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.

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.

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

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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

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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.”

Book Release: Eigen’s “Mad-Doctors in the Dock”

Posted by jknopes

Image via JHU Press website

To be published this November 2016 from Johns Hopkins University Press is Joel Peter Eigen’s Mad-Doctors in the Dock: Defending the Diagnosis, 1760-1913. This medical history examines the foundations and early development of the criminal insanity defense in England. Drawing on testimony and documents from almost 1,000 trials, this text examines how physicians, surgeons, and other health care providers connected diagnosis with legal culpability. The text promises to carefully assess the dynamic relationships between criminal justice, mental health, medicine, and the emergent disciplines of forensic psychology and psychiatry. This book will be of equal interest to anthropologists of medicine and law, as well as psychological anthropologists, historians and sociologists of medicine, and cross-disciplinary scholars in the medical humanities.

To learn more about this upcoming release, click here.

About the Author: Joel Peter Eigen serves as the Charles A. Dana Professor of Sociology at Franklin and Marshall College as well as Principal Fellow (Honorary) at the University of Melbourne. This text is the third in a series that Eigen has published on the history of the insanity defense. The first book, Witnessing Insanity: Madness and Mad-Doctors in the English Court, was released in 1995 by Yale University Press and is available here. The second book, Unconscious Crime: Mental Absence and Criminal Responsibility in Victorian London, was published in 2003 by Johns Hopkins University Press. It can be purchased here.

From the Archive: Revisiting Neurasthenia in Japan

Posted by jknopes

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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.

2016 Preview: Books Received at the Journal

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First made available online last month, Culture, Medicine & Psychiatry has released its most recent lists of books received for review at the journal (which you can access on our publisher’s website at this link.) These books include Carlo Caduff’s The Pandemic Perhaps: Dramatic Events in a Public Culture of Danger and Janis Jenkins’ Extraordinary Conditions: Culture and Experience in Mental Illness. Last year, we featured Caduff’s text (here) and Jenkin’s text (here) in book release features here on the blog.

The journal has also received the following two books for review. Here are the two releases:

Image via UPenn Press website

New from the University of Pennsylvania Press is a collection of essays entitled Medical Humanitarianism: Ethnographies of Practice (available here.) Edited by Sharon Abramowitz and Catherine Panter-Brick, with a foreword by Peter Piot, the book explores the experiences of health workers and other practitioners who deliver humanitarian medical aid throughout the world. The book promises a “critical” yet “compassionate” account of humanitarian projects spanning Indonesia, Ethiopia, Haiti, Liberia, and other nations.

Image via Cornell UP website.

From Cornell University Press comes Gabriel Mendes’ Under the Strain of Color:
Harlem’s Lafargue Clinic and the Promise of an Antiracist Psychiatry (available here.) This historical text examines a mental health clinic in the 1940s established to treat psychiatric complaints amongst a primarily black, urban, underserved population. Unlike other treatment centers for mental illness at the time, the Lafargue Clinic was unique in its emphasis on the medical as well as the social contexts in which its patients experienced distress. The clinic challenged existing notions of “color-blind” psychiatry and became both a scientific and equally political institution, highlighting the “interlocking relationships” between biomedicine, the state, racial inequity, and community-based health care.

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

Posted by jknopes

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.

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.

AAA 2015 Sessions: The Anthropology of Mental Health Care

Posted by jknopes

Beginning last Fall 2014, we began compiling lists of sessions at the Annual Meeting of the American Anthropological Association that we thought would be of interest to our readers attending the conference. These sessions included topics such as drug use and abuse, reproductive medicine, and global health. This year, we again feature our series on the upcoming conference, to be held November 18-22 in Denver, Colorado (more information here.) You can also browse last week’s installment of the blog, where we highlighted sessions on biomedicine and the body at the upcoming Society for Social Studies of Science (4S) meeting, also in Denver, to be held November 11-14 (details here.) This week, we present three paper sessions on the anthropology of mental health care. The sessions are organized chronologically by time and date.

Image via AAA Website

Re-Institutionalizing Care: Anthropological Engagements with Mental Health Courts and Alternative Forensic Psychiatry Interventions in North America

Saturday, November 21st 10:15am-12:00pm (details about this session.)

Topics in this session will include racial disparities in a mental health court in Canada; the relationship between criminal justice officials, psychiatric crisis, and mental health; dogma and psychiatry; and mental health care reform. The session lists itself as particularly of note to applied and practicing anthropologists, especially those with an interest in mental health care, policy, and reform.

From the Streets to the Asylum: Medicalizing Vulnerable Children

Saturday, November 21st 10:15am-12:00pm (details about this session.)

This session includes work on the following topics: humanitarian care and child homelessness in Cairo, Egypt; drug use and treatment amongst juvenile prisoners in Brazil; immigrant youth and mental health in France; and notions of American childhood in the context of mental health. Though the session is sponsored by the Anthropology of Children and Youth Interest Group, its topics overlap with many contemporary issues in medical anthropology and the social study of mental health care.

Making Sense of Mental Health Amidst Rising Rural Social Inequality in North America: Class, Race, and Identity in Treatment-Seeking

Saturday, November 21st, 1:45pm-3:30pm (details about this session.)

Presenters in this session will speak on these issues: mental health and poverty in rural New England; mental health and prescription drug abuse in Appalachia; citizenship and mental health in Oklahoma; care access in remote Alaskan communities; community mental health activism; and inequity and depression in rural Kentucky. These sessions will be of interest to scholars of social justice and medicine, as well as those studying mental health care access and the culture of psychiatry in the United States.

Issue Highlight: Vol 39 Issue 3, Suicide in Rural Kenya

Posted by jknopes

When a new issue of Culture, Medicine & Psychiatry is released, we feature a series of blog posts that highlight these latest publications in our journal. The current September issue includes articles that address psychiatric conditions and the experiences of people with mental illness across cultures. Readers may access the full issue at Springer here: http://link.springer.com/journal/11013/39/3/page/1. In this issue highlight, we will discuss an article on ethnographic analyses of suicide and distress amongst three communities in northern Kenya.

Suicide in Three East African Pastoralist Communities and the Role of Researcher Outsiders for Positive Transformation: A Case Study

Bilinda Straight, Ivy Pike, Charles Hilton, and Matthias Oesterle – Pages 557-578

http://link.springer.com/article/10.1007/s11013-014-9417-4

The authors of this article strive to establish a nuanced and ethnographically rich understanding of suicide and mental distress in an under-studied population of three distinct, yet interacting, pastoral communities in northern central Kenya. These three groups– the Pokot, Samburu, and Turkana– are engaged in intercommunity conflicts over territory and land use agreements, despite the communities’ shared and entangled oral histories. Such tensions are only exacerbated by mutual fear of raids by other groups, dearths in food available for forage, and the theft of livestock from individuals who sell the animals to finance political campaigns. Poverty is likewise aggravated by these patterns of loss and violence.

This turbulent social environment creates widespread mental distress amongst the three communities, yet individuals from each group stressed to the research team that they felt obligated to persevere despite these pressures, making admitting psychological suffering (and especially confessing thoughts about suicide) deeply taboo. Therefore, any mental health intervention would have to be responsive to the extent to which Pokot, Samburu, and Turkana culture disallow individuals from discussing or even thinking about suicide: an act which could create even more social strain on the family of the person who committed it. The researchers confirmed this inability to discuss suicide by the high rates of non-response on a survey question which asked participants whether or not they had experienced suicidal thoughts.

Suicide thus proves to be a unique case for anthropological analysis because it is both driven by the social conditions of those who take their own lives, as well as disruptive to the communities in which these people lived. Its treatment by global health workers must in turn be sensitive to cultural beliefs that forbid conversation about suicide, especially in communities where the death of an individual may contribute to already extraordinary social distress.