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New Systems and the Globalization of Asian Norms

The Japanese and British Indian political projects of the mid-nineteenth century, which had underpinned far-reaching debates about the mind, culture, and mental health, soured by the late 1940s: British power in India collapsed and Japan’s new state drove its people to all-out war and defeat. A fresh, internationalist tone was now set in both countries: Jawaharlal Nehru’s India as a forward- and outward-looking secular democracy and Japan-during and after the American occupation (1945-1952)-a beacon of peaceful economic development in Asia.

And yet at least two legacies of the previous era lived on: a relative lack of funding, consensus, and political will when it came to mental healthcare provision, and broad-based cultural nationalisms which, operating alongside various subnational identities from region to religion, continued to inform popular perceptions about the appropriateness or otherwise of mental health practices and goals rooted in Western science and medicine. Yet while there has been ambivalence about the implications for individuals and communities of biomedical psychiatric categories and treatments, especially when tied to neo-liberal ideologies of development, doubts have been raised too about the accuracy and usefulness of essentialist speculation over a purported ‘Indian psyche’ or ‘Japanese psyche’—a combined result of old Western fantasies about the ‘East’ and the eagerness of some Asian nationalists to play up to these (or create their own) as a means of achieving differentiation and political agency. A final feature of the post-1940s world has been a series of successful Asian cultural contributions to Global Mental Health: yoga and Transcendental Meditation from India; Zen, and Morita and Naikan therapies from Japan.

It had been the repeated claim of Indian nationalists that once the British were gone, India would act fast to undo long decades of underinvestment and inequality—and indeed the Indian National Congress, which succeeded to power in 1947, had been making arrangements for this since the 1930s. In the field of medicine and mental health, remarkable individuals like the psychiatrist J.E. Dhunjibhoy, Superintendent of Ranchi Indian Mental Hospital, had been blazing a trail by trialling the latest treatments developed internationally in his own institution (Ernst 2013). More broadly, useful ground was laid during the last days of colonialism by a Committee headed by an Indian Civil Service Officer named Sir Joseph Bhore, whose illustrious members were commissioned to look into the future of healthcare in India. The Bhore Committee stressed the urgent need to consider public health policy and provision in the context of problems of poverty, unemployment, housing and social welfare, and drastically to upgrade medical education in India. A further impetus came three years later, on the eve of Independence, with a government survey that found there to be no more than 10,000 psychiatric beds for 400 million people: a ratio of one bed per 40,000 people, compared with one for every 300 in England at the time. Most of India’s mental health institutions, with the exception of Ranchi and Mysore, were deemed out of date and oriented still towards custody rather than cure or care. Many superintendents and most staff still had no psychiatric training whatsoever, and the Punjab Mental Hospital in Lahore was said to be worse than most Indian jails (Taylor 1946). The report recommended better training, promotion of occupational therapies, separate child psychiatry units, and closer relationships with the community (Krishnamurthy et al. 2000).

And yet the Bhore Committee was largely forgotten after Independence. Indian healthcare developed along a privatized rather than a universal, socialized model, with the psychopharmacology revolution of the 1950s seen as largely obviating the need for small community-based institutions. The 1912 Indian Lunacy Act was not updated until 1987, when a new law provided for, among other things, more progressive definitions and treatment of mental illness (with an emphasis upon treatment rather than custody), new national and state mental health authorities to oversee the work of psychiatric hospitals, and the protection of the human rights of persons with mental illness (PMI) (Narayan and Shikha 2013). A new Act in 2014 updates this with significant fresh provisions, ranging from the decriminalization of suicide to the establishment of a Mental Health Review Commission to review all hospital admissions that go on past 30 days. Patients have the right to appeal doctors’ decisions to the Commission; psychosurgery is restricted and electroconvulsive therapy (ECT) without anaesthesia banned; unlicensed establishments are to be clamped down upon; and patients are to be given the opportunity to make an advance directive, indicating preferences for future treatment should they become unable to make such decisions, in addition to the right to nominate a representative for such circumstances.

Although India’s national legislative framework has been slow to evolve, and socialized community care remains patchy across the subcontinent, institutions have been established to promote advanced research and the trialling of new forms of mental healthcare. This has been most notably the case with the

All-India Institute of Mental Health (established in 1954), which took as its motto a phrase from the Bhagavad Gita—‘Equanimity is the goal of all existence’—and which later became the National Institute for Mental Health and Neurosciences (NIMHANS) based in Bangalore. NIMHANS has contributed towards a series of District and National Mental Health Programmes (NMHP) since the 1980s, aimed at decentralizing and demystifying mental healthcare— in part through specialist psychiatric training given to primary health workers.

Critics have charged, however, that the new NMHP in 2002 moved away from the promotion of service access and community participation in favour of psychotropic medication (with a budget of some US$345 million). Sumeet Jain and Sushrut Jadhav worry that ‘the pill ends up standing in for the entire mental health policy’, with rural mental health teams in particular lacking the time and training for narrative engagement with patients while patients themselves accept the pill in lieu of understanding or contextualization—and go elsewhere, to folk or faith healers, for these latter things (Jain and Jadhav 2009). In addition, health insurance coverage for mental illness is poor; people suffering from mental illness continue to be referred to in Hindi as pagal—‘crazy’—and the psychiatric profession is small and generally not well respected (it was recently claimed that there are as many cardiologists in Mumbai alone as there are psychiatrists in the whole of India [Sen 2014]). NGOs have joined the private entrepreneurs, philanthropists, and missionaries of pre- and early post-Independence India in seeking to make up for failures of political will and funding: the Schizophrenia Research Foundation and the T.T. Ranaganathan Research Foundation (substance abuse) operate in Chennai, the Richmond Fellowship Society in Delhi and Bangalore, and the Alzheimer’s and Related Disorders Society of India (ARDSI) in Kerala.

A crucial legacy of the late nineteenth and early twentieth centuries is the debate over how mental health relates to culture. Psychotherapy has been a major battleground here, with maverick transcultural psychiatrists such as N.C. Surya deriding a deracinated Indian medical profession [in which he included himself, as someone born in British India who studied extensively in the United Kingdom (Wig 1996)] and calling for forms of therapy that resonate with the aspirations of ordinary Indians. This has led psychiatrists, including Jaswant Singh Neki, R.A. Venkoba, and C. Shamasundar (see above), to seek truly ‘Indian’ psychotherapeutic paradigms in Indian philosophy and religion (Venkoba and Parvathi 1974; Shamasundar 1979) and in features of family and social life that are seen as marking India out from Western societies. A greater degree of dependence upon family, to an extent that in some Western contexts might be considered grounds for therapeutic intervention (Wig 1996), has been noted as a particular feature of the

Indian context, and a series of Indian psychiatrists have pioneered family- based therapies, which some have claimed as India’s distinct contribution to global psychiatry (Murthy 2010; Harding 2011). It could be argued that such therapies possess deep moral importance since they recognize and respect (by drawing inspiration from) the role of families as primary carers for mentally ill people throughout much of India’s history. Two further oft-cited examples are a less pronounced focus in India, compared with Western societies, upon individual autonomy (as opposed to a healthy level of dependence) and the relative uselessness of libidinal theories (see Chatterjee et al. forthcoming). In addition, Surya suggested that Hindu teaching prizes a certain degree of ‘dissociation’ (in opposition to Western integrative goals): ‘one is encouraged to be first a non-participant ‘witness’ of one’s own actions, before corrections can occur’ (Wig 1996).

One should be extremely wary of talk of an ‘Indian psyche’ in all of this, and Sudhir Kakar, among others, has pointed to the nonsensical nature of such an idea amidst the diversity of the subcontinent (Kakar 1993). But Indian debates over culture and mental health do reveal three important things about the subcontinent’s experience of the globalization of mental health ideas. First, influential members of the Indian psychiatric profession have followed on from the likes of Girindrasekhar Bose in questioning the purported universalism or global nature of psychiatric and psychotherapeutic modalities emerging from Western contexts—and they have done so through a powerful combination of philosophical, epidemiological, and clinical approaches. Secondly, however, there is a danger that the creation and advertising of ‘Indian’ psychotherapies ends up involving mental health professionals in long-running ideological and political battles over what constitutes mainstream Indian culture. The attention paid to the Bhagavad Gita and the characters of the Ramayana may seem reasonable to non-Indians, but within India, these choices imply an identification of Indianness with Hindu culture that many minority groups, from Muslims to Christians to Dalits (former ‘untouchables’), would strenuously contest. Thirdly, there is the further danger of allowing cultural accounts of mental illness and healing to get out of proportion or to distract attention away from much-needed analysis of how social and economic factors contribute towards mental ill health. This last danger is of course latent in both cultural psychology and transcultural psychiatry on the one hand, and in too narrow a policy focus on psychopharmaceuticals on the other.

A second area of controversy in India’s postcolonial relationship with the West has been the power exerted by the World Health Organization (WHO). Some have seen the WHO’s prominence in Indian policymaking as a form of neocolonialism, but others have noted the influential presence of Indian psychiatrists within the WHO and the generous funding—in the 1970s, at least—that it provided to India. In recent years, the WHO Mental Health Gap Action Programme (mhGAP) and the Movement for Global Mental Health have come in for cautious treatment by experts on low- and middle-income countries (LMICs) contexts, who welcome the involvement of social scientists but ask that the rhetoric of non-specialist and community i nvolvement in providing mental healthcare, which is a part of these programmes, be extended beyond making them ‘handmaidens of bio-medical expertise’ and instead sources of original and valuable insight. Biomedical intervention may in many contexts be a necessary and helpful first response, but over time the approach needs to become more complex (see Campbell and Burgess 2012).

Mental health in Japan was more successfully restructured in the late 1940s and 1950s than was the case in India. An American turn, under the Occupation, saw an influx of American psychology and Rogerian psychotherapy (Carl Rogers visited Japan in 1960), together with a push—launched through a new Mental Hygiene Law in 1950—for the building of the long- promised network of psychiatric hospitals across the country. Conditions in these hospitals were soon rumoured to be poor, however, with privately run institutions in particular accused of failing to put patients’ interests at the heart of their work. Moves towards community care were slowed by an attack on the American ambassador by a disturbed teenager just as a new mental health law was being considered in the mid-1960s, but there has been change nevertheless, thanks in large part to the efforts of a generation of psychiatrists who trained during the heyday of the anti-psychiatry and transcultural psychiatry movements in the 1960s and 1970s (Kitanaka 2011).

Notable contributions to Global Mental Health have emerged from critical thinking in Japan about the particular ideals of ‘self’ that seem to inform the assumptions of Western mental healthcare—in particular, a rich tradition of writing, dating back to the 1950s, located at the intersection of psychiatry, social psychology, and social and cultural criticism. The doyen of this kind of writing was Takeo Doi, a student of Kosawa who ended up equally critical of his master’s Buddhistic maternalism and the emotional frigidity of 1950s American psychoanalysis (Borovoy 2012; Harding 2014a, b). Doi offered his amae theory—which refers to a tendency to ingratiate or to presume upon the affection of others, and which rapidly became a staple of both Japanese and Western commentary on a purported Japanese cultural psychology (Borovoy 2012; Dale 1986; Ando 2014)—as a gift to the world: a tendency not unique to Japan, but one that was out in the open there, whereas it was generally repressed to an unhealthy extent in Western cultures.

Amae was just one of a number of self-conscious ‘gifts to the world’ from Japanese psy professionals from the 1950s onwards, drawn from Japanese religious traditions and from forms of human family and social life allegedly effaced by Western individualism (and/or, depending on your politics, Western-style capitalism) but surviving more or less intact in Japan. To their critics, such claims were no more than spurious attempts to rebuild in the language of ‘psy’ and mental health the pride and sense of national purpose of which Japan had been robbed by defeat in 1945. And indeed, nihonjinron— theories about the Japanese people—have frequently appeared in right-wing discourses that are less than flattering about the West and about other parts of Asia. These theories flourished for a couple of decades after the Japanese economy began to boom in the mid-1960s—the country’s apparently miraculous rebirth symbolized by a successful Olympics hosted in Tokyo in 1964 and the advent of the impossibly modern ‘shinkansen’ bullet trains the same year— and live on now as ‘common sense’ sociological generalizations in much of Japan’s mainstream media. And though writings in this vein have been out of favour in recent years, related ideas have lived on through their embodiment in psychotherapeutic and quasi-psychotherapeutic practices: modern Zen (and specifically the practice of zazen, or seated meditation), and Morita and Naikan therapies.

We may deal with Zen relatively briefly, since it is not explicitly a mental health practice in the way that Morita and Naikan are. Suffice it to say that the modern, lay practice of Zen is largely a creation of the newly instrumental view of Japanese religious traditions encouraged by the likes of Enryo Inoue. As Janine Sawada has shown, there had long been a discourse of selfcultivation in Japan, of which the practice of zazen was a part, but it was in the late nineteenth and early twentieth centuries that Zen became increasingly the property of lay—that is to say non-monastic—practitioners, who supplied much-needed funds to Buddhist temples in exchange for what was in effect the consultation services of trained monks (Sawada 2014). Although there is much argument about the extent to which the varieties of Zen that are practised globally—and especially in the United States—are ‘authentic’ continuations of Japanese traditions, there can be little doubt about the influence here upon Global Mental Health discourse of an Asian ‘norm’: the powerful emotional and psychological benefits—perhaps even the moral or philosophical imperative—of a quiet, disciplined witnessing of one’s own mental activity, together with the implied insights about the ultimate sources of internal suffering and the nature of the (no)self (Sharf 1995; Safran 2003).

Morita therapy, pioneered before the Second World War by the psychiatrist Shoma Morita, drew heavily on Zen for inspiration—alongside Morita’s highly individual critique of Western psychotherapies (including psychoanalysis, for whose extravagant theories and risible cure rate Morita had only contempt), and his experiences with anxiety. At the core of the therapy is the idea that humans have a natural disposition towards neurosis, and we try to cope with it on the basis of a mistaken dualism that insists one part of the mind is largely able to control the other. Peace lies in relinquishing this mistaken idea, and learning instead to live with reality as it is—as it comes to us (aru- gamama). Morita therapy was self-consciously a product of its period in the 1920s—advertised as a method of healing at once rooted in Japanese culture and yet perfectly in line with scientific theories about the mind (or at least those with which Morita was prepared to agree). It then went on to resonate with a post-war Western generation for whom, although talking therapies were acknowledged to work in many cases, constantly returning to painful ideas could often be counterproductive. Among those in the West to take an interest in Morita therapy was the pioneering psychoanalyst Karen Horney, who travelled to Japan not long before her death in 1952, and the therapy has gone on to be influential in the United States and elsewhere both in its own right and as a reference point for advocates of so-called quiet therapies in general seeking to make their case (Reynolds 1989).

Naikan therapy was mostly developed after the war, as its founder, Ishin Yoshimoto, took steps to secularize an ascetic Buddhist practice known as mishirabe (searching oneself) by turning it from a days-long solitary ordeal without food or water to a week’s residential therapy in which periods of solitude are interspersed with interviews conducted by ‘Naikan guides’. As with Morita therapy, Naikan represents a contribution to Global Mental Health ideas of a practice that is Asian in two senses: drawing from centuries-old Buddhist insights into the workings of the mind, and at the same time iden- tifiably a product of Asian modernization dilemmas from the late nineteenth century onwards (Kondo and Kitanishi 2014).

 
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