Chronic relationships and mental health care: global pharmaceuticals in a local healing shrine in India

Abstract

The paper explores how chronicities and chronic relationships are fostered at a state-sponsored community psychiatry clinic that has been affiliated with a Sufi shrine in western India. The clinic provides free psychotropic treatment to patients, most of whom are pilgrims visiting the shrine. While the clinic has been lauded for its collaborative approach of blending ‘medicine and prayer’ in the provision of mental health care, observations of clinical encounters reflect the prevalence of a strongly medicalized perspective of mental illness, where local narratives of distress are reframed as globalized categories of mental disorder, thereby permitting pharmacological intervention. Importantly, in a context where free medicines are offered just as other freebies are in development initiatives in India, this results in the creation of long-term, ‘chronic’ relationships with patients who only seem to return for medicines, never recovering. This paper illustrates how ‘chronicity’, in many ways, is built into the project from the beginning itself. It becomes evident in the assumptions of the officials and psychiatrists that mental illness is chronic, in the case files of patients that record their consultation and medication histories, and in the clinical conversations about the importance of compliance to treatment. Given that historically, community mental health emerged in the context of reducing long hospital stays and deinstitutionalizing mental health care, it is important to reflect on how these policies and practices result in the creation of a cadre of chronic out-patients.

Keywords:

• Chronicities
• ritual
• care
• pharmaceuticals
• somatization

Acknowledgments

The author would like to thank the reviewers for their careful reading of the manuscript and helpful comments which have strengthened the paper. All errors and omissions that remain are mine. This work was supported by the Wellcome trust [Grant number 096420/A/11/Z]. The author declares no conflict of interest.

Ethical approval

Ethical approval for the research was obtained from the Institutional Ethics Committee of IIT Hyderabad.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes

1 For a sampling of the MGMH literature, see Lancet Global Mental Health Group(2007); Patel et al. (2007); Kleinman (2009); Collins et al. (2011). See also vol. 378 of The Lancet, as well as the series on GMH in other journals: Transcultural Psychiatry, Vol. 49, nos. 3_4 (2012); and Harvard Review of Psychiatry, Vol. 20, no. 1 (2012).

2 One example is a document on the Government of India’s Ministry of Health and Family Welfare website, available on http://mohfw.nic.in/WriteReadData/l892s/9903463892NMHP%20detail.pdf.

3 In the Mira Datar dargah, for instance, one of the first steps of the program was to shut down the asylums attached to the dargah and ban certain practices in the shrine, such as the use of chains to prevent residents from running away. Sood (2016) has also similarly described several changes in the Balaji temple in Rajasthan, such as banning of practices regarded as ‘violent’ (e.g. chaining, placing heavy stones on one’s body, etc.) as well as stopping the practice of local healers within the temple premises.

4 Given that the Dava aur Dua program is very much in the public domain, I have retained the name of the organization, which figures in many media reports.

5 It must be evident by now that many of the patients at the clinic were women, and women were far more likely to be seen as ‘somatizing’. While it is not possible in this paper to delve into the gender dynamics that draw women to religious shrines, in other work, I have engaged with it (e.g. Ranganathan 2014; in 2016press) just as other scholars, too have (e.g. Bellamy 2011).

6 Nunley (1996) has argued that the overuse of pharmacology is related not to psychiatrists’ excessive workload but rather their need to legitimize their low-status profession for themselves and their colleagues and prove that psychiatry is also a medical practice. And one of the most concrete ways in which they feel they are ‘doing medicine’ is when they prescribe. Similarly, Luhrmann (2000) found that psychiatrists spoke about ‘using antipsychotics’ in the way a surgeon might use a scalpel to slice open a body and engage in surgical intervention.

7 Much more can be said about whether this ‘right to care’ for mental illness overrules the question of informed consent and justifies forced institutionalization and treatment. For a sample of the debate, see the articles on the Mental Healthcare Bill of 2010 in the Economic & Political Weekly by Davar (2012), Gopikumar and Parasuraman (2013), and Patel (2013).

8 Mujavers are the caretakers who look after the everyday maintenance of the dargah and carry out ritual practices. Some of them also oversee the management of the dargah trust.

9 See Shastri (2016) and Episode 5 (‘Nurturing mental health’) of the television program Satyameva Jayate where the Dava aur Dua project makes an appearance. http://www.satyamevjayate.in/nurturing-mental-health/episode-5watchvideo.aspx?uid=s3e5-ev-v1&lang=hindi