EASA, 2010: EASA2010: Crisis and imagination
Maynooth, 24/08/2010 – 27/08/2010
Crisis and resolution: imagination and the transformation of psychiatric care
Location Arts Classhall C
Date and Start Time 26 Aug, 2010 at 11:30
Psychiatry represents an institution at the intersection of social solidarity and exclusion, with the specific configuration of these two elements differing in various historical and cultural contexts. Looking at the history of psychiatric care, one could argue that its evolutions were achieved through various crises (the crisis of the asylum and the anti-psychiatry movement, psychiatry's inability to care for mentally ill living in the streets, human rights abuses…). For various reasons, the resolutions of these crises often relied on the creativity of groups or individuals with very practical consequences for introducing new forms of care. Often through such creative solutions, all Western countries have undertaken significant reorganization of their psychiatric care systems in the past 50 years, which also inspired changes to psychiatric care in less developed countries.
This workshop calls for reflection on the impact of 'crisis rhetoric' with regard to specific social, political and legal circumstances, and the role of imagination in informing the practices of caring and curing. We aim to explore how ideas on the appropriate forms of psychiatric care reflect specific cultural expectations and ideologies, and how the role of family, community, profession and the state in taking care of the mentally ill is negotiated in different contexts. Finally, we want to address the ways in which the anthropological perspective and research has been involved in, and is still challenged by these transformations.
Contributions in each of the three sessions relate to different aspects of social processes in mental health care: Communities (1-3); Systems and Trajectories (4-7); and Alternatives (8-10).
Discussant: Paul Brodwin, Jamie Saris
This workshop is closed to new paper proposals.
Crisis and permutations of power in Southern Brazilian psychiatry
Since the mid 1980s, psychodynamic psychiatrists in Southern Brazil have been leading a movement to shift the focus of their expertise from the private sector to the shantytown, and from the hospital to the outpatient clinic. As these therapists strive to create a political-sensitive form of therapy that is relevant for the socially marginalized (violent and criminal youth often being the prototypical emblem of this social stratum), they are forced to confront emerging professional and personal conflicts, to change the nature of the therapeutic encounter, and to modify the models of the mind and of society to which they ascribe. This paper explores the crises, conjectures and permutations of power that typify this process. Using ethnographic data collected over a period of 10 years, we show how the clinical and extra-clinical co-production of crises rhetoric between therapist and patient alters, in very material ways, the life-course of young patients.
Crisis, contracts, and care in Greek psychiatry
Since the international movement for patients' rights began, law has played a perplexing role in mediating conflicts over responsibility for the mentally ill. In Greece, this contention has been shaped by the "democratic experiment" of psychiatric reform, designed and funded largely by the European Union, following a series of humanitarian scandals in Greek psychiatric hospitals. As elsewhere, psychiatric reform in Greece has aimed to shift treatment from custodial hospitals to outpatient settings, challenging patients to help care for themselves. This paper, grounded in field research in Thrace, addresses one therapeutic technique used to foster patients' responsible participation in treatment: the therapeutic contract, which attaches legalistic determinants to the responsibilities patients and therapists bear to each other. Exploring the experiences of two patients who entered therapeutic contracts at moments of crisis in their treatment, I argue that these contracts generated intractable debts and dependencies that could not be resolved in therapy. I explore these patients' "illiberal" reckonings of obligation that were occluded by the transactional frame of therapeutic ethics defined by their contracts.
Imagination through ordinary crisis - The protection of the Nantez' spending spree
Today, long-term hospitalisation is not the only "answer" to the difficult situations and obstacles met by persons suffering of psychiatric troubles in the context of a psychiatry deeply changed by the closure of asylum and the reduction of the number of beds in hospitals. Moreover, the responsibility to respond to these situations is not anymore only on people working in psychiatric institution, but on the persons/individuals themselves, their family and social workers.
This proposal aims to focus not so much on the crisis of psychiatric institution in itself, but to look more closely into these ordinary situations of "crisis" met by people in the present context of psychiatry that may lead others individuals to make decision or to act on person's behalf. We intend to consider that these situations of crisis have their origins and their resolution in acts of imagining. In that aim, we propose in that communication to identify and observe in what extent imagination is present in the actions of both, persons themselves and people around them, and lay (but sometimes experimented) and professional actors.
Reimagine the 'human' in medicine: 'crisis rhetoric' and the social and political transformation of contemporary psychiatric care
Focusing on the social and political dynamics of psychiatric professionals' working at the Consultation Liaison Psychiatry service of two Portuguese general hospitals in Lisbon, this paper reflects on the rationales which lie behind the crisis and the transformation of contemporary psychiatric care.
Based on ethnographic data we look at the way psychiatrists try to use its knowledge and the social exclusion history of the field in order to discuss a proper social and medical role in the general hospital.
Developing terms such as 'humanization' 'bioethics' or 'biopsycosocial' as ethical and political strategies in their daily life, psychiatrists negotiate with other clinical specialties a holistic interpretation of illness. At the same time they also practice the most up to date biomedical treatment of psychiatric disorders. The surprising effect is one of bring to the forefront of medicine, as well as of anthropology, old debates on what it means to be human.
Translating Fanon in the Italian context: rethinking the ethics of treatment in psychiatry
In this paper, I reflect upon the clinical practice of a group of ethno-psychiatrists at the Centro Frantz Fanon, a clinic in Northern Italy that offers psycho-social support to migrants, political refugees, and torture and human trafficking victims. My aim is twofold: 1) to situate the clinical practice of ethno-psychiatrists at this Centro within the larger landscapes of Italian psychiatry and medical anthropology by turning to the work of Franco Basaglia and Ernesto de Martino, and to the theories of domination and culture developed by Frantz Fanon and Tobie Nathan (both authors and mental health practitioners who serve as models for the clinical work at the Centro); 2) to reflect upon ethno-psychiatry as a contested field that raises a series of complex questions about mental health, citizenship, identity, and thus opens up the possibility to rethink clinical work as a mode of politics, for both foreign and Italian patients alike.
Resolutions of war-generated crises through the mediation of sociotherapy: The travelling of the therapeutic community model from England to Rwanda
This paper focuses on 1) how the therapeutic community model that British psychiatrists developed to care for the psychiatric casualties of World War II travelled via The Netherlands to Rwanda and 2) which adaptations were made to meet the needs of respectively refugees in the Netherlands and inhabitants of Rwanda traumatized by contemporary wars. In England the new treatment developed out of a particular constellation of humanitarian ideology, wartime necessity, psychoanalytic insights and open minded pragmatism. What were the constellations of factors underlying the introduction and adaptation of the British therapeutic model in the form of respectively clinic-based and community-based sociotherapeutic care in the Netherlands and Rwanda? What in particular were the creative imaginations that informed this care in the specific social, political and legal circumstances where it has been provided? How does sociotherapy compare with the globalized psychiatric approach to trauma, its crisis rhetoric, and its in- and exclusion?
Caring citizenship. imagination, politics, and irony in a psychiatric mental health community (Havana, Cuba)
During 1980s, while Basaglia's movement as well as anti-psychiatry ones bestirred Europe, the Cuban government re-thought the mental health care system. They rejected psychoanalytic patterns trying to create a "Cuban" psychotherapy model based on philosophical elements coming from the Soviet psychology theory mixed together with therapeutic practices of the systemic psychotherapy.
In this paper I will explore how this psychotherapic model works today, and its changes in relation to the impacts of the social, economical and political transformations.
I will use my ethnographical experience carried out a Mental Health Community Centre in Havana, to suggest that - even if the politics of cure service are fixed- the care practices are dynamic and informed by the way psychiatrists imagine their own role in the Cuban society.
Moreover, this need of imagining their own role is based on an awareness -shared by both psychiatrists and patients- to live a "vida dificil" that goes beyond mental health problems. This awareness is point out by the use of irony during the psychotherapeutic encounter. Irony is also used by therapists in order to bring the political dimension in to the therapeutic setting, for making also the citizenship an object of care
From cure back to care in biomedical psychiatry: lessons from psychiatric pluralism in South India
Psychiatry and anthropology have not yet come to terms with findings by the WHO of a better recovery rate for serious mental illnesses in "developing" countries. Arguing that anthropology needs to continue to explore the implications of these findings for psychiatric care, this paper urges that biomedical psychiatry re-discover the meaning of care and re-consider what may be an overemphasis on curing in psychiatric practice. Fieldwork conducted in Kerala, India on biomedical, ayurvedic and religious treatments for psychopathology, suggest that an overemphasis on cure has led biomedical psychiatry to adopt viscerally abrasive methods of treatment (including the use of strong psychotropic drugs and ECT). Ayurvedic psychiatric treatment involves more aesthetically agreeable procedures which appeal to patients and call attention to the importance of caring or attending to the quality of the process of undergoing therapy. This paper considers whether these differences may be a factor in the differential outcome discovered by the WHO.
Competing imaginations in the care of mental illness: locating the limits of psychiatry in Cuzco, Peru
The disparity between the limited resources available to psychiatric services in the department of Cuzco, Peru, and the sizable population that they are expected to cover, might well be expected to produce a sense of 'crisis.' Yet such urgency is strikingly absent, perhaps because of the extent to which healers outside the official system 'take up the slack.' Why these Andean healers are resorted to with such frequency and persistence can only partly be understood from standard accounts emphasizing lower levels of stigma or the cultural congruence they share with their clientele. I explore some of the differences in approach between these practitioners and those of biomedical psychiatry to suggest why it might be that these alternative forms capture the imagination of so many, and what the obstacles are to a counteracting leap of imagination on the part of local psychiatry that might bridge this gap.
Madness, medication and miracles: family, state and community approaches to the control and cure of people with severe mental illness in rural Ghana
This paper explores the interaction of social responses to mental illness in Ghana enacted through popular stereotypes, psychiatric services and religious healing, with the intimate household experience of such illness. Psychiatric institutions were established by colonial authorities in response to a perceived crisis: an increase in mental illness in a modernising society. Catastrophising discourses continue to inform responses to mental illness drawing on stereotypes of the madman as violent and anti-social. African religion, Christianity and Islam, and its association with cannabis and rebellious youth, place mental illness within a moral frame and maintain practices of control and chastisement. However the experience of severe and relapsing mental illness within the family necessitates a creative negotiation with and against the cultural stereotype. Psychotropic medication is often only partially effective, whereas churches and shrines offer solidarity within communities of suffering and hope for a cure inspired by a spiritual imaginary of miraculous healing.
e-paper Cage beds, walls and bridges: symbolic dimension of the proposed transformation of psychiatry in the post-1989 Czech Republic
My research follows the implication of the fall of state socialism in 1989 for mental health care in the Czech Republic. Majority of long-term care has been provided in large institutions, that became perceived as a symbol of the totalitarian regime. The proposal for 'long-overdue' reform has been in the direction of more individualized and differentiated forms of care. I shall focus on the symbolic dimension of the process, where the discourse of 'liberation' became an appealing concept in the context of radical dissociation with the socialist past perceived as restrictive and repressive, trampling to human rights and autonomy, materialized in the symbolism of institutional walls and cage beds. However, the reform has never been enacted. I will examine the role of symbols in the transformation of care of the mentally ill from the historical perspective, and analyze why this strategy proved insufficient for the reform.
e-paper Crisis and imagination in Indian psychiatry: practicing 'domestic' care at a First Episode Psychosis clinic in South India
Indian psychiatry has gone through various crises to find its position and recognition within the society, the state, and the international community. Actively trying to disentangle itself from the colonial legacy of the asylum which still plays a stigmatizing effect on the population, Indian psychiatry competes with other medical systems in the healing treatment (Halliburton 2004) and struggles with the limited provisions provided by the state by enacting what Das and Addlakha (2001) call "domestic citizenship," a citizenship practice which sees the family as its major stakeholder.
Drawing on ongoing research collaboration with at a First Episode Psychosis clinic in South India, this paper analyses how mental health care becomes a space for negotiation of resources, values and actors in which psychiatrists, families and patients confront their "crisis" and imagine possibilities.
e-paper From the asylum to the secteur and beyond: the rhetoric of the 'psychiatric crisis' in France
This paper focuses on structural changes taking place in French psychiatry and their relationship to normative and political realities in France, in the light of an equally significant psychiatric transition that took place in the 1970s. In the 70's, both psychiatrists and social scientists produced a critique of psychiatry based on the "old" model of the asylum, while the invention of a new mode of care, "the secteur", led to new politics. Analysing the rhetoric of the "crisis of psychiatry" in the 2000's, I will discuss how the reference to the slowly and unevenly implemented "secteur" as an ideal model of care confronts to new concepts, values and techniques, which appear as innovations. I will examine the impact of such confrontation on mental health practices by focusing on two features of psychiatry's contemporary politics in France: the patient's right and autonomy, and the diversification of treatment techniques.
This workshop is closed to new paper proposals.