A Silent Revolution?
Re-Visioning Psychiatry and What an Anthropological Perspective Could Contribute
Text by Michl-Felix Bierl (Freie Universität Berlin)
Image by Pablo Dohms
Within psychiatry, and within popular public discourses, there is a tendency to “demystify” the human body, and specifically the human brain. To quantify, classify, measure, and diagnose seems to be the purpose of our kind, thrown into a world with so many questions but so little answers.
Since we are dealing with a complex system, it is comfortable to reduce psychiatric illness to a few buzzwords on a checklist, and to make sure that, at the end of the day there is an easy answer to questions like, “Why do I always feel empty and tired?”. The neo-liberal, western psychiatric system would give following answer: “It must be a chemical imbalance in your brain, called depression” (Rose 2003,46), which is based on what one could call “neurologics”, a combination of the word neurology, and logic, leading to the easy solution that, if one mentally suffers, there are simple, and practical biological solutions “[…] aimed at restoring good functioning” (Kirmayer 2015,623).
In the last half of the twentieth century, and the past two decades of the twenty-first century, health care practices were neo-liberalized, and privatized in, what the British sociologist Nicolas Rose (2003) calls “psychopharmacological” societies, which for him are mainly European countries, and the US, which then grew heavily dependent on psychopharmaceuticals (cf. 46). One could now think the availability of medicinal help for those who suffer is great news, since (at least to me, looking around my network of friends, and family) it seems like a growing number of people would need this support, but as we will see, this is not the whole story, and most definitely- by itself- not the solution to (global) mental health. The purpose of this essay is to shed light on re-visioning not the treatment of psychiatric symptoms, but the healing of people suffering from psychiatric problems, and crisis, pointing out anthropological aspects, and implications, and answering the question whether “we” need more context when it comes to (global) mental health, and the individual situations, and conditions people find themselves in. To already give a simple answer to the more, or less rhetoric question, it is a resounding and dedicated “YES”!
Are We Neurochemical Selves?
In Rose’s essay “Neurochemical Selves” from 2003, he takes a critical stance against the developments mentioned above. His opening question is not whether or not we are “neurochemical selves”, but how we became them (cf. 46). In the introduction of the book of psychological anthropologist J.H Jenkins, Pharmaceutical Self: The Global Shaping of Experience in an Age of Psychopharmacology, it was estimated that twenty-five percent of the population of the USA take some form of psychotropic medication (cf. Jenkins 2010 cited in Ninnemann 2012,11). In another article, about the widespread clinical use of psychotropic drugs, it is said that 30 to 50 percent of those individuals prescribed psychopharmaceutical agents struggle with suboptimal responses (cf. Arranz and Kapur 2008, 1130). This would mean, that in 2010 an estimated 38 million individuals in the US had problems with side effects, and unwanted outcomes of psychopharmaceutical treatment.
I am most definitely not against biochemical solutions to mental problems, and crises human beings face, since such treatment can help to restore agency, and the ability to make decisions. But what the underlying critique here is, is that a lot of those individuals first of all are treated depending on their symptoms on checklists of psychiatrists, ignoring the illness experience, and therefore the holistic basis one needs, to not just treat, but to heal (cf. Kleinmann 1988). The difference between treating, and healing is the difference between getting rid of the symptoms in relation to tackling the causes of psychiatric problems. Furthermore, psychiatry as a discipline, is often primarily focused on diagnosis, and medication, influenced by the “[…] corporatization and globalization of health care” (Kirmayer 2015,644). This is not only hindering more inclusive changes towards healthier and empathic social environments, but the economic factors, the power of the pharmaceutical industry also influences practitioners by direct, and indirect marketing forces, leading to profit driven diagnostic practices, and finally changed popular representations, and evaluations of mental illness, local health behaviour, and illness experience (ibid. 646 and Ecks 2013 cited in Kirmayer 2015,644).
Systemic Therapy and the Importance of Context
“When we meet with an individual we meet with their networks” (Lang 2014 cited in Hedges 2005,1)
Following the theoretical foundation of British-born anthropologist, and social scientist Gregory Bateson, the so-called “Milan team”, a group of Milan based psychoanalysts, started in the early seventies to try to embed the premise of a socially constructed “mind” in family therapy (cf. Hedges 2005,2). Following the constructivist line of thought, that all aspects of our social life, our “personality”, our behaviour, and the way we think about ourselves are co-created through conversations, and communication processes, is an effective way to counterbalance the nowadays hegemonic belief that all we have, to explain mental suffering is through neurochemistry with its neurons, synapses, receptors, enzymes and so on (cf. Rose 2003,57). This inter-relational, interpersonal perspective, which could be exaggerated by saying “we are nothing but a bunch of relationships” does slightly remind of Marylin Strathern’s “dividuals”, which are seen, “[…] not as unified and indivisible […] but as fundamentally multiple, composite, and divisible” (Eller 2019,132) human subjects . Put in different words, one could say that no one is an island. This systemic thinking was put into practice during individual therapy sessions by the “Milan team”, and the idea of a systemic therapy was born.
Issues, that influence the position or better the being in the world, such as sexual orientation, social status, age, gender, culture, and so forth are taken into account, in systemic therapy, and the positionality of the therapist is considered, by reflecting that “reality” is constructed through therapeutic conversation, and mostly uneven power dynamics between clients, and therapists (cf. Hedges 2005,3 and 28f.). Unfortunately, there is not enough space to go deeper into the practices of systemic therapy, with its solution-oriented, narrative, and feedback approaches, but one thing needs to be said: Even though since 2008 systemic therapy gained recognition as “[…] evidence-based treatment” (Retzlaff 2013,349), only since November 2018 it is also covered by health insurance in Germany (cf. Systemische Gesellschaft 2019). In comparison to how easy it is to get psychopharmaceutical medication, the imbalance seems to be within healthcare practices, and the promising profits involved.
Not only are contextuality, and situationality specific traits of the anthropological encounter, but the discipline can also help to shed light on specific psychopharmacological efficacy, since mental health, its experience, and evaluation are not only influenced by sociocultural, and structural factors, but are interconnected with biological factors as well (one buzzword to mention in this context is culture specific nutrition) (cf. Schlosser and Ninnemann 2012,3). There is already an academic branch concerned with the culturally specific efficacy of psychopharmacological drugs, connecting the entanglement of cultural impacts, and non-biological factors with psychiatric agents (cf. Ninnemann 2012,16). The discipline is called ethnopsychopharmacology, and together with psychological anthropology, and its focus on embodied, experiential, social, environmental, and ethical dimensions of mental health, and well-being, it could work collaboratively towards a new understanding of the self, strengthening the systemic approach of a historically, and socially constructed mind.
Now, it has been said that reductionist biological accounts of psychiatric disorders do not only tend to ignore the experiential reality of individual suffering, which is key not only for help-seeking, but also for the meaning- and sense-making through one’s “illness narratives” (cf. Kirmayer 2015,625; Kleinmann 1988). This “illness narratives” are basically the stories through which one copes with his or her experiences of suffering, self-agency, and so on. Anthropology can help systemic psychiatrists understand the whole range of underlying concerns of their clients, by working together to mobilise “[…] the full range of adaptive strategies, meaning-making processes, and social resources” (Bracken et al. 2012 cited in Kirmayer 2015,625). The question if the chicken (in this case neurochemical processes) or the egg (in this case the context embedded in lived experience) came first, can also be applied here. Phenomenology influences interpretation, experiences, and attention towards mental crises, which of course affect the communication, and social responses, which have an altering effect on neurobiological processes, and vice versa (cf. Kirmayer 2015,626). Therefore neurobiology, and its image of the self as a neurochemical one completely lacks the acknowledgement of the embeddedness of illness in individual (and collective) cognitive, and social processes (cf. ibid., 627). Such as there is not a “core-self” located simply, and only in the brain, there is no simple chemical imbalance that “produces” a crisis, which is not also at the same time communication, and transaction between person, and environment.
To re-vision psychiatry, and to change the hegemonial representation of the neurochemical self therefore, means to revolutionize psychiatric practice by adding context to mental health. This, of course is easily said, but with the emergence of systemic psychiatric approaches, and critical academic (and popular) encounters on the globalised distribution of psychopharmacological agents, and its profit driven logics, it seems, that more and more emphasis is placed on individuals as narrative beings, and “the stories we live by” (cf. McAdams 1993).
Culture provides context, systems of meaning and communication through which the questions of this world are reflexively interpreted and answered. Following Kirmayer, by stating that each kind of specific cultural knowledge “[…] has its place in causal explanations of behavior and pathology” (2015,637), it becomes clear that the “neurochemical self” is yet just another approach explaining and treating those who suffer. Since the clinical practice, and psychiatry is a product of-, but at the same time a major influence on contemporary culture (cf. Kirmayer 2015,643), anthropology is needed, not only to shed light on different representations of the self, bringing attention to culturally sensitive health practices, but also to study mental health institutions through the anthropological lens. Furthermore, systemic approaches, and empathic strategies of healing through the acknowledgement of the importance of context, and social embeddedness, could be supplemented through workshops, gatherings, talks and different modes of healing, with the alliance of psychological anthropologists. Our notions of self, and ways of (well-)being are influenced by normative representations of what is considered a healthy, “normal” part of the society. New forms of “self-technologies”, and its management discourses, in what Rose calls “psychopharmacological societies” oblige the individual to constantly minimize (mental) health risks by always reshaping diets, lifestyle, and potentially harming practices (cf. 2003,58f.). On the other hand, people experiencing mental crisis are dehumanised, and classified to possible diagnoses on checklists. In systemic psychotherapy there are no fixed labels, which would stigmatise you with a diagnose you will never get rid of anymore. If one wants to re-vision psychiatry, it is not enough to have, as the title of this essay implies, a silent revolution going. Rather, there need to be different, and loud critical voices from academia as well as from practicing individuals, not only arguing towards a contextualization of illness experiences, but also focusing on the cultural contexts of practices, such as prescribing psychopharmaceutical agents to individuals who feel tired or nervous. The representation, and understanding of oneself through the neurochemical, and biological lens is, as stated before, maybe not wrong, but most definitely, it is not the whole picture, and can therefore no longer be the premise of psychiatric practice alone.
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