Unstable States and the Biologization of Mental Illness

Abstract

We critically examine how biological narratives of mental illness mediate relations between personal experiences and socio-structural conditions of distress in crisis contexts. Using three case studies of contemporary crises in Russia, the Republic of Cameroon, and Bangladesh, we showcase the ways in which biological meanings of mental illness carry political and structural significance as authorities employ “biologization” for political ends. In Russia, biologization is strategically useful to authorities seeking to control a populace, as chronic “conditions” can be “treated” indefinitely. In Cameroon, state psychiatrists in Yaoundé incentivize patient citizenship through biological frameworks of illness and intervention. In Bangladesh, the embodied presence of Rohingya refugees is a medium by which they can engage politically; therapeutic intervention becomes a site of political consensus in which Rohingya enact a “fictive biological citizenship.” Biologization of mental illness forms a basis for reinforcing or challenging the power of the state and the meaning of citizenship in distinct ways across these three contexts, highlighting the importance of attending to its political implications as it is invoked in frameworks of diagnosis, explanation, prognosis, and treatment in global contexts of ostensible crisis.

1.1. Introduction

Around the world, multiple disciplines engage crisis rhetoric when describing the experience and context of distress and mental illness. For example, the United States Surgeon General recently described America’s “mental health crisis” (Murthy, 2023), and the World Health Organization highlighted how “humanitarian crisis” such as armed conflict exacerbates population distress (2022a). Such “global health crises,” write Alyshia Gálvez and colleagues (2020), constitute “chronic disasters… disasters within disasters.” There is a need to study how the social risks and structural factors implicated in crises interact with individual bodily risks--which are often the focus of psychology and related disciplines.

In this paper, we critically examine how biological narratives of mental illness mediate relations between personal experiences and socio-structural conditions of distress in crisis contexts. By “distress,” we refer to negative experiences that are not necessarily pathologized or medicalized by biomedical or alternative frameworks. How, we ask, do biological framings of mental illness cultivate, extinguish, or otherwise reconfigure the political sensibilities and subjectivities of those deemed mentally ill? Thinking across the disciplines of cultural psychology, sociocultural anthropology, and public health, we answer this question through three apt case studies of contemporary crises in Russia, the Republic of Cameroon, and Bangladesh. Drawing on historical, clinical, and ethnographic evidence, we trace how and why clinicians in these cases--especially clinicians who are both citizens and employees/associates of the state--seek to foreground biological etiologies of mental illness when they encounter patients and populations. We highlight these etiological framings’ biopolitical significance by exploring how clinicians and other authorities use biologization for political ends, and we examine the distinct implications for how citizenship is enacted across contexts.

We argue that this “biologization” of mental illness shapes patient and population understandings of the acuteness and chronicity of mental illness. Our use of the term “biologization” in this article foregrounds the dynamic and interactive nature of biological processes themselves in the emergence of distress (e.g., Gómez-Carrillo & Kirmayer, 2023) and the ways in which biological accounting becomes a process in its own right--what Ian Hacking (2006) calls the tendency to “biologize” by “recogniz[ing] a biological foundation for the problems that beset [and establish] a class of people.” Talking about mental illness as biological affects the way people think of it in complex ways (Haslam and Kvaale, 2015; Larkings and Brown, 2018). Furthermore, these biological narratives often individualize mental illness in ways that obscure the social ramifications of biological phenomena—particularly as such narratives are deployed in political crises. This process has complex implications for state dynamics of control and care in such contexts, and for constituents’ possibilities of enacting citizenship in contexts framed as political crises.

In Russia, stories of political dissent or civil complaints are recast by the police and security services and the collaborating clinicians as stories of biological differences that need to be diagnosed and managed with biomedical means. In Cameroon, state psychiatrists enfold biology into patients’ understanding of both mental illness and citizenship as chronic conditions in a period of armed secessionist threat to the Republic’s integrity. In Bangladesh, state employees and extra-state actors foreground biological interpretations of refugees’ psychopathologies in humanitarian mental health services, which become sites of political contestation for stateless Rohingya “beneficiaries.” In and across these case studies, biological frames are made to become a political actor. While possibilities of enacting citizenship are often explained biologically—and while such explanations are often presented as politically neutral—we showcase the ways in which biological meanings carry political and structural significance. Specifically, we show how the biologization of mental illness forms a basis for reinforcing or challenging the power of the state and the meaning of citizenship in distinct ways across these three contexts.

2.1. Dynamic Encounters of Biology and Politics: A Select Interdisciplinary Review

Our contribution to this special issue follows, in part, a long interdisciplinary line of biopolitical thought that emphasizes how power is exercised not through the ability to command death, but rather, through the capacity to regulate what Michel Foucault articulates as “the mechanics of life [and] the biological processes” (1980; Rabinow, 1996; Rose, 2001; Bradley, 2020). We pay attention to the dynamic, even unstable, aspects of power, focusing on the state as a particular locus of power. In doing so, we respond to Arthur Kleinman’s (2012) provocative call for clinicians, scholars, and other actors in the psy-sciences to “supersede Foucault” without losing sight of the moral and political texture of collective belonging. What, Kleinman asks, “happens when we see the state not primarily as the source of powerful control over the mentally ill and through them society at large, but rather as fragile, constrained, and almost powerless to provide the most basic care for its most impaired and vulnerable members” (2012)?

To this end, each of our case studies features a state whose authority or integrity is in question, sometimes explicitly under the framework of crisis. In Russia, the state is waging a costly war with Ukraine and straining to eliminate dissent. In Cameroon, the heavily Francophone government in Yaoundé has been engaged in an armed conflict since 2017, commonly known as the Anglophone Crisis, against secessionist factions in Anglophone Northwest and Southwest Cameroon. This is a region many secessionists claim as the independent Republic of Ambazonia, though it has yet to be internationally recognized. In Bangladesh, the state has been commended by the “international community” for permitting hundreds of thousands of Rohingya refugees to reside in camps inside its national borders as they fled Myanmar in recent years; it has also been criticized for restricting Rohingya freedoms and denying the possibility of Rohingya integration. As such, the stateless Rohingya live in camps administered by a combination of state and extra-state humanitarian actors with a range of formal mandates granting them piecemeal authority over various aspects of Rohingya lives and futures.

The political implications of biological frameworks and mental health interventions–particularly those affecting the possibilities and expressions of citizenship–have been explored previously. We cannot offer a comprehensive review here, but single out works we find particularly pertinent. To start, the sociocultural anthropologist Adriana Petryna (2002; 2004) highlights how biological damage may serve as the foundation for the problems, as well as for the redress, of citizens as a particular class of people--what she terms “biological citizenship.” This concept emerges from her fieldwork on the 1986 incident at the Chernobyl nuclear power plant and its aftermath, as Ukraine became an independent post-socialist state in 1991. Tracing how Chernobyl transformed from a positive symbol of Soviet modernity and accountable governance to a negative one, Petryna describes how the new Ukrainian state gained legitimacy in part by assuming responsibility for managing the radioactive site as well as caring for people exposed to radiation. To do so, it created a new classification of “sufferer,” a class whose members were entitled to “a form of social welfare based on medical, scientific, and legal criteria that both acknowledge biological injury and compensate for it” (2004). As demand for inclusion in this legal category rose and Ukraine sought international assistance in managing Chernobyl, controversy grew as to whether people might be exaggerating the extent of their injury to receive state benefits, and the new Ukrainian state, the extent of the management project to receive extra-state benefits in a period when international allies such as the United States were reducing spending. Petryna frames such concerns as a “barometer [of] changing moral fabric” (2004) in Ukraine and of the broader rights and obligations of citizenship. Vinh-Kim Nguyen describes a similar dynamic of “therapeutic citizenship” in which AIDS infection in Ivory Coast and Burkina Faso paradoxically facilitated survival in the context of a “depleted state,” where treatment resources were negotiated with international organizations and local groups that gained jurisdiction over lives and deaths (Nguyen, 2010). These examples illustrate ways in which biological framings make stabilizing claims on otherwise non-biological realms; our case studies extend this concept into the realm of psychological distress, and explore how this occurs in contexts with distinct manifestations of citizenship rhetoric.

Other writers have explored the political dimensions of mental health interventions and highlighted their implications for expressions of citizenship, especially in crisis contexts. In the critical literature on humanitarian psychiatry, Vanessa Pupavac has developed the concept of “therapeutic governance”--that is, “psycho-social intervention as a new form of international governance based on social risk management” that seeks to manage not only the conduct but also the character of the therapeutic citizenry (2001). As such, a psychologically-derived “therapeutic citizenship” emerges (in contrast to Nguyen’s [2010] biomedical concept), in which “an individual’s emotional state is therefore no longer a personal matter, but becomes public property and related to ‘the responsibilities of citizenship’” (2001). Pupavac’s conceptualization of therapeutic governance complements Petryna’s formulation of biological citizenship by describing its expression in the humanitarian response sphere as one crisis context in which “trauma confirms suffering and confers moral status and the basis for legal rights, so there is a readiness for individuals to identify themselves as traumatized” (2002). However, while such a system seems to promise certain benefits and rights for the traumatized, these boons ultimately lack political substance in contexts where populations have no hand in formulating policy (2001). Pupavac’s concept expresses the political stakes of psychosocial need, showing how therapeutic paradigms in crisis fail to address the “substance of political need” (2001). We draw on these formulations to characterize dynamics of governance and therapeutics across our case studies as we highlight the implications of biologizing mental illness.

In this paper, we build on these articulations of how biological damage and psychological need support a variety of political claims by governing entities and governed citizenries. We develop this framework to explore how the biologization of mental illness shapes the political existence of those deemed mentally ill across three distinct contexts of states in ostensible crisis.

3.1. Methods

The case study from Russia draws from human rights datasets, media reports, and historical documents to offer a cultural psychology analysis of the recent resurgence in psychiatric evaluations and hospitalizations of dissenters in Russia. Anthropological evidence from the Republic of Cameroon comes from Durham’s fieldwork at Sommeil Psychiatric Hospital. This is the Republic’s flagship, full-service psychiatric hospital, located in the capital city of Yaoundé. From 2016 to 2019, Durham conducted 24 months of participant observation and semi-structured interviews with the clinical team at Sommeil and with 30 patients and their families (if and as present in patients’ lives). Evidence from Bangladesh comes from Yan’s work in public mental health, including fieldwork in and near the Rohingya refugee camps. Yan lived and worked onsite with a Bangladeshi non-governmental organization (NGO) in Cox’s Bazar (the center of operations for the Rohingya refugee response) for six months in 2019–2020, and has continued to work remotely on research projects involving Rohingya communities in Bangladesh and Myanmar. Yan draws on her experience participating in the coordinated response; formal findings and interim observations from research projects; a theoretical literature review; and discourse analysis of key humanitarian resources and communications.

4.1. The Biologization of Protest in Russia

In the spring of 2022, soon after the onset of the war in Ukraine, Alexey Korelin, a 22-year-old college student in Nizhny Novgorod, Russia, posted a public critique of his university’s new policy requiring students to participate in pro-war education sessions (Lugov, 2022). Alexey also attended one of his virtual class meetings with an image of a Ukrainian flag drawn on his forehead. These incidents drew the attention of agents from the Federal Security Service of the Russian Federation (FSB). They moved to recast Alexey’s political dissent as a biological difference that needed to be diagnosed and managed pharmacologically.

After searching his apartment, the agents told Alexey to stop attending his regular sessions with a university psychologist, whom he saw for academic issues. Instead, they directed him to contact a local psychiatrist known for involvement in cases of involuntary psychiatric hospitalizations of political dissenters. When Alexey ignored this recommendation, he was brought in for another round of questioning and offered a stark choice: psychiatric hospitalization or a criminal case. Reasoning that psychiatric hospitalization might be less dangerous in the evolving climate of longer prison sentences for political dissent, Alexey signed paperwork to be admitted to a psychiatric hospital. As reported in the press, he was held there for over a month and treated with neuroleptics. After his release, he was required to check in regularly with psychiatric services and to continue the prescribed regimen of medications. His newly diagnosed “psychiatric condition” was presented as chronic, requiring indefinite monitoring and pharmacological management. Indeed, other cases of involuntary hospitalization of political dissenters show that, once applied, psychiatric labeling can lead to repeated hospitalizations and ongoing medication management (e.g., the case of Alexey Onoshkin, who was investigated for disseminating “fake information” and determined to require involuntary psychiatric hospitalization; IdelRealii, 2023; Radio Svoboda, 2023).

Alexey’s story is far from unique. Although precise statistics are unknown, as some cases may be handled outside the courts, the press and independent watchdog organizations have reported numerous legal cases of psychiatric labeling and pharmacological treatment of people expressing dissenting views and protesting policies of the local or national government. One such organization, OVD-Info (2024), has reported about 40 court-based cases in 2022–24. Similar cases have been reported throughout the post-Soviet era, but with a marked increase relative to the pre-2022 period (OVD-Info, 2024). The cases are not limited to a single jurisdiction, representing different regions of Russia (e.g., Moscow, St. Petersburg, but also Nizhny Novgorod, Kurgan, Kaliningrad, Vladivostok, Yakutsk, etc.). The geographic diversity of the cases corresponds to the overall rates of criminal cases against the protesters, which overrepresent larger cities but cover much of Russian Federation. In some of these cases, like Alexey’s, the concerns are political (critiquing the military, advocating for ethnic group autonomy). In others, psychiatric diagnoses and hospitalizations are doled out to those who complain about local policies or services.

These reports emerge against the background of tectonic shifts in the political, social, and economic life of Russia. Especially relevant to these cases are recent reforms in the delivery of mental health services, as mandated by the 2023 amendment to the federal law on psychiatric care and guarantees for patients’ human rights (Federal Law No. 465-FZ, 2023). The newly adopted changes allow clinicians to place more limits on patients’ communications with the outside world. Clinicians can also break patient confidentiality to communicate information to law enforcement in cases deemed to present a risk of “societally dangerous acts.” In a recent clarification, the Russian Constitutional Court has specified that prolonged, potentially lifelong, involuntary commitment is allowed under the law (Vladimirov, 2023) . Additionally, new laws criminalizing dissent have been passed since 2022 (McCarthy, Rice & Lokhmutov, 2023). It is within the medical and legal context defined by these laws that Alexey and others like him navigate the outcomes of ascribed psychiatric diagnoses.

The recent reports of involuntary psychiatric care share important commonalities that illustrate the process of weaponizing the biologization of mental illness for political goals. One common aspect of these cases is the exploitation of the shared cultural stigma of mental illness. In Russia, as in many cultural contexts, mental illness is perceived to be stigmatizing, with psychotic disorders in particular linked to concepts of abnormality and imbalance (Nersessova et al., 2019; Schomerus et al., 2007). When civil disobedience is cast as indicative of psychotic symptoms, the moral and political intuitions of the “patients” are interpreted as irrational, disorganized, and delusional. In some cases, “diagnoses” and insinuations about the irrational thoughts and behavior of the activists are released to the public, seemingly with the aim of stigmatizing the protesters.

Biologization of dissent is another common feature of these cases. Once a diagnosis is applied, the political and legal categories relevant to the case (e.g., the legal frameworks adopted in recent years that criminalize unsanctioned protests, acts of disseminating “false information” about the war, and “justification of terrorism”) are replaced by categories that are typically not just psychiatric, but specifically biomedical in nature (e.g., history of head trauma, references to the brain as the locus of the problem). The application of psychiatric diagnoses pathologizes dissent, presenting it as an expression of medical causes rather than political agency. Beyond saying that the dissenters are mentally ill, many of the cases involve assertions that the dissenters’ symptoms of mental illness are biogenetic in nature, thereby not only broadly pathologizing, but biologizing the protest.

How does biologization play out in these cases? One way is through choices of specific diagnostic labels applied to describe dissent. Very few reports reference attempts to apply diagnoses of internalizing (e.g., anxiety, depression, post-traumatic stress disorder [PTSD]) or externalizing (e.g., antisociality, substance abuse) forms of mental illness to dissenters—although these disorders are common in clinical practice. If the diagnoses ascribed to the dissenters in these cases were driven purely by the experiences of the “patients,” one might expect that the negative emotions expressed by protesters would be cast as symptoms of internalizing distress (e.g., PTSD, anxiety), whereas protest behaviors that violate societal norms would be cast as symptoms of externalizing behavior (e.g., antisociality, substance use).

Instead of reflecting this broad set of potentially relevant diagnostic categories, records of involuntary treatment or hospitalizations that provide diagnostic information suggest that the diagnoses used in these cases tend to represent two categories: psychotic disorders and disorders due to physiological conditions (e.g., head trauma, neurological deficits). These labels are understood by the lay public in Russia to be relatively more biological in nature (e.g., Dietrich et al., 2004; Nersessova et al., 2019). Framing forms of mental illness as primarily biogenetic increases essentializing, thereby promoting interpretations of symptoms as immutable (Larkings and Brown, 2018) and fostering a desire for social distance from those with mental illness (see Angermeyer et al., 2004). The diagnostic categories perceived as more biological also cast more doubt on the reasoning and judgment of the “patients,” ranging from their political intuitions to the veracity of their reports of being mistreated by law enforcement or in the psychiatric hospitals. By promoting attributions of chronicity, biologization can also be strategically useful to authorities. Even longer criminal sentences are time-limited, while chronic biomedical “conditions” can be “treated” indefinitely, with routine re-evaluations prolonging the hospitalization.

The ensuing “treatment” of dissenters also points to biologization, involving long-term hospitalizations and high doses of antipsychotic medications. The side effects of these medication regimens tend to mimic symptoms of neuropsychiatric disorders (e.g., memory issues, trembling). For example, one hospitalized political opposition volunteer was heavily medicated for “chronic delusions.” He appeared unmotivated and emotionally withdrawn to an observer, displaying slow speech, memory lapses, an unfocused stare, and flat affect (Sibir’.Realii, 2020). As such, medications can create a self-fulfilling loop (Hacking, 1996), generating not only social expectancies, but also side effects that are consistent with the purported disorder, thereby giving further credence to the claims of biologized mental illness.

4.1.1. Historical roots: Soviet punitive psychiatry

In line with the dynamic nature of the state’s influence, the tendency to biologize political opposition changed over time in Russia as the nature of governance changed. The recent reports of involuntary “diagnoses” and treatment should be interpreted against the background of a powerful legacy of the systemic Soviet-era practices of casting dissenters as mentally ill. In the USSR, psychiatry concerned itself with the relationship between psychiatric symptoms and, on the one hand, interest or participation in civil protest or social reform or, on the other hand, withdrawal from the system or “social parasitism” (see Engmann, 2022; Fitzpatrick, 2006). Timofeyev (1974), a Soviet psychiatrist, stated that “ideological dissent can be caused by the brain disease in cases when the pathological process develops very slowly and gradually (sluggish schizophrenia), and the disease’s other signs remain imperceptible until the time is ripe (at times until the criminal act is committed).” A diagnostic category of sluggish schizophrenia, presented as a diathesis—or latent vulnerability—for schizophrenia, was developed in the 1960s. This category, postulated as biomedical in origin, was systematically used to label and “treat” political dissenters (see Lavretsky, 1998; Van Voren, 2010). This diagnostic category and the strategies for managing its “symptoms” allowed psychiatrists to describe dissenting views as a manifestation of a biomedical condition in the absence of significant psychotic symptoms.

The contemporary practice of labeling dissent as indicative of disorders of the brain has clear links to the punitive psychiatry practices of the past. Although a number of diagnostic categories were applied to Soviet-era dissenters, it was common to describe dissent as a manifestation of psychotic disorders. Once applied, the label justified lengthy periods of involuntary institutionalization, a common approach for managing people with mental health problems and activists alike in the USSR. This strategy also justified administration of neuroleptics. Grigorenko (1981), a dissident who was involuntarily hospitalized in the 1960s, recalled that his psychiatrist, Daniil Lunz, who promoted the view that any anti-government activities in the Soviet Union were within the purview of psychiatrists, advised him to call less international attention to his plight, as these advocacy efforts ran the risk of having Grigorenko’s “condition” reclassified from a delusional disorder, a condition that was understood to be immutable and unresponsive to treatment, to schizophrenia, that was likewise understood as chronic, but requiring continuing treatment with neuroleptics (“horse’s doses of haloperidol,” according to Grigorenko). Stigma of mental illness and memories or rumors of the Soviet-era punitive psychiatric practices yielded deep and lasting distrust in psychiatric diagnosis and treatment that extended long past the Soviet period and presented a significant barrier to treatment in the post-Soviet space (Bonnie & Polubinskaya, 1999; Raikhel & Bemme, 2016).

During the post-Soviet period, a new legal framework for protection of the rights of the mentally ill was introduced (Korolenko & Kensin, 2002; Raikhel & Bemme, 2016); the same framework was revised in 2023. The discipline of psychology has expanded greatly, with efforts to create and/or grow psychology departments in many institutions of higher education and rapid increases in the number of students majoring in psychology (Karandashev, 2006). Russian psychiatrists have worked to develop patient-centered approaches, shifting away from the legacy of heavy-handed and institutionalization-based Soviet system of psychiatric care delivery. They developed collaborations with the global psychiatry community, working to gradually rebuild the damage to their profession’s reputation in Russia. This period witnessed the emergence and growing popularity of many forms of psychotherapy, coaching, and self-help and mental health awareness efforts (Matza, 2009, 2012; Raikhel & Bemme, 2016), many of them focused on Westernizing the Russian understandings of the self, emotional and social functioning, and psychological health and mental illness. Matza (2012, 2018) has observed that these efforts, focused as they were on cultivating the individual psychological self-awareness and wellness, tended to reify emerging social class differences and encourage the apolitical stance of locating problems and aspirations in the self rather than in the political sphere.

The contemporary cases of diagnosing, hospitalizing and medicating those with dissenting beliefs in Russia again infuse the domain of mental illness with political meanings. These cases evoke a familiar script of selecting the most stigmatizing and essentializing biomedical diagnostic categories and the most punitive treatment regimens to control the “symptoms,” thereby stripping the protesters of some of the rights still granted to healthy citizens. Although some aspects of psychiatric labeling and hospitalizations can be seen as offering the protestors advantages relative to the risks posed by prison sentences, they come with substantial costs in terms of stigma, loss of individual rights, indefinite confinements, and psychological and medical damage when treatment and medication regimens are turned into punishments. In Russian cultural settings, biologization appears to be used to stigmatize dissent and ensure long-term paths to monitoring and controlling the dissenters, with biological explanations of dissent limiting rights that come with citizenship.

These cases from Russia also illustrate how the strategies used by the state appear to be less-than-consistent. When faced with the choice of portraying dissenters as criminals versus mentally ill, the political establishment does not appear to have a clear shared script for selection and use of these categories for political control. In comparison to the Soviet systematized approach to politically motivated diagnosis and treatment, contemporary cases raise questions about situations that result in involuntary hospitalization versus other strategies of control, such as medical professionals’ differential willingness to cooperate in these cases. At times, ostensibly chronic diagnoses appear and disappear from the records as cases are handled by the system. Although one can see the cases of pathologization and biologization of distress as evidence of an increasingly totalitarian state exerting its control over the dissenters, these cases also reveal weaknesses and inconsistencies in how this control is applied.

4.2. Chronic Citizenship in Cameroon

This sociocultural anthropological case study examines how state psychiatrists in Yaoundé, Republic of Cameroon incentivize patient citizenship through biological frameworks of illness and intervention, thus rendering both mental illness and citizenship chronic conditions. To start, it is important to note that most people who come from across the country to seek in-patient or out-patient treatment at Sommeil, the Republic’s flagship psychiatric hospital, do so as a last resort, after consulting private practitioners for what in French is called folie (madness). Across Cameroon, a country with over 200 self-ascribed ethnic groups, madness is known by multiple names and symptoms, but in general is often seen as a largely acute form of moral injury. Here the mad are deemed to have caused their own distress, often presenting as visible agitation, by behaving toward others in deviant, often supernatural ways (such as seeking to harm others through sorcery) that then come home to roost. As such, madness could potentially be resolved by those afflicted by this condition correcting their own troublesome sociomoral behavior. Some of these private practitioners are affiliated with religious movements like Pentecostalism--others, with what is often glossed as indigenous or traditional medicine. Regardless, Sommeil’s psychiatrists emphasize to patients that their services are secular and focused on the brain-based biology of mental illness rather than the behavioral morality of madness. They position themselves not as denying the existence of madness or the utility of moral therapeutics, but as specializing in a parallel-but-distinct etiology of distress necessitating a different clinical approach (see Durham, 2021).

Sommeil’s approach differs from extraclinical notions and therapeutics of distress in both materiality and temporality. Here psychopharmaceuticals are key: almost regardless of diagnosis and in- or out-patient status, it is rare for clinicians not to prescribe them. This, one clinician explained, was because psychopharmaceuticals could be used to “stabilize” patients in the short term and “support” them in the long term, and because many patients ask for medication that will cure their distress (see Awah and Phillimore, 2008; Read, 2012). Prescribing drugs, he continued, meets this request while helping patients understand that mental illness, unlike madness, is “more of a chronic condition. It’s something that doesn’t give [yield] in the brain.” Thus rendered chronically deficient through no fault of the patient, the brain needs the chronic consumption of psychopharmaceuticals, framed by psychiatrists as singular substances afforded by a singular state institution. As another clinician told a group of patients, “you must [come] to the specialists at Sommeil. We [by tone and implication, only we] have medicines to give you force” (in the sense of vitality as a life force; see Durham, in press).

At Sommeil, the singular importance of psychopharmaceuticals, psychiatrists, and the state hospital are all linked. While Sommeil does not have an in-house pharmacy for dispensing the psychopharmaceuticals that psychiatrists prescribed, these clinicians are often willing to orient patients to private Yaoundé pharmacies known for reliably stocking these drugs and/or for being willing to negotiate on price for patients in exceptional need. Most clinicians recognize the financial sacrifice of routine psychopharmaceutical use—and the frustration that accompanies periods of drug shortage, for patients and psychiatrists alike—as well as the financial and practical barriers to routine consultation for patients living outside Yaoundé.

These barriers eventually expanded to include security. In 2017, tensions between the heavily Francophone government in Yaoundé and Anglophone secessionist factions in Northwest and Southwest Cameroon broke out into armed conflict. Widely known in and beyond Cameroon as the Anglophone Crisis, this conflict is not, in fact, as unexpected or novel as the term “crisis” suggests. Rather, it stems in part from the division of then-German Kamerun after World War I by Britain and France and from a 1961 United Nations plebiscite permitting residents of the then-British Cameroons to join the newly independent states of either Anglophone Nigeria or Francophone Cameroun, but not to form their own state. It was this territory that secessionists in Northwest and Southwest Cameroon sought to claim as the independent state of Ambazonia. At Sommeil, where most psychiatrists are from Francophone villages and cities outside the conflict zones, clinicians insist that they do not discriminate on the basis of language or political belief. As one such Francophone psychiatrist earnestly explained: “We receive ‘refugees’--I say refugees in quotes--rebels, [Republic of Cameroon] soldiers. We don’t distinguish; we don’t play sides. They are all Cameroonians to us. They are all our Cameroonian brothers.” Yet such ostensibly neutral sentiments of care still assume and operate within the existing Republican framework of fraternal nationalism.

Such sentiments constitute an attempt by clinicians at structural competency (Metzl and Hansen, 2014)--at addressing extraclinical conditions impacting clinical access and outcomes--that nevertheless leave intact the infrastructure of citizenship. Increasingly, patients outside Yaoundé voice concerns about the difficulty of travel: roadblocks, harassment by Republic soldiers and secessionists, confiscated or vandalized identity documents, bribes, and violence. While psychiatrists listen sympathetically, most deny that comparable psychiatric services exist elsewhere, even at a smaller psychiatric hospital in Douala, the largest city in the Republic and one that would involve less and/or easier travel for many patients in Northwest and Southwest Cameroon/Ambazonia than the journey to Yaoundé. Instead, many psychiatrists emphasize Sommeil’s flagship standing and the exceptional services they feel they offer, including their qualification to prescribe psychopharmaceuticals. Sommeil, they often said, is the Republic’s “hospital of reference” for mental illness, an expression that encapsulates both the specialized treatment available at this hospital, and a sense of professional and institutional pride. For these psychiatrists, Sommeil’s exceptional standing makes necessary repeated return to the psychiatric care offered in and by the capital, despite the potential and realized risks of travel.

To illustrate, a brief but telling encounter: in the fall of 2018, shortly before the Republic’s President, Paul Biya, was re-elected for a seventh term, a woman who identified herself as from a village in Southwest Cameroon came for out-patient treatment at Sommeil. At first, she sat quietly by herself on one of the long wooden benches that lined the corridors outside the consultation rooms, occasionally chatting with other patients, but as the hours passed, she became increasingly irritated. Finally, she announced to no one in particular and everyone in the corridor with her that it was not worth her time and safety to keep coming to Sommeil. “This hospital is not clean!” she said. “It’s not clean! It’s dirty. Dirty!” This is a common critique from patients coming from Anglophone Northwest and Southwest Cameroon, one that is both literal and an expression of discomfort and disgust (i.e. Douglas, 1966) with Sommeil as a continued site of the (neo/post) Francophonie.

When it was finally this woman’s turn to be consulted, she repeated this complaint in English to the attending psychiatrist. In French, he replied that she had the legal right as a patient to seek treatment wherever she liked, but “psychopharmaceuticals aren’t made with bleach.” Her only option to maintain her treatment—“to avoid another bipolar crisis,” in his framing—was to continue treatment at Sommeil. At this she did not protest, but accepted the renewed prescription he scribbled down and handed to her. As she left, he told her when to come back; despite her critique, he had the impression she would. In and through encounters and framings like these, it is not only biological illness but also citizenship that becomes a chronic condition.

In the Republic of Cameroon, in other words, the biologization of mental illness constitutes a form of biological citizenship. In Adriana Petryna’s original formulation in the context of Chernobyl, this term refers to “a form of social welfare based on medical, scientific, and legal criteria that both acknowledge biological injury and compensate for it” (2004; 2002). In Ippolytos Kalofonos’ later use of this term in the context of American welfare reform in the late 20th century, biological citizenship illustrates how “access to social services is increasingly contingent on biology or health rather than on socioeconomic need” and how clinicians are increasingly compelled to “gatekeep” such access while also caring and advocating for patients (2019). In the contrasting context of Sommeil, biological citizenship articulates an important two-part process. First, state psychiatrists seek to establish for patients the biological etiology of mental illness as an inherently more chronic condition than madness, near-regardless of specific diagnosis. Second, psychiatrists enfold this chronicity into the need for patients to physically enact and re-enact an ongoing, rather than gatekept, relationship with the capital and its unique forms of biological and political care. This temporal rearrangement, in turn, encourages patients to maintain their political relationship, as citizens, with the Republic in an acute moment of Crisis–of threat to the legitimacy, integrity, and future of the nation-state.

4.3. Fictive Citizenship of Stateless Bodies in Bangladesh

The final case study, from the field of public health, explores how the stateless Rohingya in Bangladesh interact politically with non-state actors at the site of humanitarian therapeutic interventions that engage a unique temporality of crisis to employ biological framings of psychopathology. Here, humanitarian workers stand in as quasi-authorities who inadvertently fulfill some governance functions toward the stateless Rohingya community, and who employ biologized approaches to mental illness for political ends in therapeutic interactions. This case study illustrates how such interactions convey “fictive citizenship,” or expressions of belonging in a political community (here, claimed on the basis of sustained or construed bio-psychological harms) which formal governance structures do not recognize. For the Rohingya, such expressions of citizenship occur in the context of indefinite interim governance by a foreignizing host state and by extra-state actors who shape the structures and possibilities of the refugees’ daily life.

4.3.1. Temporality of Crisis and MHPSS

Humanitarian mental health actors’ rhetoric and operations engage a unique temporality of crisis that implicitly but strongly endorses biological framings of psychopathology. The humanitarian mandate prioritizes immediate provision of lifesaving aid (The Sphere Project, 2011), enacting a largely presentist interpretation of crisis contexts (in the literary/historical sense), limiting historical recall. This presentism orients actors toward the contemporary moment (Hunt, 2002), focusing on the salient factors that directly precipitated the crisis at hand. These factors are invoked to justify intervention, and thus undergird the humanitarian claim of impartiality as somehow assured by acting “solely on the basis of [present] need” (The Sphere Project, 2011).

The discrete event prompting the most recent iteration of the “Rohingya response” was the Myanmar Tatmadaw’s (military) “clearance operations” of 25 August 2017. The campaign comprised brutal violence and killings against the Rohingya people while razing their villages across Myanmar’s Rakhine State. Nearly 750,000 Rohingya fled by foot and boat across the marshy Naf River into neighboring Bangladesh in the following days and weeks (Tay et al., 2018).

Within a short time, disparate actors engaged remarkably similar narratives about Rohingya mental health in this moment of crisis. Specifically, they invoked the scale and trajectory of crisis-over-time to justify urgent psychiatric intervention. In doing so, they situated both documented and projected mental health concerns within a uniquely ahistorical chronicity of crisis. Rhetorical present states of “unending trauma” (Holland Durando, 2019) metastasized into projected futures in which insufficiently-healed Rohingya could destabilize the entire region: feeling “rejected by the world” could be “planting the seeds of future enmity and hatred—unless we act now to help them” (United Nations Children’s Fund, 2017). Narratively, the Rohingya became a past-less people whose present and potential futures legitimize the place of “mental health and psychosocial support” (MHPSS) within humanitarianism’s realm of the urgent and immediate.

This temporal framing practically requires MHPSS interventionists to employ concepts and strategies from biological psychiatry and professionalized psychology (World Health Organization, 2016; Epping-Jordan et al., 2016) that explicitly aim to be universally relevant, rapidly adaptable, and implementable at scale. However, such formulations overlook distinct Rohingya framings of these conditions. MHPSS sector researchers who documented Rohingya “explanatory models” of mental health describe a conceptualization in which physical problems warrant medical care, but “mental health problems” (potentially involving spirit possession, brain, body, or mind-soul) do not (Elshazly et al., 2019; Tay et al., 2018). Although these insights were disseminated in a report endorsed by the United Nations High Commissioner for Refugees shortly after the mass displacement in 2017 (Tay et al., 2018), they are rarely discussed and virtually never accommodated in practice. There remains a “lack of correspondence between the perceptions and expectations of Rohingya refugees about mental health, mental illness and mental health services on one side and what MHPSS services tend to offer on the other side” (Elshazly et al., 2019). Such diagnostic and therapeutic dissonance gives rise to notable opportunities for political contestation.

4.3.2. Therapeutic Encounters: Political Consensus and “Fictive Biological Citizenship”

Rohingya people have minimal opportunities to participate in formal processes of consensus in the camp context. Extra-state humanitarian actors--classically, the United Nations (UN) agencies and large international NGOs--oversee camp logistics and provide basic necessities, with government permission. Each camp is under the formal authority of a “Camp-in-Charge” (CiC)--a Bangladeshi government appointee who functions somewhat like an unelected mayor who is periodically rotated out of the position. The Refugee Relief and Repatriation Commissioner (“triple-R-C”) is the government agency that oversees the entire operation from its compound-office in Cox’s Bazar. Rohingya themselves are officially engaged only as majhis or “block leaders” responsible for small-scale problem-solving in their immediate localities. They are appointed by camp administrators, to varied effect--some are beloved and respected, while others are disparaged for being useless or corrupt.

The physical camp environment embodies the practical and legal restrictions encircling Rohingya refugees’ lives and futures. Rohingya are subject to severe travel restrictions, reinforced by military or police checkpoints along access roads. A barbed wire fence was assembled around the entire camp perimeter in 2019 on the recommendation of the Bangladesh Parliamentary Standing Committee on Defense (Human Rights Watch, 2021). From the Teknaf-area camps along the Naf River, refugees still see rising smoke from the sites of former Rohingya townships--a visible sign of quiet erasure that belies assurances of safe and voluntary repatriation as the only viable solution to the Rohingya people’s plight.

Rohingya do not participate in sector meetings of coordinated response efforts, typically held in Cox’s Bazar about 40 kilometers from the main camp area. Nor do they participate in formal political negotiations with the governments of Bangladesh and Myanmar regarding matters such as repatriation. Meanwhile, both governments explicitly deny the possibility of Rohingya citizenship while formally construing the Rohingya as “belonging to” the other nation. The Burma Citizenship Act of 1982 stripped Rohingya of citizenship in Myanmar, and to date they are only guaranteed “national verification cards” upon their hypothetical return--a form of identity that “will effectively identify Rohingya as foreigners” (Reuters, 2023). Likewise, in Bangladesh the Rohingya are “Forcibly Displaced Myanmar Nationals” or FDMNs (a convention reinforced regularly at multiple levels; NGO workers have scrambled to print and paste polypropylene squares reading “FDMNs” over “Rohingya refugees” on project posters that drew the ire of local officials). Most Rohingya who arrived since 2017 are not formally recognized as refugees, implying an illegal migrant status that in turn curtails their participation in basic functions of society, including formal employment, education, and legal recourse (Bhatia et al., 2018).

The stateless Rohingya are thus contained physically, functionally, and legally apart from the processes of extra-state governance that address their daily needs--and those of foreign-state governance that negotiate their futures. One Rohingya adolescent conveyed his visceral sense of alienation from formal governance, declaring “Our body is our country” (Montanez et al., 2019). This claim implies that the embodied presence of the Rohingya is the only medium remaining by which they can engage in processes of political consensus.

In this context, MHPSS services present a surprising forum for consensus and contestation. The nature of MHPSS services requires a unique degree of active participation from the “beneficiaries,” introducing a mutuality otherwise foreign to the camp context. MHPSS workers (typically Bangladeshi psychologists or lay counselors, often supervised by international program “officers” and “technical specialists”) need Rohingya to show up and participate to meet their “targets”— the aspirational program outputs to which donors hold them accountable (typically measured as the number of sessions provided or the number of refugees in attendance). For MHPSS staff, achieving these targets ensures the continued viability of the programs that employ them. Furthermore, service providers trained in professionalized psychology are quick to summarize Rohingya problems as case formulations, often characterizing their pathologies as arising from cognitive or neuronal dysfunctions. But the Rohingya have transactional goals of their own. While the diagnostic structures of biological psychiatry and professionalized psychology may be foreign to Rohingya understandings, the targeted refugees perceive opportunities in these encounters to derive therapeutic benefit and seek solutions for other pressing needs.

Rohingya refugees find ground to express their concerns in the act of therapeutic exchange, which by its nature elicits discussions of concern and hope. From the Rohingya perspective these are often neither cognitive nor psychiatric; however, this tension often appears as conversational redirection rather than overt challenge. Rohingya “patients” make urgent requests for tangible items, such as food or medication for their families (Ozen and Ziveri, 2019). They request jobs. They express adamant concern for their children’s education. MHPSS workers most often demur in response to these claims, noting that their role is to provide MHPSS support within the bounds of a certain formulated intervention. Such tangible needs, they state (often in frustration), are not within the scope of mental health care that workers are trained to provide (Dyer and Biswas, 2019; Elshazly et al., 2019).

Such requests for employment, education, and other support enact a unique relationship in which extra-state MHPSS providers carry out certain governance functions toward the Rohingya people. Rohingya appeal to service providers (and continue appealing to foreign aid workers who left the country years prior) to accommodate their manifold needs: “I am jobless now; do you have anything?” “I need medication for my child who is sick.” “Are there any organizations or donors who support scholarships for refugee students?” “We need political support for our entire community.” In a context where the state provides no compensatory social welfare, Rohingya refugees seize potential opportunities for such compensation by negotiating their needs with MHPSS providers. These extra-state entities unwittingly open space for such contestation by employing the therapeutic strategies of biological psychiatry and professionalized psychology that often misalign with Rohingya perspectives of their own needs. As Rohingya “beneficiaries” appeal to MHPSS workers for needs ranging from subsistence to diplomacy, they endow these entities with state-like functions that are, in some sense, accountable to their citizenry. This dynamic inspires a discourse of contestation which uniquely conveys Rohingya belongingness-of-necessity to the system if not the country--a fictive if not official citizenship.

In these interactions, the Rohingya become crucial constituents of the MHPSS efforts-at-large, which require their embodied engagement to meet program goals and ensure their own continued viability. These non-state actors are emergently dependent upon Rohingya presence and interaction, just as state governments are emergently dependent upon their citizen constituents. In the absence of other avenues for political engagement, therapeutic intervention becomes a site of political consensus where Rohingya enact a “fictive biological citizenship.” In contrast to the biological citizenship of Chernobyl survivors whose physical harms certified their eligibility to receive state redress (Petryna, 2004), Rohingya citizenship is fictive in that the refugees themselves are claiming (though typically not receiving) the benefits due to citizenry. Here, biological harm does not establish such a claim; rather, when biologized framings of psychopathology interact with Rohingya interpretations of harm and need, they open a space to introduce and contest this claim. Here, Petryna’s (2004) biological citizenship is reimagined and reenacted in the space delineated by states’ disavowal of would-be citizens. Where the appellants are not formal citizens, neither must the appealed-to entities be formal government actors. A fictive element introduces possibilities for nuanced expressions of governance and citizenship on the basis of biological—or biologized—physical or mental harm. Fictive biological citizenship is an expression of the desire and need for redress by the catastrophically dis-possessed, those who belong only to their own bodies.

In such a landscape, an assemblage of state and extra-state actors hold political legitimacy as internationally recognized sovereigns of territories—or of crises. Meanwhile, both states and extra-state actors construe the stateless Rohingya as objects of intervention, as passive beneficiaries rather than political constituents. Where few other opportunities exist for Rohingya to participate in typical functions of citizenry, the therapeutic encounter becomes a rare exception in which Rohingya appeal to MHPSS actors to fulfill certain functions of governance. At the site of contested therapeutic efforts, Rohingya enact a diplomacy of sovereign, embattled bodies. But Rohingya citizenship can only be fictive, never formal, in this state of chronic exemption from the mutual expectations and assurances of state-endorsed compacts with the governed.

5.1. Discussion and Conclusion

The three case studies in this article show how biologized conceptions of mental illness have important consequences for political relations among patients, clinicians, and states. Biological framings have especially profound implications for the possibilities of citizenship in crisis contexts. Given rising interest in what is often called the Movement for Global Mental Health (e.g. Sax and Lang, 2021) and in the notion that “mental health is biological health” (Syme and Hagen, 2020), we suggest that these consequences merit further clinical and scholarly attention. Mindful of the ways in which discussing individual biological factors may mask analysis of broader social and structural issues--and of how crisis rhetoric may mask the ways in which conditions giving rise to dissent and distress are not unexpected, but ongoing-- we suggest that approaching mental illness through a biopolitical lens may yield insights for possibilities of care in and beyond the formal clinic.

5.1.1. Implications of Biologization for Clinical Practice

Each of these case studies presents an evocative challenge to the widespread presumption that biological explanations of mental illness are not only politically neutral but also provide an optimal foundation for both diagnosis and clinical intervention (Brückl et al., 2020). In each of these contexts of ostensible crisis, what has biologization implied for care and treatment?

In Russia, framing mental illness as a biomedical problem deemphasizes other aspects of existence and experience- dynamics of identities and social, spiritual, or political factors. By doing so, psychiatrists and other actors aligned with the biomedical establishment rhetorically locate problems within patients’ bodies, rather than in their context, and intervene in the functioning of these bodies. Such an approach inherently devalues other kinds of narratives–particularly those which problematize aspects of the social and political order. In following an established historical script of handling dissent, this approach also negates collective memories of the psychiatric abuses, as people are invited to participate in a farce where most actors know that the dissenters are not mentally ill (or not just mentally ill), but are asked to uphold the pretense. Moreover, this framing invites those observing these dynamics to forget the fact that similar tactics were publicly recognized as vestiges of deeply problematic historical wrongs only a few years earlier. The fact that the state shifts its tactics, casting some dissenters as criminals and then as mentally ill, reinforces the sense that these frames are applied in an arbitrary or outcome-driven fashion. Finally, the increased tendency to cast dissent as mental illness potentially reinforces stigma and interferes with models of distress and treatment that have emerged in recent decades, models that allowed for the significance of deeply personal, rather than collectively-shaped, emotions and attention to individual and collective emotional expression of anger, disappointment and distress.

While biomedical framings in Russia may foster a sense that the person is not at fault (versus, for example, in cultures with karmic explanatory models), they are also likely to promote a sense that the problem is chronic or intractable. As such, from the society’s (and, at times, even the patient’s) perspective, it may become harder to think of these problems as something they have agency or ability to change. Most importantly, these frames reinforce deep-seated distrust in psychiatry. They open up a possibility that any diagnosis and any treatment approach may reflect political motives. And vice versa, they offer an accessible script to cast any political disagreement as the product of minds in need of diagnosis and treatment.

In the Republic of Cameroon, the biologization of mental illness intervenes in popular conversations about madness as a moral problem that the mad are frequently accused of bringing upon themselves through immoral, often supernatural behavior. However, this intervention is not amoral, but rather loops patients into a different moralizing discourse about good patients and/as citizens (Durham, in press). Both the extraclinical framing of madness-as-moral fault and the clinical framing of biology-as-faulty brain speak to the temporality of distress and treatment, but in different ways, with the acuteness of madness contrasted with the chronicity of mental illness and citizenship amid the broader disruption of the secessionist Anglophone Crisis. This case study draws attention to time as an important feature of wider environments of care.

For displaced Rohingya in Bangladesh—whose mental health needs are most often attended by providers from outside their community—biologizing mental conditions has nuanced effects on the meaning and experience of care. In humanitarian responses, standardizing intervention packages has often implied biologization, as in the mhGAP program for mainstreaming mental health intervention into primary medical care (World Health Organization, 2016). However, implementing this approach has proven exceptionally challenging. In the Rohingya camps, supply chain issues severely limit access to psychotropic medication (a mainstay of the mhGAP approach), especially long-lasting injectable antipsychotics, and transportation difficulties restrict the ability of psychiatrists, patients, and caregivers to access clinical sites (Tarannum et al., 2019). Legal restrictions also accompany such strategies, and minor circumstantial changes (e.g., the resignation of a single Bangladeshi psychiatrist) create major barriers to sustaining these services (Dyer and Biswas, 2019).

Considering the unabating challenges to providing psychiatric care in the camps, it is remarkable that Rohingya refugees now expect to receive biomedical care for mental health issues. Refugees often have high expectations of medications’ efficacy (relative to “talk-therapy” approaches) for the mental health problems that the aid workers have diligently sought them out to diagnose. Ironically, some MHPSS workers further diagnose such expectations as “attitudinal barriers consist[ing] in [sic] lack of acceptance of any non-medical service”--suggesting that Rohingya prefer a pill or a handout to “talk therapy” (Ozen and Ziveri, 2019). Thus, they interpret Rohingya requests for tangible support as tantamount to “looking for band-aid solution [sic] to their problems” (Ozen and Ziveri, 2019). The omnipresent roots of the biomedical model extend throughout the humanitarian response structure--affecting Rohingya expectations of care--yet this Rohingya response-in-kind is pathologized by the very system that evoked it. This approach neither recognizes nor responds to Rohingya explanatory models of mental health, even as these are formed and re-formed in constant interaction with humanitarian therapeutic mechanisms. Rohingya perceptions of need and expectations of treatment are dynamic, existing within adaptive consensus processes in a kind of inverted healthcare market where providers have aggressive incentives to “target” patients in need of many things besides their care. Superficially, biomedical framings of mental illness might be seen as interfering with care, by virtue of their misalignment with traditional understandings of “mental health problems.” More profoundly, they elicit a relational process of exchange and contestation, illuminating tensions between refugees’ and responders’ distinct interpretations of “need” and “care.”

5.1.2. Conclusion

Each of these case studies highlights the importance of attending to the political implications of biologization as it is invoked in frameworks of diagnosis, explanation, prognosis, and treatment of mental illness. Furthermore, each example challenges the concept of biological framings’ political neutrality. As we have demonstrated, such framings may undergird a state’s response to political dissent; incentivize patient citizenship during a moment of crisis; or facilitate unexpected political contention among a stateless fictive citizenry. These examples illustrate the diversity and nuance with which these framings may be invoked across distinct contexts of political crisis; the significance of the biologized perspective is not static across these varied socio-historical contexts. Rather, the biologization of mental illness forms a dynamic basis for reinforcing or challenging the power of the state and the meaning of citizenship in distinct ways across these contexts of exception, crisis, and contested political existence.

Highlights.

• Clinicians foreground biological etiologies of mental illness in various crises.

• Biological framings of mental illness can reinforce or challenge state power.

• “Biologizing” mental illness shapes the political existence of the mentally ill.