Article Highlight: Vol. 41, Issue 2, “The Tipping of the Big Stone—And Life itself. Obesity, Moral Work and Responsive Selves Over Time”

This week we explore Lone Grøn’s The Tipping of the Big Stone—And Life itself. Obesity, Moral Work and Responsive Selves Over Time. Grøn explores moral work and moral selves in the context of the obesity epidemic and weight loss processes. Cheryl Mattingly’s notions of “moral laboratories” (Moral Laboratories: Family Peril and the Struggle for a Good Life, University of California Press, Berkeley, 2014, available here) explore moral cultivation over time that cannot be disconnected from notions of biographical and narrative self. Building off Mattingly’s concepts, as well as philosopher Bernhard Waldenfels’ phenomenology, Grøn proposes the notion of a responsive self.


Grøn begins by introducing Rita, a participant in the obesity program at The Lifestyle Center, a Danish patient school which teaches self-care, diet, and exercise practices to people suffering from or at risk of what is termed “lifestyle-related diseases.” Grøn explores Rita’s reflections on obesity and weight loss, with specific attention to the transformation in notions of self, agency, and morality from fieldwork between 2001-2003 and 2014-2015.

Rita asks herself questions about her weight loss struggles, such as, “Why don’t I grow-up enough to take responsibility for my own well-being? Why is what I know to be the right thing to do a million miles removed from what I do in reality?” References to fighting the evil will or desire of your body, to sinning and backsliding, are plentiful and situate weight loss in the domain of morality. This places the concerns and reflections on weight-loss within broader historical and cultural ideas on self, agency, and morality, asking what kind of self one is able to be in the face of conflicting wills and moral demands.

Grøn takes up an argument that Mattingly put forward and developed, namely that moral cultivation over time cannot be disconnected from a notion of self.  Up until the last decade of the second millennium, attention to the relationships between body weight, food, and health were scarce in a Danish setting marked by cultural practices and values of “hygge,” that is, socializing by sharing food and alcohol, often to excess. Over the past two decades, this relationship has changed dramatically, and the consumption of food and drink have become morally charged in all corners of Danish society, from family spaces to the widespread network of institutions constituting the Danish welfare system. Further, a politically announced “paradigm shift” in the beginning of the second millennium in Danish health care services shifts attention from the treatment of acute diseases to the prevention of chronic diseases.

Grøn states that in many ways being obese has become an uninhabitable position. What used to be big and cozy (“hyggelig”) has become obese and alien. In the face of overwhelming personal and family histories of unsuccessful attempts at weight loss, temporary success is usually followed by increasing weight gain in a pattern widely documented in the scientific literature on weight loss processes over time. Both personal and family experience and scientific evidence define success as improbable, yet families struggling with obesity continue to experiment against the odds all the same. Thus, for Grøn, life itself becomes a laboratory.

Taking the experienced and biographical self seriously has allowed acknowledgement of the immense work of moral experimentation that Rita has engaged in over a lifetime. Furthermore, many other events and projects make up her life, including the cultivation of healing powers, of a garden of flowers, as well as of a home, family, and work life. This picture of Rita’s moral self could easily be lost if we were only concerned with the “obese” self, which can be constituted through workings of the bio-power and governmentality techniques of the Danish welfare state.

Grøn concludes by detailing the characteristics of the responsive self, emerging within the demand response dynamic. The responsive self displays both an event form that persists over the years (“I respond, therefore I am”), but also changes in terms of the content of the response. Thus, the notion of the responsive self stresses equally the suffering and the agentive dimensions of action—”an active passivity and passive activity.”


Lone Grøn is a Senior Researcher at VIVE The Danish Centre of Applied Social Science in Denmark, as well as a Senior Project Manager at KORA. She has done extensive anthropological research and ethnographic fieldwork on patient perspectives on chronic diseases, obesity, and behavioral change, highlighting the complexities of health work in the contexts of everyday lives. Her recent areas of research concern include social contagion in epidemics of non-communicable diseases and conditions, specifically in relation to kinship, relatedness and obesity; vulnerability and inequality in old age and the search for the good old life; and theoretical developments within philosophical and moral anthropology as well as phenomenological approaches in anthropology, which serve as the epistemological ground for experience-near and close-up studies of patients, citizens and families.

Advertisements

Article Highlight: Vol. 41, Issue 1, “Innocent or Intentional?: Interpreting Oppositional Defiant Disorder in a Preschool Mental Health Clinic”

To begin article highlights from our latest edition of Culture, Medicine, and Psychiatry (Vol. 41, Iss. 1), this week we are featuring Christine El Ouardani’s Innocent or Intentional?: Interpreting Oppositional Defiant Disorder in a Preschool Mental Health Clinic. This article examines contradictions clinicians face when attempting to identify and interpret “intentionality” in young children with oppositional defiant disorder (ODD). El Ouardani argues that conceptualizing intentionality as a developmental, interpersonal process may help to make sense of the multiple discourses and practices clinicians use to try to reconcile the contradictions inherent in diagnosing ODD.

El Ouardani begins by introducing “Carla,” a three-year-old who arrived for evaluation and clinical diagnostic determination at the Preschool Behavior Disorder Clinic (PBDC). At first Carla appears as any typical preschooler, energetic and affectionate, but the care team quickly learns she would frequently have violent outbursts and tantrums, lashing out at her family members, other children, or even nearby animals. This type of aggressive, disruptive behavior represents the main reason for the referral of preschoolers to mental health clinics. Early intervention into and treatment of such behaviors is thus of great interest to researchers and clinicians in the field of child mental health care in hopes of helping the young children adapt and cope with life more effectively and prevent the development of later, more destructive behaviors.

El Ouardani discusses that many of the children seen in the PBDC were given a diagnosis of oppositional defiant disorder (ODD), defined in the Diagnostic and Statistical Manual IV (DSM-IV) as “a recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures that persists for at least 6 months” that impairs a child’s social and/or academic functioning. Yet with very young, preschool-aged children, the diagnosis is controversial. Many children displaying aggressive behavior come from chaotic or otherwise problematic social environments in which this kind of behavior is a reasonable reaction. El Ouardani states that clinicians “must reconcile their characterization of disruptive behavior as a matter of ‘self,’ with the social environments that seem to be producing this kind of behavior.” El Ouardani also draws attention to the values and assumptions of current treatment models and diagnostic procedures. These modules are often based on white, middle-class norms of a “proper” family, moral assumptions of how parents should discipline their children, and the assumed role of a child in social institutions. Many patients at the PBDC did not fall into those characterizations; the reality of their lives are much different.

Moving to a discussion of agency and intentionality, El Ouardani then examines the biomedical, disease model of mental illness, which attempts to remove the blame for the illness from the individual. “Ideologically, then, those afflicted with mental disorders bear no responsibility for the behaviors that directly result from their disorders,” El Ouardani writes, since the biological processes of mental illness are taken out of the patient’s control. Thus, ODD as a category defined by “intentional” defiance conflicts with the disease model of mental illness. “A central concern of psychiatric therapeutics is to motivate and use the intentionality of a patient to regain control over the self.” Yet the idea that preschool-aged children are fully capable of acting with this type of intention, and possess the capacity to do so, is disputed. Therefore clinicians diagnosing a young child with ODD are forced to face the disparities between what is out of the child’s control, and what is the “will” of the child.

While discussing the diagnostic criteria for ODD as described in the DSM-IV, El Ouardani emphasizes the criteria for an ODD diagnosis requires the child to be aware of his or her own behavior and is purposely trying to upset or defy the person with whom they are interacting. From this criteria, ODD-labeled children are manipulative and spiteful, qualities that require a degree of intentional malice and deception. These characteristics are not thought to be present in other kinds of childhood mental disorders, such as depression, anxiety, neurodevelopmental disorders, and attention-deficit hyperactivity disorder (ADHD). Clinicians also attribute ODD children with controlling their behavior to influence “weaker” adults, depicting these children as culpable and intentional in their attempts to “confuse and subvert the efforts of their caretakers who are trying to control their behavior.”

El Ouardani discuses that determining intentionality is a complex process, especially because of a child’s limited verbal capacity for expressing internal states. “In order to identify intentional defiance and diagnose ODD, clinicians had to delineate authentic displays of emotion from those that are inauthentic and manipulative.” El Ouardani explains that nuanced, intersubjective exchanges between the children and the clinicians are not captured within the DSM-IV diagnosis. Clinicians often feel frustrated when they perceive a child is trying to manipulate them. This can be compared to clinicians stating “that they feel bad for children with depressive symptoms. They theorized that disruptive behavior in depressed children is a way to cope with internal pain.” This difference means the clinicians feel less personally attacked by children without the ODD diagnosis, becoming less frustrated. Further, by diagnosing a child with multiple disorders the clinicians can discursively split the child’s “self” into different intentional and non-intentional parts. However, this leads to ODD being categorized as a feature of the individual’s character, who that child is as an individual, rather than as a biological disease.

Explanations for why a particular child’s behavior were not always attended to within the PBDC. “Clinicians tended to rely upon the widely accepted idea that behavior and psychopathology is a result of interactions between biological temperament and the social environment. According to this model of developmental psychopathology, innate temperament interacts with problematic interpersonal relationships and chaotic household environments, causing the child to react to these negative circumstances with disruptive behavior.” Yet this strategy still leaves ambiguities over etiology and treatment.

El Ouardani concludes her article with a discussion of the treatment modality. Clinicians regularly spend the majority of the treatment focused on teaching caretakers how to more effectively discipline and relate to the children. The clinicians primarily focus on a lack of consistency in discipline and structure in both interactions and routines, thus, if the caretakers correctly implement strategic routines, the child will then change their behavior over time. “However, clinicians also informally acknowledged these techniques, which took time and energy that many of the caretakers coming from stressful, low-income, single-caretaker families did not necessarily have.”


Dr. Christine El Ouardani is an Assistant Professor in the Department of Human Development at California State University, Long Beach. She is a cultural, medical, and psychological anthropologist who focuses on the anthropology of childhood and lifecourse in Morocco and in North America. El Ouardani’s current book project, Discipline and Development: Negotiating Childhood, Authority, and Violence in Rural Morocco, examines the everyday lives of children and youth in a Moroccan village as they move through their families, classrooms, and medical clinics. She analyzes disciplinary interactions between children and caretakers in their extended families and local schools that were often both violent and playful, demonstrating how local conceptions of authority, care, pain, and violence are constructed and enacted in everyday life at different points throughout childhood, and in different institutions.  El Ouardani shows how examining the nuances of child socialization practices over time and children’s roles in family and community life provides a sharp lens through which to consider larger-scale political, economic, and social change, in this case, contested norms of authority and violence in Moroccan families. For more information, visit her information page on the Department of Human Development, California State Universtity, Long Beach, available here.

 

From the Archive: AMC’s Breaking Bad, Empowerment, and Terminal Illness

In the “From the Archive” series, we highlight articles published throughout the journal’s history. We look forward to sharing with our readers these samples of the innovative research that CMP has published on the cultural life of medicine across the globe.


In “From the Archive,” we generally highlight older publications from the journal and discuss their importance for medical anthropology and cultural studies of medicine today. This week, we are taking a turn to revisit a newer piece from 2013 that has been one of CMP’s most popular articles: Mark A. Lewis’ “From Victim to Victor: ‘Breaking Bad’ and the Dark Potential of the Terminally Empowered.”

cards

Lewis, an oncologist, opens by describing a recent shift in the treatment of cancer. With new and experimental treatments growing in number, patients are encouraged to feel hopeful about therapy for their cancer, rather than defeated in the face of a potentially terminal condition. These new scientific innovations in treatment, therefore, are altering the rhetorics surrounding cancer diagnoses. Cancer is something to be overcome, or even battled. In the age of the “Live Strong” campaign, and the casting of cancer patients into fighters, new notions of what it means to endure this illness are developing.

The key to AMC’s Breaking Bad, Lewis argues, is that the creators seize upon this new model of the cancer patient and then betray the audience’s expectations that his battle against illness is a “noble” one. Rather than having a diagnosis opening a realm to hope, it lends Walter White the potential to take risks he would not have taken in good health. Imminent death “emboldens” Walter, yet this newfound audacity is channeled towards selfish, perhaps prideful, and certainly criminal ends.

Lewis notes that these behavioral, psychological shifts in cancer patients come under the purview of a new field deemed psycho-oncology. This budding discipline addresses the mental wellness and conditions of cancer patients, whose diagnosis carries somatic as well as psychological effects. As the article suggests, stress for cancer patients extends beyond the worries they have about the severity of their illness: it includes anxiety about the financial and personal costs of the treatment needed to ‘battle off’ the disease. For White, this entails not only having the means to treat his illness and support his family, but also to be self-sustaining, hence why he turns down assistance from wealthy benefactors and instead makes and sells crystal meth.

Walter White therefore follows in the steps of a cancer patient whose diagnosis opens a realm of possibilities and encourages him to take risks in fighting off his condition. However, this transformation alters what victory means for Walter. As he descends deeper into the meth business, the terms of victory are no longer noble. Walter murders his competitors, and after the publication of Lewis’ article, declares at the end of the series that his drug-dealing empire is what gives him life. His pride is in his business, not in overcoming his cancer. Walter’s potential is unlocked by the cancer, yet he subverts the narrative of a “noble” patient who survives his dire diagnosis. His cancer has merely positioned him to accomplish what he would have not otherwise set out to do.

Lewis’ article demonstrates the centrality of illness narratives and new models of illness experience to popular media. His article draws on medical science, popular health campaigns, and on modern-day encounters with terminal illness to inform viewers’ expectations of what path patients might, and should, follow.

To access the article and read an abstract, click here:

http://link.springer.com/article/10.1007/s11013-013-9341-z

AAA 2014: Perspectives on the Bruno Latour Distinguished Lecture

This year at the American Anthropological Association 2014 Meeting, Bruno Latour was invited to deliver the distinguished lecture. Entitled “Anthropology at the Time of the Anthropocene,” Latour discusses the rise in the term anthropocene to describe our current stage of natural history. Although the term makes reference to how “human” (anthro) our current age may be, Latour jests that this term was introduced by geologists, not social scientists. In the anthropocene, it is humans that play the defining role in our geological historical moment.

The assumption, Latour notes, is that human agency is the prime source of action that shapes the physical world. Humans are responsible for climate change, for pollution, for altering the literal, natural fabric of our world. Yet we know that not all humans have the same impact on our environment. As Latour quips, there is not “One Human” who is responsible for the changes we see in our climate or environment. We are simultaneously assessing human power as a plural, collective entity, as well as using this concept to suggest that the blame for global change does not fall evenly across all humans. As anthropologists and cultural theorists, we know how fragile human agency can be when we divide it amongst many contending social and cultural groups.

Our blog editor at the Latour Distinguished Lecture

Our blog editor at the Latour Distinguished Lecture

Is there another way to think about human action that does not problematically configure humans as both collective and individual, acting but not universally accountable for all human actions? Latour posits that rather than focusing solely on agency, with a strong emphasis on human intention and purpose when committing action, we could think instead about animation, or what forces–human and non-human– are in motion in a given social space. To do so, we can no longer assume that the human agent is a colloquial be-all-end-all.

How does this assertion speak to medical anthropology, social medicine, and medical humanities? At first, we might raise our brows at the discussions of geography, environment, and most of all the suspicion surrounding the primacy of human agency. Decentralizing the human agent, we might say, is perhaps the least humanistic approach to the study of human experience. Indeed, medicine is the care of humans by humans!

However, our human ability to question our own power and position in the universe, amidst other natural and non-human forces, is a mark of our species. Whether through philosophy, religion, or social science, humans have a proclivity for ruminating about our place in the material, corporal world. We crave knowledge about what sets us apart from non-human things, and how we are sometimes reliant on them. For scholars of medicine, such inquiries about our relationships with the physical universe is key. We consider the place of non-human agents in disease and care. We ask: why do physicians rely on certain tools? Why do patients see stethoscopes, thermometers, and scalpels as making a clinician legitimate in his or her practice? How are medical traditions made unique by their tools and pharmaceutical formulas? Could the layout of a hospital or clinic itself alter the way care is given?

In an age where technology permeates developed and developing societies, Latour’s suggestion to destabilize human agency is productive when considering medicine as a cultural object. We must think not only of ourselves, but the physical environments we live in and the material objects and devices we cannot seem to live without.

Many scholars understandably resist Latour’s idea that non-humans could have some primitive agency. Yet even if we do not assign agency to non-human tools, things, and environments, thinking seriously about their role in sociocultural systems is informative. Medicine is a lively site of exchange between patients and physicians, as well as practitioners and devices, patients and new medical innovations, and the built environments which house them. As Latour invites us to do, we should pause to consider humans within the midst of a rich material world around us that– like humanity itself– is constantly in motion.

Julia Balacko is a second-year PhD student in medical anthropology at Case Western Reserve University. She holds an MA in Humanities from the University of Chicago. Her research focuses on the culture of human anatomy and dissection in Western medical traditions, as well as public access to anatomical and pathological specimens.


Note on the presenter:

Bruno Latour is professor at the Sciences Po Paris in Paris, France. A central theorist in STS (science and technology studies), he is the author of We Have Never Been Modern (1991), Science in Action (1987) and Laboratory Life (1979).

You can read the full text of Latour’s lecture here: http://www.bruno-latour.fr/sites/default/files/139-AAA-Washington.pdf

From the Archive: Caregiving and Dementia in Urban India

In the “From the Archive” series, we will highlight articles published throughout the journal’s history. We look forward to sharing with our readers these samples of the innovative research that CMP has published on the cultural life of medicine across the globe.

cards3

Recently, one of our readers on the Culture, Medicine, and Psychiatry Twitter account requested that our next “From the Archive” post address an aspect of aging and community. In the spirit of the reader’s suggestion, this week we are featuring a 2008 article by Bianca Brijnath and Lenore Manderson entitled “Discipline in Chaos: Foucault, Dementia and Aging in India.” (you can find out more about the article here: http://link.springer.com/article/10.1007/s11013-008-9111-5.)

The authors posit that caregivers for those with dementia are important providers of structure: they are responsible for the patient’s hygiene, diet, and medical needs, as well as accountable for the actions of people who, experiencing symptoms of dementia, sometimes act out in ways which are not consistent with public cultural norms. Typically in India, such care falls into the hands of younger relatives. Domestic caregiving by these family members “prevents the demented body from threatening the stability of the social body.” There are tremendous “social anxieties,” the authors write, surrounding the potential for someone with dementia to resist normative behaviors per the local codes of social life.

The Foucauldian stream of thought here is quite present: the caregiver must “discipline” the body of the dementia patient to reinforce the cultural codes of the society in which both actors live. Although there exists the notion of seva, or the submission of younger relatives to the direction and advice of older relatives, this idea of the respected and powerful elder is complicated in the face of dementia where the power to attend to another person is rather reversed. Instead of being disciplined by the familial patriarchs or matriarchs, younger relatives must both discipline the elder who is unable to provide the social structure for themselves, as well as their own bodies by taking on new routines and practices to accommodate their family member with the illness.

Power, however, is still bi-directional: those with dementia have extraordinary power in altering the routines of their familial caregivers, and even act out violently: the authors note they may “kick, hit, punch, bite, and threaten with a weapon” when they are upset, and are not necessarily expected to limit these actions on their own due to their condition. The transactions of power, agency, and authority in these relationships are resonant with similar social exchanges as explored via the Foucauldian lens in other Western settings.

Brijnath and Manderson’s piece highlights important features in the care of dementia patients, and demonstrates that community-based models of caregiving for the elderly are not as simple as the removal of power from the elderly individual and the installation of authority in the caregiver. The caregiver, too, is both self-disciplined and disciplined by the acting out of their ward.