From the Archive: “A Mother’s Heart is Weighed Down with Stones”

Posted by sonya.petrakovitz

In our “From the Archive” series, we highlight an article from a past issue of the journal. In this installment, we explore Sarah Horton’s “A Mother’s Heart is Weighed Down with Stones: A Phenomenological Approach to the Experience of Transnational Motherhood,” available here. This article was featured in Volume 33, Issue 1 (March 2009).

While there is still considerable confusion and uncertainty surrounding the current state of immigration in the United States and the international movements of people, our journal article authors have continually acknowledged the importance of focusing on the lived experience of individuals within these larger political contexts. In her article, Horton discusses transnational motherhood through the embodied distress of mothers and children, showing that their suffering cannot be examined separately. Through her analysis of the narratives of undocumented Salvadoran mothers living in the United States, Horton explains the pain of these mothers’ undocumented status is experienced within the intersubjective space of the family.

Horton begins by describing Elisabeta, a Salvadoran mother working in the United States while her young son and elderly mother remain in El Salvador. Elisabeta was part of Horton’s research at a Latino mental health clinic in a New England city. Since Elisabeta was unable to hold or touch her young son, Carmelo, she instead carried his photo with her wherever she went. Elisabeta described her life as divided, “I work here but my heart lives there.” This division of “here” and “there” in transnational motherhood is not uncommon for undocumented immigrants who left their children in their home countries.

As the postindustrial, technology-based economy has grown within the U.S., women are increasingly migrating alone to find work in the high-tech sector, reshaping the immigrant family and trans-nationalizing the meaning of motherhood. At the same time, the 1996 Illegal Immigration Reform and Immigrant Responsibility Act (IIRIRA) increased both border policing and militarization as well as deportation and family separation in border communities. This meant that mothers working in the U.S. have found it more difficult to be reunited with their children, fearful of the dangerous and expensive crossing for their undocumented children, and the inability of the women to return home to visit. Thus, while many women had originally imagined their separations would be only temporary, the transnational relationship between mother and children can last years.

Horton explains that even though family separation has long been a reality for immigrants, scholarship has often ignored this lived experience as an independent factor of stress and trauma. Further, mental health analyses are frequently positioned at the individual level, and neglect the larger context of how such familial changes and separations are experienced and endured in the inter-subjective space between parents and children. Elisabeta described the aching in her chest when she would speak to her son on the phone each weekend. Later, when her son became seriously ill, Elisabeta felt an acute sense of failure – as both a mother unable to care for her ill son, and as a provider unable to pay for the operation he needed. Elisabeta was often unable to sleep at night, surrounded by thoughts of Carmelo’s words and tears. Horton explains Elisabeta’s vivid narrative expressed her embodied distress of being a transnational mother and the relational nature of the family’s suffering.

Gloria, another immigrant from El Salvador, left to find better economic opportunities after a series of devastating earthquakes in her home town. Gloria decided to leave her birthplace after it had become a space of death and scarcity, and the small business she and her husband had established had been destroyed. “There wasn’t enough food to give the kids. There was no way for me to keep them alive. And so I came here,” she said. For Gloria, and other women Horton interviewed, traumatic events reshaped familiar places and people, and triggered their decisions to migrate. Further trauma of the women having to explain their departures to their children were overwhelming.

The paradox of parenthood for these mothers is often having to choose between either financially supporting their children from a distance or physically being their caretakers. Horton explains that these parents have a profound sense of moral failing, perceiving that their inability to serve as “proper parents” is compounded by the difficulties of succeeding economically. Horton argues that placing these issues of “choice” and “decision making” against the backdrop of limited agency and “illegality” in the U.S. causes the parents’ immobility and powerlessness to reverberate through the space of a family stretched across international borders.

Children left behind in El Salvador often shoulder adult burdens, attempting to either prevent their mothers’ departure or requesting to join their mothers on the dangerous journey to the U.S. According to Horton, when the realization of the uncertainty in their separation becomes overwhelming, children respond to what they perceive as their mothers’ withdrawal of love with their own form of withdrawal. “My daughter then told me she had erased me from her heart, and that she didn’t love me anymore,” Gloria recounted. “El corazon de madre es un monton de piedras.” (“A mother’s heart is weighed down with a mountain of stones.”) This “weighing-down” is the burden Gloria had assumed in suffering the anger of her children while she only wished to protect them from hunger. Horton explains Gloria’s narrative demonstrates that suffering is relational, experienced through social connections and threats of uncertain future relationships. Horton says this transnational separation strains the bond between mother and child, as their distance is experienced both physically and emotionally.

Horton discusses strategies these transnational mothers undertake in order to attempt to substitute their parental presence. One strategy of sending gifts and luxury items, such as a color T.V. or special toys, is a way of feeling as if they are giving their children love and support. Yet this happiness from the fulfillment of financial support is temporary, and quickly overshadowed with sadness as children will often ask when they will be reunited again. Both the mothers and children know the gifts are double-edged, symbolizing the mothers’ love yet justifying their absence.

Horton concludes by calling for researchers to bridge the gap between subjective experiences of families living with separation and objective analyses of structure “illegality” and immigration policies. In hoping for more phenomenological accounts of transnational family life, Horton shows how sociopolitical inequality shapes individual experience and produces patterns of social suffering. She also places transnational mothers’ distress within a larger framework of social conditions that reproduce powerlessness and disadvantage. The sophistication of phenomenological approaches illustrates the ways that undocumented immigrants may experience embodied stress of strained family ties.

Interview: Jonathan Sadowsky and “Electroconvulsive Therapy in America”

Posted by sonya.petrakovitz

This week on the blog we’re highlighting an interview with Dr. Jonathan Sadowsky about his new book Electroconvulsive Therapy in America: The Anatomy of a Medical Controversy, released November 2016 by Routledge. The book (available here) follows the American history of one of the most controversial procedures in medicine, electroconvulsive therapy (ECT), and seeks to provide an explanation of why it has been so controversial, juxtaposing evidence from clinical science, personal memoir, and popular culture. ECT is widely demonized or idealized. Some detractors consider its very use to be a human rights violation, while some promoters depict it as a miracle, as the “penicillin of psychiatry.” Sadowsky contextualizes the controversies about ECT, instead of simply engaging in them, making the history of ECT more richly revealing of wider changes in culture and medicine. He shows that the application of electricity to the brain to treat illness is not only a physiological event, but also one embedded in culturally patterned beliefs about the human body, the meaning of sickness, and medical authority.

Dr. Sadowsky is the Theodore J. Castele Professor of Medical History at Case Western Reserve University in Cleveland, OH, the Associate Director of Medical Humanities and Social Medicine, the Medical Humanities and Social Medicine Initiative co-founder, the Associate Director of Medicine, Society, and Culture in the Bioethics department of the Case Western Reserve University School of Medicine, and on the Editorial Board here at Culture, Medicine, and Psychiatry. Sadowsky’s research concentrates largely on the history of medicine and psychiatry in Africa and the United States. His previous publications include Imperial Bedlam: Institutions of Madness in Colonial Southwest Nigeria (1999), available here from the University of California Press.

From all of us at CMP, we hope you enjoy our new interview category!

For someone who is thinking about reading your book or about to start, is there anything you would like them to know beforehand?

I would urge everyone to understand that not everybody’s experience of a medical therapy is the same. People should be careful not to generalize from experiences they’ve had, or that loved ones have had, and assume everyone has had the same experience. People who’ve had bad experiences with ECT have criticized me for to wanting to pay attention to the voices of people who’ve had good experiences, and people who’ve have good experiences have wanted to say “oh sure that might have been true in the 1950s but everything’s fine now.” ECT has a complicated story. I have met people who have told me that this treatment saved their lives and that it did so with either none or only the most mild of adverse effects. Those people are very concerned to make sure that the therapy gets represented in positive light because there are so many negative depictions. At the same time I’ve heard from and spoken to people who say they’ve lost 20 points off their IQ after having this treatment, or who had huge gaps in memory, or that they know somebody who had killed themselves after an ECT treatment. And what I find a little bit puzzling still after all these years of working on this book, is the way people are so unwilling to see that other people might have had a different experience than their own. But it’s my feeling as a social and cultural historian that it’s my responsibility to take into account all voices. So that’s the main thing that I want people to know and think about, that experiences of this treatment do vary and people shouldn’t be too quick to generalize from their own experience.

How did you become interested in ECT?

I was already several years into my career as a historian of medicine, and in particular psychiatry, and had no knowledge of the treatment other than the images that many of us have from movies like One Flew Over the Cuckoo’s Nest. Images that it was a highly frightening and abusive treatment. I was a well-trained student of medicine and psychiatry and I didn’t know anything more than that. And then I began to hear stories, both from patients and from clinicians, about it being a valuable treatment and that was just so intriguing to me. So I began to look at some of the clinical literature and it was represented in almost completely the opposite way, as this safe, effective, humane treatment that’s been unfairly stigmatized. I felt like these were two completely distinct realities. It wasn’t so much that I wanted to reconcile them, but I just wanted to understand how views of this treatment became so bifurcated. And that became the central goal of the project: to understand why it became a controversy and have such strongly held opinions on either side.

What did you find most exciting to research and write about?

I worked on this project for a long time and one of the things that sustained me was that there are so many different angles to it. I was interested in learning about how it was used to treat homosexuals in 1950s, to see what the reaction of the psychoanalytic community was, and how it figured as a symbol for all that was worst in psychiatry in the antipsychiatry moment. And then there were all the debates going back to the inception of the treatment, ongoing continual debates about the extent of memory loss. Is it a serious problem? Is it a rare problem? These debates are still raging. All of this I found so intriguing. The history of ECT is also replete with ironies. Such as the irony that it was developed initially as a treatment for schizophrenia based on a hypothesis that schizophrenia has an inverse relationship with epilepsy. That hypothesis is no longer even believed in, and schizophrenia is not the main indication anymore, and yet it’s effective. That’s so weird and so seemly random! Another irony is that this treatment which become an icon for frightening medical treatment, and became almost like people’s haunting nightmare of how medicine could abuse you if you came into its clutches, was initially developed as a way to try to create a safer, less frightening treatment than chemical convulsive therapy. So it’s these layers of irony that I just found so interesting and kept me intrigued in the book.

Did you come across anything unexpected?

Yes, I did come across things that were unexpected. I found the gender politics to be very elusive. I found very little evidence for the idea that women were given ECT for simply protesting against their social role as housewives, which was promoted in another book on ECT. But it does appear likely that over the course of the treatment’s history more women have gotten it than men, and there is likely a gender politics to this. Minimally it may mean simply that more women are getting diagnosed with depression, and that’s the main indication. And we know that. The diagnosis of depression has predominated among women. There is a darker possibility, which is that women’s cognitive abilities haven’t been as valued, and so doctors have been more willing to use a treatment that might damage cognitive abilities on women than they were on men. I didn’t see any proof for that. But I think there were suggestive circumstances that might indicate that that played a role. In many realms of medicine, and this has been really well documented by historians, anthropologists, and sociologists of medicine, women’s complaints about medical treatments are more quickly dismissed than men’s complaints. So it’s quite possible that some of the complaints about memory loss, which have persisted throughout the history of this treatment, have been taken less seriously because they were so often voiced by women. I’m not arguing that women had more memory loss than men, but if they predominated in the treatment, and there were complaints about memory loss, it is plausible to suggest that perhaps there has been too much dismissal. I didn’t have evidence such as clearly sexist language in clinical reports that would strengthen a speculation like that, but one thing I do argue in the book is that the history of ECT is filled with doctors dismissing patient complaints of adverse effects. There are a number of ECT providers now, however, who are trying to be very sensitive to these complaints about memory and cognitive deficits following the treatment, but there still exists in clinical manuals the claim that serious memory problems are extremely rare, and that rarity really hasn’t been proven. So it remains a problem. The history of ECT treatment has shown a tendency to dismiss patient complaints about adverse effects, and this has not served anyone well. If anything, the tendency to dismiss complaints has worsened the stigma attached to the treatment. It’s understandable that some clinicians might feel some defensiveness for a treatment they feel is helpful and safe, but the dismissal of complaints of adverse effects has led to embittered patients and worsened the stigma. In a recent piece in The Conversation (available here), I argued that if we wanted to spell the stigma attached to ECT, it’s going to take more than attesting to its therapeutic efficacy. It’s going to mean we have to reconcile with its full costs.

Why was it important for you to try and remain neutral and not argue for or against ECT?

I’m not trying to presume objectivity. Everyone has a point of view. But I thought I could tell a more interesting story by taking a step back and making the controversy itself my study rather than becoming a disputant in the controversy. There’s some precedent for this. Didier Fassin, an anthropologist, did a book on AIDS in South Africa, When Bodies Remember (available here), in which he did the same thing; he tried to look at the structure of the controversy. He was trying to understand the medical controversy over HIV as an anthropologist, even though he did actually side more with one than the other. But I do argue in the book there are good reasons to attest to efficacy of ECT and it is a valuable part of psychiatry’s repertoire, that it has a place in medicine. But I also argue that there were good grounds for people to contest it and have fear of the treatment. I really try to resist the view, which is very common in clinical literature on ECT, that opposition to ECT is irrational. There are rational reasons for the resistance rooted in some of its historical uses, some of which were abusive, and rooted in the experiences of adverse effects. At the end of the book I lay it all out and I say exactly what I think about ECT after trying to look at it from a step back. I think it’s an invaluable part of psychiatry and could be very useful for many people. But I don’t think it should be used as a first or second resort; other things should be tried first because there are risks. I’m glad it’s there if I should ever need it, but I hope I never need it.

Would ECT be perceived differently if it didn’t treat the brain but some other organ?

Probably. In our society now, more than any other organ your brain is you. It is the seed of the self in our self-conception. I would go beyond that. The side effects do occur, without making any kind of representation about how common these problems are, but at least some people do experience permanent memory losses. I used a lot of patient memoirs in the chapter on memory as my source material. And as one of the memoirists wrote: We are our pasts. You lose your memory it’s like you lose a part of yourself. I think in some ways people feel they lose a part of themselves if they lose their memories more than even if they were to lose a limb. Losing a limb is very traumatic, I don’t mean to minimize that. But in a way, you lose your leg and you say “I lost my leg.” It’s something that belongs to you, but it isn’t you in the same way that maybe you feel your memories are you. Memories are not just something that you have, they’re something that you are.

I think ECT is a treatment for the very ill and as a society we do generally accept that treatments for the very ill sometimes involve radical interventions. Chemotherapy for cancers for example. Most of us are glad we have it, and there isn’t a large anti-chemotherapy movement. My leading theory for why ECT treatment occasions this kind of resistance is because of depression’s uncertain status as illness. No one disagrees that cancer is an illness. When you have cancer you accept that you need surgery or radiation or chemotherapy. These are things that you normally wouldn’t do to your body if you were healthy and you didn’t need them. Cancer is clearly different from normal. But depression has this ambiguous status for two reasons. It is an ambiguous word in the English language because it refers both to an illness which can be extremely severe, yet it also refers to a mood that’s normal and that everybody at some point in their lives gets a little bit depressed. We might have disagreements about how long it has to go on and how severe it has to be to be considered an illness. But it becomes something different when we call it an illness. Secondly why I think depression’s status is a bit uncertain, is that there continue to be people who reject medical models for what we call mental illness altogether. Some might believe what people need is talk therapy and they shouldn’t have drugs or shock therapies or anything like that. Some might believe that they don’t need any treatment at all; they might want to de-medicalize the entire thing. For example, for something to qualify as disease, there has to be some kind of lesion, or something physical that can be identified. Since we don’t have the means to do that with depression, it should be removed from the medical realm. I argue against this view. The idea that there has to be some kind of visual marker is arbitrary. I do think what we consider an illness is a social decision. But if you look at it historically and anthropologically, the idea that things we call madness are medical problems is pretty widespread. And in some ways having to have something be visually identifiable is buying into a lot of biomedical hegemony. I just don’t see why that should be the criteria for illness. Ultimately it’s a philosophical question. Most people in our society do accept that severe depression actually constitutes an illness category, but I think these kinds of ambiguities leave people unsure whether this is something worthy of very strong medicine. ECT is strong medicine. It’s a big decision to undergo ECT and it’s the right decision for some people. It’s a decision that shouldn’t be made lightly and shouldn’t be treated like a trip to the dentist.

Is there anything else you want to add?

I was really gratified by the number of anthropologists who read and used my first book on insanity in Nigeria, Imperial Bedlam (available here), and I would be thrilled if anthropologists gave this book the same attention. And I’d also like to add that Routledge says there will probably be a paperback within the next year and a half.

Book Release: Pearl’s “Face/ On”

Posted by sonya.petrakovitz

Image via The University of Chicago Press website

Coming April 2017 from The University of Chicago Press is Sharrona Pearl’s Face/ On: Face Transplants and the Ethics of the Other. This engaging exploration of face transplantation is the first comprehensive cultural study of the surgical procedure. Using bioethical and medical reports, media coverage, hospital records, personal interviews, and more, this interdisciplinary study discusses the significance we place on facial manipulation, facelessness, reconstruction, identity, and sense of self. Are our identities attached to our faces? If so, what happens when the face connected to the self is gone or replaced? This book will be of interest to medical and psychological anthropologists, bioethicists, medical professionals, those in the media and beauty industries, and cross-disciplinary scholars in the medical humanities.

To learn more about this upcoming release, click here.

About the author: Sharrona Pearl is an Assistant Professor at the Annenberg School for Communication and the Gender, Sexuality, and Women’s Studies Program at the University of Pennsylvania. She is a theorist of the face and body, gender and sexuality, disability and critical race theory, and cinema and media studies. She has explored the meaning of the face previously in About Faces: Physiognomy in Nineteenth-Century Britain, released in 2010 by Harvard University Press (available here), and is the editor of Images, Ethics, Technology (Routledge, 2016), the latest volume in the Shaping Inquiry in Culture, Communication and Media Studies series.

Special Issue 2016: The Clinic in Crisis

Posted by sonya.petrakovitz

To help kick off a new year of articles, books, and highlights, Springer is featuring the June 2016 special issue of Culture, Medicine & Psychiatry, The Clinic in Crisis: Medicine and Politics in the Context of Social Upheaval, as part of a larger group of Special Issues in Social Sciences. Each article in the special issue is available for free here until February 3, 2017.

Over the summer we spotlighted several original papers from this special issue:

Salih Can Aciksoz’s Medical Humanitarianism Under Atmospheric Violence: Health Professionals in the 2013 Gezi Protests in Turkey
Emma Varley’s Abandonments, Solidarities and Logics of Care: Hospitals as Sites of Sectarian Conflict in Gilgit-Baltistan
Elly Teman, Tsipy Ivry, and Heela Goren’s Obligatory Effort [Hishtadlut] as an Explanatory Model: A Critique of Reproductive Choice and Control

Each highlighted article discusses medical neutrality in areas of political conflict and how clinical space can be an extension of violence. While many clinicians strive to maintain an environment of safety and neutrality in the hospitals and clinics, the locations are routinely entangled with positions of violent local and international political struggles. The ethnographic accounts in each of the featured articles address the concept of “medical neutrality” – the ethical norm that medicine should be practiced impartially – in the context of conflict and social unrest, and suggest medical neutrality may work as a tool that is deeply cultural, social, and political.

Winter 2016 Blog Hiatus

Posted by jknopes

Dear readers,

In light of the winter holidays, the blog will be taking a brief break from new updates. Posts will resume in January 2017, under the direction of the new Culture, Medicine & Psychiatry Social Media Editor, Sonya Petrakovitz. We welcome Sonya into her new position and look forward to seeing the features that she will debut on the blog in the coming months.

As another year draws to a close, we would like to thank all of you for your continued readership and engagement with the journal and our social media.

Warm wishes,

The CMP Editorial Team

Article Highlight: Vol 40 Issue 4, Social Withdrawal in Japan

Posted by jknopes

The December 2016 issue of Culture, Medicine & Psychiatry is now available here. In this series of article highlights, we will explore publications included in the latest issue. This week, we present a highlight on Ellen Rubinstein’s article “Emplotting Hikikomori: Japanese Parents’ Narratives of Social Withdrawal” (which you can access here.) Rubinstein observes that there has been a flurry of public attention to hikikomori, a socio-medical condition typically experienced by young people that is characterized by increasing, marked social withdrawal.

Rubinstein notes that though there is a perception of hikikomori as a condition of isolation, parents of “hikikomori children” often crafted narratives about their children’s illness that suggested it had discernible stages, signs of progress, and possibility of recovery. These narratives engaged parents in the present, facilitating connectedness between hikikomori children and their families, and thus challenging the assumption that hikikomori is a condition of perpetual or crippling isolation. For instance, some parents at a support group for hikikomori children and their families stated that their children were more mature than others, as their time away from other people encouraged them to be meditative and thoughtful.

One mother, named Kawano-san, first described her son’s hikimori as a process of productive, but not permanent, isolation in an interview with Rubinstein. Kawano-san said that her son’s withdrawal might lend him an opportunity to step away from the social world, assess his future, and prepare for college after initially failing to pass university entrance exams. She felt certain that this period would be one of reflection and reassessment, before the son eventually entered university. Kawano-san also criticized the expectation amongst many Japanese families that children should be extroverted and talkative, instead saying that her son was not pathologically isolated but simply different. Eight months after this initial interview, Kawano-san was interviewed for the second time about her son’s condition. The son had not entered college as Kawano-san expected, but the mother had readjusted her narrative such that she began to acknowledge that path might not be viable for her son. She instead noted that her son could have a disability, or that he simply needed more time to process his feelings. Kawano-san ultimately accepted that her initial expectations did not match her son’s experience, and began to try new approaches to her son’s condition: like encouraging her husband and daughter to write birthday messages to him that might make him feel more welcomed and included in their family unit.

Rubinstein examines similar cases to Kawano-san and her son, finding that many families engaged in a process of narrative emplotment and un-emplotment of their children’s hikikomori. Their narratives thereby gave order or meaning to what otherwise seemed like an ongoing and static psychological condition. Alternatively, they situated their children’s experiences in other contexts: such as expected developmental and social growth, and the efficacy of biomedical interventions or support groups for the condition. Parents of hikikomori children were not inactive bystanders, but rather active interpreters of their children’s experiences and advocates of their unique individual needs. The parents learned to read their children’s condition and support them accordingly, complicating the notion that hikikomori is solely about individual isolation or inaction.

From the Archive: Patients-as-Syndromes in Internal Medicine

Posted by jknopes

In our “From the Archive” series, we highlight an article from a past issue of the journal. In this installment, we explore Robert A. Hahn’s piece “‘Treat the patient, not the lab’: Internal medicine and the concept of ‘Person,'” available in full here. This article was featured in Volume 6, Issue 3 (September 1982.)

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Throughout the history of the journal, our authors have turned the same anthropological gaze equally onto both biomedicine and other medical systems. As Hahn introduces this article, he states that the healer in all cultural contexts fashions medical and social truths together, such that the patient and patient body are reinterpreted (and potentially reordered) through medical treatment by the healer. Biomedicine, he states, also recasts illness in ways that alter the medical position of the patient. To understand how physicians of biomedicine engage with patients conceptually in this way, Hahn conducted an ethnographic study of four internists. As internal medicine is often characterized as highly rationalistic and thus emblematic of biomedical practice, Hahn argues, he states that understanding the internists’ perspectives may shed light more broadly on biomedicine as a particular method of envisioning illness and its relationship to the patient.

Hahn begins by positing that the nature of internal medicine as a profession itself is a form of interpretation of what constitutes the patient and body over which it has medical purview. Internal medicine does not focus on mental health (psychiatry) or on the internal visceral body (surgery.) Thus, the “body” it treats exists in relative isolation from the mind, yet is not a physical or functional body such as the one manipulated directly through surgery. The conditions internists treat exist apart from the person and, to a degree, from the patient’s body: instead, the internist focuses on internal diseases and pathologies that become entities of treatment divorced from the individual receiving care. These illnesses– forged into concrete ontological “things”– are countered with similarly material antidotes. Hahn adds that the prestigious status of the internist in the culture of clinical practice, both currently and historically, lends this physiologically-based view of the body and its treatment significant legitimacy in the biomedical landscape.

To demonstrate these concepts, Hahn presents the case of internist Dr. Barry Siegler. “Barry,” as he comes to be called, repeatedly instructs his residents and other clinicians to be wary of individual metrics and lab results, as these single numbers and tests cannot be incrementally fixed: rather, he contends, they must be examined and addressed in concert such that the whole patient is successfully treated. Hahn describes this as relational knowledge of pathology, rather than “singly” reading and responding to individual metrics. However, Barry does not mean to champion holistic, person-centered care: instead, he posits that the entire patient should serve as the point of focus such that no aspect of the patient’s pathology is excluded from diagnosis and subsequent treatment. For example, Barry argues that the patient interview is a tool for the extraction of cues that would lead the clinician to better understand the etiology and symptomatology at hand.

Thus the patient’s “syndrome” comes to exist as a materially and ontologically “real” entity that is distinct from the social, personal, and existential contexts of the patient’s life. This perspective is crystallized in Barry’s tendency to refer to patients as their diseases, such as “a conversion reaction.” He also refers to patients he believes to have mental illness in the same manner, such as the “neurotic,” although he admits that psychiatric pathologies are a “Pandora’s box” beyond the limits of his professional power to address. Again, the patient as a person (and even as a subject or individual mind) fades as the disease pathologies that characterize their illness are reified and made the central objects of the internist’s medical gaze. Due to the close alignment between physiology and organic sciences (chemistry and biology), Hahn notes that the internist’s ontological transformation of the patient into their pathologies– and the pathologies into discrete objects of attention– are deemed especially real, true, and justifiable. Likewise, the body itself is interpreted as a closed, contained system that becomes the object of internal medicine: the ‘whole patient’ is instead the ‘whole pathophysiology.’

Hahn concludes that this vision of the body is decidedly Western: it individualizes the body, and makes a Cartesian division between the body (physical) and the mind (psychological, social) such that it is made treatable and conceptually readable by internists who isolate it from other contexts and who distinguish diseases as concrete, material things. The article ultimately suggests that certain biomedical visions of the body and appropriate patterns for treatment may not align with the perspectives of patients, who understand their illness within the social, spiritual, cultural, and other frameworks that structure their daily lives.

Issue Highlight Vol 40 Issue 3: Asperger’s Syndrome, Subjectivity and the Senses

Posted by sonya.petrakovitz

This week, we will highlight an Illness Narrative from the September 2016 issue of the journal (available here). Here we feature Ellen Badone, David Nicholas, Wendy Roberts, and Peter Kien’s article “Asperger’s Syndrome, Subjectivity and the Senses.” To read the full article, click here.

As previous blog highlights suggest, the intersections of research and illness narratives are important to an anthropological perspective on subjectivity and experience. Badone and colleagues situate their article within narrative phenomenology. They discuss how constructing an illness narrative gives patients and families hope, and frames their experiences in a positive direction. The personal narrative, then, allows individuals to express their agency in hostile structural and environmental settings. The narrative also serves as a valuable first-hand account from which medical anthropologists can learn more about the subjective experience of illness.

The authors perform a close reading of an autobiographical narrative recounted by Peter, a young man diagnosed with Asperger’s Syndrome, a type of autism spectrum disorder (ASD.) Badone and colleagues aim to describe Peter’s case to widen understandings of the lived experience of people with autism. Responding to Olga Solomon’s 2010 article “Sense and the Senses: Anthropology and the Study of Autism,” this paper calls into question key assumptions in the clinical and popular literature about ASD relating to theory of mind, empathy, capacity for metaphorical thinking, and ASD as a life-long condition.

Badone and colleagues begin with a brief history of the diagnostic label of ASD, then describe the ethnographic-autobiographical process. Peter, the pseudonym chosen by the young man whose story is told in this article, reflects on his life experiences and articulates his awareness of autism and its impact on his life. An important recognition that Peter makes is that he senses many of the places he encountered were characterized by the “opposite of accommodation.” In the context of his elementary and high school for example, Peter describes how his need for calm and respite were disregarded in the noisy, abrasive environments. But it is Peter’s mother who is his metaphorical, and social, link to the world he felt dislocated from. Peter describes how it was his mother’s love and guidance which kept him alive and motivated to improve his life.

As Peter continues to narrate his experiences, however, he begins to intentionally seek out interactions in unwelcoming social environments. To Badone, Peter’s later decisions to submerse himself in activities that he found difficult, such as unexpected social situations and interactions, was an unconscious therapeutic response. This response mirrored the principles of cognitive behavioral therapy (CBT). To Badone’s astonishment, Peter had unintentionally started a treatment regimen to gradually lessen his anxiety, decrease his “meltdowns,” and become more independent. But to do so, Peter had to alter his own connection to a social environment that initially felt closed to him.

Badone and colleagues conclude, upon analyzing Peter’s narrative, that quality of life improves when individuals with autism are allowed to flourish in a social milieu of acceptance and understanding. Through the narrative, and through phenomenological examination of moments in Peter’s life, Badone and Peter hope to foster understanding and to urge others to create inclusive communities where social interaction is supported and individuals are not made to feel unwelcome. They seek to make autism more coherent to the non-autistic world and thereby to promote the larger ethical goal of creating flexible communities open to accommodating neurodiversity.

Issue Highlight Vol 40 Issue 3: Contradictory Notions of Violence and Trauma in the Military

Posted by jknopes

This is the second post in a series of article highlights from our new September 2016 issue, available here. In this installment, we explore Tine Molendijk, Eric-Hans Kramer, and Désirée Verweij’s article “Conflicting Notions on Violence and PTSD in the Military: Institutional and Personal Narratives of Combat-Related Illness.” To read the full article, click here.

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Molendijk, Kramer, and Verweij observe that contemporary quantitative research reports that members of the military tend to underuse mental health services, most notably for PTSD. The reports note that soldiers’ beliefs about these services may be hindering utilization: however, existing studies have not specifically identified the beliefs or cultural factors that lead to under-utilization. Through a qualitative analysis of the literature, the authors argue that existing mental health interventions carry contradictory statements about violence and PTSD that may be casting particular social and moral frames onto mental illness. These interventions thus situate PTSD within a pre-figured framework, rather than presenting PTSD and trauma in a manner that individualizes and “decontextualizes” its presentation amongst members of the military: whose personal narratives also offer a distinct perspective on the experience of PTSD. The study focuses on PTSD and its treatment namely amongst the US, UK, and Dutch contexts.

To begin, the authors state that the diagnostic category of PTSD per the DSMV (and its implementation in practice) itself imposes a particular cadence on the disorder, stipulating that it emerges in response to an isolated or otherwise triggering single event, rather than to a diffuse string of violent occurrences or social disruptions. The diagnosis also pathologizes the degree of transition between military and civilian life which, to some degree, must and does occur for all soldiers. “The current mainstream PTSD-concept, with its focus on trauma exposure and individual susceptibilities,” the authors argue, “frames PTSD as the response of an individual to an event,” rather than an individual to a series of events, or many people to a range of traumas.

Beyond the diagnostic category, the “infrastructure” surrounding PTSD and its treatment in the military also impacts the way the illness is conceived and given meaning. The authors “divided the PTSD-infrastructure into five categories: pre-enlistment screening, basic training programs, counseling during deployment and pre- and post-deployment psycho-education, post-deployment screening through a survey and a meeting, and therapy.” In the earliest stages, potential military recruits are screened for existing mental illness, while those who pass screening are then subjected to psychological conditioning in their training intended to bolster soldiers’ emotional and psychological fortitude against combat scenarios. Throughout and after deployment, soldiers are also counseled and receive mental health guidance intended to ease adjustments between the “battlemind” state and the “civilian” mindset. These numerous institutional mechanisms indicate that the military infrastructure situates PTSD as a dysfunctional “deviation” from the ‘functional’ “battlemind,” rather than a natural response to trauma. Thus PTSD is cast as the failure of an individual to integrate and compartmentalize a traumatic event within the mental frameworks for coping that they have already been given, even though the military has already anticipated trauma and attempted to prepare soldiers in the event of psychological disturbance.

From the personal perspective of soldiers, however, the experience of PTSD is presented in a different but equally conflicting light. The authors note that soldiers are expected to psychologically identify and process traumatic events, but are also instructed to resist considering the emotional impact of these events: thereby cognitively preventing them from narrating, contextualizing, and giving meaning to traumatic instances. Furthermore, as violence is a routine aspect of military labor, responses to it are not necessarily “exceptional.” Entire squads may experience the same trauma, although they may not all be later diagnosed with PTSD, or share the belief that mental health care is appropriate for overcoming psychological trauma. Indeed, in military culture, many soldiers may not perceive violence as a trigger, but– as noted earlier– an expected and normal part of daily work. Additionally, acts of military violence may not be perceived as traumatic if they are viewed as necessary, just, or appropriate. Amongst soldiers themselves, PTSD therefore carries conflicting and multiple meanings. The authors summarize that “soldiers have learned that exposure to violence can harm a soldier, and that PTSD-like symptoms are not unusual. However, at the same time, they have learned that violence and stress are inherent to a soldier’s job, and that ‘good soldiers’ should be able to deal with it.” Soldiers who struggle with trauma, therefore, are given resources to address it, but may suspect that it is normal and does not (or should not) require medical intervention. Thus both the institution and the nature of the profession generate conflicting messages about the etiology and treatment of PTSD amongst soldiers.

To some degree, the authors remark, the transition from active deployment (and its related trauma or exposure to violence) to civilian life contains unavoidable contradictions, as the psychological mindset needed for combat versus the mindset for civilian life differ greatly, and the adjustments between them may be difficult. However, the contradictions within the institutional narrative of PTSD– that it is dysfunctional, yet expected, and provided with interventions–may be preventing soldiers from understanding whether or not their response to violence requires treatment, or if seeking help is a stigmatized act. Ultimately, the authors conclude, “the [existing institutional] PTSD-narrative can give soldiers the feeling that important elements of their problems are not taken into account, or that they are translated into an individual problem. If so, soldiers then hear no narrative through which they can understand and articulate their experiences and potential inner struggles about the meaning of these experiences.” The authors’ findings therefore indicate that there are significant and potentially problematic conceptual rifts in the understanding of PTSD between soldiers and institutions, and amongst soldiers acting within the military infrastructure.

Issue Highlight Vol 40 Issue 3: The Mental Health Treatment Gap Across Africa

Posted by jknopes

In the coming weeks, we will be presenting special highlights of our latest installment of the journal, released September 2016 (accessible here.) This week, we explore Sara Cooper’s article “‘How I Floated on Gentle Webs of Being’: Psychiatrists’ Stories About the Mental Health Treatment Gap in Africa.” The full article is available here.

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As Cooper notes in the outset of her article, clinicians and global health workers have identified a “gap” in available mental health services in Africa, and developed programs targeted at the resolution of lacking mental health services across the continent. Despite widespread attempts to research and resolve this gap, however, there remains concern about the problems that arise when a global, top-down approach to mental health services is applied in African contexts. Responding to this concern, Cooper sought out views on the treatment gap at the local level, specifically amongst African psychiatrists. Cooper gathered and analyzed narratives from twenty-eight psychiatrists from South Africa, Uganda, Nigeria, and Ethiopia. She found that while a biomedical, rationalistic narrative about the gap was certainly present, another, more phenomenological understanding of the “gap” emerged from the narratives of three of her participants, which urged a more sensitive approach to the implementation of mental health services in Africa.

Cooper first found that some of the psychiatrists in her study repeatedly turned to a dominant (or master) biomedical narrative to explain why the mental health treatment gap existed in their respective countries. In other words, the psychiatrists relied on a rationalistic, deductive, and material explanation that accounted for the mental health treatment landscapes across Africa. For instance, many of the psychiatrists argued that the lack of physical resources– hospitals, beds, clinicians to staff treatment centers– led patients to seek out non-biomedical interventions like prayer-based or spiritual-based care. The participants agreed that if there were enough services available, patients would not turn to complementary or religious forms of treatment. In their perspective, alternative forms of care were a substitute for biomedicine, rather than a legitimate venue for patients to seek mental health assistance in the absence of (or even alongside) biomedical resources.

Indeed, the act of seeking out these alternative treatments was viewed by the psychiatrists as a rational response: one borne out of the creativity of patients who weighed available options and selected the most appropriate, present service (rather than a complex response to a pluralism of local medical systems.) Conversely, however, the psychiatrists also argued that patients underutilized health services and lacked “mental health literacy,” or the knowledge needed to preface the choice to seek out biomedical assistance. Through these examples, and others, Cooper observes that this sub-cohort of psychiatrists tended to return to a rationalistic understanding of medical treatment that may not always have been sensitive to other means of medical decision-making or to the scope of biomedical interventions.

Yet Cooper also discovered that there were notable fractures in the biomedical “master narrative,” wherein psychiatrists’ narratives reveal concerns about the role of biomedical mental health services in addressing treatment gaps. Three psychiatrists admitted that biomedicine might not necessarily address the full scope of a patient’s mental illness or health concerns in the broader context of their lives or personal needs. For example, these three participants noted that the psychiatrist might have to explain that available treatments could potentially fail to fully resolve a patient’s complaint, or that they might have to accept that a patient’s past traumas, or troubling social circumstances, were beyond that which the psychiatrist could ameliorate through medical means. Here, the treatment “gap” is conceptual: the ideological place where a patient’s hopes, experiences, and expectations about their care may not be perfectly matched to the psychiatrist’s available treatments and medical diagnoses.

In this sub-cohort, one psychiatrist remarked that the “paternalistic” method of biomedical treatment could be unproductive, as the clinician may not be able to fully mend the patient’s health due to the social, personal, and individual complexities of the patient case. Another psychiatrist recounted a patient’s case in detail, noting that while he believed this person suffered from delusions, it was his responsibility to help the patient by trying to understand his view of reality, suffering, and personal struggle. Yet another psychiatrist recounted equally challenging cases, where they recognized that patients often were not satisfied with simply a cleanly-defined diagnosis or treatment plan, but required a more robust means of reordering and improving their lives with the psychiatrist’s guidance.

Cooper states that “for these psychiatrists, in taking people’s experiences and meanings seriously, on their own terms, one comes to appreciate that their understandings and behaviours are deeply complex and varied, affected by all sorts of social, cultural and emotional realities and rationalities.” Though the master narrative of biomedical rationality remained prominent, these alternative narratives were sensitive to the lived experiences and individual realities of the patient. They also explored the treatment gap, but viewed the “gap” as the product of complex interactions between psychiatrists and their patients. For the latter three participants, the “gap” was caused not by a lack of resources or knowledge, but by the friction between practitioners’ and patients’ expectations about the treatment of mental illness, and a mismatch between practitioners’ medical skills and the self-professed needs and understandings of patients. “According to the three psychiatrists in this [part of the] study,” Cooper concludes, “increasing the availability of services necessitates first and foremost rethinking the nature of the kinds of services that are expanded, and the associated epistemologies upon which these are based.”