Viewpoint
James T Antony
Dept. of Psychiatry, Jubilee Mission Medical College and Research
Institute, Thrissur.
Correspondence: Dept. of Psychiatry, Jubilee Mission Medical
College and Research Institute, Thrissur - 680005.
Email: james.t.antony@gmail.com
Psychiatry has many impressive advances to its credit in the recent past. Gene profiling, novel imaging techniques, optogenetics and stem cell studies are all areas where new research holds out hope. We even have new computation techniques and statistical methods that would make it a lot easier for a research worker to draw conclusions from complex data. When some of these new ideas eventually get translated to clinical actions, it would change the very manner in which psychiatrists think.
Our pharmacotherapy is no more totally based on mere serendipity as it used to be earlier. The more optimistic ones among us expect that, in the coming days, psychotropic drugs would be developed rationally! It is as though we may even start having a specific drug for a particular symptom domain. People have started talking about ‘multi-dimensional stabilizers’ instead of our old-fashioned antipsychotics.1
From the time Weinberger2 and Murray and Lewis3 put forward a new concept of ‘Neurodevelopmental disorder’, all research in schizophrenia started to have a fresh focus and direction. Divergent concepts like “neurodegeneration”,4 “supersensitive synapse”,5 neuronal changes owing to perinatal inflammations or trauma, and many more are also being put forward to explain schizophrenia. Studies on neurological soft signs as well as various subtle cognitive impairments are giving us new insights on the clinical manifestations of the illness.
Attempts are on to discern features of endophenotypes in an effort to understand diseases better.6 This would enable a doctor to intervene in disease states at a much earlier phase than is possible now. Study of factors that may influence phenotypes of diseases has expanded, and these days, along with risk factors, thoughtful clinicians would also study modifying factors, compensatory factors, and so on. Also, we have a new approach that persuades clinicians to interpret all clinical findings in a developmental context, which would make their understanding of all disease processes more insightful.
Ingenious concepts like the argument that schizophrenia is a “dysfunctional integration” rather than a “functional segregation” involving localized pathology7 is another idea that goes a long way to make our understanding of the schizophrenic process clearer than ever. With an overall better understanding, many ambitious clinical objectives, like early detection and primary prevention, seem to be in the realm of possibility these days. “Staging”, an idea from oncology, where the progress of disease states is assessed with precision,8 is another new approach people want to bring in to improve the quality of day-to-day clinical practice of Psychiatry.
Today we have some basic science research in the field of mental health that are virtual behemoths. The Connectome Project of the United States9 and the Human Brain Project of Europe10 are examples. When it comes to clinical research, many well-planned, large-sample studies are currently being conducted all over the world. Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE), Measurement and Treatment Research in Cognition in Schizophrenia (MATRICS) and Recovery After an Initial Schizophrenic Episode (RAISE) are all studies being conducted by the National Institute of Mental Health, United States.11
With all these developments, research in clinical psychiatry has really become an exciting field these days. The arrival of a basketful of new molecules is another factor that has given rise to a pervasive optimism in everyone.
But, a striking thing is that, besides various factors from within Psychiatry that instill optimism in professionals, the whole world is witnessing a sweeping social phenomenon which is certainly outside the boundaries of Psychiatry. This phenomenon is globalization, which fuels enthusiasm in everyone, including medical professionals. Steger has defined it as “a set of social processes that appear to transform our present social condition of weakening nationality into one of globality”.12 Fernando is of the view that globalization mean different things to different people and in different circumstances.13
Globalization arrived along with another phenomenon called “liberalization”, something that originated in fields of economy and trade. The great idea of liberalization is to do away with all kinds of restrictions that have been laid down by government agencies to regulate trade and commerce. The objective is to make the transactions easier and that way more profitable. In a drastically changed world, where unimaginably improved communication systems as well as faster-than-ever modes of transportation are mighty “drive-engines”, this new approach became something in the realm of possibility.
The impact of liberalization was much stronger than what everyone anticipated. Powerful financial institutions like International Monetary Fund and World Bank as well as various multinationals could assert a huge force to make the effects of globalization spread to areas much beyond trade and commerce. The net result is that mindsets of everybody, including medical professionals, have changed completely!
One noticeable thing is that, in the new world milieu, affluent multinationals give extremely high salaries to their employees. Their idea is to extract a huge quantum of work from them and boost profits. Such an approach has many adverse effects on the health of employees — but despite all the hardships and monotony, private sector executives believe that they are on the top of the world when their income is huge and perks are many. When they live in unheard-of kinds of luxury and pomp, it also influences the outlook of all others, including medical practitioners!
We have another recent change in our healthcare scenario whereby high-end hospitals all over the country have quietly transformed into business enterprises. Their administration is taken over by shrewd managers who have brought in a new kind of value system for the hospitals, where bottom-line of the balance sheet is the only thing that matters. And lo, old-time ethical values that were central to the practice of medicine all along are no more considered important.
It is true that globalization is not an altogether new phenomenon in the practice of modern medicine. A “mini-globalization” has always been a part of it. A modern doctor would convey an impression that he is “western” in many respects: in his thinking, dress, lifestyle and much else! When a doctor’s local identity got seamlessly melded to a western medical identity, the resultant hybrid was not just accepted, but even widely admired. At least to start with, this served a purpose, as patients could easily believe that a doctor is quite knowledgeable and wise.
But, as compared to this mini-globalization of doctors which existed since long, problems with the present day globalization are its speed as well as extremely pervasive spread. Many are just swept away by its mighty force. Many unknowingly acquire a commodified sense of identity. This identity confusion gets further influenced by the implicit neoliberal values of the global culture based on individualism, free market economics and freedom of choice.14
For many, an individualism that they gain by having more freedom of choice starts to dictate them and they get quite intolerant to others who continue to hold on to their old world values. Many a time it is the centrality of power in globalization that dictates and guides everyone.
While trying to analyse the huge change liberalization and globalization has brought about on everyone’s attitude, it will be extremely useful for us to study about another phenomenon called “Sanskritization”. This was originally described in 1950 by Sreenivas, who explained the manner in which social changes took place in the highly stratified Indian society.15 Sanskritization denotes the process by which castes lower in the hierarchy seek upward mobility by emulating the rituals and practices of the caste immediately above it and constantly exerts a dominant influence on it. It is a process similar to “passing” in sociological terms, and includes not just the adoption of new customs and habits, but also the incorporation of new ideas and values.
The concept of sanskritization is important for us while studying the impact of our present issue of globalization. This is because, today, with the drastically improved transportation and communication systems, the whole world has shrunk to a small neighbourhood. And the huge force of sanskritization is not being stopped anymore by national boundaries as in the past — the uppermost strata of Indian society blindly follows western societies in their ways of living and value systems. This is expected to permeate down to lower social strata, slowly, but for sure.
Appiah writes that globalization brings about “a new global mind-set and a cosmopolitan ethics”.16 But Chomsky has a quite different view — According to him, globalization leads to exploitation, a “cultural disenfranchisement, and a new form of colonialism”.17
Today, every aspect of our lives is shaken up by globalization. The attitude of people has transformed so radically that, for most, competitiveness is the core aspect of their very lives and ‘win by any means’ is their motto. It is as though people have started believing that selfishness is a virtue! Make money by any means and display it, even vulgarly. People are also attracted by various entitlements that go with money and power.
The status ascribed by the society for jobs and pursuits are all redefined. Show business is right on the top, as the economic gains are very high there. The field of sports is the close second. Whenever a sportsperson makes a lot of money in a particular filed, he is viewed not just as a hero but as a great statesman who has built the nation!
An attitude change is quite visible in the field of medical practice too. Nobody wants to do general practice, though that continues to be the most fascinating, challenging and rewarding area in the whole field of medicine in a true sense. But today the only question that matters to a medico is, “if I see a patient or do a procedure, how much money could I make?” No one discusses the professional satisfaction, even though just a generation ago that used to be something medicos used to discuss with passion. So, when Psychiatry gets popular these days, let us ask ourselves that disturbing question: Is this happening for all the wrong reasons?
When this scribe criticises some of the unhealthy aftereffects of globalization, many would feel that when changes take place all over the world, we as a nation have no option other than to follow it. Change is, after all, inevitable. I beg to disagree. It will be useful for us to be aware of the fact that there are some nations, many of them not as advanced as we are, who refuse to accept every idea from the west without criticism like we do. The huge force of globalization and sanskritization does not seem to affect them. Maybe they have more self-belief and confidence in their own culture than us. An example for this phenomenon is the stand taken by African nations when, in 1990, the United Nations brought in a new convention to protect the rights of children by the name UN Convention on the Rights of Child (UNCRC). India became a signatory to it very readily, but the African countries wanted a modification for the whole charter, based on their cultural differences from the west, and went for an African Charter on the Rights and Welfare of the Child (ACERWE) in 2009.18 We did not even have a national debate on the impact UNCRC would have on the process of growing up of large sections of children, who, for various reasons, could not access the schooling system we have in this country.
We also have the example of Ignatio Martin-Baro from Salvador, South America, who proposed “Liberation Psychology”.19 According to him, the concepts of western psychology are not acceptable for application to people of South America for socio-cultural reasons.
It is time psychologists and psychiatrists in India dispassionately think whether everything that is being churned out from the west by way of concepts and theories is good for us. In areas like the sanctity of institutions like marriage and family, many stands taken by western psychology and psychiatry are highly questionable. Many times they even forget that it is due to the influence of many totems, taboos and other strong cultural influences over many generations that the entire humankind has acquired most of its present belief systems, ways of conduct and attitudes.
Today, even child rearing practice, which is a cornerstone of our civilization, is being tampered with and totally mutilated by the so called western experts. Even though matters like these would go against the long-term interests of our people and nation, and human civilization as a whole, nobody bothers to raise a finger!
In the name of respecting individual’s autonomy, clinical entities like “paranoid schizophrenia” are removed from a classification manual produced by a country.20 To my mind, not wanting to call victims of paranoid schizophrenia by that name is a malady of the same category of not wanting to call a spade a spade. And if allowed to grow un-fettered, such actions would eventually have an adverse impact on the ‘collective mental health’ of groups, movements or even nations.
When a few years ago the American Psychiatric Association produced a document on core competencies needed for a psychiatrist, psychotherapy was not mentioned as an essential skill.21 In such a scenario, it is time Indian Psychiatry introspects to find out whether we should meekly allow our agenda to be determined by the west, or whether our ground realities should guide us.
There are many more things like the closing down or downsizing of mental hospitals in the west during the latter half of twentieth century. The west had to do it because in an earlier period they had built too many mental hospitals. But, when a section of psychiatrists in India want to blindly ape the west and tell us that mental hospitals are not required to deliver good quality mental health care, it is time we wake up.
We must thankfully acknowledge that since the time of Philippe Pinel, many of our great ideas originated from the mental hospitals. Even our positive attitudes about the care of mentally ill were conceived there. In those days they were the hubs from which various care models were crafted and given a trial run before being transplanted to different community care settings. The team concept in mental health care, which made a quality change in our care delivery, originated from the mental hospitals. But today we have forgotten that a team effort is required to manage complex clinical problems in Psychiatry and that we need to think holistically and integrate ideas from many streams. We are getting reduced to mere experts in the biological aspects of mental disorders.
We hear a lot about “private psychiatry” these days, but hardly any discussion on “public psychiatry” takes place during our grand gatherings. Are we not required to assume responsibility for the plight of millions of severely ill mental patients, who, for want of resources, have no way to access care from private hospitals?
(Based on Dr. Suraraj Moni Memorial Oration delivered in the meeting of Venad Guild of Psychiatrists, Thiruvananthapuram during March 2015.)
Altamura C. From classical antipsychotics to multidimensional stabilizers: do we need a new classification for novel drugs used in Schizophrenia? Neuropsychiatry 2015; 1(6):541-52.
Weinberger D. Implications of the normal brain development for the pathogenesis of schizophrenia. Arch Gen Psychiatry 1987; 44(7):660-9.
Murray RM, Lewis SW. Is schizophrenia a neurodevelopmental disorder? Br Med J (Clin Res Ed) 1987; 295(6600):681-2.
Lieberman JA. Is schizophrenia a neurodegenerative disorder? A clinical and neurobiological perspective. Biol Psychiatry 1999; 46(6):729-39.
Seeman P, Seeman MV. Schizophrenia and the supersensitive synapse. Neuropsychiatry 2005; 1(3):233-42. Available from: http://www.futuremedicine.com/doi/abs/10.2217/npy.11.18?journalCode=npy
Gottesman, Gould TD. The endophenotype concept in psychiatry: etymology and strategic intensions. Am J psychiatry 2003; 160(4):636-45.
Gray JA. Integrating Schizophrenia. Schizophr Bull 1988; 24(2):249-66.
Agius M, Goh C, Ulhaq S, McGorry P. The staging model in schizophrenia and its clinical implications. Psychiatr Danub 2010; 2(2):211–20. Available from: http://www.hdbp.org/psychiatria_danubina/pdf/dnb_vol22_no2/dnb_vol22_no2_211.pdf
Human Connectome Project [Internet]. Massachusets: Laboratory of Neuro Imaging and Martinos Center for Biomedical Imaging. [cited 2015 Oct 10] Available from: http://www.humanconnectomeproject.org/
Human Brain Project [Internet]. Geneva; European Commission. [cited 2015 Oct 10] Available from: https://www humanbrainproject.eu
National Institute of Mental Health [Internet].Bethesda, Maryland: National Institutes of Health(US). [cited 2015 Oct 10] Available from: http://www nimh.nuh.gov/health/trials/index.shtml
Steger MB. Globalization. A very short introduction. Oxford: Oxford University Press; 2009.
Fernando S. Globalization of Psychiatry – A barrier to mental health development. Int Rev Psychiatry 2014; 26(5):551-7.
Melluish S. Globalization, culture and psychology. Int Rev Psychiatry 2014; 26(5):538-43.
Srinivas MN. Religion and society amongst the Coorgs of south India. Oxford: Clarendon Press; 1952.
Appiah KA. Cosmopolitanism: Ethics in a world of strangers. New York: Norton; 2006.
Chomsky N. Latin America from colonization to globalization. New York: Ocean Press; 2000.
ACERWE 2009 [Internet]. The African Charter on the Rights and Welfare of the Child. [cited 2015 Oct 10] Available from: http:// acerwc.org
Martín-Baró, I. Writings for a liberation psychology. Cambridge: Harvard University Press; 1994.
American Psychiatric Association: Diagnostic and Statistical Manual of mental disorders. 5th ed. Arlington VA: APA; 2013.
Gabbard GO. Introduction to the core competence in psychotherapy series. In: Dewan MJ, Steenbarger BN, Greenberg RB, editors. The art and science of brief psychotherapies; Washington DC: American Psychiatric Publishing; 2004.