SPA Interview with Dr. Rebecca Lester

This week on the blog we are featuring a partial summary of an interview with Dr. Rebecca Lester, conducted by Ellen Kozelka, as part of the Society for Psychological Anthropology “Voices of Experience” series. In this audio conversation, available in full here, Dr. Lester discusses her newest book project, Famished: Eating Disorders in the Era of Managed Care, focusing on the conditions and experience of eating disorders treatment in the United States. Also discussed in the interview is Dr. Lester’s research interests, reflections on her personal experience experience with an eating disorder, and the linking of anthropology to advocacy. Dr. Lester’s book is not yet for sale.

The SPA “Voices of Experience” series is a venue to showcase the range of work that psychological anthropologists engage in, and to give listeners, virtually attending the live events, the opportunity to ask prominent scholars in the field about their work.


The interview begins with a reading of the book’s preface by Dr. Lester herself. The recitation narrates the experience of an insertion of a nasogastric (NG) tube and subsequent first “feeding” of an 11-year-old girl with anorexia. Capturing the anxiety and fear of being forcibly held down for the insertion of the NG tube, and yet still being terrified of eating, Dr. Lester describes the instructions given by the doctor before inserting the NG tube. “We are going to put it in. You can either cooperate with me here, or we can take you to a seclusion room and put you in restrains and do it there. It’s your choice,” the doctor says to the girl.

The process of having an NG tube placed is extremely uncomfortable. Feeling disconnected from the world around her, exhausted from the painful NG tube ordeal, and distraught from watching “so many calories” being pumped into her body while she is unable to do anything about it, the young girl is then further mentally assaulted by another patient nearby asking her questions about her new feeding tube.

“Is [anorexia] the thing where you’re scared of getting fat so you starve yourself and you get real skinny? Hell, I wish I could have anorexia for a day,” the older patient states while laughing and grabbing at her own stomach fat. The young girl is then left to make sense of her situation while listening to the woman and another patient chatting about how much they wish they had the willpower to starve themselves as the holiday season approached.

This preface sets the tone for what it is like to be a patient in an eating disorders clinic. This reading then transitions the conversation into the interview between Dr. Lester and Ellen Kozelka.

Ellen Kozelka: What is the managed care system as it relates to eating disorders treatment, and why is it so important to understand its moral dimensions?

Dr. Lester: Managed care operates as a moral system in our society. So in terms of eating disorders, we are in a situation where our healthcare system is really predicated on a certain kind of understanding of what health is and what a person is. This is foundationally oriented to the splitting off of behavioral health and medical care.

Managed care plans have a pot of money that goes to medical care, and another pot of money is set aside for mental health, behavioral, or psychiatric care, depending on how insurance companies classify it. What’s challenging in terms of eating disorders is that they are conditions that bridge both of those domains. Certainly there are medical complications to other things, such as addictions, but we find in eating disorders this bridging of the medical and of mental health in terms of the symptomatology.

Trying to get an integrated treatment approach for eating disorders is really difficult. Clinicians are left to try and piece together care, but getting that care reimbursed is extremely difficult. Often times managed care companies will pay for the acute medical issues, such as an inpatient hospitalization because of a cardiac incident, but you then cannot also get mental health care at the same time. Or you can go to an outpatient clinic for the psychiatric concerns, but you then are not able to also be treated for the physical complication that might be going on too. Thus it is very difficult to provide a full spectrum of care to someone in a way that is actually going to treat the problem.

Kozelka: The foundation of the system in the US is that physical medical care and mental health care are two separate things, which based on this idea of what health is and what the person is. So would that make managed care in the US a type of cultural system?

Dr. Lester: Absolutely. One of the things I’ve been interested in is what kind of philosophies of the person are embedded in our healthcare system and how is that structuring or impacting the way that clinicians are perceiving what’s going on with clients, what the problem is, or how to best intervene with them. It’s a whole epistemological and world view about humans and what motivates humans, and what the appropriate end goal of that behavior should be.

Kozelka: In your book you provide an overarching definition of care. Care “orchestrates cognitive and sensory attunement, practical agency, and affective imagination into a disposition to the ‘other’ which comes to organize attention, doing, and feeling in locally meaningful ways.” This definition of care combines two previously separate conceptual definitions of care as practical or political action, and care as affective concern. How do you see this combination linking to your understanding of care in relation to power?

Dr. Lester: Something that many of us as psychological anthropologists struggle to do in our work is try to illuminate the ways that these are not different domains. When we talk about political or practical action, and we talk about affective experience or subjective experience, they are not separate domains. We can separate them ideologically, but in terms of the way people live their lives, the domains are intertwined.

Part of what I’ve been interested in is how these structures of power operate across multiple levels of analysis at once. Care in all of the senses of the definition above, is a way of constituting not only an object of concern, but who the subject of care is, and how that person is constituted as a moral agent, or not, in a given circumstance. We have to look at how political and practical components of care are connecting and interacting with the affective dimensions and the subjective experience of care. That is where you see psychological anthropology coming in and trying to theorize about what these connections are in a way that’s rigorous and ethnographically grounded.

Kozelka: How do these moral dimensions of care, in terms of whether the or not the individual is considered to be a “good patient,” relate to the actions that these managed care systems either take or don’t take?

Dr. Lester: There are different ways of thinking about a patient, such as framing the patient as a moral actor, or discussing the patient in relation to her own quest for health, whatever that is. In the case of eating disorders, it can become a situation where it almost does not matter what the patient does. It does matter, but the same action can be interpreted in a variety of ways depending on how you are thinking about that actor as a moral agent or not.

Compliance and non-compliance are big concerns in all of healthcare, certainly in behavioral health, but particularly in the field of eating disorders where patients are historically thought to be non-compliant, resistant, or really difficult to work with. Managed care companies have concerns about patient complying with the treatment recommendations. What I saw again and again is that it almost did not matter what the patient did. There would be times where they were complying, following the regulations and meal plans, and doing what they were supposed to do. But the insurance companies were skeptical of the motivations for this behavior, so that even when clients were complying with treatment, their compliance was sometimes read as manipulation. That’s just an example of how these moral dimensions, or how you constitute the recipient of care as a moral agent or not, affects the way that care is delivered, almost regardless of what the person is actually doing.

Kozelka: In this system were patients are constantly being scrutinized, how do you think these factors affect their experience of treatment?

Dr. Lester: It’s horrible. It would be miserable for any of us to be in that circumstance. This is particularly challenging for these patients because a lot of the dynamics experienced during the course of treatment itself are the exact same issues that they are already struggling with. These are questions like, “Are you worthy of care,” “Are you worthy of attention,” “Are you worthy of time,” and “Do you matter?” These questions are really at the core of eating disorders for a lot of people.

Dr. Rebecca Lester, via Washington University in St. Louis Dept of Anthropology website

Patients are being told they should not always be monitoring or surveying themselves, yet at the same time, because of the kinds of things that the insurance companies care about in order to make their decisions, patients are being constantly monitored and evaluated. There is a constant, pervasive insecurity that pervades that clinic where you do not know from one day to the next if someone is going to be deemed “sick enough” to still need care, “too sick” to remain there, “invested enough” in her recovery, or “invested too much in her recovery” and thus deemed as manipulative. It is this constant uncertainty and people trying to make themselves into appropriate patients just so that they can get care.

This does not address the underlying issues that are going on. So this scrutiny affects them a lot, especially when clients want treatment, doctors say they need treatment, but insurance companies say “No.” There are even discussions among the clinicians, expressing that “if only she were cutting, because then we could get her treatments.”

Further, the patients may not even be able to deal with some of the underlying things that possibly got them to the eating disorder because they are so busy dealing with the feelings around not being worthy of getting treatment. If the insurance companies deny them, they cannot get treatment. There is a case I discuss in the book of a 14 year-old teenager who was struggling with anorexia in the clinic. Her weight had gone up a bit during the two or three weeks she was admitted and making progress. But then her insurance ran out, and the family did not have the financial resources to afford the $1,200 a day price tag. Their only option was to get the teenager into a research study going on at a local university where a randomly assigned treatment group would get free therapy. The problem was that she had gained too much weight for the regulations of the study, forcing the clinic staff to put her on a diet at the treatment center in order to get her down in weight enough so that she could get free treatment. That was the only option besides merely discharging her with no support.

Kozelka: What do you think the study of self brings to anthropology as a whole?

Dr. Lester: It’s absolutely critical. The self as a general category is about why people do what they do. We cannot understand why, or effectively theorize about why, unless we are willing to engage with questions about parts of experience that we cannot directly observe. We have to be open and flexible enough to understand different ways that different groups of people comprehend the components of what makes up a person, how to understand motivation, or whatever we want to call why people do things. It is imperative if we, as a field, want to have something useful to say.


The interview with Dr. Lester continues, and concludes with a question and answer session with listeners who were virtually tuned in during the live recording of the interview. The full audio interview recording is available here.


Dr. Rebecca Lester is an Associate Professor of Sociocultural Anthropology at Washington University in St. Louis, and a practicing clinical social worker. Her interests include how individuals experience existential distress, and how this distress manifests as psychiatric symptoms, religious angst, somatic pain, and other culturally informed bodily conditions.  Specifically, she considers how bodily practices deemed “deviant,” “extreme,” or “pathological” – and local responses to such practices – make visible competing cultural logics of acceptable moral personhood. Along with her many publications and previous book, Jesus in our Wombs: Embodying Modernity in a Mexican Convent (2005) from the University of California Press, Dr. Lester is also the founder, Executive Director, and a psychotherapist of the non-profit Foundation for Applied Psychiatric Anthropology.

Ellen Kozelka is a graduate student at University of California, San Diego.

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In the News: “Life After the Storm” and the Psychological Impacts of Hurricane Survivorship

In our In the News post this week, we are discussing the lasting psychological impacts people face after surviving a large natural disaster event, such as the string of recent hurricanes battering the United States and the Caribbean. Building from a recent New York Times article by Benedict Carey entitled Life After the Storm: Children Who Survived Katrina Offer Lessons, available here, this post discusses how lasting damage from natural disasters can be much more than physical and economic.


September 2017. Benedict begins his article by sharing the story of Craig Jones, now 22 years old, who was in fifth grade when Hurricane Katrina in 2005 devastated his neighborhood of Pigeon Town in New Orleans. After spending years on the move, living between hotel rooms, Jones returned to New Orleans in his late teens. He remembers that “home” was not the same place he had left, and his “homesickness” became troubling anxiety and seemingly random panic attacks.

Lacey Lawrence, 22, at work in New Orleans. She escaped the floods of Hurricane Katrina on an air mattress. Now she teaches children coping skills. Credit: Annie Flanagan for The New York Times

Another survivor, Lacey Lawrence, now 22, escaped the water of Hurricane Katrina on an air mattress. Lawrence recalls the experience of seeing police officers pushing away floating bodies with oars, missing and uncle who presumably drowned, and wondering where a young cousin disappeared to for several hours. Later, at a new school, Lawrence was ill-equipped to deal with her experience. “I was getting into fights; real fights, violent ones. That was something I never did before, ever. But you lose everything and you don’t know how to deal with it – no one prepares you for that” (Benedict 2017).

Studying the psychological impacts from previous hurricanes may offer hints of what may be to come for those who have survived Hurricane Harvey, Irma, and most recently, Maria. Mental health providers and social scientists are acutely aware of the unpredictable traumatic consequences which can emanate from surviving natural disasters. Yet the impacts of surviving a hurricane may be unique.

Benedict (2017) writes, “Unlike an earthquake or a fire, flooding from a storm like Katrina or Harvey leaves many houses and buildings still physically standing but uninhabitable, simultaneously familiar and strange, like a loved one sinking into dementia.”

In a series of publications from the Stress & Development Laboratory at the University of Washington, the research teams concluded that the prevalence of “serious emotional disturbance” (SED) in young adults after exposure to Hurricane Katrina remained significantly elevated several years after their experience of the storm (McLaughlin et al. 2010). The prevalence of SED among young adults who experienced Hurricane Katrina was considerably greater than the pre-hurricane prevalence. According to a 2010 study, approximately 8% of youths were estimated to have SED that is directly attributable to their experience of the hurricane. Further, the majority of adults who developed posttraumatic stress disorder (PTSD) after Katrina, including delayed onset PTSD, did not recover within 18-27 months (McLaughlin et al. 2011).

Prior to Hurricane Katrina, the majority of the literature focuses on the prevalence of and risk for the development of mental health problems following a storm or hurricane. For example, a study of the presence of PTSD symptoms after Hurricane Mitch in 1998 in a low-income area of Nicaragua found that the occurrence of PTSD in the areas with the least damage was 4.5%, while the most damaged areas was 9% (Davis, Tarcza, and Munson 2009). Variables such as low social support, prior exposure to traumas, and poor health status were found to be universally predictive of psychopathology symptoms (Davis, Tarcza, and Munson 2009).

A 2005 study by Fried, Domino, and Shadle looked at the use of mental health services after Hurricane Floyd in 1999 and found that visits to psychologists, licensed clinical social workers, and physicians for mental health reasons were higher in affected areas after the hurricane. However, inpatient admissions and the money spent on anti-anxiety medications decreased, indicating that there were likely problems with service delivery for those that did seek help (Davis, Tarcza, and Munson 2009).

Flooded homes are shown near Lake Houston on Aug. 30 after Hurricane Harvey hit the Houston area.
Photo from NPR: Win McNamee/Getty Images

In the aftermath of Hurricane Harvey, Texas officials were “scrambling to coordinate mental health support” and the state’s psychology board issued temporary practice licenses for out-of-state therapists (Benedict 2017).

In a recent CNN article, Jesse Cougle, an associate professor of psychology at Florida State University, said that the people who stared and witnessed the destruction of Hurricane Irma will likely experience worse mental health problems than those who evacuated (Scutti 2017).

Chief of emergency mental health and traumatic stress services branch at the Substance Abuse and Mental Health Services Administration, Capt. Maryann Robinson, stated that “when you go home and now you are actually faced with what has happened — the devastation that has occurred in your home — it really does re-traumatize the individual” (Scutti 2017).

Overall, anticipating the consequences for major hurricanes should encompass more than disaster preparedness schemes and evacuations routes. Multi-state collaborations

Katrina’s young survivors, now older and reflecting on their experiences, say that “overcoming the mental strain of displacement is like escaping the rising water itself – a matter of finding something to hold onto, one safe place or reliable person, each time you move” (Benedict 2017).


References Cited:

Davis T.E., Tarcza E.V., Munson M.S. (2009) The Psychological Impact of Hurricanes and Storms on Adults. In: Cherry K. (eds) Lifespan Perspectives on Natural Disasters. Springer, New York, NY. Pp. 97-112. (Available here: http://stressdevelopmentlab.org/publications)

McLaughlin, K. A., Berglund, P., Gruber, M. J., Kessler, R. C., Sampson, N. A., & Zaslavsky, A. M. (2011). Recovery from PTSD following Hurricane Katrina. Depression and anxiety, 28(6):439-446. (Available here: http://stressdevelopmentlab.org/publications)

McLaughlin, K. A., Fairbank, J. A., Gruber, M. J., Jones, R. T., Osofsky, J. D., Pfefferbaum, B., … & Kessler, R. C. (2010). Trends in serious emotional disturbance among youths exposed to Hurricane Katrina. Journal of the American Academy of Child & Adolescent Psychiatry, 49(10):990-1000. (Available here: http://stressdevelopmentlab.org/publications)

Carey, Benedict. (September 8, 2017) Life After the Storm: Children Who Survived Katrina Offer Lessons. The New York Times. Available here: https://www.nytimes.com/2017/09/08/health/katrina-harvey-children.html?rref=collection%2Fsectioncollection%2Fhealth&_r=0

Scutti, Susan. (September 20, 2017) Resilience, suffering and silver liniings after a disaster. CNN. Available here: http://www.cnn.com/2017/09/19/health/psychological-aftermath-hurricanes-harvey-irma/index.html


Further Reading:

Davis III, Thompson, Amie Grills-Taquechel, and Thomas Ollendick. (2010) The Psychological Impact From Hurricane Katrina: Effects of Displacement and Trauma Exposure on University Students. Behav Ther 41(3):340-349.

Domonoske, Camila. (September 26, 2017) Long After The Hurricanes Have Passes, Hard Work – And Hazards – Remain. NPR. Available here: http://www.npr.org/sections/thetwo-way/2017/09/26/552063244/long-after-the-hurricanes-have-passed-hard-work-and-hazards-remain

Fothergill, Alice, and Lori Peek (2015) Children of Katrina. Austin: University of Texas Press. Available here https://utpress.utexas.edu/books/fothergill-peek-children-of-katrina

McLaughlin, K.A., Fairbanks, J.A., Gruber, M., Jones, R.T., Pfefferbaum, B., Sampson, N., & Kessler, R.C. (2009). Serious emotional disturbance among youth exposed to Hurricane Katrina two years post-disaster. Journal of the American Academy of Child and Adolescent Psychiatry, 48:1069-1078. (Available here: http://stressdevelopmentlab.org/publications)

Shear, M. K., McLaughlin, K. A., Ghesquiere, A., Gruber, M. J., Sampson, N. A., & Kessler, R. C. (2011). Complicated grief associated with Hurricane Katrina. Depression and Anxiety, 28(8):648-657. (Available here: http://stressdevelopmentlab.org/publications)

Article Highlight: Vol. 41, Issue 1, “‘Hunger Hurts, but Starving Works.’ The Moral Conversion to Eating Disorders”

This week we’re highlighting Gisella Orsini’s “Hunger Hurts, but Starving Works.” The Moral Conversion to Eating Disorders article. Orsini suggests that eating disorders are the result of moral self-transformative processes. Women in Malta and Italy with anorexia, bulimia, and binge eating disorders are thus actively and deliberately engaged with cultural moral values embodied in thinness and the control of bodily needs and pleasure. Thus, the more control over hunger, the higher the level of satisfaction and the degree of moral conversion achieved.

Orsini begins by discussing the history of eating disorders within the Diagnostic and Statistical Manual of Mental Disorders (DSM), highlighting that the explanations of onset, classification, and treatment has often been, and to a large extent remains, unclear. Yet before the medical category of “eating disorders,” behaviors which would now be considered symptoms of pathology had different meanings, often characterized as holy behavior or as a wonder of nature. Medieval European nuns often adopted strict starvation practices in order to reach unity with Christ. Pre-Victorian and Victorian era “fasting women” were admired by the rest of society and were considered curiosities by scientists and doctors. Orsini narrows the modern gap between the biomedical construction of illness and the self-perception of patients through an understanding of the narratives of people with eating disorders and framing it as a process of self-transformation.

Between 2012 and 2014, Orsini conducted comparative qualitative research in Malta and Italy. Even though the prevalence of eating disorders was relatively similar between the two countries, the social reactions to eating disorders were markedly different. The Italian government considers eating disorders to be a “social epidemic, which leads to serious problems in terms of public health.” Malta, by contrast, has almost no concern with eating disorders at the public level as well as a lack of public and private treatment institutions. Both countries aligned with the international trend of eating disorders being mostly female.

In framing eating disorders as a moral conversion, on the basis of the interview narratives she collected, Orsini suggests that eating disorders could be considered as the body becoming a physical symbol of an attempt to redefine their lives. Yet the biomedical approach views the behavior of people with an eating disorder as stemming from a mental condition. Orsini states, “anorexics, bulimics and binge eaters actively and deliberately adopt behaviors in relation to food and their own bodies in order to morally improve themselves.” All of Orsini’s participants sought to dominate their bodily needs in order to improve themselves morally. Furthermore, all recalled negative moral feelings, such as guilt and shame, when their behavior was not in line with their moral values of purity and control. In this way, moral values became moral imperatives.

Yet not all people with eating disorders reacted to their diagnosis’ pathologization in the same way. Anorexics tended to be the most resistant to their newly achieved satisfactory personhood with illness. Bulimics and people with binge eating disorder, on the other hand, tended to experience relief at being labeled “ill,” identifying more with their condition as a disorder rather than a moral conversation.

Orsini states that although the main objective of people with eating disorders is thinness, this thinness is simply the end result of several behaviors that aim to ameliorate one’s self in highly moral terms. The process of a moral conversion requires an individual to adopt views, attitudes, or patterns of behavior that are generally thought of as morally better than their previous views. Orsini then further divides the three discussed eating disorders into levels of conversion: achieved moral conversion for anorexia nervosa, attempting moral conversion for bulimia nervosa, and rejecting moral conversion for binge eating disorder.

In the case of anorexia nervosa, Orsini presents the circumstances of Elisa, a 28-year-old woman in residential treatment in Italy. Elisa’s narrative of transforming her body from being “sinful and dirty,” to a “pure and sinless body” through her anorexia is an example of an achieved moral conversion. Yet she was forced to abandon her new perspectives and values in order to live. Elisa had to decide if the costs of her anorexic beliefs justified the benefits, leading to a painful moral choice.

For bulimia nervosa, Orsini discusses that people who are diagnosed with bulimia after having had a history with anorexia can be said to have lost the ability to practice the core values associated with anorexia, even though they still consider such values (such as controlling hunger and thinness) to be core values in their lives. Orsini’s participants who were not diagnosed previously with anorexia often spoke of their daily frustrating struggle to control their hunger; while they are unable to totally control their eating, the compensatory behavior of self-induced vomiting, laxative use, or over-exercising was still an attempt at thinness. This continuous attempt to control their hunger, followed by “repairing the damage caused by their moments of weakness,” is an example of how they are attempting moral conversion.

Finally, for Orsini, binge eating disorder is seen as a case of rejecting moral conversion. While the people in Orsini’s research diagnosed with binge eating disorder still described thinness and control over food as a core value in their lives, unlike the anorexics and bulimics, people with binge eating disorder did not believe they deserved to ameliorate themselves. Their self-transformative process can be understood as a form of self-punishment as well as a statement of their perceived failure in being the person they want to be.

Michelle, a 34-year-old Maltese woman, spoke of her body as a sign of failure after gaining a significant amount of weight during and after pregnancy. Orsini states Michelle never referred to her body in aesthetic terms, such as “ugly,” but instead as a mark of her inabilities and moral dissatisfaction. She states, “If I was slimmer, if I am slimmer, I would be a better person” (p. 134). For Michelle, bingeing was a manifestation of her moral failures.

In conclusion, Orsini reiterates that only viewing people with eating disorders as having a physiological or psychological dysfunction underestimates the active role their conditions and cultural meanings of their behaviors. Through her analysis of the narratives of people with an eating disorder in Malta and Italy, she reveals how anorexics, bulimics, and binge eaters deliberately engage in a number of practices aimed at losing weight in order to improve themselves in moral terms. Their actions are further divided into an unofficial moral hierarchy, wherein anorexics embody an ideal moral-selfhood.

Message from the Society for Applied Anthropology 2017 Annual Meeting

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“Like the roads to Rome, all trails lead to Santa Fe” (Ruth Laughlin, Caballeros, 1931)

The Culture, Medicine & Psychiatry editorial team sends our greetings this week from the Society for Applied Anthropology 2017 Annual Meeting in Santa Fe, New Mexico. This year’s meeting will be held March 28th – April 1st, with session listings and other helpful information available here. We hope all of our readers attending the conference have safe travels to– and many productive conversations at– this year’s meeting.

This year’s theme is “Trails, Traditions, and New Directions,” embracing the Santa Fe location as a place steeped in centuries of traditions, where Native histories reach back 10,000 years and follow paths through time and across geographical space. Metaphorically, this theme highlights the importance of understanding the history and intended destination of those “theoretical trails” that we follow when engaging our community partners, methodology, and active interpretations. Presentations that approach current issues from a historical perspective—including health disparities, energy and climate change, interpreting culture—or any of our broad concerns are encouraged, as is work that critically examines the motivations that have guided social science research and practice in the past.

Highlights from this conference will be featured on the blog next week.

Best wishes,

The CMP Editorial Team

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.

 

Message from the Society for Psychological Anthropology 2017 Biennial Meeting

spa-logoThe Culture, Medicine & Psychiatry editorial team sends our greetings this week from the Society for Psychological Anthropology 2017 Biennial Meeting in New Orleans, Louisiana. This year’s meeting will be held March 9-12th, with session listings and other helpful information available here. We hope all of our readers attending the conference have safe travels to– and many productive conversations at– this year’s meeting. As a reminder, we continue to accept guest blog submissions on topics spanning cultural medical anthropology and related disciplines in the social sciences and medical humanities.

Highlights from this conference will be featured on the blog next week.

Consider submitting an abbreviated version of your SPA conference presentation as a guest blog, or write a commentary on one of the keynote speeches at the event. We look forward to sharing the work and research of our readers with our colleagues on the blog! If you are interested in submitting a guest blog, please contact social media editor Sonya Petrakovitz at smp152@case.edu for details.

Best wishes,

The CMP Editorial Team

Books Received for Review: February 2017

This week we are featuring previews of four books received for review at Culture, Medicine, and Psychiatry (available here). These previews provide a snapshot of recent publications in medical anthropology, global health, and the history of medicine that we’re excited to discuss in our journal and with our followers on social media.


9780520282841

via UC Press

Blind Spot: How Neoliberalism Infiltrated Global Health

Salmaan Keshavjee

From the University of California Press, Blind Spot is a historical and anthropological case study of how market-based ideologies and neoliberal health policies impact global health and development programs. “A vivid illustration of the infiltration of neoliberal ideology into the design and implementation of development programs, this case study, set in post-Soviet Tajikistan’s remote eastern province of Badakhshan, draws on extensive ethnographic and historical material to examine a ‘revolving drug fund’ program — used by numerous nongovernmental organizations globally to address shortages of high-quality pharmaceuticals in poor communities.” The books discusses how the privatization of health care can impact outcomes for some of the world’s most vulnerable populations.

For more information, visit the University of California Press website here.


via Berghahn Books

via Berghahn Books

Cosmos, Gods, and Madmen: Frameworks in the Anthropologies of Medicine

Roland Littlewood and Rebecca Lynch, eds.

“The social anthropology of sickness and health has always been concerned with religious cosmologies: how societies make sense of such issues as prediction and control of misfortune and fate; the malevolence of others; the benevolence (or otherwise) of the mystical world; local understanding and explanations of the natural and ultra-human worlds. This volume presents differing categorizations and conflicts that occur as people seek to make sense of suffering and their experiences. Cosmologies, whether incorporating the divine or as purely secular, lead us to interpret human action and the human constitution, its ills and its healing and, in particular, ways which determine and limit our very possibilities.”

For more information, visit the Berghahn Books website here.


via UC Press

via UC Press

A Passion for Society: How We Think about Human Suffering

 Iain Wilkinson and Arthur Kleinman

“What does human suffering mean for society? And how has this meaning changed from the past to the present? In what ways does “the problem of suffering” serve to inspire us to care for others? How does our response to suffering reveal our moral and social conditions?” This highly anticipated book investigates how social science has been shaped by problems of social suffering. The authors discuss how social action, through caring for others, is reshaping the discipline of social science and offers a hopeful, intellectual basis for a fundamentally moral stance against indifference, cynicism, and inaction. They argue for an engaged social science that bridges critical thought with social action, seeking to learn through caregiving, and achieving greater understanding that operates with a commitment to establish and sustain compassionate forms of society.

For more information, visit the University of California Press website here.


via UC Press

via UC Press

It’s Madness: The Politics of Mental Health in Colonial Korea

Theodore Jun Yoo

“This book examines Korea’s years under Japanese colonialism, when mental health first became defined as a medical and social problem. As in most Asian countries, severe social ostracism, shame, and fear of jeopardizing marriage prospects compelled most Korean families to conceal the mentally ill behind closed doors. This book explores the impact of Chinese traditional medicine and its holistic approach to treating mental disorders, the resilience of folk illnesses as explanations for inappropriate and dangerous behaviors, the emergence of clinical psychiatry as a discipline, and the competing models of care under the Japanese colonial authorities and Western missionary doctors. Drawing upon printed and unpublished archival sources, this is the first study to examine the ways in which “madness” was understood, classified, and treated in traditional Korea and the role of science in pathologizing and redefining mental illness under Japanese colonial rule.”

For more information, visit the University of California Press website here.