American psychological anthropology grew out of a tradition of using psychoanalytic ideas to make sense of cultural practices. (Location 94)
Margaret Mead was one of its founding mothers. She used a loosely Freudian understanding of childhood experience in different societies to explain their adult behavior. (Location 95)
After a few months, it was impossible to doubt that there was a “there” there of psychiatric illness. Grand sociological theories that claimed that psychiatry punished those who were merely eccentric and unconventional seemed absurd to me. I began to see in students, friends, and supermarket baggers little flickers of the craziness I saw in case conferences. Then I began to worry that I was seeing more than was there. I became fascinated by what psychiatrists saw, how they knew what they knew, whether they were right, and what that even meant. (Location 127)
psiquiatría teoría crítica sociología
We assume that other people are just like us—normal—until it becomes apparent that they are not. Psychiatry forces upon you, more abruptly and with an in-your-face confrontation, the lessons anthropology is meant to teach: that the landscape of human thought and feeling is more gaunt and jagged but also more breathtaking than most of us, Horatio-like, have dreamed of in our little local worlds. I thought that if I could describe the way I was learning to see, which is the way psychiatrists are taught how to see, I would be doing what every anthropologist is supposed to do, but by traveling into the familiar, not away to the exotic. (Location 134)
Why do we suffer? (Location 150)
To understand that these circumstances are more important than the choices we make within them is to see a very different staging of human experience. That difference is the major tension in the way psychiatrists are taught to look at the world. (Location 158)
Psychiatrists have inherited the Cartesian dualism that is so marked a feature of our spiritual and moral landscape. Sometimes they talk about mental anguish as if it were cardiac disease: you treat it with medication, rest, and advice about the right way to eat and live. A person who has had a heart attack will never be the same—he will be always a person who has been very seriously ill—but he is not his heart attack. His heart attack is in the body, not the mind. When psychiatrists talk in this manner, psychosis and depression become likewise written on the body. This style of speaking has gained preeminence in the last two decades. It is usually called “biomedical” psychiatry, an approach to mental illness that treats it as an illness of the body that is more or less comparable to other physical illnesses. Sometimes, though, psychiatrists talk about distress as something much more complicated, something that involves the kind of person you are: your intentions, your loves and hates, your messy, complicated past. This style is associated with psychoanalysis and psychoanalytic psychotherapy, usually called “psychodynamic,” which dominated psychiatry in the middle decades of this century and which remains the fountainhead of all psychotherapies. From this vantage point, mental illness is in your mind and in your emotional reactions to other people. It is your “you.” (Location 160)
These two approaches now exist in uneasy alliance with each other. They are a kind of contradiction to each other because their models of how suffering works are so opposed. Young psychiatrists are socialized into this contradiction, so that they learn to believe and to say that these different models should be integrated in the practice of psychiatry. But no one really knows where truth lies, although periodically brilliant new syntheses are published in the leading journals. (Location 190)
these two approaches, the psychodynamic and the biomedical, have their roots in the more fundamental Western division between mind and body that our society, for all its sophisticated caveats, still endorses. We still think of the body as something unintentional, something given, something for which any individual is not responsible. That is why we are so interested in metabolic set points, inborn temperaments, learning disabilities, and the genetic roots of attention deficit disorder. If something is in the body, an individual cannot be blamed; the body is always morally innocent. If something is in the mind, however, it can be controlled and mastered, and a person who fails to do so is morally at fault. (Location 196)
Biology is the great moral loophole of our age. This is not to say that I think this to be entirely inappropriate. As a good American, I believe that it is wrong to hold people responsible for something they cannot control. Nevertheless, a moral vision that treats the body as choiceless and nonresponsible and the mind as choice-making and responsible has significant consequences for a view of mental illness precariously perched between the two. (Location 205)
Understanding the way a set of ideas and practices can change a person is what anthropologists are trained to do, and as an anthropologist, I was better positioned to observe these changes than a member of the tribe. (Location 209)
My job was to understand how a nonpsychiatrist (an ex–medical student) can enter the culture of psychiatry and become a fluent speaker of the local tongue. (Location 213)
A young psychiatrist—skilled, competent, articulate—learns to do psychiatry, not so much to describe what she does. She learns her psychiatry the way a young violinist learns to play the violin: to listen for the notes of a scale, to hear pitch and know when a string is in tune, to feel pride in the calluses that develop on the tips of the fingering hand, to know how to hold a bow by the feel of its weight. For someone who is good at her task, those ways of perceiving settle in so deeply that they become the way the person moves, hears, and observes when at that task. (Location 218)
anthropologist is compromised (or liberated, depending on your point of view) by the fact that I believe both the biomedical and psychodynamic approaches to psychiatric illness to be substantially correct and equally effective, although not always for the same person. (Location 242)
I don’t think that either approach mirrors the reality of mental illness, but then I don’t think that any domain of knowledge “mirrors” the world as it is. The real issue for me is how one learns to look at mental illness through different lenses and the consequences of those ways of seeing. (Location 246)
So it matters a great deal how a psychiatrist is taught to look at mental illness, because the “how” cannot be clearly separated from the “what” of the disease. To understand psychiatric ways of seeing, we have to proceed knowing that what counts as “fact” is a tinted window onto a world you cannot step outside to see. (Location 253)
George Devereux, a psychiatric anthropologist who was not so much romantic as persuaded that the shamans in the society he worked in were pretty odd, wrote a famous paper arguing that shamanism provided a social role for the mentally ill that our society conspicuously lacked. “Briefly stated, my position is that the shaman is mentally deranged.”2 He suggested that the difference between the publicly recognized shaman and the “private” psychotic is that the shaman is able to use ritualized conventions in his society to manage his distress. This is a complicated and important issue, because it is clear that the way a culture interprets symptoms may affect an ill person’s prognosis. (Location 264)
R. D. Laing argued, with the style of a social prophet, that the schizophrenic was just someone who was too creative, too insightful, too existentially aware for our society. We normals were afraid, he implied, to be so bold.4 (Location 275)
Madness is real, and it is an act of moral cowardice to treat it as a romantic freedom. Most people who end up in a psychiatric hospital are deeply unhappy and seriously disturbed, and many of them lead lives of humiliation and great pain. To try to protect the chronic mentally ill by saying that they are not ill, just different, is a misplaced liberalism of appalling insensitivity to the patients and to the families who struggle so valiantly with the difficulties of their ill family members. Most people who are really schizophrenic are far too ill to serve as religious experts. (Location 289)
I never saw anyone held against his or her will in a hospital whom I felt was there unjustly. On the contrary, my experience was that people were denied clinical care when they should have been treated. At one point during my study, my liberal friends would lecture me on the evils of psychiatric incarceration while one of my psychiatrist friends was being stalked by a psychotic man refusing psychiatric care. (Location 301)
Those who suffer from major depression cannot sleep, do not eat, and are obsessed by the thought of their own death. Their depression feels to them like a physical pain. They cannot concentrate. They cannot function. Many of them cannot leave their beds. One in every six will kill themselves. (Location 326)
“I can’t calm this murderous cauldron, my grand ideas of an hour ago seem absurd and pathetic, my life is in ruins and—worse still—ruinous.… In the mirror I see a creature I do not know but must live and share my mind with.” (Location 390)
Crazy people cannot fend for themselves when they are sick. They struggle to survive with the generosity and protection of others. There is no reasonable doubt that madness is an intrinsic feature of human life, not a by-product of asylum building or of a shift in religious practice. At the same time, (Location 399)
One of the unintended consequences of social assistance is that we reward people for becoming and remaining ill. Sometimes we trap them in their illness. (Location 411)
incentivo perverso ganancia secundaria
Dissociation is a skill, and the use of that skill can be learned. Some learn involuntarily, and their dissociation is pathological: unwanted, intrusive, uncontrollable. Some learn willingly to go into trance, possession, out-of-body states, and, for that matter, channeling. (Location 424)
History shapes the kind of madness people experience and the frequency with which it occurs. Poverty, war, and dislocation are bad for people—an obvious point, but important if you are tempted to think of psychiatric illness as purely hereditary. A recent survey on world mental health observed that in all different age, gender, and cultural categories everywhere, the most important risk factor for mental health is social disruption.24 Social isolation also seems to exact a high cost. Depression, and mood disorders in general, (Location 431)
More people live alone in America than ever before—a quarter of all Americans, compared to less than 10 percent in 1940 and probably almost none in our ancestral past. Mothers who work hand their children over to strangers for long periods of time. Mothers who don’t work are at home alone with small children. From a human evolutionary perspective, this is bizarre. In hunter-gatherer societies, child rearing is extensively social, as are work and life in general. In modern societies, isolation is a leading risk factor for suicide. (Location 438)
But Kleinman, whose 1986 study has become a classic, came to believe that to understand these patients, you had to understand their difficulties as part of a social suffering, as part of a culture’s history, not as a series of unrelated personal complaints. (Location 452)
Anthropologists have learned to address these ambiguities by distinguishing between “illness” and “disease.”27 “Disease” refers to abnormalities in the structure and function of bodily organs and systems. Physicians, for example, refer to “disease pathways” when describing the physical causes of the symptoms that bring someone to a clinic. “Illness,” by contrast, refers to the patient’s experience. A person can experience illness without having a disease (Location 455)
a result, it is particularly important to understand how psychiatrists look at these illnesses and thus how we in turn understand them (psychiatric knowledge seeps into popular culture like the dye from a red shirt in hot water). The way we understand these illnesses affects not only the way they are treated but the way they are experienced, their outcomes, and our sense of responsibility toward those who suffer. This is what an anthropologist can observe. (Location 476)
And so I was able to observe what anthropologists now call the “transformation of subjectivity.” You cannot observe a man think and feel, but if there is a group of men, you can see what a man needs to do to be a member of that group. You can see what he learns to react to, how he learns to react, how he comes to joke about it, what he comes to fear. The anthropologist Clifford Geertz pointed out that what the anthropologist can find out through fieldwork is what is public in the exchanges people have with one another. This doesn’t mean that the psyche remains closed to observation. It means that what you can observe is how the psyche is shaped by practical and mundane things. (Location 484)
But a combination of socio-economic forces and ideology is driving psychotherapy out of psychiatry. It is harder than ever before for residents to learn psychotherapy or to see its relevance in a hospital setting, harder than before for a patient or doctor to be reimbursed for it. If psychotherapy is axed from psychiatry by the bottom-line focus of managed care companies, psychiatrists will be taught to see, think, and respond only as the biomedical task would teach them. That would be a terrible mistake. It would be bad for psychiatrists, who are more perceptive about patients, even when diagnosing and prescribing medication, when they have some psychotherapeutic background. It would be bad for our society, for biomedicine encourages a way of thinking about mental illness that can strip humanity from its sufferers. And above all it would be bad for patients, who will be treated less well and less effectively if treated from a purely biomedical perspective. There is also (Location 532)
The irony is that while Freud perhaps saw himself as demonstrating that human nature was shackled by its own design, his legacy has been to create a moral expectation of human agency and self-determination that we do ill to jettison. (Location 546)
“It’s all politics,” she said bitterly. “That’s what you learn—how to talk on rounds, how to talk to patients, how to talk to nurses. You’re taught by mistakes and by apprenticeship coaching, not all of which are consistent. Sometimes people give completely different advice. You start out so idealistic. Then you begin to cut your losses. (Location 651)
This practical, rapid apprenticeship remains the primary teaching method throughout the residency period (as is typical in medicine). During the three-year training period, residents usually spend their first year in inpatient care, their second in outpatient, and their final year either in administrative positions (as “chief resident” for various services in the hospital) or in some other elective pursuit: research or in further specialized training. (Location 662)
What residents actually learn is to do what they have to do: admit, diagnose, and medicate patients, and—less pressing these days—see them in psychotherapy. (Location 677)
Of all the skills that Gertrude had to master, the most important, most tested, and most public was her ability to admit patients to a hospital service. An “admission” is a ritual-filled process that identifies an ill person as a patient and produces a few pages that are the single most consistently read document about the person as a patient throughout the hospitalization and beyond. (Location 678)