Waiting by passport control for my South Asian partner [for that is her title], I came across an article on the BBC news website last week about South Asian attitudes to mental illness. Normally I’d skim-read an article like this before passing on to something juicier or fluffier, but having just returned to UK connectivity I was (I’m ashamed to say) hungry for digital content of any texture, so read it properly.
It was interesting enough, and had a picture of Monty Panesar at the top, which I liked. It reminded me of a simpler time in English sport, before we got good at things. But there was something in the tone of the article that made me uncomfortable.
It wasn’t the premise of the piece: the question “Why do many South Asians regard mental illness as taboo?” is a very interesting one. The way that different communities regard mental health and illness is a fascinating and important subject for public policy and private understanding. My partner and I often struggle to understand each others’ preconceptions about mental health, which are partly the products of our different cultural upbringings. Encountering assumptions that are foreign to one’s own helps one to become better aware of their contingency and arbitrariness.
South Asians – “a particular problem”
What troubled me was the way that ‘regarding mental illness as taboo’ was equated in the article with ‘wrong’, or, at the very least, ‘a big problem’. For example, the Professor man describes the large role that shame plays in South Asian cultures, and tells us that South Asians do not consider mental illness to be a medical issue, instead holding “superstitious belief[s] that there is something they did in their previous life and they’re being punished”. Later in the article a report is cited which found that mental illness issues were rarely spoken about or allowed out of the house because of fears around the status of the family, and worries about arranged marriages being called off.
The implication of these various statements is, to my mind, clear: South Asian communities are doing mental health badly. We as readers are invited to conclude with the article that it is wrong for shame to play such a large role in their culture, and for mental illness to be considered a moral rather than a medical issue. It is wrong that family status and arranged marriages are put before individual mental health.
The flip-side of them doing it wrong, of course, being that we (read: middle-class, western, mainly white) do it right. We’ve got the right balance of shame and openness, and have moved beyond primitive notions of moral responsibility to a much more sophisticated medical model (or, if we haven’t, we’re certainly working towards it through constant de-stigmatisation and medicalisation). Further, we hold – correctly, mind – the needs of the individual higher than the needs of the community.
I don’t necessarily disagree with the above arguments (I do). My problem lies with the way that the arguments are (not) made, and the way that this allows a degree of unthinking racism to be smuggled past the reader.
This may sound extreme. Read the article, see how racist it feels. Maybe it doesn’t. It didn’t to me when I read it. But that, I think, is because the article and hundreds of others like it doesn’t make its arguments explicit. If they’re held up to the light you can see how contentious the article is, but to avoid any controversy they’re smuggled through the back door, in unspoken assumptions.
Hiding the most important parts of your argument in assumptions you don’t spell out is a classic philosophy trick, called an enthymeme. What are the enthymemes at work in the article? One of the main arguments being hushed through is that medicalising mental illness is a good thing. Another is that it is bad for a community to use shame to regulate itself. A third is that the needs of individuals should have precedence over the needs of family or community. There are others, especially once you get to the report, but lets stick with those three.
I’ve written before about my various beef with the first assumption, so won’t go into it much here. Suffice it to say that I think medicalisation is not obviously a good thing. At the very least, it risks narrowing the narratives available to individuals to explain and own their troubles, potentially disempowering and harming them.
But what of enthymemes two and three? Is shame a bad thing for a community to use to regulate itself? Should the needs of the individual be put above the needs of the group?
It’s easy for us to look down on shame, especially when we find it in other cultures, as it seems such an old-fashioned and anti-fun emotion. But unless you’re Carl Rogers (and I sincerely hope you’re not) there are some pretty good reasons to think that shame is essential for humans to live with one another.
For example, just off the top of my head, shame is one of the primary forces that stops me from becoming addicted to computer games. I know these are a drain on my life and cause my arthritis to flare up in ways that have terrible knock-on consequences for my physical and mental health. But it is not this knowledge that motivates me to stop – it’s the shame of being caught.
Shame is also a primary tool in the education of children. Much of the work of growing up is working out how to negotiate the balance between one’s bodily desires and the desires of others. It is shame, in the first instance, that helps a child to regulate their needs, as they seek approval from significant care-givers, and try to avoid losing this. Later on you might dress the shame up with rational argument but ultimately it’s the shame that does the work.
I know it’s unfashionable to say this, but shame does a huge amount of work in western as well as South Asian communities, as it should do. It has huge limitations, and a lot of the work that gets done in therapy is aimed at undoing unhelpful feelings of shame. But the point at which shame ceases to be useful and becomes harmful is not an obvious one, and criticising the South Asians for having a different way of drawing that line to westerners is not a useful response.
What would be useful is if the article had made clear its assumption that we’ve got the right line in the liberal West. At least that way the reader would be invited to question this, and understand the wider relevance of shame within a community.
Individual vs family
In the absence of such clarity, how might we find out how much shame is the right amount? Well, a simple way to do this would be to look at its effects: who gets hurt, who gets helped? In the article there is much focus on the harmful effects of shame on individuals, and an acknowledgement that this is often done because of the perceived needs of the family or group. The voices we hear are those individuals who have been harmed by shame, and rightly so – their voices need to be heard.
The voices that are not heard, though, are the voices of families and groups who have been helped to stay together by shame. And because of this we are not able to explore, within the article, whether or not the trade-off the South Asian communities have arrived at is a good one. As an article on a western website, the author expects us to unthinkingly accept that the any sacrifice required of an individual in the name of family or group is wrong, problematic, or backwards. But is this so?
Every culture balances the needs of the individual and the group in various ways. Obviously. Middle-class white Britain, for example, has embraced a kind of individualistic liberalism over the past 50 years which holds that family is very important so long as the individual chooses to be a part of it. We generally look up to people who sacrifice some of their own happiness to help their families (because family is important), but we do not look down on those who do not (because it was their choice). In other words, family is a good thing if and only if the individual wants it to be. In all things the individual is the final arbiter where any good is concerned.
The picture is different, I think, outside of that middle-class white bubble, but let’s not get into that now. As a white middle-class Brit, I am grateful for the freedom which individualism brings. It’s allowed me to make choices which have aimed at my individual flourishing, regardless of family or social expectations. But I also regret that some of my needs were placed higher than those of my family. For example, I was not required to visit my Grandfather when he was living in an old people’s home and, being a somewhat emotionally awkward twenty-something, didn’t choose to visit him. I regret my choices then and I regret that I didn’t belong to a culture in which my actions would have been shameful.
I regret, too, that it is not shameful for me to avoid ever talking to my neighbours, as this kind of shame would make me a better, more connected, happier human being. Without the societal expectation that I commit to something I don’t want to do, I find myself unable and unwilling to step out of my individual comfort zone and become a better person.
Ok Phil, but why spend so long pedantically tackling a pretty bland article?
Well, while the article itself may be bland, the trend it is a part of is not.
This article, like so many others we read every week about mental illness, unthinkingly holds that mental illness is a neutral object, capable of being observed free of any cultural baggage.
Mental illness is not a thing
But mental illness is not a thing. It does not exist. It cannot be treated as an object which is the same in one community as it is in another. In this respect it is not like physical illness. It is a cultural construct, as your man Foucault spent a huge chunk of his life riffing about (see this for a short, typically blinkered description of Foucault and the anti-psychiatrists). Our conception of mental illness is connected with many other aspects of our culture, including personal motivation, family structures, rituals, habits and so on. Medicalising mental health fits with Western materialistic (not in the hippy sense) individualism, but it doesn’t necessarily fit with a more collectivist culture.
By adopting a Western conception of mental illness, South Asian cultures would probably gain something (lower suicide rates, lower incidences of anxiety or whatever you’re measuring – that kind of thing) but also probably lose something. It might be that they lose something insignificant, but it might also be that they lose something of deep importance. We don’t know, because the article does not address this, and, by refusing to fess up to its enthymemes, tries to stop us from addressing it.
My gut feeling is that the price for adopting a western conception of mental illness would be pretty high. It might include the loss of established truths and norms which provide comfort and security, the loosening of family ties built through expectation and rituals of respect, and the diluting of cultural identity. Whether or not this is a good bargain is not clear, and not answerable by those, like myself, who are not a direct part of the South Asian cultures in question. And neither is it answerable by those who adopt an unthinking scientism where mental health is concerned. The ‘truth’ about mental health is ultimately not purely a physical one, but a cultural one too.
The South Asians who are quoted in the article are, to my mind, the only saving grace of the article, as they are arguing from within that their culture can and should change. These are important voices to hear. What’s missing in this article is the other side – the voices of those South Asians who value the traditional role that shame plays, for example, or who feel that the Western conception of mental health would not fit with their community in other ways. Their voices are unthinkingly erased from this account, because of the assumption that this is not a cultural issue but one of straightforward scientific misunderstanding.
Stripped of its ‘neutral’ surface dressing, an article like this which tells South Asians that they’re bad at mental health is straightforward cultural imperialism which borders on racism. That we don’t recognise it as such is testament to the power that the medicalised, individualised conception of mental illness has amongst us today. It’s become so much a part of our cultural furniture that we don’t even know it’s there.
What’s needed instead of one-sided dismissives is a genuine discussion about the broader cultural context of mental health – one which acknowledges that those on both sides of any cultural divide can learn from each other. Slating the South Asians isn’t good for them because it’s racist and plays into a stereotype of backwardness and rigid hierarchy and anti-science. But it’s not good for ‘us’ either, as it stops us from gaining insight into ourselves, and ideas from others.
Ultimately articles like this constrain rather than enable understanding. They are fundamentally conservative, and, under the cloak of ‘helping backwards Others’, serve mainly to bolster our own sense of right, preventing us from ever asking the question of the place mental health holds in our own culture: is it as good as all that? And that’s a shame.