This panel turns its attention to the anthropology of mental illness and distress. It interrogates boundaries between concepts of transience, so-called 'chronicity' and recovery as they come into focus through ethnographic analyses of lived experience in the clinic and beyond.
Responding to recent changes in psychiatric diagnoses and treatments and the growing instability of global political and economic systems, this panel calls for urgent anthropological engagement with mental illness and distress. Mental ill-health accounts for a significant proportion of the world's health burden and causes disruption to individuals and communities. Often those afflicted are already disadvantaged and marginalised, such that structural violence and mental ill-health are entangled. By retracing the footsteps of established anthropological research into psychiatry and illness experiences, alongside a commitment to critical complexity and uncertainty, the panel will forge new pathways into understanding suffering and caregiving. Concepts of care and recovery in both the clinic and community are contingent on notions of the temporal nature of mental illness. At its core, the panel will therefore be concerned with actual and imagined temporalities of suffering; by bridging anthropologies of medicine and time, it will problematise the taken for granted time-lines and emplotments pervasive in clinical discourses. It will interrogate boundaries between concepts of transience, so-called 'chronicity' and recovery as they come into focus through ethnographic analyses of lived experience in the clinic and beyond. In furthering anthropological knowledge, these explorations will contribute to broader debates, drawing anthropology into dialogue with clinical and policy frameworks and service user advocacy. In so doing, the panel seeks to envisage hopeful futures for the discipline and those it encounters.
This panel is closed to new paper proposals.
Fixing time: boderline personality disorder, temporality, and the ontological edge of diagnosis in psychiatric practice
Borderline Personality Disorder is typified by an unstable, incoherent sense of self. At the same time, BPD is understood to be a chronic, incurable condition. Diagnosis, then, is a temporal practice. This temporality is paradoxical in BPD, shaping--and sometimes foreclosing--recovery.
In Western psychiatric practice, Borderline Personality Disorder (BPD) is typified by an apparent lack of a stable or coherent sense of self. Living intensely within the immediacy of the present, sufferers' mood states, affects, perceptions, and personality dimensions shift and change rapidly, producing a sense of acute disorientation, dysregulation, and distress. The result is a fundamental disruption of intersubjectivity, hinging on "a peculiar atemporal mode of existing" (Fuchs 2007). At the same time, from a psychiatric perspective, personality disorders like BPD are understood to be stable and persistent patterns of relating over time, chronic conditions that can be managed but not cured. A diagnosis of BPD therefore "fixes" the client in a particular subjective space in ways that sit in stark contrast to the everyday lived experience of the condition. How are these differing reckonings of temporality in BPD—a condition that is both atemporal and chronic—negotiated by people with BPD? And what are the implications for how we think about mental illness? Drawing on clinical and ethnographic work with women diagnosed with BPD, this paper considers how notions of chronicity and dysregulation in BPD produce paradoxes wherein clients must figure their subjectivities across varying and conflicting temporal landscapes. In so doing, I argue for a reconsideration of how processes of diagnosis shape the ontology of psychiatric conditions.
Access to what? Contextualizing 'diagnosis', 'recovery' and `access to care' in northern India
This paper examines intersections between experiences of `diagnosis', `access', `care' and `recovery' by those affected by mental health difficulties in India. Contextualizing the local significance of these concepts may open up new ways of engaging with individuals, families, and communities.
Global mental health discourses interpret `access to care' as increasing availability of personnel and interventions. This assumes that diagnosis leads to treatment and re-emergence of a `recovered' subject. This trajectory does not consider the subjective experiences of individuals, families and communities who seek to 'access' interventions. This paper examines intersections between experiences of `diagnosis', `access', `care' and `recovery' by individuals and families affected by mental health difficulties in northern India. Drawing on ethnographic research (2004 - 2014) that maps understandings of 'distress', help-seeking trajectories, and (non) engagement between communities and a state mental health program, this paper reports on a data-subset of longitudinal ethnographic interviews with individuals, families and service providers. Mapping the relationships between `access to care, `diagnosis' and 'recovery', requires an understanding of the local particularities and tracing of how the production of diagnosis impacts 'recovery journeys'. A central question that emerges is - access to `what'? In the absence of culturally accessible mental health provision, the `what' that people access are the inner resources of their selves, families and communities to creatively seek multiple forms of care, whilst attempting to make sense of their 'distress'. The research suggests the importance of examining 'recovery journeys' through lenses of social exclusion, including gender and caste. Technical-universal conceptualizations of `access' and `care' obscure individual & collective decisions and actions in response to distress. Contextualizing the local significance of 'diagnosis', 'access', 'care', and 'recovery' may open up new ways of engaging with those suffering from mental health difficulties, their families and communities.
Waiting times: mental healthcare, chronicity and the temporality of psychic life
In this co-authored theoretical paper, we take up psychoanalytic understandings of time and mental life in order to try to understand the temporal trope of waiting and its role in mental health treatment in the current NHS.
This paper explores the relationship between psychoanalytic understandings of time and mental life and the waiting that is a core experience for those seeking mental health treatment in the NHS. Despite government interventions around waiting, it is clear that both mental healthcare professionals and service users experience the current system as demanding an excessive and sometimes intolerable wait for non-pharmacological forms of care. Alongside the ways that waiting becomes a synonym for service failure and abandonment, we explore how the durational time of care at the centre of psychoanalytic therapy remains a key component in effective treatment. We first track the chronic temporalities of psychic life - its repetitions, suspensions, and forms of binding and unbinding that resist linear temporality. This underpins psychoanalytic modes of care that function not through a 'flash' of insight, nor the future-orientated focus of CBT, but through practices of waiting, suspension of the everyday, the repetitions of the transference, and working through. In the context of social and historical conditions that increasingly demand waiting, while rendering it intolerable through instrumentalised accounts of service provision and cost-benefit notions of time, we suggest that the importance of the recent Tavistock Adult Depression Study is not so much the finding that long-term psychotherapy is an effective treatment for chronic depression, but that its impacts are felt long after the cessation of the treatment. Elongated practices of waiting, in other words, give rise to new psychic temporalities of endurance as the NHS is caught between acute crisis and chronic decline.
Reconfiguring eating disorders: from culture to structures
In this paper, I argue for a critical anthropology of eating disorders. Through attending to social suffering and health inequalities, this critical approach can elucidate the societal and medical structures in which eating disorders are experienced, expressed, and given voice in research.
Anthropologists who study eating disorders often face questions about what it is that they (uniquely) research. In many cases, the response is culture - the specificities of how participants relate to their bodies, selves, relationships, practices, and materialities. In this paper, I suggest that culture-centric framings of anthropological research on eating disorders run the risk of reducing our mission to the exoticization of already-othered people - and to the placing of social ills within the supposed pathology of people who 'succumb' to cultural messages. I argue that, although we should continue to highlight and problematize the cultural, it is equally important to attend to what participants can tell us about the societal and medical structures in which eating disorders are experienced, expressed, and given voice in research. Using examples from my work in Israel and in the UK, I discuss how participant interviews reveal overarching similarities in the embodied experiences of eating disorders, while highlighting the roles of social suffering and health inequalities in the different trajectories that eating disorders take. Attending to these differences allows us to question who is allowed to claim an eating disordered identity, whose voices are heard in research, and what structural barriers, which may otherwise be taken for granted, affect people's access to diagnosis and appropriate care. Through focusing on the structural, I argue, we can use anthropological perspectives for a critical discussion of the macro-level conditions that manifest in individual eating disordered bodies.
Personhood and dementia: challenging models of personhood and wellness
Dementia challenges the temporality of illness and the rationality of personhood. Dementia is deficit in the (perfectly) well (or curable) person. Models of personhood which downplay irrationality, vulnerability, stress and the constant need for adaptability, stimatise both sufferer and carer.
Dementia challenges the temporal notion of mental illness. It also challenges notions of personhood in uncomfortable ways. Understood as a loss of personhood, it looms as a frightening unbecoming. Incurable - and with a cure seemingly a long way off - it affects over one third of people over 85 years of age in some populations, making the cure a high priority. Only in recent years has this biomedical research preoccupation shifted to include attention on how to 'care' for those already living with dementia, as sufferers or carers. Dementia is presented as a significant challenge for professional and familial carers who have to deal with a 'person' becoming ever more unpredictable. But what understandings of personhood inform the often implicit understandings of the life cycle, vulnerability, rationality and relations of care that characterise much of the discourse of loss and challenge surrounding dementia? Anthropology's insights into personhood require rethinking so that a more dynamic and critical model which can encompass the vicissitudes of the human life cycle as it is played out in specific times and places can be brought to bear on dementia discourse and research. This model needs to recapture irrationality, vulnerability, stress and the need for adaptability as part of the human experience. The model of the (perfectly) well person - or curable person - renders dementia (and most 'mental illness') as deficit, making it all the more difficult for carers to deal with.
'Quietly starving': desire, temporality and recovery in anorexia
Engaging with both anorexia and psychosis, this paper explores lived temporalities of illness and recovery in mental ill-health. It asks whether a desire to maintain anorexia amongst some individuals suggests that it should be reconsidered in light of a paradigm of recovery as living well with illness.
Survivor-led discussions of mental ill-health have increasingly challenged and reconfigured paradigms and practices in UK mental healthcare. This has led, specifically, to a reframing of recovery; in relation to psychosis in particular, this has moved away from binaries of 'cure' and 'chronicity' towards a person-centred approach that emphasises living well with illness rather than the eradication of symptoms such as voice hearing.
A pervasive clinical and cultural understanding of anorexia as centrally about the body has disconnected eating disorders from this new recovery paradigm, and also from the interrelated recognition of the complex relationships between painful life events and mental illness. Yet accounts of being 'looked after' by anorexia demonstrate that this illness may be a simultaneous response and solution to distress, which some individuals desire to maintain. This elucidates the painful logic of wanting to be 'left alone' to 'quietly starve,' as one informant, Chloe put it.
Thus, by engaging with narratives of anorexia, alongside those of individuals with psychosis, this paper considers whether eating disorders should be reconsidered in relation to the newer paradigm of recovery. It asks what the ethical and human implications of such a rethinking might be, and what forms of care it would mobilise. As such, an anthropological attention to the lived temporalities of anorexia offers insights into the politics, uncertainties and intimacies of 'recovery'. It invites an urgent, situated, and sensitive revisiting of concepts such as health, illness and 'chronicity' as these are lived, navigated and challenged by individuals themselves.
What does 'recovery' mean in an urban Indian slum context?
This paper discusses the concept of recovery in an urban Indian context, based on research conducted with the community mental health organization Bapu Trust in Pune, India. Notions of recovery are dynamic and complex, impacting approaches and outcomes.
It is unclear whether and to what extent Western ideas of 'recovery' are cross-culturally transferable to developing, non-Western country contexts. Within global mental health discourses there is a significant lack of appropriate definitions of and approaches to recovery, biomedical clinical structures do not take into account important local social and cultural factors. This paper discusses the concept of recovery in an urban Indian context, based on research conducted with the community mental health organization Bapu Trust in Pune, India. Using analysis of secondary clinical data and qualitative interviews with mental health care staff, the research examined understanding and meaning of 'recovery' in this particular context. Within Bapu Trust, notions of recovery are dynamic and the organisation leaves space for alternative ideas, developing and adapting their approach to recovery in practice. Staff characterisations of recovery are important and may be complemented by client data as well as community perception to have a significant impact on Bapu Trust policy. Ideas about the connection between social inclusion and recovery were central while the difference between expectations and outcomes related to gender was clear. As the community roles of women and men are noticeably distinct, this cannot be ignored as a factor in definitions of recovery. Ultimately, Bapu Trust's framework of approaches to recovery differ from Western ideas, presenting an alternative to the dominant psychiatric perspective. The concept of recovery remains complex therefore understanding of multiple facets are essential for treatment, particularly to make long-term intervention effective for chronic mental health issues.
Class-based chronicities in mental health care in Uganda
The paper looks at discourses and practices in the field of mental health care in Uganda. In focusing on two alcohol & drug treatment centers, a high-class residential facility and a poorly-funded CBO, it provides insights into the class-based temporalities of mental illness and mental health care.
The paper is based on ongoing research on changing discourses and practices in the field of mental health care and new forms of psycho-social suffering in Uganda. One field of analysis concerns the 'therapeutic landscape' in Uganda, in particular emerging psychiatric and psychotherapeutic institutions, and the accessibility and affordability of these institutions for people from different class- and urban/rural backgrounds. The term 'class-based chronicities' refers to the way both the urgency with which people (can) seek treatment (i.e. when has someone suffered enough?) and the length of treatment they receive (i.e. when is someone considered 'recovered'?) are highly class dependent.
Concretely, the presentation looks at two different drug and alcohol treatment centers in Uganda. The first one, Serenity Centre, is a high-class residential facility near the Ugandan capital Kampala which offers state-of-the-art addiction therapy, but is affordable only for the very rich. The 'patients', usually young men and women from elite backgrounds, stay at the centre between 3 and 6 months before they are considered 'recovered'. In contrast, PACTA, a church-based organization in Northern Uganda, cares mainly for people from poor, rural families who cannot afford exp/tensive treatment. Due to its limited funding, PACTA can only offer short-term 'treatment camps', which last only 6 days.
Comparing the two centers provides important insights not only into the temporalities of mental illness (in this case substance abuse) and mental health care, but also into the changing discourses, practices and institutions which deal with psycho-social suffering in Uganda more broadly.
This panel is closed to new paper proposals.