I remember being seated before a board of interviewers for a viva-voce that would have been my ticket to a two-year MPhil in Clinical Psychology at a reputed university in Kolkata, India. I knew some of those faces from prior acquaintance while I was enrolled in a Master’s in Clinical Psychology in the same institute. However, some faces were new. But they all shared a thread of commonality as independent mental health professionals who were innately involved in the practice and preaching of mental healthcare.
In the conversation that ensued amongst us, mostly between me and another external faculty member, I harped on the need for an orientation to social justice in mental healthcare practices and my ambition in that regard.
Since social justice involves the issue of multiple marginalizations and addressing inequalities and inequities springing from the same, I was keen on highlighting the need for advocacy and awareness. Continuing in the same strain, I was explicit in articulating how it would be shallow for a clinical psychologist to conceptualise their role within the four walls of their private clinic, immune to the vagaries that unjust social forces often inflict on the client. Expanding further on this, I reflected on how law and psychology speak to each other and expressed my interest in taking on more of an activist-role by being vocal about the rights of the marginalized.
The question that came back to me from the other side of the table was not surprising, but it was unnerving. I was asked if all I would be doing would be activism or if I would be interested in doing anything remotely ‘clinical’.
Conscious that I may have offset my chances at securing a seat, with the humble conformity of an interviewee I started weaving a bubble about my interest in diagnosing psychological disorders and how I was looking forward to learning the various kinds of ‘treatments’ for them. That did seem to serve the interest of what was being sought in me as a trainee.
However, it was also at this point that I felt how the clamour for social justice is still only a parallel reality in the conceptions of mental healthcare — that is, it is still considered to be the onus of activists and social justice warriors — and is not conceptualised in intersection/conjunction with a clinical role. It also left me speculating how the system conveniently excuses the clinical psychologist of the need to be socially just.
At its worst, this may, in fact, enable various forms of biased praxis that may run systemically unchecked and impact clients at large. Herein also lies the question of power hierarchy, where anything to do with ‘service-user based rights’ is relegated to be a lesser disciplinary status in comparison to the conventional psychiatric jargon of diagnosis and cure.
Interestingly enough, I aced the interview and got into the Mphil programme, but it is only now that I am realising that my days of revelation have just begun.
There is a silent disregard for service-user rights on a systemic level and this has been made clear to me on various occasions, especially since my course started.
A few months into my MPhil course, I felt perturbed by the explanation that is often used to justify a preference for ‘mental retardation’ as a diagnostic label over ‘intellectual disability’ in clinical reports: that it is in line with the classical nomenclature of ICD-10 (which my institution follows). What surprised me, even more, is that my classmates were pretty unconcerned about this ‘triviality’. This lack of concern, as I have come to understand it, is not merely personal but it is also institutional. The rush to pathologize and fit individuals into diagnostic categories is a part and parcel of the drill. There is no regard for the motivation of upholding the dignity of those with developmental disabilities.
Rather, there is a privileging of the psychiatric diagnostic label over a rights-based identity that is more respectful to the personhood of the individual and is more affirmative. The funny part is that the American Psychiatric Association, in its diagnostic gospel, DSM-V, has already added the term ‘intellectual disability’ as a diagnostic label and the upcoming ICD-11 has also coded it as ‘disorders of intellectual development’ which is still less pejorative.
At this point, words fall short to explain the breadth of this systemic injustice! The same goes for the casual labelling of a child as autistic while imparting classroom instruction — as if it were the only reality and identity of this individual — once again evoking the image of a ‘walking diagnosis’. ‘Walking diagnosis’ is a term I use of my own accord to describe the conventional psychiatric gaze of looking at a person with a psycho-social disability as a disorder coming alive in flesh and bones.
Under the convenient cover of developing a ‘clinical eye,’ we are taught to trace these walking diagnoses and stamp them, no matter how crude it may sound or how it completely fails to understand the lived experiences of the individual.
I have reflected on these instances many times and felt quite helpless as an aspiring clinician who also wants to sing in tune with social justice. It almost feels blasphemous now to be unable to look at a ‘case’ as a ‘case’ — nothing more, nothing less. The typical connotation of a ‘case’ here would be a person with a mental illness/ unsound mental health who seeks service from a professional. The ‘case’ has a prescribed role and status that the system likes to assign to it, which it is supposed to abide by and thereby oblige the system. It comes with its set of sanctioned power asymmetries which dare not be toppled in clinical interactions.
Another way in which the system can be quite exclusionary is by being immune to the fact that a ‘case’ may be present in the classroom as a fellow trainee. This overlap of identities is not permissible and is invisibilized to such an extent that it remains outside the classroom’s imagination.
A normalised talk about mental health (aside from the pathological jargon) has till date never happened within the classroom space. It is never asked if there is someone in the class who might be willing to share their experiences of trauma and how they are dealing with it. It is never asked if someone has had a first-hand experience of being a caregiver for someone with a mental illness. It is never asked if the course material might be too triggering for someone who is experiencing any form of mental distress, courteously preceded by a note of apology and assurance to seek counsel from someone should a person feel the need.
The personal is therefore never allowed to inform the political (in this case, the institutional protocol itself) nor is any scope created for it to happen.
How can we then expect a normalisation of mental health outside psy-disciplines? How do we address the stigma outside the classroom if we do not destigmatise the mental health talk and its personal ramifications in the classroom space?
I have no reservations in admitting that I am unable to find within myself regard for such a decontextualised, depersonalized and product-oriented approach to mental healthcare. It is also very dehumanising for lack of a better word. The process of meaningful and holistic engagement is vital to empathising with the ‘case’.
But if we were to look at a ‘case’ as a walking diagnosis, and become so absorbed in our curing power, how are we supposed to relate to the person in the ‘case’? How are we supposed to look at the context of this person? How are we supposed to look at ourselves if we become a ‘case’ at any point in our lives?
The way in which the curriculum speaks to me or has spoken to me so far in this regard has not been very promising. In becoming a competent professional, there seems to be an unscrupulous emphasis on the products that you deliver rather than the process you undergo.
I believe that it is just not enough to complete a few assignments, learn the names of a few diseases and their causes, and to tick off a basket of case-specific requirements at the end of the year. It is more important to be open to constantly learning and evolving as a professional, which is something that is going to stay and enrich a lifetime of practice. In order to achieve this, I believe that some transitions in thinking need to happen, both at the individual and systemic level.
It is important to realise that a ‘case’ is a person with a psycho-social disability. We must start recognising and respecting their agency to seek and refuse services and regard them as a democratic participant in their care.
There is also an urgent need to relate to the person’s phenomenology of their psycho-social disability and try to make sense of it through their ways of seeing.
The way we look at a clinician’s report also needs to change. A trainee is often expected to think of it as an end to fetch marks and secure conference presentations instead of looking at it as a means to make necessary services and resources accessible to a person with a psycho-social disability.
Persons with mental illnesses are not puppets at our mercy. If that regard is absent even in higher education, I do not know when this perspective will ever manifest itself in practice. The call needs to come from the system itself. It is the system that needs to reflect this ethos.
Additionally, I cannot help but be worried about the uncertainty of the times. The haunting nature of a pandemic coupled with global state-endorsed quarantine and social distancing measures have surely evinced the need for community-based interventions. This must goad us to relook at mental healthcare systems and reflect on what more we can offer beyond the confines of our private clinics. This is also probably a good moment to unlearn and learn new ways of doing things. I shall, therefore, conclude with a couple of questions to deliberate on:
As a section of healthcare that focuses on invisible illnesses, how do we make ourselves resourceful as front-line workers in these trying times? What does a pandemic with its social ramifications mean for a person living with a psycho-social disability? How does a pandemic impact the mental health of the ‘normal’? How does technology aid us in offering a mode of care? Also, in the context of the widespread poverty and sharp inequality in the Indian subcontinent, in the face of a nation-wide lockdown that has continued for weeks, and in the absence of basic essentials for certain communities, is it a luxury to be able to think of mental health? In addition to that, how is the mental health of the average Indian citizen negotiated in terms of social locations of caste, class, religion, sexuality, gender, geographical area, and so on and so forth?
If these reflections do not unnerve you (considering the present state of affairs, they should!), unlearn your armchair complacency. That would probably do the nation some good.
Aritra Chatterjee (preferred pronoun: she/they) is an Mphil trainee in Clinical Psychology based in Kolkata, India. Their primary area of research interest lies in the area of LGBT+ mental health care. Their access to mental healthcare spaces both as a service-user and as an aspiring professional has been experientially coloured by their GSM identity. This also makes them particularly keen towards developing a social justice orientation to address multiple forms of marginalization in systems of mental healthcare.