Article Highlight: Vol. 41, Issue 1, “‘I Don’t Have Time for an Emotional Life’: Marginalization, Dependency and Melancholic Suspension in Disability”

This week on the blog we are highlighting Brian Watermeyer’s article “I Don’t Have Time for an Emotional Life”: Marginalization, Dependency and Melancholic Suspension in Disability. Watermeyer provides an introduction to key aspects of the social and economic marginalization of the disability minority experienced globally. He then explores and compares the complex debates surrounding materialist and psychological approaches and accounts of racism and disablism, particularly with reference to the place of grief and loss in disability discourse. Finally, Watermeyer considers how Cheng’s engagement with racial melancholia may help illuminate how disability inequality, like that of race, may remain a stubborn reality.

Watermeyer begins by discussing some theoretical orientations of social inequality. In the discipline of disability studies, it is a historical materialist (Marxian) approach which has dominated, with particular attention to psychological aspects of disability oppression. Disablism can be defined as discrimination based on physical, sensory, cognitive, or psychiatric impairment. Combined with critical and liberatory theory of racial inequalities, Watermeyer states it is reasonable to assume that living in the face of discrimination and marginalization will create feelings of grief, withdrawal, and suffering, as harms are sustained at both the physical and psychological levels.

In her book, The Melancholy of Race: Psychoanalysis, Assimilation and Hidden Grief, Ann Cheng (2000) presents a psychological model of racial inequality with loss at its center. For Cheng, racial inequality persists within the United States because it forbids grief. The larger, societal demand for every individual to strive for an ideal cultural whiteness continually pulls individuals away from an emotional center, creating ambivalence, a lack of self-empathy, and distortions of ideology.

Building off of Cheng’s argument, Watermeyer discusses the shared characteristics of racism and disablism. Prejudice and stigma are the ever-present companions of structural inequalities for both forms of disparity. Disabled people, especially those in low income countries, are the most vulnerable of the vulnerable, as most societies are designed with only the needs of the non-disabled majority in mind. There are formidable barriers to housing, transportation, and freedom of movement, as well as exclusion or segregation in education and other public accommodations.

Additionally, Watermeyer states the cultural embeddedness of making sense of disability via a “medical model” has reinforced the marginal position of disabled people. In this institutional view, social disadvantage is understood as a simple consequence of bodily difference or dysfunction, portraying disabled people as “damaged invalids” who are unable to contribute in community life. This view negates any consideration of discrimination’s role in inequality.

While the historical materialist view recognizes the role of biomedicine in justifying the marginalization of disabled people, it is the quantifiable, visible reality of exclusion from the workplace, and other “barriers to participation,” as its primary focus. Yet Watermeyer recognizes the analysis of oppression should not just be in the public, institutional spheres, but should also include private domains. Social exhaustion and scarcity have a psychological component, and it is important to understand the ways in which ongoing assaults on identity limit the imaging of different social organization.

For Watermeyer, there are several problems with describing feelings of damage and tragedy as arising from both congenital and adventitious impairment, with little or no attention to structural or contextual factors. This viewpoint positions impairment of the body as the central disadvantage faced by disabled people, ignoring injustices such as discrimination and rejection. Further, attaching narratives of tragedy to disabled people has been loudly rejected by the international disability movement. According to Kleinman, Das, and Lock (1997), if there is loss or grief in the lives of disabled people, it has to do with social suffering, not bodily “flaws.”

While discussing oppression and melancholia, Watermeyer describes an encounter with “J,” a male psychotherapy client living with tetraplegia (paralysis of the lower limbs and partial paralysis of the upper). A South African man in his mid-twenties, J lived a life of profound structural exclusion, unemployment, physical dependency, a poor social network, and imprisonment in his mother’s residence by poverty and poor public transportation. In his limited engagements with the world, indications that he was “broken” were commonplace.

When questioned about his emotional experience of these circumstances, J’s reply was, “I don’t have time for an emotional life.” At the subjective level, being trapped in an immovable system of structural exclusion meant being equally controlled by an “emotional economy,” with its own rules on what could be felt, loved, hated, or hoped for. In J’s life, these constraints appeared to limit emotional freedom as definitively as unreachable buses limited his movement. Emotional care, guilt, and limited space were the constant followers of his physical dependency, transferring feelings of sadness, frustration, or rage to unconsciousness. Simply, “not having time for an emotional life” meant not having the resources to overcome prohibitions on feelings and expressions of grief.

Melancholic systems deal with difference by maintaining existing racialized and discriminatory structures. This disjuncture produces a detrimental position involving both alienation from one’s emotional self, and experiences in the social world which repeatedly point to one’s failure to assume the ideals which secure real belonging. Watermeyer states that dominant culture presents disabled people with a paradox: while reaffirming the message that the disabled figure is dismal and broken, the world demands that he or she not grieve, as this would be a submission to the passivity, pessimism, and invalid status that pervade the disabled stereotype. As in the case of race, the ruling is “prove to me that you are not what I know you to be.”

Watermeyer’s perspective reframes lives of disabled people as basic to the universal human condition. The stereotype which attaches loss simplistically to impairment is rejected, and replaced by a more nuanced picture of struggle relating to discrimination, structural exclusion, pain, fatigue, and the host of everyday miseries that punctuate any human life.


References Cited:

Cheng, Ann A. (2000) The Melancholy of Race: Psychoanalysis, Assimilation, and Hidden Grief. Berkley: Oxford University Press.

Kleinman, A., V. Das, and M. Lock. (1997) Social Suffering. Berkeley: University of California Press.

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

Interview: Jonathan Sadowsky and “Electroconvulsive Therapy in America”

9781138696969This 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!

  1. 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.

  1. 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.

  1. 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.

  1. 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.

  1. 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.

  1. 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.

  1. 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

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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: The Mental Health Treatment Gap Across Africa

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.”