The National Institute for Mental Health and Neuro Sciences (NIMHANS) is the leading psychiatric and neurological clinical care center in India, and attracts more patients from across the county than any other such institution. But it was luck and serendipity that brought Andrew Willford there.

Willford, professor of anthropology in the College of Arts and Sciences, was interested in the cultural shaping of psychological symptoms. While researching another topic in Bangalore, his host recommended he conduct fieldwork at NIMHANS.

That research led to his new book, “Modernity and Malevolence in the Psychiatric Clinic: Anxious Selves in Urban and Rural South India,” published in October by University of Hawai'i Press. The book offers a detailed ethnographic study of clinical care at NIMHANS, and shows how patterns of psycho-social stress combined with modernity’s pressures can influence psychiatric practice.

Willford spoke with the Chronicle about the book.

Question: What were the big questions that got you started on this book?

Answer: This study took shape during preliminary NIMHANS conversations with psychiatrists as well as my participation within the Nilgiris Field Learning Center, a Cornell faculty-led research and study abroad program in the Nilgiris Biosphere Reserve, a mountain range in the Western Ghats of South India. In both contexts, a severe shortage of resources was noted in India for dealing with a reported mental health crisis. 

The Nilgiris has many Indigenous communities, which were facing escalating addiction, violence and suicide. My plan was to look at the purported mental health crisis from two perspectives: from that of a major tertiary center for mental health care (NIMHANS), and that of an underserved rural region that relied on traditional forms of care as well as community-based initiatives in health care. I believed a two-sited approach would shed light on the different challenges of access and culturally nuanced forms of care in very different contexts. As it turned out, this has become a two-volume study, with the Nilgiris work coming soon in a separate second volume. 

Q: Tell me about the concept of “malevolence” and the different types you studied. 

A: The term, as commonly defined, speaks to doing harm, ill intent or a sense or perception of harm being done to individuals and groups. Many of the cases within my ethnography speak to spirits and supernatural entities that are causing harm and/or haunting afflicted individuals through sorcery, possession and other spiritual maladies. 

A second usage indexes structural and symbolic violence within India around caste, poverty and patriarchal forms of gendered hierarchy. These two categories of malevolence are etiologically related, as the second often produces hauntings of the first type.

Third are projects of modernity, statecraft and identity politics, where othering, themes of betrayal and excessive fantasies of the other seemed to take hold of fragile subjects, exacerbating preexisting insecurities and bio-social traumas, now caused by the purported malevolent traits of cultural others, oftentimes figured in religious terms.

Fourth, I describe the ambivalence and perceived malevolence of biomedicine as determined by thoughtful psychiatrists, who understand the double binds caused by social pressures for the “normalization” of patients, as fueled by stigma, provided by pharmaceuticals and the bureaucratization of biomedical psychiatry, over and against gaping social wounds.

In sum, malevolence appears in multiple registers and is felt, but inscrutable at times. But I argue that these four factors are closely intertwined and co-productive of haunting affect and the violence embedded within the social. 

Q: What is “the violence of the social” and why is it important in the context of clinical care?

A:  This concept has its origins in multiple strands of critical theory, and conflict theory, more broadly, particularly in the psychoanalytic and deconstructive traditions that focus upon the inescapable normative pressures that produce fissures within the psyche, which, in turn, produce trauma, social wounding and experiences of social defeat and humiliation among those most socially vulnerable. 

These pressures can vary substantially with regards to gender, class and ethnicity. In the context of NIMHANS, these pressures might index familial violence, work conditions and normative pressures associated with religious and nationalist ideologies, as well as broader class and caste-based forms of violence that impact vulnerable communities disproportionately, adding to exacerbated psycho-social stress and/or neglected organic conditions such as malnutrition, hypertension, diabetes, epilepsy and other diseases. I use the term “violence” to include everyday forms of stigma and structural violence beyond the physical acts, though the latter is also witnessed in some cases.

Q: The concept of “hysteria” has fallen out of favor due to its gendered connotations. How have you reframed it?

A: In the broadest sense, I have used it more in an emic sense, as a term retaining great salience in the Indian clinical context. The doctors, while not using the term diagnostically from the ICD-10, the manual used in India for psychiatric diagnosis, use the term to mark psychogenic illnesses that manifest with somatic symptoms and have their provenance in social traumas, where gendered and other forms of hierarchical and structural violence are experienced. 

Inward-directed symptoms of paralysis, psychogenic (non-epileptic) seizures and other physical symptoms without a clear organic etiology were labeled as “hysteric” as a way of marking the violence of the social, as opposed to organic causality. In this sense, hysteria was relevant as an informal diagnosis that led to psycho-social interventions, though these interventions, such as family therapy or psychotherapy, more broadly, were often resisted by patients and their families due to the stigma associated with mental illness.