Constructing diagnosis in 'mental health': the negotiation of categories, the encounter of subjectivities in South Asia
Date and Start Time 26 July, 2014 at 09:00
This panel addresses the processes of negotiating diagnosis in the context of 'global mental health' discourses in South Asia and the relationship with subjectivity. We invite papers dealing with the ways in which subjectivities are expressed and shaped in the process of diagnosis negotiation.
This panel seeks to analyze the relationship between subjectivity and the processes of negotiating diagnosis in the context of 'global mental health' (GMH) discourses in South Asia. Anthropological literature has questioned how modes of subjectivity in diverse places are shaped by everyday forms of experience (Biehl et al, 2007; Del Vecchio et al, 2008). The process of negotiating diagnosis in healing encounters can be seen as connected to the experience of the subjects - both healers and patients.
The GMH agenda has dominated discussions of mental health in low income countries. A central 'technology' of 'GMH'' interventions are international diagnostic systems. These provide standardized and universal categories of psychiatric morbidity. This approach to addressing suffering raises questions about the ways in which diagnoses are negotiated, in a setting, as the South Asian one, where healing traditions are pluralistic in nature.
We welcome papers that deal with healing encounters in the field of 'mental health', offering critical reflection upon the ways in which patients and/or practitioners subjectivities are expressed and shaped in the process of diagnosis production. Some questions we wish to consider include: What takes place in these encounters? In what ways do shadows of the 'global' and subjectivities of the 'local' shape these interactions? How does accepting/refusing/discussing a diagnosis relate to and affect experiences and understandings of selfhood and subjectivity?
This panel is closed to new paper proposals.
The sense of suffering: subjectivities of depression and the neurochemical imbalance narrative
My aim is to analyze the relationship between the neurochemical imbalance narrative and subjectivities of depression in Kerala. I argue that subjectivities are fractured and that patients engage non-medical discourses to make sense of their suffering.
The narrative of depression as a neurochemical imbalance in the brain or, more precisely, a deficiency of the neurotransmitters serotonin and norepinephrine - largely produced by commercial interests of the international and national pharmaceutical industry and spread globally by international diagnostic systems - has found its way into the offices of biopsychiatrists in Kerala. In the clinical encounters, social, economic and existential suffering is thus transformed into a medical condition, treatable with pharmacological means. On the one hand, the setting of a psychiatric OPD largely shapes the way depressive patients express their subjectivities. On the other hand, the diagnosis (and explanation) of depression as neurochemical imbalance in and the prescription of drugs influences the way patients experience their suffering. Drawing from Jenkins' notion of "pharmaceutical selves" and from Rose's "neurochemical selves" and using several ethnographic examples, the aim of this paper is to analyze the relationship between the neurochemical imbalance narrative and subjectivities of depression in the context of clinical encounters in biopsychiatric institutions in Kerala.
Subjectivities of depression are, I argue, much less coherent than ambiguous and fractured, unstable and fragile and engage accentuate and sometimes merge different, often contradictory discourses. Moreover I argue that it is because the neurochemical imbalance model of depression, though quite popular in Kerala due to the literacy rate and the numerous awareness programs in the state, doesn't provide patients with existential or religious meaning of suffering, that most patients seek other models to help them in making of their suffering.
'Diagnosis' and 'subjectivity' in community mental health in northern India
This paper examines the meaning and significance of ‘diagnosis’ and ‘subjectivity’ in community mental health in northern India. This paper argues that the identities of patients and clinicians as ‘subjects’ are de-emphasized in favour of stylized forms of interaction and idealized identities.
This paper examines the meaning and significance of 'diagnosis' and 'subjectivity' in healing encounters in community mental health care in northern India. A central 'technology' of 'global mental health' interventions are diagnostic systems including the International Classification of Disease (ICD) and Diagnostic Statistical Manual (DSM). These are seen to provide a standardized and universal means of measuring psychiatric morbidity with consequent increase in 'access' to services. Drawing on ethnographic data, this paper argues that the identities of patients and clinicians as 'subjects' are de-emphasized in clinical encounters in favour of stylized forms of interaction and idealized identities. In these encounters, diagnosis is of limited value for clinicians and patients. Rather, the primary focus is on prescription and provision of medication. Patients and professionals construct 'ideal type' identities of the other in relation to medication. For patients and family members, the ideal psychiatrist is a provider of medication that will 'solve' a problem. For professionals, the ideal patient is 'compliant' to treatment. The actuality of practice is that neither the patient nor professional fulfils the ideal. This has important implications for the operation of community mental health services in this region, particularly issues of 'access to care' which is central to the 'global mental health' agenda.
Silencing spirit voices: experiencing schizophrenia between psychiatry and ritual healing
At a Muslim healing shrine, psychiatric consultations are conducted along with ritual healing. A man is diagnosed with schizophrenia and as a victim of a sorcery attack by his family. How do these seemingly contradictory types of diagnosis affect the subjectively experienced course of the illness?
Cross-cultural research on schizophrenia lists India amongst those countries of the developing world considered to allow for a comparatively better course and outcome of severe mental disorder. This axiom, although contested on the basis of recent psychiatric evidence, is based on the idea that Indian family systems provide greater support and care for the afflicted. Family care, however, often takes the form of looking for help at religious healing sites. In the last decade, Indian psychiatrists have initiated projects of collaboration with ritual healers in order to reach out to people suffering from mental illness. This paper draws on ethnographic research of a project conducting psychiatric consultations at a Muslim healing shrine. It engages the case of a young man diagnosed with schizophrenia by the psychiatrist and as a victim of a sorcery attack by his family. How do these seemingly contradictory types of diagnosis affect the subjectively experienced course of the illness? Are they translatable into coherent experiences of distress? I shall explore these questions by analyzing the consequences of the psychiatric diagnosis focusing on the individual disorder becoming manifest in the behavior of the patient and of the ritual diagnosis distributing affliction amongst several members of the extended family. Negotiating diverse categories of diagnosis implies the making and unmaking of subjectivities of patients, family members, ritual healers and psychiatrists.
Healing encounters in rural South India: the soothsayer's word as a means to relieve mental distress
This paper aims to highlight the psychotherapeutic dimension of astrological consultation in rural Tamil Nadu, through the analysis of the dialogical relationship, which is established between the astrologer and his consultant in the course of the diagnostic process.
All divinatory process begins with a request on the consultant's side. Whether implicit or explicit, this query is always motivated by angst or anxiety about a past, present, or future event. In the footsteps of Judy Pugh (1983a, 1984), and Josée Contreras and Jeanne Favret-Saada (1990), this communication will focus on the various discursive processes used by the astrologer during the consultation to unravel the problematic situation of his consultant.
Drawing on data collected during a fieldwork within the Valluvar astrologers of Tamil Nadu, between 2006 and 2008, I will show how the dialogic confrontation of two words - with different statuses in this therapeutic area - fuels the divinatory therapy and finally enables the consultant to shed a new light on his situation. Thus, the astrological consultation appears as a dialogic process which seeks to analyse, understand and reformulate the situation of the consultant - situation in which the act of divination itself actually plays a limited part. Seen in this light, the divinatory speech is not so much used to utter "real" predictions but is more of a tool which mobilises categories of the visible and the invisible, through a dialogic game back and forth between, on the one hand, the perceptible elements of the situation of the consultant and, on the other hand, those revealed by the horoscope, in order to produce the therapeutic words which bring sense and meaning to the consultant.
We treat only quiet psychotics! The encounter of psychiatry and religion - the case of Gunaseelam temple (South India)
Based on a fieldwork conducted in a South Indian temple well known for its therapeutical power and where a psychiatric center has recently opened in order to treat psychotics, this paper aims at questioning the consequences of such a diagnoses and of such a healing proposal.
In India, due to national policies to improve mental healthcare, bio-psychiatry has begun to enter traditional sites of faith healing such as temples and dargahs. Gunaseelam near Tiruchirapalli (Tamil Nadu) offers an example of a traditional space of religious healing which is challenged by a community-based rehabilitation centre that opened in 2003 inside the compound of the temple. The patients with mental illness are examined by psychiatrists and, according to their symptoms, they are admitted into the clinic with their caregivers. For forty-eight days (auspicious period), they have to take part to the temple's rituals (pūja 'ritual of offerings', darśan 'divine vision', tīrttam 'holy water') and, in parallel, to attend the three consultations per week. The clinic accepts only patients with schizophrenia and personality troubles who are provided with medication according to the diagnosis established by the psychiatrists who refer to the western nosological nomenclature. Based on an anthropological fieldwork conducted since 2012, this paper aims at questioning the consequences of such diagnoses. It analyses the different representations of illness, and the way individuals subjectively deal with different explanatory models of mental illness. It also investigates how patients and caregivers perceive and feel the therapeutic effects of both religious and psychiatric healing systems.
FILM PRESENTATION: Tīrttam and tablets: A healing proposal for mentally ill patients in Gunaseelam (South India))
Well known for its powerful deity who heals the mentally ill, the village of Gunaseelam illustrates an interesting example of mental healthcare combining rituals (tīrttam) and medication (tablets). After the Ervadi tragedy, when the government forbade the confinement and chaining of the mentally ill in unlicensed places such as in religious institutions as contrary to human rights, a clinic was established to treat patients. This documentary film attempts to explore the everyday life of the patients of Gunaseelam, circulating between religious healing and psychiatric treatment, tīrttam and tablets. It questions ultimately a new way to develop mental healthcare practices that are more acceptable to the people, notably those from lower social backgrounds.
This panel is closed to new paper proposals.