The next few months we’ll be highlighting authors who have published in Culture, Medicine, and Psychiatry.

Giulio Ongaro is a Fellow at the Centre for Humanities and Social Sciences at the Southern University of Science and Technology in Shenzhen, China. Additionally, he is a Visiting Fellow at the Department of Anthropology, London School of Economics and a Team member at Program in Placebo Studies at Harvard Medical School. He obtained a PhD in Social Anthropology from the LSE and a MSc in Philosophy of Mind from the University of Edinburgh.

What is your article “Doctors Speak: A Qualitative Study of Physicians’ Prescribing of Antidepressants in Functional Bowel Disorders” about?

The article explores how gastroenterologists in a US hospital prescribe tricyclic antidepressants to treat irritable bowel syndrome and the challenges they face in doing so. IBS is a functional disorder (a chronic condition with no precise pathophysiology) which is often surrounded by stigma. Prescribing low-dose psychiatric medication, albeit proved to be effective, can be stigma-inducing because it potentially hints that the disorder is “all in the head”. To avoid this, physicians gravitate their explanations towards the known neurophysiological mechanisms of action. Though avoiding psychological talk, their engagement with patients is nevertheless sensitive to the psychology of expectations, which they know can powerfully affect clinical outcomes (when realistic). They thus place a lot of effort in building and managing hope in patients. Overall, the study shows how physicians do their best to help under specific cultural assumptions – about mind and body – that make functional disorders so hard to treat within modern medicine. 

Tell us a little bit about yourself and your research interests.

My research lies in the areas of medical anthropology, cross-cultural psychiatry, and healing ritual. As part of my PhD at the LSE, I did long-term ethnographic fieldwork among the Akha people of highland Laos. I researched their shamanic tradition and medical philosophy, focusing on healing efficacy: on how rituals work and how people think they work. Alongside fieldwork, I have conducted research within the science of ‘placebo effects’ and surrounding areas of philosophy of cognitive science and psychiatry. In collaboration with researchers at the Program for Placebo Studies at Harvard Medical School, I have published on the mechanisms of placebo and nocebo effects and on cultural narratives around medicine-taking, including this highlighted article.  

I’m currently on a fellowship at SUSTech in Shenzhen. What’s nice about it is that gives plenty of academic freedom, so I’ve ended up delving into a somewhat disparate set of topics. I’m writing an article on the notion of ‘externalist psychiatry’, one on downward causation in neuroscience, and one on a shamanic movement that took hold in Laos while I was there. I’ve also kept an interest in global history (rekindled recently by the publication of Graeber and Wengrow’s The Dawn of Everything). Trying to bring all these strands together, I am writing a book on the global history of medicine that centres on the epistemic and therapeutic value of animistic healing traditions.   

What drew you to this project?

It was an invitation from Prof. Ted Kaptchuk and his team at the Program of Placebo Studies at Harvard Medical School. The Program investigates ‘placebo effects’ from an interdisciplinary perspective, bridging clinical sciences with social sciences and humanities, so my research interests fitted in quite well. Dr. Sarah Ballou – who shares first-authorship of the article – conducted interviews with physicians at a Boston hospital on various aspects of prescription of tricyclic antidepressants for IBS (as part of a broader project on how physicians approach functional gastrointestinal disorders). Together with Dr. Julia Haas, we analysed the central themes, which touched on the implications of giving physiological and psychological explanations of functional disorder and its treatment. These are also topics that I investigated ethnographically in highland Laos among the Akha. So, the study for me was also interesting from a cross-cultural point of view.  

What was one of the most interesting findings?

It was the care physicians took to avoid stigmatising narratives by centring their explanation on the neurophysiological processes of treatment. For instance, they’d talk about ‘neuromodulators’ rather than ‘antidepressants’; ‘nerve sensitivity in the gut’ rather than psychological factors involved in IBS. All the same, much of their approach showed a deep awareness of the importance of realistic expectations and hope in treatment, i.e., psychological factors. Though it fell outside the scope of the article, to me the fact that these physicians (who are among the best in the country in this field) had to tread so carefully on this complicated mind/body terrain speaks of some theoretical limits inherent to the biomedical approach to functional disorders. I found this interesting comparatively speaking. Many medical traditions around the world (the Akha being one) do afford rich conceptual resources for dealing with disorders that would be diagnosed as ‘functional’ within biomedicine. Typically, they externalise their causes onto the social environment. In so doing, they pre-empt the kind of stigma that the physicians we interviewed actively try to avoid in the clinical encounter. So, as an anthropologist this study was interesting for highlighting the big role played by culturally-specific explanatory frameworks surrounding the treatment of functional conditions.   

What are you reading, listening to, and/or watching right now?

I have been reading Starhawk for a course I am teaching on the anthropology of magic and healing. Fiction, I have just finished A Man’s Place by Annie Ernaux. Having a long commute, I’ve been listening to a fairly random mix of podcasts like Red Medicine, Hermitix, Srsly Wrong, Tides of History, COMPLEXITY and Mad in America. The last movie I watched was The Banshees of Inisherin and the last song played was by Rosalía. 

If there was one takeaway or action point you hope people will get from your work, what would it be?

That the main way to make progress in psychiatry will depend on externalising mental disorders: on casting both the causes and treatment of psychiatric disorders, partly, onto the social environment. This won’t be the consequence of giving up on the brain, but of knowing more about it as an organ of mediation. And that other healing traditions illuminate the kind of social conditions that enable externalisation (though all this is not something I’ve already written; it’s something that will hopefully come out soon). 

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The next few months we’ll be highlighting authors who have published in Culture, Medicine, and Psychiatry.

Ellen E. Kozelka is an Assistant Professor, Anthropology Department, University of Vermont. She is a psychological/medical anthropologist and Global Mental Health Scholar. Her research focuses on cultural conceptions of mental health and illness, specifically how those conceptions shape both available treatment options and health seeking behaviors for systemically marginalized populations in the US and México.

What is your article “Living the Process: Examining the Continuum of Coercion and Care in Tijuana’s Community-Based Rehabilitation Centers” about?

I explore why researchers must attend to cultural conceptions of health issues that expand beyond biomedical frameworks; doing so gives us the opportunity to understand the different forms of knowledge that aid or harm treatment at the individual level. By exploring one community-based (non-biomedical) treatment center’s institutional position on the therapeutic value of coercion, I highlight a different perspective on addiction’s “root problem” as well as how coercion has been incorporated into the proper method to treat that condition. I then examine several cases in which coercion was effective from women’s own perspectives as well as when it was not, challenging dominant assumptions about experience in coerced care while emphasizing its messy ethical and therapeutic reality. In doing so, I present both a method and justification for Global Mental Health researchers to attend to cultural context in a way that will promote equitable engagement with community partners around best care practices.

Tell us a little bit about yourself and your research interests.

My work examines how structures of inequity shape the formation of, access to, and experience in mental health care systems for marginalized populations in the US and México. I specifically examine why marginalized people seek out novel and “nontraditional” care options to understand how healthcare systems could be made more equitable and welcoming to all.

What drew you to this project?

This article is based on my research in community-based substance use treatment for ethnically Mexican women in the US-MX border zone. Through this work I explored the question: why are there such diverse experiences of treatment and recovery, even within the same community-based therapeutic model? My driving question was straightforward, yet revealed both the complexity and importance of understanding cultural ideas of health and illness, moral ideas of personhood, and the intersection of individual experience with structural forces. My research contributes to the assertion that “addiction” is an individualized biopsychosocial illness, as is the healing process of recovery. As such, available treatment options should be variable enough to match this continuum of experience.

What was one of the most interesting findings?

To me, one of the most interesting elements of this work has been learning the specific reasons why women use drugs, the wide range of reasons and ways they end up in compulsory treatment, and what that tells us about how culture shapes mental health experience for marginalized women in the US and México. By exploring multiple treatment and recovery trajectories, I discuss possibilities for ways to reshape care and contribute to health equity for marginalized women.

What are you reading, listening to, and/or watching right now? 

I currently reading “The Best Minds: A Story of Friendship, Madness, and the Tragedy of Good Intentions” by Jonathan Rosen and watching “Traitors”.

If there was one takeaway or action point you hope people will get from your work, what would it be? 

I hope that my work demonstrates that anthropological methods and attention to cultural context can be used to bridge gaps in understanding about different forms of mental healthcare in ways that foster equitable collaboration, both across academic/professional disciplines and stakeholder groups.

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The next few months we’ll be highlighting authors who have published in Culture, Medicine, and Psychiatry.

Jesse Proudfoot is an Assistant Professor in the Department of Sociology at Durham University. His research focuses on drug use among marginalized and racialized people, the politics of drug policy and treatment, and the relationship between addiction and structural violence.

What is your article “The Dreamwork of the Symptom: Reading Structural Racism and Family History in a Drug Addiction” about?

This article is about the relationship between oppressive social forces and illnesses like drug addiction. It’s common in medical anthropology to argue that seemingly individual illnesses need to be understood as shaped, and often produced, by social forces, but the precise ways that these forces produce illness is difficult to chart in concrete terms. In this article, I try to analyze this process, by looking at the case of one person I interviewed: Leon, an African American man from Chicago who had an addiction to crack cocaine. Drawing on psychoanalysis, and in particular, Freud’s idea of the dreamwork, I attempt to show how latent social forces like structural racism can find expression in symptoms such as drug addiction, but only through the mediation of other proximate layers—in Leon’s case, his complex relationship with his family and his own radical politics.

Tell us a little bit about yourself and your research interests.

I’ve been interested in drug use and addiction since my PhD, which was an ethnographic study of homeless drug users in Vancouver’s Downtown Eastside. I charted their experiences as the neighbourhood underwent rapid changes due to progressive developments in drug policy, as well as gentrification. My earlier work was more concerned with the politics of harm reduction drug policy, but over the years, I’ve become more interested in the broader question of addiction and the subjective experience of people with problematic relationships to substances. I’m most interested in thinking about symptoms—like addiction—as sites of connection between the social, the political, and the subjective.

What drew you to this project?

This research grew out of an 18 month period of fieldwork I conducted in Chicago in 2012-13. I was working in a halfway house for people being released from prison who were struggling with drug addictions. I was struck by the diversity of people’s experiences of addiction, which ranged from what we might call acute self-medication, in order to deal with intolerable life circumstances, to much more complex, unconscious dynamics related to childhood trauma. Having written about these different forms of addiction in an earlier paper (‘Traumatic Landscapes’, 2019), I became interested in understanding what else we can read in addictions and the broader question of how to understand the relationship between politics and symptoms.

What was one of the most interesting findings?

The hook of this paper is that understanding the causes of your illness is not the same as treating it. Critical medical anthropology places a lot of emphasis on the demystification of symptoms, implicitly arguing that by uncovering the social causes of illnesses, we can alleviate them. Even though it now sounds obvious, I was struck during this research by the gap between demystification and therapeutics. My interlocutor Leon had a very well-developed political analysis of his addiction, grounded in critical political economy and anti-racism, and we talked about this often. But these insights failed him where he needed them most, in changing his own relationship to drugs. Making sense of this gap was what prompted me to think more deeply about how we approach the question of demystification.

What are you reading, listening to, and/or watching right now?

I started running last year, which means I’m listening to a lot of podcasts. My current favorites are Know Your Enemy, which is a deep dive into American conservative thought for people on the Left, and Love is the Message by Tim Lawrence and Jeremy Gilbert, which is focused on dance music, counterculture, and collective joy—things I’ve spent a lot of time thinking about. The most recent novel I read was A Gate at the Stairs, by Lorrie Moore; a very funny and sad book about going to college, grief, and loss.

If there was one takeaway or action point you hope people will get from your work, what would it be?

The demystification of illness is a complex business and our critical efforts must be attentive to the highly particular ways that people experience and embody those social forces that medical anthropologists are often interested in. As I hope to show in the article, this is essential not only to more accurately theorize illness, but also to help people with addictions to make sense of their lives and navigate their recoveries. Care must be ‘structurally competent’ in Jonathan Metzl and Helena Hansen’s terms, but also—in the spirit of the best traditions within psychoanalysis—grounded in the particularities of life histories.

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The next few months we’ll be highlighting authors who have published in Culture, Medicine, and Psychiatry.

Hanne Apers, a female PhD candidate at the University of Antwerp’s Centre for Population, Family, and Health, specializes in mental health and migration. With a background in psychology and anthropology, she is currently completing her PhD-research on the explanatory models of mental health among East-African migrants in Belgium.

What is your article “Explanatory Models of (Mental) Health Among Sub-Saharan African Migrants in Belgium: A Qualitative Study of Healthcare Professionals’ Perceptions and Practices” about?

This study explores how mental health professionals in Belgium perceive the mental health understandings of their patients with a sub-Saharan African (SSA). 22 professionals were interviewed, including ten who also have a SSA migration background. The study explores three main aspects. Firstly, it examines how professionals perceive their SSA patients’ explanatory models of mental health. Secondly, it investigates the impact of these perceptions on their treatment approaches. Lastly, it considers the influence of professionals’ cultural backgrounds, comparing those with and without an SSA background.

The findings highlight noticeable differences in explanatory models, the main distinction was found in the beliefs about what causes mental health issues. Professionals’ understanding of SSA models affects their treatment practices, those familiar with SSA views faced fewer language and interpretation challenges. Non-migrant professionals emphasized cultural sensitivity and SSA-background professionals adopted an integrated approach. These findings contribute to discussions about what it means to be “culturally competent” in mental health care.

Tell us a little bit about yourself and your research interests.

With a background in psychology and anthropology, my interest lies in exploring how different cultural views on mental health affect how people live, seek and prefer healthcare. As an anthropologist, I focus on qualitative research, favoring participatory, community-based methods to better understand the impact of cultural perspectives on healthcare dynamics.

What drew you to this project?

Numerous barriers and factors continue to hinder migrants’ access to healthcare. My aim was to contribute to lowering these barriers by comprehending the role of cultural understandings and illustrating how the organization of healthcare systems can be adapted to these differing understandings, and contribute to closing the treatment gap.

What was one of the most interesting findings?

The comparison between professionals with and without a similar migration background yielded intriguing insights, advocating for improved representation within healthcare systems.

What are you reading, listening to, and/or watching right now?

The book ‘Crazy Like Us’ by Ethan Watters provides a compelling non-academic exploration of how global mental healthcare is shaped by a prevailing Global North perspective, sometimes with detrimental effects.

If there was one takeaway or action point you hope people will get from your work, what would it be?

I hope to underscore the significance of recognizing cultural understandings and conceptualizations of health. It’s a crucial factor to consider if we aspire to develop and advocate for healthcare approaches that are truly inclusive.

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The next few months we’ll be highlighting authors who have published in Culture, Medicine, and Psychiatry.

Mary Hawk (DrPH) is the LSW professor and chair at the University of Pittsburgh School of Public Health, Department of Behavioral and Community Health Science. Dr. Hawk’s work includes the implementation and assessment of structural interventions to improve health outcomes for oppressed populations and the development of community-engaged approaches to optimize public health. She is co-founder of The Open Door, a harm reduction housing program created to improve health outcomes for chronically homeless people with HIV.

What is your article “Harm Reduction Principles in a Street Medicine Program: A Qualitative Study” about?

In this study we partnered with Operation Safety Net (OSN), a nonprofit that provides street medicine services to rough sleepers – people who are unhoused. We conducted qualitative interviews with OSN providers to pinpoint ways that street medicine differs from other kinds of healthcare and what elements of care were most helpful to patients.  We learned this care is built on relational harm reduction, which centers the patient-provider relationship. Ways that harm reduction played out included meeting patients where there are (both emotionally and practically, in this case on the street), offering genuine concern and dignity to patients, and supporting patients them in non-judgmental ways were found to be important aspects of this work. We hope these findings help others who care for marginalized patients consider how they can engage them in care and bridge them to other healthcare services, and ultimately help expand the field of street medicine.

Tell us a little bit about yourself and your research interests.

I worked in nonprofit settings for many years, mostly providing services to people with HIV (PWH) who experience oppression and marginalization. This community-based work is the foundation of my research. I’m interested in building evidence for community-driven approaches that advance health equity for historically excluded populations.  All my work centers on harm reduction, especially as a relational approach to care, which considers ways that patient-provider relationships can improve care outcomes. At the moment, I am working on a National Institute of Mental Health (NIMH)-funded study that explores the impact of a harm reduction-based financial management intervention on adherence among unstably housed PWH, as well as a National Institute of Drug Abuse-funded study using mixed methods to investigate experiences of stigma in healthcare settings by PWH who use drugs.

What drew you to this project?

Operation Safety Net is an amazing organization.  When we first started meeting with Dr. Jim Withers, who has made an immeasurable impact on rough sleepers and street medicine providers across the world, we had an “aha moment” and realized that an essential piece of his work seemed to be rooted in relational harm reduction. It was exciting to explore these ideas with OSN providers. At the core of relational harm reduction is the idea that all patients are worthy of respect and autonomy, and we really saw that play out with the OSN team.

What was one of the most interesting findings?

In our planning meetings with Dr. Withers and other OSN leadership we could hear the genuine care they have for their patients, but seeing this through the interview data was very compelling. But the loss and grief they experience when their patients die was also clear. We talk about burnout in healthcare, but don’t often think about that in terms of grief experienced by providers.

What are you reading, listening to, and/or watching right now?

I’m right in the middle of “The Call,” an episode of This American Life that details an overdose prevention hotline, which is a great example of how we can show care for people who are too often stigmatized through harm reduction work.  I’m also a diehard Survivor fan!

If there was one takeaway or action point you hope people will get from your work, what would it be?

Humanism is at the heart of harm reduction approaches to care, including street medicine.  Affording people dignity and genuine concern is the jumping off point for engaging anyone in care, but especially those who regularly experience trauma and systematic oppression. It can make all the difference to not only their experiences of care but also their retention in care and, ultimately, clinical outcomes. 

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