Between psychiatric language and peripheral slang: the modes of subjectivation of psychiatric epidemiology in neoliberalism

Women and migrant men living urban peripheries were the most affected subgroup, with high prevalence for mood and anxiety disorders (Andrade et al., 2012). This data highlights a critical scenario for those living in urban peripheries. But the question is: how did these numbers arise, and what do they imply about the risks faced by them?

The intersection of human experience and psychiatric epidemiology poses a complex challenge: translating emotional nuances, anguish, sadness, and stress into standardised, universal indicators. This process aims to obtain tangible psychiatric diagnoses to quantify the prevalence of these experiences across social strata (Almeida-Filho, 2020). However, this translation is not neutral; it reflects a ‘political technology’ that intertwines human vulnerability with risk production, influenced by power dynamics (Carvalho et al., 2019). We must question the origins and interpretations of these epidemiological data. Are we experiencing a mental health epidemic, or, as Nikolas Rose suggests, are we uncritically accepting a narrative that frames sociopolitical and cultural suffering in strictly psychiatric terms? (Rose, 2019).

To explore this issue, I investigated a specific collaborative study relationship in which the 'interviewers' were residents from a peripheral community, and the 'interviewees' were their neighbors. The study took place in Sapopemba, an area with 46 favelas in São Paulo, in partnership with the local Human Rights Centre, the Section on Psychiatric Epidemiology at the University of São Paulo Medical School, and King's College London. Due to pandemic restrictions, Sapopemba residents were trained to administer standardised psychiatric scales over the phone with their peers (Szabzon et al., 2023; Abarca et al., 2022; Bruhn et al., 2022).

A semantic gap was identified between the scale terminology and the residents' articulated feelings of anguish and suffering during the application process. Many terms did not resonate with the people interviewed in this study, compelling the volunteers who posed these questions to explain the psychiatric terms to their local community. Would adapting the psychiatric scale to the residents' language and context ensure the reliability of these ‘numbers?’

Cultural adaptation of psychiatric epidemiological tools

As psychiatry penetrates further into daily life, cultural, social, and life-related aspects are often reduced to psychopathological terms, getting lost in translation. In global mental health, this issue is seen as a technical problem with the instruments and psychiatric language, addressed through cultural adaptations that consider local expressions. For instance, cultural concepts like "pensando mucho," (thinking too much) "susto," (fright) and "ataque de nervios," (nervous attack) common among Latino descendants and linked to anxiety and panic disorders, have been included in the DSM 5 (Kaiser et al., 2019).

My doctoral research directly engages with this dynamic by looking at epidemiological psychiatry's instrumental, discursive, and practical dimensions, investigating how this discipline enters cultural semantics, transforming them into diagnoses with biomedical responses. As Mark Nichter notes, local idioms of distress are often “redefined by Western psychology and sold back to the local population as comorbid disorders requiring medication” (Nichter, 2010, p. 411).

Cross-cultural psychiatry: the production of the peripheral psychiatric subject

Psychiatric knowledge and the ‘psych’ disciplines play a significant role in the governance of subjects and modelling their individual and collective behaviours (Carvalho et al., 2020). The psychiatric lexicon has expanded to include the complexity of human experiences, everyday challenges and the uncertainties that permeate life. This ‘psych’ language thrives in neoliberalism, shaping not only descriptions of suffering but also subjectivities (Rose, 2019).

The obstacles Sapopemba residents face with psychiatric terminologies suggests the incommensurability (Hacking, 2009) and untranslatability (Spivak, 2021) of experiences not captured by psychiatric logic, such as those that are not perceptible in an epidemiological interview and the aspects of life that cannot be revealed and formatted in an answer to a question on the psychiatric scale. Stripping away psychiatric language in favour of ‘cultural language’ without altering the biomedical paradigm is contradictory. Because including cultural expressions of suffering in psychiatric taxonomy may merely ‘dress’ new terms whose semantics are aligned with the mechanisms of subjectivity production inherent to neoliberal rationality.

Incorporating social inequalities, stigma, social exclusion, and racism into the calculation of the psychiatric categories of ‘culture’ implies attributing a psychiatric probabilistic truth to the individual of inherently structural and collective issues (Andrade, H. et al, 2022). As an effect, cultural expressions subjected to psychiatric framework anesthetise structural changes necessary to mitigate such suffering.

Politics of ‘naming’ in psychiatric epidemiology

Changing semantics rather than their usage may formulate evidence that, by classification and quantification, neutralises the political aspect of experience ‘naming’ (Storeng, K. T., & Béhague, 2014). My argument is to rethink the micropolitical relationship between words and numbers in psychiatric epidemiology, aiming to restore the ethical potency of 'quantified words,' endowing them with agency in the political fabric (Stengers, 2007). This means reclaim the vital meaning of words for the ‘target-cultures’, as opposed to its exclusive link to psychiatry. The task that remains is to foster an epidemiology that explores the political and ethical relationship of numbers-words. In a manner that makes the experiences of peripheral subjects visible and measurable, thereby countering the tendency of psychiatrisation and individualisation in the context of colonial-racial neoliberalism.

Acknowledgments

My sincere gratitude to Dominique Béhague, who co-supervised me during my time at King's College London alongside Nicholas Manning, and to my Brazilian supervisor, Silvio Yasui (UNESP- FCL) and co-supervisor Laura Helena Andrade (IPq-USP) for the immense support. I also extend special thanks to the social organisations of Sapopemba, particularly the Community Centre 'Joílson de Jesus' (CCJJ). This discussion is part of a manuscript in development for submission.