On Proximity and Distance of Psychiatry and Anthropology
Text by Saskia Sturm (Freie Universität Berlin)
Art by Lena Rorschach
Most recently I read Marge Piercy’s Woman on the Edge of Time, a feminist Science Fiction novel published in 1976. The story is about Connie Ramos, a woman with a migrant background in her mid-thirties, and deals with the institutional racism during the 1970s in New York City. Through many coincidences she is diagnosed as mentally ill and committed to a psychiatric institution. The protagonist is able to time travel incorporeally to the year 2137. Between the somewhat utopian vision of the future and the hopeless, dreadful present, the reader is invited to scrutinize the lines between truth and reality. So, the recipients themselves have to consider, what has happened. A rhetorical trickery to question those concepts of truth and reality. As a Mexican migrant Connie Ramos lives in unstable circumstances in Spanish Harlem. Not only so according to her monetary situation, but also in family life, which is shaped by discontent and violence. After being confronted with institutional force several times, in terms of police and psychiatric treatment, the story culminates in the institution's doctors trying to force her into a brain control operation. For me this pioneering piece of feminist literature evoked many questions. Especially Nikolas Rose’s paper Neurochemical Selves from 2003 elaborates similar ideas. He reveals the connection between the rise of the pharmaceutical industry and the reduction of in-patient housing and therapy (51). Connie Ramos gets locked up in a psychiatric hospital by accident. But is it really by accident? I started wondering about the institutional requirements to make people socially compliant.
So does Jessica Cooper (2018), by discussing the issues of her research partner Harriet with the American Mental Health Court in her Article Unruly Affects. Attempts at Control and All That Escapes from an American Mental Health Court. Due to her rather well-off background, the homeless Harriet, a US-citizen like Connie Ramos, is not given up upon by legal authorities quickly. Cooper raises the question, whether the system would have given up on her faster, if she had not been that privileged. Even though identifying as transwoman, Harriet is perceived as a white, well-educated male by the Mental Health Court and the people working there (2018, 93). According to Cooper (2018, 86 ff), Harriet, who is diagnosed mentally ill, seems to have a different understanding of space and time, since she for example refuses to be territorialized and also does not show up to the Mental Health Court appointments. This makes her a non-conformist not only in the eyes of the society, but also the court. Many people tried to make her fit in the masses sense of society, from social workers, over court employees, to therapists, to be considered as a hopeless case in the end (ibid.,101). So, I started wondering: if even Harriet had so much trouble living in her own definition of time and space in today’s society in the United States, how are others dealing with that trouble? Other people that share a societal nonconform concept of space and time. People that are not as privileged for example when it comes to race?
Postcolonial theory deals with the deep implications of race and racism in the whole society. And thereby I really mean every aspect of it. Almost every society on earth deals with the consequences in a more or less visible way. It is deeply rooted in history and infuses every institution, even everyone is thinking in different ways.
The Growing Difference Between Psychiatry and Psychological Anthropology
The approaches of psychiatry and anthropology differ nowadays. Beginning in the very same corner of science in the late 19th century, both disciplines developed in completely different ways. In the beginning both disciplines followed an evolutionary approach, which should prove a certain evolvement of mental illness in cultural comparison. This same root should split up over the years. So, one point which is often claimed by psychological anthropology and other disciplines is the differentiation between the universalist idea of psychiatry and the relativist approach of anthropology (Jenkins 2018, 18 f). Even if there was an agreement by the disciplines on the universality of mental illness, implementations and causes differ culturally as well as socially (Fernando 2017, 3). Whereas psychiatry is now following a more biological, neuroscientific approach, psychological anthropology still advocates for people’s embodied experiences, perceived emotions and affects, as well as environmental and cultural dimensions (Kirmayer 2015, 624). One milestone in the history of the so called ‘psy-disciplines’ are the developments in Europe after mediaeval times and the following epoch of Enlightenment. Since the term psy-disciplines is an important concept in this essay, I would like to introduce the term as an umbrella term for psychology and psychiatry in its different forms (Fernando 2017, 3). The commencing colonization, mostly carried out by Europeans, started a new kind of slavery that has never been seen before. To justify this horrible inhuman abuse a new form of racism has developed, which exceeded the earlier forms of antisemitic and antimuslim movements. New explanations based on the then popular Darwinian tendencies have been the basis for biological justification to enslave so many, mostly African people, which often have been sold by British slave traders to plantations in the US and the Pacific, some (albeit less) slaves also have been sent to Europe, as cheap labor forces to satisfy the ‘western’ hunger for goods and comforts. This ideological approach that there is a difference and also a need for segregation between ‘white people’ and ‘others’ (Fernando 2017, 4) has been and still is a common belief, which has influenced all sciences until today. For example, quoting in academia still seems to work about a net of expertise in the global North. This echo chamber stabilizes alleged more worthy knowledge and reproduces wealth and superiority, additionally constructs science further in that manner. Likewise, the development of the psy-disciplines and anthropology is based on this (scientific) superiority. Therefore, superiority must be made a subject of discussion as a hidden ideology, which needs to be deconstructed and overcome. At least, this is the tenor I experience in anthropology today. But what does it mean for psychiatry, clinical institutions and the health system which aim to ensure well-being, if the tendencies focus on biologically explicable forms of mental illness? And how can the forms of therapy developed in European societies for its own purposes cater to all people? If we consider (scientific) superiority and the idea of social justice and diversity today, the system seems to be inconvenient, especially when it comes to psy-disciplines.
On Deconstructing Race-Based Inequalities in Psy-Disciplines
Misdiagnosis seem preprogrammed (Bhugra, Bhui 2002, 119). In the postcolonial discourse, this is questioned more and more, especially after Frantz Fanon’s (1968) revelation of the just supposed equality of black and white people (Bains 2005, 147). Equality, one of the most important European values after Enlightenment, in a triad with liberty and democracy (Fernando 2017, 17).
How can equality be one of the most important European values, if everything is built on inequality? The development of psychiatry towards neuroscience and biology started in the 1970s. In transcultural psychiatry for example, an awareness of inequality in the discipline has emerged. The Transcultural Psychiatry Society therefore changed their guidelines in 1984. They decided that it is necessary to establish equality in the mental health sector, independently from race, gender, and culture. They realized important difficulties that needed to be considered subject-specifically, such as language barriers and the necessity of considering cultural circumstances (Bain 2005, 148 f). I would like to add racism generally. There is a growing awareness of the hidden structures, which cause trouble, such as misdiagnosis etc., but I cannot get rid of the feeling that these structures are still present not only in society, but in the psy-disciplines in particular. There still are numerous culture-bound categories, methods of diagnosis and treatment, as well as a contextualized training of psychiatrists, which occur out of the academic tradition, where universal theory and objectivity are quality characteristics of proper science. An ideal, which is based on a concept of science which stems from the Enlightenment.
The other side of the coin is the possibility that racism can be a cause for daily emerging problems and therefore also mental illness. Especially in terms of migration and mental illness an intercultural understanding is pivotal, although often not existing. Since there is no such thing as ‘natural’[1] intercultural understanding. I argue this has to be considered in anamnesis and therapy of mental illness. Therefore, an interdisciplinary collaboration with anthropology could offer a possibility to deal with the challenges of the underlying racism in the context of diagnosis and treatment in psy-disciplines. In connection with ethnographic research, it would be possible to include everyday experiences of persons and their surroundings, especially if we talk about diasporas and displaced communities. In terms of the psychiatric context, it can be useful to deploy psychiatrists, that may themselves be a part of the ethnic minorities they are treating, and because of this might be better sensitized to significant values, struggles and possible pressures their clients experience. If no one with a suitable background is available, or not enough people are available, it is also possible to share and train knowledge and skills related to experienced racism (Bain 2005, 149). Surely it eases the setup of trust as well. But it is still important to keep in mind where these disciplines come from. It is a hard and delicate way, which needs to be built on a willingness to scrutinize, reflect, and possibly deconstruct therapeutic regimes, if equality is the genuine goal. This relates to sensitized education in psychiatric disciplines and their raising of awareness to institutionalized inequalities. It is also about the control of medication through pharmacy and markets (Petryna 2011, 306), and becoming aware, that it concerns the century-long belief in the accuracy of psy-disciplines shaped by racism.
Besides the institutional sphere it is a political sphere as well: racist mechanisms in clinical contexts are often supported by governments (Bhugra 2002, 121). So, how to get out of this racialized predicament?
A Plea for Interdisciplinary Exchange Between Anthropology and Psy-Disciplines
Laurence J. Kirmayer writes, ‘This cultural history is essential to understand the broad range of ‘neurotic’ problems gathered under the umbrella of psychiatry’ (2015, 623). Psychiatry is more of a young discipline, even if mental illness is as old as humankind. It is important to recognize cultural history to understand what lies beneath the concept and practice of psychiatry. According to Kirmayer, social sciences are better up for the analyses of mental illness, because they are more self-reflexive and self-critical, which is why they might handle the matter of diversity better. In the center of this thesis, he proclaims his conviction of the importance of phenomenology in psychiatric practice, nosology, and treatment. In his research in China Artur Kleinman (1986) figured out that illness is not just about biological differences and well-being. In researching the connection of depression and medication after traumata, Kleinman found out that just the medication and the biological well-being did not cure the disturbance in the life of traumatized individuals (Kirmayer 2015, 622 ff). This already shows that the dream of universality of the psy-disciplines and what they deal with, is just a dream, and not necessarily a functional one. By sticking to this historicized and somewhat outdated way of doing science and therefore institutionally dealing with people, there will never be equality or justice.
With this essay I would like to plead for unfolding such obsolete structures and counter racism and oppression through a diversified collaboration of those who care. Even if there is no formal slave trade anymore, there is a more invisible structure behind societies which is still based on racist mindsets and actions. Their impact in the psy-disciplines is just one thing we can point our finger at, one out of many. Anthropology best continues to target with these invisible racist and racialized structures to remain and become a useful supplement to mental health care infrastructures. I did not mean to diminish the importance of the psy-disciplines, but instead argue for a more critical understanding and reflection of ascribed illness, institutional treatment, and personal experience. It is time to take collaborative and interdisciplinary action, if we really want to understand and care for each other, and not just pretend to.
Notes
[1] The word natural also underlies the dichotomy of nature and culture, as human-made categories and is an example for the difficulty of implied meanings itself.
References
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History of Psychiatry 16, no. 2: 139–154.
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