Toward a Postcolonial Psychiatry: Uncovering the Structures of Domination in Mental Health Theory and Practice

In a provocative essay, Sarah Kamens recommends the literature of postcolonial theory as a remedy for some of the limitations of current psychiatric theory and practice. Her provocation lies not advocating engagement with this literature, which certainly has much to offer psychiatry, but in the way she chooses to energize her argument by contrasting two very different phenomena: the experience of hearing voices and the use of ghost-writing in the psychiatric literature. Although Ka-mens acknowledges these phenomena come from “distant teleological and experiential realms,” in both cases, she suggests, there are hidden authors who may be experienced or understood as hauntings. In this brief commentary, I will consider some epistemic issues raised by her argument and relate these to a broader social science literature that can sharpen our critical reflections on the legacy of colonialism and the new forms of discursive power and domination that challenge psychiatry.

What Specters Are These?

Hearing voices spans a broad spectrum from sought-after religious experiences, through deliberately cultivated imaginal presences (with whom one can dialogue and who may provide guidance in life), to unwanted, unbidden commentators or persecutors who torment the sufferer (McCarthy-Jones, 2012). In psychiatry, voices are assessed mainly as potential signs of psychosis or other disorders and, if culturally sanctioned and not associated with suffering or impairment, may be viewed as non-pathological dissociative experiences (Adeponle, Groleau, & Kirmayer, 2015).

Kamens contrasts the current dominant psychiatric view that treats hallucinations as the manifestations of a disordered brain, with a social-structural approach that emphasizes the varied meaning of hearing voices. That social context matters is evident from studies that find substantial variation across cultures in the experience of hearing voices, even when comparing people diagnosed with schizophrenia by similar criteria. Luhrmann, Ramachandran, and Tharoor (2015) have shown that while people in the United States are more likely to hear negative, critical voices, in Ghana and India, they may hear friendly voices of relatives speaking words of encouragement.

In the case of people with schizophrenia in the United States, the persecutory voices might be readily seen as reflecting the larger social context of isolation, alienation and paranoia characteristic of a highly competitive, neoliberal, racist society (Metzl, 2009). Thus, the voices of psychosis are the kind of self-critiques of failure, dejection and marginalization that characterize the social position of the psychotically disabled person in an economy that demands consistent consumption, performance and productivity.

There is little doubt that structures of inequality in society are important mediators of the onset and course of psychotic disorders—as they are for most forms of affliction. And the content of hallucinations reflects not just individual history but salient social issues (Gold & Gold, 2015). But there is a dilemma in ascribing communicative value and agency to experiences that may not be intended as such by the person who endures them. Much the same problem has occurred in psychodynamic interpretations of symptoms as forms of symbolic communication or protest. Imputing agency or communicative intent to symptoms when people feel out of control and, indeed, when their suffering is directly related to that sense of loss of control, does a kind of epistemic violence (Kirmayer & Gomez-Carrillo, 2019). In effect, it appropriates the experience of the sufferer to launch a critique of structures of inequity in society. This may be good politics, but bad therapeutics, unless it results in increased agency on the part of the sufferer.

Ghostwritten

The ghostwriting of a substantial portion of the literature of psychiatry—especially research studies and clinical guidelines on psychopharmacology—constitutes epistemic violence of a different sort, perpetrated by pharmaceutical companies, with the collusion of psychiatrists. Ghostwriting is an ethically dubious practice that reflects the data manipulation and marketing efforts of pharmaceutical companies and cannot fairly be said to have been “embraced” or claimed by psychiatry—although perhaps we can read a tacit acceptance in the fact that there are many “opinion leaders” in psychiatry whose careers have been built in part on this kind of covert practice.

Ethan Watters (2010) describes...