ISSN (Print) - 0012-9976 | ISSN (Online) - 2349-8846
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Migrant Workers and the Politics of Mental Health

Sudarshan R Kottai (la14resch11003@iith.ac.in) teaches at the department of psychology, Jain University, Bengaluru.

The roping in of tertiary care mental health institutes by the government in providing individualised (tele) counselling services to migrant workers needs to be viewed with caution. Instead of acting as a catalyst in upholding the dignity and human rights of migrant daily wage workers who were left high and dry, mental health practice, shaped by political and institutional influences, provided “counselling” to lakhs of people who bore the brunt of governmental apathy during the pandemic crisis.

The nation may be great, but our lives are miserable.

The wicked disease struck us and wrecked our lives.

What life is this, what life is this?

A wretched life, a pathetic life, an abject life, a broken life.

Is there a disease worse than poverty?

Is there a solace greater than being with one’s family?

Aadesh Ravi1 on the migrant workers’ crisis

The COVID-19 pandemic unwrapped the social stratification entrenched in Indian society as the marginalised sections became a target of violence and state dispossession. The obsession with caste/race superiority, communal/class consciousness and xenophobic tendencies came to light as Dalits, minority religious groups, people from the north-eastern states and migrant daily wage labourers across India faced discrimination and exclusion. The spread of the pandemic aggravated the segregation that lower caste groups were facing (Venkataraman 2020). The Yanadi community of Andhra Pradesh that has been forced to engage in “filthy” jobs, such as waste picking and drain cleaning for centuries were barred from venturing outside by the dominant caste groups after the pandemic outbreak (Sur 2020).

A Dalit family in Haryana was attacked for not adhering to Prime Minister’s call to turn off lights (Ekta 2020; Scroll.in 2020). Reports about racial discrimination against citizens from the north-eastern parts of the country resurfaced during the pandemic (Bordoloi 2020; Offbeat CCU 2020). The abrupt stoppage of public transport left migrant workers completely helpless since they had lost their daily wage jobs during this period. The crisis worsened as governments failed to provide food, shelter or means of transport to those who could not afford to pay rent. Then began the long march on foot, cycles and trucks to their homes thousands of kilometres away killing many en-route.2 Ramachandra Guha observed that this was the greatest human-made tragedy since independence and which could have been easily averted (Hindu 2020). While the policy framework of the union government was oblivious of the lifeworld of the migrant workers, it was at the forefront in responding to the privileged class stranded in COVID-19 affected countries, including China.

The reason for the untold sufferings of these migrant workers3 and the very poor is clear: the state failed to chart out a plan concerning daily wage labourers across the country, denying them “cognitive justice” (Visvanathan 1997).

Politics of Psychiatry

Psychiatry has often been employed as a political tool to support destructive regimes and reinforce social control. Several psychiatrists have employed bogus diagnoses to punish enemies of the state exposing the dark side of psychiatry (Lifton 1986; Luty 2014). Metzl (2011) narrates the compelling story of the politics of psychiatric diagnosis; how racism was written into the diagnostic language; and the processes through which American society equates race with insanity. Medical journals describe a condition called dysaesthesia aethiopis as a form of madness manifested by “rascality” and “disrespect for the master’s property” that was believed to be cured by extensive whipping.

Psychiatry under the Influence: Institutional Corruption, Social Injury, and Prescriptions for Reform showcases psychiatry as a case of institutional corruption given the political and economic influences in its theory and praxis (Whitaker and Lisa 2015). Cracked: Why Psychiatry Is Doing More Harm Than Good by Davies James (2013) is a compilation of evidence against psychiatry’s claim to be an objective science that is value-neutral and apolitical. Cultural contexts and political struggles are left in the dark in this pursuit of techno-psychiatry resulting in an imbalance in knowledge. Aware of this, Lewis (2006) proposes post psychiatry, an alternative vision bringing the two sides together.

The heinous murder of George Floyd in the United States in May 2020 led to the Black Psychiatrists of America, issuing a press statement urging the government to declare racism as a public health problem. The press statement ends with the evolution and purpose of this organisation.

Fifty-one years ago, the Black Psychiatrists of America was founded in response to the failed response from the European model psychiatric system in America, to fight against racism, marginalization and other forms of racial discri­mination against Black people. We will continue to fight for an end to these acts of racism that threaten the health of our community and all other areas of life for Blacks in America. (Howard 2020)

The book Institutional Racism in Psychiatry and Clinical Psychology: Race Matters in Mental Health calls for a model shift in both theory and practice of clinical psychology and psychiatry infected with deep racism (Fernando 2017). Mainstream psychiatry and a majority of psychiatrists equate the mind with the brain and invent fake diagnoses, theories and cures resulting in the indiscriminate prescription of psychotropic medicines. Such dehumanising conduct of psychiatric “science” has led to a situation where it is the only medical discipline against which user-survivor movements are in place (The Cape Town Declaration 2011).

There have been similar profound critiques of the practice of modern psychiatry in India in recent times. In her moving ethnography on suicide among transgender people, Rao (2012) showed how premier mental health institutions depoliticise suicide with substantial political, economic and gendered ramifications addressing it as just a mental health problem. “It [psychiatry] thus ‘depoliticises’ suicide by situating it within the realm of medical and psychiatric science, controls it through regulating access to substances and space” (Rao 2012: 10). Central to an ethnographic study of psychiatric practice in north India is how kinship aberrations of love, marriage and divorce are probed by psychiatrists with clinical attention to women. Emotions related to marriage and the scrutiny of moral boundaries of relationships become the ground for psychiatrists’ clinical efforts to “locate biological truth” (paranoia, schizophrenia) and assess illness, thereby reinstating patriarchal norms producing distress (Pinto 2011). Saiba Varma (2016) highlighted the contradictions within the National Mental Health Programme where psychiatrists support the generation of the specialist professional workforce through transforming mental hospitals into “centres of excellence” so that psychiatry is shored up as a modern, scientific discipline. Still, they opposed the other policy objective of de-professionalisation and task-shifting of psychiatric practice to non-specialists by questioning their ability to diagnose and treat mental disorders correctly, which, according to them is not easy even for psychiatrists with years of experience.

Although the [mental health] reforms were intended to address human rights and humanitarian concerns around asylums, these concerns were occluded by the desire to build specialized psychiatric manpower. (Varma 2016: 13)

The coalition of the state and psychiatry in framing non-heteronormative people as mentally ill is one of the most recent and much-criticised instances of mainstream psy disciplines acting as a political agent of the state (Kottai and Ranganathan 2019).

A whistle-blower government doctor in Andhra Pradesh who spoke openly about the shortage of personal protection equipment (PPEs) to treat COVID-19 patients was suspended and later committed to a mental health centre by the police when neither he nor his mother wished to be treated for an alleged mental disorder (Assuncao 2020). The visuals of the half-naked doctor being taken into custody with his hands tied with rope are symbolic of political abuse of psychiatry. There is a larger room for malpractice and manoeuvre in psychiatry as it lacks any objective laboratory test or clinical investigations for diagnosis. Keeping this in mind, when the inability to access psychiatric care itself is dubbed as human rights violation by popular (biomedical) discourse, grave psychiatric violations by dominant technocratic biopsychiatry are rarely brought to light. The knee-jerk response of mental health systems that provided “counselling” to the hunger-stricken migrants is yet another story of violence perpetuated by mainstream psy disciplines.4

Sugarcoating Suffering

The central government called upon centrally run mental health institutions to assist state governments in providing counselling to stranded migrant workers (Agarwal 2020; Dutta and Chandna 2020). These mental health institutions opened helpline numbers to address “mental health concerns.” The website5 of a central mental health institution read, “Wish to share any mental health concerns during this crisis of COVID-19 pandemic? Feel free to call our helpline….” (https://www.lgbrimh.gov.in/). Such notifications that keep flashing on the websites of the mental health institutions flag the reductionist approach to mental health as they remain silent about the grave human rights crisis that the vulnerable communities are facing. Mental health concerns are not to be resolved through counselling over telephone or distributing pills when people are being discriminated, physically assaulted, humiliated, denied food and shelter and left to die on the highways for mental health and human rights are co-constructed.

Concerns about hunger, concern to be with near and dear ones at home, pain of being not acknowledged as an equal citizen, violation of fundamental rights, the feeling that “We are not part of this country” also constitute mental health concerns that need be resolved through concrete political, community and systemic response. Addressing these issues of survival through pills and teletherapies almost always exhort the individual to adjust to an unjust system as the site of intervention remains the suffering person. Mental health professionals understate sociopolitical factors that cause mental health issues seldom speaking about it loudly and clearly. This paves the way to loosely execute armchair therapies without inviting the wrath of the power structures.

Writing in Nature on the mainstream global mental health response to COVID-19, including that of the World Health Organization guidelines, Rochelle Burgess presses the point that these individual-centric recommendations miss out on social realities and systemic vulnerabilities like poverty and inequality that contribute to poor mental health. “A woman who has lost her job and cannot feed her family will find little relief from a meditation app … Are mental-health campaigns arguing for better social protections so that unemployed people don’t fear death from starvation during lockdown?” (Burgess 2020). Scheper-Hughes’s (1992) research in drought-stricken villages of Brazil showed how hunger became so normalised that medicines began to replace food for the starving poor. A report by the United Nations special rapporteur on right to health presented evidence showing that social justice and quality of social relationships are the main determinants of mental health (UNHROHR 2019). Experiences of multiple discrimination put people at higher risk for mental health problems. Stefan Priebe, a psychiatrist, maintains that lack of political involvement has been a significant failure for the profession of psychiatry. He succinctly states that “political engagement appears a moral imperative for a credible profession with coherent values” (Priebe 2015).

My experience at two central government-run mental health institutions first as a trainee and later, as a clinical psychologist revealed the intense power play among the various stakeholders. These included psychologists, psychiatric social workers, psychiatric nurses and psychiatrists and the mental health professionals and “other” supporting staff and patients. The display of hierarchy was so intense that the greetings extended by the Class IV workers were not reciprocated by most of the clinicians even though they met each other at the workplace every day. This shows the lack of acknowledgement of the “other” based on one’s superior social status; a vivid case of erasure and violation of natural justice. This mimics what Harsh Mander (2015) refers to as “looking away” at both the state and individual levels. Lack of acknowledgement denies the existential rights of the staff and is a painful feeling that affects mental health. Are mental health professionals who maintain such an emotional (cultural) distance from their immediate “social” in their real lives equipped to tap the phenomenology of people living in different planes of consciousness, forget the migrant workers? The emphasis of mental health institutions on technobureaucracy over values, rights and political consciousness reflected in their curriculum, clinical training and practice boils down to offer a very narrow world view of persons as patients, distress as disorders and power imbalances as chemical imbalances.

I remember my clinical training days when I was eager to learn family therapy that was popularly the domain of the department of psychiatric social work. When I expressed my eagerness to my clinical psychology faculty, I was not allowed to reach out to them. My friends from psychiatric social work were denied permission to learn to conduct IQ (intelligence quotient) tests and the much-hyped Rorschach tests by the clinical psychology department. Some modules of the workshops were reserved to students of the hosting department so that other department students do not get the “secrets” of their popular therapies. While four of us were block-posted at a mental health institution, the reply to the request to clinical psychology faculty to allow us to sit for classes on psychotherapy was spontaneous but shocking: “Psychotherapy classes are only for our students.”

Sheer insularity among mainstream mental health institutions in opening up towards even their own fraternity is monumental evidence of parochialism towards “others” constricting a broader world view about the mind, mental health and different ways of being in the world. We also see a dearth of mainstream mental health professionals, including clinical psychologists and psychiatric social workers speaking about sociopolitical sufferings from a rights-based perspective even though a lot of prominent social scientists and activists have fervidly expressed concerns about the denial of natural justice to lakhs of migrant daily wage workers (Bhargava 2020a, 2020b; Baruah 2020; Nair 2020; Mander 2020; Stranded Worker’s Action Network 2020).

In contrast, mental health institutions and professionals have charitably gifted mental health helplines and free treatment to the migrant workers when children and pregnant women look forward to food and water, are thrashed by baton-wielding police personnel when they try to walk home and are humiliated in public by spraying disinfectants (Times of India 2020). Offering a corrective, Miraj Desai presses for a paradigm shift away from insularity towards travel and movement to the world outside the clinic that radically has an impact on the public mental health

to allow clinical psychology to better understand people’s lives in their communities, to more deeply perceive social structures, to help challenge the field’s theoretical and cultural presuppositions, to better engage diverse viewpoints, voices and practices that often get marginalised, and to more directly partner with those groups fighting for social change. (Desai 2018: 4)

Johnstone (2000) remarks that in the course of professional training of psychiatrists, common sense attempts to make sense of people and their distress are ignored as evidence-based medicine precludes such efforts. Limited or no exposure to social sciences and humanities and psychiatry’s shift towards the “neuro”—neuroanatomy, neurophysiology, neuropathology, neuropharmacology and genetics—makes the situation worse. In the age of “many psychiatries” where psychiatry is divided along various perspectives, ontologies and epistemological standpoints, a majority of mental health professionals who get trained in mainstream psychiatry largely appropriate the biomedical “ways of knowing” as a part of their strategy to stay within the prestigious camp of medicine (Rose 2018).

Mental Health Institutions

Mental health policy rhetoric of biopsycho­social model and intersectoral approach seldom gets translated into praxis. For a recent example, mental health institutions have failed to uphold its constitutional duty (primarily a moral obligation) to adhere to the Supreme Court’s order asking state parties to disseminate its landmark 2018 judgment on decriminalisation of same-sex love to create awareness on sexual diversities amongst the public. Mental health systems in India have not been able to come out with a single awareness campaign on lesbian, gay, bisexual, transgender, queer, intersexed and ally community (LGBTQIA+) issues when news of suicides on account of non-heteronormative sexual orientations keep coming in. A bisexual student’s
suicide (in Kerala) exposed yet another instance of notorious conversion therapies practised by mental health professionals to “treat” non-heteronormative sexualities (Desai 2020; Sharma 2020). The Analysis of the websites of three central mental health (academic) institutions (www.lgbrimh.gov.in, www.cipranchi.nic.in, www.nimhans.ac.in) suffices to signify how medicalised they are in their approach to mental health. Even the legislative provisions of various mental health-related affirmative laws (for example, the Mental Health Care Act, 2017, the Rights of Persons with Disabilities Act, 2016) and copies of judgments of the apex court which have immense social justice repercussions are not available for public dissemination on any one of these websites.

Mental health is thus transformed into an individual medical problem to be rectified by helpline numbers and psychopharmacological interventions divorcing them from oppressed people’s traumatic contexts. The National Institute of Mental Health and NeuroSciences (NIMHANS) guidance manual on mental health in the times of COVID-19 has comfortably transmogrified every aspect of COVID-19 beginning from quarantine to post-COVID-19 phase as a mental health crisis that needs to be rectified through individual counselling, and psychopharmaceuticals eclipsing the exterior aspects of human lives lived on the margins of the social (NIMHANS 2020). This narrow outlook overstates vulnerability in the vulnerability-stress model and reinforces the idea that adverse contexts are consequences and not causes (Boyle 2011, 2015). Scholars have expressed concerns at the increasing prescription of psychiatric drugs during COVID-19 for sadness and anxiety, which are natural and “normal” reactions to an unprecedented situation (McKinnell 2020; Serdarevic 2020). Researchers also contend that task-shifting has the danger of becoming merely task dumping of healthcare activities (Kohrt and Griffith 2015). Another reason why mental health is witnessing intense task-shifting may be attributed to the lack of objective medical investigations and struggle for explanatory power characteristic of psychiatric diagnostic categories. Research on task-shifting in Kerala has shown that it is a complex socio-politico-moral process that accelerates medicalisation and professionalisation of non-psychiatric professionals with fatal consequences for the most marginalised population (Kottai and Ranganathan 2020).

Avoiding Social Context

NIMHANS conveyed to the court that it provided “counselling” to 21,000 migrant workers in Karnataka (Chauhan 2020; Plumber 2020). This is a demonstration that intervention is being “done” by the state, which is quickly and easily materialised through knee-jerk tele-counselling to the most vulnerable and weak citizens. Will counselling restore/improve “mental health” when life itself is on the verge of total collapse? As Boyle poignantly puts it, such strategies to avoid social context “are actually ways of obscuring the operation of power and of protecting relatively powerful groups from scrutiny” (Boyle 2011: 39). This fear of social context, widespread among all mainstream psy disciplines, including psychiatric nursing, clinical psychology and psychiatric social work, is dangerous, for it does more harm than good for the most vulnerable people. Focus on the individual “creates a kind of institutionalised ignorance about how our social and personal contexts relate to how we feel, think and act” (Boyle 2013) that fails to locate “mental and emotional distress as a social justice issue” (Rimke 2016). Writing about child mortality, Mehdi (2019) argues in her book that child mortality, which is perceived widely as a biomedical issue, and vaccination being projected as its solution, is primarily a problem of justice and that a justice-oriented approach is vital for affirmative policies to check child mortality. Similar focus is essential in mental health systems to shape a humane discipline of psychiatry. Even though I do not deny the existence of extreme conditions where judicious interventions by sensitive mental health professionals may be helpful, it becomes imperative to respond systemically if the problem is systemic rather than “pathologising and treating everyday life” (Burstow et al 2014).

Should mental health professionals from tertiary care mental health institutions be roped in to provide “counselling” when we have a severe shortage of mental health professionals to take care of people with severe mental health issues? Criticisms were raised by NIMHANS alumni themselves against NIMHANS closing its door on patients for more than two months even after the lockdown was eased. Many poor patients had to rely on private hospitals for treatment (Rao 2020) as priority of NIMHANS shifted to providing counselling to lockdown citizens and migrant workers (Urs 2020). There is a need to reflect on the paradox inherent in this overstated approach to mental health during COVID-19 pandemic. At such a juncture, framing of COVID-19 as a significant mental health problem in need of mental health assistance opens up critical questions.

First and foremost, can we label the very disturbance, distress and disability caused by the pandemic as mental health problem? Is it ethical to deflect attention of the already scarce mental health professionals from people with severe mental health issues to COVID-19, which has turned out to be a human rights disaster for the most vulnerable? In this context, regular expression of sadness for living in such harsh environments get reconfigured as symptoms of mental illness to be treated by the globally dominant biomedical model (Mills 2015). Scholars have emphasised on the need for understanding distress in marginalised populations outside the medical framework and addressing its social determinants by employing a rights-based approach (Gikonyo 2014; Tribe 2014). Nikolas Rose argues prolifically that increasing mental disorders projected as “burden” in the global South has to do with high prevalence of social determinants of mental health related to neo-liberal capitalism. He asks prolifically:

[D]o the figures on the prevalence of mental distress, however it is organised, reflect the personal consequences of the “organisation of misery” that characterises the political management of so many societies in our contemporary world? (Rose 2018)

Roping in mental health institutions by the governments to provide “counselling” to migrant daily wage workers who have been the worst victims of state oppression illustrates the connivance
of psychiatry and state in ignoring a human rights crisis. Both psychiatry and the state happen to be in a win-win situation; psychiatry’s voice gets amplified, and the state’s oppression gets reconfigured as individual psychological problems to be cured by the “expert” mental health professionals. The Indian Association of Clinical Psychologists’ (IACP) Kerala chapter complained that school psychologists without an MPhil degree in clinical psychology and Rehabilitation Council of India (RCI) registration were providing psychosocial support for laypersons and people in quarantine. The state nodal officer of the mental health programme responded that it is the professional rivalry that instigates clinical psychologists to term government school counsellors with a postgraduate degree in psychology as unqualified to provide psychosocial support. The officer also clarified that as the programme is not intended for treatment of mental illness, it cannot be mandated to have clinical psychologists on board as hunger cannot be addressed by counselling. Psychosocial support is meant to identify those who require food, he explained (Manorama Lekhakan 2020). This exemplifies the urge of clinical psychologists who are in the lower hierarchy of mental health professionals to gain visibility and authority to “treat” everyday life hassles pitching a large tent of “patients” to be cured by their “expert” professional interventions.

Conclusions

The fundamental problem in the response of mental health systems to the COVID-19 pandemic crisis is the avoidance of the sociopolitical circumstance, which is at the core of suffering of the vulnerable sections. In this context, a more ecologically valid intervention is aggressively addressing the systemic failures other than framing the distress as “mental health concerns” in need of (tele)therapy and drugs. Either adjustment or maladjustment to injustice does not invalidate injustice. Maladjustment to injustice is a sign of resistance and agency. When the pandemic and an apathetic state combine to cause immense suffering to the most vulnerable citizens, psychiatry should not be allowed to distil that suffering into a simplistic psychiatric diagnostic category that is not as straightforward as a diagnosis of a broken bone.

The elitist mainstream mental health discourses have miserably failed to offer richness of rights-based language to account for the trauma suffered by the daily wage migrant workers. We did not see the flagship organisations of psychiatric social workers, psychologists, and psychiatrists voicing concerns or issuing a position statement over this human rights crisis when social scientists, lawyers and people across the spectrum of society converged to offer support to the workers demanding safe stay, food, accommodation and safe travel back home.6 By “making [their] world go away” (Boyle 2011), psychology, psychiatric social work and psychiatry have benefited in front-staging a “mental health crisis” that would cease to exist once they are provided justice and
human rights protection. The landmark book Compound Solutions: Pharmaceutical Alternatives for Global Health written in the context of tuberculosis argues that due to overwhelming population tuberculosis affects, pharmaceutical companies are not interested in developing better drugs for the deadly disease (Craddock 2017).

Taking this fast forward, avoiding social context and abstaining from political activism in the face of human suffering benefits the mental health industry in gaining visibility and market for “global monoculture of happiness” where people are urged to think that all social ills can be cured with pills and individualised psychological therapies (Ecks 2014). The inhibition to diagnose an unkind system is indicative of failure of “embodied interaffectivity” and “intercorporeality” (Fuchs 2017) and deficiency of political empathy; “empathy that joins with the individual and group based on social location and oppression” (Burstow 2003: 1310). A human science that does not address oppressive political structures while seeking to improve personal experiences amounts to extraordinary failure.

I invoke Gandhi’s Talisman (Tripathi 2020) to take a hard look at experience-distant mental health practices, for it is a call to bring the ethics question back into our mental health systems: Have counselling and psychopharmaceuticals helped the poorest of the poor, the starving daily wage workers? Until and unless mental health systems recognise the fact that mental health is not only about disordered individual minds and brains but also about disordered societies, they tend to put the psychological at the heart of the psychological. It is high time all of us urged the mental health systems to put the “political at the heart of the psychological and the psychological at the heart of the political” too (Good et al 2008: 2). It would go a long way in resisting the gravitational pull of psychiatry in defining and redefining political economy of hunger, homelessness and increasing inequalities to the extent of losing its sheer meaning (Mander 2012).

When diverse understandings of a complex human rights issue are replaced with a single story of mental health problem, it is vital to resist the psychiatric politics that executes psychiatric responses to systemic problems. Such a much-needed shift away from psychiatric forms of truth-telling and knowledge making about social suffering would also help us in ensuring facilities and medical care to those who are really in need of psychiatric services. Ultimately, human rights need to be invoked as an essential tool in the practice of mental health to enable reconstruction of people’s sufferings, which would pave the way in bridging the vast gulf between academia and activism.

Notes

1 The full song titled “The Long March of the Locked-down Migrants” can be accessed at People’s Archive of Rural India YouTube channel, https://www.youtube.com/watch?v=qQ5
ZrakzmIQ.

2 The state of Kerala is an exception as its response to the pandemic has been caring and inclusive of their guest workers. See Week (2020) and Jacob (2020).

3 I use “migrant workers” as employed in majoritarian public discourse. I prefer to refer to them as guest workers, a term coined by the Government of Kerala. See Bose (2020).

4 Psy disciplines including psychiatry are heterogeneous entities divided along various perspectives, ontologies and epistemological standpoints.

5 The exclusive tendency of these websites can be gauged by the fact that no information is given that caters to people with disabilities, for example, sign language.

6 On 9 June 2020, the Supreme Court instructed the governments to send migrants home within a span of 15 days and to drop cases filed against them for violating lockdown regulations under the Disaster Management Act, 2005. See Vaidyanathan and Varma (2020) and Talwar (2020).

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Updated On : 5th Aug, 2020

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