Lectures

Corpses in the street, psychologist on the phone: Telepsychology, neoliberalism and Covid-19 in Ecuador

This article is part of the series:
Pavel Égüez, “Cuarentena (Quarantine)” (2020), Oil paint on cardboard.

In March 2020, the health and funerary system collapsed in Guayaquil. The largest city in Ecuador was one of the places most affected by Covid-19 in Latin America, perhaps even the world (Benítez et al., 2020; The New York Times, 2020). During the first weeks of the crisis, crude images of corpses in the streets of the city emerged. A truly Dantesque scene; the result of an overwhelmed government. The images circulating on digital social media were an implacable mirror of what was happening in the streets while we lived the nightmare from within, obligatorily confined to our homes. Corpses piled up in hospitals, lay in the houses of their relatives for days, or were left in the streets. One image on Twitter struck many of us particularly. It portrayed an inert body under the scorching sun, covered with a blanket, an umbrella, some simple flowers, and a handwritten note: “We called 911 and there is no help.” Many of our people died. We knew of their passing through phone calls, WhatsApp messages, and Facebook posts. A relative called me and recounted how at his daughter’s house, the grandfather’s body remained unburied for five days. I feared for the lives of my family and loved ones. Digital practices across our communities – such as utilising social media – brought to us these distressing and painful realities, while simultaneously allowing us to stay connected. To keep company. To shorten distances. To show solidarity. To resist.

There was also a different type of digital technology in place. The Ecuadorian government implemented a phone line for “telepsychology” and “telepsychiatry”, in addition to the traditional 911 emergency line. This intervention, as I will discuss, seemed relatively disconnected from our embodied local experiences, because it failed to capture the gravity, complexity and structural nature of the suffering people experienced. The telepsychology proposed by the government functioned mainly through the voluntary work of psychologists, teachers, and – especially – numerous students. I am a practicing psychologist trained in clinical and social approaches, and I teach and conduct research at a local public university. Thus, I accepted the invitation to participate as a volunteer from the institution where I work. I even attended an expedited online training, which was organised by a governmental committee and delivered by a private university. However, I retired from this role before actually taking any calls and decided to channel my solidarity and empathy towards other spaces.

This decision, and the personal experience that led me to it, had ethical, ideological, and pragmatic underpinnings. What follows is a reflection on some of these, from a critical and partially autoethnographic perspective. This reflection highlights a sharp contrast between digital technologies driven by governments, and the more impromptu, bottom-up digital practices within local communities. These cases demonstrate how technology can operate as a means to reproduce or to contest dominant ideologies. 

The political context: Tele-psychology and the neoliberal shift

Describing the political context within which the telepsychology unfolded is crucial, because it helps convey the constraints on the work of well-meaning psy volunteers. I knew that volunteers started their telepsychology work after receiving a chip that activated the service on their personal phones. I waited several weeks to receive such a device, but in the end my decision to quit the volunteer job arrived before the chip. It was not this operational limitation that motivated my decision to shift my solidarity to spaces outside of the government initiatives. The straw that broke the camel’s back was something I perceived to be a blunt contradiction in the government’s crisis response. The governmental commission in charge of providing emergency mental health care asked for volunteer work from teachers and students, including hundreds from public universities. At the same time, the governmental actors in charge of financial decisions reduced the budget for those same universities, in the midst of a pandemic. Several colleagues lost their jobs. Teaching and research were expected to be affected; not to mention the mental health of subjects working on precarious conditions, or those who were simply unemployed.

The cuts to the public budget imposed by the Ecuadorian government were nothing new, as they had become a regular occurrence in the recent past. However, it was still striking that they were implemented in the middle of a pandemic: a “shock doctrine” at its best (Klein, 2007). Since the 2017 elections, Ecuador has experienced a neoliberal turn: a direction radically opposed to the one officially elected at the polls (Long, 2020). The extremely low level of popular approval increasingly calls into question the democratic legitimacy of the government. Poverty and unemployment have increased. Investment in public health has stopped. Public statements by government officials called for a halt to the construction of hospitals and the hiring of new staff, suggesting that instead, we should shift our vision towards “telemedicine” and its promise of efficiency. Digital technological innovations thus are not neutral, but interlinked with specific, in this case cost-cutting, neoliberal ideologies. Large numbers of public health professionals were laid off. A loan was requested from the IMF even though this strategy is known to have negative effects on the health of debtor countries (Forster, Kentikelenis, Reinsberg, Stubbs, & King, 2019). A massive protest, led by indigenous movements, erupted in response to these drastic, neoliberal measures and was violently repressed in October 2019, resulting in a dozen deaths and thousands of injuries. In other words, bodies appeared in the streets long before Covid-19 arrived.

It is this government that set up the “telepsychology” phone line with one hand, whilst (in the middle of a pandemic) paying millions of dollars of foreign debt and approving reductions in the public budget with the other. Such cuts negatively affect the well-being – including the mental health – of the vast majority of the population.

Telepsychology and Power: Hegemony and Resistance

These complexities related to power were not addressed in the Ecuadorian mainstream media when speaking of “telepsychology”. Instead, the more than 40,000 calls registered nationwide were emphasized as an achievement. A “traffic light” system was communicated to the population (green, yellow and red), for potential service users to assess the severity of their symptoms. Conventional information was provided to promote mental health, with no mention of the violent context shaping distress. A link to a website accompanying the telematic initiative was also disseminated. 

The website presents three sections: “know your mental health” (via digital self-assessment); “take care of your mental health” (via getting information); and seek “psychological and emotional help” (from professionals via telepsychology and telepsychiatry). Links to YouTube videos and tutorials are included. 

The “know your mental health” section illustrates how local suffering is framed. It also entails a particular contradiction which can be interpreted in terms of psychologisation. The official discourse urges you to use telepsychology only if “symptoms do not decrease, but aggravate” over time, which may or may not be an attempt to avoid pathologisation. Yet it also urges you to call the helpline if “the situation surpasses you, having no one to talk about it”; if your “actions and emotions are out of control”; when family, friends or others are also “affected” by what is troubling you; or when you have queries that cannot be solved through the “available information” – information that has been limited and unreliable, to say the least (Benítez et al, 2020; The New York Times, 2020). Given the gravity of the situation in Guayaquil, all of us would have needed to call the telepsychology helpline for at least one of these reasons at one point or another, if we were to comply with these recommendations. In order to “know your mental health”, the digital tool provides a range of “tests”: tests to measure your “emotional state”, if you are experiencing “depression” or not, or your “level of resilience” (Figure 1).  

Figure 1: “Know your mental health”: measure your “level of resilience” Source/credit: https://www.coronavirusecuador.com/conoce-tu-salud-mental/#1598054738684-04ed4f54-a9a1

Psychologisation, individual symptoms, anxiety, depression, emotions and resilience. Mental health appears to be disconnected from the political economy that shapes it. This is consistent with neoliberal views which can, in turn, shape subjectivity in particular ways (Rose, 2019). The underlying assumption: know and manage yourself, breathe, think positively, talk about it and you will feel better, rely on the support of family and friends; but do not discuss power, trampled rights, or politicised community organising. Interestingly, Figure 1 cites an official slogan (of the mental health initiative): “juntos salimos de esta” (“we will overcome this together”). Such rhetoric of collective healing contrasts with an actual praxis that seems to be politically decontextualized and focused mainly on individual symptoms and resilience. It also contrasts with the more individually focused slogan (of a wider campaign by the government, not specific to “mental” health): #YoMeCuido (#ItakeCareOfMyself). The complexities and apparent contradictions of these discourses and practices are yet to be fully examined. 

Tools – including digital ones – can only be conceived in the context in which they are produced, and the purpose (conscious or not) that they serve. One way to understand the “digital” is as a product of its time. Artefacts, e.g., theories, methods, instruments, devices for communication, can be used by subjects – including psy professionals – for either the reproduction of the hegemonic ideology, or in resistance to it.  

Hegemony. The workings of ideology in, and through, professional practice may be a familiar topic within many scholarly traditions, including critical psychology (Pavón-Cuellar, 2019). Psychology is not just a helping profession. It is also a normative technology of the self, marked by the asymmetric power relations inherent in the economic, political and cultural systems with which it is co-constructed. Technological innovations regarding the platforms and channels of communication through which psychology operates (e.g., phones, computers, tablets) would not necessarily imply substantive changes that challenge hegemonic ideology. As illustrated in Figure 1, digital technologies may need to be analysed in terms of their reproduction or resistance to ideological decontextualization and depoliticization. Some calls by psychologists for expanding the use of helplines as a mental health strategy in times of Covid-19 seem rather disconnected from these sociopolitical concerns (i.e., Owings-Fonner, 2020; Zhou et al., 2020). In contrast, the implementation of State-operated helplines seems to require a deeper examination around the complexities of their intended and unintended consequences (e.g. Zeavin, this series). 

Resistance. During the time of confinement in Guayaquil, social networks allowed us to know – and let others know – what was going on, no matter how painful it was. Many times, this was content that the conventional media of our country kept silent about, while echoing the official discourse by emphasizing the disobedience of the population as the main cause of the infections and deaths. The latter has been described as a misleading and victim-blaming discourse, which ignores underlying structural determinants (Drury, Reicher, & Stott, 2020). 

This brings us back to the ethnographic introduction of this essay. Despite a strong motivation to help others, I distanced myself from governmental telepsychology. I did not want to feel like an accomplice to political decision-makers who exacerbated suffering and death while deferring to telematic and digital patch solutions that – probably inadvertently – veiled the structural causes of suffering. This was not just a disembodied ethical abstraction or partisan dogmatism. The corpses in the streets were those of my fellow citizens. I feared for the survival and wellbeing of my loved ones, my relatives, my friends, my colleagues, my students, myself. All of us felt our lives – including our “mental” health – being dramatically affected by the neglect and shortcomings of those in power. So, I decided to focus my solidarity elsewhere; this included (but was not limited to) proposing possible ways to understand, amplify, and vindicate the way local communities managed to survive and protect their wellbeing under such harsh circumstances.

There was a contrast between the top-down implementation of governmental telepsychology, and the more impromptu digital practices by local communities, which were messier, more capillary, organic, horizontal and, arguably, democratic. For example, during the worst periods of confinement, digital platforms (e.g., social media, messaging services, software and apps for video meetings) allowed us to provide social support, through our closest informal groups. These platforms, such as such as apps for instrumental and emotional support, also allowed mutual aid across diverse individuals and communities. Despite well-documented risks of misinformation (Van Babel et al., 2020, p. 464), digital spaces facilitated the sharing of important information that most mainstream national media were not showing. Calls for legitimate, yet risky, bio-safe protests were disseminated by some parts of the population, as well as calls for joining collective legal to demand constitutional rights. We also used digital tools in order to share academic ideas, feelings and experiences. Such exchanges often focused on innovations related to new approaches, forms of communication and adaptation of therapeutic or educational techniques from the physical to the virtual world. Others, more profoundly, focused on rethinking the possibilities of humanizing our forms of social organization from a political and community perspective. These practices, and others, have the potential to operate as forms of “digital” resistance. 

The Limitations of Telepsychology

Just a few brief chats with a handful of volunteers, and reflection on my own personal experience, have led me to speculate that telepsychology can have some positive impact at the level of subjective relief. However, as illustrated in this essay, telepsychology has significant limitations that play out beyond this realm of individual symptoms, especially – yet not exclusively – when dealing with scenarios as painful and complex as those we experienced in Ecuador. 

We do not know yet if the concrete interventions by psy volunteers who took calls reproduced discourses which were closer to hegemonic ideology, or if they resisted it. Based on analyses regarding the ideological nature of psychology in Latin America (Pavón-Cuellar, 2019) – including the discipline as taught in Ecuador (Capella & Jadhav, 2020) – I would be sceptical that there was any significant challenge to the status quo, or at least a proper contextualisation of the structural causes of suffering. The framing of “mental health” observed on the website accompanying the telepsychology program suggests that standard prescribed interventions may be consistent with ideologies and practices of self-assessment, self-management, and self-care. If this is true, neoliberal governance is not only visible as state policy, but as naturalised social discourses which veils structural oppression and embody the “ethics of individual striving for self-improvement” (Rose, 2019, p. 50). This is, of course, hypothetical, and further research may – or may not – discover complex forms of resistance by callers and volunteers.

Despite the possible benefits, and a great deal of good intentions, what telepsychology could offer in the midst of the suffering in Guayaquil seemed insufficient, to say the least. No telematic technology – particularly if it fails to be reflexive regarding its ideological role – will be able to contain the deep pain that was made visible through the pandemic. This is especially important when it comes to understanding and accompanying the struggles of the most excluded social groups (Burgees, 2020; Montero & Sonn, 2013). For numerous people, these are not struggles for “mental health” as an isolated category, but for basic needs such as survival, food, health and the defence of collective rights when they are threatened or trampled. 

Recall the opening scene to this essay and consider a person who has just lost a loved one at home, because they did not have the money to buy an oxygen tank, nor access to a hospital bed. They are forced to share space with the body for five days or more, because they call the government emergency line, and there is no answer. They fear contagion, while dealing with the shock and pain of this violent situation. They may also be concerned about the economic impact of the crisis on their family, food security, and the guarantee of their right to work. 

What do we say to this person from the other side of the psychological phone line? To breathe? To think more positively? Is that the best we can do? Is that enough? What useful information can we give them, if we know that those who govern us are not fully protecting the rights of the population, nor giving a timely response to prevailing human needs? In the case of at least sixty families, the corpses of their relatives were lost (yes, lost) inside public hospitals. Nine months after the initial pandemic shock, there is still no trace of them.  

I would suggest that despite best intentions, valuable volunteer work, and potential contributions to subjective wellbeing, state-mandated telepsychology programs may be making certain promises they fail to fulfil, or that are simply outside their logic altogether. Such interventions may be lacking psycho-political validity (Prilleltensky, 2008), as they fail to engage more profoundly with issues or power dynamics beyond the individual and their family. The political decisions of those who exercise official power could save lives, or lead thousands to suffering and death. For example, there is a crucial difference between advancing policies that strengthen public health (before and during the catastrophe), versus prioritizing those which mainly benefit national and international capital. Similarly, providing the population with transparent, consistent and trustworthy information is vital, but was not done in this case; something which may have limited the informational support that volunteers were able to provide to callers. 

  Beyond well-intentioned attempts at individual improvement, telepsychology may fail to encourage community dialogues and actions that transcend the hegemonic cliché centred on individual cognition, emotion, and behaviour. This is to say, one that transcends the self-improvement discourse, and engages with the needs and ethical-political projects of diverse communities. For example, it may be that volunteers are unable to provide information in relation to politicized collective initiatives such as bio-safe protests or legal actions involving governmental agencies. As illustrated throughout this essay, these limitations seem to be associated with structural blind spots in conventional State-operated telepsychology. Yet, we must also pay attention to an additional subject, one that transcends the specific scope of this piece:  the way “structure” and “culture” are understood in mental health contexts; including structural and cultural inequality (e.g., Metzl & Hansen, 2014; Napier et al. 2014). Previous ethnographic research suggests that most psychologists in Guayaquil may have a limited understanding of both categories (Capella & Jadhav, 2020); a limitation that may have made its way into telepsychology.    

Conclusions

One of my intentions with this auto-ethnographic essay is to stimulate further discussion regarding the possibilities and limitations of psychology, including cases where it operates through artefacts imbued with an aura of technological innovation (e.g. smart phones, webpages, social media), and especially in pandemic contexts marked by neoliberal governance, such as Ecuador. This poses a series of challenges, which are interdisciplinary and intercultural, analytical and ethical-political, global and local. Rather than drawing hasty conclusions, I have limited myself to raising some questions and reflections, from a critical and situated perspective, consistent with Latin American perspectives that understand knowledge as “partial and relative” (Martín-Baró, 1989, p. 6). 

During the first months of shock in Guayaquil, we experienced a stark contrast. On the one hand, the state deployed its official tele-psychology, framing it as an efficient technological innovation for providing emotional care. On the other, the painful image of inert bodies in the streets underscored the rights that were not guaranteed by the government. Such violence – which affected working-class communities in particularly pervasive ways – was not caused by the virus alone, but by the political decisions of a questionably democratic government, within the context of a sharp a neoliberal turn; the same government that used “telepsychology” and “telepsychiatry” as its emblematic proposals for mental health in the face of the pandemic. This serves as a reminder that any technology needs to be understood in context and in relation to the ideology it serves, or challenges.

Which voices do psychological technologies listen to and amplify, and which voices and realities do they silence? What do they say, and what do they stay silent about? What do they do – or not do – when the macabre result of structural violence becomes dramatically visible in thousands of lifeless bodies? Perhaps, and only perhaps, it is this fundamental ideological dimension that we must look at when we speak of technological innovations, whatever the artefacts that embody it.

Here in Guayaquil, we continue to mourn and resist. Neighbourhoods and local families play a key role (Moser & Peek, 2020). We have lived, to say the least, through what many experienced as an abandonment by the central and municipal government, during the worst moment of shock. We do not forget suffering and death that was largely preventable. We do not forget the political and economic decisions behind the pain. Nor do we forget the complex ways in which an official “telepsychology” was articulated in this particular conjuncture, with all its potentialities and limitations; nor do we lose hope that our voices will be heard, and that others will know of the diverse embodied experiences that we lived. Experiences around which we will continue to construct meanings and possible horizons, inside and outside the “psy” field; inside and outside our phones and our computers. 

References

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Zhou, X., Snoswell, C. L., Harding, L. E., Bambling, M., Edirippulige, S., Bai, X., … Smith, A. C. (2020). The role of telehealth in reducing the mental health burden from covid-19. Telemedicine and E-Health, 26 (4). https://doi.org/https://doi.org/10.1089/tmj.2020.0068


Manuel Capella is a lecturer at the Faculty of Psychological Sciences, University of Guayaquil, Ecuador. He is currently the director of a local research project that examines community action in the aftermath of the pandemic shock at the city. He has a background in clinical psychology (Bsc., University of Guayaquil); social psychology (MSc., Complutense University of Madrid); and critical psychology (PhD, University College London). His teaching, research and professional practice seek to explore human wellbeing as an intersubjective construction shaped by context and power.

Tracking Digital Psy is a series edited by Dörte BemmeNatassia Brenman and Beth Semel.


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