Tuesday, January 25, 2011

(Re)Constructions of Mental Illness

The DSM as symbolizing the dominance of discourse in the creation of mental illness, definitions of mental disorders as prior to and separate from culture and personal experience, and American imperialism in regards to the construction of mental disorders

“…We’ve been changing not only treatments but also the expression of mental illness in other cultures. Indeed, a handful of mental-health disorders – depression, post-traumatic stress disorder and anorexia among them – now appear to be spreading across cultures with the speed of contagious diseases. These symptom clusters are becoming the lingua franca of human suffering, replacing indigenous forms of mental illness” (2).

“Western mental-health practitioners often prefer to believe that the 844 pages of the DSM-IV prior to the inclusion of culture-bound syndromes describe real disorders of the mind, illnesses with symptomatology and outcomes relatively unaffected by shifting cultural beliefs. And, it logically follows, if these disorders are unaffected by culture, then they are surely universal to humans everywhere. In this view, the DSM is a field guide to the world’s psyche, and applying it around the world represents simply the brave march of scientific knowledge” (4).

“This current view (intersection without ideology), like the earlier one (ideology without intersection), is premised on the positivist idea, shared by the patients and nearly all of the staff, that science uncovers its objects and does not construct them” (Young, 119).

“Critics have been concerned that with the rapid increase in brain imaging techniques, the traditional basis of psychiatric diagnosis will be overtaken by crude biological reductionism” (Cohn, 81).

Both the Young and Cohn articles demonstrate how mental illnesses are constructed in certain contexts. In conjunction with the medical definition of the disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM), both seem to focus on the importance of scientific knowledge in the construction of the illness. However, the examples of posttraumatic stress disorder (PTSD) and the mental disorders indicated by brain scans complicate a simplistic scientific construction of illness by introducing the role of ideology and technology in the patient’s construction of the disorder.

Young claims scientific knowledge to be the result of scholarly discourse and institutional ideologies (118). He uses the example of how PTSD is constructed and treated at an Institute that was created by the Veterans Administration (VA) to provide “specialized treatment” for PTSD (110). He discusses the interplay of discourse (scholarly work that provides a rubric for diagnosis) and ideology (local systems of knowledge that provide an arena for the materiality of PTSD) in creating scientific knowledge. Though historically the perceptions of the relationship between discourse and ideology have varied at the Institute, currently the notion of ideology has been abandoned for a sole focus on discourse, confirming “that science uncovers its objects and does not construct them” (119).

However, ideology continues to dominate the construction of PTSD at the Institute because of its authority and efficacy (126). The power of the Institute’s ideology persists because it is “sanctioned by the administrative authority” and because therapists must not only adhere, but also believe the legitimacy of the ideology (126). Meanwhile, patients use ideology as a means of “throw(ing) meaning around the unbounded and incoherent misfortunes of (their) postwar lives” (127). The patients are also able to avoid moral responsibility for their present state by medicalizing the past. This “sickness without psychosis” provides the men with comfort and a sense of self-efficacy (127).

Cohn address the claim that brain imaging technology will succeed at locating diseases –such as depression and schizophrenia – fully within the brain (68). In evaluating this possibility, he discusses the virtual impossibility of creating a stable and distinctive object of illness because of its contingency on the establishment of a “normal” brain (71). However, the use of brain imaging technology in the form of brain scans seems to provide patients with the illusions of objectivity and fact. Though many professionals are uncertain of the ability of the scans to define illness, an air of certainty still surrounds these images. “This imbued sense of certainty emanates from the illusion, largely colluded with by the researchers themselves who are anxious to demonstrate their expertise to the volunteers, that somehow the images are divorced from the many people and technical decisions involved in their construction” (76).

Though this new technology seeks to locate disease within the brain to further scientific knowledge of mental illness, patients attempt to use the scans not only to make their illness external, but also to provide an explanation of their condition for their social relationships (74, 79). Technology masks the uncertainty surrounding the meaning of the scan, so patients appropriate the images as extensions of themselves in their social lives, assigning personal (and perhaps scientifically unjustifiable) meaning to the images (67, 78). This, however, reveals a paradox: while patients “wanted to use the images to find ways of divorcing themselves from the illness, the illness itself refuses to be redefined because in the end it emerges not from the internal body but the nature of the person’s social relationships” (80).

Therefore, in these examples, both ideology and technology serve as a means of providing patients with a false sense of security regarding the stability or meaning of their disorder. Mental illnesses defy concrete definition, as they are a reflection of social relationships and culture. Ethan Watter’s article entitled “The Americanization of Mental Illness” addresses this issue in confronting the problems surrounding the globalization of American definitions of mental disorders (the DSM). Though “scientific leaps in understanding the brain haven’t yet created the sorts of cultural stories from which humans take comfort and meaning,” these definitions and technologies are presented as fact not only in the United States, but also globally (8).

Without the existence of a “stable, distinctive object of illness,” how could we possibly expect to apply the DSM in other countries (Cohn, 71)? Though the DSM blatantly ignores culture (until the “culture-bound syndromes” section on pages 845-849 of the DSM-IV), the role of culture cannot be ignored in the construction of a mental disorder (Watters, 4). Since “mental illnesses are not discrete entities,” nor will they ever be, we should use caution while introducing our ideas of mental disorders into other cultures (1).



Cohn, Simon. 2010. “Picturing the Brain Inside, Revealing the Illness Outside: A Comparison of the Different Meaning Attributed to Brain Scans by Scientists and Patients.” Pp. 65-84. IN Technologized Images Technologized Bodies. Edited by Jeanette Edwards, Penny Harvey and Peter Wade. New York: Berghahn Books.

Watters, Ethan. 10 January, 2010. “The Americanization of Mental Illness.” The New York Times. http://www.nytimes.com/2010/01/10/magazine/10psyche-t.html?_r=1

Young, Allan. 1993. “A Description of How Ideology Shapes Knowledge of a Mental Disorder (Posttraumatic Stress Disorder).” Pp. 108-128. IN Knowledge, Power and Practice: The Anthropology of Medicine and Everyday Life. Edited by Shirley Lindenbaum and Margaret Lock. Berkeley: University of California Press.


Friday, January 21, 2011

Risks, Control, and Public Health

“…The ‘web’ of causation that is often constructed to show why individuals may choose to smoke draws attention to such factors as stress, lack of knowledge about side-effects of smoking, addiction to nicotine, low self-esteem, and low self-efficacy. While the sociocultural context is clearly important here, it is generally reduced to the individual level: a person feels stress and smokes to alleviate it, lacking the self-esteem and self-efficacy she or he requires to give it up. The questions of how ‘stress’ is generated, why that particular individual should be suffering from ‘stress’ in comparison to others, and the sources of that individual’s lack of self-esteem and self-efficacy are often glossed over for a focus upon ‘improving’ self-esteem and self-efficacy and alleviating stress, so that the individual may then give up smoking. Such individualistic understandings of smoking behavior tend to ignore or at the very least play down the whole panoply of broader sociocultural phenomena around smoking, including the cultural and symbolic meanings of smoking, the use of cigarettes as commodities to define the self, and the economics and politics of the production and marketing practices to do with cigarettes” (48).

The above news clip entitled “E-Cigarettes: Healthy Habit or New Hazard” from The Associated Press presents the phenomenon of the “e-cigarette.” These electronic pipes, manufactured by a Chinese company, serve as a possibly “healthy” alternative to the normal cigarette. Instead of smoke, they produce a fine nicotine spray that is quickly absorbed by the lungs. Therefore, one can have an e-cigarette around others without the concern of second-hand smoke. However, these facts do not prove to be universally accepted. While the product designer claims the e-cigarette to be a safe alternative to regular cigarettes and a way to kick the habit, the World Health Organization (WHO) remains concerned about the content of e-cigarettes and of long-term medical effects. Additionally, since they contain nicotine, e-cigarettes are still addictive, which seems to be in contrast with the overall goal of the product.

The mere existence of a cigarette alternative indicates an issue with normal cigarettes, with which Peterson and Lupton would surely agree. Classified as a “risky behavior,” cigarette smoking joins a wealth of other activities and life-style choices that public health labels as “risks” (23). Other “risk factors” include, but are not limited to, smoking, alcohol, diet, exercise, reproductive behavior, driving behavior, social relationships, the occupational environment, pollution, and the built environment (19).  The authors claim that “one of the key tasks of this expanding system of expert knowledge (public health) is to track down, calculate and eliminate the ‘risks’ that are seen to pervade all aspects of human life” (18). They acknowledge the social, cultural and political processes that shape risks and recognize that morality influences the interpretation of risk factors (18). Ultimately, the “calculation of risks” legitimates interventions based on an “expert assessment that an undesirable event may occur,” which helps them advance their goal of achieving health through intervention (19).

Later in Chapter 2, Peterson and Lupton discuss the epidemiology of risk. Though the term “risk” usually designates “something that can be given a numerical value,” in the case of public health the term mostly denotes danger (48). They also acknowledge that, in the realm of risk, epidemiology manipulates which outcomes and risk factors to focus on (47). These decisions are “surrounded by culturally defined moral problems in which power relations always have a central position” (47). Therefore, risk is a “sociocultural construct” informed by moralism with an emphasis on personal responsibility (48). Smoking cigarettes is no exception. The introductory block quote illustrates the framing of cigarette smoking in a complex socio-cultural and political context. The “web of causation” includes not only individualistic understandings of the behavior, but also the “broader sociocultural phenomena around smoking” (48).

Among these “sociocultural phenomena” lies the “use of cigarettes as commodities to define the self” (48). Therefore, cigarette smoking may constitute a part of a person’s identity, helping them form their sense of self. Relatedly, Peterson and Lupton discuss the constructions of “self” and “other” in epidemiological discourses, which tend to focus on the categorization of social groups as “normal” or “abnormal” (55). “As part of this process of drawing a dichotomy between ‘high risk’ or ‘unhealthy’ groups and ‘low risk’ or ‘healthy’ groups, fears about social order, death and disease may be projected by the latter onto the former” (55). Therefore, in trying to construct their identities, non-smokers may use commonly held moral assumptions about smokers to bolster their sense of self, while smokers may just be using smoking to help form their identity. Therefore, smoking and non-smoking and moral judgments regarding the habit all serve individuals in the fabrication of their identities.

Ultimately, the demand for e-cigarettes demonstrates Peterson and Lupton’s assertions that society is obsessed with notions of health to the point where they comply almost voluntarily with the principles and guidelines of public health. The authors stress the remarkable extent of “health-related concerns” in contemporary Western societies (1). Therefore, it logically follows that “by providing norms by which individuals are monitored and classified, and against which individuals may be measured, the emphasis of the new public health is upon persuading people to conform voluntarily to the goals of the state and other agencies,” including public health (12). Thus, in identifying smoking as a “risk factor,” public health attempts to dissuade people from smoking, and the demand for e-cigarettes proves their attempts to be successful and provides evidence for the control of public health on society. People conform voluntarily to public health standards because of their desire to achieve “health,” which may be a reason for them to transition from normal to e-cigarettes. 



Alan Peterson and Deborah Lupton. 1996. “The New Public Health: A New Morality?” and “Epidemiology: Governing by Numbers.” Pp. 1-60. IN The New Public Health: Health and Self in the Age of Risk. London: Sage Publications.

Friday, January 14, 2011

The Black and White of Biomedicine

It is a mistake to underestimate the force of Cartesian dualism in medicine today. In spite of a growing disaffection of a section of the populace with traditional approaches to health, the dualist philosophy is alive and well, the guiding light of almost all theoretical and clinical efforts of Western medicine” Dossey, (1984:15), Gordon (20)

Biology leaves unexplored an aspect of the mind-body problem that is essentially ethical. This residual mind-body problem occurs because mind and body symbolize contrasting poles in human experience: the voluntary or intentional and the involuntary or accidental. It is because the contrast between willful action and impersonal accident is central to both the private sense of self and the public concept of the person that mind-body dualism persists in Western thinking about morally significant events like sickness and disability” Kirmayer (57)

The dichotomies upon which modern biomedicine is constructed are as stark and rigid as the hues in the above images. The primary dichotomous relationships found in biomedicine include not only classic Cartesian dualism of body and mind, but also ideas of irrationality and rationality, patient and physician, and illness and disease. I argue that this scientific tendency to “rationally” classify and polarize results in the precarious construction of Western biomedicine, and ultimately perpetuates (the perhaps otherwise unfounded) authority of the institution of medicine.

Kirmayer outlines how biomedicine was founded on a “Cartesian division of man into a soulless mortal machine capable of mechanistic explanation and manipulation, and a bodyless soul” (59). Gordon furthers this notion in asserting a distinction between “naturalism,” “individualism,” and biomedicine, claiming that they thrive on mutual support. He ultimately draws several key parallels between naturalism and individualism. Both use the atom as the fundamental building block, and neither acknowledges the importance of society, culture, or the body in the construction of the atom. Thus, the individual body is alienated from exterior factors and robbed of its ability to define itself.

Although the mind/body split exemplifies a primary dualism in modern biomedicine, Kirmayer uses the metaphor of the body as a biochemical machine to illustrate how dualistic values in Western biomedicine also fixate on a rational mastery of the body. This metaphor elicits ideas of biomedical control and the value of rationality. Under this model, patients, if rational, adhere to particular guidelines given by medical professionals. Only when patients fail to behave rationally do they experience medical problems, which, according to this model, represent individual failure.

Kirmayer also describes the dualism between the “physician as active knower and the patient as passive known” (59). This dichotomy is manifested in the medical distinction between disease and illness. While disease represents the physician’s biomedical interpretation of disorder, illness merely refers to the patient’s “personal experience of distress” (59). Biomedicine deals with this divide by applying “rational techniques to sickness,” viewing the body as a machine by “distancing from the emotional significance of illness” (60). Kirmayer discusses the various ways medical practice distances from the body as a person. First, the architecture of hospitals provides concrete barriers between sick bodies and social persons. Second, physicians manipulate language (mostly in the form of “codes”) to reduce the “affectivity” of the discourse (61). This distancing further removes the patient from not only the outside world, but also from the possibility of relating to the institution on a personal or emotional level. Ultimately, medicine trumps the “bodily-felt” reality of the patient, posing sickness as a threat to rationality (Kirmayer, 61).

Gordon illuminates this distinction between disease and illness by considering the separation between the objectivity of nature and the subjectivity of the individual’s experience of the world (25). This separation can be applied to distinguishing “signs,” objective indications of the patient’s body, from “symptoms,” the patient’s complaints (25). Using this model, “disease” is defined as biological abnormality while “illness” is merely the patient’s experience. This distinction is problematic for several reasons. First, it assumes that the physician is rational and unconditionally correct, identifying and evaluating infallible “signs” of disease. Meanwhile, the irrational patient determines her illness by evaluating her subjective distress. This interpretation leaves no room for a more holistic, cultural or emotional understanding of illness.

After considering the relationship between naturalism, individualism, and biomedicine, Gordon questions whether a “holistic” approach to medicine is possible in a society so focused on atomism and the individual as separate from culture and society (42). However, she also claims that “sickness expounds a truth about the order of the world as much as the body of the sick person” (42). In stating this, she exposes her belief that the patient’s interpretation of her illness is imperative to the overall understanding of the condition.

Ultimately, in considering these various dichotomies and power structures as a whole, we see that they work together to promote the (mostly) unquestioned authority of biomedicine in our culture. The patients’ desire for answers leads to the reinforcement of the legitimacy of the answers given by medical professionals, which indirectly affirms the dominance of biomedicine and the way in which it operates. Therefore, the dichotomies and distinctions remain unquestioned, not providing an arena for change. Patients must be aware of the power dynamic and assumptions of biomedicine in order to claim their contribution to the meaning of their “disease.”