Psychology first lost its soul, then its mind, it still has behaviour of a sort.
-Woodworth
Clinical psychology is a core constituent of the mental health team in India along with psychiatric nursing, psychiatric social work and psychiatry. Synergy among these disciplines is paramount to implement a holistic, bio-psycho-social model of mental health care. However, in reality, due to the quest of clinical psychology to garner authority and dignity, it almost always aligns closely with mainstream biomedical psychiatry and moves away from a social sciences approach. Even though mainstream psychiatric disciplines struggle for explanatory power for their diagnostic categories, clinical psychologists loosely deploy fragile and fluid professional conceptualizations and subjective judgements of rationality and irrationality to dictate ‘normal’ and ‘abnormal’. In this way, clinical psychology fabricates ‘objective science’ whilst caught up within fields of psychiatric power by creatively appropriating mainstream biopsychiatric ‘ways of knowing’ and acting. Clinical psychologists don’t speak against the violent practices of psychiatry because they rely on its medico-scientific nature to garner prestige and respect.
Psychotherapy formulation and practice becomes mere moral, social and cultural judgements dressed up as ‘medical assessments’ and modification of behaviours that are disapproved by the society thereby strengthening social control and political status quo. As psychologists don’t prescribe medicines, there is a larger room for them to play fast and loose as it is hard to scrutinize their interventions, which are often geared towards inducing people to be in-charge for their own structural sufferings by instilling coping skills and attitudes towards life that are individualistic, thus, reframing the political as personal. In this article, I examine what ‘mental health’ means to clinical psychology and how it positions itself with other disciplines and the extended communities, as revealed by M. Phil clinical psychology curriculum and training of clinical psychologists.
M.Phil. clinical psychology syllabus: Playing on science’s chessboards
The syllabus prescribed by Rehabilitation Council of India (RCI) for the 2-year M. Phil course in clinical psychology demonstrates how distant psychology is from the larger social ecosystems and subaltern concerns. Half of the papers are strictly an import from mainstream psychiatric science, viz., psychiatry, biological foundations of behaviour and statistics. Topics which are central to interpretative social science paradigms such as social constructionism, intersectionality, justice, freedom, equality, social suffering, structural violence to name a few, are shunned out at a juncture when activists and scholars have demonstrated that mental health cannot be cleaved from human rights, gender rights, disability rights, indigenous rights and more-than-human geographies. Alternative paradigms in psychology such as critical psychology, user-survivor movements and mad studies remain suspended in clinical psychology curriculum.
(a) Statistical climate in clinical psychology practice and research: Need for a climate change?
Objective symptom checklists are loosely employed by clinical psychologists to pathologize subjective worlds of the ‘patients’, thereby decontextualizing suffering enmeshed in adverse socio-politico-economic conditions.
To fulfill the quest for science, paper on research is termed “Statistics” and research methodology. The word qualitative doesn’t find mention in the whole syllabus. Emphasis on quantification of the self spills over into practice as both feed into each other forming a closed circuitry. “Standardized” questionnaires are used as double edged swords to diagnose the ‘different’ and the ‘deviant’ ‘others’ and as ‘reliable’ and ‘valid’ ‘tools’ for research to satisfy the technological imperative in clinical psychology. Objective symptom checklists are loosely employed by clinical psychologists to pathologize subjective worlds of the ‘patients’, thereby decontextualizing suffering enmeshed in adverse socio-politico-economic conditions. Consequently, psychological practice evolves into one that is transactional, impatient and small-minded when knee-jerk therapies are deployed without paying attention to phenomenologic diversities. Varied coping strategies get framed as potential sites for psychological interventions. Thus, it sets an ecologically invalid trend where clinical psychological ‘science’ evolves from normative statistical values rather than from people’s inherently complex life worlds.
(b) Sexuality, pleasure, disability & clinical psychology: “We remain strangers after so many meetings.”[1]
The term sexual appears in the syllabus only with regard to sexual disorders and dysfunctions. This recasting of every aspect of sexuality as pathology fails to locate sexuality at the intersection of ideas around pleasure, human rights, intimate citizenship, morality, ethics, bodily autonomy, freedom and dignity, as many disciplines have demonstrated. RCI has not included sexuality education in any of its courses designed to care for disabled persons including clinical psychology, even though the intersectionality between disability and sexuality is crucial and wanting. LGBTQIA+ issues don’t figure in the syllabus even though psychiatry and psychology have been accused of pathologising gender non-conforming people, ‘treating’ them with medicines and aversion/conversion therapies respectively. LGBTQIA+ activists, UN human rights mechanisms, anthropologists, philosophers, litterateurs have vigorously uncovered the trauma and violence meted out to LGBTQIA+ people including in the hands of psychiatric/psychology professionals. But Indian Association of Clinical Psychologists(IACP) and their flagship journal Indian Journal of Clinical Psychology (IJCP) went a step ahead of the psychiatrists by brokering complete silence about LGBTQIA+ rights when their own fraternity still engages in therapies to “treat” homosexuality even after Supreme Court order not to do so.
In July 2018, the day before the Supreme Court started hearing the petitions against Section 377 of the Indian Penal Code which criminalized same-sex relationships between consenting adults, the Indian Psychiatric Society (IPS) issued a position statement on homosexuality not being a mental illness requiring treatment. Neither did IJCP have a single rights-based article covering LGBTQ issues nor has there been a press statement or a position statement seeking to make the professional body’s position clear despite LGBTQIA+ issue being discussed ad nauseum by the public, media, judiciary, activists and academia. Psychology in India imbibes what psychiatry professes without having a mind of its own to voice against traumatizing practices within mainstream technocratic psychiatry. The Supreme Court has not quoted even a single scholarly work on LGBTQIA+ issues by a psychologist in its judgement on IPC 377. Mainstream psychology and psychiatry have sleepwalked into an intellectual and moral embarrassment when the apex court stepped in to advice the psychiatric/psychology fraternity to be sensitive enough about LGBTQIA+ lives and to initiate social change as a part of their ‘treatment’.
The tunneled vision of psychiatric epistemology negatively affects the institutional culture of mental health institutions erasing the chance for another narrative for social emancipation. None of the three premier mental health institutions under the central government viz., Lokopriya Gopinath Bordoloi Regional Institute of Mental Health (LGBRIMH), Tezpur, Central Institute of Psychiatry (CIP) , Ranchi, and National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, have a support group for LGBTQIA+ students till date, whereas such mechanisms have become an integral part of many academic institutions like Tata Institute of Social Sciences (TISS), Indian Institute of Technology (IITs) and Indian Institute of Management (IIMs) since a long time. TISS introduced the first gender neutral hostel in a significant move towards gender inclusivity in India. In yet another gesture of promoting self-identification and recognition of gender fluidity, NALSAR University of Law, Hyderabad became the first educational institution to issue a gender neutral degree in the country. There exists a profuse disconnect with social justice and human rights orientation in mental health institutions which has resulted in creating silos marked by cultivated ignorance, attitudinal inertia and limited space for dialogue.
There exists a profuse disconnect with social justice and human rights orientation in mental health institutions which has resulted in creating silos marked by cultivated ignorance, attitudinal inertia and limited space for dialogue.
Experiences of a clinical psychology trainee: Encounters with exclusion and everyday terror
For me, undergoing M. Phil in clinical psychology at a prominent central government mental health institution demonstrated how the psychiatric culture marred with hierarchical structures, skewed training practices and narrow professional attitudes came together to inflict new normal of violations, silences and violences leaving deep scars on my mind. There was immense scrutiny and control on the way I talked, dressed, emoted and behaved in the mental health institution. My perceived gender identity and sexual orientation became the talk of the institution where mental health professionals consistently exhorted me to be ‘normal’ putting constant pressure to erase differences. To be brief, there was always an ‘obligation to recover’, which brings Nikolas Rose to mind. There were very few professionals and colleagues who were empathetic and non-judgemental. A senior psychiatry student eager to probe my sexual preferences constantly quizzed me on the hostel’s public spaces, blatantly violating my fundamental right to privacy. The academic space was bruising and intimidating that even the junior students used to mock me by paraphrasing my tone of voice and speech. I was reprimanded for being friendly with library staff and class IV employees by the faculty members at the institution, accusing me of not maintaining professionalism. For the mental health professionals, this constituted “a blot on the entire psychology community”.
As an Indian citizen, these were not only violations of my fundamental right to freedom of expression but also right to dignity and privacy flowing directly from the fundamental right to life guaranteed under Article 21 of the Constitution. A shroud of surveillance in the form of behavioural micro-targeting guillotined my individual freedoms imposing an oppressive psychological conformism. All said, personal interactions at various levels in the former mental asylum spotlighted subject-object relations than subject-subject relations. The extreme treatment given by the mental health systems when I was labelled simply as homesick while suffering from tuberculosis was little more than horrific torture.
Prejudice, discrimination and ignorance of basic ideas of natural justice were at the core of the mental health institution. At the age of 21, Reshma Valliapan participated in a psychology experiment in her college where she was deemed to be ‘abnormal’. The autobiography of the psychiatric survivor is moist with pain when she writes: “I had my own frustration, firstly, in accepting the very label of madness” (p. x). If insiders have to undergo trauma of this nature, the systemic violence and human rights violations that these institutions inflict onto the wider society is imaginable and critical to introspect. The above vignettes stand testimony to the cultural climate of mental health institutions which seldom focus on making space for dealing with heterogeneity and promoting safety for their own insider trainees. Disjunction between clinical psychologists and the larger social sciences and humanities stifles person-centric care, thereby, enabling provider-centric system where professionals become statutory decision makers.
In reality, mental health education in India trains people to be logical to the exclusion of being emotional, to be technologists of the mind to the exclusion of becoming artist-philosophers who can empathetically care, share and heal sufferings.
The common sense expectation that mental health education and training amplifies empathetic understanding about different ways of being in the world is fairly misplaced. In reality, mental health education in India trains people to be logical to the exclusion of being emotional, to be technologists of the mind to the exclusion of becoming artist-philosophers who can empathetically care, share and heal sufferings.
There were very few mental health professionals who offered value based education. I fondly remember a professor of psychiatry who exhorted us to always use honorifics (Mr/Ms) as prefixes while addressing patients as he convincingly said, “Person comes first, not the patient”. He was an exception among the psychiatry faculty members where most of the male mental health professionals almost always brought masculine dominance with them to the system, further worsening the system. Values, morals, context-specific meanings and relationships are brushed under the carpet of modernizing psychiatry precipitating a culture of violence, helplessness coercion and oppression in the field. Mental health institutions as a cultural system is trapped in twilight between its colonial past and its continuing legacies of asylums and an aspirational, rights-oriented future.
When critical questions were raised regarding the practice of psychiatric disciplines, the trainee-clinical psychologists were exhorted to follow established algorithms and ‘evidence based’ protocols to prove the point that it is a science with only one conclusion and only one reality. It is this constant repetitive performance which I would call as medical posturing that creates the illusory reality of objectivity, logic and positivism in clinical psychology, for repetition is a political act performed to uphold power. Thus, it becomes imperative for the ‘professional’ trainers to act ‘scientifically’ and relay this scientificity to the trainees to stage a collective political performance for the profession. The refusal to acknowledge with humility the limitations and ambiguities that plague psychiatric disciplines, starting from the very definitional status of mental disorder, itself fueled an emotional climate characterized by authoritarianism, intimidation and mistrust.
The landscape of the modern psychiatric institution is politically fissured into various levels of hierarchies among the psychiatrists, clinical psychologists, psychiatric social workers and the psychiatric nurses, between the mental health professionals and patients, between the clinicians and trainees, to name a few. Even though the former asylum metamorphosed into a modern mental health institute, it still produced, reproduced and co-constructed these power differentials. During ward rounds, psychiatrists walked in the front ‘leading the team’. Seating arrangement in the seminar hall symbolized psychiatric power in action with the psychiatrists seated in the front. Another level of hierarchy acted out was when the nurses and psychiatrists camped in the domain of medical professionals reducing non-medical professionals of clinical psychology and social work as insignificant ‘others’. In sum, the mental health disciplines are compartmentalized without hand holding each other.
Biomedical hegemony was something which vitiated the yearning for a democratic team spirit in the mental health team. When trainees of all the four disciplines in the institution were ordered by the Director to wear white coats, the decision couldn’t be implemented as the MD psychiatry students protested by not adhering to the instruction as they wanted to stand out as doctors in appearance.
Clinical psychology training: Fissured by logic and modernity
Clinical psychology seeks refuge in such performances in the face of feeling uncomfortable while operating in a world of ambiguities while confronting the unknown.
Many students who got admission in premier mental health institutions drop out in the middle of the course due to the inability to cope with the institutional culture demanding ‘hard labour’ out of the trainees. A perception that clinical psychology course is as heavy and tough as that of medicine is engineered as a public discourse. Clinical psychology seeks refuge in such performances in the face of feeling uncomfortable while operating in a world of ambiguities while confronting the unknown. In fact, it is not the subject but the rigid system which is tough to tolerate. Clinical psychology trainees often seek protection behind science to feel high. When a mother curiously quizzed a clinical psychology trainee about the two-hour long psychological test that she administered on her son, she replied evasively that it is a ‘scientific’ test whose results can be collected after two weeks. In this narration, the budding clinical psychologist equates Rorschach inkblot test with that of any other objective medical investigation referring to it as ‘scientific’ to 1) feel dignified and satisfied as she sways towards medicine which has objective investigations, 2) silence further queries expected from the mother about such a long-drawn test which might reveal the real ‘softness’ of the perceived and ‘performed’ rigorousness of psychological tests. This vignette gives us a sense of the politics of representation that emerges when the identity crisis of the discipline interweaves with its uneasy relationship with its public optics. Only when knowledge is accessible and verifiable can it be questioned. Clinical psychology remains in silos to maintain status quo, thereby hijacking new possibilities.
Joint ‘othering’ by psychiatry and state: Case of psychopolitics in Assam
“Maathaa bethakoriche…, shorir bethakoriche…” (Headaches…, body aches…)-Ms. Jamila Khatoon (name changed), an ‘illegal Bangladeshi’ Muslim woman told the psychiatrist in Bangla at the OPD of a premier mental health institute in Assam. She continued to speak about all the troubles she endures, frequently breaking down by resting her head on the table. Jamila, like many others, who constituted half of the OPD turnout, spontaneously received a prescription for antidepressants supplied free of cost by the government of India abruptly interrupting her eventful ‘trans-national’ stories of migration, oppression, violence, resistance and struggles. All of them experienced constant, chronic trauma in multitudinal forms such as poor nutrition and sanitation, prejudice, discrimination and violence on a daily basis from the Assamese majority and the state apparatus targeting every black burqa-clad woman and bearded men branding them as ‘Bangladeshis living illegally in Assam.’
Psychiatry colludes with the nation-state and majoritarian society to jointly choreograph the ‘othering’ of Muslims.
Mocking caricatures of “Sylheti psychosomatic” (Sylhet district in Bangladesh) drawn by mental health professionals could be seen in most of the clinical spaces of this ‘centre of excellence’ suggestive of the intellectual and emotional partition between Assam and Bangladesh. Many majority Assamese mental health professionals expressed resentment and anger towards the minority “patients” frequently chewing the cud of religious animosity. Sheer political and cultural antagonisms rumbled continuously under the membrane of clinical interactions resulting in didactic and experience-distant monologues. Loose representational images of the ‘illegal Bangladeshi migrants’ becomes the ‘reality’ upon which psychiatry and the state collude to achieve a common end of eviction. This reading of Indian psychiatrist-Bangladeshi migrant/refugee relationship opens up articulations of the nexus between psychiatry and international politics. For the clinical psychologists and psychiatrists, these women were merely simple cases of ‘Sylheti psychosomatic’ who can be diagnosed and psycho-therapized at the drop of a hat, reducing their personhood, life experiences and trauma to a symptom to be remedied. Any extended conversation with these people was unwelcome as it represented a weak, incapable psychologist who failed to ‘do’ diagnosis of a routine diagnostic category.
The book Madness in International Relations has shone light on the controversial political involvement of psychiatric disciplines in international relations where they assume positions as resources for national security and technologies for the management of trauma produced by global politics. When psychiatric gaze extends to persons such as Jamila to transform communal, inter-state politics as problems within their psyche, an individualization of trauma caused by global events, it essentially politicizes psychiatry when sovereign, disciplinary, and governmental strategies wear the garb of ‘treatment’. Every social ill is diagnosed as mental disorders to be treated with pills.
It is for this very reason that the diagnostic category of PTSD has been criticized significantly by psychiatrists themselves for medicalizing the troubling moral implications of war. Scholars have shone light on how psychiatry joins state and humanitarian organisations to capitalize on PTSD for political gain in conflict ridden Kashmir. Pharmacological agents are engaged in reducing a complex bit of reality into a simple form evidenced by slogans like “mental illness is a brain disorder”, “Defeat depression, spread happiness”, “happy pills” etc. More people are on psychiatric medicines and at the same time disorders are increasing as attention shifts to addressing individual psychological redress instead of addressing the causes of trauma, which requires more commitment and political action. Lowering the threshold of diagnosis for psychiatric disorders has moved psychiatry beyond the domains of mental illness and its prevention into a practice of addressing all states of mind as pathological. Expansion of the scope of psychiatric treatment extends to treat social problems and social deviance by posing as a panacea that can identify and ameliorate the miseries that plague society in various forms.
When psychiatric gaze extends to persons such as Jamila to transform communal, inter-state politics as problems within their psyche, an individualization of trauma caused by global events, it essentially politicizes psychiatry when sovereign, disciplinary, and governmental strategies wear the garb of ‘treatment’. Every social ill is diagnosed as disorders to be treated with pills.
How does all this add up?
The vignettes described above denote the failure of clinical psychology in evolving culturally sensitive, human rights oriented and person-centered care in the light of an everyday which can’t be detached from the sticky web of connections with humans as well as non-humans. This has wider implications that go beyond the specificities of the above anecdotes. The lack of focus on power structures, structural violence, and social ecologies in the training module spills into practice, disabling the professionals from dialoguing with diversities and subaltern political ecologies. There seems to be a dire need for clinical psychology in India to constantly return back to fundamental questions of social and environmental justice marked by class distinctions, caste structures, global politics and gender locations to recognize the complexity of social environment in shaping individual mental health conditions. To understand barriers that people confront, it is vital to get closer to their experiences because anything taken off the context becomes problematic. Deflecting causality and correlations to a wider ecology of relations has implications for thinking broadly about effective interventions.
Just because someone is trained as a mental health professional, they are not experts in capturing everything that constitutes human predicament. Collaboration is the key to understand the mind which is situated in complex transactions among the brain, people, state and society. How do clinical psychologists see a gender-queer person or the Bangladeshi migrant/refugee? Do they inherently have poor mental health or are their mental health compromised due to their interaction with the society, psychiatry and the state and their response to them? For clinical psychology to become a genuinely human(e) science, it is pressing to shed its mission for objectivity which even neuroscience has extraordinarily failed to accord to psychiatry.
Scientific posturing of mental health disciplines arrests people’s stories that they wish to narrate for every life is in search of a narrative.
Scientific posturing of mental health disciplines arrests people’s stories that they wish to narrate for every life is in search of a narrative. Kearney (2002) puts it in perspective: “We all seek, willy-nilly, to introduce some kind of concord into the everyday discord and dispersal we find about us”. If we want to treat everyone equally, we need to treat everyone uniquely. Psychiatric expert’s knowledge, expertise and perspectives are not the only stories. When psychiatric disciplines patiently listen to the experiencing expert’s stories without scaling up from molecules or psychometric data to minds, they get to belong to this world we all share. Feeling of belongingness is a necessary precursor to healing which will set in motion only when people are freed from unjust, discriminatory and violent life contexts. Psychiatric institution itself happens to be the right place to demonstrate this change. There is a dearth of psychologists and psychiatrists who are humans first and scientists, psychologists and doctors second, and, that, I think, makes all the difference. I wish to close by invoking Martin Luther King: “Injustice anywhere is a threat to justice everywhere”.
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Disclaimer: What I have foregrounded in this article relates only to mainstream psychology practice in India. It needs to be kept in mind that there have been sincere efforts on the part of feminist mental health professionals, critical psychologists and psychiatrists who have continued to resist violences in mainstream psychology teaching, knowledge production, and practice indicating that psy practice is a heterogeneous entity.
Acknowledgements: I would like to thank Jhilmil Breckenridge for inviting me to write for Mad in Asia Pacific and Dr. Shubha Ranganathan and Dr. Chandan Bose, IITH for their insightful comments.
[1] “Ham ke thahare ajnabee, itnee mudaraton ke baad, phir banenge aashna kitnee mulaaqaton ke baad”This phrase is translated from a ghazal written by prominent Pakistani poet Faiz Ahmad Faiz
Sudarshan R Kottai is a PhD candidate in the Department of Liberal Arts, Indian Institute of Technology Hyderabad. His PhD research focuses on mental health care policies and practices in the Indian context from critical perspectives. He had a brief stint as clinical psychologist at the Department of clinical psychology, Lokopriya Gopinath Bordoloi Regional institute of mental health, Tezpur, Assam before enrolling for PhD. His broad interests include psychotherapies with marginalised people, mental health at the intersection of gender, disabilities and sexualities, ecology and environment, close relationships and its dysfunction, psychological emergencies and North-East India.
