“What do I know?” Scholastic fallacies and pragmatic religiosity in mental health-seeking behaviour in India

Abstract

This paper draws on ethnographic fieldwork on psychiatrists and their patients (their care-givers and their communities) in North India. It addresses the questions as to when and why people approach psychiatrists and religious healers by arguing that approaches assessing “explanatory models” and other knowledge structures relevant to the people's health-seeking behaviour should place more emphasis on the people's strong desire to get well, in any way possible. Secondly, the difference between beliefs rooted in the patients’ life-worlds and explanations suggested to them by experts has to be acknowledged. These insights motivate a shift away from the concept “religion” towards the differentiation between pragmatic and scholastic religiosities. This argument relates back to the Greek meaning of “pragma” understood by Hans-Georg Gadamer as “that within which we are entangled in the praxis of living”.

Keywords:

• mental health
• health-seeking behaviour
• India
• psychiatry
• religion
• religiosity
• explanatory model

Acknowledgements

The work on this article was kindly supported by the Cluster of Excellence “Asia and Europe in a Global Context: Shifting Asymmetries in Cultural Flows” at Heidelberg University and a generous stipend by the Fritz Thyssen Foundation. The article was completed while working as a post-doctoral research fellow at the Division of Social and Transcultural Psychiatry at McGill University. Previous versions were presented at the Cluster's Annual Conference “Frontiers of Knowledge: Health, Environment and the History of Science”, the anthropological research colloquium at the University of Luzern, the Annual Conference of the American Association of Religion (AAR) in San Francisco, and the research colloquium of the Division of Social and Transcultural Psychiatry at McGill University. The extremely helpful and friendly discussions there are greatly appreciated. Special thanks go to Don Gardner and Alberto Sanches, and to Nabil Ahmed for proof-reading the English.

Notes

Notes

This article primarily draws on an ethnographic study conducted over nine months in the psychiatric wing of an urban hospital in North India in 2010. The overall question underlying the research concerns the role of religion within mental healthcare in India, as perceived by psychiatrists, patients, and care-givers. Besides participant observation, 93 self-designed questionnaires were jointly filled with the patients and 68 semi-structured narrative interviews were conducted in Hindi by the author (in many cases accompanied by a resident doctor). In all cases written informed consent was given. The author further draws on research on traditional as well as institutionalised mental healthcare in India since 2005. This includes visits to different mental healthcare sites such as Balaji Temple (Mehandipur), the Vineyard Workers’ Church (Pune), the Mirawali Dargah (Ahmednagar), Mahanubhav Temple (Phaltan), Farshiwale Baba (Nasik), and Mira Datar Dargah (Palanur), interviews of patients, healers, psychiatrists, mental-health activists, representatives of NGOs and self-help groups in Maharashtra and Delhi, as well as extensive research on the criticism of religious healing practices in public discourse.

Since the fieldwork was based primarily in a hospital the people are referred to as “patients”.

“Folk” is thereby used as an umbrella term for a set of quite heterogeneous practices. The places where they are applied are often referred to in the literature as Traditional Healing Centres (THCs), a term which includes private homes as well as the public treatment centres of healers, astrologers, tantriks, and oracles; or religious specialists practicing at Hindu temples, Muslim dargahs, and Christian churches. The notion “folk” in this respect was made popular by the work of Kleinman. He differentiates between three overlapping parts within a (local) health care system: the popular, the professional and folk sector. The folk sector consists, in his scheme, of non-professional, non-bureaucratic specialists whose knowledge is usually passed down orally from healer to healer often through family tradition (see Kleinman, 1980, p. 59).

The borders between these realms are fuzzy given that there are practitioners who combine and fuse different therapeutic approaches (see Connor & Samuel, 2001). The crucial role of the families providing the large majority of daily care is unfortunately widely ignored.

It is important to add that the concept of mental health is not regularly applied in the folk sector. Representatives of the folk sector also deal with financial problems, runaway children, runs of bad luck, family problems, and so forth. Elsewhere it has been argued that it would be as wrong to reduce all the practices within the folk sector to mental healthcare, as it would be to ignore their important contributions to mental healthcare in India (Quack, in press).

Furthermore, there are the Short Explanatory Model Interview (Lloyd et al., 1998), the Mental Distress Explanatory Model Questionnaire (Eisenbruch, 1990), and the Barts Explanatory Model Inventory (Bhui, Rüdell, & Priebe 2006). For applications of these research tools in India see Banerjee & Banerjee, 1995, p. 219; see also Campion & Bhugra, 1997; Banerjee & Roy, 1998; Nieuwsma, Pepper, Maack, & Birginheir, 2011; Paralikar et al., 2011. Religious explanations might refer to Karma; bad or prior deeds or parent's deeds; the will of God(s); fate; deities and demons; the evil eye; astrological factors; spiritual deficits; sorcery; or other supernatural factors (see Nieuwsma et al., 2011, p. 549).

For the most thorough analysis to date see Skorupski (1976).

“Dusting” (jhāṛna or jhāṛ-fuk) refers to a practice where an affliction is swept out of the body with a broom; it is often used as an umbrella-term for all kinds of healing rituals.

Further factors to be listed are approachability and reputation of the expert, social norms and social relationships, potential social consequences and stigma, and further behavioural patterns and habits prevalent in the respective community. The way in which experts interacted with the patients was also crucial. If one doctor was considered to be incompetent (e.g. because he adjusted the medicine too often, or if the prescribed medicine was considered too expensive) patients would consider stopping the medication and/or going somewhere else.

It can be hypothesised that different kinds and degrees of desire are connected to the length and severity of the problems. In the case of Mrs Rawat and her father, after 15 years in search of help, their desire for improvement oscillated between hope and despair.

Statements like “What do I know” are often rhetorical parentheses with no further meaning. But in the cases presented here the point was clearly to express indetermination and nescience on the one side and a description of the scope of the health-seeking attempts on the other.

Talking about half understood-beliefs might sound problematic to those acquainted with the criticisms of the use of the notion “belief” in anthropology in general, and medical anthropology in particular (Good, 2001, pp. 20–21). The apparently knowing anthropologist ascribes half-understood beliefs to the believing object. But Sperber's point is quite the opposite. First, his paradigmatic example of half-understood reflective beliefs is taken from Christianity: the dogma of the Holy Trinity. Second, his argument necessarily implies that many (reflective) beliefs in the realm of science are only partially understood by scientists themselves. The author, for example, believes that nuclear fission is a way to generate a tremendous amount of energy, but definitely does not have a full grasp of the way it works. He cannot think with atoms, neutrons and photons the way the experts can. Nevertheless, he thinks about nuclear fission a lot. He even protests against nuclear reactors, because he considers those experts who consider this method of generating energy as dangerous to be more trustworthy, compared to those who do endorse nuclear energy.

In a comparable context Kalpana Ram speaks of “pre-familiarity” with respect to Siddha and Ayurvedic paradigms, that does “not depend on the capacity of villagers to exhibit the same kind of knowledge as the intellectual specialists of Siddha or Ayurvedic medicine” (2010, p. 203).

The mode of religiosity can hereby change over time. One father was initially indifferent to diverse ways of explaining and treating his son's problems, but the great the number of experts they had consulted without success over the years, the more convinced he became that the problem was such that it exceeded the limited reach of doctors.

“[D]as, worein man in der Praxis des Lebens verwickelt ist, […] worin man sich bewegt und womit man es zu tun hat. Das ist eine Orientierung, die in der modernen, durch die Wissenschaften strukturierten Weltbemächtigungen und in der auf sie gegründeten Technik an den Rand gedrängt ist” (Gadamer, 1985, p. 6).

To paraphrase a section from Bourdieu by replacing the word “school” with “mental health”: The sociologist can easily forget the gap that separates the interest that he may have in the mental health [school] system as a scholar who simply wants to understand and to explain, and that consequently leads him to set a ‘pure’ gaze on the functioning of the mechanisms of differential elimination according to cultural capital, and the interest that he has in this same system when he acts as a father concerned with the future of his children (1990, p. 383).

Ram criticises a focus on pragmatism that suggests that the lay subject has available, as if displayed in front of her, all the branches and varieties of medicine from which to choose. “Informed by a strategic consciousness, and with perfect awareness, the lay subject proceeds to put together a package of curative possibilities” (2010, p. 202). Obviously, neither the notion of pragmatic religiosity nor Bourdieu's logic of practice implies such an idea.