Socialist Health Review 1986 Vol. 2, No. 4, March Mental Health.pdf.pdf
Media
- extracted text
-
COMMUNITY HEALTH C7' L
47/'!-
Fioor) St. M9r;;s RoacJ
Bangalore - EOG CC1.
AMBIVALENCE OF PSYCHOANALYSIS
MAKING OF A PSYCHIATRIST
PSYCHOSURGERY AND MIND CONTROL
HOW RELEVANT IS PSYCHIATRIC SOCIAL WORK TRAINING?
ORGANISING WOMEN ON HEALTH ISSUES
TORTURE OF POLITICAL ACTIVISTS: ROLE OF DOCTORS
Vol II Number 4
MENTAL HEALTH
153
Editorial Perspective
MENTAL HEALTH AND SOCIETY
Ravi Duggal
I
u.
157
PSYCHIATRY. STATE OF THE ART
Dilip Joshi
160
THE HELPING PROFESSION. IS IT REALLY HELPFUL
fO
U
XZ
Annie George
163
THE AMBIVALENCE OF PSYCHOANALYSIS
2
y
o
<n
Working Editors:
Amar Jesani, Manisha Gupte,
Padma Prakash, Ravi Duggal
Editorial Collective:
Ramana Dhara, Vimal Balasubrahmanyan (A P),
Imrana Quadeer, Sathyamala C (Delhi), Dhruv Mankad
(Karnataka), Binayak Sen, Mira Sadgopal (M P),
Anant Phadke, Anjum Rajabali, Bharat Patankar,
Srilatha Batliwala (Maharashtra), Amar Singh Azad
(Punjab), Smarajit Jana and Sujit Das (West Bengal)
David Ingelby
171
THE MAKING OF A PSYCHIATRIST
Anand Nadkarni
179
Problems of Praxis
OUR BODIES, OURSELVES
Organising Women on Health Issues
Gabriele Dietrich
Reports
177
DOCTORS AND TORTURE
A Report on Chile
Editorial Correspondence:
185
Socialist Health Review,
C/o 19, June Blossom Society,
60 A, Pali Road, Bandra (West)
Bombay - 400 050 India
POLITICS OF INFORMATION
Printed at: Modern Arts and Industries, 151, A-Z
Industiral Estate, Ganpatrao Kadam Marg, Lower Parel,
Bombay 400 013.
Rosalie Bertel I
Book Reviews
173
DIFFERENT VOICES
Nalini
175
Annual Contribution Rates:
Rs. 30/- for individuals
Rs. 45/- for institutions
US dojlars 20 for US, Europe and Japan
US dollars 15 for other countries
We have special rates for developing countries.
Index to Volume II: 188
(Contributions to be made out in favour of Socialist
The views expressed in the signed articles do not
Health Review.)
necessarily reflect the views of the editors.
THE SORRY STORY OF PSYCHOSURGERY
Bindu T Desai
The Printed Word: 170
Editorial Perspective
Mental Health and Society
Nowadays, men often feel that their private lives are a series
of traps. They sense that within their everyday worlds, they
cannot overcome their troubles, and in this feeling, they are often
quite correct: what ordinary men are directly aware of and what
they try to do are bound by the private orbits in which they live;
their visions and their powers are limited to the close-up scenes
of job, family, neighbourhood; in other milieux, they move
vicariously and remain spectators. And the more aware they
become, however vaguely, of ambitions and of threats which
transcend their immediate locales, the more trapped they seem
to feel—C.Wright Mills in “The Sociological Imagination.”
THIS is the condition of modern man. In order to under
stand mental health and illness it is very important to know the
concept or nature of man within a given social milieu; for on
this depends the definition of what is mental health and illness,
the normal and the pathological. The human situation or human
existence in a social milieu thus becomes the key to understanding
mental health.
It is not necessary to go into the various conceptions held
historically but it should suffice to state that the definition of
mental health in a society is intimately related to the concept
of human in that society. These conceptions are the result of the
relations of production prevailing within a given society. They
have a direct bearing on the human situation and determine
mental health of individuals as well as classes. Marx described
this aptly in the ‘German Ideology’: “The production of ideas,
of conceptions, of consciousness, is at first directly interwoven
with the material activity and the material intercourse of men,
the language of real life. Conceiving, thinking, the mental inter
course of men, appear at this stage as the direct afflux from
their material behaviour. The same applies to mental produc
tion as expressed in the language of the politics, laws, morality,
religion, metaphysics of a people. Men are the producers of their
conceptions, ideas, etc. real, active men, as they are conditioned
by the definite development of their productive forces and of
the intercourse corresponding to these, upto its furthest forms.
Consciousness can never be anything else than conscious
existence, and the existence of men in their actual life-process.”
(Marx, 1956)
Thus, pathology stems from society itself and no amountof cure of an individual who manifests symptoms of being
mentlaly ill, will provide a complete solution to this sickness.
Mental helath is not a question “of the ‘adjustment’ of the
individual to his society, but, on the contrary it (requires) the
adjustment of society to the needs of man ... whether or not
the individual is healthy, is primarily not an individual matter
but depends on the structure of his society. A healthy society
furthers man’s capacity to love his fellow men, to work creatively,
to develop his reason and objectivity, to have a sense of self which
is based on the experience of his own productive powers. An
unhealthy society is one which creates mutual hostility, distrust,
which transforms man into an instrument of use and exploita
tion for others, which deprives him of a sense of self, except
inasmuch as he submits to others or becomes an automaton”
(Fromm, 1956). It is therefore clear that the understanding of
man’s psyche “must be based on the analysis of man’s needs
stemming from the conditions of his existence” (ibid).
Historical Background
In the past mental illness was generally the equivalent of
lunacy or madness but in post-industrial societies things are
March 1986
different. Understanding of mental health was earlier
dichotomised into being mad or being sane. Now the situation
has changed.
A change in the social formation cuts across the length and
breadth of a social structure and leaves none untouched. The
sphere of the human psyche too is affected. Traditional societies
are close-knit and therefore have a greater capacity for absorp
tion of distress, frustrations and conflicts that impinge upon
individuals because of prevailing class-relations. Family, clan and
community ties cushion members against them temporarily
releasing them (individuals) from the traps of daily living.
With the industrial and French revolutions the old order
received its death blow. Individuals, uprooted from their
traditional ties, had to face new realities of changed production
relations, but this time with little or no support from their family,
clan or community. The new production relations under
capitalism made alienation of man complete and mental health
acquired additional dimensions. It was no longer confined to
“madness” but smaller deviations from accepted norms became
equally important, because a mass society that was emerging
required stronger measures and mechanisms for social control
if the status quo had to stay undisturbed.
The first break came during the “Paris Commune” when
Philippe Pinel, a French physician, obtained permission of the
commune to treat inmates of asylums with kindness and
sympathy: instead of incurable lunatics they were now considered
as “sick” persons who were in need of treatment rather than
being evil and deserving punishment. Pinel’s therapeutic inter
vention advocated a moral treatment—treating afflicted persons
with care and concern and at the same time improving their
environment; patients were taught the value of w'ork, recreation,
religion, social activities and self-control (Bockoven, 1963).
Thus for the first time the theory of unadjustment to society
was put to practice and mental health henceforth became a
matter of adjusting the unadjusted through a process of
correction.
With further advancement of industrial society and
strengthening of capitalism, issues of mental health were no
longer confined to the lunatics, but increasingly neuroses began
to acquire a central focus. This was thanks to the weakening
of human ties and the process of alienation. Karl Marx described
this as the negation of productivity in that man (the worker)
can no longer “fulfill himself in his work but denies himself,
has a feeling of misery rather than wellbeing, does not develop
freely his mental and physical energies but is physically exhausted
and mentally debased” (Marx, 1967). The man who has thus
become subject to his alienated needs is “a mentally and
physically dehumanized being .. . the self-conscious and selfacting commodity” (ibid).
Through Marx’s writing it became clear that pathology
resided not in the individual but within the social system itself.
Mental illness originated in the pathological society and it was
society that needed a total transformation; man’s mental state
depended upon the nature of the social system.
However, this explanation was set aside as it was a challenge
that suggested the destruction of the existing system. Soon after
Marx, Max Weber’s verstehen approach came to the rescue of
capitalism. Weber upturned Marx and provided a foundation
for a new- explanation to emerge about man’s mentality. This
new break was that by Sigmund Freud who directed attention
to the intrapsychic life and emphasised the importance of the
153
unconscious. This psychology of the unconscious was indeed
“revolutionary” and path-breaking because until Freud
philosophers had always equated the mind with consciousness.
Freud’s now famous “ice-berg" theory revealed that “only a very
small part of what is mental is conscious; the rest is unconscious
made up of inadmissible and involuntary ideas which motivate
behaviour” (Appignanesi and Zarate, 1979).
Sigmund Freud
“Where id was, there shall ego be” was Freud’s way of
describing mental health. Id is the unconscious, governed by the
pleasure principle, and ego is the preconscious that emerges
because of the reality principle. These ideas of the unconscious
devolved around the oedipus complex which has generally
acquired the expression ‘father . .. murder, mother ... incest’. ”
In Freudism ‘libido’ plays the part of the mythical ‘caloric’ of
eighteenth century health mechanics, or of the ‘gravity’ of
Newtonian physics (Caudwell, 1971).
As a consequence, Freud’s obsession with sexuality
prevented him from using to advantage the contributions of
Marx to the understanding of human behaviour.
Freud’s sexual determinism is unrealistic. A child’s desire
for his mother’s breast and subsequently for her love is not an
incestuous response but that of hunger and emotional support;
for the child it is the mother who provides social, economic and
emotional security. Nor does the child see the father as a rival
or, in his unconscious, desire to murder him. The father’s role
as a patriarch bestowed by society is interpreted by the child as
a stranglehold on his freedom, creativity and object of security
(the mother), and therefore in his unconscious he seeks to
challenge it. A review of anthroplogical studies of matriarchal
societies may indicate possibilities to further substantiate and
support this critique of Freud’s conception.
Freud’s insight of the human psyche was based on an
understanding of the individual, and as a consequence his inter
pretations of mental manifestations suffered severely. He did not
see the individual’s psyche in the context of the social milieu
and therefore got trapped in the confines of the libido instinct.
Caudwell (1971) writes: “We must establish sociology
(Marxist) before we can establish psychology, just as we must
establish the laws of time and space before we can treat satisfac
torily of a single particle . ..” This Freud has failed to see. To
him all mental phenomena are simply the interaction and mutual
distortion of the instincts, of which culture and social organisa
tions are a projection, and yet this social environment, produced
by the instincts, is just what tortures and inhibits the instincts.
However, Freud’s influence on the various disciplines of the
human psyche is still very substantial. Freud’s contributions have
greatly been responsible for the extensive attention that mental
health receives, especially in western countries. It was largely
due to the emergence of Freudian psychoanalysis that the men
tal health movement became popular in the USA. Ttfe profes
sions of psychiatry and psychoanalysis subsequently acquired
a new importance in the field of medicine—they became big
business; a new technology developed around them—psycho
tropic drugs, psychosurgery, electrotherapy and the like. Until
the late sixties, this individualistic approach to mental illness
remained predominant.
Community Mental Health
At the turn of the seventies, by when the futility of.the in
dividualist approach was proved beyond doubt, things began
to change. The community basis of mental health was recognised
in the USA, but still the problem continued to be seen as one
154
of adjustment and unadjustment to society. The difference was
that it was not the individual that required to be adjusted, but
the entire community in which he lived. Thus, if the mentally
disturbed person came from a ghetto then psychiatric social
workers and other paramedics were to be used for resocialisa
tion of the immediate community of the mentally ill person;
these paramedic workers thus became a new arsenal in the forces
of social control.
It would be of interest to list out the characteristics of this
community mental health movement (Bloomy 1973): a) emphasis
on practice within the community rather man in institutional
settings such as menial hospitals; b) effort io provide services
and programmes directed at the total community rather than
individual patients; c) prevention services given higher priority
than therapeutic services; d) clinician offering indirect services—
consultation, mental health education, training of community
care givers (teachers, clergy, public health nurses, etc.)—rather
than working directly with patients, thus reaching larger number
of persons; e) innovative clinical strategies developed that more
promptly meet the menial health needs of larger number of
people (eg: crisis intervention) than was possible before; f) more
rational basis for developing specific programmes, based upon
a demographic analysis of the community being served, its unmet
mental health needs, identification of those persons who are at
special high risk for developing disordered behaviour; g) use of
new personnel—para-professionals—to supplement services
delivered by psychiatry, clinical psychology, psychiatric social
work and psychiatric nursing; h) committment to “community
control” dealing with community representatives in establishing
programmes; and i) identifying sources of stress within the com
munity and not simply within a sick person.
From the above listing it becomes clear that the community
mental health movement is no different from the community
health movement which aimed at developing resources in a
decentralized manner (at the community level) so that through
a new category of resource persons (such as paramedics, “volun
tary” agencies or NGOs, etc.) the ruling class could strengthen
mechanisms of social control, making them appear as self (or
community) regulatory and democratic; thus, preserving the
status quo. This fits in with the ‘circulation of elite’ framework
of Vilfred Pareto which is regarded as a weapon of the ruling
class (elites) to protect its own decadence “by introducing the
idea of new ‘social forces’ among the masses” (Bottomore, 1966).
Dimensions of Mental Health
In spite of the understanding that the social structure of
capitalism is in itself responsible for mental illness an overwhelm
ing proportion of psychiatrists and psychoanalysts continue to
treat mental illness as a primarily biological and behavioural
problem. Therapeutic systems that have been evolved in recent
years are therefore based on these assumptions and hence
inadequate.
The problem of mental health, though having its own
peculiarities, .is no different from that of health in general or
other social problems such as poverty, communalism, racism,
sexism, arms race, etc. All these problems, both under capitalism
and totalitarian socialism, are dealt with by society from the
perspective of commanding social control. In the case of men
tal illness those afflicted, i e. those not conforming to the norm,
are subjected to degradation, segregation and isolation (in
asylums) and more recently to incarceration, surgery, various
chemical treatment procedures and inhuman psychological
therapies, all directed towards driving home the point (to the
patient as well as the population at large) that norms of society
are sacred and unquestionable and must be followed at all cost.
Socialist Health Review
Those whose behaviour is not accounted for by the rule
following model face not only the above stated consequences
but are also labelled (eg: schizophrenic, hysterical, manicdepressive, catatonic) and stigmatised.
Erving Goffman calls this process ‘mortification’. He writes
(Goffman, 1984): “On admission to-an asylum the ‘patient’ is
stripped of his identity and any social support he enjoys. He
begins with a series of abasements, degradations, humiliations
and profanations of self. His self is systematically, if often
unintentionally, mortified. The staff employs procedures on
admission that complete this process of mortification—taking
of life history, photographing, weighing, fingerprinting, assigning
numbers, searching, listing personal possessions for storage, un
dressing, bathing, disinfecting, haircutting, issuing institutional
clothing, instructing as to rules, and assigning to quarters.”
Mental asylums are thus not very different from penal
institutions having as their main function the correction of un
adjusted behaviour; a process one may call resocialisation, which
at times may go to the extent of disculturation (rendering tem
porary incapacity of managing normal day to day life processes
when one gets out of the asylum).
It has been proved adequately that the therapeutic effects
of currently practised psychotherapy “are small or non-existent
and do not in any demonstrable way increase the rate of recovery
over that of a comparable group which receives no treatment
at all” (Eysenck, 1965). Thus, concludes John Ehrenreich that
psychiatry “is the branch of medicise which openly specialises
in the social control of deviant behaviour” (Ehrenreich, 1978);
and Thomas Szasz adds, “therapeutic interventions have two
faces; one is to heal the sick, the other is to control the wicked
. . contemporary medical practices—in all countries regardless
of their political make-up—often consist of complicated com
binations of treatment and social control . . . psychiatric
diagnoses are stigmatizing labels, phrased to resemble medical
diagnoses an'd applied to persons whose behaviour annoys or
offends others” (Szasz, 1974).
Beyond the asylums, in daily life, such interventions are
increasingly manifesting themselves, becauses problems which
are essentially social are being further appropriated by the
medical professions.
Mental illness is today generally classified into two
categories—psychoses and neuroses. “What most patients of
the first group suffer from is anxiety or depression, which if
it exists in a mild form, may only be neurosis. When it reaches
a severe stage, the person becomes totally abnormal, the opposite
extreme of depression is excitement or elation; when depression
and elation are manifest in a cycle, it is known as manicdepressive psychosis . . (Among neuroses) the commonest is
the anxiety neurosis, followed by obsessional neurosis, the com
pulsive urge to wash your hands, a fetish for cleanliness, an ab
normal concern about pollution. All the phobias too come under
this classification” (Chakraborty, 1985).
In a survey conducted recently in Greater Calcutta it was
found that 140 per 1000 persons suffer from some mental ill
ness or the other. Neuroses affect one in ten of the population.
The psychotic group is smaller, 16 per 1000 persons and half
of these are acute cases, incapable of functioning socially; this
is a very low figure in the international context, surprisingly so
in a city like Calcutta where one expects more psychotic problems
since the major factor, stress, is so overwhelmingly present (ibid).
Poverty and inhuman living conditions, especially in the
third world, play a significant role in determining mental health.
The working classes trapped in unfavourable work situations
an0 unhygienic conditions are probably the worst off due to their
alienated state. These cases of mental disturbances may not be
recorded as neuroses or psychoses but-the fact remains that their
March 1986
mental health is poor because even obtaining two square meals
is a struggle: which means a lot of insecurity and mental trauma.
Minority communities and underprivileged castes in India,
blacks in South Africa and a few western countries also live
under a fear psychoses that adversely affects their mental well
being. Women as a group have historically faced and continue
to experience mental trauma as a consequence of their place
ment in a patriarchal society. Males have throughout history
enjoyed the privilege of double values whereas females have
always been suppressed, their entire life-cycle being explained
in terms of their uterus and sexual function, especially from the
medical perspective (Ehrenreich and English, 1978). This results
in differences of interpretation of the same qualities held by men
and women. This is explained very well in a paper by Vibha
Parthasarathi (quoted by Kalpana Sharma in the Indian Express
Magazine, 27th October 1985). She writes that the quality of
being “open” is interpreted as “flexible” for men and “fickle”
for women; the quality of being “forthright” is interpreted as
“frank” in the case of men and “rude” in women; “resoluteness”
as “firm” for men and “rigid” for women; “unflinching” as
“strong-willed” for men and “stubborn” for women; and so on.
As a consequence these biased interpretations are in a large
measure responsible for the neuroses or psychoses in women.
The modern world of advertising in capitalist societies and
propaganda under both political systems promote values of the
status quo, numbing creativity of the human species, inculcating
a consumerism that drives man into becoming an automaton;
he either becomes obsessed with the advertised or propagated
norms and is labelled as an obedient or good citizen or he rejects
these norms and is classified as a deviant, and if the deviance
goes beyond the acceptable limits the person is labelled mentally
ill, thus becoming a prey to the therapies of psychiatrists and
psychoanalysts.
And finally patriarchy, which manifests itself through
exploitative production relations, also contributes to mental
pathology. Patriarchy, besides promoting sexism and suppres
sing women, promotes the idolatory of the clan, the race and
the nation; it is in Freudian terms an incestuous fixation. It is
manifested in our times in totalitarian regimes, bureaucratiza
tion and monopoly control of productive forces, among other
things. Fromm puts this point forcefully when he points out that
“nationalism is our form of incest, is our idolatory, is our
insanity; ‘patriotism’ is its cult” (Fromm, 1956). He furthers this
argument by indicating the similarities between capitalism and
totalitarian socialism. “Both systems are based on industrialisa
tion, their goal is ever-increasing economic efficiency and wealth.
They are societies run by a managerial class, and by professional
politicians. They both are thoroughly materialistic in their
outlook regardless of Christian ideology in the west and secular
messianism in the east. They organise man in a centralised
system, in large factories, political mass parties. Everybody is
a cog in the machine, and has to function smoothly. In the west,
this is achieved by methods of psychological conditioning, mass
suggestions, monetary rewards. In the east by all this, plus the
use of terror (or course, the west also uses terror—the ‘spectre
of Communism’). It is to be assumed that the more the Soviet
system develops economically, the less severely will it have to
exploit the majority of the population, hence the more can terror
be replaced by methods of psychological manipulation. The west
develops rapidly in the direction of Huxley’s ‘Brave New World’,
the east is today Orwell’s ‘1984’. But both systems tend to con
verge” (ibid).
Conclusions
Medicalisation of human mental situation, the social con
trol that goes with it, the alienation that class-relations generate
155
References
and the general drugging of the human mind through the modern
information systems have made an obedient cog of him/her.
Appignanesi, Richard and Oscar Zarate, Freud for Beginners, Pantheon
Then, if the currently prevailing social formations are largely
New York, 1979.
responsible for mental distress and frustrations, what does the Bloom,Books,
B L, Community Mental Health—A Historical and Critical
common man look towards?
Analysis, General Learning Press, New Jersey, 1973.
It is a difficult question to answer. Psychoanalysis, like Bockoven, J S, Moral Treatment in American Psychiatry, Springer, New
psychiatry, has failed in its purpose. In the west, as well as east
York, 1963.
bloc nations, the former has become only an appendage of the Bouomore, T B, Elites in Society, Penguin, 1966.
latter—which is highly medicalised. In the underdeveloped coun Caudwell. Christopher, Studies and Further Studies in a Dying Culture,
Monthly Review Press, 1971.
tries, especially of Asia and Africa, both psychoanalysis and
psychiatry have not found any significant roots, but in most of Chakraborty, Ajiia, Statesman, Calcutta, September 15, 1985.
these countries traditional ties are still strong enough to provide Ehrenreich, John, “Introduction” in the Cultural Crisis of Modern
Medicine (ed: John Ehrenreich), Monthly Review Press, New
comfort from the trappings of the social system.
Isn’t this itself an indicator that a community-life that is
York, 1978.
free from exploitative class relations, patriarchy and a centralised Ehrenreich, Barbara and Dierdre English, “The ‘sick’ women of the
and bureaucratised social control system will lead us towards
Upper Classes” in the Cultural Crisis of Modern Medicine (ed:
John Ehrenreich), op cit.
a mentally and socially healthier life?
It has indeed been a difficult theme to compile. All the Eysenck, H J, “Effects of Psychotherapy”, International Journal of
articles, except David Ingleby’s which has been reproduced from
Psychiatry, 1, 1965 (quoted in Ehrenreich, op cit).
a collection of the Radical Science Collective, are on psychiatry. Fromm, Erich, The Sane Society, Routledge and Kegan Paul, London,
We begin with Dilip Joshi’s Psychiatry: State of the Art, which
1956.
takes a look at present day psychiatry and its medicalisation.
Goffman, Erving, Asylums, Penguin, London, 1984.
Next we have Annie George’s article which reviews the train Marx, Karl, German Ideology (1845-46) reprinted in T B Bottomore and
ing programmes for medical and psychiatric social work and
M Rubel (ed) Karl Marx: Selected Writings, Penguin, 1963.
the role social workers play in psychotherapy. Psychoanalysis,
Marx,
Karl,
Economic and Philosophical Manuscripts (1844), reprinted
that is extremely popular in west, is of little consequence (in
in Erich Fromm (ed), Marx’s Concept of Man, Fredrich Ungar,
practice) in our country—we present Ingleby’s article that deals
New York, 1967.
with ambivalence of psychoanalysis. This is followed by a short
piece on a psychiatrist, Anand Nadkarni’s experience in becom Szasz, Thomas, The Myth of Mental Illness, Harper and Row, New York,
1974.
ing one. We have two review articles, one on psychosurgery by
Bindu Desai and the other on gender differences by Nalini. In
Ravi Duggal
addition we have a long non-theme article on experiences of a
D-3, Refinery View
participatory research project on women and health by Gabriele
62-63, Mahul Road
Dietrich.
Chembur
ravi duggal
Bombay 400 074
LOCOST
Research Proposals Invited
LOCOST is a non profit trust that seeks to promote the rational use of medicines. We also supply quality
drugs to those working with rural/urban poor.
LOCOST offers support for research in the following areas: (1) Review of academic literature of specific
drug categories like analgesics, antispasmodics, haematinics, etc. and/or of controversial drugs like analgin,
etc. (2) Identification of information gaps in drug usage, ADR reporting, and designing and implementing
study to fill up gaps. (3) Review of contents, sales, prices, market share, etc. of top selling allopathic and
traditional medicines, fixed dose combinations, and over-the-counter products. (4) Review of promotional
literature of top selling formulations and companies. (5) Production/distribution bottlenecks of some essen
tial drugs like Vit. A, Rifampicin, INH, etc. (6) Price/sales trends of essential drugs. (7) Social cost benefit
analysis. (8) Prescription pattern studies and prescription guidance. (9) Perceptions and responses related
to communication processes and aids in drug selling and in drug therapy.
LOCOST’s priorities are towards rural poor and urban poor. Our budget is modest. Well designed short
term (one month to six months) research proposals, with concrete output on which action can be taken
are welcomed. Write to: LOCOST, GPO BOX 134, BARODA 390 001.
156
Socialist Health Review
Psychiatry: State off the Art
dilip joshi
Psychiatry, over the years, has been thoroughly medicafsed—it views mental illness as a purely biological problem.
The author presents a critique of the prevailing worldview of psychiatry and its practice. He argues in favour of a dis
counted alliance between psychiatry and medicine so that a more human psychiatry may be evolved.
MENTAL illness seems to be the major problem of our time.
In the United States doctors write 200 million prescriptions each
year for psychoactive drugs. Half to one million people are
treated for ‘schizophrenia’. In Britain, on the other hand, 25 per
cent of all hospital beds are occupied by the mentally ill. One
in nine men and one in six women can be expected to enter a
mental institution in their lifetime (Ingleby 1980).
Psychotherapy—Current Perspectives, a book written by
a group of psychotherapists, reveals an astounding scenario. The
child consults a school-counsellor, mother of the child attends
consciousness-raising groups for women, father attends ‘Tsessions at factory and the grand-parents participate in a
workshop conducted by a professional on ‘pains of ageing’.
Psychiatry today permeates and encompasses all significant
events in human life. (Cottle and Whitten, 1980). On the other
hand within psychiatry there is no consensus about:
(a) What are mental illnesses? (b) Who should treat them?
(c) What are the means (how to?) and what are the ends? (What
is cure?)
We have a vast amount of literature on mental illness com
pared to our inadequate understanding about it. Is there
something fundamentally wrong? This article takes up these
issues and examines them critically.
ing that whole world is against you, etc.) is accompanied by a
change in body chemistry (excess of dopamine in brain) one can
not conclude that excess of dopamine is the cause of this
behaviour or experience because:
(a) One considers excess of dopamine as abnormal only because
one took the behaviour or experience as abnormal in the first
place.
(b) One is correlating an entity in the natural domain (excess
of dopamine) with a phenomenon in experimental domain which
one cannot correlate scientifically.
(c) The excess of dopamine can be subsequent to the experience.
Let us further clarify the difference between a physical ill
ness and a mental illness by taking the example of hypertension
and ‘schizophrenia’.
When as a doctor I find that the blood pressure of the per
son sitting next to me is more than 120 over 80 millimeters of
mercury, I tell him that he is suffering from hypertension.
Whatever my values, my beliefs they do not influence what I
see or observe, hypertension remaining a similar entity all over
the world.
On the other hand when a psychiatrist makes a diagnosis
of ‘schizophrenia’ he is judging the behaviour or experience of
the person sitting next to him according.to certain prevalent
(cultural) beliefs about human nature and what he sees is in
Mental Illness Not a Disease of the Body (Brain) fluenced by what he believes.
The findings of United States-United Kingdom Joint
One is often told during training that ‘schizophrenia’ is a Schizophrenia project reveal that American'-.psychiatrists tend
disease of-body (brain) like diabetes, hypertension (high blood to diagnose ‘schizophrenia’ much more frequently than their
pressure). One is also told that we are ignorant about the cause British counterparts. For a similar case an American psychiatrist
of ‘schizophrenia.’ but is it also not true of a bodily disease like will diagnose the person as ‘schizophrenic’ while the Britisher
cancer? ‘Schizophrenia’ is presented as a disease of body (brain) would not (ibid).
with a fixed cause which is being found out. One is reassured
that with the advance in medical technology, psychiatry will be
Objectivity of Diagnosis in Psychiatry
able to solve the riddle of ‘schizophrenia’.
The present day trend in psychiatry is towards explaining
“The diagnosis of schizophrenia should rest on whether a
mental illnesses as disorders of brain chemistry. It is speculated normal person understands the person concerned’s behaviour’—
that tomorrow we will possess such powerful drugs to cure Manfred Bleuler, a leading psychiatrist (Laing, 1982).
So how are psychiatrists different from lay people? A lay
mental illnesses that psychiatry will not exist as a separate
discipline but will be incorporated in clinical medicine and even person also understands that a person is behaving in an un
orthodox way, the psychiatrists call it ‘schizophrenia’. But what
general practitioners will be able to tackle these problems.
But let us look for evidence. Seymour S. Kety has done the have they gained in the process? Has calling the person
most extensive work on ‘Bio-chemistry of Schizophrenia’. He ‘schizophrenic’ rendered his situation, his response, more intelligi
says that his work is inconclusive about ‘schizophrenia’ being ble? No. One feels that the exercise of diagnosis is for screening
normal, good, conforming behaviour or experience from an ab
a bodily illness (Avieti).
One does not deny that physical illnesses and drug-induced normal, bad, nonconforming one; rather than to really under
states produce a picture resembling mental illness. But Seiger, stand the genesis of that behaviour or experience. This distinc
Osmond and Mann (1969) disagree about closeness of drug in tion is made by the psychiatrist on the basis of certain prevalent
duced states with real illness. Dr. Joseph Berke argues that in beliefs about human nature and hence in the psychiatric inter
‘schizophrenia’ hallucinations are mainly auditory. While under view a fact never remains a fact, it already becomes an inter
the influence of psychedelic drugs people rarely have hallucina pretation, a value judgement (Goldmann).
tions of any kind. Most of the experiences of false perceptions
(illusions) are visual in nature (Berke).
A-priori Assumptions About Human Nature in
One of the main theories about ‘schizophrenia’ is the
Psychiatry
dopamine theory. It states that the specific behavioural symp
toms are produced by excess of dopamine in the brain (Kaplan
These assumptions are based on an image of the human
and Saddock, 1980). If one finds that an abnormal behaviour being as a sociable, non-violent, hardworking, rationally profit
(inability to work consistently, inability to relate to people, etc.) making organism. These assumptions are revealed when one sits
or an abnormal experience (inability to experience pleasure, feel in the psychiatry out-patient department and makes a list of most
March 1986
157
frequently asked questions. These questions are:
(a) whether the person works regularly? (b) whether he/she mixes
with others? (c) if in business, is there adequate profit making?
(d) whether he/she is violent towards self or others? (Thines)
This human nature is supposed to be all pervasive and
universal, according to the psychiatrist. But let us look around,
let us go into the past to find out whether this is true.
Can one say that human nature is essentially peace loving,
non-violent when one looks back at Nazi concentration camps,
the bombing of Hiroshima and Nagasaki? Where is the sociable
human nature when two communities exist side by side in the
world with evergrowing paranoia about each other?
Can one find a hardworking human being amongst those
few who rule the world today and enjoy at the cost of toiling
masses? Isn’t the wealth of many European countries smeared
with sweat and blood of the colonised people?
Man is yet to be born. On the totality of images that we
create by our praxis in the world depends the future image of
man. As of today, this is a period of inhuman exploitation of
men and women and a narrative of violence to maintain and
perpetuate that oppression. It is surprising then that those who
are most frequently diagnosed as mentally ill belong to the
category of defenceless (poor, children, women, aged) or those
whom the middle-class, superior caste/race psychiatrist cannot
understand—the ethnic minorities, people who live on fringes
of cities. Half a million children in the United States receive treat
ment with powerful psychoactive drugs for being ‘hyperkinetic’
(Ingleby, 1980). The incidence of ‘schizophrenia’ is more in the
lower socio-economic strata (Lidz).
Practice of Psychiatry
“Cure is accomplished when the former person becomes
an obedient robot moving around either in the chronic
backwards of mental institution or without any human sense
in the outside society ...” (Cooper, 1974).
Antonin Artaud, a great poet, wrote with anguish after be
ing given electroshocks in. a hospital at Rodez “I died at Rodez
under electroshocks. I say dead, legally and medically dead”
(Greene).
Ernst Hemingway describing his experience of shocks to
his friend said, “it was a brilliant cure, but we lost the patient.
It killed both my soul as well as my mind” He committed suicide
a few months later (Madness Network News, Fall 1984). A
violonist who was given shocks for depression in a Glasgow
hospital, could not later on give her performance as she lost
her violin repertoire (Laing, 1976). Most of the groups working
for a ban on electroshocks in different countries of the world
claim that not only do shocks cause memory loss, disorientation
wild excitement or terror, but shocks can also kill. Shock is not
only a procedure wherein electric current is passed through the
brain of a person but also the dehumanising ritual of being for
cibly held by people, being forced to lie down, etc. which a per-.
son has to go through. Why are people not told about the after
effects of shocks? Why are they not told about the procedure?
I am sure if the procedure is described to the person, he will
never like to undergo such a dehumanizing experience. Shocks
are either mystified—-‘Its only an injection’, ‘You will be cured,
or they are offered as an alternative to long term hospitalisa
tion. In a similar situation a group of prisoners agreed to par
ticipate in an experiment which they knew would damage their
health, so as to get their prison stay reduced.
Dr Caligari’s Psychiatric Drugs, a book published from
Berkeley, informs us that psychiatric pills neither tranquillise nor
elevate our mood, they actually deaden our feelings and our
bodies. Drugs like thovagine, steliazine, nlehavil, haldot (all anti-
Towards a Human Psychiatry
Present day psychiatry considers the person as a passive
object, who reacts in a determinate way to his situation. It shows
complete disregard for human subjectivity. Between our interiorisation of exteriority (family, class experience) and our reexteriorisation of this interiority, i.e. in the passage from
exteriority to exteriority (objective to objective) there is a moment
of human subjectivity. We do not necessarily reproduce in the
same exact fashion the exteriority which we interiorise. In other
words we can always make something of what is made of us.
This is the realm of human freedom. This is ignored in the con
stitution of the person as passive object.
Economic and Political Weekly
A journal of current affairs, economics and other social sciences
Every week it brings you incisive and independent comments and reports on current problems plus a number of well-researched
scholarly articles on all aspects of social science including health and medicine, environment, science and technology etc Some
recent articles:
Mortality Toll of Cities-Emerging Pattern of Disease in Bombay: Radhika Ramsubban and Nigel Crook
Famine, Epidemics and Mortality in India-A Reappraisal of the Demographic Crisis of 1876-78: Ronald Lardinois
Malnutrition of Rural Children and Sex Bias: Amartya Sen and Sunil Sengupta
Family Planning and the Emergency-An Unanticipated Consequence: Alaka M Basu
Ecological Crisis and Ecological MpvementS: A Bourgeois Deviation?: Ramachandra Guha
Environmental Conflict and Public Interest Science.- Vandana Shiv? and J Bandhyopadhyay
Geography of Secular Change in Sex Ratio in 1981: Ilina Sen
Occupational Health Hazards at Indian Rare Earths Plant: T V Padmanabhan
Inland Subscription Rates
Institutions/Companies One year Rs 250, Two years Rs 475, Three years Rs 700
Individuals Only One year Rs 200, Two years Rs 375, Three years Rs 550
Concessional Rates (One year): Students Rs 100; Teachers and Researchers Rs 150
(Please enclose certificate from relevant academic institution)
[All remittances to Economic and Political Weekly. Payment by bank draft or money order preferred PIpacp aHh
cheques for collection charges]
P^crrea. riease add Rs 14 to outstation
A cyclostyled list of selected articles in EPW on health and related subjects is available on request
158
Socialist Health Review
For lay people psychiatrists wearing white coats, dispens
psychotics), tofanil, elavil (antidepressants) have a damaging
effect on the brain.
i ing medicines appear scientific, objective. But if there is no con
Thndive dyskinesia is a syndrome charecterised by involun-' sensus on fundamental issues in psychiatry, if there is more em
tary movements of tongue, face, neck, developing after long term phasis on labelling than understanding, and if the therapy is ar
antipsychotic medication. It is difficult to cure. The addiction bitrary and damaging, any amount of scientificity that psychiatry
potential of diazepam (valium, calmpose) is also mentioned in will try to bring in from outside, from its white coats, its pills,
the book. A separate chapter instructs the readers on how to its sophisticated research on the body of ‘schizophrenics’, its
safely and gradually withdraw from psychiatric pills. But people alliance with medicine, will be futile.
coming to psychiatry’ departments are hardly told about the after
On the other hand the present day psychiatry believes that
effects of pills. Why?
the psychiatrist is a passive observer. He does not influence the
situation, he does not see what he wants to see. By constituting
the person as an object, an ensemble of physico-chemical en
Critique of Medicalised Psychiatry
tities, which is only worth effort of labelling and classifying,
In his postscript to ‘Discussion of Lay Analysis’ Sigmund the psychiatrist remains totally external to the lived experience
Freud emphasised that psychoanalysis is not a branch of of mental illness.
medicine but comes under the head of psychology and the train
Mental illness is nothing but a response of the person to
ing for psychoanalysis differs from that imparted to physicians. his situation. We will be able to comprehend it only when we
More important than whether the trainee is a medical graduate grasp the situation to which it is the response. It is also essen
or not, is the specialised training for psychoanalysis. He also tial to understand the lived experience of mental illness with the
stressed that the trainee will have not only to study psychology help of mediations like family and class.
but also sociology, history of civilisation, Darwin’s theory of
Instead of being a discipline which of necessity must give
evolution, etc. But has psychiatry paid any heed to Freud’s, respect to the dignity and freedom of the individual, present day
advice? No. Even to pay heed to it, it will have to read, remember psychiatry is repressive. It should be our common endeavour
his work and not repress it.
to reinstate this respect for human dignity and freedom in
psychiatry so that it will really be a human psychiatry.
Today the alliance between psychiatry and medicine is com
References
plete with incorporation of psychiatry into general hospitals.
Those who train in psychiatry are medical graduates who take Avieti, Silvano, Understanding and Helping the Schizophrenic in
American Handbook of Psychiatry.
up psychiatry as a postgraduate discipline, while in his days Freud
Berke, Joseph, Interview in R D Laing and Anti-Psychiatry by-Robert
defended ‘lay analysis’ (McGuire).
Bayers et al., Philadelphia Foundation.
Cooper, David, The Grammar of Living, 1974.
The present day psychiatry is medicalised psychiatry with Cottle, Thomas and Philip Whitten, Psychotherapy—Current Perspec
its belief that mental illnesses are due to disorders of brain
tives, 1980.
chemistry, with its emphasis bn diagnosis and classification Goldmann, Lucien, Human Science and Philosophy.
(labelling) and its promise of instant cures with pills and shocks. Greene, Naomi, Antonin Artaud—Poet Without Words.
Ingleby, David (ed), Critical Psychiatry—The Politics of Mental Health,
By proclaiming that mental illness is a physical illness, it
1980.
situates the problem inter-individually, allowing family and socie Kaplan, H. and B Saddock, Comprehensive Textbook of Psychiatry,
1980.
ty to wash its hands of the person and hence it remains essen
tially status-quoist. By giving more emphasis on diagnosis and Laing, R. D. Facts of'Life, 1976.
classification than understanding, intelligibility, which requires Laing, R. D. Voices of Experience, 1982.
empathy, it is basically screening people who cannot fulfil the Lidz, Theodor, Interview in R D Laing and Anti-Psychiatry, op cit.
expectations the society has of them, on behalf of the ruling McGuire, Williams (ed), Freud and Jung Letters.
Seiger, M. H. Osmond and H. Mann, Laing’s Model of Madness in
class.
British Journal of Psychiatry, 115:525, 1969.
By its reliance on pills and shocks it ends up by medicalising Thines G., Phenomenology and Science of Behaviour.
human problems and hence psychiatric therapy has on the con
Dilip Joshi
trary damaging effects.
through SHR
Socialist Health Review
will now be
RADICAL JOURNAL OF HEALTH
We regret to announce that despite all our efforts we have not been able to register the publication under the name
Socialist Health Review. We have been allowed the use of RADICAL JOURNAL OF HEALTH, which incidentally was our
last choice! The issue of June 1986, Vol III number 1 of SHR will appear as RADICAL JOURNAL OF HEALTH. Please note
that the objectives and purpose of the journal and therefore the choice of content, will remain the same.
March 1986
159
The Helping Profession: Is It Really Helpful?
annie george
The role of medical and psychiatric social work in dealing with the mentally ill has
due to the community mental health movement. What is the role of the social worker. o\
for handling their task? In this article the author, herself a trained social worker, addresses the
a critique of psychiatric social work programmes as they exist today in -the context of e
IT is generally accepted today that the causative factors for mental
ill health are multifarious and interlinked and so their handling
on many fronts—curative, preventive and promotive—is done
by a multidisciplinary team. Traditionally, and till today, mental
ill health has been seen as an illness in a clinical sense, and so
the doctor is the person with whom the mentally ill person comes
in contact for treatment. But increasingly, and cardinally,
through the influence of developments in this field in the west,
other professions have been roped into the field of mental health.
Psychiatric social work is one such profession.
Who is helped through the intervention of social work, the
“helping” profession, in the field of mental health? What were
the roles assigned to it historically, and how have they changed
to fit the mental health situation in India today?
Evolution and Contributions of
Psychiatric Social Work
nuestions and presents
<!
situation
social diagnosis and to suggest means of treatment together with
physical and other psychological methods which would help
them revive their strengths and become-active citizens (emphasis
mine) (Marulasiddaiah and Sharriff, 1981). In other words the
social worker used all possible means and resources to help the
person adjust to the very conditions w'hich caused the problem.
Through experience, social workers realised that other social
groups to which the mentally ill person belonged, like the family
and the work group, could also be used in the process of getting
the person readjusted. Thus emerged treatment methods like
family centered therapy and milieu therapy.
By the seventies there was a growing disillusionment with
the p.erson-centered, curative approach. Individual care in help
ing the mentally ill person to adjust was time consuming, ex
pensive, and its results were seen only after a long period of in
tervention. Community based mental health services were seen
as an alternative. In this approach like the earlier individual
centered one, the basic understanding of mental health had not
changed; the contributions of social conditions—growing aliena
tion, pressures of urban competitive life, erosion of traditional
community support systems—to mental ill health were not
acknowledged. Mentally ill persons, those who deviated from the
norms determined by society, still had to be adjusted to fit into
that society. The difference was that the adjustment would start
with the community, would focus on preventive measures and
would reach out to more people by training people from the com
munity as frontline mental health- workers. For the social worker
the essential difference was that instead of treating the individual
as an unit of work, the community became the work unit. Her
major role would now be to provide psycho-social data about
the community, and to plan programmes to prevent mental
illness, programmes which includes recreation facilities for
adolescents, family life education, and so on. Since the com
munity health movement has not gained much ground in India,
there are not many community based mental health program
mes. Activities like organised recreation activities for children,
fun fairs and sports days which are organised by social work
agencies for disadvantaged groups usually go under the garb
o community mental health programmes. These programmes
nrnhumpo?aj1 u di-V«n the attention of the people from their
ms o aily living but they do nothing to alleviate them.
The concept of what constitutes mental health and ill health
has always varied, and with it has changed the role of the social
worker. The western practice upto late 19th century was to
segregate the mentally ill persons in asylums, away from the
mairtstream of society. Since such persons w'ere considered in
curable, no psychiatric attention was given to them; social work
intervention was also non-existent. By the end of the 19th century
the understanding of mental illness in western society had
changed considerably: mentally ill persons were now considered
“sick” and various physical and psychological therapies were
tried on them. The underlying assumption of such an approach
was that people became mentally ill because of their inability
to adjust to the pace and demand of urban industrialised life.
Various theories citing psychological factors intrinsic in the
“sick” individuals were put forward as the cause of their
maladjustment; but whatever the understanding and the line of
treatment, the end goal of the process was definite—the men
tally ill person had to be treated such that he/she would be able
to adjust back to society.
In the practical application of this conceptual framework
there was tremendous scope for social work. Medipal and
psychiatric social work emerged in the USA and Great Britain
in late 19th century because doctors there felt the need for a
person who would supplement the service of medical care pro
chaneed^hm/hh
°f the psych’atric social worker has
vided through hospitals. Social workers were .used by them to
get a more complete picture of the patient’s background by pro tai ill health hJ vari?^s approaches to the treatment of menviding psycho-social data about the patient. In India psychiatric to identify menra?inlI’!|)UtlOn 10 society has remained the same:
social work started because Indian doctors had gone abroad and
qUef’ '° resocialise the Per'
had seen psychiatric social workers and wanted them to act as son to the requhements of J
“acolyte” to the high priest, the doctor. (Marulasiddaiah and is not possible, to segregate the n *
‘f SUCh resocialisation
Sharriff, 1981).
normal people are not^isturhed"0"/™"1 SOC*ety S0 that other
fu“tionin?- In
Right through the sixties, in the west, the treatment of the fact, the social control aspect^nh^ioh
mentally ill was predominantly individualistic, institution-based the background and wh„.
th Job 8enerally remain tn
and curative; this is the approach which is prevalent in India and the public ’at large to bThold^ ‘he mentally iU perSOn
today. The role of the social worker was to understand the (psychiatric social worker)
-S a gentle> caring woman
behaviour of people when they are (mentally) ill, the poten service and to look after °.se entlre function is to be at their
tialities within individuals and their families, the resources in psychiatric social worker? □
pro^ems- Most medical and
the community, the environmental effects associated with the social work like commnnitv Je ^Omen; other specialisations of
disease, creation of insight into their problems, to bring out a • sidered the male domain
Ol?ment or criminology are con-
"..,2,h“‘
domain. Medical and psychiatric social work
160
Socialist Health Review
is probably seen by most people as an extension of the tradi
tional role assigned to women as the caretakers of the sick and
helpless members of the family. Moreover, traditionally, the
woman bears the responsibility of socialising the child and
psychiatric social workers, as an extension of this traditional role,
resocialise the mentally ill person who has lost the social skills
which are necessary to survive in an industrial, competitive
world. Thus through their legitimately assigned task of labell
ing (diagnosis), treating and/or confining persons with deviant
behaviour, the psychiatric social workers perform a subtle and
sophisticated form of social control. Her efforts to identify and
change the stress inducing elements inherent in the way society
has been organised are negligible. The present day social work
education programmes are partly responsible for this state of
affairs.
Psychiatric Social Work Training Programmes
Entrants to the field of psychiatric social work are trained
for the profession through a two year course, generally conducted
at the post-graduate level. Some schools of social work in India
offer specialised training in medical/psychiatric social work. At
such schools, in the first year students are taught basic courses
in the methods of social work, human behaviour, man and
society, and some electives. It is in the second year generally that
courses related to the specialisation are taught. These usually
include courses on psychiatric information for social workers,
courses on methods of social work used by psychiatric social
workers—mainly casework, or working with an individual and
his family—and concepts from different schools of thought, like
Freud, Rank and Parsons which have practical use in casework.
Much of the theoretical base and action of medical and
psychiatric social work is derived from Talcott Parsons’ model
of the sick role, in which, sociologically, illness was seen as a
form of social deviance where an individual adopts a specific
role. The sick role was characterised by the patient’s temporary
exemption from social responsibilities, and freedom from blame
for being sick. However, since the role was considered undesirable
and socially not approved, the sick person was expected to seek
professional help to get well, and to comply with the treatment
prescribed by the medical personnel. Though Parsons’ model
of the sick role provides the basis of work for the psychiatric
social worker, in terms of treating mentally ill persons and get
ting them back to perform their socially defined roles, it also
is a legitimisation of the power of mental health personnel over
mentally ill persons who have to comply with the treatment of
the professionals in order to have the label of social deviant
removed. In the theoretical part of the training most emphasis
is given to casework than on any other method of social work.
In casework the focus of content is on various theories which
explain human behaviour and which therefore help the
psychiatric social worker understand, arrive at a social diagnosis
and plan out the treatment of mentally ill clients. Thus these
courses lend to stress psychiatric analysis of individual problems
rather than skills in dealing with the core of the problem situa
tion itself. They are also institution centres and stress the
remedial aspects in mental health (Miranda, 1985). At the level
of theoretical training mental health is not seen in its wider sense
with contributions from other courses on social work methods.
Specialisation courses are so compartmentalised that students
of psychiatric social work" generally cannot take courses offered
by other specialisations like community development or family
welfare, even though the information content of these courses
may be very relevant for the psychiatric social work student to
develop a holistic understanding of her field of training.
Field work is the practical component, in the training to
become a psychiatric social worker. Field work experience, in
March 1986
which the student is attached to various social work agencies
for two or three days per week for the entire period of the train
ing, is largely limited to institutional urban settings like child
guidance clinics, mental health day care centres, and psychiatric
departments in wards of urban hospitals. Here the student gains
maximum experience in-casework or in working with individuals
who are diagnosed as mentally sick. Any experience in com
munity mental health is usually unplanned and incidental. It
is expected that when students become practitioners they will
be able to transfer their skills to other settings. This never really
happens. In field work students spend more time learning about
the “what” and the “how” in field work tasks than in engaging
in the “why” or analytical and conceptual learning (Miranda,
1985). Hence, students are more bothered about what are the
symptoms and how to counsel a mentally ill person than in
understanding why he has been labelled as sick, and what were
the forces in his immediate and extended environment which
caused him to behave in a different way than is normally
expected.
Field work is critical learning experience for the*social work
student because this is the period when her concepts about the
practice of the profession are being formed, based on her prac
tical experiences; she is also trying to work out her professional
role as a social worker. Relating theory to practice becomes the
major learning activity in field work. When theory and prac
tice focus exclusively on the mentally-ill person and on his treat
ment so as to get him resocialised and readjusted to the demands
of society, it is inevitable that by the end of the training period
the student social worker has equated working on treatment and
rehabilitation of mentally ill persons as the main role assigned
to her. She in turn becomes a practitioner and carries on this
tradition.
Relevance of Training
Observing the practice of psychiatric social work today, it
would appear that the effectiveness of the training is limited to
the time tested casework method. However, as Desai (1981) says,
the effectiveness of a profession depends on the quality of
preparation of the practitioners. The objectives of the curriculum
in social work training are to prepare the type and quality of
manpower capable of performing tasks and functions which
ultimately achieve the goal the profession has set for itself in
the context of the society in which it seeks to serve. Desai analyses
and lists the social realities of India as poverty, population and
its interface with problems of housing, water supply, sanitation,
accessibility to services; unemployment, disability resulting from
social and economic inequity, and the exploitation of the
vulnerable and weaker sections of society. Constant coping with
these problems could lead to a breakdown in an individual’s
mental health functioning. Therefore the tasks of the
(psychiatric) social worker would be to identify policies and
socio-economic structures which are exploitative of the majority
and which are not designed to achieve social goals for all. A
second major role would be to develop and/or modify services
and/or institutional structures for educating people to recognise
their inherent capacity for action. By and large psychiatric social
workers do not perform these roles because neither at the train
ing level nor at the practice level has it been consciously realis
ed and acknowledged that it is these societal problems of daily
living which are contributing to the mental ill health situation
in India.
The present day training programmes do not address these
tasks. The training curricula are basically borrowed from the
west, mainly the USA. They aim at helping people adjust to an
urban, industrial and metropolis dominated social milieu—
because Indian social scientists accept the western model of
161
development for the elimination of poverty. Social work was
established to help the deviants of the system to adjust to it and
to provide remedial services to those who are victims of new
social systems (Desai, 1981).
The training and practical efforts of psychiatric social work
is relevant; to whom it is so is the question. If serving the needs
of the majority of the population in order to bring them into
the mainstream of development is the goal of social work, then
the training for psychiatric social work, particularly the
knowledge about what constitutes mental health and mental ill
health, the skills in treating mentally ill persons based on the
understanding of what constitutes mental health, and the values
embedded in such an interpretation are not relevant to the
majority of the people, not even particularly to the mentally ill.
Social workers have not been able, in any significant way, to work
out strategies to deal with the daily problems of living of the
majority—problems which take thejr toll in terms of familial
tensions, and menial ill health. What the professions involved
in mental health have successfully done is to medicalise social
problems, to make it appear that problems stemming from social
causes are actually due to individual deviance, solvable or at
least controllable by the individual’s doctor (and others involved
in the therapeutic process) (Ehreinreich, 1978). Psychiatric social
work, in this sense, is very relevant to the powers that be, th ough
the semblance of a profession based on scientific knowledge,
which helps deviant people adjust, it ensures that the way society
is presently organised is maintained.
References
Desai, A. S., “Social Work Education in India: Retrospect and Prospect”
in Nair T. K. (ed.) Social Work Education and Social Work Practice
in India, Association of Schools of Social Work in India, Madras, 1981.
Ehrenreich, John, “Introduction”, in Ehrenreich, John (ed.) Cultural
Crisis of Modern Medicine, Montlhy Review Press, New York, 1978.
Marulasiddaiah, H. M. and Shariff I., “Medical and Psychiatric Social
Work Education in India” in Nair T. K. (ed.), op cit.
Miranda, M M , “A New Perspective in Medical Social Work”, Indian
Journal of Social Work, Vol. XLV, No. 4, Bombay, 1985.
Annie George
5, Varsha Sangam
Chakala, Andheri (E)
Bombay 400 099
UN List of Banned Products
LAST June, the UN decided to delete all trade information from
future editions of the “UN Consolidated List of Banned and
Severely Restricted Products”, an international directory of trade
and regulatory data on over 500 products contributed by 60
countries. Just this week, the UN announced its intention to
reverse that decision. The reversal came after months of lengthy
debates on the issue within the UN in a highly politicised
atmosphere. Ultimately, reason pre-vailed over pure politics and
the public interest perspective—including trade data—emerged
as the only rational solution to the debate. The 1986 edition will
include trade data and the unique trade name index for pesticide
and pharmaceutical products.
Hundreds of very thoughtful letters from the NGO community
were in a large part responsible for allowing the debate to occur
at all and for eventually helping to turn the decision in the direc
tion of including trade data. While opposition to the mere
existence of the ‘List’ has clearly diminished over the past several
years, it has not disappeared. At the present, claims are being
made that the ‘List’ is not really useful to governments, but is
only a duplication of other efforts at information sharing laready
in place in other UN agencies.
The United Nations is currently preparing its report on the
Consolidated List Project for the Economic and Social Council
(ECOSOC) meetings to be held in July. The office preparing
the report would like to include examples of instances where the
List has been useful to governments. The UN has recently written
letters to countries in order to collect that information from
them.
NGOs could be helpful in supporting the UN effort to collect
data on the List’s usefulness in a number of ways:
1 Encourage your government to reply to the UN’s request
for information. The UN has sent requests for information on
the ‘Lists’ usefulness to World Health Organisation correspon
dents, United Nations Environment Programme correspondents,
and the United Nations Development Programme’s Resident
Representative in all countries, and have asked those Reps to
contact government officials for that type of informaton.
2 Contribute your own examples of how your organisation
has used the List to bring about positive changes in laws or prac
tices in your country. Brazilian groups, for instance, have used
the UN Consolidated List in their efforts to persuade their
government to severely restrict certain very dangerous pesticide
products. A British organisation has reported that it has found
the List very useful in its work with the United Kingdom’s Food
and Environmental Protection bill.
If you do send data on positive contributions of the ‘List’,
please try to make your descriptions as specific and as well
documented as possible. For example, it would be helpful to
include the date of any legal or administrative action taken and
a copy of the actual taxt of the law with your description of
the, action. If it is impossible for you to collect background
documents, but you know of an action that has been taken as
a result of the UN ‘List’, please report it anyway. Background
can be collected later, if needed. All information must be received
by May 15, 1986, it is to be included in the UN’s format report
for the Economic and Social Council. The UN address is:
Assistant Secretary General, United Nations, DIESA-PPCO,
18th floor, New York, New York 10017; USA. Also, please send
a copy of all correspondence to us for our information.
Eileen-Nic
n
Program Coordinator
coordinating Committee on Toxics and Drugs
C/o NRDC, 122 East 42 St.
New York 10168
USA
162
Socialist Health Review
The Ambivalence of Psychoanalysis
david ingleby
Almost since the beginning of the century, psychoanalysis has sat like an undigested meal in the collective stomach.
Unable finally either to assimilate or eliminate it writers have endlessly churned over its merits and demerits. The list
of books on psychoanalysis which are offered to the public year after year never ceases to amaze. For, as well as being
one of the most daring and radical ideas ever put forward, psychoanalysis is also part of a deadening and conformist
apparatus. This paradox, which underlies the permanently troubled relationship between psychoanalysis and the Left
is the subject of the article, condensed from “Psychoanalysis Groups Politics Culture” edited by the Radical Science
Collective Free Association, 1984.
The Essential Ambivalence
WITHOUT doubt it is the ambiguous political message of
psychoanalysis which has kept the discussion open so long. If
it were possible to classify it once and for all as ‘progressive’
or ‘reactionary’, the issue would long since have been dropped.
Writing a political character reference for psychoanalysis is no
easy matter. So deep are the contradictions involved that one
comes to mistrust anybody who has arrived at a simple conclu
sion ‘for' or ‘against’.
The political arguments against are well known. As a
therapy, psychoanalysis can be authoritarian to the point of
‘brainwashing’ its patients; and concerned both with ‘inner’ fac
tors to the exclusion of ‘outer’ ones, and with adjusting the in
dividual to the status quo, rather than society to its inhabitants.
As a theory, it is reductionistic, ignoring social factors and
obscuring political tensions, and embodies many conservative
and socially pessimistic assumptions. When this theory becomes
disseminated as a popular world-view, we are in the grip of an
ideology which stifles political action even before it can be
expressed.
Yet as often as it is vilified, psychoanalysis is redeemed by
leftist (and feminist) enthusiasts who come to its rescue. In the
Frankfurt School tradition, it offers, first, a critique of the col
lective psychoanalysis which makes capitalism tick (Reich,
Adorno, Marcuse); and, second, a mode of analysis—Critical self
reflection—which provides a paradigm for ‘emancipatory’
thought (Habermas). In French structuralism (Lacan, Althusser),
it decentres human subjectivity away from the Cartesian ego,
in a paradigm shift as radical as that achieved by Copernicus
four centuries before. For those seeking to give content to the
slogan, ‘the personal is political’, it reaches beneath the banality
of everyday consciousness to grasp the processes which underly
the power-structure of relationships. Lacking any serious com
petitors on this terrain, psychoanalysis is likely to survive any
denunciation its critics heap upon it.
We are not likely to find which side psychoanalysis is ‘really’
on by scrutiny of Freud’s own political views. Aside from the
fact that quotations can be dredged from his writings which show
him in any light one pleases, the assumption on which such a
search is based is a faulty one; there may be little correspondence
between an individual’s conscious attitudes to society and the
message which speaks through their writings and actions.
The truth is, as I shall attempt to show in this essay, that
the political character of psychoanalysis is inherently ambivalent;
this is due, not only to the fact that different readings of it can
be produced which argue in different directions, but also to cer
tain contradictions built into its practice and theory.
Psychoanalysis As Therapy
The strongest criticisms of psychoanalysis as a set of prac
tices arise from the fact that these practices are part of a system,
labelled by Kovel (1980) the ‘mental-health industry’, which
March 1986
basically exists because of its effectiveness in maintaining social
order. Psychoanalysis shares with other types of ‘mental welfare’
concern to adapt or adjust individuals to their allotted place
in society, by reference to an hypostasised set of norms of
‘mature’ human behaviour. Like them, it ‘blames the victim’ for
his or her breakdown, leaving unscathed the larger social
framework within which breakdowns occur. Seeing itself as a
technology, it dehumanises its patients by submitting them to
a rigid set of rules and modes of understanding; it infantilises
them, the better to be able to control their development.
The same criticisms can be made of virtually any other
aspect of the mental welfare system. It is a convenient over
simplification to say that this is because the system is based on
psychoanalysis; in reality, the system is formed out of many dif
ferent theories and practices, and what is visible of
psychoanalysis within it is only the lowest common denominator
which it shares with these other approaches. Berger (1955) may
be right in claiming that, if Freud had not existed, American
society would have had to invent him, but what this means in
fact is that the success of psychoanalysis within the mental health
system was (to use a favourite term of Freud’s) overdetermined.
Some of the determinants had little to do with Freud, and much
more with the demands of the system.
That system, to a large extent, can be identified with
psychiatry, but we must not overlook the dialectical change
which psychiatry and psychoanalysis wrought upon each other.
Unfortunately, most of the political critiques of psychiatry are
focussed on precisely those parts of it which resisted this transfor
mation; anti-psychiatry, and accounts of ‘the medicalisation of
deviance’, have as their point of departure State-run, asylum
based, and physically oriented methods of treatment.
Psychoanalysis, on the other hand, normally takes place with
a private contractual relationship between client and profes
sional; it is seldom institutional; and its method is purely verbal.
Moreover, far from being something that can be imposed on
people, it in fact demands from them a level of motivation which
leaves many patients emotionally and financially exhausted. The
continuity with nineteenth-century asylum psychiatry is an
illusion; in reality, psychoanalysis resolved a profound crisis in
mental welfare, by providing the savoir for new forms of in
tervention aimed at the population outside the asylum. Freud,
of course, was not a psychiatrist but a neurologist, and from his
out-patient practice he brought into psychiatry a method of
dissecting everyday lives which the asylum doctors, with their
largely cadaverous population of-subjects; could never have
developed.
A critique which can encompass psychoanalytic practice
has to take as its starting-point a whole system for the manage
ment and surveillance of social life, the ‘psy complex’, of which
traditional psychiatry forms only the backstop. The psy com
plex is an ensemble of agencies, including clinical, educational,
developmental and industrial psychology, psychotherapy, and
social work, whose discourses are not confined to particular sites
of professional intervention, but which traverse the family, school
163
and work-place—"indeed, ‘the social’ itself. The most effective
ways of analysing this system have come not from anti
psychiatry, but from the ‘post-structuralist’ writers surrounding
Foucault: Castel, Donzelot, Deleuze and Guattari.
Apart from the fact that these writers adopt a much broader
definition of the mental health system than the anti-psychiatrists
did, they diverge from the latter on three fundamental issues.
The first concerns the relation between professionals and the
State: whereas anti-psychiatry saw the former as agents of the
latter — a kind of mental police force — writers on the psy com
plex emphasise its disorganised nature and its tendency to create
its own goals. The second difference concerns the nature of the
power exercised: for anti-psychiatry, this was essentially
repressive, being concerned to stop people doing things they
weren’t supposed to. Post-structuralists, however, stress ‘produc
tive power’ - the dissemination of discourses among a recep
tive population, discourses which shape and structure new forms
of subjectivity. Lastly, whereas, for anti-psychiatry, the medical
model and positivism played key roles in the legitimation of
psychiatric interventions, the post-structuralists treat with con
tempt the notion of ideology and ideology-critique.
At least on the first two points, the post-structuralists’ ap
proach to the psy complex seems far more relevant for understan
ding psychoanalysis. (This is hardly surprising, for these authors
to a great extent approached the subject by way of
psychoanalysis.) For them, the growth of interventions in mental
welfare has to be seen in the context of a gradual transfer of
power from the family to other agencies.
With the decline of patriarchal power under capitalism,
many of the traditional functions of the family in controlling
and caring for individuals could no longer be exercised. The
welfare state came into being through the piecemeal replacement
of these functions by public agencies. Important among these,
of course, was asylum psychiatry; but this came to be seen as
not only an ineffective response to social ills, but one which came
too late. Just as good drainage and physical hygiene had im
proved the physical health of the population, so analogous
measures would guarantee its mental (and moral) health. The
breeding-ground of all disorders came to be seen as the family,
and it was on this site that measures were concentrated.
As Donzelot shows, a large apparatus was set up to monitor
and deal with the ‘failures’ of family life, opening up in the pro
cess new avenues of intervention into the family itself. The
achievement of psychoanalysis was to provide a systematic
theory, a set of norms and a technology for regulating private
lives. Some of its major advances were in fact made in the con
text of the two World Wars, when new opportunities arose to
develop psychological remedies for military problems.
Psychoanalysis achieved its dominant position within American
psychiatry, however, by riding in on the wave of the Mental
Hygiene Movement, which sought a radical reform and broaden
ing of mental welfare services. This approach, with its emphasis
on detection and prevention of mental disorder at an early stage,
called into being a system as much concerned with socialisa
tion as with care and relief.
The precise role of psychoanalysis within this system is
perhaps the key issue that most sharply divides its supporters and
detractors on the Left. According to Althusser (1971, p.'178),
the French Communist Party’s rejection of psychoanalysis was
based on a failure to recognise the travesty which American
psychiatry had made of it: ‘the “dominant” ideas, in this case,
were playing their “dominating” role to perfection, ruling
unrecognised over the very minds that were trying to fight them’
Lacan’s more authentic reading would show that (he biological
and medical interpretation of psychoanalysis was, in fact, a
heretical departure. Jacoby (1975) repeated what the Frankfurt
School had argued all along, that psychoanalysis was■
^°ut
‘nature’ so much as ‘second nature, quoting Marcuse (1962) as
follows- “Freud’s theory is in its very substance sociological
and no new cultural or sociological orientation is; needed to^reveal
this substance!’ According to Jacoby, the authentic gloom of
Freud’s analysis of modern life had been excised for the
American market, and replaced by a view in which achieving
harmony between individual and society was merely a technical
problem.
.
/1Aon
♦
It is indeed true, as Paul Hirst points out (1981), that
psychoanalysis has been by no means as universally influential
in the formation of the psy complex as Donzelot and others
assume. However, the mere fact that analysis remains a minority
treatment should not blind us to the enormous influence that
Freudian ideas have had on a wide range of forms of interven
tion. Even where an approach was adopted (such as learning
theory) which nominally opposed psychoanalysis, such alter
natives were fashioned in debate with psychoanalysis — a debate
conducted in its own terms. And to complain that psychoanalysis
was unwillingly co-opted into the mental welfare system is to
ignore the prodigious efforts made by Freud himself to gain a
foothold for it in the USA (see Castel, 1982, p.324).
This widespread dissemination of psychoanalysis, however,
was indeed accompanied by a transformation of its original prin
ciples. Freud’s ideas were only taken up in so far as they suited
the aims of the psy complex; it would be as misleading to read
off his views from the practices which purport to'be based on
them, as to try and infer Piaget’s thought from the ‘child-centred
pedagogy’ which claims him as its mascot (Walkerdine, 1984).
In both cases, the take-up was selective, and one can imagine
other uses io which the theories could have been put. To decide
what psychoanalysis ‘really’ is, is like speculating about what
Jill w'ould be like if she hadn’t married Jack twenty years ago;
Jill may have had characteristics before the marriage which seem
to have disappeared now, but on what grounds can we claim
that this was the Teal’ Jill? Nevertheless, in concentrating on
the lowest common denominator which psychoanalysis shares
with the rest of the psy complex, we may miss more essential
features which set it apart.
The very lowest of these common denominators is some
thing so obvious that one may easily overlook it - the in
dividualism of psychoanalysis; the fact that it treats problems
arising on social life in terms of the properties of individual sub
jects. It is the defining feature of all psychology that it takes
the individual as the,unit of analysis; Henriques et al. (1984)
see this as intrinsically connected with psychology’s functions
of surveillance and regulation.
At the next level of specificity, which sets psychoanalysis
apart from organic or genetic theories of personality, but leaves
it undifferentiated from other environmentalist approaches, is
the conviction that the determinants of individual dispositions
are to be found in childhood, and that treatment can modify
these dispositions. This, it will be noted, says nothing about the
unconscious, or about sexuality, therapeutic technique, or the
discontents of civilisation. To that extent it overlaps with the
principles of behaviourist learning theory: Castel (1982 p.5l)
points out that, so-far from being sworn enemies, psychoanalysis
and behaviourism in the USA have often made a fruitful part
nership. (It was J.B. Watson himself who suggested that ‘any
man in a position to serve in high public office should be obliged
o submit to psychoanalysis!) But only a superficial acquain
tance with the content of the two theories is required to see how
much of Freud s thought must be set asidp tn moVo
u
nership possible.
t0 make SUch a partha . ?Vhereas the focus of intervention for the asylum system
had been insanity, twentieth-cehtury forms of mental welfare
164
Socialist Health Review
concerned themselves with malfunctioning in everyday settings tured people’s ideas about what would constitute an adequate
- ‘failure to cope’ (Armstrong, 1980). Such failures were en response to personal difficulties; it has become a world-view.
coded via the theoretical construct, ‘neurosis’, which - in the As Castel (1982, p.261) puts it, ‘Psychoanalysis was the main
new sense which he gave to it - was Freud’s chief gift to the instrument for the reduction of social issues in general to ques
psy complex. The concept of the unconscious, on the other hand, tions of psycholog/
was taken up somewhat selectively by American psychiatrists.,
To describe the political character of psychoanalysis,
Rather than furnishing them with a critical perspective on however, it is not simply to list the types of intervention which
bourgeois society, or a ‘decentering of the human subject’, it it informed, without describing the content of the interventions.
mainly served to reassure them that they could safely adopt a What sort of values and social ideology were associated with
psychological approach without giving up their traditional claim, the name of psychoanalysis?
as doctors, to know better than the patient what was wrong with
Here we reach the kernel of the contradiction which forms
them. The notion of the unconscious thus played a central part the topic of this essay. For to characterise psychoanalysis simply
in building a professional ideology for the psy complex (Scull, as ‘conformist’ or ‘libertarian’, ‘progressive’ or ‘reactionary’, ‘pro1979). A theory which relegated the patient’s own views about family’ or ‘anti-family’, is impossible; in reality, it is all of these
what was going on to the status of fantasy, and which took things. This ambivalence can be traced to the essential paradox of
disagreement, or ‘resistance’, as a sure sign that the professional the welfare system of which psychoanalysis forms a part. For
was in the right, did wonders for professionals anxious to secure at the same time as it maintains and reinforces traditional forms
their cognitive authority as experts on the field of human of social life - in particular, the family—the psy complex under
subjectivity.
mines their very basis, by taking away their rights to selfAs I have remarked above, classical Freudian therapy was determination. To adopt a global metaphor, it props up the ail
by no means the main contribution of psychoanalysis to the psy ing regime of the family, by turning it into a puppet dictator
complex. Such treatment was too expensive and time-consuming ship or client state with no real autonomy. Thus, the psy com
to be suited to more than a tiny minority of cases: for other plex does not simply reinforce the family, nor simply undermine
patients, and other fields of intervention, new ‘psychodynamic’ it. In a subtle holding operation, it manages to do both.
methods had to be evolved. The most obviously recognisable
This point is made most effectively by Donzelot (1979), who
are the post-Freudian, neo-Freudian, and even anti-Freudian compares Freud’s role in the social realm to that of Keynes in
forms of individual therapy, which sprouted prolifically in the the economic. Just as Keynesian economics maintained the
fertile soil of the American market. In addition, Freudian prin mainspring of capitalism—the profit motive—but brought it
ciples were extrapolated to the construction of institutional under political control with a system of checks and balances,
regimes, of which group therapy was the mainstay; in this case, so Freud devised a technology which enhanced individual
the object of transference became the group, rather than the doc autonomy in some respects, yet retained the family as ‘the
tor running it. When such methods were employed in the con horizon of all individual path's’ (op. cit., p.232). In doing so,
struction of therapeutic communities, we see a remarkable revival he struck the necessary balance between ‘the necessity of im
of the moral treatment pioneered over a century before by Tuke posing social norms of health and education, and that of main
and Pinel. The aim of both treatments was to recreate the family taining the autonomy of individuals and the ambition of families
environment in which disorders had supposedly arisen, this time as a principle of free enterprise’ (ibid<-). (There is a further parallel
under strict technical control, so that the deep-seated problems between Freud and Keynes, which Donzelot does not remark,
but which is pointed out by Hirst (1981): that the doctrines of
could be ‘worked through’ in a new context.
Other forms of intervention did not use Freud’s prescrip both were significantly distorted by the agencies which took them
tions regarding therapy, but instead took his notions about up.)
Though Marxists have long emphasised the role of the
development and family life as their guiding principles. Social
workers, for example, did not ask their clients to free-associate family in physically reproducing and servicing producers and
or produce dreams, but they commonly understood the client’s consumers, Donzelot’s emphasis on the family as a generator
altitude to them in terms of ‘transference’, and attributed their of ‘ambition’ (what we might call ‘the Dallas principle’) points
problems to the insidious workings of unconscious fantasy - to individual identity and motivation. Ambition, in fact, is not
rather than to real social difficulties, which they had no man quite an adequate term to describe the scenarios and compul
date to remove. Agencies concerned with the promotion of sions which the family bequeathes to its offspring. We must also
norms of family life (such as family or juvenile courts) looked take into account the mechanisms described by Chodorow (1979),
to psychoanalysis for the normative principles which defined through which the urge to mother reproduces itself, and also
a ‘healthy’ upbringing (e.g. the notion that boys need a father the general process of appropriation of cultural resources posited
in order to grow into men). The wide range of services designed by Vygotsky and elaborated by the Berlin school of ‘critical
to monitor and regulate the environment of early socialisation psychology’ (see Elbers). The more we study these processes,
(child guidance clinics, parent education courses, early detec the more illusory becomes the opposition of individual
tion schemes) was founded on the Freudian dogma of the in autonomy and family structure; the two are, in fact, mutually
fantile origins of neurosis - even though actual psychoanalytic constitutive.
The ambivalence of psychoanalysis in relation to the family
theory was from time to time deemed unfashionable. John
Bowlby’s ‘attachment theory’, for example, is a set of ideas which lies in the fact that it can unmask, and potentially dismantle,
have been highly influential in forming pedagogic attitudes and the mechanisms which hold the family together; it can untie the
public policy, based on a bowdlerised - or should one say sacred bonds which hold fast man and woman, parent and child,
in its stifling embrace. Yet it can also use fhis knowledge to tie
Bowlbyised? - version of analytic theory.
Wider afield, we may note the influence of psychoanalysis the bonds even tighter, if it chooses. The wealthy intelligentsia who
on marketing, on industrial organisation, and educational prac were the first clients of psychoanalysis (and will probably be
tices. Finally, there is the dissemination of Freudian ideas into its last) sought an escape from conventions of family life and
popular culture.This process, which by-passes the professional sexual morality which were seen as no longer functional (what
nexus, is an aspect of what Brinkgreve et al. (1979) term ‘proto- would nowadays be called ‘getting rid of your hang-ups’). Castel
professionalisation’, and is perhaps the most far-reaching of the (1982, p.32) claims that the first adherents of psychoanalysis in
effects of psychoanalysis. In the USA, it has not merely restruc the USA were ‘in rebellion against New England puritanism and
March 1986
165
moral conformity’, and no doubt Freud served them well. Yet
the extent to which such an escape was permitted was cir
cumscribed by psychoanalysis itself; and there is little doubt that,
^specially in the versions produced for consumption lower down
the market, psychoanalysis defended more traditional values than
it opposed.
It did so chiefly by reducing the elements of human ex
istence to the nuclear family (what Deleuze and Guattari (1977)
term the ‘mama-papa matrix’), and by insisting on the in
evitability and universality of certain emotional patterns, notably
the Oedipus Complex. (If you were unfortunate enough not to
have an Oedipus Complex to start with, Deleuze and Guattari
wryly note, the analyst would start by installing one for you.)
In addition, rhe dominant American version of psychoanalysis
(ego psychology) emphasised the reinforcement of the ego, that
is, of the ‘reality principle’, which is as much concerned with
social realities as with physical ones. By conflating the two sorts
into one absolute and unquestioned principle, psychoanalysis
reified the social order into a timeless law. Thus, the conser
vative effects of psychoanalysis were closely bound up with the
theory underlying it—a topic we shall deal with in the next
section.
We may analyse the political stapce of psychoanalysis, not
only in its attitude to family structure, but also through its deal
ings with the individual subject. Here, criticisms relate to the
power-relationship between analyst and patient, and the pic
ture (oncfe again) is by no means straightforward.
The commonest criticism, from a liberal standpoint, is that
psychoanalytic technique is authoritarian and manipulative; it
exercises a kind of totalitarian power that treats the patient as
an object, or at best a sort of child. Castel (1972) stresses that,
despite the liberal connotations of ‘free association’, the power
relationship between analyst and patient is highly asymmetrical;
the analyst, in the name of ‘technique’, banishes certain topics
by treating them only as masks for other topics. Any questioning
of the way the analyst exercises his or her powers, for example,
is treated as material for interpretation only. This one-sided rela
tionship parallels that to be found between professionals and
clients throughout the rest of psy complex. Elsewhere (Ingleby,
in press) I have argued that the power of these professions is
very largely based on the parental nature of the relationship
which is on offer. (To this it shoud be added parenthetically that
thesry/e of parenting offered has changed in recent years, away
from an autocratic and omniscient posture towards a more
democratic and ‘client-centred’ one.)
Yet it is too simple to regard psychoanalysts as paternalistic
in the same sense as priests, doctors or social workers. What
is unique in analysis is the fact that this ‘transference’ is quite
explicit and becomes, indeed, the main vehicle and topic of the
therapy. Though it looks as if the analysts are merely aiming
to install themselves in the parent’s place, the better to control
their patients, it is paradoxically the aim o’f analysis to destroy
the very scenario on which it is built. Analysts are supposed to
act as a ‘blink screen’, in order to reveal the images being pro
jected on to them. They are, in effect, playing at not being there,
in order to demonstrate that the patient’s attitude to them is
not based on reality, and must therefore be given up. So, far
from telling patients what to think or do, much of their efforts
go into sidestepping the patients’ attempts to get them to do
just this.
In psychoanalysis, then, transference is like a ladder which
is thrown away when the goal is reached; not to have ‘worked
through’ it thoroughly is the tell-tale sign of an ‘incomplete’
analysis. The aim of analysis is a relationship thoroughly
cleansed of all parental undertones, which enables the patient
to dismantle the familial scenarios which have previously struc
166
tured and dominated his or her life. Doesn’t this sound like
emancipation?’
, . . , ., .
The critics, however, are not attacking the ideal outcomes
of analysis, but what goes on within it, which is rather like a
game of football played on a sloping pitch. What is constitutive
of dialogue is the equality of the speakers—the fact that both
sides respond to each other’s utterances according to the same
rules, and accept a commitment to respect each other’s com
municative intentions. A situation in which everything one part
ner says is routinely reduced by the other to the status of material
for interpretation is clearly incompatible with this ideal. Indeed,
as Lomas (1982) points out, it is probably rather bad for
people—especially if they find relationships problematic in the
first place. The lack of reciprocity between analyst and patient
makes the relationship less than a human one: Freud’s ‘rule of
abstinence’ specifically forbids analysts from presenting
themselves to their patients as persons.
Psychoanalysis, however, never set out to be a humanistic
or phenomenological method. Ft is true that understanding
another’s point of view requires treating them as an equal in
the dialogue; but if you want such a therapy, the analysts would
say, you are free to choose another variety such as client-centered
therapy or (better still) co-counselling. Psychoanalysis, as Ricoeur
(1970) pointed out, is not a species of phenomenology, and its
method can never be purely hermeneutical; its systematic
mistrust of the patient’s viewpoint is required in order to gain
a leverage on resistance and to reveal the patient’s compulsion
to lie about certain topics. One dosen’t enter into negotiations
with the Unconscious. To be liberated from one’s own selfdeceptions, which is the sort of emancipation Habermas (1972)
sees in psychoanalysis, one has therefore to forego the ‘uncon
ditional positive regard’ enjoined on therapists by Carl Rogers.
But the problem with this ideal of critical self-reflection
is: where do the criticisms come from? If they come from an
authority regarded as absolute, the so-called emancipation leads
straight back into domination. (This, in fact, is the basic criticism
of ‘critical theory’). Now insofar as the criticism of one’s self
perceptions comes from the analyst in person, we have seen that
the authority ascribed to this figure is but a symptom of im
maturity, which is fostered only in order to eradicate it. The ‘full
analysed patient is free to treat the analyst as a cognitive equal,
v-hose interpretations may reasonably be rejected if one can come
up with better ones.
To see the analyst in person as the locus of authority,
owever, is a basic error. As we have seen, technique requires
that the analyst’s person should be kept totally hidden (witness
the P acmg of the chair behind the patient’s head); the interwWrh t°hpV°?e’m faCt’ fr°m the doctrines of psychoanalysis,
renrpcpntc th
represenls in much the same way that the priest
me n ThKitd°
neS °f3he Church’ (‘Not I, but Freud within
tions can <?tand°meS aS r}<^surp,dse that the patient’s interpreta-
taWlitv of Aio/A dPn T teJmS With the analy«t’s; the accepof psychoanalysis^ Wha??/^eiF 5onformity with the framework
of the'analyst
?atlent sbbmits to’ is not the rule
every bit as subiert Th ru e.° analysis, to which the analyst is
lies not in the dominlt^ authoritarianism of psychoanalysis
-- '■“
paradox’tto^oTking^hrowhlhf ?
resolution of the
analyst’s authority while bufldino anSJerence’ abolishes the
itself. I would submit f± 8 ? that of Psychoanalysis
psychoanalysis itself is also ruled h ■
‘he relationshiP t0
cesses, and that * fc fn°
? by lrratlonal- unconscious prothrough, since the analyst is lifelvtob^c
* never worked
in it as the patient That LVh0 be ?S thorou8h^ immersed
uent. i hat psychoanalysis is a supernatural.
Socialist Health Review
authority of analysts, as well as for patients, is betrayed by the
TorsomebehtaVIOltr °f “S practitioners awards their profession.
nfdTT™rheir protectiveness >s justified by the necessity
h^ii.rendlnS- 11 u°m the real enemies that surround it; but their
behef m its intellectual omnipotence, their obsessional preserxation of its rituals (see Lacan, 1973), their scornful attitude
h°onU Ie T11 r1Sm and internaI heresy-all these are more the
hallmark of religion, than of a practice that claims to be the
quintessence of rationalism. What the analytic community fails
to understand is that it is not the truth of its beliefs which needs
defending, but the grounds on which they are arrived at.
sychoanalysis can never claim legitimate authority if it is
presented as a divine revelation.
We thus arrive at the conclusion that, although psycho
analysis is concerned with raising consciousness, and thus with
raising certain powers of the self, it does so by attenuating cer
tain other powers. Though productive, in Foucault’s sense, it is
also repressive; it demonstrates how wrong it is to regard pro
ductive power as replacing the repressive sort.
.
wa>’ ’n which psychoanalysis ‘produces’ new forms of
subjectivity, both for patients and in the culture generally, is the
same as the process by which those around the child create his
or her subjectivity in the first place. To understand this process,
it is necessary to introduce the ideas of Vygotsky or Mead rather
than Freud himself. The disclosure of psychoanalysis provides
a framework of interpretations and implicit responses, in terms
of which individuals may orient and articulate themselves; it
thus gives them a ‘position’ wjthin a discourse, in which to exist
as subjects. Autonomy and awareness come into being in the
space between analyst and patient (Ingleby, 1983).
This process also describes the productive effects of
psychoanalysis within the culture generally. According to
Foucault (1978), sexuality was not ‘repressed’ in the Victorian
era, but endlessly talked about at a professional level; Freud did
not shatter a silence, but merely transformed one discourse into
another one. The discourse about sexuality (which had its
ultimate origin in the religious confessional) embodies the codes
which structure and regulate social life. Though these codes func
tion ‘productively’, they are nevertheless imposed in a thoroughly
‘repressive’ way—as is also true, incidentally, of the codes within
which subjectivity originates in childhood. Every discourse has
a non-negotiable foundation which must be accepted as a con
dition of participating in it. As English people know from birth,
there are things one simply doesn’t talk about, and things one
simply doesn’t do: the child soon discovers that to certain ‘why?’
questions, the only answer is ‘because’. It is in the parts of itself
that the discourse does not allow to be questioned that its
repressive power is concealed. In psychoanalysis, these parts are
rather extensive. As Donzelot puts it (1979, p.230), ‘the discourse
of the psy professions credits the family with being both the
only model for socialisation and the source of all dissatisfac
tion: it enables them to circumscribe the position of their clients,
to mark out its circuits and block it exists!
Psychoanalysis As a World-View
To bring in psychoanalytic theory at this point is not to
change the subject: rather, to try to analyse the discourse of
psychoanalysis as if it did not have an explicit and elaborate
theoretical basis would be absurd. The theoretical counterpart
of the ‘familiafism’ embodied in psychoanalytic practice is the
Freudian insistence on the elemental nature of certain types of
family relation as the cradle of subjectivity. In this gaze, every
influence on socialisation except that of the family is rendered
invisible.
.
_ ,, .
Not only does the family become the horizon of all in
March 1986
dividual paths’, but it is a family frozen into the particular
historical form in which Freud happened to find it. Marcuse
may be right to argue that Freud’s theory ‘does not require the
addition of a sociological dimension’, in the sense that it places
development firmly within the parameters of a basic social in
stitution; but these parameters function exactly like constants
in a physical law—they do not explain anything since they can
never vary.
One might argue that Freud treated the social order of his
lime as a constant out of conscious conservatism, because he
did not think there could be a better one; but in fact the theory
that he wrought gave him very little choice, s’ince it insists that
this social order is the only possible one, given the ‘human nature’
out of which it has to be constructed. Freud did not see political
ideals such as equality between the sexes, solidarity among man
kind, or fulfilment in work as either practicable or desirable,
save in miniscule amounts. This is because, on his view of human
nature, alienation in all of its forms is inescapable. American
psychiatry thus did not suppress the ‘radical vision’ of
psychoanalysis, as Jacoby or Althusser would have us believe:
there was no such vision to suppress.
The Inevitability of Alienation
For Freud, civilised man was inescapably at loggerheads
with himself and with other men—and increasingly so as civilisa
tion progressed. Both intelligent behaviour and social organisa
tion entailed conflicts with human nature which made frustra
tion inevitable: in Freud’s metapsychology, the relationship bet
ween Ego and Id was essentially one of colonisation. This set
severe limits on what could be achieved by therapy, and the op
timistic project of using psychoanalysis to produce a happy
reconciliation between individual and society—as American
Freudianism sought, by and large, to do—was a hollow travesty
of Freud’s own philosophy. ‘Transforming hysterical misery in
to common unhappiness’ was the most that Freud claimed to
do for his patients (1984/1954). Neither, of course, could Marx
ism free us from our chains, for the.chains were part of our
humanity itself.
To mitigate the severity of Freud’s diagnosis, Marcuse (1962)
introduced a distinction between ‘basic’ and ‘surplus’
repression—the former being that which was required to main
tain civilised behaviour generally, the latter being added to this
by forms of social domination. As far as Freud was concerned,
however, the removal of ‘surplus’ repression would make hard
ly a dent in the sum of human misery. In the following sections
I shall examine the different ways in which psychoanalysis can
be thought to imply the inevitability of conflict. Freud’s belief
in this inevitability was, as he would say, ‘overdetermined’; several
different lines of reasoning led him to the same conclusion.
The Axiomatic Approach
Occasionally Freud makes it clear that for him, the opposi
tion between ‘reason’ and ‘instinct’ is axiomatic, inherent in the
concepts themselves. In accepting this presupposition, he was
merely subscribing to the dominant conceptual framework of
his time; that ‘natural’ desires were inherently ‘unreasonable’
ones was, for the average citizen of the nineteenth century, an
unquestionable piece of wisdom, and we will be committing a
pardonable solecism if we regard Freud as a typical Victorian
m this respect. The dualism can of course be traced back to
Descartes, and still further—although it was not without its
critics, such as Rousseau, in the romantic epoch.
We see Freud elaborating this idea in his discussion of ag
gression in the case of Little Hans (1909/1956): Here, he refers to:
167
. . .a universal and indispensable attribute of all instincts and
impulses—their ‘impulsive’ and dynamic character, what
might be termed as their capacity for initiating motion (p. 28).
The attribute, Freud goes on to suggest, lends to all con
duct an aggressive (and, by implication, anti-social) character.
Horowitz (1977) demonstrates the same sort of preconcep
tion in his assertion that human drives are inherently ‘distant
from reality’ (p. 9). Having accepted this idea, of course,
Horowitz commits himself to a form of ‘basic repression’ that
effectively pre-empts much of his subsequent discussion. A lit
tle conceptual analysis, however, soon shows that this notion
is not a logically necessary one. For if what we mean by ‘in
stinct’ is simply an end which the organism innately seeks, then
instincts have to be controlled merely because they lack form—
not because they have the wrong form. In this sense it is a
category-mistake to see an opposition between reason and in
stinct, because they are logically not the kinds of entities that
can be in conflict. Rationality is concerned with means, instinct
with ends, and insofar as rationality provides the means of
gratification of instinctual needs, it removes a conflict rather
than creating one.
Clearly, there are no grounds here for regarding the rela
tionship between Ego and Id as one of repression; the relation
ship between cognitive and motivational mechanisms is essen
tially one of cooperation, not competition. Opposition can only
arise because instincts themselves conflict with one another, or
because the human mind inherits irrational modes of thought
in addition to instincts themselves. However, making this elemen
tary point does not go very far towards refuting Freud’s
pessimism; precisely such postulates form the basis of his whole
theoretical system.
Elsewhere (Ingleby, 1983) I have tried to show that Freud’s
failure to explain the origins of rationality and consciousness
comes from looking in the wrong place—in the individual, in
stead of ‘the ensemble of social relations’, and that this reflects
a contrast between two world-views, ‘Enlightenment’ and
‘Romantic’, in terms of which most psychology remains rooted
in the former camp. A theory of the social construction of the
ego is implicit in the practice of psychoanalysis, and can be
articulated in theory with the help of constructs borrowed from
Mead, Vygotsky, and recent developmental psychology inspired
by these two.
The Competitive Paradigm
I hope to have shown in the above that Freud approached
the field of psychology with strong preconceptions about the
inevitability of conflict between man and other men, nature and
himself. (The conflict between man and woman is another part
of the story, too, but one to which I have not been able to do
much justice here. See however, Chodorow(1979, Ch.9).) In the
case of libido, it is primarily because Freud assumes tiiat the
patriarchal nuclear family is inevitable that he sees frustration
as necessary; primary process, however, constitutes an apparently
innate mode of unreasonableness which militates against adap
tation to any form of society. I have argued that it is the latter,
cognitive postulate of Freud’s which most seriously undermines
a belief in' social progress.
Though I am thus proposing that part of Freud’s pessimism
should be regarded as warranted, I have argued that most of
it is not and it is therefore interesting to consider where his beliefs
about human nature might have come from.
Chiefly, it would appear that it is Freud’s tendency to ig
nore the social context of his observations that leads him to make
the inferences he does. Freud’s method was essentially ahistorical,
in that he attempted to infer the nature of what had been repress
ed from its (unconscious) form after repression—without tak
168
ing into accoinr( the possibility that whatever led to its being
repressed in the first place might also have affected its form.
"Had he done so, the act of repression would have lost its self
justifying appearance, and Freud would have had to seek
elsewhere the reasons for man’s self-alienation.
For Freud characterises the Id in the same way that white
Americans characterised the Red Indian, and colonial peoples
generally have characterised the victims of their exploitation.
The Indian had to be brutally repressed, so the myth ran, because
his behaviour was lawless and wanton; likewise with the criminal
violence’ of the Algerians under the French—so coolly
demythologised by Fanon(1967)—and so too with the lawlessness
of children, mental patients, the working class ... and the Id.
But these myths can only be sustained by leaving out of
view the political facts of the case; the restoration of historical
perspective brings back the justice and intelligibility of what has
been repressed. We see that the domination and exploitation of
the colonised person produces the characteristics which are sup
posed, by entirely circular logic, to justify it. Thus, the behaviour
of the Indians does not reflect the intrinsic character of their
culture, but that of the oppression they experienced; likewise,
the ‘seething chaos’ of the Unconscious does not reflect man’s
biological predispositions so much as the savage force by which
they are suppressed.
In order to understand what Freud found in the Un
conscious, then, we must bear in mind the violence with which
nineteenth-century Europe exploited its citizens—something to
which Freud was remarkably insensitive, as his discussion of the
case of Schreber demonstrates (Shatzmann, 1973). (For all this,
we must hastily disavow the attitude that Freud’s observations
were somehow unrepresentative of civilisation before and after.)
Thus, we can see that the myth of inherent opposition bet
ween nature and culture was congruent with Freud’s own con
ventionally conservative politics, precisely because this myth
renders invisible the objective contradictions in society. Viewed
in this light, Freud’s theories seem not so much a challenge to
the received ideology of his time, as a new and sophisticated
reformulation of it.
What is this ideology? I have called it the ‘competitive
paradigm’, because it sees any gain to one individual as entail
ing a corresponding loss to another. This, of course, is also the
ideology of ‘possessive individualism’ (see Macpherson, 1962);
although this view of society has its roots in the eighteenth cen
tury, it has enjoyed a sudden and spectacular revival in recent
years, as part of the philosophy of monetarism. The concept
of free enterprise embodies an implicit assumption that enter
prise which is free is competitive, because human nature is such
that people would never of their own accord enter into
cooperative arrangements. (The. fact that-even under capitalism,
they persist in doing so, is always conveniently overlooked )
‘Laissez-faire’ economies, instead of being seen as the forced
contrivances which they are, are implied by their very name to
be the outcome of letting things happen ‘naturally’
The assumption that ‘free’ enterprise is competitive entails
m turn, that cooperation in the common interest must be coerced’th-’socia^.is identified a priori with iron rule and the
end of liberty. Christianity is regarded in much the same lightfor Freud, love thy neighbour as thyself was a ridiculous and
repressive injunction. ‘The commandment is impossible to fulfil*
such-an enormous inflation of love can only lower its value, not
get nd of the difficulty’ (Freud, 1930/1961, p. 80) In shdrt
therefore, we do not need to seek the origins of Freud’s belSs
in his discoveries, his private political views, or his person^ sue
of rnrnd; they were very much a part of his timefand of “
do Wvll*
Socialist Health Review
The Necessity of ‘Revisionism
Il should be clear by now that Freud’s theories, in the form
tn whtch he left them, are not compatible with Marxism, or even
utth a liberal belief in progress. This raises problems for the ‘new
Freudians, who maintain that it is only subsequent ‘misreadings’
of Freud that have given rise to the impression of reactionary
ideology. Jacoby (1975) sees Marcuse as ‘unfolding’ Freud’s con
cepts into a revolutionary vision of history; but this ‘unfolding’
turns out to be of precisely the same kind as that of the
conjuror who unfolds a handkerchief to reveal a flight of pigeons
or a white rabbit. Jacoby is scathing in his attack on ‘revisionist’
versions of psychoanalysis—but without a substantial amount
of revision, Freudian theory cannot legitimately be used for any
but its traditional conservative purposes.
Of course, it may be the belief in progress which ought to
be revised in the light of Freud; but in view of the foregoing
discussion, I do not think Freud's arguments for the permanence
of the existing order can be sustained—with the possible excep
tion of ‘primary process’, to which I shall return below.
What would Freudian theory look like, then, if its more
obviously ideological components were removed? I would argue
that provided primary process remained intact, little of substance
would be lost: the ‘intertia principle’ is neurologically false any
way, the ‘Death Instinct’ is a speculative afterthought, and the
| inevitability of the patriarchal nuclear family was never a truly
psychological postulate in the first place. A psychoanalytic ac
count of child development which takes into account the infant’s
sociability already exists, in the British school of ‘object relations theory’. Obviously the question deserves a more careful
answer than these few lines provide; but I do not think that the
removal of ideological preconceptions from psychoanalysis
would leave the theory either unrecognisable or unworkable. Un
fortunately, until the necessity of this task is appreciated, pro
gress on it is bound to be slow.
What of the remaining postulate, primary process? It could
be argued that a species with such a talent for self-deception
as Freud ascribes to the human race had but a miserable pro
spect of discovering a rational mode of social organisation, and
could only make things worse if it tried to seek one.
However, primary process is not as incompatible with Marx
ism as this argumen* implies. Firstly, as we noted above, the
theory that all thought is a delusion is self-refuting. Although
Freud’s theory of rationality is unsatisfactory, psychoanalysis
needs such a theory in order not simply to be ‘acceptably’ op
timistic, but to be coherent as a theory at all. Secondly, Marx
himself (who incidentally shares this problem) places con
siderable emphasis on self-deception or ‘false consciousness’ in
his account of the production and reproduction of social systems.
Although self-deception for Freud operated primarily to main
tain mental (rather than social) order, there is no reason why
false-consciousness and emotional defences should not take the
same form (the paradigm case being, perhaps, jhat of religion).
Hence, Freud is useful to a critical view of society not simply
because he describes the inner conflicts of its members so
faithfully—in contrast to the bland reassurances of ‘humanistic’
psychology; he also offers a detailed explanation of the com
pulsions and delusions which make people more at home in an
oppressive society than they would be in a free one, and hence
suggests what changes are necessary in order to make social pro
gress psychologically possible. It is this psychological problem
which Marxists after World War I, and feminists after the 1960s,
turned to psychoanalysis to solve. Why was it that when the con
ditions for social change seemed ripe that people seemed emo
tionally incapable of accepting a new order? The FreudoMarxists answered this question in terms of the ‘normal
March 1986
neuroses’ and compulsions which serve from one point of view,
as emotional defences, and, from another, as social ideologies.
What* Reich, Fromm, Marcuse et al, were essentially arguing
was that a society which runs on fairy-tales requires that, in
certain fundamental respects, its members should not grow up—
particularly the less privileged ones; the task for radical
psychoanalysis is to show how crippling compulsions arise in
the course of normal socialisation, and persist because they serve
so well the maintenance of oppressive institutions. Freud himself
inevitably started this line of criticism by blurring the distinc
tion between sanity and madness, arguing that religion, mass
movements and character traits manifested the same structure
(in psychological terms) as neuroses.
The development of a truly ‘emancipatory’ form of
psychoanalysis, however, requires its disembedding from the
system of practices—the spy complex—within whose constraints
it must remain an individualist, adaptationist and essentially
conservative form of praxis.
References
L Althusser, ‘Freud and Lacan’, in his Lenin and Philosophy and Other
Essays, New Left Books, 1971.
D Armstrong, ‘Madness and Coping’, Sociology of Health and Illness
2 (1980), 293 316
P Berger, ‘Towards a Sociological Understanding of Psychoanalysis’,
Social Research 32 (1955), 26-41.
C Bnnkgreve et al,De Opkomst van het Psychotherapeutisch Bedrijf
(Sociolohe van de Psychotherapie, Vol 1), Utrecht/Antwerpen,
Aula/Het Spectrum, 1979
F Castel et al, The Psychiatric Society, N Y, Columbia University Press,
1982.
R Castel Le Psychanalysme, Paris, Maspero, 1972.
N. Choderow, The Reproduction of Mothering-. Psychoanalysis and
the Sociology of Gender, Berkeley, University of California
Press, 1979.
G Deleuze and F Guttari, Anti-Oedipus, N Y, Viking, 1977.
J Donzelot, The Policing of Families, N Y, Pantheon, 1979.
E Elbers, ‘The Development of Motivation as an Historical Process’,
Human Development (in Press).
F Fanon, The Wretched of the Earth, Harmondsworth, Penguin, 1967.
M Foucault, The History of Sexuality, Vol I: An Introduction, N Y,
Pantheon, 1978.
S Freud, Project for a Scientific Psychology, in M Bonapart et al, (eds),
The Origins of Psycho-analysis, Hogarth, 1895/1954.
S Freud, ‘A phobia in a five-year-old boy’, Standard Edition, Vol X,
Hogarth, 1909/1956.
S Freud, Civilisation and its Discontents, Standard Edition, Vol XXI,
Hogarth, 1930/1961.
J Habermas, Knowledge and Human Interests, Heinemann, 1968.
J Henriques et al, Changing the Subject, Methuen, 1984.
P Hirst, ‘The Genesis of the Social’, in Politics and Power 3, Routledge
and Kegan Paul, 1981.
D Ingleby, ‘Freud and Piaget: the Phoney War’, New Ideas in
Psychology I (1983), 1-21.
R Jacoby, Social Amnesia, Boston, Beacon, 1975.
J Kovel, ‘The American Mental Health Industry’, in D Ingleby (ed),
Critical Psychiary, N Y, Pantheon, 1980.
J Lacan, Ecrits, Tavistock, 1973.
P Lomas, The Case for Personal Psychotherapy, Oxford, Blackwell,
1982.
C Macpherson, The Political Theory of Possessive Individualism,
Oxford, Clarendon Press, 1962.
H Marcuse, Eros and Civilization, Boston, Beacon, 1962.
J Mitchell, Psychoanalysis and Feminism, Allen Lane, 1973.
W Reich, The Sexual Revolution, Socialist Reproduction, 1930/1972.
M Richards, ‘First Steps in Becoming Social’, in M Richards (ed), The
Integration of a Child into a Social .World, Cambridge, Cambridge
University Press, 1974.
P Ricoeur, Freud and Philosophy, New Haven, Yale University Press,
1970.
A Scull, Museums of Madness: the Social Organisation of Insanity in
Nineteenth-Century England, Allen Lane, 1979.
M Shatzman, Soul Murder, Allen Lane, 1973.
V Walkerdine, ‘Developmental Psychology and the Child-Centred
Pedagogy’, in Henriques et al, Changing the Subject, Methuen,
1984.
169
The Printed Word
Newsclippings on Mental Health
Neglected Mental Health
IT is highly distressing to note that
mental health is not receiving the priority
it deserves from the government. An
estimated 14 million people in this coun
try suffer from severe mental illnesses.
Besides, nearly 40 million people who
include an increasing number of drug
addicts and alcoholics, require mental
care.. . (according to Dr. G.N.Reddy) a
disproportionate amount has always been
granted to technology at the cost of
human health. It pains one to note that
health, education and social welfare have
taken the backseat... (according to
Mohsinai Kidwai) only 10 per cent of
mental patients were being cared for at
present as there were only 1,000 qualified
psychiatrists, either working in hospitals
or practising on their own in the coun
try. .. and for every 32,000 people there
was only one psychiatric bed (Deccan
Herald, Bangalore, 20 August 1985).
No Hope for the Insane
The Lumbini Park menial hospital
(Calcutta), set up in 1940... (has) no
treatment facilities at the hospital, no
surgical equipments ... not even an
X-ray machine. Though there are six
visiting physicians only one psychoanalyst
works part-time at the clinic, while three
-resident physicians, two of them superan
nuated, hold the fort in their absence. This
is hardly sufficient for the 160 inmates,
125 male and 35 female. The patients
are kept in sub-human conditions and
provided whatever meagre meal is avail
able at a government subsidy of Rs.4 a
day... Even drugs, requisitioned from the
Central Medicine Store, it is alleged, are
insufficient, if available (Statesman,
Calcutta, 21 April 1985).
Clinical Depression
Depression, a modern term for
melancholia, is a common mood (affec
tive) disorder with a long ancestry. The
others in this group of disorders are mania
and anxiety neurosis... Nearly 100 million
people in the world suffer from depres
sion each year... A study from Chan
digarh indicates that nearly 20 per cent of
patients seen in general medical practice
suffer from depressive symptoms with or
without any physical illness... In a
mental health survey carried out recently
near Madurai, depressive illness was
found to al feet 60 persons per 100 among
those aged 60 and above. . The drugs
which are used to treat high blood
pressure, and psychotropic agents which
are used for mental illness like tran
quillisers, barbiturates, and hormonal
preparations such as ACTH cortisone and
contraceptive pills tend to induce
‘iatrogenic’ depression. There has been an
increasing use of these depressogenic
drugs over the years. The fast disappear
ance of the protective influences of the
family and social support, a sense oi
‘anomie’, a dessication of values, a mode
of living bereft of ethics, and a state of
‘existential despair’, have contributed
to augment the numbers depressed.. .
Depression, a recurring illness, affects per
sonal health, bringing psychological
misery, precipitates domestic unhappiness,
entails a loss of man-hours, and is a
significant cause of mortality through self
destruction (suicide) (Science Today,
November 1984).
tion. Deaths were also caused by diar
rhoea and dehydration. The Committee
fell concerned that 58 patients had died
over a span of 37 days... (The Telegraph,
Calcutta, 21 October 1984).
Corruption in Mental Hospital
Relatives of the mentally ill accuse
hospital staff (of Agra Mental Hospital)
of corruption and callousness and of
trying to'fleece .penurious patients. The
staff they say refuse to admit those who
do not have clout or cannot pay. The
relatives, along with their mentally ill
wards, have been forced to hire cots and
live on the pavement. They struggle to
cope with a situation which looks more
hopeless with every passing day, ag
gravated by rapidly diminishing funds.
Apart from paying for the cots, they have
to buy food from the numerous shanty
stalls that have sprung up to cater to the
unexpected refugees. According to. Dr. B.
S. Yadav, senior medical superintendent
of the hospital, patients coming from
wealthy families are admitted to the pay
ing ward which charges about Rs. 200 per
Ranchi Asylum Deaths: PUCL month. For poor patients, provision of
food, medicine and treatment is free at the
Report Indicts Government
general ward. . Hospital sources allege
A non-government inquiry con that free medicines meant for poor
ducted by the Bihar unit of PUCL has in- patients are being sold. . . A visit inside
dieted the State Government for inhuman the hospital has its own tale to tell—bare
conditions in'the Ranchi Mansik Arogyabodied patients in tattered khaki shorts
shala. Several hundred patients had cower in fright as guards force them to
escaped from this asylum last month...
pull weed or cut grass in the fields (Ihdian
The Committee found that requests by the 1 Express, Bombay, 13 October 1984).
hospital managing committee to the state
government to increase its annual outlay
Mental Institute only in Name
from Rs. 87 lakhs to over Rs. 2 crores went
The Institute of Mental Health,
unheeded. The government allowed doc
tors’ posts to lie vacant for years, sanc housed in the Alipore special jail, is still
tioning only 14 posts for nearly 1300 virtually a jail even though the state
patients. Moreover, just one post of government declared it to be a mental in
lady doctor existed for over 400 female stitute for lunatic prisoners a year and
patients. The Committee found no trace a half ago. In fact, the government
of nursing staff, nearly 80 of whom are renovated the special jail and converted
supposedly employed. There was no staff it into a mental institute for accom
room in any of the wards... The report modating non-criminal lunatics (NCL) of
said the mortality rate at the asylum has t e um Dum Central Jail with a promise
risen alarmingly from seven per cent in to give them a fair deal... Investigations
1979 to 20 per cent in the first eight have revealed that only about 200 NCLs
months of this year. In.other asylums in were taken to the institute from the Dum
the country the mortality rate is one per Dum Central Jail, out of a total of 800
cent. The report attributes the high death dnrH 11^8uls?ing [here (Business Stan
rate to government ‘"indifference”. The dard, 1 October 1984).
asylum’s medical records indicated that a
°f C™ln! (or
majority had died of prolonged malnutri Eduealio?’’
and Documentation, Bombay.
170
Socialist Health Review
Making of a Psychiatrist
anand nadkarni
The author is a practising psychiatrist as well as a teacher of the subject. In this article he looks critically at the
training of a psychiatrist. He highlights the deficiency of the clinical approach and hopes for the emergence of a more
socially relevant psychiatry.
PSYCHIATRY as a science never had a privileged position in
medical education until recently. The picture has started chang
ing slowly though not substantially. A major reason for this is
the undue emphasis o”n the biomedical model of medicine in
clinical training. An integrated or bio-psycho-social model of
medicine even today seems a distant subject. I must confess that
my comment is mainly based on my own experience in Bombay
and some medical institutions in Maharashtra. But people will
agree about similarities in the situation all over the country, with
a few notable exceptions.
When 1 was on undergraduate student, not long ago, oui
month long clinical term in psychiatry was usually designated
as a “leisure term” because we used to get only an optional short
question (of 5 marks) on psychiatry in the theory papers of
general medicine. The insistence by undergraduate students to
take ‘clinics’, which usually takes resident doctors on an egotrip,
was a privilege shared only by our medical and surgical col
leagues. Things have changed’of late. Students attend the term
in psychiatry, and more sincerely. However, much of the credit
for this goes to the introduction
a 35 marks section on
psychiatry in the medicine theory paper by the University of
Bombay.
Now, it is for the teachers in psychiatry to use this oppor
tunity to inculcate genuine psychological awareness in students
who will be general practitioners and consultants of the future.
Recently one of our patients suffering from schizophrenia was
advised by a medical consultant to get married, as that was the
only remedy. Such statements although given (presumably) with
a lot of goodwill underline the lack of basic psychiatric training
given hitherto to the undergraduate students.
The.average student, because of these lacunae, never ever
develops a sound psychosomatic approach in his future career.
Hence a patient complaining of persistent functional vomiting
entering a general-surgical OPD of a big hospital first undergoes
a series of investigations, including ‘scopy’, before being referred
for a psychiatric evaluation.
This attitude of looking towards a patient as a mere ‘case’
stems from the basic lack of psychosocial orientation.
Undergraduate students are never taught essentials of doctor
patient relationship, therapeutic effects of doctor-patient inter
actions, communication skills which can have both good and
bad prognostic implications for the patient. It will be a surprising
fact for some, but these subjects are not taught even to most
postgraduate students of psychiatry. Virtues of spontaneity and
intution are seldom stressed. Failure to master communication
skills, makes us mere ‘tic-markers’ on the symptom check-list.
Suppose I want to examine a four year old child in the psychiatry
OPD, I make him sit on a stool near me. He has to literally strain
his neck to look upto me. But suppose I place him on the table
before me, our eyes come on the same level; I can pat his
shoulder, I can also observe the spectrum of emotions on his
face and corroborate it with his words.
Unfortunately we tend to cover up our failures to com
municate under the term ‘clinical distance.’ To keep clinical
distance between a patient and a doctor is one of the vague terms
in an otherwise accurate medical vocabulary. If I visit some of
my recovering patients’ homes as a ‘part of the process of
rehabilitation, I am branded as a ‘social worker’ as if a doctor
March 1986
cannot and should not be a ‘social worker’ when the patient’s
welfare demands it. If a consistent bond of friendship is built
between a patient and a clinician, which helps the medical bond
then either the clinician is labelled as having a ‘counter
transference problem’ or is simply ridiculed. Again, everybody
in theory acknowledges the need for better communication, and
everybody tries to explain the ‘nobleness’ of our profession on
that basis. But ‘doublespeak’ is the rule of the day.
Most undergraduate studnets never grasp objectivity of
mental status examination, during their clinical term. It has been
a troublesome experience for me, when our clinical (mental
status) examinations are often branded subjective; whereas even
if two or more cardiologists argue on presence or absence of
a murmur, the objectivity of their examination is never in doubt
Fluctuating signs and. symptoms is as much a property of
schizophrenia as multiple sclerosis. This fact is often forgotten.
One of my undergraduate students was amazed to note that
‘insight’ and ‘judgement’ could be really tested. He had thought
of mental status examination as a mere data of inferences.
It is important to note that the average postgraduate student
in psychiatry comes for his clinical training with such a
background. In addition, I have often seen fresh entrants com
ing with a lot of dreamy notions about psychiatry. They think
of it as a merely ‘interesting’ subject, something that is thril
ling. During their period of residency their views usually get
crystalised in the domain of biological psychiatry in contrast.
After all the undergraduate biomedical influence tells, and that
spicious by their absence in the postgraduate arena. But even
a broad based psychosocial perspective is lacking. Average
postgraduate students do not come to terms with the prevalent
psychosocial reality of people from various stratas of society.
Many students brand psychological and social angles as too
theoretical and too abstract. Nor surprisingly, psychotherapy
techniques never come higher up on the priority list for such
students. Any psychotherapeutic work that the student does is
only out of that perosn’s own initiative and is hardly supervised.
Wherever ‘honorary’ system for teachers is prevalent, this is
likely to be ‘the truth’. One of the essential therapeutic tools for
a psychiatrist in our circumstances is to be conversant with
SUBSCRIPTION RATES
For two years now we have been bringing to you 200-odd
pages each year of thought-provoking, analytical and often
controversial reading matter for an incredibly low Rs 20/Rs 30.
This has only been possible because we have been subsidis
ing the cost from donations from some of you. Now, however,
we are compelled to hike subscription rates because our pro
duction costs have gone up. We hope you will continue to
support us despite this small increase in subscription rates.
NEW SUBSCRIPTION RATES
Annual
Individuals:
Rs 30
Institutions:
Rs 45
Foreign Rates Remain Unchanged
Single copies: Rs 8 per copy
171
techniques of group psychotherapy. Many postgraduate students
pass their examinations without even facing a single group. No
wonder, patient-education is conspicous by its absence in
psychiatry. Psychiatry students (postgraduate) seldom venture
into explaining the essence of psychopathology in simple terms
to the patient.
Not that postgraduate training is totally deficient; analysis
and elicitation of signs and symptoms is taught upto the mark.
At many places, training in psychopharmacology is adequate.
What is not taught, is how to face many controversies in
psychiatry with a balanced head. We are encouraged to take sides
too early in our training. Hence we come out either as ‘pro-ECT’
or ‘anti-ECT’, to take one example. What is not realised is that
such crystallisation of views essentially does not evolve from our
own. studies and clinical experience but as continuation of what
‘boss’ (i.e. senior teacher) is following over the years. Clinical
training in general is more by precept than debate.
Because of our emphasis on western textbooks we tend to
see many problems through their viewpoints. Let us take a con
crete example of a young patient suffering from drug addiction
It is a widely noted observation that psychopathic personality
traits are more common (either primary or secondary in origin)
among drug addicts. Many of our urban addicts, especially from
the working class, start the habit not because of these traits but
because of ignorance about the whole process. Examples are
coming to light from rural Maharashtra, where some
unscruplous chemists had started giving unpurified heroin
(brown sugar) as medicine to unsuspecting rural patients who
approached them with a prescription note from the doctors.
Some children in Bombay who earn money by collecting garbage
have been lured by their area-goons into becoming brown-sugar
addicts; many of them are in the age group between 9 and 11
years. The moral-.of the story is that any disease neds a dynamic
question of oetiology and it cannot be rigid and puritan. We
should also contemplate new equations and then try to analyse
them.
I think, during our postgraduate training we let ourselves
be moulded too much by our mileu. By mileu I mean the outlook
of the institution in which we are trained, inclinations of our
teachers and the general clinical value-systems adopted. A col
league of mine does not give an injectionof an antipsychotic
depot preparation in the buttock of male schizophrenia oatuebt
but prefers to give it in the arm so as not to arouse the latent
homosexuality conflict which is thought to be present in
schizophrenia according to the freudian school. His teacher
believed in this and so does he. I personally think this to be too
farfetched, though I must admit of having seen a couple, of
schizophrenics who had accusatory hallucinations with emphasis
on homosexuality.
Most of our biases wnich arise from our training are because
we tend to try and fit things into established, rigid models rather
than using them as a base and then basing our interpretation
in accordance with the un-que characteristics that every patient
brings in with him or her.
The entire medical training is devoid of the study of
philosophical issues in medicine and a candid exposure to the
student of social realities. This is all the more reflected in a
branch like psychiatry where the art and science of medicine
should meet. Usually any medico turns defensive when he hears
the word ‘philosophy! Philosophical issues in medicine are both
simple and complex, depending on your abilities to face them.
One of the major issues, for example, .is about the scope and
function of a ‘clinician’. Is it to be restricted to only ‘clinical’
situations? Should a clinician be a willing analyst of the wider
sociomedical issues? Should he take an active part in community
health education? Should he attempt to make creative use of
the media ... In short, should he metamorphose a clinician with,
a global perspective or get tied down to consulting rooms and
operation theatres? In theory, many doctors agree to the
expanded role of the doctor but in practice it is hard to behave
that way. We fail to understand that the so called ‘busy’ schedule
and social interactions limited to cocktail parties, indicate a
philosophical shift under the guide of practicality.
Hence any correction in the present status of training in
psychiatry should be one which will influence the overall training
in medicine. Only then it will be useful and different from the
patch-work remedies. Unfortunately most of the experts on
medical education believe that if the present structure of ex
amination is changed then the content and quality of medical
training will also change. Hence the emphasis till now has been
mainly on examination reforms and widening of curriculum,
on paper. Concrete plans and methods of implementation are
hardly discussed as they are likely to threaten the existing
biomedical structure. Well, there is something called the ‘expert’s
paradise’.
Dr Anand Nadkarni
Lecturer in Psychiatry
Seth G S Medical College &
K E M Hospital
Bombay.
FRONTIER
SHR BACK NUMBERS
A radical weekly covering political, economic, social and
cultural issues
We have in stock the following issues:
Subscription Rates^r
Vol I: No. 2—Women and Health (Reprinted edition)
India (annual)
Rs 44
India (half yearly)
Rs 22
Overseas air mail-USA, Australia and China: 45 US dollars
Overseas surface mail—All countries 20 US dollars
No. 3—Work and Health (Limited stock)
No. 4-Politics of Population Control
Vol II: No. 1—Imperialism and Health (out of stock)
Vol I No. 1 and Vol II No. 1 are out of print. We can get
Send Money Order/Postal Order/Bank Draft in favour of
FRONTIER, Calcutta to Samar Sen, FRONTIER, 61 Mott Lane,
Calcutta 700 014.
tain individual copies of any of the other issues, please
he entire issue photocopied at Rs 25. If you wish to ob
VoH|US|te €aCh P€r iSSUe Vo11 and
6 each .per issue
Vol II plus postage of one rupee (ordinary post) '
172
Socialist Health Review
Book Review
Different Voices
nalini
In a Different Voice: Psychological Theory and Women’s
Development”: Carol Gilligan, Harvard University Press
Cambridge, Massachusetts, and London,
England, 1982, pp 184, 5.95 dollars.
A THEORY is only a representation of truth perceived from
right thing for Heinz to do, so Amy is confident that “if Heinz
a particular point of view. When theorists formulate
and the druggist had talked it out long enough, they could reach
psychological theories based mostly on observations of men’s
something besides stealing!’ As he considers the law to have made
ives and find that women’s experiences do not fit, it is the women
mistakes, so she considers this drama as a mistake, believing that
who are held at fault, not the theories. Since theory performs
“the world should just share things more and then people
the powerful function oi validating one’s perceptions, when
wouldn’t have to steal!’ Both children thus recognise the need
psychological theory negates the truth of women’s perceptions,
for agreement but see it mediated in different ways ... he im
are not the seeds of madness being sown? For society, all percep personally through systems of logic and law, she through com
tions, experiences and behaviour, that fit into a particular
munication in relationship. Just as he relies on the conventions
predetermined mould, are considered normal, those that do not of logic to deduce the solution to this dilemma, assuming these
fit are considered abnormal. Does this then mean that women conventions to be shared, so she "relies on a process of com
are by definition abnormal?
munication, assuming connection and believing that her voice
A man named Heinz considers whether or not to steal a will be heard, (emphasis mine).
drug which he cannot afford to buy in order to save the life of
The differences in the responses of these two children shows
his wile. Two eieven-year-olds are asked to resolve this dilemma, that infact they see very different moral problems in the dilem
which is one'in a series devised by Kohlberg to measure moral ma. Jake responds to the question “Should Heinz steal the drug”
development in adolescents by presenting a conflict between whereas Amy responds to the question “should Heinz steal the
moral norms and exploring the logic of its resolution. In the drug!’ As can be expected these two responses receive different
standard format of Kohlberg’s interviewing procedure, the scores on Kohlberg’s scale.
description of the dilemma itself . . . Heinz’s predicament, the
Kohlberg’s six stages of moral development trace a three
wile’s disease, the druggist’s refusal to lower his price ... is level progression; from an egocentric understanding of fairness
followed by the question. “Should Heinz steal the drug?” The based on individual need (stages one and two), to a conception of
reasons for and against stealing are then explored through a series fariness anchored in (he shared conventions of societal agree
of questions that vary and extend the parameters of the ment (stages three and four), and finally to a principled
dilemma in a way designed to reveal the underlying structure of understanding of fairness that rests on the free-standing logic
moral thought.
of equality and reciprocity (stages five and six).
Jake, at eleven, views the dilemma as a conflict between
While Jake’s judgements at eleven are scored as conventional
the values of property and life, discerns the logical priority of on Kohlberg’s scale, a mixture of stages three and four, his ability
life and concludes that Heinz should steal the drug. While taking to bring deductive logic to bear on the solution of moral
the law into account and recognising its function in maintaining dilemmas, to differentiate morality from law, and to see how
law and order, (the judge, Jake says, should give Heinz (he lightest laws can be considered to have mistakes, points toward the prin
possible sentence) he also sees the law as man-made and therefore cipled conception of justice that Kohlberg equates with moral
subject to error and change Both his judgements, regarding what maturity. When considered in the light of Kohlberg’s definition
Heinz should do and the law being subject to change, rest on of the stages and sequence of moral development, Amy’s moral
the assumption of agreement, a societal consensus around moral judgements appear to be a full stage lower in maturity than
values that allows one to know and expect others to recognise Jake’s. Scored as a mixture of stages two and three, her responses
“what is the right thing to dov. Since his solution is rationally seem to reveal a feeling of powerlessness in the world, an in
derived, he assumes that anyone following reason would arrive ability to think systematically about the concepts of morality or
law, a reluctance to challenge authority or to examine the logic
at the same conclusion, including the judge.
Amy’s response to the dilemma is in sharp contrast to Jake’s of received moral truths, a failure even to conceive of acting
response. She replies in a way that seems evasive and unsure, directly to save a life or to consider that such an action, if taken,
and thinks that Heinz should not steal but find some other solu could possibly have an effect.
Asking different questions that arise different conceptions
tion such as raising money somehow. According to her, neither
should Heinz steal, nor should the wife die. She considers neither of the moral domain, the two children arrive at answers that
properly nor law but the effect of theft on the relationship bet-. fundamentally diverge, and the arrangement of these answers
ween Heinz and his wife. Even if Heinz saved his wife’s life by as successive stages on a scale of increasing moral maturity,
stealing the drug, he might be sent to jail for it and then wouldn’t caliberatcd by the logic of the boy’s responses, misses the dif
be able to help his wife if she became sicker. So they should talk ferent truth revealed in the judgement of the girl. To the ques
tion, “What does he see that she does not?” Kohlberg’s theory
it over and find some way to make the money.
Unlike Jake, who is fascinated by the power of logic and provides a ready response, manifest in the scoring of Jake’s
considers the moral dilemma to be “sort of a math problem with judgements a full stage higher than Amy’s in moral maturity;
humans”, Amy views the dilemma as a narrative of relationships to the question, “What does she see that he does not?” Kohlberg’s
that extend over time. Her moral judgement is grounded in the theory has nothing to say. Since most of her responses fall
belief that “if somebody has something that would keep through the sieve of Kohlberg’s scoring system, her responses
somebody alive, then it is not right not to give it to them.’ She appear from his perspective to lie outside the moral domain.
Yet, the world she knows is a different world from that
considers the problem in the dilemma to arise not from the drug
gist’s assertion of rights but from his failure of response. Just refracted by Kohlberg’s construction of Heinz’s dilemma. Her
as Jake is confident the judge would agree that stealing is the world is a world of relationships and.psychological truths where
COMMUNITY HEALTH C^L
March 1986.
47/1. (First Floor) St. Marks Roadt
Rsnnalor© - 560 001.
an awareness of the connection between people gives rise to a
recognition of responsibility for one another, a perception of
the need for response. Seen in this light, her understanding of
morality as arising from the recognition of relationship, her belief
in communication as the mode of conflict resolution, and her
conviction that the solution to the dilemma will follow from its
compelling representation, seem far from naive or cognitively
immature. Instead, Amy’s judgements contain the insights cen
tral to an ethic of care, just as Jake’s judgements reflect the logic
of the justic approach.
The above extracts represent the basic arguments set forth
in Gilligan’s book In a Different Voice. Her main contribution
lies not in revealing sex differences, which she states have been
noted throughout psychological literature. The importance of
her contribution lies in discerning that these difference repre
sent two entirely different yet cohesive ways of thinking and look
ing at the world. Consequently unlike the interpretation offered
by most developmental theorists that women’s development is
deficient because it does not fit into the male pattern, Gilligan
interprets the difference as representing two different but equally
valid patterns of development.
Gender identity, the “unchanging core of personality for
mation” is “with rare exception firmly and irreversibly establish
ed for both sexes by the time a child is around three.” Despite
the fact that for both sexes the “primary caretaker” in the first
three years of life is usually female, the interpersonal dynamics
of gender formation are different for boys and girls. Since girls
experience themselves and are experienced by their mothers as
being more “like, and continous with, themselves” for girls iden
tity formation is fused with the experience of attachment. In
contrast, boys experience themselves and are experienced by their
mothers as being different and separate, hence male identity for
mation entails a “more emphatic individuation.and a more
defensive firming of experienced ego boundaries.”
From here on each sex starts off viewing themselves and
others as if through a different lens. Gilligan says, “From the
different dynamics of separation and attachment in their gender
identity formation through the divergence of identity and in
timacy' that marks their experience in the adolescent'years, male
and female voices typically speak of the importance of different
truths, the former of the role of separation as it defines and
empowers the self, the latter of the ongoing process of attach
ment that creates and sustains the human community!’
In the transition from adolesence to adulthood, while the
dilemma itself is the same for both sexes, a conflict between in
tegrity and care, a recognition of the need for intimacy becomes
the critical experience for men, while for women it is the ex
perience of choice. Since this conflict is approached from dif
ferent perspectives by both sexes, it generates the recognition
of opposite truths. This gets reflected in two different-moral
ideologies, “since separation is justified by an ethic of rights
while attachment is supported by an ethic of care.”
Criticising the one-sideness of development theory, Gilligan
says, “Attachment and separation anchor the cycle of human
life, describing the biology of human reproduction and the
psychology of human development. The concepts of attachment
and separation that depict the nature and sequence of infant
development appear in adolesence as identity and intimacy and
then in- adulthood as love and work.
“This reiterative counterpoint in human experience,
however, when moulded into a developmental ordering, tends
to disappear in the course of its linear reduction into the equation
of development with separation'' (emphasis mine).
The real significance of Gilligan’s work becomes apparent
when we consider how development theory shapes the viewpoint
of not just psychologists and psychiatrists, but also the general
understanding of female nature as portrayed in humour.
174
literature, the media. This has serious implications for the way
in which women view themselves in relation to society and in
turn how society views women in relation to itself.
Since women do not fit into the pattern of male develop
ment, they are considered to have a weak sense of self, an inability
for clear thought and action, a lack of objectivity ... This image
of womanhood gets reflected in day to day interactions, and for
women, becomes a very debilitating image of themselves.to live
with. “Women’s place in man’s life cycle has been that of nur
tures caretaker, and helpmate, the weaver of those networks of
relationships on which she in turn relies. But while women have
thus taken care of men, men have, in their theories of psycho
logical development, as in their economic arrangements, tend
ed to assume or devalue that care. When the focus on individua
tion and individual achievement extends into adulthood, and
maturity is equated with personal autonomy, concern with rela
tionships appears as a weakness of women rather than as a
human strength.”
For all of us, our sense of self depends on a validation of
our perceptions from others. When women continually feel that
they are not being understood or are somehow not saying the
right thing, they become more and more unsure of themselves.
“As the interviewer conveys through repetition of questions that
the answers Amy gave were not heard or not right, her confidence
begins to diminish, and her replies become more constrained
and unsure.” It is this sense of vulnerability, repeatedly heard
in women’s vioces, that “impedes women from taking a stand,
what George Eliot regards as the girl's ‘susceptibility’ to adverse
judgements by others, which stems from her lack of power and
consequent inability ‘to do something in the world”’
“Further, in a society where women have an unequal status
with men, the above mentioned perceptions of women give men
the ‘right’ to view women as inferior, especially since their views
are backed by ‘scientific theories’ which consider women to be
deficient. This also gives men the right to exclude women from
direct participation in society, and women are thus forced to
see themselves “as subject to a consensus or judgement made
and enforced by the men on whose protection and support they
depend any by whose names they are known!’
According to Gilligan, the notion that virtue for women
lies in self-sacrifice has “complicated the course of women’s
development by pitting the moral issue of goodness against the
adult questions of responsibility and choice”. For women the ethic
of self-sacrifice is directly in conflict with the concept of their
rights as individuals. This conflict also surfaces time and again
within the women’s movement, which has emerged in an effort
to raise the collective demands of women and to struggle for
their right to choose. S’rangely, men, whose moral development
is so much focussed on the question of rights, in reacting to the
women’s movement often revert from the higher stages of maturi
ty to stage one or two of Kohlberg’s scale of moral development!
The paradox of women’s lives lies in the fact that the “very
trails that traditionally have defined the ‘goodness’ of women,
their care for and sensitivity to the need of others,, are those that
mark them as. deficient in moral development.” Yet if women
were to be equally concerned with separation, autonomy, in
dividuation, and their natural rights, as men are, women would
cease to fit into the social roles assigned to them by society. Seen
from this viewpoint, women would again appear ‘abnormal’, and
perhaps their own family would take them to psychiatrists’who
would then attempt to make them ‘adjust’ better to society.
In this context, Gilligan’s .assertion of the need to broaden
development theory, so that it encompasses the various dimen
sions of human existence, is a necessary first step. A broaden
ing of development theory would mean incorporating the
positive aspects of both male and female development as it exists
at present. This would also amount to recognising that both male
(Continued on p. 178)
Socialist Health Review
Review Article
The Sorry Story of Psychosurgery
bindu t. desai
The Stealers—Psychosurgery and Mind Control’' By Samuel Chavin, Houghton Mifflin Co. Boston, 1978 S 8.95.
'What is matter? Never Mind,
What is mind? No matter.' Punch.
THE human condition, through history, has always been incapacitated the individual’s life and which no other form of
marked with dread, anxiety, awe, fear, humbug and much con therapy can help. The method of surgery itself should be a stan
fusion about the entity of ‘insanity’. Everyone seems to know dard one so thdt identical areas are removed or destroyed at the
what it is, yet there is no general agreement about the whole patient’s outcome judged not by the operating surgeon but by
concept of psychiatric illness, much less regarding the consti an impartial observer. None of this was true for psychosurgery.
tuents of possibly specific entities like schizophrenia of hyper
activity. For instance, the diagnosis of schizophrenia varies with
The Historical Perspective
geography; it is made more stringently in Great Britain than in
“
This
was
the most unkindest cut of all” Julius Ceasar.
the United States or the Soviet Union where the condition
mushrooms into subtypes (Szasz, 1976). It may have biological
The history of psychosurgery, even as recounted by the
markers such as neurotransmitters or chemical messengers that strictly ‘medical’ account of Kucharski (1984), reads like a
affect the way brain cells work. However ‘no unequivocal macabre piece of science fiction. In fact, the .initial proponent
abnormalities’ have been found in the neurotransmitters after of psychosurgery was a world renowned professor of neurology,
three decades of intensive research into their possible role Egas Moniz of Lisbon, who had invented the technique of
(Snyder, 1982). Both a genetic pre-disposition and as yet un cerebral angiography, a method by which dye was injected and
defined infectious agent have been suggested as causative factors x-rays taken to see the blood vessels of the brain. In 1935, Moniz
(Crow, 1983). Arguments continue whether schizophrenia is one heard two American neuroscientists, present a paper at an in
disease or a group of widely different entities presently ternational conference. They described the effects of destroying
erroneously being lumped together, nearly a century after the the prefrontal area of the brain of two trained chimpanzees thus:
disorder was identified (Hays, 1984).
“the animal without frontal areas no longer appears to worry
There are other ill defined entities, that once appearing on over mistakes. Whereas the normal monkey or chimpanzee may
the medical scene grow with time. The ‘hyperactive’ child in the become excited, cry or have a temper tantrum or on the other
U S or the ‘maladjusted’ child in the U K grew from three per hand turn away and ignore the problem after several successive
cent of the U S school children in 1971 to 15 per cent in 1974, failures, the subject lacking frontal areas seems quite impervious
with about two per cent of all school age children receiving to any frustrating effects or errors” (Jacobsen, 1936). After the
medications to control hyperactivity in that year. Hyperactivity presentation, Moniz stood up and asked “Why would it not be
is defined as: unmanageable, defiant, disobedient, aggressive, feasible to relieve anxiety states in man by surgical means?” A
lying, truant, unable to concentrate, violent, overactive etc. No few months later, Moniz’s colleague Almeida Limm used alcohol
wonder Thomas Szasz calls all mental illness a myth—a category injections to destory areas of the frontal lobe of a middle-aged
error. The brain can be sick says Szasz, but the mind is not an woman with ‘agitated depression’. Following surgery the woman
organ; “it is an abstract noun that lacks a concrete referant”. was said to be markedly less agitated than before. After four
patients had been operated upon, Moniz admitted that the pa
(Szasz, 1984)
So we have a field of study where the entities themselves tients were more apathetic than he had hoped. The four were
are not clearly defined, the possible underlying mechanisms ill- sluggish, disoriented and incontinent. The alcohol that had been
understood, the role and effect of mainstays of therapy like injected tended to seep further down into the brain than intend
shock-therapy (E C T) and drugs (the major tranquillisers) con ed, and damaged vital centres that regulate breathing and blood
troversial. In all of this for the past five decades there was yet pressure in the brain stem. The referring psychiatrist refused to
another aspect—the surgical removal or destruction of a part send further patients for surgery.
of the brain to help or cure individuals with severe mental illness.
But the era of psychosufgery had begun and in the next
It is this form of brain-surgery or psychosurgery that two decades nearly 100,000 individuals were operated upon
Samuel Chavkin’s book discusses, not only in a narrow medical (BMJ, 1971) in many countries including India (Valenstein, 1980).
sense but in its wider social and political context. On reviewing The operations were performed for a variety of conditions: ag
Chavkin’s book on other related material, I am amazed at the gression, neurotic depression, psychotic depression obsessivevirtual absence of any medical or scientific basis for compulsive neurosis, schizophrenia and other psychosis etc., with
psychosurgery and of the overwhelming social, political and surgical procedures directed at different parts of the brain: the
cultural influences that determined the indications for it. For frontal lobe, the cingulum, the amygdala, or multiple sites. Moniz
any surgery, say removal of an abscess or an inflammed appen refined the technique of injecting alcohol to a leucotome—a
dix, the rationale is two-fold: non-removal will result in greater mental rod with a wire loop that could be extended from its end
harm or fatality, and removal result in some alleviation or even to cut a bit of the white matter of the brain. In the U S A with
a permanent cure. In a non-life threatening condition such as true American expertise the technique was further simplified so
chronic mental illness one is presumably aiming at substantial that the operation could be performed in the doctor’s office.
alleviation if not a cure. Surely removal or destruction of as im Initially an icepick was used as a leucotome by the American
portant and crucial a part of the body as bits of brain requires psychosurgeon Walter Freeman because other instruments “dog
clearly defined entities at the outset, which have disrupted or gone things would break. They weren’t as good as an ice-pick.”
March 1986
175
(Shuns, 1982). The ice-pick leucotome would be forced through
the skull immediately above the eye, and the surgeon destroy
parts of the frontal lobe by manipulating the instrument. Moniz
was awarded the Nobel prize for medicine in 1949 “for his
discovery of the therapeutic value of the prefrontal leucotomy
in certain psychoses’’.
Opinions on psychosurgery divided the scientific com
munity almost from the beginning of the operation with pro
ponents consistently claiming that the procedure made it possi
ble for patients who were suffering from crippling mental illness
to lead normal or near normal lives. Others strongly disagreed.
They viewed psychosurgery as a mutilation of the brain to
eliminate troublesome behaviour which turned the patients in
to ‘vegetables’. Informed consent, that is, the patient’s active con
sent to the procedure was not a factor in the decision to operate.
Children too were operated upon.
All the while the operation rested on the basis that mental
characteristics as different as creativity, memory, initiative and
anger were transmitted via a fixed pathway in brains of the men
tally ill. A normal person could be angry, happy or sad at various
times, but not any of these all the time. Cutting the fixed ab
normal fibres in the mentally ill would discontinue their sen
ding the s’ame emotion through the brain Contrast Moniz’s cer
tainty with the comments of Phillips et al, in 1984. They are
answering questions put by an imaginary individual who meets
neurobiologists every 50 or hundred years. To the question “but
can you tell me how the areas of the brain interact to display
the integration evident in thought and behaviour?” The answer
today would be “no”. (Phillips et al., 1984). Surgeons who had
performed hundreds of leucotomies were themselves aware of
the lack of any physiological basis. One of them. Dr Harry
Solomon had been asked by the Veterans Administration in 1948
to “describe the rationale of the operation at somewhat greater
length and in terms of pathologic physiology”. Solomon replied
that a. discussion of the rationale “would of necessity be very
theoretical, and probably completely unsound. We would be bet
ter advised not to attempt it” (Shutts, 1982).
Not only did the psychosurgeons lack a theoretical basis
for their procedure, ‘they had no way of knowing what they had
cut when they made radical stabs with their instruments’
(Kucharshi, 1984). They failed to consider damage to blood
vessels, or to make allowance for differences in skull size when
they made their cuts. The fibres that were supposedly intended
to be cut changed as autopsy failed to provide evidence to cor
roborate the surgeon’s theory. Though editorials in the medical
literature had repeatedly asked for carefully controlled studies
to assess lobotomy (Finesinger, 1949) none were done. A long
term follow-up of 707 patients who had undergone lobotomy
four to 30 years before showed that 70 per cent of those
hospitalised for less than a year prior to surgery were either still
living in hospital or were at home in a ‘stale of idle dependancy’.
(Kucharski, 1984).
The Recent Past
"That’s the reason they’re called lessons” the Gryphon remark
ed, "because they lessen from day to day” Alice in
Wonderland.
The advent of major tranquillisers in the early fifties and
their widespread use led to a decrease in the number of
psychosurgical operations. However in the late sixties, these
operations were advocated as a means of controlling urban
unrest. Summer after summer in the years 1964-1968 American
cities exploded in anger. In 1967 alone, there were riots in 127
cities as black people in the urban areas vented their frustra
tion, despair and rage. Some Harvard doctors chose to inter
176
pret these riots differently, as follows.
“It is important to realise that only a small number of the
millions of slum dwellers have taken part in the riots, and that
only a sub-fraction of these rioters have indulged in arson,
sniping and assault. Yet, if slum conditions alone determined
and initiated riots, why are the vast majority of slum dwellers
able to resist the temptation of unrestrained violence? Is there
something peculiar about the violent slum dweller that differen
tiates him from his peaceful neighbour?
“There is evidence from several sources, recently collated
by the Neuro-Research Foundation, that brain dysfunction
related to a focal lesion plays a significant role in the violent
and assaultive behaviour of throughly studies patients. . . we
need intensive research and clinical studies of individuals com
mitting the violence. The goal of such studies would be to pin
point, diagnose and treat those people with low violence
thresholds before they contribute to further tragedies” (Mark,
Sweet, and Ervin, 1967).
Not surprisingly their view was popular with the U S
establishment, for here social injustice was medicalised, racism
not mentioned, the victims were blamed, declared to be men
tally ill, suitable as candidates for ‘scientific research’, and possi
ble psychosurgery. The letter caused a furore in the U S but was
not without its defendants. The two main authors subsequently
published a book called Violence and the Brain and continue
to hold prestigious university appointments to this day.
Psychosurgery is performed very infrequently nowadays, but
it has not been rejected by the medical community. It has an
aura of respect, and its opponents are labelled as politically
motivated, fanatic in their hatred etc. (Morley, 1985).
Psychosurgery is a tragically perfect example that “science is not
an objective truth machine, but a quintessentially human ac
tivity, affected b? passions, hopes, and cultural biases” (Gould,
1980). Many examples of such science and of the pursuit of
sociobiological de'.erminism, its popularity and its extensive
patronage by the rifh and powerful are found in Chavkin’s book.
It is a chilling story which continues. . Every field in biology
is claimed as fortifying the belief that while “we may not live
in the best of all conceivable worlds we live in the best of all
possible worlds” (Lewontin, 1984). Needless to say such a world
is capitalist with the white males at the very top. Biology is
recruited to convince us that intelligence is genetically determin
ed, that we have ‘selfish geners’, arid that men are “compelled
by their gender to be rogues”. (Beckwith, 1984). For a reader
who wants to know more about the sorry story of psychosurgery
and the larger dimension of sociobiology The Mind Stealers can
be highly recommended as a good introducton.
References
Beckwith B. He-man, woman: playboy and cosmo groove on
genes, in Biology as Destiny: Scientific fact or social bias?,
Science for the People, 1984, p 49.
British Medical Journal, Modified Prefrontal Leucotomy. 3: 595,
1971.
Crow T. Is Schizophrenia an Infectious Disease? Lancet
1: 173-175, 1983.
Finesinger J. Comment, Prefrontal Leucotomy as a Therapeutic
Procedure. Amer. J. Psychiat. 105 :790, 1949.
Gould S. The Panda’s Thumb. W. W. Norton, New York 1980
p 225.
Hays P, The Nosological Status of Schizophrenia, Lancet
1 :1342-1345, 1984.
Jacobsen C., The Functions of the Frontal Association Areas
in Monkeys. Comp. Psychol. Monog. 13:3, 1936.
Kucharski A. History of Frontal Lobotomy in the United States,
(Continued on p. 178)
Socialist Health Review
Doctors and Torture
A Report on Chile
r uherSi!ren§th and awareness °f organisations working in the
tield ol health and medicine increase, they will have to identify
newer areas and issues to intervene into the many social,
economic and political processes in society. For only by generalis
ing their intervention or activities they will be able to generate
a health movement. One such issue is the alliance and complicity
of the medical profession with the repressive apparatus of the
state in both capitalist and post-revolutionary societies. There
are many ways in which the individuals and the established
organisations of medical profession help the slate to better
implement, cover-up and justify the repression and its repressive
function. One of the most inhuman of them is the torture of
dissident political activists and all other prisoners who refuses
to submit to the wills of the law-enforcing personnel.
Democratic rights organisations in our country, as well as
all over the world have taken up numerous cases of systematic
violation of rights of dissidents, more consistently in the last
15 years. Interrogation, torture and other harassments with the
complicity of medical personnel have been reported. They have
also campaigned to build up public opinion and have pressurised
governments on this issue. However, they have not been able to
draw the serious attention of the organisations working in the
field of health to the complicity of medical personnel in their
inhuman acts. Such health organisations, due to their own
weakness and the fact that they have started working in
dependently only very recently, have not yet taken cognisance
of the very political as well as medical nature of this issue.
A country which has witnessed the most brutal repression
for over a decade has now shown the way. If the medical pro
fession decides to fight, decides to genuinely observe and
implement the code of ethics it always talks about, it can take
positive steps in this regard. This is the country where a doctor
social democrat, who also became its president tried to change
the social order through parliamentary reforms and was over
thrown by a military coup sponsored by the CIA. He and his
supporters, and tens of thousands who protested were brutally
massacred in 1973 by the military junta of Pinochet. Yes, this
country is Chile, and the president was Dr Allende.
Action of Medical Profession Against Torture
A special report submitted by Eric Stover and Elena
Nightangle of the Committee on Scientific Freedom and Respon
sibility, Washington DC, and published in the New England
Journal of Medicine (October 24, 1985), under the title, “The
Medical Profession and the Prevention of Torture” states that
the Chilean Medical Association “has called on the military
government to end secret detention, the situation in which tor
ture is most likely to take place. Its leaders have met with
members of the judiciary to press for the expedition of more
than 200 complaints of torture that are stalled in court pro
ceedings” This is indeed a highly politically conscious and bold
act in a country where political dissent is dealt with bullets.
The leaders of the Association, of course, suffered for their
boldness. Last August, Dr Pinto Castillo, a member of the
Association’s ethics committee and a Fellow of the American
College of Surgeons, was detained by Chilean security forces.
This act instead of demoralising these progressive forces in the
medical community brought out a new mood of solidarity amongst
them, and the medical and scientific associations in Chile,
USA and other places came out in aid of Dr Castillo who was
banished for 90 days to a small desolate island in Southern Chile
March 1986
without charging him with an offence. The international pro
test, however, had its effect and on August 22, 1985, 16 days
after he was banished, the Chilean military dictators were forced
to release him.
The Chilean Medical Association (Colegio Medico de Chile)
was established in 1948 and has now a membership of more than
9000 doctors who constitute about 90 per cent of all medical
practitioners in Chile. After the military coup of 1973, the
Association, along with all other such professional bodies, lost
its right to elect its own office bearers. However, this right was
restored to it in 1981, and since then, it has played a key role
in focussing attention in Chile as well as abroad, on the medical
profession’s complicity in torture. Dr. Castillo, other members
of the Association have done painstaking work in documenting
the use of torture by the state and in providing treatment to
victims. Dr. Jaun Gonzales, president of the Association in
November 1984, presented to the Chilean supreme court
documentary evidence of cases of torture, and expressed his con
cern over the continuing practice of torture. The association has
not restricted its activities only to Chile. In mid-1985, Dr. Gon
zales along with Dr Carlos Trejo, Chairman of its ethics com
mittee, testified before the US Congress about the Association’s
efforts to stop professional complicity in torture.
Guidelines to Prevent Professional Complicity
in Torture
Stover and Nightingale in their above mentioned report in
form that the Association issued in March 1985, a set of
guidelines instructing physicians not to attend to patients under
certain conditions. This was as a follow-up to the Association’s
public statement in November 1984 warning that it would not
allow itself to be “turned into a haven and bastion for people
who transgress professional ethics”. According to the guidelines,
doctors should not attend to patients:
(1) If the physician has been ordered not to identify himself or
to conceal his identify by physical means;
(2) If the physician encounters a patient who is blindfolded or
hooded or otherwise prevented from seeing the examining
physician;
(3) If the patient is held in a secret detention centre; or
(4) If contact between the patient and physican can be carried
out only in the presence of a third party.
The association has also taken concrete steps to see that
these guidelines do not remain on paper. It has held disciplinary
hearings on the role of five doctors alleged to participated in
the abuse of political detainees. They have also suspended one
army physician, Dr. Carlos Herman Perez Castro, for certifying
that a political prisoner who was tortured, was in a good physical
condition upon her release from a secret detention centre. It
should be added here that all such investigations and hearings
are conducted by the Association in secrecy and public an
nouncement is made only after its 20 member council reaches
a verdict. According to Dr. Gonzales, the president of the
Association, as many as 30 to 40 physicians have participated
in covering up torture in the last one decade and they will con
tinue their investigations till each is properly^ examined by the
committee.
Although these guidelines were issued less than a year back,
they have started to show positive effect. The Association’s ethics
committee chairman reported that after the guidelines were an
177
nounced several military and police doctors had approached the
members of ethics committee to report that they had been asked
by the authorities to examine or treat prisoners who had been
tortured. They also sought assistance from the Association in
informing military authorities that they would not become in
volved in covering up torture.
In a backward bourgeois democracy like India, the flagrant
violation of democratic rights of people is a routine affair. Our
readers need no introduction on the daily torture of detenus
carried out in a small police station to a well maintained tor
ture chamber (like the ‘retreat’in Calcutta) all over the country.
The women prisoners need a special mention as they, in addi
tion, face sexual abuse. In fact, the rape of a teen age woman
triggered off a new wave of protest in the women’s movement
in recent times.
The democratic rights organisations have done significant
work in making torture a political issue. No doubt, doctors have
also participated in such organisations. The recent killings of
a doctor, who was a prominent human right activist, by the police
in Andhra Pradesh shows that individual doctors have played
their role, even at the risk of their lives.
However, the medical community as such has much at stake
in the system and therefore, its official organisations have con
sistently shunned resoonsibility to do anything in this matter.
(Continued from p. 174)
and female development, while complete in certain aspects is also
deficient in other aspects. However, such a change would need
to be accompanied by an effort at understanding how much of
the pattern of human development is a result of socialisation
and how much of it is due to ‘inherent’ or ‘innate’ human nature.
Such an effort is vital, for without it, there is the potential danger
of development theory recognising the importance of both male
and female perspectives of development, yet drawing a clear
distinction between the two patterns and declaring male and
female nature as being ‘inherently different’. As it is difficult
to say different without saying better or worse, women may once
again become victims of such a theory. Finally, since theory
reflects a given social context, a change in development theory
is likely to come about only when social conditions permit a
They did not have enough courage even to issue a sta emen when
a doctor was killed for his human rights act.yH.es. Indeed, they
will take a long time to learn from what their counterparts are
doing in Chile. Thus, the responsibility is now with voluntary
organisations of socially-conscious individuals working in the
field of health to show courage, to build public opinion and
agitate in the official associations to pressurise the medical
community.
Secondly, at the same time, socially-conscious doctors will
have to look into the medical aspects of the problem. As Stover
and'Nightingale suggest in (heir report, physicians (particularly
psychiatrists) need to become familiar with immediate and long
term physical and psychological effects of torture, for the pur
pose of diagnosis and treatment. Although research on the after
effects of torture and the means of treating these effects is still
in its infancy, recent medical research indicates that the major
symptoms of torture victims, which sometimes occur years after
the torture, include feelftig of helplessness, heightened anxiety,
impaired memory and inability to concentrate, nightmares and
phobias. Publishing research on victims aids in the prevention
of torture by informing the public of the pernicious effects of
torture on victims, their families and society at large’’
aj
change in our conception of what we consider ‘male’ and ‘female’
in the psychological realm.
Nalini
C-152 MIG Flats
Saket
New Delhi 110 007.
(Continued from p. 176)
1935-1955, Neurosurgery. 14:765-772, 1984.
Lewontin R, Sociobiology: Another Biological Determinism, in
Biology as Destiny: Scientific Fact or Social Bias?, Science
for the People, 1984, p 4.
Mark V. Ervin F. Violence and the Brain, New York, Harper
and Row, 1970.
Mark V., Sweet W, Ervin F, The Role of Brain Disease in Riots
and Urban Violence. JAMA 201: 895, 1967.
SUBSCRIPTION RENEWALS
Is this your last subscribed issue? A prompt renewal from
you will ensure that your copy of Vol III No.1 on ‘Health
Care in Post-revolutionary Societies’ is mailed directly from
the Press. Many of our issues have sold out fast! So book
your copies by renewing your subscription now!
Our new subscription rates:
For individuals—Rs. 30/- (four issues)
For institutions—Rs. 45/- (four issues)
Foreign subscriptions: US $ 20 for US, Europe and Japan
US $ 15 for all other countries
(special rates for developing
countries)
Single copies: Rs. 8/D.Ds, cheques, IPOs to be made out to SOCIALIST HEALTH
REVIEW, Bombay. Please write your full name and correct
address legibly. And please don't forget to add Rs. 5/- on
outstation cheques.
Morley T. Some Professional and Political Events in Canadian
Neurosurgery. Canad. J. Neurol. Sci. 12: 230-235, 1985.
Phillips C, Zeki S, Barlow H, Localisation of Function in the
Past’ Present- and Future. Brain.
iu/.
iyo4.
Shutts D, Lobotomy-Resort to the Knife Van Nostrand, New
York, 1982, P 50. ibid, p 143. ibid, p 199.
Synder S. Schizophrenia. Lancet. 2: 970-974 1982
S,,M
PsychosurSery Debate; Scientific. Legal
and Ethical Perspectives. W H Freeman, pp 548, 1980
Hindu T Desai
Attending Physician,
Division of Neurology,
Cook County Hospital,
1825 West Harrison,
Chicago, II. 60612,
U.S.A.
178
Socialist Health Review
Problems of Praxis
OUR BODIES, OURSELVES
Organising Women on Health Issues
gabriele dietrich
This article tries to draw on experiences which were made while organising rural women in Tamil Nadu, mainly landless
a^r^cli tural labourers of Dalit background. Health had not been a primary aspect in this process of organisation, it
ta been used as one of several “entry points”, but as things developed, it turned out that health education became
a focal point since it raises the crucial question of women gaining control over their own bodies. This control over women's
bodies, as it emerged, is one of the most important factors conditioning women’s potential to organise and to participate
in decision making. This discovery came as a surprise because “health” is not usually seen as a high priority by village
women themselves. The participatory research process itself was a means to build consciousness about such social con
trols and to find ways and means to break them down.
THE participatory research process which was part of a
project of PR]A (Participatory Research in Asia), took place
in villages near Arkonam, North Arcot among members of a
voluntary organisation called Society for Rural Education and
Development (SRED) and among women belonging to an in
dependent organisation called Rural Women’s Liberation
Movement,
It is characteristic that even the formation of SRED as an
organisation trying to facilitate rural women’s movement, was
already the result of a longer process of organisational ex
perience. The initial attempt had been to organise Dalits (they
were using the term Harijans at the time).
SRED today works in 50 villages of Arkonam and Thiruttanni taluks, 35 villages are “consolidated” villages where cells
of the Agricultural Labourers Union and the Rural Women’s
Liberation Movement Sanghams (founded in 1982) have been
formed, 15 villages are “new” villages in which work has only
started recently. Women’s Sanghams and Agricultural Labourers
Union function largely independent of SRED. North Arcot, like
• Chingleput, is on the whole a very dry area depending on the
monsoon which often fails. Irrigation will be by wells and village
tanks. As in many other parts of Tamil Nadu, the water table
has been affected by the bore wells. There are two crops, mainly
rice, but also dry crops like ragi, maize and kambu (a millet).
Women agricultural labourers have 120-180 days of employ
ment, men up to 220 days. Agricultural wages are as low as
Rs. 6 for .men and Rs. 4 for women. Supplementary income
comes from wood-cutting and selling, also from brickmaking.
The land holding pattern is such that there are largely small
holdings and only very few cases of land concentration. This
of course confines the scope for wage struggles within narrow
limits. It is obvious from this background that the people with
whom SRED works live in abject poverty and struggle for their
very survival.
Integrating Health Work with Women s
Organisation
The SRED did not start off as a health organisation.
However, poverty being so rampant, health is clearly an impor
tant problem. Thus, health work came in mainly as an entry
point for women’s organisation. It was integrated with other ac
tivities like self-employment schemes: mainly embroidery and
tailoring to start with, then mat-weaving, weaving of towels and
sarees and carpentry. Plans are in process to branch out into
March 1986'
cycle and transistor repair. Dairy and poultry schemes have also
been tried.
In Arkonam, a special women’s shop sells sarees and
readymades. The effort to offer weekly opportunity for
gyneacological check-up had to be abandoned due to lack of
response. Apart from such attempts of income generation,
building up rural women’s organisation was the main objective.
The Rural Women’s Organisation has again and again taken up
rape cases, wife murder cases, wife-beating cases, also issues like
water supply and road building, accessibility of the village tank
to all (i.e. including harijans and menstruating women) as well
as health issues, much of the time by putting organisational
pressure to make defunct government services available to the
people. Recently, a journal Women’s Voice (Mahalir Kural) has
been launched to report on women’s problem and the activities
of Rural Women’s Organisation. Again, the journal will also
have a section on health, especially drawing attention to nattu
vaittyam (indigenous herbal medicine). A drawback is that there
are too many men on the editorial board because women lack
training in journalism.
The basic concept is to equip women activists to be barefoot
doctors, to have a basic understanding of common illnesses and
treatments and to make them conscious of improving nutritional
standards even under pressure of abject poverty.
The need for sustained health work first became visible in
1979, when a widow approached the organisation in need of an
abortion. Since she was ashamed of expressing her problem
straight away, she shrouded it in flowery expressions common
ly available in village Tamil for this kind of occasion. (I have
“not taken bath” for 2 months, i.e. missed the menses). The two
young health workers did not understand her and sent her away
with some aspirin. A few days later the village drums announc
ed a death. The widow, in fear of ostracism, had committed
suicide. It was decided to intensify health work and to link it
up with rehabilitation of widows who are generally considered
to be inauspicious and a social liability. A full time health worker
trained in primary health was appointed and she took respon
sibility for training mainly middle aged and elderly women in
primary health, among these a number of widows and village
dais.
From the original 35 villages covered by SRED work, the
women were drawn to get training as barefoot doctors. Since
they are nearly all illiterate, the training went on for three to
four years.
179
There are hardly any institutionalised health services pro
vided by SRED. The community centre at Ulliambakkam runs
a primary health clinic providing allopathic as well as nattu
vaittyam (non-allopathic) services for common illness. Once in
a week a private allopathic doctor comes voluntarily for con
sultation in more serious cases. At Kaverirajapuram, a cobblers
village, once in a week a health clinic goes on under a tree with
a homeopathy doctor who comes as volunteer. In Konalam cen
tre, clinic work was started but had to be abandoned because
of transport problem (it is inaccessible by public transport). At
Mulvai a clinic was started with a gynaecologist, but this too
had to be abandoned because of transport problem.
There are now eleven girls at the Kallaru centre who are
working in self-employment schemes. Six of these also do pan
time health work. Three women full timers of SRED are ap
pointed for training work in primary health. SRED has
altogether eleven full-timers now (seven men and four women).
Even the men animators who mainly work with the union and
do work with men and women there, get all the primary health
education with special emphasis on women’s problems.
Emerging Concepts of Health
When health work was taken up by SRED, it was only partly
integrated with the perspective of women’s organisation. It was
intended that health work should help to rehabilitate widows
and would make basic knowledge of primary health available
to a large number of women. However, the content of health
education was rather complex and, as it turned out, rather con
tradictory. It cannot be claimed that all the underlying assump
tions have been fully clarified but at least certain trends have
become identifiable.
On the one hand, there was an attempt to make govern
ment health services available which would imply a curative
allopathic approach. This was complemented by seeking the help
of voluntary agencies working with an approach of preventive
medicine along allopathic lines. This also implied a certain
technical enlightenment about family planning methods, much
along the lines of government programmes but without the coer
cive implication of these. The underlying assumption here was
that use of family planning methods would automatically benefit
women. On the other hand, there was an effort to enable women
to really master their own health situation as self-reliantly as
possible. This effort was undertaken by methods of nattu
vaittyam mainly on herbal base, as well as cheap food sup
plements. The participatory method which was pursued, finally
led to the insight that, instead of using health exhibitions
prepared by.experts, a team would be formed to prepare an ex
hibition, especially on the reproductive cycle and birth control.
This led to a conflict with the technical approach pursued before
and to the discovery that perceptions of sexuality were crucially
influencing women’s ability to apply birth control methods as
well as women’s ability to gain mobility and organise. Since these
discoveries were an integral part of the participatory research
process, it is necessary to follow this process step by step.
In the initial phase, a two day meeting took place, one day
with animators of SRED and one day with about 30 women
from the Rural Women’s Liberation Sanghams. Initial discus
sions circled around questions like: (1) What are the most com
mon illnesses? (2) How frequent are death in childbirth and child
mortality? (3) How frequent are abortions? and so on. It turned
out that all of these questions can only be answered within the
overall context of abject poverty of the people in this area. Most
common illnesses like diarrhoea, dysentery, fevers, breathing pro
180
blems have all to do with general malnutrition, lack of water
and basic hygiene and the constant worries of survival. Apart
from this, some ailments were identified as occupational or en
vironmental. There was widespread tuberculosis, probably with
underlying byssinosis, among the workers of a cotton mill and
there was a village where people suffered from water-induced
paralysis. While death in childbirth is not a very frequent oc
currence nowadays (partly because of the thorough retraining
of village dais), child mortality remains high, especially among
girls. Abortions were obviously widespread and a follow-up on
this question showed that they are more rampant than assumed.
While government services are available in a number of places,
they are often defunct and in many cases people also do not
have the money for the bus to go to the next health centre.
This overall situation accounts for some of the basic
priorities in the health work which were pointed out: To
strengthen self-reliance by teaching cheap basic nutrition and
herbal medicine; to help to make existing government services
available; to propagate family planning.
It was then decided to proceed with the participatory
research in the following manner: (1) To document experience
where people had organised in order to make government health
services available to them. (2) To document the use of herbs,
home remedies, indigenous medicines (nattu vaittyam) and to
record the positive and negative experiences with such methods;
also to document positive and negative experiences with
allopathy in comparison. (3) To go more specifically into the
question of women and health—how do women understand their
own bodies? What is their understanding of the reproductive
cycle, of birth control etc? Are information and contraceptives
available? What are the social taboos? (4) In which sense is the
health work an entry point for other women’s work? How does
it relate to the other work and to the process of getting organis
ed? Why does this work pick up in some places and not in
others? (5) What are the most important aspects of the women’s
work to the women themselves? Why do they feel it is an ad
vantage to get organised? What are their difficulties in getting
organised?
It was felt that in order to come to grips with questions
2-5, it would be necessary to have extended discussions and one
way to generate them would be to conduct health festivals in
different villages with exhibitions, skits, songs and pattimantrams (debate). Apart from the festival itself, the collective pro
cess of preparing it would give a lot of opportunities for ex
change and clarification.
Already at this stage it became visible that there are indeed
very strong social barriers against women taking control over
their own bodies. It turned out that many of the village dais
who knew everything about delivery, have a very rudimentary
understanding of the reproductive cycle. Many women said they
did not know about birth control methods. Some had used
abstinence in order to space births.
The women said that the health work helped them a lot
to build women’s sanghams and most sangham members have
an acute awareness of health and nutrition, so much so that
many sangham leaders become free lance barefoot doctors and
health workers. They felt that they learned a lot in the process
and derived self respect from this. At the same time their com
petence about nutrition and simple illnesses also had increased
their awareness of health as a business, the profits of the drug
industries. Ironically, it seemed often to be the abject poverty
which turned out to be a learning aid here. Since expensive nutri
Socialist Health Review
tional supplements and sophisticated medical services were out
of reach anyway, the -do it yourself” approach looked hke?he
°he drive forPXn’ i^0”8
S‘ightly m°re affluent familiesadver sine a s.elf-reliance."ould be less and the influence of
a„S and ,lmPact
a consumerist allopathic approach
hp d
h m?re’ ‘ WaS als0 felt that the health t0Pic ne«ied to
be discussed more in the agricultural labourers union and that
building a new health system needs to be part of overall transfermation of society.
Deepening Levels of Participation
Originally, the health festivals which were organised also
included family planning propaganda. Though this propaganda
was not particularly oriented towards achieving targets, it shared
the commonplace middle class assumption that small families
are necessarily happy families, that women only have too many
children out of sheer ignorance and that women will happily
apply family planning methods once they get acquainted with
them. These assumptions had obviously been inculcated in the
process of training health workers to propagate family planning
and were not supported by the actual experience of working with
village women. It became clear in the process of the participatory
research where they went wrong and how they needed to be
corrected.
A series of health education meetings were held with dif
ferent types of people, e.g. the girls who learn tailoring in the
Kallaru Centre, social workers, nurses, village dais, women who
belong to the women's organisation. Apart from general health
topics like hygiene, use of native medicine, etc. special emphasis
was laid in these meetings in building up knowledge about the
functioning of the reproductive system and to build up a dif
ferent attitude among women towards their own bodies. This
is no doubt an extremely difficult task, since everything related
to menstruation, sex, childbearing and childbirth is usually taboo
and it definitely belongs to the upbringing of a “good girl” not
to mention about “these things”. The general pattern is that
“men are supposed to know” while women are best kept in ig
norance. The underlying social assumption is that a girl who
has any sexual experience, has been “spoilt”. A further assump
tion often is that even “knowing about those things” “spoils”
a girl.
It is also difficult to evolve methods which allow women
to open up. One method is sharing personal problems in small
groups of two and three. Another method is to talk about all
parts of the human body and their functions in order to build
an awareness that sexual and reproductive functions are as
natural as any other functions of the body. Besides, slide shows
were used about the reproductive system. On delivery, role play
ing has also been used.
There are different kinds of barriers to be overcome in dif
ferent categories of participants in this kind of a programme.
Among young participants, most of whom will be unmarried,
there is a general embarrassment which' has to be dealt with,
giggling, and a certain reluctance to face realities. Among village
dais and more elderly women from the women’s sangham, there
is greater sobriety in facing reality and drawing on one’s own
experience but the actual level of information is very low.
In a meeting with young girls in which I participated, the
embarrassment was such1 that participants closed all the win
dows while slide show was going on so that nobody would be
able to overhear what was discussed and the showing of slides
was accompanied by exclamations and giggles. While the girls
March 1986
expressed afterwards that they found it useful to know all these
facts, the question arises how they can be dealt with in real life
since the actual taboo of knowing is so great that admitting such
knowledge easily leads to accusations.
In another meeting with elderly women (village dais and
women’s sangham leaders) it turned out that though the women
had experience and understanding about childbearing and
delivery, many of them did not know about methods of birth
control. Some of them had used abstinence in order to space
child births. Some confessed to having had abortions. Some had
reservations because they found it risky to go in for permanent
methods because of child mortality. The tendency in the discus
sions was to place before the woman the options of birth con
trol (e.g. loop and copper T, operation, etc.) in such a way that
they appeared as the scientific way to go about things while
abstinence from intercourse was looked at as unscientific and
unnecessary infringement of the marital rights of the husband
which would create tension and misunderstanding.
In the course of the discussions it became visible that the
approach of the SERD animators was somewhat inconsistent.
They had the tendency to depict tubectomy as a very good
method of family planning because it solved the problem once
and for all. It also transpired that, if a woman gets operated,
she may have even less control over the frequency of intercourse
than before because “nothing can happen” anyway. The man
can assert his “right” over her body more easily since no risk
of creating further offspring is involved. Woman also felt that
they would face more accusations of infidelity if they used con
traceptives. The animators applied a “harmony model” oriented
towards fertility control only, suggesting that it was quite un
necessary and unscientific to deny a man intercourse in order
to space births. It became visible that abstinence in some cases
was a simple way of ascertaining sovereignty over one’s body—
an effect which could not be achieved with all the nice scien
tific technical methods which may in fact contribute to weaken
a woman’s control over her sexuality. Women also come up with
their views that having to be sexually available hampered their
mobility. They found it difficult to come for night-meetings
because they would be late in coming home. Even elderly women
complained of the need to be sexually available very frequently.
Sexuality was very much perceived as part of the sexual divi
sion of labour, women providing services and man consuming
the same. It also became apparent that even women’s access to
hygiene is very much related to sexual division of labour as well
as threat of sexual violence.
While certain general rules like tethering cattle or covering
food can be easily followed, it turned out that women do not
easily have basic access to hygiene. On being questioned about
when they take bath, the usual answer is “on Friday”. Friday
is the day then they take bath, put turmeric, flowers and clean
clothes and go to the temple. The men on the other hand have
a daily bath. The problem is not scarcity of water because women
may be handling water all the time, washing clothes, scrubbing
vessels, watering plants. The problem is one of the division of
labour and length of the working day. Women simply do not
find the time to take bath. A bath is a luxury reserved for man.
(Indeed, detailed enquiries into the working day of women and
men among landless agricultural labourers have shown that
women work up to six hours more every day.)
Another problem is the lack of privacy. It is more difficult
for women to take a bath because women have to be constantly
careful not to expose themselves to other men’s eyes. This pro
blem also affects their toilet habits. Women go to the fields very
181
early in the^morning or late in the evening. The contradiction
is that it should be dark in order to be less exposed, on the other
hand, it is more dangerous to go out in the dark because of the
danger of assault. All this leads to constipation and strain on
the bladder. The problem gets aggravated during menstruation
and pregnancy.
These conditions are so much taken for granted that it is
extremely difficult to discuss them at all. It is extremely hard
to think of any alternatives. Common toilets in the villages
(“WCR toilets”, a government programme) never work for lack
of maintenance. One alsb wonders whether it is right to have
public toilets for women and men in one cubicle just separated
by a wall and with different entrances. If the toilets for women
were in one locality and those for men in another, it might work
better. Private toilets are entirely absent because of the money
investment, water problem and fear of bad smell close to the
living place. An experiment with a Gandhian dry toilet by two
health workers was also given up. So at the moment, it is very
unclear in which direction to go. However, by being able to slowly
talk about the problem it becomes clear that the situation is quite
unbearable and thus the motivation to tackle it slowly grows.
There are also questions about how to deal with menstrua
tion. Women use old rags for sanitary towels and it should be
explored whether it could become an avenue of self-employment
to produce cheap sanitary towels at the sewing centre in Kallaru.
It was also observed that bathing places for women have vanished
over the last ten years due to environmental factors. Generally,
the water table in the area has gone down because of bore wells.
Many temple tanks have gone dry and others have been reclaimed
for agriculture. Even where they still exist, the men are washing
lorries in them. So the old custom of women going to the
village tank to bathe, wash clothes and chat with each other has
been abandoned. This not only undermines cleanliness but also
women’s solidarity. The question comes up whether the women’s
organisation can try to create a new place for women where they
can wash, bathe, chat and spend some time together.
The Social Roots of Abortion
It transpired in the course of time that abortion is a much
more gigantic problem than was evident from the beginning. In
a discussion with middle aged and elderly village women it turn
ed out that nearly all of them had experience with abortion,
either undergoing them or performing them or both. Abortion
is virtually a ‘cottage industry’. It is usually carried out with home
remedies as eating green papaya, swallowing large quantities of
camphor and turmeric. The most widespread and most
dangerous method seems to be the use of irakkan chedi (a plant
the white blossoms of which are offered at Ganesh chathurthi).
A dried yellow leaf of the plant is taken and the stick in the
middle of the leaf is taken out and shoved up the birth channel
into the uterus. This procedure causes ferocious infection and
bleeding and any lead to severe puss formation and even blood
poisoning and death. All the same, the method is widespread
since it is free of cost and very “reliable” in the sense that the
foetus does not survive. Often women have to go in for medical
treatment in order to survive.
As far as infanticide is concerned, it remains a pious wish
to say that girl babies should be treated equal with male babies.
A substantial part of the problem of child mortality is in fact
the problem of the morbidity of the social system of patriarchy.
At the present moment, it is not yet visible how the women can
go beyond discussions towards concrete solutions. The sobriety
with which some of them admit infanticide is breathtaking and
heartrending at the same time.
182
The facts of abortion and infanticide again raised the ques
tion why family planning is used only by a few. It was recognised
in the course of the discussions that “family planning as such
is often resented as a form of government interference in family
affairs. It is therefore much more meaningful to discuss the pro
blem as birth control in the overall context of allowing women
control over their bodies and over their health. The unpopularity
of sterilisations is based on two factors: a) People shun irrever
sible methods because of child mortality, b) socio-cultural bar
riers. Men think they lose their “virility” when they get sterilis
ed. They think they will be “weak” and unable to work suffi
ciently to support the family. There is also a feeling that a woman
who has lost her fertility for good is treated with less respect.
The problem seems to be that such “loss of respect” does not
get compensated by a feeling of having gained control over one’s
own body because control over sexuality remains entirely with
the man and may in fact be more than before. So the humilia
tion and actual subjugation which may go with operation may
make it less acceptable than the risk of having abortions. Though
the abortions entail great.suffering, they are a matter of woman’s
own choice at a crucial moment and they are executed entirely
among women. Thus, to get away from the abortions can only
be achieved by means which would in fact enhance a woman’s
control over her own body.
Conceptualising Sexuality, Fertility and
Male-Female Relationships
A series of 45 posters was made (basically using VHAI slides
and Our Bodies, Ourselves as models) entirely on the the
reproductive cycle, the sexual and reproductive organs, ovula
tion, fertilisation, pregnancies, the birthing process, cancer detec
tion, sterilisation etc.
This exhibition has advantages over slides in that it can be
used without electricity and that women can look at it at their
own place. While a slide show just reels off under their eyes,
they can go back to earlier posters for clarification, can con
template them at length if necessary and ask for explanations.
It is very important to be able to dwell on the problem at length
because the actual embarrassment of facing one’s own insides
in this way is beyond all measure. Women admitted again and
again to have been shocked at what they saw but they also
expressed surprises, joy and pride. Even the health worker who
explained the posters had to fight her embarrassment and had
a tendency to rattle down the information in great haste in order
to have done with it as soon as possible. It was later decided
to avoid this and to first give the women a chance to react and
to ask questions. One old woman objected violently: If women
know all this in advance, how will they ever have the courage
to get married at all. But young women counter-argued that this
would support them to be less ignorant and helpless than before.
The exhibition was first shown in Ulliambakkam to about
50 women of.different ages who had come from surrounding
as well as far away villages. They were all-sangham members.
It was later shown to the girls in the Kallary centre who are in
the self-employment training and partly in health training. When
we discussed the exhibition in these different collectives, we
discovered some lacuna in it which were later overcome as a result
of these discussions. The 45 posters only dealt with the female
body exclusively. It therefore did show tubectomy but not
vasectomy.
This had done out of a feminist motivation to come
to terms with “our bodies, ourselves”. However, it was felt that
this approach was not true to reality. The male contribution to
pregnancy became visible only in the form of a few sperms the
Socialist Health Review
most expressive poster of this kind being that of a giant sperm
wriggling its way towards the egg (“pampu pole”—“like a snake”,
as the women said). It was felt that there is surely more to getting
pregnant than just that. Why did it seem to be difficult to face
and depict this “more”? One underlying problem seems to be
the sheer habit of exhibiting, exposing and even dissecting a
women’s body without great problems, quite in contrast to the
actually imposed “modesty” and “shyness” of women. On the
other hand, while men uninhibitedly and even shamelessly ex
pose themselves, including their private parts in public while they
relieve themselves, there is much more of a tamboo to actually
depict a man’s body, leave alone his genitals on a poster. This
is one reason why we feel so free to dissect a woman’s genitals
and reproductive organs while we find it difficult to look at a
man’s penis and testicles with the same kind of detachment. It
was therefore felt necessary to depict the man’s reproductive
system as well and to admit the involvement of the penis in in
tercourse. It slowly surfaced that there is a need to understand
in greater depth the relationship between sexuality and fertility
in order to come to terms with the overall problem of birth con
trol and control over a woman’s body.
The difficulty in doing this can be easily illustrated by the
fact that one of the great revelations to women is the news that
they actually have “three holes” i.e. urinary outlet, vagina and
anus. Virtually none of the women were aware of this before
marriage since there is total taboo on talking about one’s body.
One young girl said that she thought for a long time that talking
to a man and laughing could make a girl pregnant since this
was what her parents forbade her to do. Even when giving birth
the first time, some women, are still confused where the child
actually comes out. In the posters, the female genital organs
were entirely depicted from the point of view of fertility. The
fact that women have a sexual organ of their own in the form
of the clitoris which is not related to fertility was felt to be too
much of a shock to be disclosed at this stage. The female body
is seen entirely in terms of fertility, even as far as woman’s own
subjectivity is concerned. Women may be “male sex objects”
but the question how they could possibly be subject of their sex
uality and perhaps enjoy it, is kept out completely. Even women’s
protest against making women sex objects is often carried out
by mobilising values of motherhood and nurturing. Women as
sovereign sexual being seem to be unthinkable to women and
men alike. However, this is not just a question of a women’s
general quality of life, it has quite devastating medical implica
tions and at times becomes a question of life and death.
to control her own sexuality to acknowledge man’s responsibility
for fertility which would also establish the necessity tojsee male
sexual needs in relationship to female sexual and other physical
needs and to the problems of fertility as a shared problem.
Perceptions of Marriage
These discoveries led to deeper discussions on sexuality and
fertility and on th£ actually existing patriarchal system of the
family. It came out that women, while they see themselves as
childbearers and as beasts of burden, most of the time experience
sex as one more household chore like fetching water and
firewood, cooking and serving food, finally surrendering their
own body. These discussions were very interesting because the
women felt free to speak out in a large group while at t^e same
lime a few of the men animators were also present so that there
was a certain amount of interaction between women and men
as well. Since men are seen as primarily sexual beings, the
assumption seems to be that sex is their birthright and their
supreme need, their “full satisfaction** an ultimate goal to which
all other considerations have to be subordinated (e.g. refusal to
use condoms). In a big meeting with fifty women only two said
their husbands used them. On the other hand the sexual satisfac
tion of the women does not come into the picture. Since the
men enjoy sex, they presuppose that women also do so. On the
question whether they know what their women feel they said:
How can we know, we have no words to talk about “such things”.
Men were completely taken aback when married young women
said that they enjoyed caresses and tenderness while they often
hated actual penetration.
Since “full sastifaction” of the man is the supreme value,
the women needs to be ever ready. Women are often not allow
ed to go to night meetings leave alone to seminars which last
several days, because they will not be available at home. The
women are also frightened that if they do not provide these con
stant services, the man may shift to another woman and ditch
them. Even elderly women face the problem of daily intercourse.
This led to the characterisation of a man’s attitude towards
marriage as a “facility” (Tamil: vasathi). Men get married when
their mothers get too old to cook for them and they expect from
it all the services like cooking, washing, health care, childbear
ing and rearing and sex. The one service they render in return
is “protection”(pathukappu) which in fact only becomes
necessary because of the general violence against women in socie
ty which makes marital rape preferable to the constant danger
of indiscriminate sexual use, gang rape and the like.
Men, on the other hand, are primarily seen in terms of sex
uality, they are first of all sexual beings. The fact that their
orgasm is achieved by ejaculation of sperm which make preg
nant (while a woman’s orgasm is entirely independent of fertility)
is generally neglected. Since it is the woman who gets pregnant,
fertility is “her” problem. But in fact “her” problem is that sexual
satisfaction in the man is related to fertility. Precisely this is her
actual health hazard. It was therefore felt that an exhibition on
the reproductive cycle needs to depict these facts of life in a
truthful manner.
It seems to be clear that unless woman’s right to control
their own bodies becomes an accepted human right, the use of
contraceptives remains a remote possibility and women may go
on for a long time undergoing home made abortions and allow
their babies to die of neglect.
Summing up, it can be said that the health work had focus
entirely on problems of fertility which was seen as a “women’s
problem” which had virtually nothing to do with'sexuality as
far as the woman is concerned. Sexuality only came into the
picture in the form of rendering sexual services to men who were
seen as sexually starved and needy but had virtually nothing to
do with fertility except'that, unfortunately, the sexual act does
make women pregnant. The task identified was therefore to
acknowledge woman as a sexual being, to acknowledge the right
In the workshop which accompanied the exhibition and
which brought out most of the crucial insights which are summed
up above, a lot of other information also came to light which
at a closer look, seems to be very much related to the social
rrfechanisms which withhold from a woman control over her own
body. All the women believe in seclusion during menstruation
They should not touch foodstuffs (especially pickles), should
not go out, should not bathe and put flowers etc. They experience
March 1986
Discussions on Menstruation, Pregnancy
and Delivery
. 183
jects in dealing with their bodies instead of making them ob-
themselves as impure and weak. They should not use disposable
sanitary napkins because if some animal eats these, this will cause
the fertilised egg not to settle in the uterus or early miscarriage.
If menstruation ceases in a woman due to anaemia (which does
happen since anaemia is widespread), this is ascribed to a
“spirit”. It is also related to the goddess Katteri. When they are
pregnant, women are more susceptible to be possessed by spirits.
They are also not to cross rivers and should avoid going out.
There are the me^t comprehensive food taboos on pregnant
women (on the list of foodstuffs to be avoided are : coconut,
mango, papaya, jaggery, raw rice, grapes, bananas, jack-fruit,
sweet potato, potato, maize, kambu (a millet), tinai (another
millet) and a number of vegetables, including kirai, and eggs).
Women are even restricted in their water intake. One really
wonders how they keep alive at all with a diet chiefly consisting
of rice and virtually nothing else to go with it. The idea is that
the placenta may grow too big or that the child will be too big
and delivery difficult.
Women are also kept in the dark about delivery. Since they
are brought up in the belief that a spirit or a god leaves the child
at the doorstep or that the old lady who sells vegetables has
brought it along, they find it difficult to envisage the process
of delivery even during first pregnancy. Some think the child
many come out through vomiting from the mouth, others believe
the belly may open underneath the naval. Some believe that the
child comes out from the rectum. Some believe that the child
comes out piece by piece, hand from hand, eye from eye and
then gets assembled. Only three young girls had learned about
pregnancy and delivery at school and one girl had got a rather
realistic picture by overhearing other women talk about it. While
exposures like the poster exhibition go a long way to set such
beliefs right, a lot remains to be done to enable women to be
in command of their bodies during delivery, by breathing
exercise and methods of natural childbirth. It is quite a step
to recognise that the pain during labour is due to contrac
tions and that the rpost efficient way of dealing with it is
not to clench one’s fists and grind one’s teeth while waiting
for it to go over, but that there is an active way of combatting
the pain by systematic breathing and relaxation. It is envisaged
as a future step to go into methods of natural childbirth more
systematically. It also remains to be explored to what extent this
process can be explained to men and whether men can be in
volved in deliveries in a supportive way.
It is also important to see these prevailing superstitions
about women’s bodies during menstruation and pregnancy in
the overall perspective of violence againast women and oppres
sion through perpetuated ignorance. The tendency sometimes
is to ridicule women for their ignorance and superstitions.
However, many of these are just an expression of concretely ex
perienced powerlessness and isolation. Nodbody would nowdays
easily come forward to blame a Dalit for his belief in un
touchability. His mindset will be seen as the product of an op
pressive system. Women’s minds deserve to be understood in this
overall framework as well.
Lessons Drawn
It is certainly not easy to draw clear cut lessons from a lear
ning process as complex as the above described. One definite
result is that the participatory research project itself has created
more intense involvement and mass participation in the health
education. Apart from this, the following observations can be
made:
I. Certain contradictions were discovered between different ob
jectives within the health programme, e.g. the activity of mak
ing defunct government services available and then dispensing
health services rather at random, was in contradiction with the
overall approach of using nattu vaittyam, making people sub
184
iects and consumers of treatment.
This is no doubt a very far reaching and complicated pro
blem which can probably not be resolved on the ground of ex
perience within SRED alone. Experiences of a more participatory
use of allopathy have to be taken into account and also ex
perience in the use of different systems (like, ayurveda,
homeopathy, yoga treatments) need to be absorbed.
2. Another contradiction which became visible was between
organising and pursuing a very technical, propagandistic ap
proach towards family planning, much along the lines of govern
ment programmes. In the course of the research this approach
changed completely towards birth control in the context of
establishing women’s control over their own bodies and their
own health, and becoming clearer about the link between sex
uality, fertility and social controls.
3. During the change of approach, major changes in language
became necessary, e.g. today it will no longer be said that a girl
“has been spoilt” if she has been sexually used. Also, the tradi
tional word karparhippy for rape (which means destruction of
chastity) has been replaced by balat karama (sexual violence).
While it may look surprising that all this should be part of
a health programme, it touches deeply upon the underlying
assumptions about and attitudes towards a woman’s body.
4. It became increasingly clear thay many health problems can
not be tackled without tackling the underlying social root cause.
E.g. the prevalence of illicit abortion and occurrence of female
infanticide cannot be tackled without making the effort to break
male sexual controls over women’s bodies and transforming
social relations and production relations within the family. Even
access to basic hygiene is dependent on this.
5. It was felt that this is indeed quite a frightening perspective
because it means overthrowing thousands of years of historical
heritage. The question is how this can be done concretely. Some
possibilities seem to emerge: (a) The discussion on the relation
ship between sexuality and fertility as reproduced above and the
different impact it makes on the roles of men and women in
the family and in society at large needs to be deepened in the
women’s sangham and among men as well, (b) Methods have
to be evolved to help people, women and men alike, to face these
new insights and to live with them. Since women in the village
as a rule cannot walk out on their husbands, they have to find
a way to survive in dignity as also to take a lead to transform
ing the relationship. Since women are traditional relationship
builders, they have the wealth of a historical heritages to own
and to fall back on. Of course, their major objective should not
be to redeem men but to learn to live their own lives. All the
same, some redemption of man may occur in the process.
Apart from the need to collectively support women (e.g.
against wife-beating in concrete cases or by holding seminars
on rape, including marital rape), there will also be the need for
individual counselling of persons and couples. If such counsel
ling happens in the overall context of building women’s'movement, agricultural labourers union, health movement and peo
ple’s science movement, the effects of it will be much more con
structive and transforming than the normal opiatic marriage
counselling or just technical advice on family planning.
The experience of SRED on the relationship between
women’s health and the structures of patriarchy in the family
and society at large need to be shared with people working in
the field but also in the women’s movement, people’s science
movement and other mass movements.
—gabriele dietrich
c/o ECC
Whitefield
Bangalore
Socialist Health Review
Politics of Information
rosalie bertell
Recently two US women whose husbands had died of cancer due to radiation exposure filed a suit for damages against
t ie company concerned as well as the United States government. This article, condensed from “Index on Censorship”
(14 5 October, 1985) reports how the US judge assigned to the case subordinated public health and safety to the interests
of the government nuclear programmes. Nuclear advocates including scientists and scientific journals have applauded
the judgement and have widely circulated it. What is being sought to be overlooked is that the judgement is not only
biased but uses false scientific arguments and is full of obvious errors and misstatements.
TWO widows of cancer victims and two survivors of cancer
conclusions. Both Cliff Goff and Dr Michael Fox, workers at
among former employees of the Aircraft Instrument and
the Hanford nuclear facility ( a US weapon factory complex),
Development Company (AID Co) brought suit against that com have used it as the basis for letters-to-the-editor attacks on
pany, 23 other companies and the US federal government, which
reporters who have quoted Dr John Gofman. Dr Sidney Marks
has the ultimate responsibility for regulating industries using
of Battelle Northwest Laboratories—a former Atomic Energy
radioactive material. This case, cited legally as Johnston vs
Commission official who has tried to suppress the findings
United States, 597 F. Supp. 374 (D.Kan. 1984), involved a com of excess cancer among Hanford workers as reported by
pany which purchased instruments with radium-painted dials
Drs Thomas Mancuso, Alice Stewart and George Kneale—has
at salvage for reconditioning. In addition to its regulatory role,
handed reporter Karen Dorn Steele an underlined copy of the
the US government was the first owner of the instruments pur Kelly opinion. The February 1985 issue of Nuclear News con
chased by AID Co. The 23 companies had manufactured and
tained an uncritical summary of the judge’s opinion with no
marketed these instruments without warning signs.
reference to the underlying scientific debate or issues in ques
The companies involved, after reviewing the plaintiffs’ case,
tion. The magazine has never carried stories on the praise given
the expert testimony and their own defence, decided to settle these same scientists in other court cases.
out of court, jointly awarding S 400,000 to each of the four plain
The April 1985 Newsletter of the Health Physics Society
tiffs. The federal government however, refused to settle out of contained the first article of a four part series called: ‘Highlights
court and launched a vigorous case defended by a team of seven from the Decision of Judge Patrick F. Kelly in the case of Johnson
US Justice Department lawyers in the US District Court for the vs United States’, by John R. Horan, former Chief of
District of Kansas. The judge was Patrick F. Kelly and there was
Radiological Safety, International Automic Energy Commission
•no jury. After 42 days of testimony (5,509 pages of transcript), (retired 1983). This lead article gives some background to the
Judge Kelly closed the case of Johnston versus US government
Kansas event mentioning the case previously lost by the US
with a 150-page opinion issued on 15 November 1984, ruling government, the more than 4,000 lawsuits pending against the
against the plaintiffs and'for the government.
United States alone, and the 1979 decision of the US Depart
The extraordinary aspect of this ruling concerns the use of ment of Justice to devote ‘the necessary time and effort to
this case to vilify three expert witnesses called to testify for the developing a team of specialised lawyers with the requisite scien
workers: Dr Karl Z. Morgan, Dr Carl Johnson and Dr John tific background and expertise’. It was this specially developed
Gofman. To quote from Judge Kelly’s written opinion:
team which the US government used to fight the two widows
The paramount and obvious everriding interest (of this case) and two surviving cancer victims and ‘discredit’ their expert
has been to ‘put to rest once and for all, the likes of Drs Gof witnesses in the Kansas court room.
man, Morgan and Johnson’...
This is an extraordinary way to conduct science. The first
The plaintiffs’ claims are simply secondary to the interest of three pages of the Health Physics Newsletter contain nothing
the United States.
but exerpts from the Kelly opinion, without allusion to even one
He expressed the hope that his views of Drs Gofman, piece of scientific evidence or interpretation disputed before his
Morgan and Johnson would influence other courts in which they court. Unless the readers had access to the 5,409 pages of trial
are scheduled to appear. On the other hand, Judge Kelly finds transcripts they would have no way to test Judge Kelly’s opi
the US government’s expert witnesses, Drs Maletskos and nion on the health effects of radiation against their own opi
Auxier’s methods ‘wholly objective,honest and. reliable’. Judge nions. Similar excerpted vignettes from the Kelly opinion have
Kelly declared that he believed nothing of plaintiffs expert been duplicated by General Public Utilities, the company respon
testimony and all of the government’s expert testimony. He sible for the Three Mile Island reactor accident, on 20 x 20 inch
praised the government’s witnesses- as ‘superb’, ‘eminent’, ‘the posters and sent all over the world.
court’s favourite witness’, ‘a refreshing and wholly qualified
witness’, ‘wholly effective, honest and reliable’, ‘brilliant’, ‘realistic
What Is ‘Safe’?
and sound’, ‘impressive’ and ‘most convincing’. The opposite
This extraordinary personal attack on three US scientists
remarks were made about Dr Karl Morgan, Dr John Gofman
calls us to a serious study of its motivation. It requires, at the
and Dr Carl Johnson.
Judge Kelly’s conclusions do not merely pose a question very least, a reflection on the basic scientific issues ‘settled’ by
of unrestrained character defamation. They also represent a the court. The passing off of a judge’s opinion which apparently
break with previous US court cases dealing with exposure to endorses the nuclear industry and censures its critics, without
ionising radiation. Judge Kelly failed to quote or append to his issue discussion is unprofessional, to say the least. Never before
ruling any previous court rulings, even the recent Colorado, Utah have scientists appeared so needy of praise from a non-scientist
and Pennsylvania court decisions in which radiation injury set as the nuclear community exhibits in this instance.
First let us look at Judge Kelly’s logic. He repeatedly ex
tlements were awarded. In these cases the expert witnesses pro
duced by the government failed to convince the court that ex tols the Biological Effects of Ionising Radiation Committee
(BEIR) of the US National Academy of Science as the ‘world’s
posure to ionising radiation at low levels was harmless^
Nuclear advocates have widely distrubuted Judge Kelly s irrefutable experts’. Although the BEIR committee states that
March 1986
185
a 0.5 rem radiation dose to the general public yearly will result
in 6 per cent cancer increase, 0.6 per cent increase in birth defects
and a 15 per cent increase in ill health, Judge Kelly concludes
to the contrary that there is no evidence leading one to cJxpect
radiation injury at exposures less than 50 rads (this is comparable
to 50 rem). He states that even 72 rads may be safe. This con
clusion of the court was not quoted in the Health Physics
Newsletter or the other nuclear public relations material. The
judge’s notion of ‘safe’ is not clear, but certainly most persons
ih the Health Physics community would find even 0.5 rem per
year to the general public ‘not safe’. Judge Kelly’s opinion (that
allowing such high exposures carries no risk, is the ‘international
consensus among experts’) is quite false.
Judge Kelly’s preferred experts pronounced 40,000 picocuries
of plutonium and americium a ‘safe’ body burden for atomic
workers. In contrast, a US Department of Energy study show
ed a 33 per cent increase in chromosome damage among workers
receiving 400 to 4,000 picocuries body burden. These studies of
workers have also shown excess brain, lung, central nervous
system and digestive system cancers, and leukemia (see New
Scientist, 11 October 1984). Judge Kelly wrote: ‘The four plain
tiffs in this case have had numerous whole body counts (of
radioactivity), each reported as negative, and which conclusively
prove that they have no radium in their bodies’ This is in direct
contradiction of the trial Exhibit No 12, 148, showing that the
plaintiffs had whole body counts, performed by Helgerson
Nuclear Services, which were between 132 and 330 times normal.
The judge apparently confused the radium dial painters exposure
and tne exposure of the plaintiffs to the hardened, flaked radium
dust 10 to 20 years later. The GI tract uptake for the water solu
ble radium paint would have been much higher, and incorpora
tion of radium in bone for dial painters was- detectable with
whole body scans. Three of the four plaintiffs were exposed
primarily to inhaled radon gases and its decay products, not to
radium. One plaintiff had cancer of the colon. For these types
of exposure there is no expectation of finding radium, the precur
sor of radon gas, in borfe. These facts were not conveyed to the
Health Physics audiences.
The company at which the plaintiffs worked had dubious
radiation safety practices. A letter from Mr Gaughan, Radia
tion Officer to Mr Fulks, Manager of Aircraft Instruments
Development (AID Co) was also submitted to the court as
evidence. The four workers with cancer had never been warned
of the hazards of radium dials and pointers of the instruments
they were re-conditioning or the dubious safety record of the
plant. A US Occupational Safety and Health Administration
inspection of the AID Co reported readings up to 100 mR/hr
(a reading which would be normal for a year but not an hour)
and over 2 million counts per minute (2 to 25 counts would be
considered normal). It was only after the plant had operated
for over 15 years that it first purchased an instrument capable
Now
CED offers its Documentation Service by POST.
D O C POS T
* low cost
* culled from over 150 newspapers and magazines
* over 500 information sources
’ tailor-made to suit your needs
* saving your time, money and the bother
DOCPOST (Regular)-Ongoing clipping service in the topics of your interest.
DOCPOST (Spot)-Bulk material from our past files as and when you need it.
DOCPOST (Selective)—Copying of specific and selective documents and data from our documentation
For details contact:
Centre for Education & Documentation
3, Suleman Chambers,
4, Battery Street,
Behind Regal Cinema,
Bombay 400 039.
Phone No. 2020019.
(Service available only to non-commercial organisations)
186
Socialist Health Review
ot measuring the beta and gamma radiation io which workers
were exposed. It never possessed instruments for measuring the
radon gas released continuously from the radium which was the
principal hazard in the plant. The plant had received numerous
complaints from the Kansas Department of Health and Environ
ment because of its lack of radiation protection and the high
levels of contamination throughout the plant. None of this wor
ried Judge Kelly. None of this was reported to the Health Physics
or nuclear establishment audiences.
to cause him to conclude that ‘the plaintiffs’ claims are simply
secondary to the interests of the United States’. Those interests
are the same in 1985 as they were in 1958, namely to convince
people (however wrongly) that exposure to low level radiation
causes no harm. Thus the American people will be willing to
handle the uranium, run the nuclear reactors, separate out the
plutonium, fabricate and test the bombs, and tolerate the
radioactive debris from each part of the weapon cycle. The vic
tims of this deception must be ignored because of the greater
The risk coefficients for cancer were another point of con ‘good’ of national security in a nuclear age.
Although the Judge made many obvious errors and mis
tention in the trial. Dr Karl Morgan was criticised for ‘inflating’
statements, these were not reported either in Donald Jose’s let
the predicted number of cancers. Dr Morgan had doubled the
ter, the Health Physics Newsletter, or the nuclear public rela
BEIR III estimates, a practice now accepted by Seymore Jablon,
US National Research Council, and Dr Edward Radford cur tions material. The Judge referred to autoradiographs as
audiographs; called the inverse square law the immense square
rently correcting the atomic bomb survivor data on which the
BEIR III estimates are based. On the other hand, Judge Kelly law; thought MeV was a unit of power whereas it is a unit of
accepted the dose estimates for the plaintiffs calculated by Dr energy; described alpha rays as bombarding tissues in millicuries
John Auxier, the person most responsible for the errors of dose per.second; and said that electrons gave off daughter products.
calculation in the atomic bomb data (Science Vol 12, 22 May In a still more serious error, he claimed that there were no
1981). Since Dr Morgan made only a correction of 2 on the BEIR epidemiological studies or findings to support occurrence of
II cancer risk estimates, and did not use the added correction cancer at radiation exposure levels below 50 rad.
The government lawyers used some rather crude tricks to
factor of 2 to 3 for conversion from absolute to relative risk,
nis cancer estimates would be generally considered conservative, convince the Judge that the radium handled by AID Co
employees was harmless. They brought the dials into court and
ie too low, by most radiobiologists.
had Dr Robley Evans explain radiation threshold theory which
was scientifically discredited in the late 1960s. This false theory
Justified Lying
led to an estimated 1100 excess lung cancer deaths among US
The ‘court’s favourite witness’. Dr Lauriston Taylor, perhaps uranium miners. They also brought into court a camping man
gives us the best clue to understanding why the US specially tle whose beta emissions caused impressive clicks on a geiger
prepared legal team was sent to Kansas to defend an obviously counter. They failed to make available to the Judge the US
Nuclear Regulatory Report No NU REG/GR-1910 , ORNL-5815,
poorly run second-hand aviation instrument factory against the
1981, ‘An Assessment of Radiation Doses from Incandescent
cancer death claims of two widows. He helps to situate the ver
Gas Mantles that Contain Thorium’, which assessed the hazards
bal attacks on the three scientists who tried to assist the court
of occasional use of such mantles. These two court-room
in coming to a verdict within the overall US predicament.
demonstrations were used to minimise the years of work by the
Dr .Taylor was quoted on Seattle television in February 1985,
plaintiffs under unsafe radiological conditions at the AID Co
by Dr Richard Rappaport, president of the Seattle Physicians
plant. A special committee has been appointed to develop cancer
for Social Responsibility, as having said that lying to the public risk assessment tables to estimate the probability that a particular
about nuclear matters is sometimes justified. As reported in the
cancer is attributable to radiation given the victim’s age, sex,
recently released minutes of the US National Advisory Com
cancer type and radiation exposure dose.
mittee on Radiation, 10 November 1958, Dr Taylor participated
The six-person committee is composed of three of the
in the cover-up of a fall-out episode in Los Angeles caused by
government’s expert witnesses who testified against the plain
a nuclear test at the Nevada Test Site. The accident was described
tiffs who had lived downwind of the Nevada nuclear lest site
by Dr Edward B. Lewis of the California Institute of Technology and who had contracted cancer. The government lost this lawsuit
as a ‘really serious episode. We measured hot spots of about
in Utah. None of the experts who testified on behalf of the per
2 mR/hr on the roof of our building and 2 mR/hr on our
sons exposed to fallout were asked.to be on the Risk Assess
shoes... The reaFhazard is the inhalation of these in the lungs’.
ment committee. None of the scientists who have published
These exposures were much lower than those experienced by the
research papers on the cancer effects of low-level radiation were
deceased workers. In spite of the danger to the public, Dr
invited to sit on the committee. It is expected that the govern
Lauriston Taylor urged that the public be assured that all was
ment will settle the ‘scientific dispute’ its own way—by legislative
well. In the 1958 minutes, Dr Taylor was quoted as having said
decree. This new tool will add to the effectiveness of the legal
that in order to actually protect the public from genetic damage
team with its scientific disinformation.
‘you will have to talk about values set down by one hundredth
or more’. He stressed that ‘if you ever let these numbers get out
to the public you have had it’. Birth defect rates have doubled
in the US over the past 25 years according to a recent New York
Tinies special report, but Judge Kelly wrote:
FORTHCOMING ISSUES
This court finds that sincere and eminent scientists, like
Dr Taylor, who have constituted the radiation protection com
June 1986: Volume III No 1: Health care in post-revolu
munity for over a half a century, have carefully studied all
tionary societies
known literature on the carcinogenic potential of radiation
September 1986: Volume III No 2. Primary Health Care
an d'have set safety standards that were not expected to cause
December 1986: Volume III No 3: State Sector in
bodily injury during the lifetime of exposed individuals.
Health Care
Just as Lauriston Taylor avoided public disclosure in the Los
March 1987: Volume III No 4: Medical Technology
Angeles fall-out episode to safeguard the US nuclear weapon
testing programme, so perhaps-Judge Kelly found similar reasons
March 1986
187
INDEX TO VOLUME II, 1985-86
163
The Ambivalence of Psychoanalysis by David Ingleby
42
Bhopal Disaster: Bibliography
.
6
The Colonial Legacy and The Public Health System in India by Radhika RamasuDDan
84
Community Health Projects: At the Crossroads? by Sumathi Nair
91
Criticism of Tubectomies Unscientific by Anant Phadke (Dialogue)
A Dialectical Approach to Traditional Medicine: A Lesson from the Chinese Experience
105
by Dhruv Mankad
173
Different Voices by Nalini (Review Article)
177
Doctors and Torture: A Report on Chile
57
Doctors in Health Care: Their Role and Class Location by Sujit K. Das95
Dust Hazards in Coal Mines: A Brief Overview by Amalendu Das
144
Green Revolution and Health: Changes of Pattern of Health in Nanded by Sunil Dighe
1
Health and Medicine under Imperialism by Anant Phadke (Editorial Perspective)
160
The Helping Profession: Is It Really Helpful? by Annie George
31
Ills of the Health Industry by Ravi Duggal (Review Article)
151
In Defence of My Confusion by Imrana Quadeer (Dialogue)
171
Making of a Psychiatrist by Anand Nadkarni
153
Mental Health and Society by Ravi Duggal (Editorial Perspective)
Cover 3
The Miner of Dhanbad by Sachidanandan (Poem)
23
Monopoly Capital and the Reorganisation of the Health Sector by J. Warren Salmon
90
Need for Population Control Cannot be Ignored by Vrijendra (Dialogue)
151
One-sided Defence of Professional Interests by Anant Phadke (Dialogue)
148
Organising Doctors:. Towards What End? by Anand Phadke
Cover 2
The People (excerpts) by Pablo Neruda (Poem)
53
People in Health Care by C. Sathyamala (Editorial Perspective)
116
Policies Towards Indigenous Healers in Independent India by Roger Jeffery
Political-Economic-Structure—Approaches to Traditional and Modern
135
Medical Systems by Catherine A. McDonald
185
Politics of Information by Rosalie Bertell
170
The Printed Word—A Collage of News Clippings on Mental Health & Illness in India
157
Psychiatry: State of the Art by Dilip Joshi
Race and Health Care: Perspective from Chicago by Bindu T. Desai
45
92
Revolutionary in Form, Reactionary in Content: A Critique of Ivan Illich by B. Ekbal
A Search for Alternative: Organising Vaidus in Gadchiroli by Ravindra R.P.
132
Social Dynamics of Health Care: The Community Health Workers Scheme in Shahdol
District by Imrana Quadeer
74
The Sorry Story of Psychosurgery by Bindu T. Desai
175
Systems of Medicine: Role and Relevance by Sujit K. Das and Swarajit Jana
124
Tragedies and Triumphs: Health and Medicine in Bhopal by Padma Prakash
(Bhopal Update)
38
Transferring Medical Technology: Reviving an Umbilical Connection?
by Meera Chatterjee
17
Upside Down Medical Research: The Case of Anaemia by Rajkumari Narang
67
Voices of Silence by Padma Prakash (Poem)
Cover 1
Whither Other Systems of Medicine by Srilatha Batliwala (Editorial Perspective)
101
Why the Scope of SHR Should be Confined to Health and Medicine by Anand Phadke
and Dhruv Mankad (Dialogue)
43
Work and Health: An Alternative Perspective by Bharat Patankar and
Jogen Sengupta (Dialogue)
89
[Please Note: Issue no. 1 (Imperialism and Health) covers pp. 1-52; no. 2 (People in Health Care) pp. 53-100;
no.3 (Systems of Medicine) pp. 101-152; no. 4 (Mental Health) pp. 153-188]
AUTHOR INDEX
Batliwala, Srilatha
Bertell, Rosalie
Chatterjee, Meera
Das, Amalender
Das, Sujit
Desai, Bindu T.
Dietrich, Gabriele
Dighe, Sunil
Duggal, Ravi
Ekbal, B.
George, Annie
Ingleby, David
Jana, Swarajit
Jeffery, Roger
Joshi, Dilip
Mankad, Dhruv
McDonald, Catherine
188
101
185
17
95
57, 124
45, 175
Cover 4
144
31, 153
92
160
163
124 .
116
157
43, 105
135
Nadkarni, Anand
Nair, Sumathi
Nalini
Narang, Rajkumari
Neruda, Pablo
Patankar, Bharat
Phadke, Anand
Prakash, Padma
Quadeer, Imrana
Ramasubban, Radhika
Ravindra, R. P.
Sachidanandan
Salmon, J. Warren
Sathyamala, C.
Sengupta, Jogers
Vrijendra
171
84
173
67
Cover 2
89
1, 43, 91, 148, 151
38, Cover 1
74, 151
6
132
Cover 3
23
53
89
90
Socialist Health Review
Why don't you write for us?
This periodical is a collective effort of many individuals active or interested in the field of health or
interested in health issues. The chief aim of the journal is to provide a forum for exchange of ideas and
for generating a debate on practical and theoretical issues in health from a radical or marxist perspective.
We believe that only through such interaction can a coherent radical and marxist critique of health and
health care be evolved.
Each issue of the journal highlights one theme, but it also publishes (i) Discussions on articles publish
ed in earlier issues (ii) Commentaries, reports, shorter contributions outside the main theme.
Our forthcoming issues will focus on: Health Care in Post-Revolutionary Societies, Primary Health
Care, and Medical Technology.
If you wish to write on any of these issues do let us know immediately. We have to work three months
ahead of the date of publication. A full length article should not exceed 6,000 words and the number of
references in the article should not exceed 50. Unless otherwise stated author’s names in the case of joint
authorship will be printed in alphabetical order. You will appreciate that we have a broad editorial policy
on the basis of which articles will be accepted.
We have an author’s style-sheet and will send it to you on request. Please note that the spellings and
referencing of reprint articles are as in the original and are NOT as per our style.
We would also like to receive shorter articles, commentaries, views or reports. This need not be on
the themes we have mentioned. These articles should not exceed 2,000 words. Please do write and tell us
what you think of this issue.
All articles should be sent in duplicate. They should be neatly typed in double spacing, on one side
of the sheet. This is necessary because we do not have office facilities here and the press requires all material
to be typed. But if it is impossible for you to get the material typed, do not let it stop you from sending
us your contributions in a neat handwriting on one side of the paper. Send us two copies of the article
written in a legible handwriting with words and sentences liberally spaced.
The best way to crystallise and clarify ideas is to put them down in writing. Here’s your opportunity
to interact through your writing and forge links with others who are, working on issues of interest to you.
WORKING EDITORS
Please send me Socialist Health Review for one year (four issues). I am sending Rs.
as subscription and/or donation by Demana Draft/Cheque. (D D and cheque in favour of
Socialist Health Review and for cheque add Rs. 5, if outside Bombay).
Name
Address
_______________________
Cancer Research
My agonies
are fed
into a computer
together
with five thousand
other women’s
tears
terrors
hopes
relief
and despair.
We have been
categorised properly
to. fit in nicely
there will be
a deathrate of course,
that is failure,
but most of us
will be a success
of modern science
and technology
of medical competence
and human endeavour
only no one
will measure
our resilience,
our love of life,
and the worries
about our children
There is no number
for the humiliations
we face when
they screw us open
to paint our uterus
from the inside
No one counts
the needles poked in,
the tubes inserted,
the bloodstained pads
the fact that
we will never be
the same again
making love.
And we are
grateful £o them
for the tortures
inflicted >
for; they save
our lives
an<4 we wonder
how they can live
dtjing this
every day.
—Gabriele Dietrich
January 1986
Bangalore
The poem in the issue 11:3 was by Sachidanandan. We regret the omission.
Position: 2628 (2 views)