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'What is an Ethnographic Interview? Thoughts at the Intersection of Anthropology and Psychiatry', was the title of the EdCMA Annual Lecture 2022 delivered by Dr Bhrigupati Singh. In this lecture he shared material from his ongoing ethnographic research at the All India Institute of Medical Sciences (AIIMS, New Delhi, India) and upcoming book on concepts of the psyche, entitled: 'Waxing and Waning Life: Investigations at the Threshold of Mental Illness and Health'.  

This is a summary of the lecture, with gratitude to Dr Singh for generously sharing his lecture notes.  

You can stream the lecture recording here.  

Introduction  

Anthropology stands in an almost 100-year old conversation with psychiatry, traceable to disciplinary founders such as Boas, Sapir, Ruth Benedict and Bateson, to more recent investigations of Postcolonial Disorders and Subjectivity . As anthropologists, we know that intersections between anthropology and psychiatry may occur not just in the realm of texts and concepts, but also in the more ordinary register of everyday questions and curiosities.   

This intersection is at the heart of Dr Singh’s ongoing fieldwork which began in 2015, when he became a Visiting Faculty member at the Department of Psychiatry of the All India Institute of Medical Sciences (AIIMS, Delhi). AIIMS is one of the most prestigious places to study medicine in India: it is both a leading hospital and one of the few remaining democratic health institutions in India that caters to a diverse population of rich and poor patients. “You can find everyone from beggars to the Prime Minister in treatment here”, patients frequently joke.  

Dr Singh’s research at AIIMS included long hours with psychiatry residents and faculty at AIIMS observing each others’ respective work practices. The AIIMS psychiatrists were not only keen to incorporate ‘social’ and ‘narrative’ perspectives alongside psychiatric rating scales, but after observing Dr Singh’s anthropological interview methods with patients and their family members, asked for advice on how to replicate these methods in their conversations with patients. Although he initially suggested  the McGill Illness Narrative Interview Schedule (MINI) which offers a replicable model of Arthur Kleinman’s Illness Narratives, he realised there was no clear formula to offer and the MINI did not seem to satisfy the AIIMS residents.  

Dr Singh therefore began examining the question: What is an ethnographic interview? The anthropological method is after all not limited to structured interviews and ethnographic insight frequently happens outside the formal spaces of interviews. ‘Semi-structured interviews’ don’t, so Dr Singh argues, capture the affect, concepts, or rigor of the interview process; and terms from ‘interpretive’ anthropology – e.g., ‘deep hanging out’, ‘friendships in the field’, ‘reflexivity’ and ‘power relations’ - can be too vague as to recommend to interlocutors from neighboring discplines.  

To answer the question - What is an ethnographic interview? - Dr Singh signposted his talk as follows:  

• Part 1:  An exploration of the neighbouring literature in social science and psychiatry, attempts to introduce narrative techniques into medicine, and the impossibility of reducing ethnographic relatedness to a formula.   
• Part 2:  The pursuit of singularities as distinct from regularities, with the interview as a signature technique of the pursuit of singularities.  
• Part 3:  Examine the conceptual and clinical significance of the ethnographic interview drawing on two patient-interlocutors at AIIMS.   
• Conclusion:  The pursuit of singularities as a form of what Deleuze calls the “reversal of Platonism”, and how the struggle between regularities and singularities may be relevant even for narrative initiatives within medicine.  

Part 1

In the discussion of helpful neighbouring literature, Dr Singh reached (with hesitation) for Research Methods in Anthropology in which Russell Bernard argues that: “the key to successful interviewing is learning how to probe effectively – that is, to stimulate a respondent to produce more information.” Bernard lists seven kinds of probes: the “silent probe; the echo probe, the uh-huh probe, the tell-me-more probe, probing by leading,” and so on. Dr Singh’s critique of this is it does not cover the question of care or affective relatedness. Ethnographers, after all, may feel care for the people they meet. In Being There, Borneman and Hammoudi argue that the crux of fieldwork is that the “ethnographer invests in long term relationships with key interlocutors”. But - is there a manual to teach us how to create long-term relationships? And is the length of time really what is most singular about ethnographic method? Rather than duration, Dr Singh argues that it is the intensity and form of interaction.  

The question of affect in anthropological research is not new; however, Dr Singh took this question further to ask two important questions: Why are we drawn to particular interlocutors? How are conversations built with particular persons without necessarily reducing this form of relatedness to idioms of kinship or friendship and without necessarily creating an opposition between companionship versus the desire for information?  

Within psychiatry interviews are important because they are the primary and often only diagnostic tool. At AIIMS, the initial psychiatric interview was usually conducted by a junior resident following global protocols. The interview consisted of taking the patient’s history and the so-called Mental Status Examination, i.e., “appearance, gait and grooming; mood and affect”, and so on. Much like in anthropological technique manuals, psychiatry textbooks emphasize “rapport building” and other questions important to the discipline, e.g., how to deal with delusional, violent, hostile, depressed, or uncommunicative patients; how to avoid premature reassurance; and how to start and end the interview.  

As a point of intersection between the anthropological and psychiatric interview, Dr. Singh asks us to consider the Cultural Formulation Interview (CFI) is a set of three questionnaires meant to “assist clinicians in making person and family-centered cultural assessments to inform diagnosis and treatment.” Consider the CFI in relation to Michel Foucault’s discussion of the psychiatric interview in his 1973-74 lectures on Psychiatric Power. As Foucault argues in Lecture 8:   

“Questioning is a way of quietly substituting for the information wormed out of the patient, the appearance of an interplay of meanings which give the doctor a hold on the patient.”    

What, if anything, is the patient’s stake in the interview? Here is Foucault’s suggestion in Lecture 10:      

“My impression is that at the heart of every psychiatric interview there is always a sort of transaction. The psychiatrist says to the person: I really want to remove the weight of your legal and moral responsibility for your being here, but I will perform this subtraction precisely on the condition that you give them to me, in one form of another, as symptoms. Give me some symptoms; and I will remove the fault.”   

What form of questioning would not take the form of extracting a confession? What we find in the psychiatric interview, as Dr Singh argues is a ‘pursuit of regularities’. He defines this as repetition grounded in empirical evidence but where the element of difference is suppressed. What would it mean, he asks, to pursue such differences, and to move towards something like a counter-concept of regularities, which he names ‘the domain of singularities’: the difference between this grain of salt and another, between this illness in this body, and no other.  

Part 2

The question of what ethnographic interviews actually are has accompanied Dr Singh from early stages of his research trajectory. In 2001-02 he conducted research on the decline of older, pre-multiplex cinema halls and its accompanying cinematic culture in Old Delhi. A key ethnographic personae in this research was a man in his early 60s, BKji, and Dr Singh’s most significant memories from this time consisted of BKji’s life story. While Dr Singh’s method of requesting interviews from BKji seemed straight-forward, a problem soon arose: What is to know an other mind and what would constitute ‘success’ in such a pursuit? Despite his semi-structured interviews and subsequent portrait of this key ethnographic personae, Dr Singh eventually realised that he knew very little of his interlocutor’s actual life. And yet, the ethnographic interview can reveal worlds we did not expect: “I learnt more about Bombay Hindu-Urdu cinema as a living lyric tradition, through BKji than I had learnt from any course in film and media studies,” Dr Singh told his EdCMA Annual Lecture audience. Where else, he asked, can ethnographic interviews take us?   

Dr Singh next discussed a chapter of his book Poverty and the Quest for Life, focussed on Sahariya woman named Kalli, a former bonded laborer and now a well-known human rights activist and spirit medium in central India. Kalli’s activism navigated the intensities of inter-caste antagonisms which could result in violence. Dr Singh asked if she was afraid of dealing with local strongmen who could kill her, she responded laughing: “I have always been poorna pagal (totally mad), since childhood.” This was not a joke: mental instability had punctuated her life, caused – according to Kalli – by a Jinn, a category of spirit shared by popular Hinduism and Islam. Her relationship to this Jinn made Kalli known as a healer and she delivered spiritual cures prescribed by the Jinn to locals. Psychiatrists would call this a ‘culturally sanctioned’ form of auditory or visual hallucination, and Kalli reiterated: “You think that I am brave, when you see me in rallies and meetings, but I am brave because I am mad.”  

What is the clinical significance of an ethnographic pursuit of singularities? How can we situate this method of inquiry within the history of anthropology? Who would be our anthropological ancestors and kin?   

Dr Singh asks us to think about Malinowski’s Argonauts of the Western Pacific as a founding text of ethnographic regularities, I.e., how one arrives at replicable formulations through questions in the field; how one moves from specific cases to try and ‘exhaust all possible cases within reach; and how these variations may be organized as ‘charts’ and ‘synoptic tables’.  

In contrast, a founding test for ethnographic singularities could be Zora Neale Hurston’s recently published book Barracoon: The Story of the Last “Black Cargo”.  Written in the 1920s, the book never found a publisher during Hurston’s lifetime because - alongside the pressures of race and gender - it was deemed ‘unreadable’ for the painstaking detail it shared of the method of questioning. The book was mistakenly read as being an ‘overly detailed… first person narrative’. However, a different reading of the book offers a visceral description of the slave-trading economy and a complex picture of freedom in the aftermath of anti-slavery laws. It is not a novel or a polemic, but it is unmistakably recognisable to ethnographers as what we do.   

Part 3

However, in thinking about healthcare, particularly in a context like India, amidst conditions of ontological pluralism, chronicity, and pervasive uncertainty – what space might we find for the humble ethnographic interview? To unpack this, Dr Singh returns to his ethnography at AIIMS; two patients he calls Shyam and Mita; and the community clinic in Trilokpuri in East Delhi. Trilokpuri one of 55 ‘resettlement colonies’ across Delhi, a government term for settlements where slum-dwellers from more gentrified parts of Delhi were forcibly or sometimes voluntarily relocated during a period known in India as “the Emergency” from 1975-77 when democratic rule was officially suspended.  

The population of Trilokpuri is around 170,000 and it is infamous infamous for crime and heroine addiction and recurring Hindu-Muslim violence. Its inhabitants all belonged to the lowest castes of the Hindu and Muslim hierarchy, with the largest group known as the Balmikis, the lowest in the Hindu social hierarchy. One of the Dalit-Balmiki patients in Trilokpuri was Shyam, a recovering heroin addict on a bi-weekly dose of buprenorphine, as part of Opioid substitution therapy. Shyam’s file noted his first contact with the community clinic as June 2009, his occupation as a sanitation worker cleaning drains in central Delhi, and his diagnosis as HIV positive in June 2013 most likely as a result of needle sharing for heroin. It recorded his subsequently erratic trajectory on antiretroviral therapy.  

During his interviews with Shyam in February 2016, Shyam attributed his thin physique and anxious mental health to spirit attacks. These are relatively common in Indian rural and urban neighborhoods, but seemed to take a more vicious spiral with Shyam. He claimed his neighbour made threats which only Shyam could hear and that he was forced to do things against his will, as the following excerpt from Dr Singh’s interview transcript shows:   

S:  “They made me eat dog shit. They told me to go bald (signifying a death in the family). Won’t I feel like killing them? I’ll color the earth with their blood. I am the seed of a real bhangi. They have done a lot of wrongs!”  

B:  “Who has?”   

S:  “My (upper caste) neighbors. Who knows why they hate Balmikis? Their voice makes my head spin.”  

B:  “Have you thought of hurting them?”  

S:  “Many times, but they have children. And it is a neighborhood issue. Otherwise who can dominate whom these days?”  

B:  “Have you ever told the doctors this trouble?”   

S:  “No sir, these are not things to tell doctors. These issues of spirits attacks, they won’t understand.” 

In psychiatric classification, delusions are globally standardized as ‘form’ (such as ‘persecution’ or ‘grandeur’) and anti-psychotic medications are prescibed. What varies culturally is the delusional ‘content’ of the identity of the persecutor: upper caste neighbors.  Lurhmann addresses a longstanding puzzle famously called the ‘better prognosis hypothesis’ which finds that the long-term outcomes for schizophrenia, counter-intuitively, are better in so-called non-western cultures despite the lack of psychiatric support systems, because in spirit-infused cultures, hearing voices, and a range of other symptoms are perceived as common and thereby less threatening.  To this, Dr Singh offered: 

“As an anthropologist I have the freedom to believe Shyam, and to say that he is not suffering from a delusion. Instead of delusion, I consider Shyam as expressing varying intensities of skepticism, a more or less real shaq, a suspicion and certainty of oneself as repugnant to one’s neighbor, confronted by the wish of one’s nonexistence.”  

So what happens if a patient insists that theirs is not a medical problem? Are we willing to take a leap of faith with them? To explore this question, Dr Singh turned to another interlocutor: Mita had a PhD from the University of Cambridge and was a member of an esoteric religious sect with Hindu and Sikh followers. Returning to the question of why we are drawn to particular interlocutors, Dr Singh and Mita sometimes joked that of all the patients he knew, Mita was the person he could most easily have switched places with.  When he met her, Mita had already been admitted twice to the AIIMS psychiatry ward by her parents in a ‘catatonic state’, non-responsive even to ‘painful stimuli’, and had reduced her food intake drastically in what she claimed was an advanced practice of meditation. Citing Gananth Obeyekere’s famous essay on depression and Buddhism, Dr Singh made the argument to the AIIMS psychiatry department that biomedical diagnosis could be hindering how to best approach Mita’s situation:  

“How is the Western diagnostic term ‘depression’ expressed in a society whose predominant ideology of Buddhism states that life is suffering and sorrow, that the cause of sorrow is attachment or desire, and that there are ways of living with suffering, and that the interruption of such experience may even disrupt the higher goal of the cessation of suffering?”   

Mindfulness meditation has been shown to be effective for mental health issues, and AIIMS psychiatrists were themselves leading initiatives on meditation. However, the argument remained that Mita was suffering from a psychiatric crisis since her mother, a member of the same sect and aware of their meditative techniques, had brought her in for hospitalisation.    

Dr Singh continued to interview Mita once a year for the next six years. According to her psychiatrist her inability to find a suitable job after a PhD from Cambridge had turned this high achiever onto a path of “pathological meditation”. She, however, claimed not to use meditation as a solution to ‘post PhD blues’ but instead to “merge with the Lord. That is the purpose of human life”. Although she couldn’t describe the state of consciousness she reached in meditation, she was clear that it was not a medical problem.   

Dr Singh began to think of his conversations with Mita through a different metaphor. Building on Plato’s Allegory of the Cave and Deleuze’s ‘reversal of Platonism’, he described ethnographic interviews as receiving assertions from interlocutors-as-experts and offering our reinterpretations back to our interlocutors for approval or dismissal, in ways that might lead further into light or dark. To counter the argument that Mita’s mother knew the sect’s meditation practices and therefore bringing Mita to AIIMS was a definitive sign that Mita was mentally ill, Dr Singh offered the following interpretation:     

S- “Here is one idea I had. It doesn’t matter that your mother is part of the same sect. It may be that she has done BA in this practice and you want to do a PhD. And the people who do BAs feel that is where education should end, and so they may be against people who want to do a PhD in meditation. So that would be one way of understanding it.” 

M- “Yes, that would be a good way of understanding it actually.”  

When they spoke again years later, during the global pandemic, Mita referred back to this interpretation:  

“Remember how we used to say that I was doing a PhD in meditation? Well, I failed in the PhD”.  

Conclusion  

As Dr Singh showed in his Annual Lecture at EdCMA, the ethnographic interview does not necessarily arrive at ‘cultural formulations’ since illness may consist of irresolvable conflicts “within” cultures. At the same time, interviews are not necessarily or only about individuals but about individuations, that may not have ‘prototypes’ like the MINI. Further, it cannot be reduced to a method of ‘case studies’ since the case may exceed the study and this excess may be anthropologically and clinically relevant. Instead, the pursuit of singularities involves a process of learning with the great challenge of not arriving at a questionnaire but at a set of questions nearer to and further along specific life trajectories.  

As Nietzsche perhaps uniquely pointed out: Socrates is a ‘symptom’ of the Greek conversational agon in decline. The contest is primed and Socrates will always win. As a reversal of Platonism, as Dr. Singh contends, the ethnographic interview is something like the opposite form of a love of sophia, as a way of examining life, with others.     

Dr Bhrigupati Singh is Associate Professor of Anthropology and Sociology at Ashoka University, Visiting Associate Professor of Psychiatry, Brown University, and a Research Fellow at the Carney Institute for Brain Science. He is currently working on two books: a book of essays on concepts of the psyche titled Waxing and Waning Life: Essays at the Intersection of Anthropology and Psychiatry, and an anthropological monograph titled Life Unsettled, set in the “resettlement colony” of Trilokpuri in East Delhi.