Culture

Issue Highlight Vol 40 Issue 1: Depression, Gender & Power

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The March 2016 issue of Culture, Medicine & Psychiatry has recently debuted. Over the coming weeks, we will feature article highlights from a selection of the newest research published at our journal. To access the full issue, click here.

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This week’s article highlight examines Alex B. Nietzke’s piece “An Illness of Power: Gender and the Social Causes of Depression” (accessible here.) Nietzke argues that a mechanistic and biological model of depression overlooks the extent to which women across the world are frequently diagnosed with the disorder at a higher rate than men. When bioscience and biomedicine fail to attend to underlying social and gendered dimensions of depression as a diagnosis, the author holds, they are “silencing women” and “marginalizing” a discourse surrounding the problematic social power of the biomedical model.

The article opens with a review of the literature on medicalization, which describes the shift from a psychodynamic model (where external factors were typically considered the source of reactive mental distress) to a biopsychiatric one (where, given the development of medications for mental disorders, mental illness was increasing viewed as seated within the patient’s biology.) The DSM-III later “eliminated” the categories for “reactive” mental illness, and placed physical symptoms (like weight loss) alongside psychological ones (like feelings of hopelessness) such that both expressions of illness were physiologically equated to one another.

Upon biologizing symptoms, the causes of depression thus fall wholly within the realm of biomedicine to diagnose and to treat. This leads to a nearly unilateral assumption of control over depression by psychiatrists and clinicians, even if other individuals such as family and friends– and the patient herself– has insights into the social determinants of a psychological condition. Furthermore, when biomedicine interests itself only in the biological and not social basis of women’s mental illness, it delegitimizes the very roots of many women’s distress and reinforces their inability to verbalize forms of oppression. Nietzke thus adds that “what begins to emerge here is that the psychiatric disease model of depression may actually be disempowering women by legitimizing the pathologies of a social system of gender as it delimits one’s expression of suffering and testimony to its causes.”

When biopsychiatry quiets the discussion of social determinants of mental illness, so too does it lend power to the systems of oppression that enable women’s suffering to continue, and limits their ability to express their psychological state. Put another way, by biologizing rather than contextualizing depression, women are inherently marginalized because they may have few other recourses outside of biomedicine for ameliorating the psychological ramifications of social disenfranchisement. The “silencing” Nietzke cues in the early paragraphs of the article returns here, as the author reminds readers that biomedicine’s biologizing of depression may problematically close the conversation around the social situatedness of women’s psychological experience and social status.

Issue Highlight Vol 40 Issue 1: Hope, Despair, and Chronic Pain

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The first 2016 issue of Culture, Medicine & Psychiatry has arrived! Over the coming weeks, we will feature article highlights from a selection of the newest research published at our journal. To access the full issue, click here.

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In this week’s blog, we visit Eaves, Nichter, and Ritenbaugh’s article “Ways of Hoping: Navigating the Paradox of Hope and Despair in Chronic Pain” (accessible here.) The authors carried out a series of qualitative interviews with patients experiencing temporomandibular disorders (TMDs) throughout a clinical trial where these patients received traditional Chinese medical treatments (TCM.) The authors’ research with 44 patients in the clinical trial highlight the paradoxical nature of hope: that is, a tendency to both place faith in the possible efficacy of a treatment, while cautiously gauging these expectations to avoid feelings of despair should treatment fail to produce a positive result. The authors argue that hope serves as a complex placebo, in that while not itself being an active pharmaceutical or other intervention, it can have significant implications for a patients’ course of care.

Following a review of methodology and the theoretical basis of medical “hope,” the authors present a diverse array of examples from their interviews that illustrate the range of expectations, beliefs, and experiences of the chronic pain patients. For some patients, hope is secular: related to realistic treatment goals (such as a small reduction in overall pain), or to utopian ideas about the treatment’s future potential for other patients. For others, hope is an expression of spiritual faith, or a form of almost religious belief in the effectiveness of bioscientific breakthroughs, or even a belief that biomedicine has failed the patient and a remedy for their pain can only be found in other medical systems (like TCM.) Other patients described an embodied response to the treatment that, the authors comment, underscores the relationship between placebo and (psycho)somatic healing.

In all these examples, however, what is perennially apparent is the patients’ tenuous balancing of hope with tempered expectations for a cure. However it comes to be framed, hope both enhances and complicates the treatment of chronic pain. In some cases, hope acts as a “positive” placebo in that it bolsters the patients’ faith or trust in the potential (or even observable) efficacy of the treatment. In other instances, hope can prove to be a harmful placebo in that it may promise beneficial change and render any failing of an experimental treatment more troubling for the patient. Because hope offers such conflicting possibilities for patients’ satisfaction and trust in a treatment modality, it is essential for both anthropologists and clinicians to consider the cultural, cognitive, embodied, and religious frameworks in which a patient conceptualizes and subsequently approaches treatment.

Book Releases: New Texts on Sex Tourism, Biotechnology

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This week, we are featuring two book releases from the University of Chicago Press. The first book is Gregory Mitchell’s Tourist Attractions: Performing Race and Masculinity in Brazil’s Sexual Economy. This new book, published in December 2015, presents an ethnographic perspective on gay sex tourism in Rio de Janeiro, Salvador de Bahia, and the Amazon. Mitchell examines issues of race, masculinity, and sexual identity amongst both sex workers and sex tourists. In particular, he asks how men of various racial, cultural, and national backgrounds come to understand their own identities and one another’s within this complex series of commercial, sexual, and cultural exchanges. Details about the book can be found here.

About the author: Gregory Mitchell is assistant professor at Williams College, where he teaches in the Women’s, Gender and Sexuality Studies program and in the Department of Anthropology and Sociology.

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Image via UC Press website

The second book, debuting in September 2016, is Hallam Stevens’ Biotechnology and Society: An Introduction (cover image not yet available.) Each chapter of the text will address a different topic in the cultural and historical study of biotechnology, from gene patents, to genetically-modified foods, to genetic testing and disability, assisted reproductive technologies (ARTs), and the intersections of race, diversity, and biotechnologies. The text will be of equal interest to scholars of science and technology studies (STS), posthuman theory, and the history and culture of medical technology. Details about the book can be found here.

About the author: Hallam Stevens is assistant professor at Nanyang Technological University in Singapore. He teaches courses in the history of the life sciences and information technologies. He is the author of Life Out of Sequence: A Data-Driven History of Bioinformatics, also available here via the University of Chicago Press.

 

Spring 2016 Blog Hiatus & Update

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This week, we are taking a one-week Spring hiatus on the blog. In our coming installments, we will return to highlight articles published in the first issue of Culture, Medicine & Psychiatry for 2016. You can access the full March 2016 issue here from our publisher’s website.

As always, we continue to accept guest submissions to our blog showcasing research and recent projects by our readers. We are also pleased to invite authors of newly-published books in medical anthropology, sociology, history of medicine, and medical humanities to contact us with publication information so that these new works can be featured here on the blog. For details on guest submissions and book features, please contact our social media editor Julia Knopes at jcb193@case.edu.

In the meantime, we look forward to sharing previews of the latest research in our journal in the coming weeks.

Best wishes from the Editorial Staff at Culture, Medicine & Psychiatry

From the Archive: Revisiting Neurasthenia in Japan

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In 1989, our June special issue centered on the theme of neurasthenia: an illness category made most recognizable in current medical anthropology by Arthur Kleinman in his book Social Origins of Stress and Disease: Depression, Neurasthenia, and Pain in Modern China (1988.) Neurasthenia is a flexible diagnosis that encompasses a set of broad psychosomatic symptoms: fatigue, emotional unease, irritability, and bodily pains. It has fallen in and out of favor throughout history, yet in China and other Asian countries, it continues to be used to describe psychiatric distress. The special issue was published during the final year of Kleinman’s tenure as the editor-in-chief of Culture, Medicine & Psychiatry, and represents the culmination of research carried out throughout Asia on the diagnosis and treatment of the illness. You can access the full issue here.

 

The focus of this From the Archive feature is Tomonori Suzuki’s article on the diagnosis and treatment of neurasthenia in Japan. Unlike China, where neurasthenia continued to be clinically relevant through Kleinman’s research in the 1980s-1990s, the disease category fell out of its original use in Japan following World War II. Suzuki writes that this shift was not directly due to changes in Western psychiatry, in which European and American physicians replaced ‘neurasthenia’ with new categories under the umbrellas of neuroses, depression, or anxiety. These shifts may have influenced psychiatric disease models elsewhere, but in Japan, neurasthenia was instead rebranded and treated via a different historical pathway.

Morita, a renowned Japanese psychiatrist who lived in the late nineteenth and early twentieth centuries, was the first to suggest that neurasthenia was not exogenous: in other words, it did not stem from social disorder on the outside, but from psychological unrest within the mind. His therapeutic regimen for this newly-conceived “neurasthenia” became widely adopted, even into the contemporary age. Thus neurasthenia– while formally removed from the diagnostic lexicon– took a new form with an accompanying treatment as proposed by Morita.

Following WWII, when Japanese medical practitioners did begin to employ American principles of psychiatry, clinicians began to replace “neurasthenia” with the new category “neurosis.” Although this aligned with shifts in the nature of treatment that occurred in other places where biomedicine was practiced, Japan was unique in that many patients labeled as neurotic nevertheless sought out Morita therapy: a treatment initially designed to ameliorate an illness closer to the original form of neurasthenia. Some patients also opted for Naikan therapy, another indigenous psychotherapy based on Buddhist principles similar to those woven into the practice of Morita therapies. While the importation of “Western” diagnoses of neurosis brought with it accompanying forms of therapy native to Europe and North American, Morita and Naikan proved to be durable therapies equipped to treat Japanese patients with illnesses somewhere within the neuroses-neurasthenia spectrum.

Although the author notes that the use of these therapies (in the 1980s) could decline as Western models of psychotherapy continue to spread, Suzuki’s research into Japanese psychiatry practice revealed that many patients continued to seek out indigenous Morita and Naikan therapies. The two treatments’ focus on inner self-mastery, connectedness to the social and physical worlds, and the minimization rather than elimination of symptoms echo native Japanese spiritual beliefs, making these therapies legitimate alternatives to imported models of treatment. In sum, though the category for neurasthenia changed across time, foreign models for the conceptualization of mental illness did not always neatly correspond to foreign models for treatment. For the Japanese, local therapies such as Morita and Naikan proved to be quite resilient, as the therapies adapted to address psychiatric disorders despite the repackaging of mental illness into new forms.

 

In the News: Telemedicine in the United States

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The intersections between technology, medicine, and health are a frequent site of discussion at Culture, Medicine & Psychiatry. In our last issue of 2015, for instance, Yael Hashiloni-Dolev[1] examined the role of new medical technologies that enable posthumous reproduction, while Petersen and Traulsen[2] shed light on the nuanced social uses of psychoactive medications amongst university students. These articles underscore the centrality of technology in everyday human health behaviors, and on the cultural meaning of these new tools in local medical landscapes.

Another technological innovation altering the social world of medicine—one making headlines in recent months—is telemedicine. In the Journal of the American Medical Association[3] (JAMA), telemedicine has been described as “the use of telecommunications technologies to provide medical information and services,” often a shorthand “for remote electronic clinical consultation” via phones and internet applications.

In the December 2015 AARP Bulletin, author Charlotte Huff[4] remarked that over 1 million patients will use telemedicine services this year, and remote access to physicians by phone, video chat, and email is more and more commonly covered by American employers’ health insurance packages. A Reuters article[5] adds that in Texas, a telemedicine company is working to block a state law that would require physicians to see a patient in-person before consulting with them via phone, email, or other means. And in the New York Times[6], a physician observed that telemedicine may prove a useful tool for children and adolescents: many of whom have grown up in a digital culture of “oversharing” and would not balk at texting their physicians images of strange rashes or lesions on their bodies. As this new tool of health care delivery is negotiated in different societal arenas, so too are its implications increasingly worthy of anthropological attention.

Telemedicine is altering the social fabric of medicine in a number of significant ways. Here, we will outline two potential outcomes of telemedicine on medical exchanges facilitated by technology. First, telemedicine extends the professional reach of biomedical clinicians. Areas where biomedical care is inaccessible, or where only indigenous medical systems exist, may now fall under the electronic eye of a faraway practitioner. This has extraordinary consequences for the ubiquity of biomedicine and the consolidation of biomedical power. Second, and rather conversely, telemedicine empowers the patient in the clinical encounter. Because the physician or clinician is not physically present to examine the patient’s body, the patient themself is the one who touches a swollen throat, or flexes a stiff joint, and relays their response through phone or web camera. In sum, the patient gains greater control over bodily (and verbal) narratives that, unlike an in-person exam, the clinician does not have total access to.

The rise of telemedicine speaks to medical anthropologists, certainly, but it also presents a fascinating case more broadly for science and technology theorists and scholars in health communication. As the topic of telemedicine continues to capture the interest of medicine and the media, so too will it fall under the consideration of researchers piecing together the networks that bring patients and their caregivers together in novel ways.

[1] http://link.springer.com/article/10.1007/s11013-015-9447-6

[2] http://link.springer.com/article/10.1007/s11013-015-9457-4

[3] http://jama.jamanetwork.com/article.aspx?articleid=386892

[4] http://www.aarp.org/health/conditions-treatments/info-2015/telemedicine-health-symptoms-diagnosis.html#slide1

[5] http://www.reuters.com/article/health-case-to-watch-teladoc-idUSL1N14H0CT20151228

[6] http://well.blogs.nytimes.com/2016/01/18/using-phones-to-connect-children-to-health-care/?ref=health

 

Book Release: Tomes’ “Remaking the American Patient”

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Images via UNC Press website

Released in January 2016 from the University of North Carolina Press is Nancy Tomes’ Remaking the American Patient: How Madison Avenue and Modern Medicine Turned Patients into Consumers. Through historical and cultural analysis, Tomes illuminates the threads between public relations and marketing in medicine, asking throughout: how have patients in the United States come to view health care as a commodity to be “shopped” for? What connections are shared between the history of medicine and the growth of consumer culture? Likewise, Tomes investigates what it means to be a “good patient” in this system of marketed care, and how “shopping” for care can both empower and disorient patients in the contemporary age. She also reviews the resistance, and ultimate yielding, of the medical profession to this model of care seeking. The book was recently reviewed in the New York Times (read the article here.)

The book will prove insightful for both historians of medicine and medical anthropologists who study the political-economic landscape of biomedicine and patienthood in the United States. It will also speak to conversations in bioethics about patient autonomy, choice, and medical decision-making.

About the Author

Nancy Tomes serves as professor of history at Stony Brook University. She is also the author of The Gospel of Germs: Men, Women, and the Microbe in American Life, published by Harvard University Press (details here.)

Have you published a recent book in medical anthropology, history of medicine, social medicine, or medical humanities? Email our blog editor (Julia Knopes) at jcb193@case.edu with a link to the book’s page at the academic publisher’s website, and we will feature it here.

Book Release: Kleinman and Wilkinson’s “A Passion for Society”

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To herald in the New Year 2016, today we feature a book publication highlight of a new text in medical anthropology co-authored by Culture, Medicine & Psychiatry‘s 2016 Honoree, Arthur Kleinman. Read our editor-in-chief Atwood Gaines’ announcement of the annual honoree here.

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Image via UC Press website.

Out this month from the University of California Press is Arthur Kleinman and Iain Wilkinson’s A Passion for Society: How We Think About Human Suffering (paperback edition details here.) The book examines the concept of suffering as a broader social “problem,” both in the contemporary age and through history. The authors explore how notions of suffering and care are reflective of present social and moral conditions, and how social science as a profession responds to “social suffering.” They argue that enlivened discussions about care have invigorated a new approach to the study of suffering by social scientists, who no longer engage with human suffering dispassionately. This shift has widespread implications for an “engaged social science” that takes a humanitarian approach to analyzing, understanding, and ameliorating human suffering. The text will interest applied social scientists as well as medical anthropologists and scholars of social medicine, who study illness and social inequities both across time and in cross-cultural contexts. The book can be purchased in hardcover here.

About the Authors: Arthur Kleinman is a medical anthropologist and psychiatrist who serves as professor in the departments of Anthropology, Social Medicine, and Psychiatry, and Director of the Asia Center, at Harvard University. Iain Wilkinson is a sociologist and Reader in Sociology in the School of Social Policy, Sociology and Social Research at the University of Kent.

Issue Highlight: Vol 39 Issue 4, Stimulant Use in the University

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This blog post is the last in a three-part series highlighting our newest installment of Culture, Medicine & Psychiatry (released December 2015) which readers can access here. This week, we explore Petersen, Nørgaard, and Traulsen’s research on the use of prescription stimulants amongst university students in New York City. The full article is available here.

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In recent dialogues on the widespread use of prescription stimulants amongst university students, drugs are often described as enhancing productivity or a student’s ability to successfully focus on academic work. However, Petersen, Nørgaard, and Traulsen found that university students in New York City often cited the use of these drugs as rendering their work more pleasurable, “fun,” and “rewarding.” Their study included 20 students spanning BA, MA, and PhD programs: representing a diverse sample that, in the aggregate, universally suggested that the use of stimulants in an educational setting was not centrally connected to academic output or production. This outcome, the researchers assert, complicates existing neoliberal readings of American personhood, premised on the idea that the self is primarily cultivated and disciplined through labor and individual productivity.

For example, rather than feeling shameful about using stimulants to improve study skills or produce better work, the students instead expressed guilt for enjoying their academic labors and for transforming “monotonous” and “boring” activities into an engaging experience. The “optimization” of the mind to perform intensive intellectual labor was not related strictly to productivity, which would evoke traditional neoliberal notions of the person-as-producer. Instead, the students described the drugs as optimizing pleasure first, which rendered them more productive as a secondary consequence.

Take this instance: a 32-year old PhD student, identified as Ben, reported using Adderall when he felt too “lazy” to initiate work. Rather than continuing by discussing the extent of his productivity while on the drug, he instead explains that the drug makes him eager “to tackle” his projects. This is often the case for students who struggle to find the desire to complete academic tasks that are not interesting enough to begin without being made pleasurable through stimulant use. Further, another student added that using stimulants helped him to “reconnect” with his interest in sociology during a difficult class on social science theory. In other cases, using Adderall kept students from being distracted from social media or entertainment websites: not because they lacked the inherent ability to be productive, but because without the drug, these sources of interest were simply more engaging than the work at hand. In other instances, students noted that stimulants made them feel more secure and positive about the quality of their work, and helped them to diminish the physical and mental stresses that came with “all-nighters,” or extended overnight studying stints.

Throughout all these cases, enhancement is not described as a means to make the human brain meet the demands of a “high-speed society.” Instead, “enhancement” relates to students’ satisfaction with their resulting work, to their enjoyment of otherwise “boring” tasks, and to reduced the negative psychosomatic effects of studying or working on a limited time frame.

The authors do not eschew the neoliberal model through these cases: indeed, they suggest that the use of stimulants does have cognitive effects that bolster students’ abilities to produce academic work. However, they note that we must complicate a strictly neoliberal model that would indicate that stimulants are employed by students strictly in order to achieve a certain amount of studying or to complete an assigned amount of work. Enhancement may include productivity, but for students who use stimulant drugs, it also involves increasing the pleasure of finishing intellectual labors, and decreasing the negative consequences of engaging in challenging or otherwise tedious academic work.

In this way, cognitive-enhancing drugs indeed fortify the mind and the conception of the self as a producer and academic laborer. However, they also shape human experience by altering students’ sense of confidence, their satisfaction with academic work, and their passion for their chosen topics of study. In these ways, enhancement drugs not only increase productivity in the neoliberal sense: they also broadly impact notions of pleasure and individual ability related to students’ quest to heighten academic production.

 

 

Issue Highlight: Vol 39 Issue 4, Incarceration & Medical Anthropology

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This blog post is the second installment of our three-part issue highlight on the new December 2015 issue of Culture, Medicine & Psychiatry (the full issue is accessible here.) In this week’s blog, we examine Carolyn Sufrin’s article on the shared roles of clinicians and anthropologists working with incarcerated women in the United States.

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Clinician-anthropologists are in a unique position to lend voice to their participants and to care for their medical needs. For Carolyn Sufrin, who served both as a physician and an ethnographic researcher for incarcerated women in the United States, the clinical and anthropological roles intersected in deeply meaningful ways. Sufrin notes that in these dual roles, she observed with female prisoners and analyzed their experiences, and provided reproductive health care and delivering the same women’s babies in a county hospital, where imprisoned women gave birth. The women were alternately enrolled in Sufrin’s study upon ceasing to officially be her patients, or were individuals that Sufrin cared for during her tenure as their OB/GYN.

Sufrin uses her case as an example of how to interpret the ethical consequences of working as a clinician-anthropologist. Part of the challenge she faced as both a physician and anthropologist to the women was that IRB and HIPAA regulations divided the types of data she could use in her anthropological research. Though some details of her participants’ lives, such as past trauma or childhood abuse, were essential to their experiences as mothers and as incarcerated women, she could not use this data inasmuch as it had been shared with her in the context of a patient-practitioner interaction: in other words, it was considered classified personal health information that could not be subsequently utilized in her ethnographic research. These methodological hurdles, Sufrin explains, shed light on the complexities of what constitutes “sacrosanct” data. It also suggests how the safeguarding of medical data does not necessarily translate to the “protective” collection of ethnographic data which is not isolated to the case of individual patients, and which relies on knowledge of participants and their connections to other people (in this instance, to individuals in the participant’s life who had caused past psychological harm.)

Likewise, as stated earlier, relationships between the participant/patient and the clinician/anthropologist are another form of interpersonal connection which must be reconfigured depending on the nature of the exchange taking place. In Sufrin’s case, this meant being clear with her participants that– upon entry into her anthropological study– she was no longer their physician, and that the nature of their exchanges and their professional relationship would take a new form. She could share their information (albeit de-identified), unlike information drawn solely from their medical records or from an examination.

Yet here, Sufrin notes that the anthropologist– like the clinician– is still engaged in an ethic of care. For example, one of Sufrin’s former patients in the prison was charged with child endangerment after giving birth in an alley and handing her child to a stranger, unable to afford treatment at a hospital following her release from prison. The story made news headlines, and as public knowledge, was within the realm of information that Sufrin employed in her ethnographic analysis of reproductive health in the American prison system. However, Sufrin knew an added piece of information that was not already publicized from her interaction with the woman in prison: a clinical detail that she understood as a physician, but was shared during her time as an ethnographic researcher. This detail would have enhanced her analysis of the situation, but she chose to omit it out of concern that to publicize the detail would be to betray the woman’s trust in her as a researcher and as someone who served in the prison as a physician.

In other instances that Sufrin discusses, her role as both an anthropologist and clinician led the women she worked with in each capacity to feel as if she was especially attentive and caring. Rather than always relying on her medical authority, Sufrin underscores her decision to remain non-judgmental and supportive even when the women in her study had made potentially harmful choices; for example, she chose not to openly admonish a woman who was continuing to use crack upon release from jail, despite being thirty-two weeks pregnant. Sufrin notes that her silence hid her own frustration with this choice, but it strengthened the woman’s trust in her as an anthropologist and “as a doctor.”

In sum, these dual roles ultimately bolstered her relationships to the incarcerated and formerly incarcerated women that she served. Thus, the author argues that both anthropologists and clinicians share an “ethic of care” in their relationships with research subjects or patients. This ethic involves a careful fostering of the professional, interpersonal connections that ethnographers make with research participants, or that physicians make with their patients. This care entails the protection of private information and the researcher/clinician’s conscious attendance to interpersonal exchanges that bolster the patient/participant’s trust in the clinician/anthropologist. Likewise, an analysis of the clinician role alongside the anthropological one demonstrates both the delineations between multiple forms of care and social connection, as well as the shared commitment in medicine and anthropology to the sensitive attendance to patient and participant experiences.