Book review: Mahima Nayar,Against All Odds: Psychosocial Distress and Healing Among Women

The focus of the book under review is mental health concerns of women, an area that has either been relatively under explored or been primarily examined through the biomedical lens that has by and large overlooked the social context and determinants of mental health. Bringing together cultural anthropological, feminist, public health and social justice perspectives, and critiquing the biomedical paradigm in mental health, the author foregrounds the intersecting layers of psychosocial distress in women’s lives. The locale she has chosen to illustrate her argument is the urban slum resettlement colony of Jahangirpuri in the capital city of Delhi.

The literature in India on the linkages between social and economic development and mental health in general and on the determinants and manifestations of women’s mental health in particular is relatively scarce. Apart from the fine, now almost a classic, text of Bhargavi Davar (1999) titled Mental Health of Indian Women: A Feminist Agenda, the ethnographic study of a psychiatric institution (Addlakha, 2008), Vikram Patel and his associates’ work on linkages between public health and mental health (e.g., Patel, 2015), empirical research through a gender lens on mental disorders in women by Vindhya et al. (2001), to cite a few, the mainstream disciplines of psychology and psychiatry have been relatively muted in unpacking the social determinants of women’s mental health. Consequently, the social context of women’s mental health such as persistent gender inequalities in access to resources, in household roles and at the workplace, and varied forms of gender-based violence, have not been closely examined for their contribution to mental disorders and distress among women. It is in this context that the significance of this volume must be seen. Against All Odds contributes to illumining the structural determinants—poverty (absolute and relative), gender-based inequalities, social exclusion and conflict—that contribute to mental disorders/distress among women.

The author thus positions herself in the feminist/social determinants of mental health paradigm and argues for a serious examination of the causative role of these social determinants in women’s mental health concerns. She goes on to underscore the point that medicalization of these concerns and overlooking of social determinants do not squarely address the question of how social ill-being contributes to psychological ill-being of women in particular.

The central argument underlying this volume therefore is that there needs to be a shift from the dominant biomedical curative model to a social well-being model in mental health care. Not only does the author buttress her argument by presenting literature from the West on the critique of the politics of the dominant biomedical model but her field work also supports the need for advocacy efforts of community mental health organizations for integrated services.

Divided into seven broad chapters, beginning with the historically contentious question of what is ‘abnormal’, the volume presents the different and often opposed theoretical frameworks to understand causes of mental disorders/distress, the social and cultural context of mental disorders and particularly so in women, followed by a thematic analysis of the author’s field work in the slum resettlement colony of Jahangirpuri in the remaining chapters. While exploring women’s lives and their psychological distress, the author turns on an intersectional lens and unravels the interstices between gender, caste, religion and class with poverty to capture the causes of mental disorders as located in these interstices. In doing so, she is able to effectively highlight the vulnerabilities, agonies and daily hassles—in short, the perpetual struggle that these women have to undergo in not only keeping their bodies alive, but also their minds sane.

By presenting snapshots of the women participants’ lives, the author attempts to drive home the key components of mental health empowerment essential to the model of social well-being care—having a sense of choice and control; changes in power relations enhanced through knowledge and awareness, skill development, and supportive community contexts; and access to valued resources (Nelson & Prilleltensky, 2010)—which are sadly lacking in the kind of field location on which the volume is based. The author argues that unless the socioeconomic context of mental illness and distress in developing countries, such as ours in particular, is emphasized, the gap between public health and mental health cannot be bridged.

While the book does present this picture of the women’s lives in a graphic way, with the narratives being in the voices of the informants, a key limitation of the book, in the reviewer’s view, is the inability to situate the field work findings to the larger context of recent mental health policy and legislation in the country. For instance, both the National Mental Health Policy (2014) and the recently enacted Mental Healthcare Act, 2017 recognize the right to access mental health care as well as social care, with emphasis on services in the community. This community approach marks a shift from the earlier emphasis on institutional care for persons with mental illness. It is the community approach that had inspired the District Mental Health Programme in India which the author mentions as the keystone of the NGO intervention in her field work location. While the nature and evaluation of this intervention may not be the objectives of her work, the author could have used her experience of working alongside the intervention introduced by the NGO in order to come up with insights and lessons drawn from the intervention in order to suggest a way forward. The author’s analysis of strengths of the intervention and its limitations in practice could have been marshalled in order to come up with more concrete insights into how a social well-being model can actually be put into practice. Her critique of the biomedical model and her argument for a psychosocial model for explaining and intervening in women’s mental health concerns could then have led to more practical solutions for feeding further into policy.

Second, the book appears to be a product of the author’s doctoral thesis and follows the dissertation format of chapters consisting of a review of literature, methodology and analysis and discussion of data. However, being an ethnographic study, the writing style veers between following this formal format and a narrative style interspersed with presenting slices of the informants’ lives, anxieties and struggles. As stated earlier, this rich description could have been yoked to a more analytical and evidence-based recommendations for future policy.

Third, the author adopts a rather unquestioning and uncritical view of indigenous practices of healing. Taking an anthropological view of mental illness hinged on people’s interpretations of causes of illness, she looks at severe mental disorders (SMD) through the idiom of ‘possession’, of the attribution of ‘madness’ to the supernatural realm made by the women, while the common mental disorders (CMD) is attributed to the ‘tired body’ on which ‘social suffering is inscribed’ (p. 214). Mental health literature makes a distinction between SMD that are more biological in origin and require biomedical intervention and CMD that are psychosocial in origin and need different pathways of help and care. However, the case study that she presents wherein she reports that her informant’s ‘daughter’s condition had improved with the new medication’ (p. 101) somewhat blunts her original critique of biomedical reductionism. Indeed, her case study demonstrates how, in fact, both biomedical and psychosocial interventions are needed for different manifestations of mental health concerns.

Having said this, it must nevertheless be pointed out that the field-based work such as the present volume is a fine contribution to the emerging literature in India on the relationships between socioeconomic adversity and mental health that in turn can inform primary and secondary preventive strategies in the area of women’s mental health.