The Neoliberal Project: Mental Health & Marginality in India
Neoliberalism as paternalism
The increasing prevalence of mental illness amongst Scheduled Tribes (ST) has been a source of worry for community health workers in ST populations, case studies among adivasis highlight the need for mental health equity. For instance, histories of marginalization have been observed(1) to have had critically adverse effects on the mental health of adivasis in Wayanad district in the state of Kerala. “Poverty, low living standards and related factors,”(2) are risk factors for MH, and community health workers must attempt to address these health inequalities for historically disadvantaged communities. However, the responses of both, the health community and the government, often involve a paternalistic form of governance that functions within neoliberal frameworks of health: individualized pathologization (where social suffering is covered up by the veil of individual-level mental illness); and the prescription of free psychotropic drugs. These frameworks involve the “marketization” of healthcare and, with their focus on the individual, may serve to cast a veil over shortcomings in the area of human rights.(3)
The individual in the mental health marketplace
Scholars drawing from Mudge’s conceptualization of neoliberalism’s three interconnected spheres argue that neoliberalism and globalization have catalyzed widening health inequities between various communities.(4) These interconnected faces, namely the political, bureaucratic and intellectual domains, intersect insidiously to reconfigure the delivery of health services. They go on to highlight how various domains of neoliberalism have lead to the commodification of health. The role of the state as provider of health as a public utility has, under late capitalism, been replaced with the marketization and privatization of health, regulating service demand and supply. The rise of philanthro-capitalism, along with neoliberalism’s ties with conservative politics, has drastic consequences for marginalized groups, with health governance emerging as a means of social control. Ramifications include scant access to quality health resources, languishing public infrastructure such as sanitation and water supply, poor nutrition, and limited health-seeking behaviour.
Drawing on the above framework, this piece further argues that besides its impact in the sociopolitical, economic and academic realms, neoliberalism has also aided in the dubious reorganization of the subjective, psychological self. This argument becomes crucial to the analysis of neoliberal ideology and its involvement in psychiatric treatment, given how the psychopharmacological revolution gave birth to an obsession with situating mental illness within the individual, decontextualized from their social reality, and how that viewpoint continues to be supported by neoliberal ideologies that gloss over structural inequalities.(5)
Scholars have also traced how the biomedical discourse dominates health circles, supported by a market rationale that evaluates merit (and notions of normalcy) based on notions of individualized responsibility, productivity, and – eventually – success. This aligns with the Psy-disciplines’ conventional concepts of mental illness, in which immense value is placed on work and productivity. For example, one of the diagnostic criteria for alcohol use disorder in the DSM-V is the failure to fulfill obligations at work, school or home, and the inability to be a productive member of society similarly informs the descriptions of other disorders.(6) This fetishization of productivity, and how it dictates notions of normalcy and deviance, has vastly benefited the pharmaceutical industry. Sophisticated prescriptive drugs are able to modify behaviour to make it fit neoliberal notions of the functional person, who is seen to be in primary charge of their own happiness, success, and health. This reconfiguration of the self is strengthened by market forces, notably in the intellectual realm through the drug industry’s blatant sponsorship of motivated medical research – conferences, training seminars, branding and product placement – that has led to a substantial increase in the number of drugs prescribed(7) and, worryingly, an increasingly neurochemical approach to mental illness.
Colonization makes a comeback in mental health
Categories such as post-traumatic stress disorder and substance abuse are arbitrarily appropriated and applied to mask the social suffering brought about by neoliberal notions of development. For instance, based on physical and symbolic violence perpetrated on the bodies of marginalized caste groups in Kerala, Kottai traces how paternalistic governance of mental health practices has led to the categorization of poor, displaced adivasis as “alcoholic” and “mad”.(8) Meanwhile, funds poured into de-addiction centers, rehabilitation homes, and the mechanized dispersal of free drugs and treatment enable narratives of “development” to flourish – not only in the systematic expropriation of tribal lands for neoliberal development, but also in the construction of a “normal” self (as opposed to mad and/or alcoholic), that suits regional and cultural sensibilities.(9) What transpires, then, is not just the colonization of psychiatric nosology (the branch of medical science dealing with the classification of diseases) in Kerala, drawing as it does from Euro-American frameworks, but also involves shaping models of mental health to fit into local subjectivities of normalcy and development.
Philanthro-capitalism further aids in the constructing of good health as a commodity, which makes a right into something that depends on the benevolence of the rich, perpetuating the lack of accountability and power asymmetries in health services.(10) Non-governmental organizations, too, often rely on certain given scripts of mental illness, both while training mental health practitioners and treating clients. Such scripts tend to emphasize treatment of the “deviant self”, and use workplace productivity as a measure of successful recovery. Besides, when the role of such NGOs includes the rehabilitation of “at-risk” populations through counseling and psychiatric modalities, “vulnerability” is understood, and gets treated, as an individual-level phenomenon removed from its sociopolitical origins.
Similarly, ethnographic research from Nandigram, West Bengal,(11) shows how neoliberal policies (manifested, in this case, in dispossessing villagers of their land for the establishment of SEZs) are fundamentally anti-people, violently causing(12) displacement, a range of suffering, a sense of betrayal. Euro-American nosology might read the ensuing symptoms as being indicative of PTSD – one of the categories that have colonized our notion of the self. This neoliberal notion of the self-contained self allows for the explaining away of poverty, violence and discrimination in terms of “individual psychiatric disorders”.(13)
The way forward
Where maximization of profit takes precedence, the human brain is perceived as capital. In a world where the capitalistic logic of demand and supply determines the ups and downs of a volatile eco-political environment, the onus to transform, in spite of all odds, is placed on the “unhealthy” individual. Humans are, however, not only neuronal but political as well.(14) With mental illness increasingly being used as a means of social control (as the ethnographic evidence outlined above suggests), it is imperative that we ensure that the disenfranchised receive cognitive justice, which would involve explicitly underscoring that an unjust social order contributes to neuropsychological conditions. I offer this criticism not to invalidate advancements made in biomedicine, but more to highlight the kinds of cognitive injustice perpetrated in the name of “development”. A more compassionate analysis of mental illness, therefore – while remaining wary of certain constructions of health and personhood – is perhaps the way forward for how we categorize, diagnose and treat mental illness.
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“Fetishization of productivity, and how it dictates notions of normalcy and deviance, has vastly benefited the pharmaceutical industry”
References
(1) Sadath, A., Kumar, S., Jose, K., & Ragesh, G. (2019). Mental health and psychosocial support program for people of tribal origin in Wayanad: Institute of Mental Health and Neurosciences model. Indian Journal of Social Psychiatry, 35(4), 224.
[2] Sadath, A., Uthaman, S. P., & Kumar, T. S. (2018). Mental health in tribes: A case report. Indian Journal of Social Psychiatry, 34(2), 187.
[3] Kottai, SR. (2018). How Kerala's poor tribals are being branded as' mentally ill. Economic and political weekly, 29(13), 11117-11123.
[4] Baru, R. V., & Mohan, M. (2018). Globalisation and neoliberalism as structural drivers of health inequities. Health research policy and systems, 16(1), 91.
[5] Esposito, L., & Perez, F. M. (2014). Neoliberalism and the commodification of mental health. Humanity & Society, 38(4), 414-442.
[6] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
[7] Esposito, L., & Perez, F. M. (2014). Neoliberalism and the commodification of mental health. Humanity & Society, 38(4), 414-442.
[8] Kottai, SR. (2018). How Kerala's poor tribals are being branded as' mentally ill. Economic and political weekly, 29(13), 11117-11123.
[9] Kottai, SR. (2018). How Kerala's poor tribals are being branded as' mentally ill. Economic and political weekly, 29(13), 11117-11123.
[10] Baru, R. V., & Mohan, M. (2018). Globalisation and neoliberalism as structural drivers of health inequities. Health research policy and systems, 16(1), 91.
[11] Carr, E. S. (2010). Scripting addiction: The politics of therapeutic talk and American sobriety. Princeton University Press.
[12] Bhatia, S., & Priya, K. R. (2018). Decolonizing culture: Euro-American psychology and the shaping of neoliberal selves in India. Theory & Psychology, 28(5), 645-668.
[13] Kottai, SR. (2018). How Kerala's poor tribals are being branded as' mentally ill. Economic and political weekly, 29(13), 11117-11123.
[14] Malabou, C. (2009). What should we do with our brain?. Fordham Univ Press.