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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SPA 2017 Biennial Meeting: Breakfast Lecture with Richard Shweder and Byron Good

This week we’re featuring a summary of The 2017 Biennial Meeting of The Society for Psychological Anthropology Breakfast Lecture. This year, the Breakfast Lecture presented a conversation with the 2016 Lifetime Achievement Awardee, Richard Shweder, and the 2017 Lifetime Achievement Awardee, Byron Good. In this event, Dr. Shweder and Dr. Good reflect on morality and “the mental” in both Cultural Psychology and Psychological Anthropology, discussing how profoundly different worlds still share some moralities and orientations. They also discuss some critical challenges and opportunities for psychological anthropology. By interviewing each other, a foundational technique in anthropology itself, Dr. Shweder and Dr. Good explore their past works, theoretical orientations, and their anticipation of where anthropological explorations of psychological processes are heading.

2016 SPA Lifetime Achievement Awardee Richard Shweder

The conversation begins with Dr. Good asking Dr. Shweder to “tell us about your history.” Dr. Shweder delves into his upbringing in Great Neck on the north shore of Long Island, at the time an emerging suburb with a very progressive, left-wing population. He discusses the first time he heard the word anthropology in his 11th grade English class when “Mr. Beal” said, “for any of you who don’t know what to do in life, there’s this thing called anthropology.” After graduation Dr. Shweder went to the University of Pittsburgh where Dr. Arthur Tuden, an Africanist and Cultural Anthropologist, taught his Introduction to Anthropology class, bringing in the study of culture with current events and ultimately solidifying Dr. Shweder’s path in Anthropology. From Pittsburgh, Dr. Shweder progressed to Harvard, where he states several figures had an impact on his intellectual growth, including Cora DuBois and John Whiting. After finishing his Ph.D. at Harvard, Dr. Shweder taught at the University of Nairobi in Kenya before finally landing at the University of Chicago.

Dr. Shweder then, discussing approaches and schools of thought in Cultural Psychology, defines Cultural Psychology as “the study of differences in mentalities across human populations.” Psychological Anthropology, for Dr. Shweder, has been more interested in taking universal psychological schemes and applying them to particular cultures to see whether or not different practices or beliefs were essentially manifestations of a broader psychological concept, such as a variation on an Oedipus complex. There is not a denial of universals in Cultural Psychology, however, since, to Dr. Shweder, there is not a way of studying differences without also studying universals. Dr. Shweder describes his way of defining the Cultural Psychology of Morality as “investigating the fates of moral absolutes in history and to show the way they get transformed, take on different content, and lead to different judgments.” To Dr. Shweder, behind a culture or individual is a set of moral absolutes, or rules of moral reason. Yet these moral absolutes and rules are abstract concepts which do not present determinations of actual cases, histories, or cultural contexts. Cultural Psychology is not about looking for likenesses, but looking for the differentiations and local adaptations that have taken place. For Dr. Shweder, the psychological means looking at differences in “the mental.” “The mental” refers to what people know, think, feel, want, and value as good and bad. Dr. Shweder states, “Anywhere you look in the world you’re going to find that people know, think, feel, want, and value things as good and bad. In some sense, that’s what it means to be a person.”

Dr. Shweder follows up with a discussion that anthropologists are supposed to fairly represent the groups they study; to try to portray their way of life in a way that the people the anthropologist is writing for might see them not as “exotic aliens,” but as morally sensitive persons who do things for recognizable reasons. Dr. Shweder proposes the conspicuous use of the notion of “oppression,” or seeing the social order as oppressive, combined with the now popular term “agency,” suggests that to have agency was to be opposed to culture. Thus, for Dr. Shweder, the concept that there might be people whose agency was used to carry forward a cultural tradition which was in a framework where they felt they could be fulfilled, was gone. “When I went to India I was in a world where if I approached it as ‘a good liberal,’ assuming everything is free choice and the world is there to satisfy my preferences, I would have seen it as an oppressive order. Yet the people who live there, for the most part, feel quite at home with rich, meaningful lives,” Dr. Shweder states.

Building off the discussion of morality, Dr. Good then engages with concepts of morality and oppression. Dr. Good states that for him, the experience of morality is often an experience of oppression. He expresses that many people spend at least parts of their lives resisting or fighting against morality, feeling that the moral system around them is actually an oppressive system causing them to live their lives “wrongly” within it. It seems to Dr. Good that reading ethics with a grand “they” or a grand “we” misses, ethnographically, another side of the story. Dr. Shweder responds that there is a multiplicity of the moral world. The moral world has many goods and desires that are in conflict with each other, and one cannot have them all. This sets up the dynamic of resistance since the system of conflict and prioritization pushes alternatives to the side. Dr. Shweder states that within any society there is the orthodox and the heterodox, that which is center stage and that which is done covertly. The mistake is to privilege one ethic over another, to act as if that privileging itself is not a choice or commitment, or to label the ethic of autonomy as the “natural way” in which anyone who is fully enlightened will ultimately go. Dr. Shweder cautions against the view of “liberalism as destiny,” where there are stages of moral development, the height of moral development being an autonomous, individualized person or society.

2017 SPA Lifetime Achievement Awardee Byron Good

Dr. Good then discusses his personal and academic history. He starts by commenting that his childhood and upbringing couldn’t have been more different than Dr. Shweder’s, growing up on a Mennonite farm in the Republican mid-west. Dr. Good spent much of his life feeling that religion and divinity grounded and oriented aspects of his academic life. “I don’t romanticize ethical norms if they, over time, have become more and more interested in controlling our lives in ways that we have very little direct knowledge of,” Dr. Good states. “I don’t romanticize suffering.” While at Goshen College in Goshen, Indiana, Dr. Good started studying mathematics before spending a year at the University of Nigeria. Dr. Good expressed this time as having a powerful impact which changed his life. “My worldview became profoundly different,” he states. Coming back from Africa convinced that there had to be something more than mathematics, Dr. Good decided to go to Harvard Divinity School. It was there that he began taking courses in anthropology and religion. Attending the University of Chicago for his Ph.D., Dr. Good states his first year at Chicago was Clifford Geertz’s last year. Yet even after Geertz left, Dr. Good still considered him a mentor and inspiration. This was also a very political moment for universities and the country in general. Dr. Good describes how he came of age in anthropology in a time of the Vietnam War, in a time of activism, and in the time of the Civil Rights Movement. These were all very powerful influences on how Dr. Good conceptualized the importance of anthropology.

Discussing his research, Dr. Good describes the time he spent in a genuinely post-colonial conflict setting of Aceh, Indonesia.  He became very aware of colonialism and its colonial history and how it had impacted political life along with a diverse set of religious and cultural influences. It was a setting that had a history of tremendous violence. “It was my first experience of working in areas of really intensive conflict,” Dr. Good states, “and I have to say that I went home from that experience very affected by listening to stories of violence.” Terms like “post-colonialism” and “post-colonial subjectivity,” and even terms like “haunting” and “hauntology” became central to his vision of what Psychological Anthropology can be today. Dr. Good poses the question of how one does Psychological Anthropology in settings of violence. “My thinking about hauntology started off with being in Aceh, and thinking about what Aceh was like post-tsunami and post-conflict,” Dr. Good remarks. Aceh was a place where ghosts and spirits of the dead were everywhere, alongside the ghosts of the recent violence and the emergence of political gorillas who had been previously hidden away. “Suddenly Aceh was no longer in the midst of a war and people who had been fighting were coming back and appearing in everyday life,” Dr. Good explains, “and I began thinking about post-authoritarian Indonesia and why it is that there are certain moments in a society that ghosts begin to appear in a very powerful way, and ghosts that are related to historical violence.” Dr. Good became fascinated with the relationship between historical memory, histories of violence, how they make themselves present, and how they reintroduce themselves in psychological experience.

To wrap up the Breakfast Lecture, Dr. Shweder discusses how the issue of nationalism is front and center in a very powerful way at the moment. He suggests that anthropologists should be qualified to talk about the ethno-national impulses people are facing and examine why it is that some people feel like their way of life, or their control over their life, is being threatened by globalization, for example. He calls on anthropologists to give a native point of view instead of simply reacting with fear and mainstream ideology. “This is anthropology. There are in-groups and there are out-groups. People have ways of life and traditions; they want to exercise control over their way of life. This has to be examined,” Dr. Shweder states. He further discusses that one of the things that’s exceptional to the United States is that we are a nation in which constitutional patriotism is the binding feature. In principle, that means there is space for cultural diversity. “The ways in which tyranny can be built up and balanced through distribution of power are all rich topics right now. Immigration. Making sure we represent minority views in a way that majority groups understand them and why the way they live is both meaningful and justifiable.” Dr. Shweder finishes by stating that there are also threats to anthropology from within. He warns against a “liberal tyranny” which can be compared to a “white-man’s-burden-style” of thinking with regard to cultural differences. Dr. Shweder sees this as using the notion of oppression or exploitation as an excuse for interventions into other people’s ways of life rather than starting by seeing whether or not one can understand other practices and social organizations in a morally-motivated way. Dr. Good closes the conversation session by encouraging anthropologists to be engaged in both theoretical debates within the discipline as well as policy and implementation projects and practices which can benefit the people in the communities we study.


Richard Shweder is the Harold H. Swift Distinguished Service Professor of Human Development in the Department of Comparative Human Development at the University of Chicago. He is the author of Thinking Through Cultures: Expeditions in Cultural Psychology (1991) and Why Do Men Barbecue? Recipes for Cultural Psychology (2003), both published by Harvard University Press. Dr. Shweder is also an editor or co-editor of many books in the areas of cultural psychology, psychological anthropology, and comparative human development. For more information on Dr. Shweder, visit his page at the University of Chicago here, as well as the Society for Psychological Anthropology 2017 Biennial Conference Breakfast Lecture website, available here.

Byron Good is a Professor of Medical Anthropology at, and former Chair (2000-2006) of, the Department of Social Medicine, Harvard Medical School, and Professor in the Department of Anthropology, Harvard University. Dr. Good is director of the International Mental Health Training Program, funded by the Fogarty International Center to train psychiatrists from China in mental health services research. Dr. Good’s broader interests focus on the theorization of subjectivity in contemporary societies, focusing on the relation of political, cultural, and psychological renderings of the subject and experience, with a special interest in Indonesia. He is the editor or co-editor of many significant volumes, books, and is a former editor-in-chief of our Culture, Medicine, and Psychiatry journal (1986-2004). For more information on Dr. Good, visit the Harvard Medical School Department of Global Health and Social Medicine website here, as well as the Society for Psychological Anthropology 2017 Biennial Conference Breakfast Lecture website, 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