Indianizing Psychiatry - Has the Case Been Made Enough?

Abstract

Byline: Anindya. Das, Urvashi. Rautela Sir, We congratulate Professor Avasthi (2011) [sup][1] on his award paper published in the Journal of Psychiatry (Vol.53, pp.111-120) for a fresh look on the importance of culture in psychiatry and its practice in India. He has pointed out the uniqueness of the discipline; the distinctiveness of psyche; the ill-fitted-ness of Western described clinical syndromes in India; cites certain biological differences implicating mental health of Indians; and discusses various other issues related to service provision and treatment. To us, the paper brings out the importance of culture in psychiatry but its arguments are weak. Such as the case for uniqueness of the discipline, Avasthi argue that similar chronic incurable physical conditions (such as diabetes) have vast differences in terms of diagnostic uniformity and treatment. Yet, we know the assumed diagnostic uniformity in chronic physical disorders often do not reflect as uniformity of practice (in diagnosis and more often in treatment) in widely different cultures, social settings, over different time periods, and in different health systems. On the other hand, expert-driven diagnostic (and management) uniformity is also a truth for psychiatric problems. Similarly, Avasthi constructs the psyche as fragmented, multifaceted due to and [sup][2] brought about by the onslaught of British colonialism. But the discipline of discursive psychology shows these processes to be universal. In fact, it particularly focuses on how identity, subjectivity, and agency are constructed within available personal, familial, social, and cultural discourse, opening up various interpretive repertoires making way for a socially emergent self. [sup][3] Thus, we see compartmentalized and often mutually contradictory ways of dealing with various social and personal situations that define self and identity. Moreover, the distinctive Indian influence on compartmentalization and contextualization is not just colonialism, traditional values, and modern ways of life but institutional structures, networks, and social movements. [sup][4] Thus, issues of social position/hierarchy, class relations, caste dimensions, religious affiliation, and the political trends of the time needs to be considered to understand the influence of culture on psyche and collective identity. On the other hand, Avasthi rightly points out the incongruence in Western diagnostic systems and ways of manifesting psychological distress, described as category fallacy. [sup][5] But it confuses us who does the author imply to wield the power to characterize problems. Kirmayer (2006) [sup][6] warns that the ways, by which psychological decompensation is defined, needs evaluation within the context of global systems of knowledge generation and power. Thus, psychiatrists talk about validating (Western) diagnostic systems. Avasthi also notes people's preference for folk medicine to be partly traditionally inspired and partly due to the lack of availability/affordability of health services. We would in addition like to impress on the cultural incongruence of mental health services as a vital reason for this. [sup][7],[8] In addition, the consideration of Indianization of psychotherapeutic practice lacks consideration for the need to understand how the culture perpetuates certain power differentials between the client and the healer (of biomedical kind or otherwise). Culturally appropriate forms of healing (e.g., faith healing, shrine healing, etc.), and their dynamics in terms of power differentials, meaning generation, family role, and manipulation of psyche need consideration for the above task. …