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

Lawrence D. Blum, M.D. is a Clinical Associate Professor of Psychiatry and Adjunct Professor Fanthropology at the University of Pennsylvania. He is also Faculty at Psychoanalytic Center of Philadelphia. He is a psychiatrist/psychoanalyst in private practice.  His undergraduate thesis focused on anthropology and psychoanalysis; both became lifelong interests. He has enjoyed teaching trainees in psychiatry, psychology, and psychoanalysis for decades. In recent years he helped found and co-direct the undergraduate minor in psychoanalytic studies at the University of Pennsylvania. 

What is your article ‘Minding our Minds: Obsessive-Compulsiveness, Psychiatry, and Psychology‘ about?

It is nearly impossible to be a good scientist or doctor without the advantage of some obsessive-compulsive personality traits, but these traits can also have significant disadvantages. While obsessive-compulsive traits tend to promote scientific rigor and conscientiousness, they can lead to an emphasis of method over meaning, and measurable behavior over the emotions and fantasies that are also essential aspects of being human. These traits are pervasive enough in professionals, I argue, to create an obsessive-compulsive background within scientific and medical culture. In my article, I discuss the influence of this obsessive-compulsive culture on psychiatry and psychology, using the Diagnostic and Statistical Manual (DSM) and Cognitive-Behavioral Therapy (CBT) as examples. The DSM and CBT have many salient obsessive-compulsive features, but to my knowledge, this article is the first to discuss the obsessive-compulsive qualities of either the DSM or CBT, or of psychiatric and psychological culture in general. One could regard the article as a kind of psychoanalytic ethnography of current psychiatry and psychology.

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

One of my principal ongoing research interests is “counterdependency.” This is a term that indicates having objections to “dependent” wishes, i.e., wishes to be taken care of or helped by others.We humans start out as dependent babies, needing and wanting to be taken care of.  Though we also grow up and want to be independent, and to be able to take care of others, those early wishes to be taken care of never go away. Some cultures encourage tolerance of and continuing expression of dependent wishes, and others don’t tolerate such wishes and encourage their suppression. In my view, the United States, compared to other countries, is a cultural outlier in its rather extreme counterdependent intolerance of those who need to be taken care of. We have a conquer-the-frontier mythology of extreme self-reliance accompanied by corresponding contempt for anyone who needs to be taken care of, so compared to other developed countries, the United States does far less for new parents, children, the sick, and the poor.  As compelling as these observations seem to me, as far as I know, counterdependency has never been empirically studied on a cultural level.

I first became aware of the importance of counterdependency early in my career when I was seeing a lot of women with postpartum depression. They were often very capable, successful women who were used to doing everything themselves and never needed to ask for help. When they had a baby, they couldn’t survive without help but were emotionally unable to ask for help; their way of adapting to life failed and they became acutely depressed and anxious. Those women who, with a bit of help from me would then allow themselves to ask for a bit of help from others (often as little as possible), frequently recovered very quickly. It soon became clear to me that this counterdependent stance was a) an important unrecognized risk factor for postpartum depression, b) a significant factor in individual psychology, and also c) a pervasive aspect of our culture. A colleague and I developed a self-report instrument to assess counterdependency, which we have tested in relation to postpartum depression, and which could easily be used to compare different cultures.

Any reader who may be interested in empirically studying counterdependency, in relation to either culture or individual psychology (or who may have an interested graduate student), should feel free to contact me.

Here are two relevant references:

Blum, L.D. “Psychodynamics of Postpartum Depression,” Psychoanalytic Psychology, Vol. 24, No. 1, 45-62, 2007.

Blum, L.D., Horenstein, A., Carper, M.M., Stange, J.P., Cohen, J.N., Doyle, A. & Smith, V. (2020). A New Instrument to Assess Counterdependency, Evaluated in the Context of Postpartum Depression. Psychoanalytic Psychology, 38:1, pp 49-57, January, 2021. Published online June 25, 2020, https://psycnet.apa.org/doi/10.1037/pap0000317 .

Since reading Mary Douglas’ paper ‘The Self as Risk Taker: A Cultural Theory of Contagion in Relation to AIDS’ (1990), I have been intrigued about perceptions of risk and protection from HIV.  During research in Baltimore, Maryland in 2015, an interviewee commented that although they were engaged in sex work, they only went in their own circle. They saw this boundary as protective against HIV risk and it resonated with Douglas’ ideas about community boundaries as a protective barrier to contagion. I then developed this project as a pilot for investigating the use of Cultural Theory among people who use drugs

What was one of the most interesting findings?

I think the most central point is that an obsessive-compulsive professional culture has led to a very narrow biological and behavioral reductionism in psychiatry and psychology, with an unfortunate de-emphasis of humanism, mind, emotion, and fantasy.  A more truly scientific approach in these disciplines would incorporate a broader view of what it is like to be human, including all of our irrationality

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

A student recently brought to my attention an excellent article called “Melancholy Anthropology,” by the Australian anthropologist, Holly High.  She draws on Freud’s “Mourning and Melancholia” and argues that the ethnographer in the field not only, necessarily, becomes deeply emotionally engaged with the people she is studying, but also inevitably becomes the object of their many often deeply irrational desires.  She cannot possibly fulfill those desires and tends to feel deeply guilty.  High then argues that this intolerable, often unacknowledged, guilt tends to be transformed into needs for ideological purity that characterize some parts of the discipline, thus making an important connection between experience in the field, individual psychology, and the culture of anthropology as a discipline.

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

From my paper in CMP, I think the most central point is that an obsessive-compulsive professional culture has led to a very narrow biological and behavioral reductionism in psychiatry and psychology, with an unfortunate de-emphasis of humanism, mind, emotion, and fantasy.  A more truly scientific approach in these disciplines would incorporate a broader view of what it is like to be human, including all of our irrationality.

For my work in general, I think perhaps what is most central is the wealth of fascinating, bidirectional interaction between individual psychology and culture that is heavily influenced by early developmental experience, and that is typically unconscious. 

Other places to connect:
Website

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

Dr. Shannon Hughes, MSW, PhD, is an Associate Professor at the School of Scoial Work at Colorado state University. She teaches, consults, and conducts research on how we use drugs and medicines in our society today. She is a community organizer and leader in articulating the shifting paradigms around our relationships with Self and medicines/drugs.

Dr. Robert Colbert, MA, PhD, LPC-S is Therapist and Owner of An Enduring Love, Co., in Fort Collins, Colorado, and a Sub-Invesitgator for MDMA-Assisted Psychotherapy REsaerch for MAPS Public Benefit Corporation. He is a is a counselor, clinical supervisor, and published researcher on therapeutic and social uses of psychedelics. He has sat on multiple non-profit and advisory boards, and has over 25 years of advocacy, education, and volunteer work in harm reduction and support services for people who use drugs.

What is your article “Evenings with Molly:Adult Couples’ Use of MDMA for Relationship Enhancement” about?

Our article explores the use of MDMA (also called Ecstasy or Molly) among couples taking it in the privacy of their own homes for relationship enhancement. MDMA is being tested in clinical trials as a breakthrough treatment for PTSD, but this article investigates its uses outside of the therapist’s office, and too, outside of the recreational party scene that the drug is often associated with. Couples described preparing for their “evening with Molly” through modifying their physical space, communicating their intentions and hopes for the experience, and taking care of their health (e.g., eating healthier, avoiding alcohol) in the days leading up to their MDMA use. Couples further described durable positive impacts on their relationships, including improved communication, enhanced intimacy, and providing a relationship “tune up” when things felt stagnant or stuck. Couples’ MDMA use suggests that non-problematic adult use of the drug is possible outside of clinical settings.

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

Dr. Shannon Hughes: I have been a researcher and educator in Social Work for over a decade with a focus on how we use drugs and medicines in our society today. As a researcher, I seek to improve best practices around how psychotropic drugs are prescribed, assessed, and monitored in mental health practice, and empower people with lived experience of mental distress in reclaiming the power to define their own stories and their own paths forward, which may or may not include psychotropic drugs. My research lab at CSU, the Alternatives for Mental Health and Healing Lab, aims to advance holistic, person-centered, and cutting-edge behavioral health alternatives founded in the synthesis of research evidence, innovative thinking, and community partnership. As an educator, I have developed and delivered curriculum for professional social workers, counselors, and administrators on the topics of safety and efficacy of psychoactive substances used in mental health care, shifting paradigms of drug use, and roles of helping professionals in supporting empowered relationships with psychoactive substances. Outside of my academic and professional life, I find balance in the mountains of Colorado and regular travel to places with coastlines and beaches.

Dr. Robert Colbert: I am a social artist who utilizes creative creative artistry within networks of advocates and community members who strive to enact meaningful, lasting social change as it relates to how we use drugs and medicines. In my private psychotherapy practice, he works with clients as a steward for discovery, and to empower change in people’s lives by exploring relationships, identities, and choice points which encourages lasting personal transformations. As a researcher, my primary interest is the discovery of hidden groups and social networks of substance users, with a focus on exploring the lived experiences and complex interactions which exist within our substance-using communities. Outside of my professional life and community organizing, I appreciate the Colorado outdoors and spending time with friends enjoying live music and dance.

Together we are founding members of the The Nowak Society, 501c3, a Colorado-based non-profit providing community education and professional organizing around psychedelics and drug policy reform. We also offer workshops and training to therapists and helping professionals seeking to expand their practice into the emerging field of psychedelic-assisted therapies. We believe that, as exciting as the present psychedelic renaissance is, we must not forget the numerous harms done by decades of prohibitionist drug policies and the propaganda of the Drug War. Critical thinking here requires that we understand our history, bring attention to power, and anchor into our ethics and values.

What drew you both to this project?

MDMA has so many potential therapeutic applications – such as for trauma work and PTSD, eating disorders, social anxiety, autism spectrum disorders, and more – but it also has a very interesting history of use recreationally in the PLUR (Peace, Love, Unity, Respect) and rave culture of the early 90’s and through to today. Drug War fear-mongering painted MDMA as a dangerous drug that would take ice-cream scoops out of your brain, leaving you forever damaged and broken, so it was kept underground and deviant for a long time. We now know, of course, that much of the research at the height of prohibition was skewed and flawed in a way to inflate the dangers of MDMA, but the “dangerous drug” story sticks in our minds. With MDMA nearing completion of Phase III testing for FDA approval, I think most people will easily find it agreeable to open up drug access through a doctor, under tightly controlled and supervised conditions because, we assume, MDMA is otherwise still a dangerous drug. In the spirit of critical thinking and unpacking cultural remnants of the Drug War, we thought it would be interesting to seriously investigate other less explored applications of MDMA.

Outside of the clinic and outside of the rave music scene, we knew there were individuals using MDMA quietly in their own homes, without supervision or therapeutic support, to improve their intimate relationships. We were curious what their use looked like, how they decided to use MDMA and how they prepared themselves for it, what benefits they experienced, and what safety issues or adverse effects they experienced. We thought this line of inquiry might hold implications for present drug policy reform discussions where stakeholders debate the merits and limitations of medicalization, legalization, and decriminalization as different paths forward for MDMA and other psychedelic drugs.

What was one of the most interesting findings?

What was most interesting about our interviews with couples was how thoughtful and deliberate they were in curating their MDMA experiences – including, planning the details of how they would spend the evening together, being sure they were mentally and emotionally ready to be fully present with their partner for the MDMA experience, and taking time following the experience to slow down and revisit the discoveries they made through the experience. One couple described it as “conscious use” of MDMA. We believe this speaks to a potential new model of drug use that opens up possibilities for how we might engage our relationships to drugs. It is not escapist drug use or drug use that creates harm or dysfunction in users’ lives. Neither is it supervised use for treating a mental health condition. It is something else entirely, and if taken seriously, might serve to counteract the cultural baggage of the Drug War by giving us alternative paths toward engaging informed, non-problematic, healthful adult drug use.

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

Dr. Shannon Hughes: I am reading “Saving Our Own Lives: A Liberatory Practice of Harm Reduction” by Shira Hassan and “The Mind and the Moon: My Brother’s Story, the Science of our Brains, and the Search for our Psyches” by Daniel Bergner. Also listening to the audiobook, “A Fierce Heart” by Spring Washam

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

We are steeped in baggage from the Drug War and from a highly medicalized system of mental health care that requires people to defer to western-trained medical authorities to understand the nature of their suffering and which drugs are okay to take for it. From my collective body of work, I hope people will begin to interrogate for themselves taken-for-granted concepts, as simple as “what is medicine?”. We each must do the work of de-colonizing our own minds on the subject of drugs and medicines. For example, Do I believe that some substances are good and others are bad? Where do those beliefs come from? What is medicine – is it a pharmaceutical product only prescribed by a doctor? Is food medicine? Water? And as we enlarge our concept of what is medicine for people, then we can also ask the question: Who owns this medicine? Who owns healing? Who should have rights to access this and how?

Other places to connect:
Enduring Love Therapy
LinkedIn and Dr. Hughes’ website

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

Hilla Nehushtan is an Israel Institute Teaching Exchange Fellow in the Jewish Studies program at the University of Pittsburgh. She wrote her MA master’s thesis on women exiting commercial sex work. Her Ph.D. is from the Hebrew University of Jerusalem, where she investigated the social constructs of weight loss surgeries.

What is your article “The Ethical Work of Weight Loss Surgery: Creating Reflexive, Effortless, and Assertive Moral Subjects” about?

The article discusses some moral issues surrounding higher-weight bodies and their portrayal in consultation sessions between bariatric professionals and patients. I suggest that bariatric surgery becomes a site of a “moral breakdown” (the supposed immorality of people allowing themselves to get “this big”), where professionals advise patients to recuperate through minor everyday moments of experimentation with ethics. Drawing on ethnographic inquiry in a bariatric clinic, I argue that this moral recovery is made in three ways: First, patients are advised to “listen to their bodies” and to reconnect to their embodied sensations. They are further guided to imitate a “thin state of mind.” And finally, they are instructed to “put themselves first” by reorganizing their family and work responsibilities. While these instructions consonant with the common cultural ethos of self-discipline and self-control, they expand and, at times, undermine these notions and contest elements of fat stigma.

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

I am a medical anthropologist interested in health and illness and how these issues interact with cultural and social constructs. I also explore gender inequality, primarily body size issues and how the overweight body is perceived and experienced. Today I am an Israel institute teaching exchange fellow and enjoy developing and teaching various courses about gender, body size and health and illness at the welcoming and thought-provoking Jewish studies program at the University of Pittsburgh. I am a passionate qualitative researcher enthusiastic about unmediated encounters with interlocutors.

What drew you to this project?

When I started contemplating this topic for my research, I was fascinated and shocked by the countless stereotypes associated with larger bodies that had never even occurred to me. For instance, a former colleague told me she did not hire the service of a big-bodied Doula because she felt this woman could not have positive relations with her own body. The more I delved into this issue, the more I found its cultural and social constructions intriguing. Furthermore, it is a broad topic that includes numerous dimensions of daily lives: the way larger-bodied people are treated by their family and peers; the discrimination against larger-bodied people in the workplace and the fashion industry; the way people are judged while eating in public; the ways children and adolescents are socialized to dislike their bodies; the evergrowing diet industry that shames larger-bodies, and of course, the biomedical point of view and its influences all of the above. I feel like this is a topic that deserves more nuanced attention.

What was one of the most interesting findings?

The most interesting and surprising finding was how the weight loss professionals’ messages empowered patients. While often medical professionals’ statements are interpreted by critical literature as oppressive and disciplined, the fact that women were encouraged to pass some of their responsibilities and housework to other family members, and take time to eat well and care for themselves, even temporarily after surgery, was experienced by them as empowering and well deserved. Medical professionals legitimized taking a break from daily responsibilities at work and home, encouraging patients to care for their bodies and selves. This was particularly meaningful for women, who are often responsible for house work and child care.

Furthermore, I found that prodessionals frame the reason for larger bodies as derived from constantly putting others first,and not taking care of themselves in terms of healthy eating and bodywork. This, I argue, subverts fat stigma. It diverges the blame for obesity from lack of control or gluttony.

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

I recently read (or listened to, more precisely) the book “Hunger: A Memoir of (My) Body “by Roxane Gay. This book is a disturbing and fascinating documentation of her life story, which is often sad and painful. In the book, she emphasizes life with a body size that is considered much larger than average. She describes her physical and health difficulties, but mostly the social challenges of living with a larger body. The book evokes a lot of empathy and enables a deep understanding of her life as a successful award-winning author on the one hand and a person with many daily struggles on the other. I highly recommend it.

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

A more nuanced listening to interlocutors’ experiences, whether patients or medical professionals, even within critical literature, can benefit our understanding of patients and professionals. Such listening can open new possibilities for a deeper insight into people’s motives and interpretations of these procedures and allow a better understanding of medical professionals who also sometimes struggle to negotiate and rationalize these procedures for themselves.   

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

Mille Kjærgaard Thorsen holds a position as Assistant Professor at the School of Social Work and at the Research Centre for Health and Welfare Technology both at VIA University College. She obtained her PhD from the Department of Anthropology at Aarhus University in 2019.

What is your article “Under Pressure: Living with Diabetes in Cairo” about?

The article examines ethnographically the topic of type-2 diabetes in Cairo, Egypt. It depicts two different prevailing understandings of what causes the condition among those living with it and their healthcare providers. It shows how those diagnosed with type-2 diabetes primarily relate their condition to experiences of ḍaghṭ, translated as “stress” or “pressure,” whereas their healthcare providers primarily relate the condition to matters of obesity. The article exemplifies these different understandings of type-2 diabetes by drawing on the topic of food. It argues that whereas those diagnosed with type-2 diabetes relate issues of food scarcity and insecurity to their condition (specifically to the ḍaghṭ brought on by such scarcity and insecurity), their healthcare providers relate an excess consumption of food and calories to the condition. Overall, the article shows how transnational policies, markets and research interfere with the physiology of bodies – manifesting in ailments such as type-2 diabetes.

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

I worked as a healthcare assistant in a nursing home and at a hospice during my first formative years as an undergrad student at the Department of Anthropology at Aarhus University. This drew me to the field of Medical Anthropology during my grad and post-grad years. Since finishing my PhD in 2019 (the article above is based on research I conducted as part of my PhD), and through the last couple of years as an Assistant Professor at the School of Social Work in Aarhus, I have grown particularly interested in issues of inequity in relation to healthcare issues. During my PhD I was especially interested in exploring the notion of (mis)trust in relation to such issues; this theoretical interest has more recently evolved into a focus on the relations of (mis)trust, empathy and ethics more broadly.

What drew you to this project?

I have always been keen to learn different languages and decided during my undergrad that I would devote six months to studying Egyptian Arabic in Cairo before resuming to grad school. Of course, I fell for Egypt; its people, history, culture and language. When forming my PhD project several years later I knew from my time in Egypt that the prevalence of type-2 diabetes within the country was as high as, for example, in Denmark, however little research had been conducted locally in regards to understandings and treatment paths in relation to the condition. I also discovered that the Danish-founded medical company Novo Nordisk was quite vested in diabetes care and prevention strategies within the public healthcare system in Egypt, which further drew me to examine the global and local intersections of type-2 diabetes within the country.

What was one of the most interesting findings?

One of the most interesting findings of my overall PhD project (the above article touches upon this briefly) is the fact that ḍaghṭ (translated as “stress” or “pressure”) is in fact biomedically acknowledged as a risk factor of type-2 diabetes; however, it is was not acknowledged in medical practices in Egypt or in Denmark throughout my research. Put differently, certain etiologies of type-2 diabetes transformed into medical practices and others did not. These findings raised the subsequent questions of 1) why this happens, and 2) what we potentially overlook that could make a difference in succeeding with diabetes treatment and prevention strategies within Egypt and within the region at large?

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

Staying on the topic of Egypt: I am halfway through Alaa al-Aswany’s “I ran to the Nile” which depicts the time of the uprisings in 2011. It is simultaneously beautiful and painful, but also full of humor and warmth.

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

To apply the fact that diabetes care and prevention cannot solely take place in a doctor’s office or through treatment targeting individual bodies – it should also take place in the offices of those who form national and transnational policies that affect the conditions in which those individual bodies exist.

Other places to connect:
Website
LinkedIn

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

Fahimeh Mianji (Ph.D., R Psych) is a transcultural clinical psychologist and global mental health researcher in the Division of Social and transcultural Psychiatry, McGill University. Dr. Mianji’s research is on globalization of American psychiatric diagnoses and treatments; sociocultural, structural, and political determinants of mental illness; and access and barriers to mental health services for refugees and immigrant populations. As a clinical psychologist, she currently works with minoritized populations in Quebec and British Colombia.

What is your article “Women as Troublemakers”: The Hard Sociopolitical Context of Soft Bipolar Disorder in Iran” about?

Despite the promising trend of women’s health in Iran over the past four decades, there is still a significant difference between women and men with respect to mental, physical, and social health. Among women’s burden of disease, psychological disorders ranked first in this country. We used multi-sited focused ethnography and archive analysis to explore the sociocultural and political dynamics of the over-use of bipolar spectrum disorder (BSD) diagnosis among women in Iran. The dominant biological psychiatry system in Iran has led many psychiatrists to frame sociopolitically and culturally rooted forms of distress in terms of biomedical categories like soft bipolarity and to limit their interventions to medication. This bioreductionist approach silences the voices of vulnerable groups, including those of women, and marginalizes discussions of problematic institutional and social power. To understand the preference for biomedical explanations, we need to consider not only the economic interests at play in the remaking of human identity in terms of biological being and the globalization of biological psychiatry, but also the resistance to addressing the sociocultural, political, and economic determinants of women’s mental suffering in particular contexts.

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

I am a clinical psychologist and global mental health researcher. My clinical work is influenced by my training in transcultural psychiatry at McGill university where ecosocial, anti-oppressive, and community-based perspectives to individual’s mental wellbeing are promoted in both research and clinical domains. My published works focus on the vicissitudes of Bipolar Spectrum Disorder diagnosis and treatment in Iran, medicalization of women’s social and political conflicts in Iran, and cultural and linguistic barriers to access mental health services among refugees and immigrants in Quebec.

What drew you to this project?

When I was a psychology graduate student from 2006 to 2008, I noticed that my psychiatry and psychology professors and colleagues spoke passionately about finding features of “bipolarity” in their patients. And, over the subsequent few years, this diagnosis has become so common that a group of psychiatrists who disagreed with the dramatic increase in bipolar diagnosis started calling their colleagues, “bipolar-minded” psychiatrists. The term “bipolar-minded psychiatrist”—that is, a psychiatrist who looks at everyone through bipolar glasses—has become a popular professional label in Iran. It was at about the same time that I noticed a related jargon of “bipolarity” was being used by friends and families as well. But in this case, it was more than just talking about their bipolarity as a metaphor for emotional ups and downs; it was lay people, mostly women, talking about taking mood stabilizers and antipsychotic medication as easily as taking acetaminophen for the common cold! It appeared the professional embrace of bipolarity was penetrating far into society to affect everyday discourse about emotional distress and the ways that people handled such problems. So, in a way, my first idea for this study came from my experience as trainee in psychology and an observer of the ongoing emergence of new psychiatric disorders. Since then, I have developed a broader interest in the anthropology of psychiatry and in the cultural analysis and critique of the institutions and practices of psychiatry itself.

What was one of the most interesting findings?

To me, understanding how psychiatric institutions can collude with the political and ideological agendas in oppressing voices (particularly youth’s and women’s) that confront the sociocultural and structural factors involved in the violation of individual’s rights and freedom was an interesting finding of this study.

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

In the past two months, I have spent most of my spare time on reading and watching how young women and youth in Iran are using their great energy of injustice anger to break down the walls of a patriarchal and oppressive state; and how these people enact their agency through repositioning their bodies in a society where the state has practiced his power through controlling women’s bodies for over four decades. The videos and stories of the current feminist revolution in Iran as well as people’s resistance and hope are great means for reorienting my research and clinical knowledge, my values, and my first-hand experiences as a woman who had to work hard to protect her beliefs over “knowing what she knows” in the context of a patriarchal and oppressive political, social, and cultural climate in Iran.

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

As mental health clinicians and researchers, we must not forget that our responsibility is to be invested in truth and to protect our patients from the social, cultural, and structural defects instead of colluding with the rigid and oppressive institutions through normalizing and individualizing such defects which affect people’s wellbeing on different levels.

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

Mattias Strand, M.D. Ph.D, (Region Stockholm & Karolinska Institutet) is a post-doctoral researcher at the Centre for Psychiatry Research at the Karolinska Institute and senior psychiatrist at the Transcultural Centre in Stockholm, Sweden. His main research areas are cultural psychiatry, medical humanities, trauma, and eating disorders.

What is your article “Could the DSM-5 Cultural Formulation Interview Hold Therapeutic Potential? Suggestions for Further Exploration and Adaptation Within a Framework of Therapeutic Assessment“ about?

Our paper is about the so-called Cultural Formulation Interview (CFI) in the DSM-5, which is a person-centered clincial tool for assessing and discussing the importance of cultural issues in health and illness with your patient—a kind of “mini-ethnography” if you will. In the paper, we discuss how the use of the CFI could be further developed by applying a Therapeutic Assessment approach. In brief, Therapeutic Assessment is a collaborative approach to psychological assessment in which the assessment procedure itself is meant to induce therapeutic change. This is achieved by explicitly focusing on the particular questions and queries that patients have about themselves with respect to their mental health or psychosocial well-being, rather than on those issues that the clinician is primarily interested in. We do not offer any definitive answers on how to integrate these models but hope to further the discussion of a therapeutic potential of the CFI.

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

I am a psychiatrist and a postdoctoral researcher based in Stockholm, Sweden. I work at the Transcultural Centre, which is a public health resource centre for issues related to migrant health and cultural psychiatry run by Region Stockholm. Before that, I worked for many years as a psychiatrist at the Stockholm Centre for Eating Disorders, which is one of the largest specialist services for eating disorders in the world. Eating disorders are still very much a main focus of my research—my postdoctoral work is about eating disorders in migrant populations and experiences in treatment in these groups.

What drew you to this project?

I was actually introduced to the Therapeutic Assessment framework by a patient of mine a few years ago, and although I am certainly not an expert in that field I see clear similarities to the concept behind the Outline for Cultural Formulation and the CFI in the DSM-5 that I thought would be interesting to explore.

What was one of the most interesting findings?

To me, one of the most interesting similarities between the CFI and Therapeutic Assessment that we stumbled upon in our exploration is that they both start from what we call a “second-person perspective”, in contrast to a narrative first-person perspective or a supposedly obejctive third-person clinician perspective. The second-person outlook acknowledges that in any clinical encounter, or pretty much any situation in which there are two or more people involved, there are inherent limits to how much we can understand about ‘‘the Other’’—100% empathy can never be achieved.

Rather than mere analogy between the world of the clinician and that of the patient, this perspective presupposes difference that cannot fully be overcome. Importantly, however, instead of resignation, these limits of empathy call for greater efforts in jointly exploring the patient’s world and co-constructing meaningful understanding. All of this may perhaps sound self-evident, but in my experience it is very rarely an explicit starting point in psychiatric assessment.

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

I am reading an old Swedish book on icons in the Russian Orthodox church. I am mostly watching various rock climbing videos on YouTube and trying to catch at least one movie at the Stockholm International Film Festival this month.

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

I would hope that the fields of cultural psychiatry and Therapeutic Assessment, which are now fairly distant, could learn from each other. Not least, there are a lot of case studies describing the use of Therapeutic Assessment in situations in which the cultural backgrounds of the patient and the therapist differ in important ways, and I just wish that therapists working within a Therapeutic Assessment framework would also discover the CFI and incorporate it as part of their toolbox.

Thank you for your time!

Other places to connect:
Website
Transkulturellt Centrum
LinkedIn

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

Mar Rosàs Tosas is a full-time lecturer at Blanquerna School of Health Sciences at Ramon Llull University, Barcelona, Spain.

She specializes in how illness narratives are shaped by (and reproduce) mainstream economic, political and cultural logics at stake in that context. She previously coordinated the research on applied ethics of Ethos Chair (Ramon Llull University, Barcelona, 2014-2022) and was the editor in chief of its Ramon Llull Journal of Applied Ethics, was a full-time lecturer at the Department of Romance Languages at the University of Chicago (2012-2014), and held a doctoral scholarship at Pompeu Fabra University (Barcelona, 2008-2011).

What is your article “Interrupting Patients in Healthcare Settings: What is Being Interrupted?” about?

Scientific literature since the 1980s examines the phenomenon of healthcare professionals interrupting patients: at which second patients opening expositions are interrupted and how long they take if unrestrained. Although the goal of this literature is strictly numerical—determining interventions’ length—, it reveals several its authors’ views and preferences. Our discourse analysis reveals, first, that, often in between the lines, this literature suggests reasons for letting patients speak freely and tries to dismantle the myth of the overly-loquacious patient. Second, by turning to some philosophical inquiries into the notion of ‘‘interruption,’’ we explore how, within this literature, the ultimate reason for interrupting patients and silencing several of their concerns is often the fear of a certain medical logic being interrupted—a logic that dates back to Vesalius and Bichat, and that informs nowadays biomedicine: patients’ speech is valuable as long as it contributes to a diagnosis in the form of the identification of an underlying tissue damage. This literature presents the interruption of patients as a device of claiming power on the part of an eminently biomedical approach to illness. The paper provides further reasons for not interrupting patients proposed by the biopsychosocial model, ‘‘narrative medicine,’’ and anthropologists who study the functions of illness narratives.

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

I specialize in how illness narratives are shaped by (and reproduce) mainstream economic, political and cultural logics at stake in that context. I hold a PhD in Philosophy in the role that the Jewish messianic tradition plays in philosophy of Jacques Derrida and other contemporary philosophers, such as Rosenzweig, Lévinas, Taubes, Agamben, Badiou, and Zizek.

What drew you to this project?

The frequency with which patients complain that physicians do not listen to them, as well as the training physicians receive to conduct patients’ interviews (which, in my view, all too often does not allow them to become better listeners, but worse listeners).

What was one of the most interesting findings?

 My review of the existing literature since the 1980s on how and why patients are interrupted allows us to conclude that there have been no major changes since then: even those who advocate for listening more to patients seem to suggest that this extra attention is necessary in order to guarantee that the healthcare professional does not miss any ‘‘useful’’ information for diagnosis or in assessing the effect of a previously prescribed treatment. This clashes with the trends in medical humanities in the last four decades that value patients’ speech and narrative for several reasons beyond the contribution to a diagnosis. Within this literature, the ultimate reason for interrupting patients and silencing several of their concerns is often the fear of a certain medical logic being interrupted—a logic that dates back to Vesalius and Bichat, and that informs nowadays biomedicine: patients’ speech is valuable as long as it contributes to a diagnosis in the form of the identification of an underlying tissue damage.   

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

The last book that I read was Idaho by Ruskovich.

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

Don’t be afraid to listen to everything your patients want to say. Your schedule will not collapse. And your work will be clinically and morally better.

Thank you for your time!

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

Sydney Silverstein is an Assistant Professor at the Center for Interventions, Treatment, and Addictions Research/Department of Population & Public Health Sciences, Boonshoft School of Medicine. She is an anthropologist and filmmaker with a mixed-methods, multimedia research practice. Her scholarship explores the diverse social worlds that come together around the production, circulation, and use of illicit drugs. She conducts research in both Peru and North America.

What is your article “‘Visualizing a Calculus of Recovery: Calibrating Relations in an Opioid Epicenter” about?

This article uses participatory visual methods (photo elicitation) to explore barriers to, and motivators for recovery from drug addiction among a group of people with opioid use disorder living in Dayton, Ohio, an epicenter of overdose death.

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

I came to anthropology later in life – I was nearly 30 and working full-time at a non-profit when I took my first anthropology class at a community college. But after that I was hooked! I have pretty diverse research interests, but mostly I love the research practice of being an anthropologist. Being employed at a medical school—and often the only person advocating for qualitative, let alone ethnographic methods to be incorporated into research design—I have only come to appreciate my training more. For me, there is no substitute for the holistic approach that anthropology brings to studying the human experience.

What drew you to this project?

I got interested in this project because I was trying to carve out a space for my visual and ethnographic research praxis amidst my work on a study that was much more straightforward public health. As an anthropologist, I often felt limited by the kinds of insights I could gather from a one-time qualitative interview. I was constantly trying to figure out ways to develop relationships I was building with participants in the longitudinal, federally funded study that I had been hired on to as the project ethnographer. I thought that the photo-elicitation project would be a good excuse to follow up with some of the study participants that I found interesting and learn more about their worlds.

Another special thing about this project is that my co-authors included three undergraduate students who worked with me as part of a virtual internship over the Summer of 2020. Because I work in a medical school, I don’t often have contact with undergraduate students, but when COVID hit I saw a post from a colleague asking if anyone new of virtual internship opportunities for students who were now unable to complete their summer plans due to the pandemic. So, I created one, and very much enjoyed collaborating with these outstanding and highly motivated students even though we have not, to this day, ever met IRL!

What was one of the most interesting findings?

The profound ambivalence of things in the context of recovery. For instance, I have heard people tell me how their children have been a huge motivator in their recovery, but just as often (perhaps more) participants described how a deep sense of shame over losing custody of their children kept them in their addiction. Same with money. In early stages of recovery, participants described feeling helpless when they did not have enough money to buy a bus pass to get to work, or pay rent, but others told me that they were petrified to start earning money, and especially to have cash in their pocket, lest they get the urge to use and have the resources to do so.

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

I keep track of the all the books I read each year on the last page of my planner, so my book list is available upon request – ha! One of my favorite books that I read this year is called Hostal Amor, by Cayo Vásquez, although this may only appeal to those who have spent time in the beautiful city of Iquitos. I have a long commute, so I listen to a lot of podcasts—All the Smoke, Radio Ambulante, El Hilo, Fresh Air, Ear Hustle, and Mad in America are in the heavy rotation.

As for moving pictures, I just finished the last season of Atlanta and am kind of at a loss for what to watch next. I think that the third season of Atlanta (when Paper Boi is on tour in Europe) was some of the best TV I have ever seen. For now, I’m mostly watching NBA basketball. It is frustrating because I have League Pass, which lets me watch all the games except the ones that are broadcast locally, but my local team (the Cavaliers) are really, really good. But I refuse to get cable just to have Fox Sports!

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

Just how hard and all-encompassing recovery can be. I think that this is not unique to recovery from addiction, but there are consequences that people who use drugs suffer more so that people dealing with other kinds of chronic illnesses. For instance, the fact that so many people who use drugs over a long period of time end up entangled in the criminal justice system makes recovery about a lot more than reckoning with one’s relationship with a substance. Many times, you are also trying to navigate the world with a felony on your record, a wrecked credit score, no employment history, etc. It’s just a lot to deal with, and I think it is hard to understand unless you have direct experience. And treatment centers don’t often help with this. Their goal is to help an individual stop using drugs, but recovery is much more than that. The good news is that there is a growing movement to incorporate peer supporters—individuals with direct, lived experience—into treatment and recovery systems, which I think is a step in the right direction. Shout out to all the amazing peer supporters in Montgomery County who have given me hope during dark times.

Other places to connect:
Wright State University

The next few months we’ll be highlighting authors who are in the December 2022 issue of Culture, Medicine, and Psychiatry.

Dr. Ronita Mahilall is a PhD at Stellenbosch University, the CEO of St Luke’s Combined Hospices and a Research Fellow at NIH, Clinical Centre, Bethesda, Maryland, USA.

Professor Leslie Swartz is a Distinguished Professor of Psychology at Stellenbosch University and Editor-in-Chief at both the Scandinavian Journal of Disability Research and the South African Journal of Science.

What is your article “‘I am Dying a Slow Death of White Guilt’: Spiritual Carers in a South African Hospice Navigate Issues of Race and Cultural Diversity” about?

This article focuses on the complex and painful question of whiteness in relation to spiritual care in a diverse country.  We show that volunteer spiritual counsellors working at a hospice in Cape Town, South Africa are acutely aware of and sensitive to issues of diversity and privilege when engaging with clients from a range of backgrounds. Though South Africa has been a nonracial democracy since 1994, the long shadow of apartheid and continuing inequality profoundly affect contemporary palliative care.  Our participants discussed the ways in which they work to create common ground and inclusion, but also how they acknowledge and continue to struggle with challenges related to difference and privilege. In health care work, cultural competence is commonly trumpeted as the solution to working with difference and inequality; our participants show that the issues are not just questions of competence or knowledge but include deeply felt emotional responses to inequality.

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

Ronita Mahilall: I am a social worker by training and my career trajectory focused on health and disability. I am the Chief Exec Office of St Luke’s Combined Hospices (SLCH) and came to this work with an established and personal interest in spirituality. Reviewing the palliative care programmes and interventions that are offered by the Inter-Disciplinary Team (IDT) at SLCH, I have noted a significant absence of formal guidelines that shape spiritual care interventions. For a long time in my organization there was a felt need to develop a national spiritual care curriculum which I learned from many discussions with members of the IDT, and with hospice management. This led me to ask the questions: what are the current spiritual care practices within hospice palliative care settings in SA? What are the spiritual care training needs of hospices in SA? Is there a need to develop a national curriculum for spiritual care intervention? To ask those questions, I needed to establish if there is in fact an appetite, wider than expressed at SLCH, for such a curriculum. 

Leslie Swartz: I have spent much of my career thinking about the politics of culture and mental health, and about access to services and participation by people who are marginalized.  One of the first articles I ever published, in 1985, was on race, politics, and mental health care in apartheid South Africa – this was my first publication in Culture, Medicine and Psychiatry.  There is for me a direct line from that publication of 37 years ago to this article, in which we show that the concerns I raised in the apartheid context have not magically disappeared with the end of apartheid. For me, one thing which tends to distinguish South African mental health researchers from those from countries in the global north, is how embedded we are in thinking about racial and class privilege and how this affects every aspect of our work, including work we do to change things for the better

What drew you to this project?

Ronita Mahilall: My fascination with spirituality was heightened after the loss of my beloved husband and son in 2007; five months apart from each other. While they did not suffer from any longstanding terminal illness, having experienced such deep losses left me questioning life, and death, and the after-death phenomenon. Being a devout Hindu, I am also a believer in reincarnation; yet I found that religion alone did not provide me with the broader existential answers I was seeking. With that as a backdrop and having joined St Luke’s Combined Hospices (SLCH) as CEO, I was introduced more meaningfully to palliative care work, and more in-depth to the spiritual care services offered. I was struck by the scale and scope of the spiritual care services on offer. I was somewhat saddened that, as I and others saw it, spiritual care was not recognised and prioritised as it deserved to be. I was impressed by the work of the spiritual care team at SLCH, and by the spiritual care services provided by other hospices in the Western Cape, and hospices throughout SA. I became interested in questions of why spiritual care services were not given the prominence and recognition that spiritual carers and others in my organization believed they deserved, as part of the overall palliative care service package. Through this research project, I set out to understand how spiritual care is practiced in hospices in SA and crucially if there is a need for a national spiritual care training curriculum. This was accomplished through a three-tiered study.

I was grateful to have in Leslie Swartz a supervisor who is not only an accomplished academic but someone who has an intimate knowledge and firsthand experience with and of death, dying and issues of palliative care and spirituality. Under his mentorship and guidance not only did I grow as an academic, but I also grew emotionally.

Leslie Swartz: This paper comes out of the PhD work of Ronita Mahilall, the first author. Ronita is CEO of the largest hospice organization in Cape Town. I became interested in palliative care through my experiences caring for my mother while she was dying. I have described these experiences in my memoir How I lost my mother (Wits University Press, 2021) – the hospice which Ronita heads was central in helping my family through this process, and after my mother died, I started doing bits of work for the hospice as a way of trying to pay back. Part of this was agreeing to supervise Ronita’s PhD. I honestly did not realise when I started working with Ronita that our work together would lead me back to considering the same issues of privilege and exclusion in health and social care which have preoccupied me throughout my career. I was very lucky to work with Ronita on this.

What was one of the most interesting findings?

Ronita Mahilall: Complex issues of privilege and power, and the emotional effects of these, do not disappear – they are with us always. We need to continually shine a light on these issues and unpack them as they present themselves. 

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

Ronita Mahilall: Alice in Wonderland by Lewis Carroll. It’s my 8th read. I love how I take away something different each time I read it. Reading it now with the hindsight of my PhD work is almost like a spiritual journey to a form of wisdom and understanding and more critically I realize that my work on this subject is not over yet. I have accepted an offer to undertake a 2-year post-doctoral fellowship at National Institutes of Health, Clinical Center (NIH), Bethesda, USA where I seek to advance my work on this subject. This takes place in December 2022.   

Leslie Swartz: I have just started following a wonderful podcast called The Academic Citizen, curated by two South African academics, Nosipho Mngomezulu and Mehita Iqani (available on Apple Podcasts and elsewhere) – a fabulous example of science communication and centered academic citizenship – well worth checking out!

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

Ronita Mahilall: Never think that difficult social problems are ‘solved’- everything is a complex and challenging work in progress!

Thank you for your time!

Other places to connect:
LinkedIn
St. Luke’s Combined Hospice