Caste On The Couch: Erasure In India's Mental Health Systems

All my life, I have mistaken duty for identity. Aged nine or ten, I tagged along with my grandmother to a wedding function in the neighbourhood of an Indian hamlet pretending to be a city on steroids. It is equally famous for daylight caste-rooted beheadings and being that palm of land where Buddha ascended to nirvana. We were invited to the haldi ceremony of a “colony friend”.

This pre-wedding ritual, where a scented turmeric and sandalwood paste is applied to the bride-to-be while women sing and celebrate around her, became the first act of radicalisation for me. In Indian small towns, “colony friends” are people whose houses stand next to each other, leading to camaraderie through proximity. 

Caste is a whisper in these corridors. A persuasive whisper. It is only with time that you realise that this whisper is the echo of a scream trapped in the walls of a breathless monolith.

On the surface, power differentials seem equalised through a haloed meritocracy that camouflages as equality; degrees, titles and paychecks are peddled as equalisers. Yet, quite like the lapses in electrical voltages crackling through overhead wires of these small towns, the algorithm of belonging fluctuates with its obvious glitches.

Underlying all of it is the repetitive query: “What is your surname?” 
The euphemism is a coiled viper: “What is your caste?”

Caste surveillance hungers for rerouting the power of purity back to the orthodoxy of separateness.

I went to that soiree simply because I lived within the radius of my Nani’s hip. As a child who struggled with the unnamed dissonance of social autism, she was the whole orbit of my sensory gravity— a jukebox draped in immaculate paithani silk sarees. She loved to sing so much, I called Manna, a mispronounced version of Mynah.

Each morning before the sky went from navy to powder blue, she walked nearly an hour to fetch fresh buffalo milk and came back with her basket of yellow trumpet vines peeking from behind its jute-woven veins. Her hands— rough as loofahs, precise as meat cleavers— could slice through thorned river fish like she was conducting surgery on survival. I don’t remember her ever being sick in bed. Or resting. Rest was a luxury for other women. She was always at work. Her labour was her worth.

At the event, a cluster of women sat between marble and mud in a sun-dappled aangan where the walls still wore the scent of rosewater and henna freshly scraped off the mortar. Someone had begun an old wedding refrain— nasal, lilting—that billowed and ebbed like heat-waves over the freshly painted walls. The family we were visiting was of a dominant caste. We aren’t. At first glance, the joyful, raucous revelries appeared all-embracing.

Suddenly, the side of the courtyard where the song-and-dance was being performed started to flood with a water leak from a broken pipe, and the women were asked to shift to a different part of the enclosure. This area had some chairs and two weather-worn stools leaning on each other like punished children.

My grandmother occupied a chair and placed me on her lap. No sooner had she sat down, the bride’s mother—her evening tea companion—smilingly bent over and said - “Do you mind sitting on the stool? Then, pointing to another woman in the group, she said, “She wants to sit in this chair.”

My grandmother—who belonged to what the national census calls a 'backward caste' of landless labourers—was relocated to the squat perch, the kind that skims the heartbeat of the earth in close quarters. The upper-caste women, meanwhile, reclined and chattered in plastic chairs that creaked with the weight of entitlement that comes from sitting atop the totem pole of a timeless hierarchy.

Still, my grandmother kept singing, her labour unceasing. Her voice surged above the others—not louder, but deeper, like a wave that knew the precise map of its own hoisting before the plummet.

Her smile stayed stitched to her face, but even at nine, I could read the seam where it pulled—her soft joy shapeshifting into shame. Her fingers peeling the golden embroidery of her carefully pleated saree.

That day, I realised the difference between acceptance and tolerance as I watched her warmth curdle into regret. The regret of being there. The regret of bringing me along.

Even though I was too young to fathom it then, now I see the same depersonalisation ferment from the aloneness within her as it has within me for all the years that I have worn the nametag of clinical depression.

A blind eye

Three decades later, I am slowly evaporating under a creaky colonial-era fan inside the amphitheatre of a reputed educational institute. We are literally sitting ducks as the unsuspecting audience of a psychology conference that has promoted itself as a “psychosocial wellbeing seminar”. One of the panellists is a psychiatrist who parades about with a book-length resume and a surname that opens doors.

The panel is addressing psychiatric aetiology, the complex interplay of epigenetic and psychosocial factors that contribute to severe mental illness. We have collected here to discuss a rights-based approach to mental healthcare.

This man with a career spanning 30 years casually soft-launches his vehemently held opinion - “These days people stress too much on social causes of mental health. We just need to learn to be strong. Look at the labourers working outside this building on the metro
construction site. How come they don’t have depression and anxiety? They work 18 hours and they are fine! Look at their smiling faces! Only these kids on Instagram experience so much depression at the drop of a hat."

He giggles at the end of that appalling declaration as if he has landed a punchline as a stand-up comic. The crowd is a mix of varying demographics. Some laugh along. Others remain still, stunned. During the Q&A, a young man counters his deleterious narrative. The psychiatrist hushes him by flaunting his credentials. Another woman, a psychiatric nurse, questions the purpose of such misguided hectoring. The organisers get antsy and cut off her mic after a point.

The workers he is referring to often trace their roots to itinerant rural communities that move to cities for better job opportunities while also seeking refuge away from stringent caste structures in the hinterland. The myth of a flatlined urbanity is supposed to be subtracted from the origins of caste. Except, caste trails us everywhere. They often come from socioeconomically oppressed ghettoes. A job in the city is sometimes an escape, at other times a dream.

On June 8, 2025, before I started to write this essay, I browsed social media for my daily doom-scrolling, and I read about a sanitation worker - a 40-year-old Dalit man died of suffocation after accidentally falling into a manhole in the Thoothukudi district of Tamil Nadu.
At least 113 people died in sewers due to manual scavenging between 2023-24.

Mind you, this is a massively underreported number. 77% of manual scavengers in India are Dalits. The State denies that manual scavenging is a caste-based occupation. These deaths are “accidental”.

When the entirety of someone’s (lived) experience can be erased to protect the image of another, how do we even begin to parse a theory for the intensity of psychological distress? When we attempt to define trauma in psychiatric terms, what should account for the invisibilisation of a group of people based on what kind of cog case shapes out of them?

Caste walls between touch & trust

During a mental health workshop, a man came up to me to discuss his self-identified “OCD”

“Touch is like a door I push when I should pull and vice versa. I want to be touched, hugged, held. And yet, it is the one thing for which I have developed the most aversion.”

A son grows up watching his father return from work, his body drooping like a broken tree branch, his face carrying feral imprints of soot-stomped lines and the half-moons of his nails are darkened by the dirt of a peculiar foreboding. His father wouldn’t enter the house immediately.

Instead, he spends an hour on the small steps outside their tenement. Lifebuoy soap and a small bottle of Nilgiri oil. He scrubs himself repeatedly. Eyes closed and hands speeding up in each iteration. Inside, the wife heats lentils on a kerosene stove in the 1 room kitchen extension.

The son waits on a watergrass mat, rote-learning the tables for 10, then 20, then 30, and then he forgets the count. Waits for a hand to heal his bruised forehead, still smarting from a playground scuffle with a boy who keeps teasing him about his father’s job.

His father - a tall, imposing man with beautiful curls in his hair that the son inherited as well. The father who skulks like a ghost in a haunted house, but in reverse. You see him, but you can’t hear him.

Then one day, the father shaves his hair.

“The stench sticks to it the most.” He mutters while running the blade across his scalp.

“I didn’t have this vocabulary of mental health when I was 20. I watched my father slip down the stairwell of dementia. All his life, he yearned to forget. And his brain complied in the end.”

The architecture of caste has constructed most, if not all, the major edifices of psychiatric and psychological textual knowledge in the sub-continent. A therapy room is not a vacuum; it is a crucible. We like to pretend the room in which therapy happens is neutral, like still water in a sealed jar. But space is never inert — it murmurs with the residues of gazes, ghosts. Every containment carries a pulse, an atmospheric voltage that shapes what can be said, felt, or safely silenced.

When we look up clinical criteria for OCD in the Diagnostic Statistical Manual (DSM), we are presented with definitional gauges - “Recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.”

When a father and son live in a matchbox-sized home and never get to hug each other because caste defines labour and by extension, the perimeters of their relationship, what is intrusive and what is innate?

Identity and mental health erasure

As a psychologist, I have sat through individual therapy sessions, groupwork, symposiums, conferences, and seminars where the discussion about psychic distress is conveniently individualised and separated from the constellations of social and ecological encounters. The outcomes of the madness that an upper caste, socially mobile person fears are the orbits around which people like me are thrown time and again.

To be heard above the din of engineered indifference, one must transmute the grief of generations into a signal. One must conjure the myth of scale, build Babels out of inescapable burnout, and scream hoarse over the lullaby of neoliberal sedation — just to be briefly registered.

In caste-centered extractive capitalism, the state of heightened anxiety is a reactive effect. It is carefully engendered and maintained to ensure that the wheels of exploitative labour never stop. And there is no language, no system to address the collective traumas of those who keep us afloat. No ontological explanation is proposed because we are expected to be satisfied with the therapeutic “clarity” of self.

My rage is blood-lipped and volcanic when I'm ambushed, reel after reel, by glib life coaches and wellness oracles who peddle personal healing like it’s a subscription box.

They flatten the nuanced topography of mental illness into a bland terrain of personal failures. “Heal yourself,” they proselytise — as if healing were some solo act of spiritual bootstrapping. What disturbs me more is that this snake oil sales funnel is not very different from some of the standard therapeutic frameworks of today.

A central premise of Cognitive Behavioural Therapy, the most commonly used therapeutic framework globally, is the discretion one must gain to recognise distorted thoughts and how they incite certain emotions.

E.g. - My boss thinks I am incompetent, and this makes me feel under-confident and anxious at work.

This "distortion" is considered a misperception, an irrational belief. But what happens when this so-called irrational belief—"People will treat me as inferior"—is not a cognitive error, but a structural whiplash from having witnessed intergenerational trauma inflicted by caste apartheid?

My people were repeatedly told they are inferior. It is not a distortion they fell into due to their own irrationality. The therapeutic method of individual self-examination necessary for dismantling these maladaptive beliefs fails to take root without interrogating how the social order built on caste and class births “irrationality”.

We need some irrationality to imagine our own glorious fugitivity from this oppressive spiderweb. The caste system aims to rob us of our imagination. In a therapeutic relationship, imagination is the baseline for trying to rewrite the script of your suffering.

Majoritarian spaces of healthcare in the Indian subcontinent and the diaspora have evolved their clinical lexicon from the grammar of caste. Like a maggot-mangled wound on a stray animal that everyone can see but no one wants to touch, you are not supposed to bring up the discussion of caste because if you do, you are the one being casteist.

A study found that 38.5% of persons with severe mental illness (PSMI) were poor on six or more dimensions, compared to 22.2% of controls in urban India. This indicates a significant association between SMI and multidimensional poverty. Poverty and caste are interlinked. So how do we elevate the disability burden of severe mental illnesses without accepting that caste worsens it?

Healing in a divided world

In The Wretched of the Earth, prolific psychiatrist and theorist Frantz Fanon surmised that the oppressed will believe the worst about themselves.

The failure to recognise caste labour structures as inherently enmeshed with a mental illness diagnosis further exacerbates the sufferings of those who are invisibilised by this combined collapse. We are instead encouraged to replace grief with guilt.

The guilt of harbouring joy for a “dirty” stray dog instead of a well-bred one. The guilt of sitting on a chair, instead of a footstool. The guilt of cooking non-vegetarian food of a specific odour that disturbs the neighbour’s pious nostrils. The guilt of being equal. The guilt of doing better. The guilt of succeeding instead of barely surviving.

Without structural reckoning, without a necessary ethical tension that politicises the tropes of resilience related to work, caste and class, what good is the therapeutic encounter?

The current language of therapy is so pallid, so truncated that it has no limbs to support the body it needs to sit with this guilt. In its flimsy understanding, it asks you to be the master of your own story. The depression I am flooded by when I fight my guilt is not a disorder. In The Burnout Society, Byung Chul Han writes how violence of positivity does not deprive, it saturates; it does not exclude, it exhausts.

My depression, like the one that my grandmother endured, is not a disorder. It is a rejection. A rejection to be productive for a system that is designed to decompose me.

It is a desire to reject the tropes of self-healing as the desirable antidote to psychosocial distress. I don’t want to master this ship of self. The masters of ships were not the kind of people I want to emulate. Not even metaphorically. I know their cargo. I am their cargo.

Empire repurposes obedience as ethics. Caste is the oldest of empires on this planet. Medical-industrial complex is among the newest. As a psychologist and a woman who has lived with casteism, I have carried the weight of this convergence in the shape of psychiatric pathologies that aim to isolate the locus of my depressive disturbance in some locked place within me. I am encouraged to do the same thing for my therapy clients. And this, I find to be the greatest of betrayals.