‘turn’ (through the interpellating
formula of the ‘turn’) to the mechanisms by which psychiatric subjects are
formed, I want to examine what counts here as knowledge, and how it
constitutes the ‘real ity’ of mental health being made for all. This is to map
how GMH may operate as a ‘rationality’ – making up a kind of
‘intellectual machinery’ or apparatus for rendering reality thinkable in
such a way that it is amenable to political programming (Rose, 1996 :54)
and, here, to pharmaceutical industry marketing techniques.
18 Making mental health a reality for all
The dominant story – the one where ‘mental illness’
is treatable by drugs
In the Global Burden of Disease Report (2005) the contribution of mental
health problems to global disease were measured using the ‘disability
adjusted life-year’ (DALY – the sum of years lost to early death and years
‘lost’ due to disability). In order to measure the global burden of ‘mental
illness’, and compare this to the burden of other health conditions, the
MGMH and the WHO employ a strategy of grouping together neurologi
cal, mental and substance-use disorders into one category – ‘neuropsy
chiatric disorders’. Within the mhGAP Intervention Guide (2008:iii) (a set
of guidelines specifi cally developed to aid treatment decisions in nonspecial ised health care settings in low and middle-income countries) the
‘disorders’ included within the category of ‘neuropsychiatric disorders’
are; Moderate Severe Depression, Psychosis, Bipolar Disorder,
Epilepsy/Seizures, Developmental Disorders, Behavioural Disorders,
Dementia, Alcohol Use and Alcohol Use Disorders, Drug Use and Drug
Use Disorders, Self-harm/ Suicide, and Other Signifi cant Emotional or
Medically Unexplained Complaints’. This move to subsume the above
diversity of experiences and diagnostic categories into one category is
made so that ‘burden’ can be cal culated and compared to other (often
physical) disease categories, with the ‘neuro’ under which they are
subsumed suggesting where we should be fi xing our gaze – within brains.
In the Global Burden of Disease Report (2004) the contributions of
neuropsychiatric disorders to global disease were measured using the
DALY, and were found to result in a global loss of 148.8 million
disability-adjusted life years (Collins et al., 2011 ). Thus, around ‘14% of
the global burden of disease has been attributed to neuropsychiatric
disorders’ due to their ‘chronically disabling nature’ (Prince et al., 2007
:1). According to Collins et al. ( 2011 :27), this is a burden greater than
cancer and cardiovascular diseases, and one that is partly explained by
‘limited under
standing of the brain’ and by a lack of availability of treatments. Framing
mental health problems within a register of disability enables those who
call for GMH advocacy to identify ‘priority disorders’ (such as depression,
schizophrenia and dementia) ‘on the basis that they represent a high
burden (in terms of mortality, morbidity, and disability), cause large
economic costs, or are associated with violations of human rights’ (Patel et
al., 2008 :1355). GMH advocates can then mobilize the call for govern
ments to take ‘mental illness’ more seriously through increasing public
spending on mental health and ‘to scale up the coverage of services for
mental disorders in all countries, but especially in low-income and middleincome countries’ (Lancet Global Mental Health Group, 2007 :87). For
Patel ( 2006 :1312), the idea that there is ‘no health without mental health’
means
Making mental health a reality for all 19
that ‘mental health interventions must be tied to any program dealing with
physical health’. Therefore, the ‘WHO’s goal is to see that mental health is
integrated into primary health care systems across the world’ (WHO, 2008a
, mhGAP launch video).
The underlying logic of GMH advocacy states that mental health prob
lems are ‘illnesses’, and that ‘mental illnesses’ have underlying biological
components comparable to those for dementia and epilepsy. In terms of
interventions, this invokes parallels between access to psychiatric medica
tions and, for example, to medication for epilepsy or anti-retrovirals for
HIV/AIDS. This parallel is apparent in the mhGAP Action video (WHO,
2008a ), which begins, ‘50 million people suffer from epilepsy’ and
‘Depression haunts and hurts 150 million people’. It is also made apparent
in the stories in the video. Zhaoming He, who has epilepsy, says, ‘I started
to take this medicine and started feeling much better’; Suresh, who has
psychosis, says ‘I’m normal now, thanks to my doctors.’ Here the logical
progression implied in the placing of epilepsy and mental health problems,
such as psychosis, alongside each other, is that interventions, including
medications, should be made accessible to those in LAMICs for both of
these disorders equally. Perhaps contrary to this, the WHO ( 2001a :x) read
ily acknowledges that ‘[e]pilepsy is not a mental problem’, but they ‘have
included it because it faces the same kind of stigma, ignorance and fear
associated with “mental illnesses”’.
Thus, Patel et al. ( 2006 :1312) then call for a move beyond the ‘scientifi
c evidence base’ of particular treatments (which are taken as wellestablished) and push the ‘moral case’: ‘that it is unethical to deny effective,
acceptable, and affordable treatment to millions of persons suffering from
treatable disorders’.
Another story – the one where the ‘treatment’
is part of the problem
However, let us fi rst briefl y examine the ‘scientifi c evidence base’ that
Patel et al. ( 2006 :1312) are urging us to ‘move beyond’. There are some
prob lems in making the argument above, in that there is, as yet, ‘no
convincing evidence that psychiatric disorders or symptoms are caused by
a chemical imbalance and no evidence that psychiatric drugs exert their
effects by cor recting such an imbalance’ (Moncrieff, 2009 :101). As
Summerfi eld ( 2008 :992) points out, ‘claims for the universality of a
particular psychiatric category would be compelling if a straightforward
biological cause had been established’ – of which very few ever have.
Currently, psychiatry assumes that psychotropic drugs work in a
‘disease specifi c’ way, correcting biochemical imbalances that are
assumed to be the
20 Making mental health a reality for all
cause of much ‘mental illness’. This attribution of distress to the individu
al’s brain chemistry has been criticized from many quarters: as a means of
diverting attention from the social conditions and inequalities that may lead
to distress (Parker, 1997 ); as a mechanism for pathologizing and medical
izing people’s behaviour, widening the boundaries of abnormality (Timimi,
2002 ); and as a means to depoliticize distress, preventing it from being
read as personally and politically meaningful (Johnstone, 1997). By
locating people’s distress within their brains, simple technical solutions
can then be advanced – ‘pills for life’s ills’ (Moncrieff, 2009 :105).
Thus, many critical psychiatrists seek to abolish psychiatric diagnostic
systems, based on evidence that, in summary; psychiatric diagnoses are not
valid … they increase stigma … they do not aid treatment decisions and they
impose Western beliefs about mental distress on other cultures (Timimi,
2011 , online). According to Summerfi eld ( 2008 :993), the term depression
should not be used, as it is by the WHO, to denote a ‘universally valid mental
disorder that is amenable to a standard mental health toolkit’. Similarly,
there is much research that questions the validity and reliability of the schiz
ophrenia label (see Boyle, 1990/2002 ; Bentall, 2003 ), a label which many
feel should be abolished altogether – not exported globally (Hammersley
and McLaughlin, 2010). This needs to be taken very seriously when we
consider the push to ‘scale up’ psychiatric treatments across the globe.
The moral argument
Furthermore, the Movement for GMH urges HIV/AIDS activism to be used
as a model for GMH advocacy, with Patel et al. ( 2006 ), connecting mental
health to the ‘moral argument’ made by some HIV/AIDS activists that led
to reductions in the price of anti-retroviral medications by pharmaceutical
companies, and the free provision of such medications by many govern
ments. Thus Patel et al. ( 2006 :1314) call on us to
Consider the moral argument that persons with HIV/AIDS in develop
ing countries had the right to access antiretroviral drugs, that the state
had to provide them for free, that drug companies had to reduce their
prices … that discrimination against people with HIV/AIDS had to be
combated vigorously, and that knowledge about HIV/AIDS was the
most powerful tool to combat stigma. These arguments were moral
and human rights based. … We believe that the time is ripe for such a
GMH advocacy initiative that makes the moral case for the mentally
ill.
Here HIV/AIDS activism operates as a framework for mental health
advocacy, within which access to anti-retroviral medications for
HIV/AIDS
Making mental health a reality for all 21
is situated as parallel to access to psychiatric medications in the fi ght for
global social justice and equality. This is further complicated by the fact that
while research that uses placebos, for example in HIV/AIDS, has been
widely criticized because it denies participants the best currently available
treatment (Shah, 2006 ), in many trials for depression, drug–placebo differ
ences have been found to be not statistically signifi cant (Kirsch, 2009 ), and
signifi cant adverse effects have been found in the drug groups of a number
of trials, including increased risk of suicide (Healy, 2006 ).
A further problem lies in the fact that trials of medication (both
psychiat ric and for physical illnesses) are often sponsored by the
pharmaceutical industry, meaning that when results are negative (i.e. a
drug has been found to have no effect or to be harmful) they are often not
published. This ‘publi cation bias’ distorts and pollutes all evidence
throughout medicine, meaning that the ‘evidence based medicine’ that
Patel takes for granted could be cur rently said not to exist anywhere in
medicine (Goldacre, 2012 ). In a system atic review of published and
unpublished data, Whittington and others (2004) found that when
unpublished data was considered for the use of Selective Serotonin
Reuptake Inhibitors (SSRIs) (anti-depressants) in children, risks far
outweighed benefi ts, including a higher incidence of suicide-related
behaviour (compared to placebo), leading the authors to con clude that
SSRIs are not effi cacious for use with children. In fact, most trials in the
use of (SSRIs) in childhood depression have failed to show any benefi t,
leading to the conclusion, in an editorial of The Lancet ( 2004 :1335) (a
medical journal that keenly promotes GMH), that ‘the story of research
into [SSRI] use in childhood depression is one of confusion, manipulation,
and institutional failure’ and that these drugs are both ‘ineffective and harm
ful in children’. And yet, the anti-depressant fl uoxetine is on the WHO
Model List of Essential Medicines (for children and adults) (WHO, 2011a ,
b ), as is the anti-psychotic chlorpromazine. And the World Health Report
(WHO, 2001a :xii) states that:
Essential psychotropic drugs should be provided and made constantly
available at all levels of health care. These medicines should be
included in every country’s essential drugs list.
However, while these medications are framed by the WHO as ‘essential’,
research not only increasingly points to their ineffectiveness, but also to their
harmfulness. Psychiatric drugs, like any psychoactive substances, alter brain
chemistry through intoxication (Moncrieff, 2009 ), disrupting normal brain
function and constituting, for Breggin ( 2008 ), the ‘brain-disabling’ princi
ples of psychiatric medications. Therefore, the WHO is promoting the
global prescription of highly addictive drugs, that have no proven longterm benefi t
22 Making mental health a reality for all
and that have been shown to cause harm. That the fi ndings of the adverse
effects of psychiatric medications often remain unknown presents a serious
challenge as to the issue of what counts as evidence within GMH. A review
of the trials on treatment and prevention of ‘mental disorders’ in LAMICs,
that are cited in a paper by Patel and others ( 2007 ), shows that 80% of the
trials for depression were for psychopharmaceuticals alone. Das and Rao (
2012 ) point out that this refl ects a bias in the research agenda, particularly
when we attend to research where pharmacological and psychological inter
ventions have been found to be equally effi cacious (Casacalenda, Perry and
Looper, 2002 ). Furthermore, the non-publication of trials leads to an errone
ous evidence base and to potentially harmful treatment decisions, skewed
when data is often not published because pharmaceutical industry sponsors
withhold negative results that would damage the marketing of their products
(Whittington and others, 2004 ). Thus, Moncrieff ( 2009 :101) concludes
that ‘there is no basis on which to accept a disease-centred account of
psychiatric drug treatments’, and yet it is this model that is being scaled up
globally.
A further complexity in the call for GMH is that fi ndings from interna
tional comparative studies by the WHO and the World Mental Health
Survey suggest that LAMICs actually have better long-term outcomes for
mental health problems (such as schizophrenia) (WHO, 1973 ; 1979 ), and
despite so few people in LAMICs receiving treatment, prevalence of
‘mental illness’ appears to be much lower than in HICs (Kessler and Ustun,
2008 ). Also, fi ndings from within HICs similarly point to better long-term
outcomes for people with a diagnosis of schizophrenia who are not medi
cated, and worse outcomes for those who are (Rappaport, 1978 ). In the
UK, a HIC, where access to psychiatric medication is relatively high,
Healy et al. (2001:26–27) point out that since the development of modern
psychotropic drugs we ‘now compulsorily detain three times more …
[and] admit fi fteen times more patients’.
Pills that ‘make up’ illness
The relation between ‘mental illness’ and impairment becomes even
messier when we consider the evidence that long-term use of psychiatric
medications may lead to iatrogenic impairment, impairment caused by the
medication, including (long-term) cognitive defi cits, motor tics, headaches,
dementia, atrophy of the brain, and tardive dyskinesia (an irreversible neu
rological disease) (Breggin, 1990 ; Gardos and Cole, 1978 ), and in the long
term may alter brain weight and lead to early death (see an extensive account
of this research literature in Whitaker, 2010 ).
Thus, while there is little evidence that most ‘mental illness’ is caused
by a chemical imbalance, when impairments are found in the brain they
are may
Making mental health a reality for all 23
be caused by psychiatric medications. Moncrieff ( 2009 ) points out that
psy chiatric drugs are psychoactive substances that alter brain chemistry
through intoxication. That psychiatric drugs can induce experiences that
come to be read as ‘mental illness’ is not uncommon, and suggests a
powerful mecha nism for ‘making up’ ‘mental illness’ and psychiatric
subjects – a form of psychiatrization that is swallowed. Even the American
Psychiatric Association (APA) has confessed ( 1993 :22) that ‘all antidepressant treat ments, including ECT [electro-convulsive therapy], may
provoke manic or hypomanic episodes’ – an iatrogenic manufacturing of
bipolar patients (Whitaker, 2010 ). It speaks to the power of psychiatry
that instead of this mania being understood as drug induced, calling into
question the long term effi cacy of medication, iatrogenic impairments are
often framed by psychiatry as ‘symptoms’ of an underlying psychiatric
disorder, just as increased suicide is read as being due to ‘mental illness’.
Here the risk of suicide in children is used to justify ‘treatment’ with antidepressants – a ‘treatment’ that has been found in clinical trials on
children to actually increase suicidal behaviour (Healy, 2006 ).
This begins to hint at the power of psychiatric frameworks to frame what
counts as evidence, calling attention to the question of what exactly is GMH
‘scaling up’? Summerfi eld ( 2008 :993) points out the irony of the WHO’s
use of checklist technologies to estimate prevalence of ‘mental ill
ness’ globally ‘when the strength of their evidence base even in Western
societies remains controversial’. There are other uncomfortable questions to
be asked.
Is there a gap?
Ecks and Basu ( 2009 :68) note that there ‘can be little doubt that the overall
assessment of a psychiatric “treatment gap” is correct, if one accepts the
premises of DALYs, the effi cacy of drugs, and the lack of govern ment
spending in this area’. However, they argue that in India this ‘gap’ has been
constructed on a tenuous evidence base that overlooks the ‘actual
availability and affordability of antidepressant drugs’ – which are often sold
without a prescription (Ecks and Basu, 2009 :69). Ecks and Basu ( 2009 )
make these claims on a different evidence basis to that of the WHO data
sets: evidence from ethnographic studies ‘on the ground’ in India. They
make the point that interviewing the staff at local medicine shops about their
sales of anti-depressants can yield very different sets of information to largescale ‘offi cial’ epidemiological studies, making clear that ‘in the case of
depression and its treatments in South Asia, it is more truthful to work with
less exact numbers than with misleadingly precise ones’ (Ecks and Basu,
2009 :79).
24 Making mental health a reality for all
Their fi ndings about the wide availability of anti-depressants in India
are challenging to the WHO mhGAP initiative as they render ‘its claims
about the treatment gap undependable’, and point to the ‘misplaced effort to
make antidepressants more widely available through government health
services’ (Ecks and Basu, 2009 :79) in areas where over-prescription may
be just as problematic as a lack of access to anti-depressants. This ethno
graphic (re)reading of the ‘treatment gap’ challenges the very idea that
there is a gap, and calls for different ways of approaching and reading
issues of prevalence of ‘mental illness’ and of access to psychiatric medica
tions. Here the calling into question of the evidence base of the ‘treatment
gap’ can be further supplemented by a reading of the ‘conditions of possi
bility’ that enabled the ‘gap’ to emerge – a partially post-colonial reading
of the means by which psychiatry travels.
The coming into being of the ‘gap’
Back in the days of the ‘old cross-cultural’ psychiatry, before Kleinman
(1977) spoke of the ‘new’, the discipline was divided by two opposing
approaches – the ‘etic’ and the ‘emic’. The etic approach assumes that
‘mental illnesses’ arise from pathological biological processes and are thus
universal, giving rise to international diagnostic systems, such as the DSM
and the ICD, and to the application of these across cultures. Conversely,
those who adopt an emic approach consider ‘mental illnesses’ as subjective
experiences, infl uenced by culture, meaning they should be studied within
their particular cultural context.
Within the ‘new cross-cultural psychiatry’ (Kleinman, 1977) and within
GMH, there is a call to bring together these two approaches. Thus at a course
on GMH that I attended at the Institute of Psychiatry in August 2011,
Vikram Patel, a leading fi gure in GMH, stated that ‘[m]ental health research
across cultures must integrate etic and emic methodologies and
perspectives’. 1
Vikram explained that when he fi rst started his research on culture and
depression, he was convinced that depression was a cultural artefact of the
west. However, now he is convinced that depression is a real, and universal,
cause of human suffering (Patel, 2011).
Why the change? When I sat and listened to Vikram saying this, I won
dered why a cultural artefact can’t be experienced as ‘real’, and I thought
about the part GMH is playing in making depression a universal ‘reality’.
Here the synthesis of the etic and emic approaches forms part of the ‘condi
tions of possibility’ for the ‘treatment gap’ to emerge, for the formation of
the MGMH, and the justifi cation for ‘scaling up’ interventions to close
that gap.
Making mental health a reality for all 25
Universals
Calls to close the treatment gap emerge from the closing of another gap,
then, the gap between the etic and the emic. This synthesizes the differences
between the two approaches (differences that grate against each other) into
a seemingly higher category, seen to transcend cultural differences, one that
is universal. For GMH, a key trope by which this synthesis has been made
possible is the brain. For example, in the WHO World Health Report ( 2001a
:x),
We know that mental disorders are the outcome of a combination of
factors, and that they have a physical basis in the brain. We know they
can affect everyone, everywhere. And we know that more often than
not, they can be treated effectively.
While research has shown that cross-culturally people have different
understandings of what we might call the ‘mind’ (for example, see Kakar,
1982 ), particularly around mind/body relations and dualisms, the brain is
seemingly assumed to be universal – everyone has a brain – there’s even
been a Decade of the Brain. Because everyone has a brain, and according to
the WHO ( 2001a :x), mental disorders ‘have a physical basis in the brain’,
it becomes possible to understand ‘mental illness’ in universal terms. It
becomes possible for the WHO to state that mental disorders ‘are truly
universal … found in people of all regions … at all stages of the life course’
(WHO, 2001a :22). Universality is claimed here, staked out in the very
concept of mental health as ‘global’, in the three words ‘Global Mental
Health’.
Therefore, within much WHO policy and GMH literature cultural differ
ences are not overlooked, they are encountered as different expressions of
an underlying physical component to ‘mental illness’. This is evident in a
study by Wilcox et al. ( 2007 ) that examines how the explanatory models
used by parents in India whose children have been diagnosed with attention
defi cit hyperactivity disorder (ADHD) affect help seeking. The research
found that, for many families, seeking biomedical help was the last step
and that parents preferred non-medical interventions. However, the study
con cludes that ‘children with a clinical diagnosis of ADHD are identifi
able in developing countries’ (Wilcox et al., 2007 :1608).
Thus, while explanatory models may vary across cultures, these different
models do not seem to disrupt psychiatric frameworks, which are taken as
being identifi able globally. As with the treatment gap, Wilcox et al. ( 2007
) identify a wide gap between biomedical ways of understanding children’s
behaviour and Indian parents’ understandings – a gap that may narrow as
26 Making mental health a reality for all
more families have increased contact with doctors, a trend that tends to lead
to an adoption of biomedical explanations of children’s behaviour as
‘chemical imbalances’ and ADHD (Wilcox et al., 2007 ).
When ADHD is described as ‘a neurobiological syndrome’ that ‘affects
individuals… across all cultural contexts’, the ‘scale up’ in global access to
psychostimulants is thus seemingly justifi ed (Flisher et al., 2010 :1 & 6).
Similarly, then, for the WHO ( 2001b :33):
Since child mental health symptoms do not differ signifi cantly across
cultures, it is feasible to use expertise from child psychiatry services in
developed countries to compile training packages for primary care
workers in developing countries.
Despite recognition, in this statement, of the possibility that cultural differ
ences may be a factor, this is pushed to one side in favour of an assumption
of the universal applicability of mental health, and of the expertise of those
in ‘developed countries’. Here cultural interpretations of distress ‘are down
played and regarded as secondary to conquering the “scientifi c” challenge
of “mental illness” ’ (Thomas et al., 2005 :26). For Burman ( 2008 ), as
devel opment discourse (both child and economic) and psychiatric
discourse fail to deliver what they claim to know, it is through this failure
that they produce increasing technical devices for their proliferation,
enabling the slipping away of markers of difference (gender, culture) in
the very pre sumption of the models’ global applicability. Such technical
psychiatric devices often, then, facilitate a rapid growth in psychiatric
diagnoses and in pharmaceutical solutions – the ‘McDonaldization of
children’s health’ (Timimi, 2010 :686).
This echoes Nieuwenhuys’s ( 2009 :148) assertion that development
agencies push the global South for ‘the emulation of a kind of childhood
that the West has set as a global standard’, and any move against this
standard is dismissed as ‘cultural relativism’ – ‘as attempts to challenge the
innate, universal rights of children’. This leaves the role of Indian
researchers into studies of childhood as solely to ‘fi ll in the gaps in quanti
tative knowledge, not to question underlying assumptions about the
problematic aspects of childhood in India’ (Nieuwenhuys, 2009 :148).
Filling in the gaps in quantitative knowledge about treatment of mental
disorders in the global South (leaving issues about their very validity or
usefulness unquestioned) is also sometimes promoted by advocates of
GMH. However, here the argument is also made that ‘[a]lthough there are
few studies on medication for AD/HD from LMICs, effi cacy data from
studies conducted in HICs are likely to be applicable to these settings’
(Flisher et al., 2010 :1). This would suggest, then, that fi ndings of the lack
Making mental health a reality for all 27
of effi cacy of many psychiatric interventions from the global North may
also be applicable to the global South.
While advocates of GMH and WHO policy emphasize closing treat
ment gaps, the very allusion to a ‘gap’ suggests that different ways of
understanding do exist (though these other frameworks are often deni
grated as being ‘non-scientifi c’ in a hierarchy where psychiatric
knowledge is privileged at the top). In his exploratory account of different
healing traditions in India, Sudhir Kakar ( 1982 :31) (my copy of whose
book is saturated with mildew, making the edges curl) suggests that the
line of cleavage between different healing systems, that which cuts across
cultures, ‘is not simply between “traditional” and “modern” or between
“Western” and “Asian”, [it seems to be] between those whose ideological
orientation is more towards the biomedical paradigm of illness … whose
self-image is close to that of a technician, and others whose paradigm of
illness is metaphysical, psychological or social’, those who recognize ara
tionality and emphasize the relational. The prescriptive lists of Ayurvedic
medicine, for example, emphasize the relation of the person who is dis
tressed with others, framing distress as ‘disorders of relationships’, and the
role of healing as aiming to restore lost harmony between that person and
their community (Kakar, 1982 :274–275).
An illness like no other?
It is possible, then, alongside the strong push to see ‘mental illness’ as ‘an
illness like any other’, to read another story, an alternative ‘evidence base’,
where ‘mental illness’ is an illness like no other, or indeed better not con
ceptualized as an illness at all. This revisits arguments from the early days
of anti-psychiatry; Szasz’s assertions that mental health problems should
be read not as illness, but as ‘problems in living’; as sane reactions to an
insane, unequal society (Szasz, 1960 :114).
However, anti-psychiatry may, in its push to divorce distress from med
icine, invoke a mental/physical binary that problematically assumes that
medicine and physical illness are value-free. For Sedgwick ( 1982 :31),
medicine is ‘not simply an applied biology, but a biology applied in
accordance with the dictates of social interests, and thus always value
loaded’. In any debate as to whether ‘mental illness’ is an ‘illness like any
other’, we must fi rst address our assumptions as to what constitutes an
‘illness’. This calls attention to how the dictates of social interests ‘apply’
and make claims to biological and medical knowledge, and to what
political rationales are being served by constructing mental distress as a
biochemical impairment, particularly as (mental) health emerges as a
global marketplace.
28 Making mental health a reality for all
Burdens and markets
Ann Plumb (1994:5) notes how users and survivors of psychiatry have his
torically pushed for a ‘widespread shift away from talk of “illness”, “disor
der”, or “defective mechanisms” (chemical imbalances) to talk of distress
or dissent’, a language that places us fi rmly ‘in a relationship with our soci
ety and culture’. Many user/survivor organizations in HICs, such as the
Hearing Voices Network, explicitly reject the framing of experiences such
as hearing voices as ‘symptoms’ within an illness model. Such groups
have usually mobilized around the discursive ensemble of ‘trauma/abuse/
distress’, rather than illness (Cresswell and Spandler, 2009 :138), situating
people’s experiences within their personal life history. However, this lan
guage does not seem to have made it into GMH and WHO policy, as
evident in the excerpts about schizophrenia below:
Schizophrenia is a psychotic disorder of low prevalence, which is
often chronic and very disabling (Patel et al., 2007 :48).
Schizophrenia causes a high degree of disability. In a recent 14-country
study on disability associated with physical and mental conditions,
active psychosis was ranked the third most disabling condition, higher
than paraplegia and blindness, by the general population (Üstün et al.,
1999, cited in WHO, 2001a :33).
‘Chronic and very disabling’, more disabling than paraplegia and blindness
– this is the ‘offi cial’ story of schizophrenia within WHO accounts. This
stands in direct contrast to the focus on recovery in some HICs that stemmed
from a sustained grassroots critique by users and survivors against psychi
atric assumptions of lifelong pathology and defi cit. This chronic, disabling
language is explicit throughout the texts of the WHO, and in the very con
ceptualization of ‘mental illness’ as a ‘burden’. This is apparent in the
World Health Report, which
focuses on a selection of disorders that usually cause severe disability
when not treated adequately and which place a heavy burden on com
munities (WHO, 2001a :22, Box 2.1).
For the WHO, ‘mental illness’ constitutes a burden not only on individuals
and communities but on the economy, as is evident in the following two
statements:
The cost of mental health problems in developed countries is
estimated to be between 3% and 4% of GNP. However, mental
disorders cost
Making mental health a reality for all 29
national economies several billion dollars, both in terms of expendi
tures incurred and loss of productivity (WHO, 2003a :5).
The economic cost of schizophrenia to society is also high. It has been
estimated that, in 1991, the cost of schizophrenia to the United States
was US$ 19 billion in direct expenditure and US$ 46 billion in lost
productivity (WHO, 2001a :33).
‘Years of life lost’, death, suffering, disorder, economic cost – this is how
the WHO and GMH frame ‘mental illness’. Here people’s identities emerge
as ‘bodies that cost the state a certain amount of money’ (Murray, 2009 :12).
However, according to Davar ( 2007 ), within this economics of mental
health, there are other ‘hidden costs’: the cost of psychiatric diagnosis; of
‘wrongful confi nements’; the cost of creativity lost due to long-term institu
tionalization; and arguably the cost of precarious employment that produces
impairment, and of economic reforms that produce distress. These are costs
that do not seem to fi gure in the offi cial story of GMH.
Burden
The discourse of burden is used here by the WHO and the MGMH to convey
to governments (worldwide, but particularly in LAMICs) the need to
increase spending and allocation of resources on mental health:
Despite the relatively high contribution to the total burden of disease,
28% of nations have no specifi ed budget for mental health. About one
third of people (33 countries with a combined population of two bil
lion) live in nations which invest less than 1% of their total health
budget in mental health (Thornicroft and Maingay, 2002 :608).
Perhaps the WHO and the MGMH feel governments are more likely to
listen when this plea is framed within a discourse of the economic costs of
‘mental illness’. They may well be right. However, is the language of burden
the only, or even the most useful, way to frame mental distress? In speaking
of ‘mental illness’ as a burden, implied through increased depend
ency on others, the WHO forecloses the recognition of dependency as a
mode of interconnectivity, present among all peoples and yet often covered
over ‘in the domain of western hegemony’ (Shildrick and Price, 2006 :20).
This does not imply that we cannot seek to understand distress and disabil
ity as at times urgent, and differentially distributed globally – it does
however call for a serious questioning of how we can conceptualize urgency
outside of the language of burden. Further, it leads us to wonder how the
30 Making mental health a reality for all
‘burden’ of undiagnosed ‘mental illness’ interlaces with the ‘white man’s
burden’ to civilize the ‘natives’, to teach the populations of LAMICs about
‘mental illness’. However, there is another dominant and deeply problem
atic framework for reconceptualizing the ‘burden’ of ‘mental illness’, a
framework where ‘[e]very difference is an opportunity’, and where
‘burdens’ become markets (Hardt and Negri, 2000 :152).
Burden as market
While it is of central importance that the lives of those who live in distress
are improved, and while the WHO may play a key role in this, Thomas et al.
( 2005 :26) argue that ‘the WHO, in foregrounding the role of biomedicine,
is inadvertently playing into the hands of a different set of interests’.
Kirmayer ( 2006 :131) shares this concern that ‘the tendency to portray
mental health problems as fundamentally biological (or, even more reduc
tively, as genetic) is an ideological move that serves certain political and
economic interests’. It further enables a sidestepping of any critique of the
deleterious effects of social arrangements (Kirmayer, 2006 ).
Seemingly, then, the hands being played into through the mobilization
of biochemical, ‘within brain’ explanations of distress, are the hands of the
pharmaceutical industry, for whom LAMICs, such as India, are an ‘untapped
market’ for psychiatric drugs (Equity Master, 2004 ), a ‘new promised land
for drugmakers’ … who are ‘targeting the subcontinent’s countryside for
expansion’ … as ‘part of pharma’s new focus on emerging markets’ (Staton,
2009 ). This points to another reason for the deployment of the ‘unitary con
cept of illness’ – as ‘part of a strategy of psychiatric expansionism’ (Castel
et al., 1979 ; Cresswell and Spandler, 2009 :138). Like colonialism’s search
for new markets, this expansion is hugely profi table, with worldwide sales
of psychiatric drugs totalling $82 billion in 2012 (New Internationalist, 2012
).
This fi nancial incentive casts a strange light around the ethics of calls to
scale up access to psychiatric drugs in LAMICs. Here attempts by the WHO
and the World Psychiatric Association (WPA) to ‘scale up’ the availability
of psychiatric drugs and to develop standardized global approaches to diag
nosis are highly biased towards ‘Western’ psychiatric constructs. This is not
only the globalization of psychiatry but the recognition that ‘psychiatry
itself is an agent of globalization’ (Kirmayer, 2006 :136). For example,
Kirmayer ( 2006 ) charts the role of cultural psychiatry in the marketing of
anti-depressants in Japan, where somatic symptoms and distress were rein
terpreted as being amenable to drug treatment, marking both a
much-needed transformation of Japanese mental health care that is fi
nally providing treatment to many people suffering from depression
Making mental health a reality for all 31
who were hitherto unrecognized or inappropriately treated [and] a
reconfi guring of other forms of suffering in ways that suit the interests
of the pharmaceutical industry (Kirmayer, 2006 :137).
Here, it seems the privileging of one framework of understanding – the
bio-psychiatric – serves particular political interests and fi nancial incen
tives, leading Summerfi eld ( 2008 ) to query how much of the impetus for
the ‘scale up’ of psychiatry has come from those on the ground in
comparison to interests from the outside. This also points to the process by
which other frames of reference for distress, such as the somatic or bodily
experience of distress, are encountered by psychiatry and made sense of in
a different language – as ‘symptoms’ of an ‘illness’ located in the brain.
Sublation and the brain
Throughout this chapter we have caught glimpses of how psychiatric
frameworks encounter alternative healing systems and ways of under
standing in the global South. It seems possible here to trace a key way that
this encountering takes place, a method of encountering difference as
being the same, encountering difference through the creation of a ‘median
category’, where:
Something patently foreign and distant acquires, for one reason or
another, a status more rather than less familiar. … a new median cate
gory emerges, a category that allows one to see new things, things
seen for the fi rst time, as versions of a previously known thing … a
method of controlling what seems to be a threat to the established
view of things. The threat is muted (Said, 1978 [1995]:58–59).
Here difference is encountered only to be made familiar, to be accommo
dated and domesticated, meaning that the threat such difference might pose
to the hegemonic is muted. Reading this alongside Said’s Orientalism, this
marks ‘a way of … coming to terms with the orient in terms of occidental
categories’ (Chakrabarti and Dhar, 2009 :26). That is, in the Orientalism at
work in GMH, a way of ‘coming to terms’ with the populations of
LAMICs in terms of biomedical and psychiatric categories. In this
process, ‘the occi dent [the ‘West’] fi rst transforms the orient into an
image (albeit lacking) of itself and then shows that the orient is the same
as the occident, but not quite ’ (Chakrabarti and Dhar, 2009 :26).
Within GMH literature, LAMICs are constructed as having the same
mental health problems, the same biochemical imbalances, the same brains,
as in HICs (the occident). The same, that is, but not quite , for there is a lack,
32 Making mental health a reality for all
in access to psychiatry and in scientifi c knowledge about mental health
problems. This universality – the WHO’s construction of mental disorders,
and their ‘physical basis in the brain’ (WHO, 2001a :x) – then ‘occidental
izes the orient in terms of a “shared telos” and a “shared worldview” but
where the occident is still somehow more advanced, a step ahead in this
developmental telos’ (Chakrabarti and Dhar, 2009 :26).
Here, there is a simultaneous move to homogenize – to make the same,
and yet to hierarchize – to establish chains of equivalence around a pre
sumed universal criterion or standard, evident in the launch of The Lancet
’s (2011) second series on GMH:
The mhGAP guidelines should become the standard approach for all
countries and health sectors; irrational and inappropriate interventions
should be discouraged and weeded out. (Patel et al., 2011b :1442).
This universal standard, then, comes to be that which all countries, and
approaches to distress, are compared to, and judged by, with the standard
itself determining what can be thought of as ‘irrational’ or ‘inappropriate’,
and what should be ‘weeded out’. Here the populations of LAMICs are
predetermined to fall short of the norms imposed by a universalizing global
standard – itself a cultural construction (often of the ‘West’) (Hook, 2004b
). Thus, in the homogenizing, universalizing move of applying these psychi
atric classifi cations globally; a hierarchy is established, whereby HICs will
always appear more advanced, in part because the criteria to be met with
come from these countries. This homogenizing/hierarchizing may also be at
work in another synthesis that is central to the emergence of GMH – the biopsycho-social model. The World Health Report (WHO, 2001a :xiv) states
that
Advances in neuroscience and behavioural medicine have shown that,
like many physical illnesses, mental and behavioural disorders are the
result of a complex interaction between biological, psychological and
social factors.
The integration of these three areas (bio-psycho-social) has become
increasingly dominant. However, according to Read ( 2005 :597), this
model accords a role for social stressors as being ‘triggers’ for an assumed
under lying genetic predisposition, meaning that this ‘is not an integration
of models, it is a colonisation of the psychological and social by the
biologi cal’. Such colonization is enabled by ‘coming to terms’ with
research that emphasizes contextual (socio-economic, political) factors as
contributors to distress, such as trauma (or the political reforms explored
in Chapter 2 ), or preventing this research from being seen as ‘evidence’.
This resonates with
Making mental health a reality for all 33
Steven Sharfstein’s (2005) (an ex-president of the American Psychiatric
Association) comment, that ‘we must examine the fact that as a profession,
we have allowed the bio-psycho-social model to become the bio-bio-bio
model’ (cited in Read, 2005 :597).
Re-biologizing psychiatry
This rebiologizing of psychiatry, for Lakoff ( 2005 ), is made possible
through psychiatry’s construction of chains of equivalence between the
global North and South, and between mental and physical/somatic illnesses.
The WHO claims this equivalence between mental and physical health to
mobilize increased government recognition of and spending on mental
health:
Unfortunately, in most parts of the world, mental health and mental
disorders are not accorded anywhere near the same degree of impor
tance as physical health. Rather, they have been largely ignored or
neglected (WHO, 2003a :4).
However, while these claims help to point out the discrepancies in govern
ment spending between physical and ‘mental health’, they also hint at how
the WHO may increase its focus on the social determinants of mental
health, while largely focusing on ‘solutions’ within the brain. Here
presumed bio logical causes of both physical and ‘mental illnesses’
become privileged, resting on the ‘assumption that biology is universal
and culture local’ (Kirmayer, 2006 :129).
Non-medical spaces
However, within this chapter, other ways of knowing have spoken back to
GMH, making us wonder whether: if there is no impairment or biochemical
aetiology to ‘mental illness’; if it is not illness, and perhaps more usefully
understood as distress; if we attend to evidence of the disabling iatrogenic
effects of some psychiatric medications, and to the fi nancial interests that
enable much of this research to remain unpublished; then we may come to
a different conclusion as to what constitutes ethical psychiatric interven
tion. If ‘mental illness’ is better understood as distress, then should this be
responded to through global health legislation? Echoing much survivor
testimony, Plumb ( 1999 :463) asserts the need for provision of non-medical
sanctuary, just as a number of survivor organizations in the global South call
for the provision of non-medical and non-Western spaces of healing
(PANUSP, 2012 ; Bapu Trust, 2006 ). However, in India, where such nonmedical spaces for healing are widely available in the form of
34 Making mental health a reality for all
religious and traditional healing sites, the Indian Government is attempting
to prevent people with ‘mental illness’ from seeking treatment at such sites,
sometimes forcibly removing them and taking them to local psychi atric
hospitals (Davar and Lohokare, 2009 ). Within GMH literature,
‘expenditures on ineffective or inappropriate care outside the formal healthcare system’ are seen to be a key economic consequence of mental disorder
(Patel et al., 2007b :51–52), thus framing treatment that lies ‘outside’ the
formal health care system as ineffective and ‘irrational’, something to be
‘weeded out’ (Patel et al., 2011a :1442).
In fact, GMH advocacy sets ‘mental illness’ fi rmly within a public,
global health agenda, advocating ‘to ensure the inclusion of mental health
on the global public-health policy agenda, and the effective integration of
mental-health care into every level of general health care’ (Patel et al., 2008
:4). Here, a key programmatic aim of GMH advocacy is that ‘mental health
care must be piggybacked onto all existing health programmes’ (Patel, 2007
:13). This seems ironic considering that ‘[t]oday psychiatry is under
criticism as a basis for mental health service development in the United
Kingdom’ (Fernando and Weerackody, 2009 :196).
What are the implications of these debates for GMH? Perhaps labelling
distress as ‘mental illness’ limits the mechanisms for responding to it solely
within a medical register, eclipsing alternative non-medical interventions.
In fact, we might question whether there is ‘a legitimate role for doctors in
relation to madness and distress’ at all, or what this role should consist of
(Bracken and Thomas, 2008:220). Thinking this through on a global scale,
then, is there a legitimate role for psychiatry in relation to responding to
distress in the global South? What function does conceptualizing mental
suffering as impairment and illness serve? What interventions does it make
visible, and what ways of intervening does it foreclose? I want now to
explore some specifi c implications of locating distress within the brain; the
reconfi g uring of socio-economic crisis as individual crisis, as ‘mental
illness’.
Note
1 Patel, V. (2011). The social determinants of mental disorders: implications for
international mental health research. Lecture delivered as part of GMH Summer
School (one week course) at the Health Service and Population Research
Department of the Institute of Psychiatry, London (22–26 August 2011).
2 ‘Harvesting despair’1 –
Suicide notes to the state
and psychotropics in the post
A chapter on pesticides and suicides, on global markets and cotton prices,
on suicide notes written to the Government, and on pills that swallow policy
.
The suicide district
An increasing number of suicide notes today directly address the Prime
Minister … taking the form of a public statement accusing the state of
betrayal (Perspectives, 2009 :2).
This chapter aims to approach some of the global implications of locating
distress within the brain, as ‘mental illness’, through a discussion of farmer
suicides in India, with a particular focus on the responses to these suicides
by the Indian Government and within GMH advocacy. I aim to draw upon
farmer suicides in India as a lens through which to situate the question of
what function the conceptualization of distress as ‘illness’ serves, to illumi
nate what political rationales may be at work in this mobilization, and to
explore how this lays the ground, degraded as is it by over-use of the same
pesticides that farmers swallow to end their lives, for socio-economic and
agrarian crisis to be reconfi gured as individual crisis – as ‘mental illness’.
However, farmer suicides in India are more than a conceptual lens – they
are a matter of life and death, and thus to draw upon them, to look through
them as a lens, also implies an ethical responsibility in rethinking how these
suicides might be responded to and from what registers this might be
possible. While questioning the role of a solely psychological or psychiatric
register for understanding suicide, this chapter does not argue for the
complete abandonment of this register for a solely structural or economic
lens, or for a collapse of the biological and psychological within the
economic.
36 ‘Harvesting despair’ – Suicide notes to the state
The agrarian crisis
Vidarbha is an area in Eastern Maharashtra (in India) known for the culti
vation of cotton and soybean, and as a ‘suicide district’ where, from June to
September of 2008, there was a suicide every 8 hours (Perspectives, 2009
:1). In 2007, more than 4000 farmers committed suicide in the state of
Maharashtra (Das, 2011 :23). The suicide rate for farmers in Maharashtra,
in 2004, was nearly four times the national average than for non-farmers; 53
in every 100,000 farmers committed suicide, and in affected areas the rate
was nearly ten times more (Perspectives, 2009 ). Vibardha is not the only
‘suicide district’ for farmers; there have been over 200,000 farmer suicides
in India since 1997 (Lerner, 2010 ). And farmer suicides are not phenomena
specific to India; there are estimates of 300,000 deaths due to self
poisoning with pesticides a year, in the Asia–Pacifi c region alone (Patel et
al., 2007 ).
Research into farmer suicides in India has led to debates as to what the
suicides signify, particularly what the suicides are a ‘symptom’ of. While
the Indian Government tends to conceptualize and respond to farmer
suicides
through an individual (often psychological and genetic)
framework, others call for understandings of farmer suicides to be grounded
in a historical anal
ysis of agricultural reforms in India, attending to the current ‘agrarian crisis’.
Agrarian crisis/‘Mental illness’
Until the 1970s, in India, cultivation of many crops relied on indigenous
varieties of seed, with little cost to farmers as these seeds were not bought
from the outside market. After 1970, with the advent of the Green
Revolution, hybrid varieties of seeds were produced, which from the 1980s
began to be released onto the market by private seed companies, pushing up
market prices (Perspectives, 2009 ). In the ‘suicide district’ of Vidarbha, the
cultivation of cotton and soybean has become completely dependent on pur
chased inputs, meaning that in order to sow seeds farmers must have access
to cash or credit, usually borrowed from private moneylenders. This reliance
on credit puts farmers in a precarious position, as they become particularly
vulnerable to crop failure or to price fl uctuation of crops in the world
market.
Therefore, currently for farmers there is no guarantee that their profi ts
will cover cultivation costs (which are also increasing with the
introduction of genetically modifi ed crops), resulting in an indebtedness
to private money lenders that was found by Mishra ( 2007 ) to be the main
reason given for suicide, with 87% of farmer suicides being linked to
debts. Much research into the reasons behind farmer suicides points to
factors such as indebtedness,
‘Harvesting despair’ – Suicide notes to the state 37
economic downfall, crop failure, family confl ict and addiction, yet often
interventions attribute ‘the reasons for suicide to socio-behavioural practices
of farmers’ (Das, 2011 :29). This fails to fully acknowledge the role of the
wider agrarian crisis in farmer suicides (for example, how volatile economic
markets may lead to substance abuse or family confl ict, which may then
lead to suicide) and how global power imbalances and socio-economic
inequalities are played out between people, within homes, and on bodies.
Government
sponsored studies into the causes of the suicides have also tended to be
limited to individual-level factors (Das, 2011 ).
The psychology of farmers has been the site of much Government inter
vention and relief efforts, and often ‘statements have been made suggesting
that the victims needed psychological counselling’, with the State
government of Maharashtra responding by providing ‘psychological
healing sessions’ for farmers (Perspectives, 2009 :4). Simultaneously,
psychiatry has also provided a platform for intervention, with the former
Chief Minister of Andhra Pradesh sending teams of psychiatrists to visit
farmers in an attempt to prevent them from committing suicide (Sharma,
2004 ). Understanding and responding to farmer suicides through a
psychological and psychiatric register, what might
be called the
psychiatrization of farmer suicides, also interweaves with a simultaneous
medicalization or, more specifi cally, a geneticization. A glimpse of this
emerged when, in 2007, the Indian Government responded to a sudden
increase in farmer suicides through launching a study to ‘probe the genetic
link to the spate of farmers’ suicides in Vidarbha’, exploring whether there
is a ‘genetic factor which makes people in a particular community more
prone to suicidal tendency’ (Arya, 2007 , online).
Thus, the Indian Government interprets and intervenes in farmer suicides
through the lens of psychiatry and genetics, despite research that suggests
that those farmers who committed suicide did so due to chronic stress and
not because of pre-existing ‘mental illnesses’ (Prasad et al., 2006 ). The fact
that the Indian Government chose to examine farmer suicides through a
genetic register and respond with psychological and psychiatric
interventions has been criticized by some as ignoring the systemic nature of
the suicides (Perspectives, 2009 :4), working to depoliticize farmer suicides,
and foreclose critical analysis of the policy context in which the suicides
take place. This policy arguably makes certain lives unliveable, and then
reduces analysis of the factors contributing to this solely to the individual
body and mind (which could be read as a double constitution of Agamben’s
‘bare life’, 1988).
‘Why I am giving up my life’
It seems to be the farmers themselves, in the act of suicide, who call for a
political reading of their actions. In fact, ‘[a]n increasing number of
38 ‘Harvesting despair’ – Suicide notes to the state
suicide notes today directly address the Prime Minister … taking the form
of a public statement accusing the state of betrayal’ (Perspectives, 2009 :2).
One note from a young male farmer said: ‘[t]he cotton price has fallen to
Rs. 1,990 a quintal. We cannot manage with that. Which is why I am giving
up my life’ (Perspectives, 2009 :2). The research team from Perspectives (
2009 :17), who collected these stories, thus call for recognition that
[s]uicides by farmers of Vidarbha are not individual acts of
desperation but part of a systemic problem located in a much larger
socio-eco nomic-political context. It cannot be and should not be
reduced to a phenomenon confi ned to the individual self.
In highlighting the role of the agrarian crisis in farmer suicides, the
Perspectives ( 2009 :1) team calls for a conceptualization of this as
‘homicide, not suicide’ in an attempt to create a framework away from
individualized causes to highlight the role of the State in making farmers’
lives unliveable, thus illustrating that economic reforms can be literally and
fi guratively crippling (Loomba, 1998 ) – they can kill. Here, death itself is
political. In fact, for Hook ( 2012 :33), the most powerful form of resistance
to the oppressive brutality of colonial existence occurred when the
oppressed confronted, and brought themselves into a ‘living proxim ity’ to
death. For Biko ( 1978 :152), ‘[y]ou are either alive or you are dead, and
when you are dead, you don’t care anyway. And your method of death can
itself be a politicizing thing’. This would suggest plac
ing suicide on a psychopolitical register, rather than a psychiatric or
psychological one.
But what does this recognition of the role of the political in farmer
suicides do to our understanding of suicide more generally? Rather than
demarcate farmer suicides as inherently political, assuming suicide more
generally is in the realm of ‘mental illness’, perhaps this could enable a
reading of other suicides as responses to social inequalities and economic
reforms in different contexts. This is important when we consider that
‘[e]very year, about 800 000 people commit suicide, 86% of whom are in
low-income and middle-income countries, and more than half of whom are
aged between 15 and 44 years’ (Prince et al., 2007 :2).
A key strategy of the survivor movement has been to read what psychia
try frames as ‘symptoms’ (such as self-harm) psychopolitically, meaning
that they are both personally and politically meaningful in that they may
constitute ‘rational and resistant reactions to maladaptive environments’
(Goodley, 2001 :215). This may also enable a way of reading farmer
‘Harvesting despair’ – Suicide notes to the state 39
suicides as being ‘rational and resistant’ reactions to maladaptive global
socio-economic environments.
Psychiatric ‘solutions’
However, analysis through a GMH framework enables particular psy
chiatric ‘solutions’ to be made visible to the ‘problem’ of farmer sui cides
globally. Within the GMH literature these ‘solutions’ tend to centre on the
‘effectiveness of reduction of access to pesticides; improvement of
medical care for pesticide poisoning in low-income or middle-income
countries’; improvement of treatment for depression; and access to antidepressants (Patel et al., 2007 :50). The assumption at work here is that
‘mental disorder’ is a contributor to suicide, and there fore can be reduced
through psychiatric interventions, and through lim iting access to pesticides
and increasing access to anti-depressants. However, GMH literature does
not attribute farmer suicides entirely to ‘mental disorder’. For example,
Patel ( 2007 :14) acknowledges that ‘[u] nrestrained economic reforms,
which lead to the loss of employment of vulnerable populations in
societies with no social welfare net, amount to no less than sanctioning
their starvation and the only escape route avail able to many is suicide’.
Suicide here is an ‘escape route’; an escape from economic reforms and
from poverty. But if this is one of the only means of escape, what might
Patel et al.’s ( 2007 ) suggestion of limiting farmers’ access to pesticides as
a form of suicide prevention mean for farmers? However, there’s a further
irony here that prevents a romanticized reading of suicide as escape from
poverty.
Rescue missions and benevolent outsiders
In India’s Green Revolution pesticides were ‘aggressively promoted, with
huge subsidies being doled out to keep the fertiliser companies afl oat’
(Sharma, 2004 , online). The result has been devastation to the sustainability
of agriculture (Sharma, 2004 ), ‘made fl esh’ through an increase in farmer
suicides. Therefore pesticides, swallowed as one of the means for escaping
poverty, are also part of the reason that an escape is required in the fi rst
place. Furthermore, as access to pesticides is also determined by the world
market, even this form of suicide becomes dependent on the same economic
rationale that made life unliveable for many farmers initially (for example,
in the opening of India’s cotton market to the world market). Here, both life
and death are dependent on, and made possible through, the workings of the
global capitalist market.
40 ‘Harvesting despair’ – Suicide notes to the state
This is further complicated by the fact that ‘the same breed of scientists
and policy makers [who promoted pesticides in the fi rst Green Revolution]
are now being asked to provide a solution to the prevailing agrarian crisis’
(Sharma, 2004 , online). Unsurprisingly perhaps, these experts push for the
increased role of biotechnology and agribusiness – interventions framed by
the same neoliberal rationales that many argue led to the crisis initially. This
is also evident in Chakrabarti and Dhar’s ( 2009 ) analysis of the logic of
development discourse employed by governments and capitalist enterprises
to destroy forms of life lived in countries of the global South (a destruction
echoing that of colonialism), who then, paradoxically, send in ‘rescue mis
sions’ of NGOs and international agencies to ‘help’ the dispossessed
through acts of resettlement and compensation.
Here ‘[e]ven as it smashes and shatters life within world of the third, the
hegemonic (with its organs) strives hard to emerge as the benevolent out
sider’ – making it so that the people of the global South must be grateful for
compensation, never losing faith in the rule of the hegemonic (Chakrabarti
and Dhar, 2009 :186). And so the dispossessed splinter out to the border of
the camp of global capital, providing the cheap, disposable labour which
helps to ‘secure the hub of (global) capital – a hub whose very coming into
being has been made possible through the dismantling of their forms of life’
(Chakrabarti and Dhar, 2009 :186).
Here development discourse can be seen to draw upon two related yet
seemingly opposing frameworks; ‘growth through capitalism-induced
industrialization that is aggressive and ruthless and poverty management
that is, as if, benevolent’ (Chakrabarti and Dhar, 2009 :41). In the case of
farmer suicides, it seems that the distress and unliveable lives caused by
economic and agricultural reforms (pushed by a capitalist agenda that ben
efi ts many HICs and multinational businesses) is evoked as being offset by
benevolent psychiatric and pharmacological interventions; or, more often,
there is a failure to recognize any connection between them at all. This is
despite the fact that such interventions (particularly in the case of the phar
maceutical industry) are often implicated within the same neoliberal logic
as that which contributed to the distress – that which made life unliveable –
in the fi rst place. Thus, the psychiatric and pharmacological interventions
implicit within much GMH advocacy may be one example of such ‘rescue
missions’, coming to the rescue as the ‘benevolent outsider’ while simulta
neously drawing upon and securing the hub of global capital, the rationale
of neoliberalism. This illuminates the symbolic violence of developmental
discourse (child, national, economic and global development) and the mate
rial violence made possible through it.
For Chakrabarti and Dhar ( 2009 ), such violence is affl icted on those
in the global South along two axes: brute violence and benevolent
violence.
‘Harvesting despair’ – Suicide notes to the state 41
Brute violence is the violence marked by the logic of development, of dis
location from place as well as from local forms of life, ways of living and
understanding the world. This brute violence acts with impunity (and often,
as we will trace throughout this book, is not recognized as being violent at
all). Then there is violence that is benevolent, that works through the ‘image
of a destitute fi gure waiting to be rescued’ (Chakrabarti and Dhar, 2009
:96). This destitute fi gure – ‘the wandering destitute’, homeless, mentally
ill, ‘rescued’ by many NGOs in India, and the image of the black child in
chains in the article in Nature – is a common image and justifi cation for
psychiatric interventions globally. This speaks of a continued colonialism,
the creation of new dependencies, where to die or to continue living both
depend on the fl uctuations of the world market, and on the often imported
expertise of psychiatry and pharmaceuticals. However, those who are
benevolent are not always ‘outsiders’ – India has the third largest
pharmaceutical industry in the world (Gopakumar and Santhosh, 2012 ).
Psychopharmaceutical imperialism
For Tsao ( 2009 :1), ‘blinkered conceptions of psychic suffering acquire
especially ironic undertones in regions subject to the depredations of the
IMF and World Bank’. These ironic undertones also haunt the MGMH’s
call upon multilateral agencies such as the World Bank to increase fund
ing into mental health interventions in LAMICs (Lancet Global Mental
Health Group, 2007 ). This is apparent when Horton ( 2007 :806) says that
the ‘WHO is not the only institution with a responsibility to strengthen
mental health services’, and goes on to name the World Bank as having a
‘duty to make mental health a central theme of their strategies and fi nan
cial fl ows’.
But what are the ethics of making this call when it is reforms by the
World Bank that may contribute to distress and lead to suicide in the fi rst
place? This is, for Tsao ( 2009 ), a form of ‘psychopharmaceutical imperial
ism’, or what might be seen as the psychiatrization of economic suffering.
This is illustrated by Scheper-Hughes’s ( 1992 ) account of how hunger in
the drought-wrecked villages of 1960s Brazil became so normalized that it
was no longer a sign of nutritional deprivation but a mental pathology –
‘delirio de fome’, hunger madness – to be managed by tranquilizers and
sleeping pills imported from the United States. Thus ‘delirio de fome’
became a ‘national codeword for mental instability rather than a symptom
of socioeconomic inequality’ (Tsao, 2009 :1). This, as Parker ( 1997 :27)
notes, ‘constructs a place for people to experience their economic distress
as a psychological problem and to look into themselves as if they were the
cause of social ills’. Thus by locating the source of distress within the brain,
42 ‘Harvesting despair’ – Suicide notes to the state
‘psychiatry and epidemiology can be used as a tool to mute important
issues that underlie social suffering’ (Aggarwal, 2008 :27).
This reduction of the lived complexity of distress to biochemical
impairments, and thus interventions to pills, interlaces with a politics of
reductionism, put forward as science (Shiva, 1990 ). According to Shiva (
1990 ), while this way of doing science may have its place in certain fi elds
of abstraction, it fails, in systems where the whole is not solely the sum of
its parts, to lead to a perception of reality. This is because, where the parts
are so complexly interwoven, to isolate one part is to distort the whole
(Shiva, 1990 ). This problematizes the MGMH’s call upon a ‘scientifi c
evidence base’ to ‘make mental health for all a reality’, for if psychiatric
reduction ism fails to represent complex lived realities how does this sit
alongside ‘making mental health a reality’?
As I write this now, a conference is being organized by the Royal Society
of Medicine (RSM) (for March 2013) called ‘the World in Denial: Mental
Health Matters’. The conference takes the stance that ‘Simply put, the
World is in denial and this event is a reality check’.2 However, the MGMH’s
use of psychiatric check-list technology to measure prevalence, in their
reduction of complex lived realities to entries in epidemiological boxes that
belong to biology (Sedgwick, 1982 ), become the tools of denying the mul
tiple realities of distress, not the tools for reality checks. This politics of
reductionism, closely tied to the capitalist economy, enables a ‘threefold
exclusion’ to occur, that is: ontological – alternative elements are not noted;
epistemological – other modes of perception remain unrecognized; and
sociological – meaning that ‘the non-expert is deprived of the right both to
access to knowledge and to judging claims made on its behalf’ (Shiva, 1989
:30).
‘McDonaldization’
This global reductionism, alongside polices that promote aggressive capi
talism, tends to promote, according to Timimi ( 2010 :686), narrow
biomedical understandings, which often facilitate a rapid growth in
psychiatric diag noses and in technical, often pharmaceutical, interventions
– the ‘McDonaldization’ of people’s health. Here, non-medical
alternatives rarely fi gure as a choice for those who are distressed.
Moncrieff ( 2003 ) points to how the infl uence of the pharmaceutical
industry on psychiatry reinforces narrow biological conceptions of
experience, drives expansion of biomedical frameworks of understanding
into wider areas of everyday life, and forecloses public debate about the
adverse effects of psychiatric drugs.
‘Harvesting despair’ – Suicide notes to the state 43
In northern India this means that ‘psychiatric professionals operate in a
national and international professional environment dominated by biologi
cal approaches to psychiatry’, where ‘mental illness’ is an ‘epidemic’ and
where psychiatry seeks to legitimize itself, resulting in reliance on multiple
prescriptions and ECT (Jain and Jadhav, 2009 ). Such reductionism, then,
also lays the ground for new markets for pharmaceuticals, as Tsao ( 2009
:2) points out:
In India, where over a decade of structural adjustment has led to both
widespread collapse of agricultural markets and soaring suicide rates,
antidepressant sales are so reliable that marketing managers for best
selling brands no longer bother to advertise them.
This fi nancial incentive is apparent in the fact that while AstraZeneca were
fi ned $520 million for illegal promotion of anti-psychotics to children and
the elderly; between 1997 and 2009 their total sales made on Seroquel (an
anti-psychotic) equalled $21.6 billion (Wilson, 2010 ). Many critics
conceptualize this as the medicalization of suffering, a process that decon
textualizes suffering from its socio-economic context. However, for Lakoff
( 2005 :151), such critiques are rendered redundant in contexts such as
Argentina, where psychodynamic explanations of distress are dominant and
where the link between depression and the socio-political was assumed to
such an extent that ‘social accounts of suffering served not as a critique of
the role of pharmaceutical marketing but as its basis ’.
‘Pharmaceutical reason’
This is evident in how the drug company Gador developed its marketing
campaign for anxiolytics and anti-depressants in Argentina (Lakoff, 2005
). Aware of the dominance of psychodynamic and social explana tions for
the origins of distress in Argentina, Gador’s ‘lock and key’ images of
neurotransmitters and depression, so popular in the United States, were
redundant. Instead, aware that the public and the medical community are
conscious of the deleterious effects of globalization, Gador’s marketing
campaign depicted globalization as a cause of anxiety, and the company’s
‘pharmaceuticals as a means to alleviate social suffer
ing’ (Lakoff, 2005 :151). Here there is an assumption that while depres
sion and anxiety may be caused by globalization they can still be
intervened with at a biochemical level.
This slightly alters Parker’s ( 1997 :27) assertion that capitalism creates
a space where people understand economic distress as psychological and
44 ‘Harvesting despair’ – Suicide notes to the state
‘look into themselves as if they were the cause of social ills’. In this refram
ing, people are actually encouraged to look to economic and political
systems, and to poverty, rather than themselves, as the cause of ‘mental
illness’. Yet despite this, the site of intervention and transformation
remains the individual’s brain, often through psycho-pharmaceuticals.
Here, ‘phar maceutical reason’ (Lakoff, 2005 ) can take diverse and
multiple forms in different social contexts, and even in contexts that
emphasize the economic and political causes of distress.
Pharmaceutical reason also lays the ground for the ‘biosocial journey of
psychotropic pills from the centre to the periphery’, and, in the context of
community mental health programmes in India, may enable ‘technically
sound and multifaceted programs [to] metamorphose into narrowly medica
tion-focused interventions’ (Jain and Jadhav, 2009 :60 and 75). This was
evident to me in the work of some of the NGOs I visited in India.
Free medication for life – ‘Power that speaks softly’
The fi rst NGO I visited in India works with the ‘destitute mentally ill’;
both ‘rescuing’ homeless women from the streets and bringing them into
their ‘transit centre’ for psychiatric and psychological treatment and
rehabilita tion, and also running an outpatient clinic. The NGO buys
medication for their patients from pharmaceutical companies at slightly
discounted prices, and as part of their services they offer many lowincome families ‘free med ication for life’, posting envelopes full of
psychiatric medicines all over India. The founder asked me if I would like
to come and visit the outpatient clinic; they were going in a moment and I
could get a lift. I said yes, and off we went.
Located in a hot dusty courtyard sits the out-patient clinic. Here people
who have been diagnosed by the NGO as ‘mentally ill’ come for check
ups and to collect medication, with their families. Some families have
travelled from miles away, from rural Tamil Nadu, hours on a bumpy
bus. I stood in the outdoor square, while the patients formed a circle,
where shiny blue and white leafl ets were distributed. Someone gave me
a copy of one. It was a leafl et from the drug company Pfi zer. The leafl
et asks people to rate how strongly they experience particular sideeffects of one of the company’s anti-depressant drugs. It was in Tamil
and English. Instead of fi lling in the form individually, everybody
formed a circle, with a man in the middle who read out the list of side
effects, asking people to move in or out of the circle depending on how
strongly they experienced particular effects. Then the circle dispersed;
on to a quick meeting with a social worker, and to join the long queue
outside
‘Harvesting despair’ – Suicide notes to the state 45
the room that dispensed the psychiatric medications. I stood there
smiling nervously, the Psychiatrist in charge came to chat, he told me
they had wanted to make the outpatient clinic a community resource
centre, but he felt it had never really developed beyond being a drug
dispensary. I had a quick look at Pfi zer’s leafl et; it was for Daxid
Sertraline (known in the USA as Zoloft), an anti-depressant. The leafl
et says; ‘Sertraline, power that speaks softly’, and ‘Pfi zer, working
together for a healthier world’. I wondered what constitutes Pfi zer’s
idea of a ‘healthier world’? [Field notes, January 5th 2011].
How does Pfi zer’s idea of a ‘healthier world’ interlace with the softly
spoken power of psychiatric medications, promising forms of ‘pharmaceu
tical citizenship’? (Ecks, 2005 :239). And does this relate to why the
NGO’s outpatient clinic had ‘never really developed beyond being a drug
dispen sary’? In fact, worldwide, many outpatient clinics seem to function
mainly as drug dispensaries. Many miles away, on a different continent,
MindFreedom Ghana et al. ( 2011 :5) describe an outpatient clinic in Accra
where:
Treatment consists of medication and is provided free of charge.
Patients are received in one of fi ve or six small rooms that make up the
small outpatient clinic. When we came by, about 100 people sat in rows
of benches in an outside courtyard underneath an awning, waiting to be
called in for treatment. Treatment consists of the dispensing of psychi
atric medication, and in some cases, ECT [Electroconvulsive therapy]
treatment (MindFreedom, 2011 :5).
‘Never really developed beyond being a drug dispensary’
Thus, in India as in Ghana,
As the pill journeys from the Ministry of Health to the clinic, its sym
bolic meaning transforms from an emphasis on accessibility and par
ticipation to the administration of a discrete ‘treatment’. Instead of
embodying participation and access, the pill achieves the opposite:
silencing community voices, re-enforcing existing barriers to care, and
relying on pharmacological solutions for psychosocial problems (Jain
and Jadhav, 2009 :60).
This is a silencing perhaps even more evident in the ‘free medication for
life’ provided by many NGOs, that travels in envelopes, by post, across
46 ‘Harvesting despair’ – Suicide notes to the state
India. For Jain and Jadhav ( 2009 :65) this acceptance of medication as the
‘common minimum’ serves to ‘reify the “pill” as central to the delivery of
care at the rural clinic’. Thus the multiple complexities of the lived realities
of distress and poverty are overlooked, with many NGO clinics retreating
into a ‘monologue on compliance with medication’ where patients’ non
compliance is constructed as ‘antithetical to progress and advancement,
construing patients as backward, uneducated, and irresponsible’ (Jain and
Jadhav, 2009 :66 & 71). A psychiatrist at an NGO in India explained to me:
The main problem we face is medicine compliance, which is very
important for the patient’s well-being … once they start getting better,
they leave the place and go to some other place, we may track them or
we may not track them. To track them down … there are care givers,
who provide them with food or who are entrusted with giving medi
cines in addition to the social workers and fi eldworkers that we have.
They most of the time give us the information that the person has left
this place and gone there, so go and look there, you might fi nd him or
her there. So that building up that caregiver community is very impor
tant. …We do not force them … but at the same time the person is not
willing to take medicines, taking the medicines in a formal fashion …
we mix the medicines with food. And once they start improving they
start taking medicines by themselves. So that block, that block that they
have regarding medicines … can be broken and that person feels that he
or she is improving after taking medicines, the person starts taking med
icines by themselves (Interview with a psychiatrist at an Indian NGO).
What constitutes the ‘block’ that people have regarding psychiatric medi
cines? Might this ‘block’ come about from different cultural frameworks
for understanding distress or from disjunctions with bio-psychiatric transla
tions of local idioms of distress? Here, in the multiple translations that
occur within rural psychiatric clinics, Jain and Jadhav ( 2009 ) noted how
staff interpreted local idioms of distress in a way that enabled them to ‘fi t’
with global diagnostic categories. Thus, the local expression of ‘uljhan’
with its nuanced meanings of unfulfi lled economic ambitions, and its
increase in the current ‘cash-crop environment’ leading to family tensions,
came to be translated, from Hindi to English, as the psychiatric categories
of anxiety and depression (Jain and Jadhav, 2009 :72). Similarly, Skultans
(2007) doc uments how in psychiatric consultations within countries of the
former Soviet Union, where a somatic language of distress connects
personal expe rience with cultural and historical plots of rapid economic
change, the patient’s polyphonic presentation of distress is reframed
through a western
‘Harvesting despair’ – Suicide notes to the state 47
psychiatric nosology where intervention is confi ned to writing a prescrip
tion. In many cases this moves the ‘patient’ ‘quickly away from poverty
and life’s diffi cultues to medicine as the solution’ (Skultans, 2007:147).
Here the dominance of psychiatric medication mutes the lived realities
of those whom the pill is prescribed to, meaning that the healing power of
psychiatric medication, and the policy and practice of the NGOs that it
symbolizes, are interlaced with and limited by its ability to engage with
problems on the ground. In fact, even when socio-cultural issues are
acknowledged, they are often used as a way to increase compliance to psy
chiatric approaches (Higginbotham and Marsella, 1988 ). It is in this way
that community mental health policy often ‘fails because it has been swal
lowed by the pills’ (Jain and Jadhav, 2009 :74).
What else is swallowed with psychiatric medication? So far, we have
traced how the ‘pill’ and all that it symbolizes enables a rearticulation of
local idioms of distress and of socioeconomic crisis into bio-psychiatric
categories. Further, according to some, the World Health Report (WHO,
2001a ) frames social problems, such as poverty and violence, as psychi
atric problems (Desjarlais et al., 1995 ). This may be because, as Furedi (
2004 :27) notes, it seems that ‘society is much more comfortable dealing
with poverty as a mental health problem rather than a social issue’. This is
a psychologism that Fanon rallied against, for ‘the poor are plagued by
poverty … blacks by exploitation [and psychology and psychiatry often
deal] with all of these estranging affl ictions as if they were … mere states
of mind’ (Adams, 1970 :811). However in calling to locate distress within
the systemic – by seeing ‘symptoms’ as coming from oppressive systems
and not faulty brains – it is important to resist a complete abandonment of
the psychological register, for a solely structural or socio-economic lens, or
for a collapse of the biological and psychological within the socio economic.
This is to resist an ‘anti-psychologism’ that is often made in reaction to
over-psychologization, and yet which often works to belittle ‘the long-term
cultural and psychological effects of violence, poverty and injustice’, which
persist in the post-colonies after centuries of oppression, violence and
inequality – a ‘manufacturing of suffering’ that distorts cul tures and minds,
and often establishes powerful justifi cations for suffer
ing ‘in the minds of both the oppressors and the oppressed’ (Nandy,
1987:26).
This colonial ‘manufacturing of suffering’ moves suffering away from
the Movement for GMH’s and the WHO’s stories of personal tragedy, to
locate suffering in the social – to speak of wounds and burdens that are
culturally and historically located and impact on both the global social body
and the individual bodies that make this up (Kleinman, Das and Lock,
1997).
48 ‘Harvesting despair’ – Suicide notes to the state
Poverty and ‘mental illness’
Within GMH and transcultural psychiatry literature, the link between pov
erty and ‘mental illness’ is often emphasized. In an article titled ‘Poverty
and Common Mental Disorders in Developing Countries’, Patel and
Kleinman ( 2003 ) point out the stress on farmers caused by indebtedness
to moneylenders and suggest a key aspect of primary prevention of mental
disorders could be the establishment of radical community banks and
microcredit schemes.
It is in their suggestions for secondary prevention of common mental
disorders, however, that Patel and Kleinman ( 2003 :612) emphasize ‘the
effi cacy and cost-effectiveness of psychological and pharmacological inter
ventions … in developing countries’. It seems that although the social deter
minants of ‘mental illness’ are discussed widely in GMH literature, they
are articulated through the assumption that poverty (and economic
reforms) can lead to ‘mental illness’. Here the framing of this response to
poverty as being ‘mental illness’ makes it possible to work on the
individual (brain), while still openly acknowledging the role of social
inequalities.
The ‘solutions’ to farmer suicides put forward by Patel et al. ( 2007 )
within a GMH framework, such as limiting access to pesticides and increas
ing access to anti-depressants, work as strategies that centre on managing
populations who have been constructed as being ‘at risk’. In fact the very
analysis of farmer suicides creates a population of people identifi ed as
potential suicide victims, pre-emptively ‘making up’ particular kinds of
people (Hacking, 2007 ). The calculation of certain populations as being ‘at
risk’ of committing suicide is partly based, then, on an analysis of the social
environment in which these people live, for example, that they are farmers
who have smallholdings in areas affected by agricultural reform, and so
epidemiological data would suggest that they are at risk of committing
suicide. Here the very constitution of certain groups as being ‘at risk’ is
saturated with an analysis of the socio-economic environment.
However, despite this implicit acknowledgement of the role played by
economic and agricultural reforms in contributing to farmer suicides, many
of the interventions put forward do not operate at this societal level (other
than brief and often vague comments in the conclusions of some journal
papers that call for advocacy in changing society – see Patel, 2007 ).
Interventions tend to focus on the individual, and often on the brain, and
while analysis centres on the economic costs and burdens of ‘mental illness’,
the potential economic contributors to mental distress are often overlooked.
However, there are some exceptions to this, for within GMH advocacy
there are glimpses of other ways of responding to and intervening in
‘Harvesting despair’ – Suicide notes to the state 49
suicide. In the mhGAP launch video (WHO, 2008a ), Dr Laksmi
Vijayakumar, founder of SNEHA, an NGO in Chennai, explains that many
students in the state of Tamil Nadu commit suicide each year due to exam
failure. Dr Vijayakumar goes on to explain how SNEHA called upon the
Government of Tamil Nadu to take action, to which they have responded by
making ‘a new rule in which a student who has failed in the 12th exam, can
write the failed subject within one month after the results, so that he doesn’t
lose a year.’ This is conceptualized as one example of ‘low cost suicide
prevention programmes, currently being initiated in other parts of India and
elsewhere’ (WHO, 2008a , mhGAP launch video). In calling for structural
change at a government level, this intervention stands in contrast to inter
ventions into suicide prevention that centre on increasing access to psychi
atric drugs. It is an example of intervening with distress at a structural level.
Social determinants
While biological explanations of ‘mental illness’ are relatively dominant,
the acknowledgement of social determinants by predominantly biomedical
organizations, such as the WHO, may also work to divert criticism of bio
logical determinism or of interventions that tend to focus on individuals.
The allusion to individual-oriented social determinants also enables the
neoliberal rationale that frames those social determinants of health to often
remain unquestioned.
Culture as an infl uence on biology – this seems to be the framework in
which ‘social determinants’ of health are understood. The fact that the
WHO’s focus on social determinants of health came after the 1990s ‘Decade
of the Brain’ seems telling here. For Raphael ( 2006 ), despite the vast
amount of evidence on materialist social determinants of health, there is
little action at this level to improve health. Here mention of social deter
minants of mental health, such as economic reforms, in GMH literature
seems to enable a discursive existence of mental health as affected by the
social, while delimiting a discourse of structural or systemic change or
transformation.
For Das ( 2011 ), this marks an individual-oriented materialistic
approach to social determinants of health, problematic because the lesser
the focus is on structural defi ciencies and state institutions, the more likely
that the political message will be a conservative one, attributing inequities
and suicides (and sometimes even poverty) to personal attributes and to bio
logical or psychological inferiority. According to Raphael ( 2006 ), while
recognition of the social determinants of health has become common, the
further acknowledgment that such social determinants are determined
50 ‘Harvesting despair’ – Suicide notes to the state
themselves by the political and economic forces that shape the organiza tion
of societies and resource distribution is rare. Raphael ( 2006 ) goes on to
attribute this as due to an individualist approach to health, consistent with
neoliberal governance and a free-market rationale, which fosters the very
social inequalities that may lead to poor mental health in the fi rst place.
Thus, many critics point out that ‘farmers’ suicide is symptomatic of a larger
crisis in the agricultural sector in India’ – that of agricultural trade
liberalization and the infl uence of the World Trade Organization (WTO)
(Das, 2011 :23).
It is interesting to be aware, then, of the mechanisms by which agrarian
(and economic) crises come to be rearticulated and reconfi gured as indi
vidual crisis, as ‘mental illness’. It seems possible to trace a double move
ment here, whereby the distress caused by a neoliberal rationale of reforms
and inequality is mediated through a bio-psychiatric lens as ‘illness’, open
ing up interventions that are individual and often pharmaceutical and that
are, thus, part of the same neoliberal rationality as that which may have
caused distress initially. This seems to work, like Fanon’s ( 1967 :13)
‘double process’, where sociopolitical and economic conditions of
inequality and alienation play on the body and invoke bodily reactions.
For one ‘poor woman’ (cited in Narayan, 2000 :6), ‘[p]overty is pain; it
feels like a disease … It eats away one’s dignity and drives one into total
despair’. This is a process where inequality and poverty are internalized,
made fl esh – a process of ‘epidermalization’ (Fanon, 1967 :13), of
‘making up’ categories of ‘mental illness’ and the psychiatric subject
peoples who will occupy them. The plot thickens.
Notes
1 I have taken this from the title of the book by Perspectives (2009). 2 RSM
http://www.rsm.ac.uk/academ/ghd01.php (accessed 14th February 2013).
3 Educating, marketing,
mongering
A chapter on the ‘making up’ of psychiatric ‘subject peoples’, on eliciting
and fostering, on the blurry boundaries between educating and marketing,
on global disease mongering, on ‘native madness,’ and on whether mental
illness exists .
To make mental health a reality for ‘ all ’ suggests the global spread of
psychiatric ways of being a person and how we all come to understand our
selves within this register. For Rose ( 2006 :481), this is a process of
psychi atrization, of ‘making us the kinds of people who we have become’.
But many people in LAMICs have not (yet) become psychiatrized peoples
– something which the translation of diagnostic and classifi catory tools in
order for them to travel across geographical borders, described by Rose (
2006 :478) as a ‘diagnostic creep’, may change. Here GMH and psychiatri
zation might be read as meeting two of Bhabha’s conditions for colonial
discourse: a) ‘the creation of a space for a “subject peoples” through the
production of knowledges’; and b) through ‘marking out a “subject
nation”’ operating as a form of governmentality that ‘appropriates, directs
and dominates its various spheres of activity’ (Bhabha, 1983 :23).
This chapter will read psychiatric subject formation alongside colonial
subject formation, and also pharmaceutical marketing, in order to traverse
the terrain of how psychiatric diagnostic systems travel globally and what
subjects they make possible. Like colonial discourse, psychiatry and GMH
seem to form ‘a system of representation, a regime of truth, that is structur
ally similar to Realism’ (Bhabha, 1983 :23). This seems to be doubly so, as
it is dominated by psychiatric systems of knowing the difference between
reality and unreality, between sanity and insanity. But by what mechanisms
does psychiatry travel? What sort of ‘subject peoples’ occupy the space of
GMH? If GMH ‘makes up’ ‘mental illness’ in the global South, does this
imply that it does not yet exist there? I want to address how Patel’s ‘myth
52 Educating, marketing, mongering
that mental illness does not exist’ (cited in Bemme and D’Souza, 2012 )
intersects with ‘making mental health a reality for all’ (Patel et al., 2011
:90).
‘Poor people do not suffer from “mental illness”’
Much of the GMH literature attempts to oppose the idea that ‘mental ill
ness’ simply does not exist in the global South. This is evident in a booklet
published by BasicNeeds (undated:1):
There is a commonly held view that very poor people do not suffer
from ‘mental illness’. This view is founded on the assumption that
somehow ‘mental illnesses’ are generally a disease of affl uence and
that poor people would not have time to be depressed. In fact of course
people living in severe poverty are not protected from the plight of
‘mental illness’.
It is also apparent in the WHO World Health Report, where ‘[t]he belief that
rural communities, relatively unaffected by the fast pace of modern life,
have no mental disorders is also incorrect’ ( 2001a :22). I started to wonder
where the assumption in GMH of a commonly held view that ‘mental ill
ness’ does not exist in ‘poor’ countries had come from. This took me to
colonial Java, a divergence I want to follow now.
‘Ethnic psychosis of occidental society’
Emil Kraepelin, ‘the designer of modern psychiatric nosology’, the ‘father
of schizophrenia’, made his fi rst trip to Southeast Asia in 1904, a trip that
led to the founding of a new discipline – comparative psychiatry (Jilek,
1995 :231). Kraepelin wanted to examine ‘whether certain forms of insanity
that provide the main content of our [European] institutions, occur in like
manner and frequency as among us [Europeans] also under entirely differ
ent conditions of living and among entirely different ethnicities’ (Jilek,
1995 :233). Kraeplin did not fi nd severe deterioration in the Indonesians he
studied, concluding, along with many prominent psychiatrists of the time,
that Western civilization had a negative effect on mental health (Jilek, 1995
:235). This was based on the assumption that those in poorer countries lived
simple, contented lives, and were thus less plagued by ‘mental ill
ness’, and that it was the ‘progress inherent to Western civilization [that]
was apt to produce mental derangement’ (Ernst, 1997 :165). The ‘rarity of
major mental disorders among “primitive” peoples was a widely held
notion in 19th century psychiatric thinking’ (Jilek, 1995 : 235–236). This
led to schizophrenia, seen as absent among ‘primitive’
Educating, marketing, mongering 53
peoples, to be defi ned as the ‘ethnic psychosis of Occidental society’
(Devereux, 1980 :235). Kraepelin observed that in Java patients were rarely
depressed in comparison to those he had worked with in Germany, and he
perceived these cross-cultural differences ‘in terms of genetic and physical
factors rather than culture’ (Fernando, 1988 :59). However, despite his work
marking the ‘starting point for modern pharmaco
psychology and subsequently pharmaco-psychiatry’ and psychiatric epi
demiology (deVries et al., 2008 :1), there was a social dimension to
Kraepelin’s work. For example, on a trip to North America, Kraepelin
noted that the native Americans, having been exposed to disease and
deprived of their previous ways of existing, had ‘sunk into fatalistic
apathy’ (Kraepelin, 1925, cited in Jilek, 1995 :232) sugesting a link
between distress and alienation from indigenous forms of life. There is an
explicit acknowledgement here of the social factors involved in ‘mental
illness’, particularly in the dispossession of certain forms of life through
development and ‘modern civilization’ as leading to mental disor der.
While retaining an assumption of the superiority of the West, this
resonates strangely with calls from GMH, and NGOs such as BasicNeeds,
who seek to explicitly frame ‘mental illness’ as a development issue. These
calls assume that ‘mental illness’ impedes development (for example, pre
venting the realization of the Millennium Development Goals – though it
is worth noting that mental health remains absent from the MDGs), and
that lack of development contributes to ‘mental illness’, assuming that with
development mental health will improve. Conversely, assumptions from
colonial psychiatry see ‘mental illness’ as coming about from develop
ment, as a direct product of being ‘civilized’.
Findings from the International Pilot Study of Schizophrenia (IPSS)
(1967) and DOSMED (1978) complicate this further, as they have ‘consist
ently found persons clinically diagnosed with schizophrenia and related
disorders in the industrialized West (chiefl y Europe and the United States)
to have less favourable outcomes than their counterparts in “developing”
countries’ (Hopper and Wanderling, 2000 :836). In considering these fi nd
ings, many, like Warner ( 1994 ), have concluded that it may be easier for
those who have experienced distress to integrate back into, and fi nd mean
ingful roles in, non-industrialized societies, and thus socio-cultural factors
infl uence the outcome of so-called schizophrenia far more than treatment
options. Murphy’s (1961) concern that ‘mental illness’ was linked to the
‘rapid Westernizing of non-Western peoples’ (cited in Jilek, 1999 :236)
also enables a strange reading of the implications of psychiatrizing people
in LAMICs through ‘Western’ psychiatric frameworks. Here again is a
double movement; the globalization and Westernization (of agriculture,
econo mies) that may cause distress, followed by the mediation of that
distress
54 Educating, marketing, mongering
through ‘Western’ bio-psychiatric systems of classifi cation: a second
‘Westernization’ through psychiatrization.
Native madness
Colonial psychiatry in India, beset by assumptions that the ‘natives’ were
too ‘primitive’ to experience ‘mental illness’, then encountered a dilemma:
madness among the ‘natives’. This colonial encounter with ‘native’ madness
brought into being the ‘native insane’ (Ernst, 1999:164) as a category of
personhood, while simultaneously troubling assumptions of the uncivilized
barbarity of natives that were used in part to justify continued colonization.
Importantly, however, this colonial dilemma of the uncivilized becoming
mad was resolved with the medicalization of madness through psychiatry
during the second half of the 19th Century, when social and colonial prob
lems came to be ‘construed in the allegedly impartial technical idioms of
medical science’ (Ernst, 1999:166). This German–British biological
approach to psychiatry assumed the universality of ‘mental illness’ globally.
GMH seemingly also negotiates a similar colonial dilemma through recourse
to increasingly bio-psychiatric terminology – ‘that mental disorders … have
a physical basis in the brain … they can affect everyone, everywhere’
(WHO, 2001a :x) – a similar strategy to that employed by colonial
psychiatrists.
Interestingly, the argument that the hyper-capitalism and consumerism
that make up life in many HICs lead to ‘mental illness’ has remained a key
critique of bio-psychiatry, and one fi ercely rejected by the WHO:
Mental disorders are not the exclusive preserve of any special group;
they are truly universal. … The notion that mental disorders are prob
lems of industrialized and relatively richer parts of the world is simply
wrong. The belief that rural communities, relatively unaffected by the
fast pace of modern life, have no mental disorders is also incorrect
(WHO, 2001a :22).
For Oliver James ( 2007 ), ‘mental illness’ is a different kind of disease,
an ‘Affl uenza’ that spreads like a virus through (usually high-income)
coun tries where people’s self-defi nitions revolve around money and
consump tion. However, for Patel this may be an example of perpetuating
‘the myth that mental illness does not exist’ (Patel, cited in Bemme and
D’Souza, 2012 ), denying the ‘reality’ and ‘existence’ of ‘mental illness’
for the popu lations of LAMICs. For according to Patel, GMH, unlike its
colonial predecessors, is shaped by a postcolonial framework of
collaboration between the global North and South (Bemme and D’Souza,
2012 ). Yet this very statement is shaped by colonialism, haunted by
colonial preoccupations
Educating, marketing, mongering 55
with the existence of ‘mental illness’ in the colonized ‘natives’, and the
problems such an existence would mean for justifying colonialism. Here
it seems that the work of GMH advocacy to map the prevalence (and the
existence) of ‘mental illness’ in LAMICs attempts to work against, and yet
simultaneously mobilizes, colonial assumptions of Western superiority of
mind. It is haunted by, in its very refutation of, a colonial assumption that
‘mental illness’ is linked to ‘modern civilization’ and Western superiority.
And yet such advocacy often invokes the assumption of the superiority of
‘Western’ knowledge through promoting ‘scientifi c’ bio-psychiatric
approaches to mental distress over indigenous healing sys tems. It seems,
then, that ‘Western’ bio-psychiatry is interwoven from its very beginnings
with both cross-cultural comparisons (from colonial set tings) and
assumptions of the social aspects of ‘mental illness’, and thus that
schizophrenia may be always already interlaced with colonialism.
Does ‘it’ exist?
Did ‘mental illness’ always exist in LAMICs prior to ‘Western’ infl uences?
Do the populations of LAMICs experience the same ‘mental illnesses’ as in
the ‘West’? These questions, while important, sometimes seem to lead to a
dead end. Hacking ( 1998 ) uses the metaphor of an ecological niche to think
through the fact that in certain times, in certain places, certain experiences
are understood as ‘symptoms’ of certain kinds of ‘illness’ – meaning that
they are ‘transient’ not for the individual’s life but within social life, and are,
for a time, experienced as ‘real’. Thus, there are a concantenation of vectors
at play in allowing certain ‘disorders’ to fl ourish at different times, marked
by four principle factors; a medical taxonomy (system of categorization),
cultural polarity (currently co-existing competing social phenomena),
observability (a system of surveillance and detection that enables certain
behaviours to be understood as ‘strange, disturbing, and noticed)’, and
release (the ‘disorder’ provides a means of escape from normative
standards) (Hacking, 1998 :82). This framework enables a shift in focus
from people’s brain chemistry, to the socio-political conditions of
possibility for certain experiences to be framed as ‘illnesses’, such as
depression, to fl ourish, and to be constituted as an epidemic. And that once
the conditions of this niche are destroyed, the disorders that thrived within
may also disappear. It also allows analysis of the conditions that enable
GMH to fl ourish as a means of intervening upon particular ‘disorders’.
Thus, for Elliott ( 2000 ),
By regarding a phenomenon as a psychiatric diagnosis – treating it,
reifying it in psychiatric diagnostic manuals, developing instruments to
measure it, inventing scales to rate its severity, establishing ways
56 Educating, marketing, mongering
to reimburse the costs of its treatment, encouraging pharmaceutical
companies to search for effective drugs, directing patients to support
groups, writing about possible causes in journals – psychiatrists may be
unwittingly colluding with broader cultural forces to contribute to the
spread of a mental disorder.
Taking this further, Hacking (2006) elaborates on the subject positions
made available within the ecological niches of ‘mental illness’ – the ‘making
up’ of people. For Hacking ( 2006 ), ‘making up’ is the bringing into being
of specifi c ways of being a person that may have not been possible before.
In adapting his discussion of the ‘making up’ of multiple personality disor
der, for GMH and psychiatric subject formation, we could say that, either:
a) Prior to colonialism and recent GMH and WHO mental health literacy
campaigns, there were no ‘mental illnesses’ in India, or:
b) Prior to colonialism and recent GMH and WHO mental health literacy
campaigns, ‘Western’ bio-psychiatric categories of ‘mental illness’ (for
example, as caused by biochemicals) were not an available way to be a
person; people did not experience themselves or their family mem
bers in this way.
Thus, for Hacking ( 2006 , online), it is the human sciences and their tools
of measurement and classifi cation that ‘create kinds of people that in a
certain sense did not exist before’. This is helpful because it enables a
different understanding of claims that in many LAMICs ‘mental illness’
does not, or did not until recently, exist. This is not to deny that people who
were distressed, who heard voices, who self-harmed and so on, did not exist.
However, such people may not have been conceptualized within bio
psychiatric classifi catory systems as being ‘mentally ill’, and as thus
requiring psychological or psychiatric intervention.
But what are the mechanisms by which the ‘mentally ill’ are ‘made up’?
I want now to map some specifi c mechanisms of psychiatrization as modes
or fi elds of subjectifi cation for the production of particular subjectivities
(Coonfi eld, 2008 ) and the means by which these subjects are secured and
maintained – the ‘putting into place of a subject’ (Butler, 1997 :90–91). The
next section will trace the technical processes by which ‘mental illness’ is
‘made fl esh’ (Cromby et al., 2011 ), how it is made a ‘reality’ for all.
A ‘mental health literate society’
A key part of the Movement for GMH’s ‘scale up’ of psychiatric interven
tions has been to raise awareness and increase knowledge about ‘mental
Educating, marketing, mongering 57
illness’ and its treatment in LAMICs. One of the ten recommendations for
achieving this, in the World Health Report (WHO, 2001a :xii), is to ‘educate
the public … increasing awareness of the frequency of mental disorders’.
GMH advocacy and the WHO point to the evidence that many LAMICs
have ‘poor mental health literacy’, meaning a lack of ‘knowledge and
beliefs about mental disorders which aid their recognition, management or
prevention’ (Jorm, 2000 :399 and 396), or as lacking ‘the ability to correctly
identify ‘mental illness’ in oneself or one’s peers’ (Saxena et al., 2007 :884).
According to Jorm ( 2000 :399), there is a continuum of mental health
literacy from professional to lay knowledge; where ‘professionals have
expert knowledge which is to a large extent based on scientifi c evidence
and expert consensus’, while the public hold beliefs based on the media,
anecdotes and personal experience. Here the public’s negative views about
medication are framed as ‘beliefs’, in comparison to professional ‘scientifi
c’ ‘knowledge’ about mental disorders.
GMH literature frames ‘poor’ mental health literacy and ‘negative
beliefs about medication’ (Jorm, 2000 :398) as explanations for a diverse
range of issues, such as: young people’s avoidance of health care (Saxena et
al., 2007 ); for making people ‘vulnerable to misinformation from unscrupu
lous providers’ (Saxena et al., 2007 :886); for hindering public acceptance
of evidence-based mental health care; for people’s failure to seek medical
advice; and for ‘lack of compliance with any medication recommended’
(Jorm, 2000 :398). Vulnerability here is constructed as a lack of scientifi c
information about ‘mental illness’.
Mental health literacy campaigns thus equate ‘knowledge’ with accept
ance of a bio-medical model of ‘mental illness’, evident in a recent
campaign by the World Psychiatric Association which labelled those who
understood schizophrenia as a ‘debilitating disease’ as being
‘sophisticated’ and ‘knowl edgeable’ (Read et al., 2006 ). Some of the
problems with this approach are acknowledged to some extent in the
literature, which points to potential limi tations in assuming ‘the superiority
of expert psychiatric knowledge over lay beliefs’, and also in constructing
‘the sufferer’s interpretation of his or her condition as less valid’ (Jorm,
2000 :400). Despite these limitations (men tioned as a brief bullet point in
Jorm’s [2000] article), the Movement for GMH and the WHO state that
‘we need a “mental health literate” society in which basic knowledge and
skills are more widely distributed’ (Jorm, 2000 : 399 and 396). As an
outcome of the WHO Round Tables it was decided that the ‘WHO has a
critical role to play in turning this knowledge into reality’ ( 2001b :7) and
‘to make mental health for all a reality’ (Patel et al., 2011 :90).
But what are the formations and contours of a ‘mental health literate
society’? GMH and mental health literacy campaigns enable new ways of
talking and thinking about people in LAMICs, and about distress,
58 Educating, marketing, mongering
marginalization, social equality and justice in ‘biologically colored’ lan
guage (Rose, 2007 :140), marking a shift in human ontology that enables the
biomedical reshaping of global citizenship. This shift makes available,
‘makes up’ (Hacking, 2006 ) new selves; ‘neurochemical selves’ (Rose,
2003 ), and bio-psychiatric activists. In this way, it seems central to attend
to how GMH may operate (within a Foucauldian register), as a ‘regime of
practices’, that elicits, promotes, facilitates, fosters and attributes ‘various
capacities, qualities, and statuses to particular agents … successful to the
extent that these agents come to experience themselves through such capac
ities’ (Dean, 1999 :32). These capacities and subjectivities, then, tie those
who are subjected to specifi c governmental and socio-economic rationales
(Dean, 1999 ).
The ‘not-yet-citizen patient’
According to Ecks ( 2005 :240), in an increasingly pharmacological world,
to be marginal, under-developed and vulnerable often ‘means to be cut off
from the circulation of biomedical substances’. Here ‘the biomedical
promise of an effective pharmacological treatment becomes a promise of
“pharma
ceutical citizenship” … that works on redefi ning belonging, personhood,
exclusion, rights’ (Ecks, 2005 :239 and 241). However, Ecks ( 2005 :240)
explores a friction within pharmaceutical citizenship,
between citizen-as-patient who is entitled to medicines because he or
she is already a full citizen, and the not-yet-citizen patient, for whom
the taking of medicines becomes a practice of becoming a full citizen.
If the taking of medication is a mechanism for producing citizens, then
NGOs, as key distributory channels for psychiatric medication in the global
South, where state-provided welfare is often rare (Fernando, 2005 ), must be
key sites in the ‘making up’ of psychiatric citziens. While the MGMH and
the WHO aim to push governments to recognize the ‘burden’ of ‘mental
illness’ and increase public spending on mental health interventions, they
see NGOs as having a key role to play in the delivery of mental health ser
vices (WHO, 2001b ). NGOs thus enact the putting to work of GMH and
WHO policy ‘on the ground’; they constitute the capillary networks that
these particular ways of understanding distress travel along, the ‘vectors
“from below” [that] pluralize biological and biomedical truth’ (Rose, 2007
:142). In the global South, a key mechanism for mental health literacy to
travel, often to rural communities, is through ‘mental health camps’
organized by mental health NGOs.
Educating, marketing, mongering 59
Mental health camps
Many of the NGOs I visited in India were relatively small, often set up and
funded by Indian people. However, BasicNeeds is different. It was set up by
a British man, Chris Underhill, in 1999, with a programme starting in India
in 2000, which later became a seperate Indian charitable organization. A
booklet produced by BasicNeeds (undated:15), explains that:
BasicNeeds India realised that the model had to take into account two
important aspects: one that a scientifi c knowledge base of ‘mental ill
ness’ does not exist in the minds of rural people. It is diffi cult for
them to understand that just as for physical illness medicines are
available to cure mental illness too. Secondly, knowledge regarding
‘mental ill ness’ is overwhelmingly dominated by the local knowledge
of faith healing. This needed to be respected while disseminating
information about medical support for ‘mental illness’. A scientifi c
approach was to be promoted.
A key strategy in the promotion of this scientifi c approach to ‘mental ill
ness’ by BasicNeeds has been through the development of mental health
camps held in rural areas because district hospitals are often far away in
urban areas, and the medications may be unaffordable; thus camps ‘ensure
that every person with a ‘mental illness’ receives treatment’ (BasicNeeds,
undated:20). The BasicNeeds website explains that:
At a mental health camp, mentally ill people and their carers from the
surrounding area all come together to be seen by a visiting psychiatrist.
The psychiatrist diagnoses them or checks their progress and then pre
scribes the next instalment of medication. Mentally ill people can then
go to a medication dispensary, which is part of the camp, to get their
medication. After they have been seen by the psychiatrist, they can also
take part in other activities that are taking place, for example, group
therapy sessions, occupational therapy sessions, consultation meetings
or advocacy groups.
From its beginnings in India (funded by donors in the UK), BasicNeeds
now works in twelve countries, and has reached 217,500 people. In the
foreword to their annual impact report (2013), Chris Underhill recognizses
this as ‘our biggest contribution yet to the World Health Organisation’s
programme of work known as mhGAP in recognition of the very big
treatment gap that still exists worldwide but specifi cally in resource poor
countries’.
60 Educating, marketing, mongering
Figure 3.1 Photo from Iswar Sankalpa’s website www.isankalpa.org (reproduced
here with their kind permission) .
‘Into the heart of the [global] community’
The interweaving of international development with mental health, through
mental health literacy and camps, works, according to the BasicNeeds
website, to:
bring issues of mental health into the heart of the community – they
aren’t locked up in a psychiatric hospital anymore. Mental health camps
bring mental illness into the open and show people that mental illnesses
are just like any other disease and are nothing to be feared. They are an
important tool in the battle against stigma.1
This suggests that through mental health literacy campaigns, both people
with mental health problems and the mental health problems themselves are
unlocked from inside the confi nes of psychiatric hospitals and brought into
communities – they are made a ‘reality’ for all. In a similar movement, then,
psychiatric categories are somewhat ‘unlocked’ or enabled to travel from
countries of the global North to the global South.
For Sarbani Das Roy, the co-founder of Iswar Sankalpa, an organization
that works with the ‘homeless mentally ill’ on the streets of Kolkata, these
camps do far more than promote mental health literacy; these medical
encounters are human encounters with the ‘other’. They are an opportunity
to touch the other, and to be touched by them, and through touch to ‘see that
this is another human being’. They also, then, enable medication to ‘touch’
a person. Touch has particular signifi cance in India, where because of the
caste system a whole section of society are excluded from social
interactions,
Educating, marketing, mongering 61
constructed as ‘untouchable’ and ‘unseeable’, where ‘even their shadow,
[is] held to be ritually polluting and abhorrent’ (Teltumbde, 2010 :14). In
the above photo, taken from Iswar Sankalpa’s website, as the psychia trist
bends to give treatment, to diagnose, the streets of India become the site,
the fi eld, of psychiatric subjectifi cation. Calls to ‘scale up’ psychiatric
services in LAMICs, of which mental health literacy campaigns form a key
part, thus operate as a site to release psychiatry from within the walls of the
asylum, to take it out into the community, across global borders, to ‘make
mental health for all a reality’.
‘Making up’ schizophrenics in Ethiopia
On day four of the course in GMH that I attended at the Institute of
Psychiatry (London, August 2011), as the rain continued to fall and I
noticed with suspi cion that the breakfast pastries seemed to be getting
smaller each day, a psy chiatrist arrived from Ethiopia to talk to us about
schizophrenia and a study he had been involved in. The study aimed to
examine the clinical outcome for schizophrenia in a ‘predominantly
treatment-naïve cohort in a rural commu nity setting in Ethiopia’ (Alem et
al., 2009 :646). ‘Treatment-naïve’ refers to the fact that large populations
of people in many LAMICs have not had access or been exposed to
psychiatric interventions and medications. This lack of access to
medications that are widely available in HICs, this ‘naivety’, is in part
conceptualized by the pharmaceutical industry as an ‘untapped’ or
‘emergent’ market to sell drugs to, and as potential subjects for clinical
trials.
The study in Ethiopia came about as a means to further investigate the fi
ndings from the WHO’s DOSMED (1978) study, which found overall more
favourable outcomes for people with a schizophrenia diagnosis in
‘developing countries’. In order to identify those who were ‘mentally ill’,
the researchers carried out an initial screening that targeted ‘the entire adult
population of the 44 subdistricts … estimated to be 83,282 [people]’ (Alem
et al., 2009 :647). The screening involved door-to-door surveys and the
administering of the Composite International Diagnostic Interview (CIDI)
(version 2.1). This was administered to 68,378 people; 82.1% of the total
population of the district.
The Composite International Diagnostic Interview (CIDI) is a diagnostic
tool specifi cally designed to be used in cross-cultural research and to be
administered by lay people. According to the WHO ( 2004 ),
The CIDI is a comprehensive, fully-structured interview designed to be
used by trained lay interviewers for the assessment of mental disorders
according to the defi nitions and criteria of ICD-10 and DSM-IV. It is
intended for use in epidemiological and cross-cultural studies as well as
for clinical and research purposes.
62 Educating, marketing, mongering
The CIDI allows the investigator to:
– Measure the prevalence of mental disorders
– Measure the severity of these disorders
– Determine the burden of these disorders
– Assess service use
– Assess the use of medications in treating these disorders – Assess
who is treated, who remains untreated, and what are the barriers to
treatment.
Thus the CIDI, alongside other tools such as the ICD and DSM, work as
instruments of psychiatric technology that elicit ‘symptoms’ of ‘mental ill
ness’, bring into being particular people ‘with mental illness’, and concep
tualize these people as in need of treatment. However, according to
Sedgwick ( 1982 :24), psychiatric epidemiology ‘achieves this social
insight by regarding the contours of the boxes into which its numerations
fall as uncontroversial, objective boundaries, analogous to the physical
disease categories’. Epidemiology was, after all, originally the study of
epidemics of infectious disease, and while it has now become possible to
speak of epidemics of ‘mental illness’, for example, the ‘depression
epidemic’ (BBC, 2001 ), it bears the implicit assumption that ‘mental
illnesses’ are compara ble to diseases caused by bacilli (Sedgwick, 1982 ).
Furthermore, another key issue is that the very validity of the category of
schizophrenia, and the assumption that it is universally applicable, are
deeply problematic – an example of ‘category fallacy’ that may apply both
to the Ethiopian study
and to the DOSMED (Kleinman, 1977, 1987; Fernando, 2010 ). In fact,
diagnostic tools and statistical technology have been key to the growth of
transnational psychiatry and GMH, as it is assumed that they enable the
standardized diagnosis of diverse populations for comparison, and that
diagnostic categories and therefore ‘mental illness’ are transferable across
cultures. This is despite the fact that ‘both the concepts under inves tigation
and the standardized means for measuring them were created and imposed
by Western researchers onto nonWestern cultures’ (Higginbotham and
Marsella, 1988 :556). Thus, despite being ‘Western cultural documents par
excellence’ (Summerfi eld, 2008 :992), such diagnostic tools are translated
into many languages and widely distributed by pharmaceutical companies
in LAMICs. According to Rose ( 2006 :478), such ‘diagnostic tools elicit
signs that are taken as evidence of pathologies that would previ ously have
been invisible’, which are then conceptualized as in need of treating,
enabling a ‘diagnostic creep’ that is often ‘elicited by the technol ogy
itself’. Perhaps here we should heed Fanon’s cry ([1967]1986:231), that
the ‘[t]he tool never possess the man [sic]’.
Figure 3.2 Pictures of ‘symptoms’ from BasicNeeds (2009b: 117–119), with their
kind permission.
Behaving in a strange manner Unusally cheerful or boastful
Abnormally suspicious of others Suffering from fi ts
Feeling unusually sad Seeing and hearing things others do not
Having suicidal tendencies Becoming moody and withdrawn
Figure 3.3 Illustrations taken from the WHO–NIMHANS ‘ten features of mental
disorders’ fl ip chart and reproduced here with the kind permission of the Bapu
Trust.
Educating, marketing, mongering 65
The fl ip chart of mental disorders
A key mechanism for the globalization of psychiatric categories has been
the training of lay people to administer diagnostic and epidemiological
tools, such as the CIDI. This training, in areas ‘where there is no psychia
trist’, has been central to community mental health interventions, marked by
Vikram Patel’s ( 2003 ) mental health care manual of the same name, which
is widely used by many NGOs in the global South. Training in the
community is also a key part of the work of BasicNeeds. In their ‘facilitator’s
manual for training community mental health workers in India’, BasicNeeds
( 2009b :26) suggest an activity using ‘symptoms of mental disorders cards’
to ‘help participants recognize symptoms associated with mental disorders’.
Some of the pictures from these cards are on the previous page.
That the training of lay people to administer psychiatric diagnostic
check lists is key in recruiting psychiatric subjects seems to resonate with
the colo nial imaginary of developing ‘a class of interpreters between us
and the millions whom we govern – a class of persons Indian in blood and
colour, but English in tastes, in opinions, in morals and in intellect’
(Macaulay 1835, cited in Theodore de Bary, 1958:49). Many NGOs, in
India, also use pictures of ‘symptoms’ for community mental health
education, and ‘key informants’, to identify people with ‘mental illness’
within the community (see pictures taken from the WHO–NIMHANS ‘ten
features of mental disorders’ fl ip chart).
In many Indian states the pictures from the NIMHANS/WHO fl ipchart
have been made into posters and are often displayed prominently in hospi
tals (Bapu Trust, 2006 ). However, Bapu Trust, a survivor-led organization,
in Pune, is calling for the need to advocate with India’s mental health
authorities, and the WHO, to push for the withdrawal of these materials.
This is because the pictures, in summary; portray all socially unacceptable
behaviour as ‘mental illness’; may actually increase stigma as they depict
‘mental illness’ as ‘aloof’, ‘strange’, ‘abnormal’ and ‘unusual’; and because
there is a bias against traditional healing, with a suggestion that going to a
‘mantravadi’ (healer) is itself a symptom of ‘mental illness’. Furthermore,
an article in Bapu’s advocacy magazine Aaina (2006) raised concerns that
the use of the fl ipchart within communities
may actually lead to witch hunting in communities…People who do
not have an identity as a ‘mentally ill person’ would be identifi ed and
compulsorily brought for treatment to the satellite clinics (Bapu Trust,
2006 ).
Bapu Trust also raised concerns that the reasons why people might
become ‘mentally ill’ are not discussed in the fl ipchart and that the voices
of those