Thursday, January 29, 2009

Taking in Mumbai


The Food Court at Phoenix Mall, next to the Guest House


Ubiquitous Machine for Making Sugar Cane Juice


Girl Begging Car-to-Car


Slums Comprise 55-60% of Residences in Mumbai

















Military Presence on Colaba Causeway


The Bay by Taj










Gate of India




















Last Day
Today is my last day for this trip, my last day in Mumbai. It has been an experientially highly dense trip, and from the first day I’ve been here to now there have been so many changes. While I’ve learned much while here, for a long time I'll plumb my experiences here.
I spent the afternoon walking around and drinking in as much as I could - I will miss this city, her people, her smog and grit. While strolling, I saw my first and only pretty flower of the trip today in Colaba - I always like to take pictures of flowers.

Feelings Upon Leaving
My feelings upon leaving are turbulent. The time here has been very good, at times a bumpy ride, and multi-faceted. It has been hectic and compressed, with little time for casual meetings - this is compounded by unpredictable schedules and travel times. One day a car ride might take 45 minutes; a similar ride the next day 2 hours. Metaphorically, I am like the bird in this photo, leaving but taking with me sustenance.


In some ways I am ready to go back to New York, and in other ways I would like to spend a couple of weeks more here, mainly because I am just starting to get to know some of the people here, most of whom I’ve only met once, and would like to meet more leisurely.


The pace of time is different here, things are less pressured to be on time, and the expectations people have of one another are at times quite similar to home, my home that is, and at times quite alien. In fact, on occasion I think when I’ve felt most out of tune, I’ve felt like I was on some other planet.
It feels bittersweet to be leaving. I would like to return and continue this work, but I am uncertain as to when and under what circumstance. I would like to see how things have evolved a few months down the road, when things are a little less immediate. I hope nothing else happens but there's a good chance it may.


After being here for just a week and not seeing anyone with my complexion, the image looking back at me in the mirror started to look unfamiliar. Now (editing this post from my apartment and looking out the window) the view is also different.

A Couple of Particular Observations
One thing which I’ve found especially hard to get used to is the way servants act, so eager to jump in, deferential, often smiling broadly, yet always a little bit off. Even the idea of servants... and so many people here are employed as such, quick to jump in get the door, deferential, smiling.


I don’t like being waited on generally, so it is that much more of an adjustment.


Nevertheless, I felt much more comfortable today than that first day, more adept with the basics, and for whatever reason there were tons of tourists all over. I went by the Leopold as well, and took a gander at the gunshot holes in the marble entryway.
It is such a strange thing to imagine armed men moving through those streets superimposed on the tourist bustle. I thought about what I would do, where I would hide, and so on. I imagine I have my camera, moreso since talking with and reading about journalists on 26/11. Bullets hitting marble...

Strozier (2002) wrote, of 9/11/01: "The apocalyptic exists in a realm that extends beyond what Kurt Vonnegut wistfully called 'plain old 'death' and embraces a comprehensive vision of collective death, of vast suffering, of the very end of the world". With 9/11, the "zone of terror" was circumscribed, geographically localized; with 26/11, the "zone of terror" was diffuse in time and space, amoeboid, unpredictable.

Not Disbelief but A Challenge
It simply doesn’t make sense, this juxtaposition, and yet I know it happened. It's not disbelief... it just is a challenge to the imagination and not something one would necessarily want to think about.

Admittedly, it is a bit scary to walk around in such a place, yet with the touts and people grabbing at me and little kids coming up to the taxi and asking for chocolate… I guess things have shifted back to normal, and the social context being normative is persuasive to assuage fears. I don’t know that the truly disadvantaged here think 26/11 was really any different from any other time, but I don’t know because I didn’t have a significant conversation with anyone.

I also went to Kala Ghoda, next to the banking area, Fort, and meanandered in and out of the art galleries.


Some of the art here spoke to 26/11, and one which struck me showed a calendar with each day painted a different scene or image, for November 2008. The 26th iss a red splash, and the days after dark and unformulated, foggy, cyclonic. I spoke to the artist briefly, a jolly older woman with a great spirit. She didn’t let me take a photo of her painting, though.

What is Terrorism?
Now I am wondering, what is terrorism? There’s a lot of buzz about it… but what is it? What does it mean, and how does that meaning differ from person to person, and place to place? My own terrorist is now different from what it was, in ways I don’t know, and in some ways yet the same. My experience of 9/11/01 is altered by these experiences, but it remains a primary point of reference among a few other major ones.


I've gathered some local publications to read over later. One is Verve magazine, a popular upper class fashionista magazine. The January cover is white with what appears to be a red flower, which on closer inspection is a bloody bullet hole. It is full of first-hand accounts from editors, journalists, socialistas, and some psychotherapists. The tone of the writing reminds me of much of the sentiments shortly after 9/11. Trying to make sense of a new world.

My parting observations are that I've been here as a disaster psychiatrist, as a tourist, as a human being, as an intruder, as a welcome guest, and as an anthropologist. It doesn't all fit together for me but it is a good place.

Tuesday, January 27, 2009

Para-Military Terrorism: A Report From the Field

Para-Military Terrorism
Being in Mumbai has given me occasion to consider the implications of what is arguably an evolving form of terrorism: Para-Military Terrorism. While there have been instances of such assaults in Russia several times, in the United States (e.g. Washington sniper, Virginia Tech, Columbine), and in Japan recently to name a few, the assault on Mumbai presents novel features for PMT.

PMT Basics
In PMT, non-military agents assume military roles and commence quasi-military activities, invasively enter the territory of the target population, and establish an authoritative presence. This is done coercively and over the objections of the target population, and causes not only fear and other responses associated with invasion of home territory, but also involves physical assault and injury with associated emotional impact and media coverage, and utilization of resources. Images and reports of blood and viscera have a powerful impact on the psyche, compounded by the rape-like non-consensual penetration into one's own territory. PMT verges on warfare, but does not abide by the rules of war.

Features of PMT
The features of the PMT event are 1) number of agents, 2) distribution of agents geographically and in terms of compactness (local versus spread out), 3) types of weapons deployed including projectile weapons, explosive devices (e.g. grenades, bombs) and other weapons, 4) whether hostages are taken and how they are used, 5) time course, 6) the invading group’s mission (for instance, whether they take control of territory and establish a secure perimeter for siege within the target territory or enter, do damage, and either leave or get killed) and 7) the nature of targets selected in terms of their strategic and psychological significances. These elements are of course not fully independent of one another, but interact synergistically to produce a massive, and often game-changing, impact.

PMT and Complex Terror Events
Although a fearsome concept to consider, PMT can certainly be combined with other forms of terrorism. For example, the invading group may use the PMT event to deliver a biological, chemical or radiological weapon into a secure area. Such an attack would have a first stage followed by a surprise second event (deployment of the weapon after a delay). There are of course many possibilities.

PMT Alone - Collective and Individual Impact
Even without considering such dire complex terror events, PMT itself can be understood on several important levels as having a significant impact, in some ways similar to other terrorist events, and in other ways unique. Ultimately, PMT forces the invaded group and usually larger cultural system to face up to its own disavowed vulnerabilities over a very short interval of time, leaving to collective and individual emotional and psychological upheavals. The impact extends from the most global level of the world, to the level of nations and religions, to the level of various groups and organizations, to the family, to the individual level in terms of both psychology and biology. All these different layers are interconnected and form a dynamic and evolving whole.

Collective and Organizational Responses
Politically, a PMT event may reveal underlying flaws or long-term complacent assumptions and behaviors, such as corruption, mis-allocation of resources, and long-term neglect of underserved groups. As such it may provoke feelings of being let-down by governmental, police and military forces, and evoke anger as well as positive action from the populace, though often accompanied by feelings of confusion, helplessness, and frustration borne out of an inability to conceptualize effective action for change.

Specific organizations are differentially impacted depending on their roles in context, organizational structure and history, composition in terms of personnel, and relationship with prior disasters and terror events. A major media house may serve as a cohesive force to bridge private and public sectors to strengthen disaster response, and it may respond initially with graphic images spreading trauma, and allowing PMT agents to better function during the attack by providing information. A religious organization may offer support and assistance, and it may take advantage opportunistically of the situation to gain more followers. To give but a few superficial examples.

PMT events also evoke anger at the authority seen as having responsibility for supporting the terrorist group, as for instance anger directed toward the secret service of Pakistan for reputedly funding the terrorist group which invaded Mumbai – this is (conventional wisdom among many?) taken as common knowledge by many. In spite of whether or not it is actually true, what is additionally of importance is the perception that it is true and the impact this has in the collective response e.g. going to war.

PMT attacks may demonstrably interact with issues such as poverty and public health issues, in addition to more obvious disasters. An event such as Hurricane Katrina may interact with issues such as racial bias and lack of resources for selected population, for example. As such, terror events and disasters evoke prior collective traumas, an effect which is exacerbated if there is a history of not adequately adressing such events psychologically and in more material reality; though I strongly believe psychological reality is just as real as more observable concrete reality in terms of influence on actual events and socially-constructed reality.

In a more personally immediate way, PMT events are humiliating and frightening, humiliating because they are acts of coercion and abject domination, and frightening because they are uncontained and unpredictable, bearing in this regard some resemblance to biological and chemical attacks. Furthermore, PMT events create the perception that many future terrorist attacks could very easily be committed and convince people that efforts to protect are not effective (e.g. personal fantasies about how to circumvent shoddy security). Attacks upon well-selected targets shatter the identity of the target population on many levels, and sweep away key aspects of assumptions about reality which have served to group the local population in context. PMT events “burst the bubble” as one participant in a focus group put it, revealing long-standing problems on multiple societal levels which had been ignored for decades, if not longer.

Individual-Level Responses
PMT events may lead citizens to feel angry toward themselves for failing to have acted preventively, in addition to considering ways they could have a different impact in the future. PMT events evoke fear and suspicion directed toward one’s neighbors, with a sense of disbelief that a citizen of my city could have aided the terrorists both in terms of planning and information gather prior to the attack, as well as providing support and logistical information during the attack. This sense of “the enemy within” enhances the deep tearing apart of security and predictability and inveighs against the enhanced sense of community cohesion and activism following mass trauma. As with any terrorist event or disaster (or other traumatic event for that matter), re-activation of prior traumatic responses via re-traumatization, is an ever-present possibility to be taken into consideration.

Provisional Conclusions
To conclude this incomplete consideration, a fundamental feature of terrorism in general, accentuated with PMT events specifically, is the experience of total or near-total humiliation. The singular event is arguably on cross-section in time of an ongoign systemic enactment related to prior humiliations experienced by the terrorist group committing what is often conveyed as an act of retaliation, related to still earlier events, and so on, sketching the outlines of a broader psycho-historical and contextual understanding for terrorism. Reverberating cycles of impulsive violence and strong unregulated negative affect prevent useful communication and collaboration.

Alternatively, to end on a more hopeful note, when things get bad enough, terror events may serve as a “wake-up call” (as one Mumbai child wrote within a drawing about 26/11 “It’s sad we needed such a big wake-up call”) and lead to more restrained, less violent, and more collaborative approaches. Terrorism may therefore be seen as a symptom within the global psyche, if one takes the somewhat fanciful view of the world as an individual - a self-mutilating cry for help for a chronically and complexly traumatized world. It would be preferable to reach this tipping point without excessive destruction and suffering, however.

Paucity of Thoughts













Today is hard to render into words yet. Not sure why. A bit wistful anticipating leaving... so much not explored, especially getting to know people I've met here better, and get to know the city. I hope I can return and remain involved at a distance. Talking with more young people helped me to see that there is real potential for change here, solid hope and much opportunity.


Conducted two focus groups with medical students today... learned a lot. Perhaps too much to write about in a formulated manner, yet. I found myself thinking, though, that the groups did not surface much if anything about foreign people being targeted, and wondering if that was in part due to my presence in the room. There is a kind of politeness which is hard to overcome, where people won't speak freely for many reasons, not the least of which seems to be a deeply ingrained adherence to structure and social constraints. Future groups will have to take this into account more specifically.

The other thing is I am struck by how kind and hospitable most everybody has been. While I miss my home, Marina, and other familiar elements of life in New York, I feel two weeks has been a very very short time to get a handle on such a complex place. I am just beginning to feel a sense of connection with people I've met, and we've been working so hard there has been little time to see things with any depth or sense of leisure.

With a bit of surprise, I didn't connect until yesterday that I'd lived in England in college with being in Mumbai, which has so much British influence... but when I made the connection I think it helped.


Monday, January 26, 2009

Trauma: Contagion & Pollution



Republic Day Respite
Today was Republic Day. It is also the 2 month "anniversary" of 26/11 and the 8th anniversary of the Gujarat earthquake.

There was celebration and were parades all day long. The news featured the show of military might of India in parades, and bypass surgery for the PM of India, with many get-well soon sentiments. Yesterday’s meeting with Bombay Psychiatric Society continues to resonate with me as I work on understanding something about trauma in a different light as a consequence of my experiences thus far.








Pollution and Trauma
Pollution is a strong Hindu idea, very much in the fabric of Indian culture. Siddharth and I were talking with friends about hand washing before and after meals, and he noted that there is often a hand-wash out in the restaurant, a special sink for that purpose, noting that the bathroom, even if very clean, would be considered polluted.

This got me thinking about the idea of traumatic experience being polluting of the purity of the mind. I thought about the Buddhist idea of right thinking, and Yogic ideas of using the mind with clear intention to direct the body, and how in some sense the idea of Yogic control of consciousness over body with the purpose of enlightenment could also be understood as Yogic control of consciousness over unconsciousness. There is a strong pull here away from psychodynamic models, and toward directive models with clear guidelines, such as CBT - if there is any therapy at all.

I wondered if the idea of pollution could fit in with the above, when considering how trauma is often described as “contagious”, especially in vicarious trauma models. On one hand, this could suggest that the other person’s trauma is a disease, and to blame for vicarious trauma, and suggests the idea of contamination or pollution.

Which helps me to conceptualize the distancing responses to trauma I’ve noted in Mumbai so far, which don't quite feel like dissociation or repression, and perhaps the general trend away from reflective capacity – if there is an element of pollution, and therefore contamination, the best bet would be to stay “clean” in the first place. If one could not avoid becoming polluted, then there would be various ways of regaining a state of non-pollution. Since trauma is ubiquitous, there is a problem to be constantly solved.








Mr. Clean
An ongoing effort to maintain psychic cleanliness, bolstered by constant rituals of purification and appeals for luck and removal of obstructions could do the trick. As I’m currently thinking about it, this resembles but does not map completely onto repression or dissociation models of dealing with uncomfortable material, but has added cultural elements typical to South Asia. At the same time, recognizing this re-contextualizes Western ideas such as repression and dissociation into their own cultural framework… Judeo-Christian, Capitalistic/Puritanical… where these concepts become culturally-bound just as much as any other. But bound in the dominant culture…


Sai Baba of Shirdi
Not the current living Sai Baba with the voluminous hair, but a figure from Maharashtra representing a unifying agent among multiplicitous religious belief systems. Out for a stroll, we were ushered through a large gate into a temple courtyard. People were extremely eager to draw me into the temple, and according to Siddharth I was taken as kind of a blessing or good omen, being able as pale as an earthworm. I felt shy at first, and the more they gestured for me to enter the more I felt like going at first, feeling trapped or too desired.








I warmed up behind my camera, and eventually ended up sitting among a group of boys and men singing adorational songs. I was concerned about being transgressive taking photos, but as has been the case here with almost no exceptions, everyone is eager to be in photographs. I considered remaining here and starting a religious following, but reluctantly returned to the guest house. The children playing can be quite delightful.










Next Few Days
Tomorrow I plan to do some pilot focus groups with university students, with a co-leader Dr. Kamal Jeshwani from HHI, a psychiatry resident currently. He grew up and did part of his training in Mumbai, so we are expecting that element will be a useful part of the group process. Later in the day Siddharth and I are going to give a short presentation for “the public” at Breach Candy Hospital. The next day, a presentation for journalists, and dinner with a psychiatric luminary from Mumbai… if it works out with the traffic and all. Then Siddharth has his 2 day workshop with TISS (Tata Institute for Social Studies), and I will help out with that, but leave before the 2nd day. Then, back in New York for reverse culture shock and jet lag… I expect things will seem different for at least a little while.
I hope to be able to get involved in ongoing work in Mumbai.


India’s 9/11?
Although I see that 26/11 and 9/11 are quite different, and there is a need to differentiate oneself from the other regardless, there are many parallels which are relevant, in addition to the substantial differences from 9/11. Much of the response on a collective and emotional level is in parallel. There is a sense of having been both caught off guard and humiliated, exposed as vulnerable, an anger at authority for failure to protect, an element of the symbols of economy and wealth, and transportation hubs, being targeted, a desire for military action and a rapid re-establishment of the sense of powerfulness and rightness, and the adoption of much of the same language and security responses, and so on. Perhaps this could be seen as paralleling the difference between “trauma contagion” and “trauma pollution”.









Sunday, January 25, 2009

Adjusting to Feeling Constantly Disoriented

Presenting to the Bombay Psychiatric Society






The last few days have been a bit of a whirlwind. Dr. Siddharth Shah and I have been working hard to develop a one day training for the Bombay Psychiatric Society, and we compiled an updated curriculum with an introduction to Disaster Psychiatry, a section on Interventions, a section on Working with Children, a section on Interagency Collaboration, and related sections on Trauma Theory and Vicarious Trauma. The day unfolded well, and some powerful material was evoked, I believe especially around drawings from children affected by Mumbai’s recent attacks. The Piramel R & D Center was a lovely setting, and there were scupltures, a figure which was striking in the morning light, and the interesting lighted installation below.




On the Beach
In addition to working on this training for the last few days, we met with Udayan Patel, a psychotherapist living and working in Whorli. We had an opportunity to see photos from the terrorist attacks - they were graphic and brutal. His office and home were wonderful; in particular his office is very placid, and has views on two sides overlooking the ocean.


Birds wheeling outside his window only add to the therapeutic feeling. Naturally, this reminded me of the view from my office on 13th and Broadway. Leaving Udayan's office was characteristically not as pastoral. A constant juxtaposition of seeming opposites.





Haircut
We also got haircuts in a local barber shop, "with A/C" (code for a decent place). The haircut was good, not hard given my coiffe requirements but sometimes nothing seems reliable or consistent here except unreliability and inconsistency. Of course, just when I thought I was in the clear I asked him to trim around my ears and he shaved weird little bald spots on the side of my head. My annoyance at these constant things is palpable... I'm scared because it is starting to shift toward reassuringly familiar if things go awry when they seeemed ok at first. As if to have a haircut go off as expected would now freak me out.
I believe this is the germ seed of understanding an important component of how trauma interacts with culture here. Perhaps it is a form of a talismanic warding off of something more dire?
Although I’ve been to India twice before, this is the first time I’ve gotten a traditional head and face massage. It was a very relaxing experience, much needed as a break. The sense of things being unfamiliar here both in terms of relatedness and mindset, as well as simply physical environment and procedures, is quite striking. Everything feels a bit decentering and there are constant interpersonal happenings which complete elude my understanding; for instance, the younger barber and the owner started arguing heatedly around my head massage. I began to feel uneasy.
The owner appeared to want to step in and do it, and they kept grabbing one another's heads and talking rapidly and clandestinely, almost like a dance or at times a wrestling match. It didn't help that the owner had been intently staring at me in the mirror all along. Then without any explanation, they became calm and the massage resumed on its original course. I accepted this as if nothing had happened as well, with a bit of mental effort, and odd dissociative flip, and the ensuing bliss of ignorance-by-self-design.


Implications?
Disaster and terrorism are strongly interactive with culture. This comes up powerfully when interacting with audiences and groups about individual and collective trauma, especially when negative feelings are directed toward authorities for failure to protect.
On one hand, there is a dramatic display of respect for expertise and a great desire to listen and learn. On the other hand, there are a million social cues and standard exchanges which completely elude me, even more than my usual cluelessness. There's this kind of British colonial internalized aggressor which is implicit and hard to deal with, at least for me. Speculatively.

The learning part has been extremely rewarding though quite draining and even painful and humiliating at times, and interacts with the cultural level, and the cultural level in turn is intimately connected with the complex history of multiple traumas, individual and collective, which are a part of this city’s tapestry.
Social issues represent a potential stressor for most here, and what people have told me over and over again in many different ways that the basic approach to dealing is to not talk about things. One hypothisis is that while being protective, this may also prevent interpersonal and collective linkage and meaning-making, while preserving internal understanding. There's more to elaborate on this point.




Yet today at the Bombay Psychiatric Society training, I started to feel some commonality. A week is not very long at all.