Last Sunday, the New York Times magazine featured an article about the booming industry of behavior-modification drugs for pets. It seems as though unruly dogs have become too much for Skinner’s behavioral conditioning methods: pet-owners (and vets alike) have discovered the fast fix of a pill. True to form, the pharmaceutical industry has picked up on this as a new source of income. The article writes: “The practice of prescribing medications designed for humans to animals has grown substantially over the past decade and a half, and pharmaceutical companies have recently begun experimenting with a more direct strategy: marketing behavior-modification and “lifestyle” drugs specifically for pets. America’s animals, it seems, have very American health problems.” Eli Lilly has produced Prozac for dogs: it’s the same drug, but it’s chewable and tastes like beef.
And that’s exactly it. This new trend of chemically altering our pets’ behavior seems to be the latest incarnation of the phenomenon known as humanization. We project our own emotions, thoughts, dreams, and expectations onto our pets, to the point where we mistake them for human and attribute to them our own likes, dislikes, fantasies, and expectations of life. Marketers, of course, have provided a wealth of products with which we can express our love for our pets in material ways. It’s led to the emergence of high-class pet product stores at the mall (I know at least two in my little San Diego neighborhood), buying Christmas presents for your dog and – apparently – treating its behavioral issues with Prozac. We want our pets to behave like we do, too – we want them to be polite, and well-adjusted to urban apartment and/or family life. And when they’re not, we want to treat that problem in the same, convenient way that we treat our own: pharmaceutically.
The question that ultimately resonated throughout the article was this: is that humanization justified? In other words, are dogs, or pets in general, like us humans? Can we expect them to adapt to our clean and sterilized lives? Do dogs experience emotions, fantasies, and fears? Do they have the same mental processes that we do? And if so, can they be mentally ill? If they cannot adapt to our lifestyle, can we really stamp this inability as ‘pathological’?
I won’t go into this debate here – I don’t think we’ll ever know the extent of animal emotions, consciousness, or rational thought. But the question brings up another issue, which is that of mental illness. If animals do not possess consciousness like we do, and do not experience the same level of emotion, can they have mental illness? “If the strict Cartesian view were true – that animals are essentially flesh-and-blood automatons, lacking anything resembling human emotion, memory and consciousness – then why do animals develop mental illnesses that eerily resemble human ones and that respond to the same medications?” Let’s say that a dog with ‘separation anxiety’ really has something pathological going on in his brain – whether or not it’s aware of this anxiety.* If a drug like Xanax works for this dog, what does it say about the neurological nature of anxiety in our own brain? Can we then still connect mental illness to emotion and consciousness? And if not, do we then need to redefine mental illness? Does mental illness then become something purely neurological?** If it has nothing to do with awareness, what then are delusions and hallucinations? Can you be mentally ill if you don’t have consciousness, or when you are not aware of yourself existing in the world?
Pet-owners do expect pets to be too much like themselves. The lives we expect our pets to lead are too unnatural. A dog is not made to live indoors in 1500 square feet of space. When it subsequently develops behaviors that disrupt our calm and sterile routine – aggressiveness, or an obsessive chasing after its own tail – it is unfair to stamp it as pathological.
But don’t we do the same to ourselves? In his autobiographical account of depression, Andrew Solomon (the Noonday Demon) mentions evolutionary lag as one potential reason for the existence of mental illness among humans. Basically, the argument here is that our lifestyles have become unnatural to ourselves – our nature, our biology, has not yet caught up with the fast-paced industrial lives we lead, in which we are increasingly isolated, have too many options, and too many expectations. I don’t necessarily agree with this scenario; I don’t think modern lives are any more difficult than the lives we led as hunter-gatherers (difficult in a different way, certainly, but not more difficult in any abstract, objective sense). But I do think that we increasingly try to live lives in which there seems to be no room for the very natural occurrence of emotions. I’ve arrived again at Stefan Ecks’ “monoculture of happiness.” In the ambitious life plan of a young high school student trying to make it into a good university, then the young adult trying to get a well-paying job and then trying to perform well enough to hold on to said job and perhaps make a promotion or two, there seems to be no room for sadness, fear, anger, and the like. The thing is that these emotions are a natural part of being human. We cannot turn them off – and so we, too, ultimately develop alternative ways of expressing these feelings. Perhaps we don’t obsessively chase our tails for hours on end, but we obsess over other things. Like our make up, our email – or even our work performance (Emily Martin also writes about the place of emotions in daily life. She argues not that there is no room for emotions, but that there is only room for certain emotions. She suggests, for instance, that modern society in some way cultivates and admires certain aspects of mania). And when we cannot channel our emotions into even slightly productive directions, we take a pill.
So maybe this is the aspect of humanization we should really be worrying about.
* The article at some point distinguishes between ‘primal feelings’, a sort of basic emotional palette, and more evolved emotional states like anxiety and depression. The difference, it seems to suggest, is a component of awareness, or reflexivity. Primal feelings are primal – they’re Freud’s basic drives, perhaps. They’re purely limbic, instinctive. Emotional states on the other hand – the ones mentioned are anxiety, obsession, depression – are more cognitive (I’m reminded here of Martha Nussbaum’s work; she defines emotions as judgments about the world and its relationship to you, the experiencer). The article describes the difference as that “between a gazelle spooking at the sight of a lion and a gazelle worrying that a lion may appear.” The latter, the emotions, involve some kind of mental process that is based on recollection, foresight, experience, and so on – a kind of consciousness. But can you really distinguish between these two categories of primal feelings and emotions? Can any feeling be categorized as one of the two? Like anger. Where would that one go? Or shame? Is it a difference of degree, perhaps?
** I wonder, actually, on what basis distinctions are made between neurological and psychiatric disorders. Both affect behavior. Both affect the brain. Both can affect mood – think of a brain tumor located in just the wrong place. What is it that makes Tourette’s a neurological, and schizophrenia a psychiatric disorder? Perhaps it’s just the fact that we don’t actually know what schizophrenia does, in the brain?
Sunday, July 20, 2008
Tuesday, July 15, 2008
psychiatry and spirit possession
In this year’s June issue of Ethos, Bambi Chapin (“Transforming Possession: Josephine and the Work of Culture” in Ethos no. 36 vol. 2, pp. 220-245) discusses a question that underlies a – perhaps THE – central assumption on which I base my own research: do cults of religious healing, and of spirit possession in particular, serve the same therapeutic purpose that psychotherapy does?
Cults of spirit possession have been the object of steady anthropological interest over the years. Ethnographers have described these traditions as they are practiced all over the world, from Africa to India to Native American cultures. Unfortunately I have not been able to read much on this topic beyond what has been written about these cults in Morocco (for a classic account, read Vincent Crapanzano’s work on the Hamadsha), but I can refer you to the work of scholars such as Gananath Obeyesekere, Melford Spiro, Janice Boddy, Erika Bourguignon, and George Devereux for accounts of practices elsewhere. The particulars of the way in which these cults are practiced varies widely, of course, but the general idea is fairly universal. In the most basic terms, communities in which such cults are practiced believe in the existence and presence of a certain kind of spirits, deities, or demons, who – at certain times, or for particular reasons – take possession of human bodies. Cults of possession prescribe certain treatments when this occurs. This may involve exorcism, but in a lot of cases it actually does not: rather, treatment consists of attempts, by healers and sufferer, to establish some kind of communication with the possessing spirit and subsequently transform the relationship between spirit and possessee into something more symbiotic – beneficial for both parties. As far as I know, communication with the spirit is in most cases established in ritual performances by inducing a kind of trance-state in the sufferer.
If exorcism is not always sought (even if that is the case because it is thought that exorcism is impossible), this means that spirit possession is not always absolutely negative. And in fact, you’ll often see that the healers in these possession cults are themselves involved in such a symbiotic relationship with a spirit, and that it is from this relationship that they derive their (positive) healing powers. Such healers work themselves into a state of trance to treat and assist supplicants who come to them with a wide variety of physical and social troubles. Many sufferers from possession go on themselves to become members of these cults, reinducing trance at frequent intervals to re-establish the relationship with their spirit.
Nevertheless, scholars of spirit possession mostly agree (as does the DSM-IV) that spirit possession is an expression of something psychologically pathological. In other words, the general consensus is that spirit possession is a culturally specific way of displaying symptoms of psychosis, dissociation, social anxiety, and such. That is, while a western psychotic may believe himself to be the reincarnation of Elvis Presley, a psychotic member of a community that believes in spirit possession may believe his body to be taken over by a demon.
The phenomenology of spirit possession is often described as episodes of a complete loss of control and consciousness – I imagine it as a sort of fainting or swooning – during which the spirit exerts complete power over the possessed body, displaying his (or her) control by making the body do extreme or inappropriate things (according to the standards of the cultural environment at hand). It is described by scholars as akin to what we in the world of the DSM and ICD know as an episode of dissociation – a state in which a person is so lost in internal goings-on that he or she loses touch with external reality. This becomes problematic when these episodes recur habitually, and do so outside of a person’s control. Dissociation often occurs in response to traumatic experiences, and may thus be a part of disorders like PTSD. Indeed, most possessees described in the ethnographic literature have experienced considerable (social) trauma in their lives leading up to the first experience of possessed trance (for some great ethnographic descriptions, see Obeyesekere’s Medusa’s Hair).
But while there is consensus on the pathology of spirit possession, there is disagreement about the purpose of these ritual performances. Specifically, there is disagreement about whether or not such performances – those ritual inductions of trance – work as a form of ‘treatment’, or whether they just allow the possessed person to express his or her symptoms. Chapin nicely lays down the point of contention in her article. Scholars like Mel Spiro believe that only western psychoanalysis can adequately treat symptoms of dissociation and/or psychosis. Ritual performances provide a space for a sufferer to express these symptoms, but that’s where it ends. For Spiro, the experience of spirit possession is a form of hallucination, and belief in its reality is pathological, because it shows an inability to distinguish between mental representations and actual reality. The cult lends cultural legitimacy to the symptom by ritualizing it – its expression thus gains a level of social acceptance. But because the cult ultimately reinforces this belief in the reality of possession, it only reinforces the pathology. No therapy is provided, because nothing is done to return the sufferer to reality.
Obeyesekere (and others with him, I’m sure, but Chapin – whose work I think relies heavily on his – mentions him as the representative of this viewpoint) disagrees. For him, the cultural meaning given to the symptoms actually carries the seed for resolution and catharsis. By providing the sufferer with culturally meaningful ways to express his or her inner conflicts, a kind of transformation becomes possible. When the mode of expression – the symbols used – are both deeply personally AND culturally meaningful, a connection between inner and outer worlds is established, the person is no longer lost inside himself but can reconnect; with this shared language, sense can be made of the experiences, control over one’s inner conflicts can be regained, and relationships with the outside world can be re-established.
Chapin, of course, sides with Obeyesekere, and provides an interesting ethnographic illustration of one woman ‘cured’ by her association with possession cults. What cures, she points out, reinforcing Obeyesekere’s arguments about “the work of culture,” is the cultural connection provided by these cults. For that cultural connection entails a few things that are crucial to catharsis. In a very simple sense, it provides an audience who understands. When you are able to express your experiences in words that make sense to your audience, those experiences don’t seem so anomalous and weird and ‘crazy’ anymore. They make sense, they can resonate with others’ experiences, or concepts and beliefs common to a cultural world. All this means that you have a basis to reconnect with your community. While psychiatric suffering often leads to marginalization and even ostracism, this kind of establishment of a shared language enables a re-integration.
But what “the work of culture” also effects – and this I think is very important – is a sense of control and mastery over one’s symptoms. In my research thus far, I’ve come to the belief that a loss of agency is a crucial element in suffering from a psychiatric disorder. It often goes along with an utter sense of having lost control over one’s mind, thoughts, and/or emotions. And, according to most scholars of possession cults as well as many scholars of mental illness in the west, the onset of such distress is often triggered by experiences of powerlessness (including trauma) in one’s daily life. Treatment, then, involves the regaining of control. Medication can regulate the chemical pathways in your brain, and you yourself can regulate the administration (dosage, timing) of medication. Alternatively, talk therapy can help you pinpoint exactly what’s gone wrong in your head (or behavior) – and once a problem is identified, a solution often becomes apparent. It’s Foucault’s power-knowledge: defining something means establishing control over it. Once you know something you can come to master it. The same is true of these possession cults. By lending meaning to one’s experiences, these cults help sufferers understand – come to know – what they are going through. Moreover, the ritualized performances provide a very overtly controlled way of giving expression to one’s experiences. In other words, these ritual performances allow the sufferer to regain some mastery over his inner conflicts, and thus enable him to resolve them. The trance – and loss of consciousness and control – that first occurs beyond the sufferer’s control – is transformed into a willfully and ritually induced state. A healer who him- or herself has a symbiotic relationship with a spirit, deity, or demon still experiences these trances, these episodes of dissociation. But the big difference is that now, they are deliberately induced in a very controlled fashion, and the individual remains in control of the experience – to the extent that he or she remains ‘present’ during the episode to effect healing cures through the power of the possessing entity.
In a sense, psychiatry works in the same way. I think that it, too, provides a culturally acceptable framework to understand one’s suffering – in this case, one that resonates with our beliefs in the truth of medical science and brain chemistry. Because it provides such culturally resonant meanings, the patient can re-establish a connection with the environment (it goes something like this: because it’s not him but a skewed brain chemistry, he’s not just acting out. It’s not his fault, so we can welcome him back into the family. There is, as you can see, a moral element involved here. That might be something for a future post). And, as already mentioned above, psychiatry provides ways for the sufferer to regain some control – whether it be chemical or psychodynamic.
My dissertation research will be comparing psychiatry to religious healing traditions in Morocco, exploring what makes individuals choose one form of treatment over the other, and the impact of that choice on their experience of illness. I base all this on the fundamental assumption that both are, in fact, valid forms of treatment, and on the assumption that both are forms of treatment that work because they attach some form of cultural meaning to an inner experience of suffering. I believe strongly in both assumptions, but I’m very glad that someone else does, too.
The article was interesting for me also because it brought up some issues that really intrigue me about spirit possession.
First of all, there is the question of what all this means for the definition of psychiatric illness and its treatment. If we believe that possession cults can treat (certain) psychiatric disorders, what does that imply for the nature of such disorders? For instance, does it deny a biochemical component? And if treatment is so culturally specific, what is the role of culture in the nature and experience of illness? If Spiro believes that only psychotherapy can treat psychiatric distress, even in areas of the world where this is not a common practice, this must mean that all psychiatric disorders everywhere are of similar nature. But if someone in Sri Lanka (in the case of Obeyesekere’s and Chapin’s work) responds to possession cults in the same way that a sufferer from PTSD responds to psychotherapy, does that mean that their illnesses are fundamentally different? Personally, I’m inclined to say no. I think that in the end, both biochemical and socio-psychological factors are involved in the development of mental illness. I think culture plays a huge role in our experience of such distress – because culture plays a role in shaping all of our mental activity. Anyone who has been used to speaking two languages from a young age will know that you think about things differently in different languages, because things are conceptualized differently. It makes sense, then, that the way you understand your inner conflicts should also be shaped by the meanings and beliefs prevalent in the culture you are a part of – and as such, it makes sense that each culture offers specific, culturally meaningful, ways of resolving those conflicts.
Chapin also brought up a few elements of possession that I have come across in my own research on these cults. My focus has been on Morocco, which is a literature that Chapin does not cite (it’s too outdated, probably), but the similarities with her discussion strike me. One such element is related to something I briefly mentioned above – the fact that spirit possession does not seem to be an absolutely negative phenomenon. When it takes you unawares, possession is a bad thing – that loss of control is undesirable, and the possessing spirit is depicted as a force of evil and maliciousness. Yet there is some seed of potential power in there, too. Possession can become a positive force of empowerment, too – it becomes a special connection with a spirit or deity, a link to the supernatural that lends one unique abilities such as that of healing. There seems to be a fine line, then, between the forces of good and evil. A possessing spirit can be both deity and demon, and possession can link you to the power of divine grace, or ensnare you in the temptation of a demon. Which way the scale tips, seems to be mostly up to you, and your ability to communicate with and control the spirit inside of you.
Another very interesting issue is the fact that possession always seems to carry a certain sexual charge. The relationship between spirit and victim always seems to carry certain sexual undertones – or a kind of gender-contrast, in the least. Chapin’s ethnography seems to draw attention to this, as did Obeyesekere’s. For the women who establish these intimate relationships with deities, it often means the renunciation of ‘earthly’ sex with her husband, and the symbols that express a woman’s relationship with a god are often sexual in a very Freudian way – phalluses everywhere. Moreover, most of the women described by Obeyesekere (and also the one described here by Chapin) have undergone rape, incest, or other kinds of forced sexual encounters, as part of the traumatic events of powerlessness that preceded their possession. It seems that sexuality (and perhaps there is a larger truth to that), like the spirits, can be both good and evil. For a woman, it can be synonymous with an ultimate powerlessness, the kind of serious trauma that would lead to dissociative symptoms. But of course, it can also be empowering, positive, the source of energy and life, the productive force one gains when a symbiotic relationship is established with a deity.
These accounts of women in Sri Lanka make me wonder how all this works for possessed women in Morocco. Vincent Crapanzano (1973, 1980) describes only men, but in his account too the gender contrast is important. He also identifies experiences of powerlessness as the source of the inner conflict expressed through possession. Crapanzano explains these experiences of powerless as a symbolic ‘feminization’ of the suffering man: because masculinity stands for dominance and femininity for submission, being possessed by a spirit means being deprived of one’s masculinity. Like it does in Sri Lanka, treatment involves the establishment of a more productive relationship with the spirit – the re-establishment of control over the relationship, the reclaiming of some dominance or autonomy, and as such, the reclaiming of one’s masculinity. Paradoxically and interestingly enough, the possessing agent is most often a female demon, a jinniyya. So it is a female force that deprives the man of his masculinity, that takes complete possession of a man and renders him unable to resist. To take this even further, Crapanzano suggests that treatment (the regaining of masculinity) must occur through infusion of the sufferer with the power of divine grace – a symbolic impregnation.
If it is a female force that takes possession of a man, femininity cannot stand simply for submission, it cannot simply be equated with weakness and dependence. It means that in fact, femininity is dangerously powerful. This idea is expressed forcefully by Fatima Mernissi, the well-known Moroccan feminist author who, in the days that she wrote about women and Islam, argued that Muslim women were not secluded in the harem because they are so weak, but because they are in fact so powerful that a woman’s simple gaze can send a man – and society as a whole – into frenzied chaos (another well-known feminist author – Nawal el-Saadaawi – makes similar arguments).
All this suggests to me that female participation in the possession cults of Morocco must be complex. I wonder how notions of gender and sexuality inform their experience of inner conflict, of possession, and of treatment. I wish I could end this post with some kind of answer to these questions, but I have none at the moment. All this is going to be a central pursuit of my dissertation research.
Cults of spirit possession have been the object of steady anthropological interest over the years. Ethnographers have described these traditions as they are practiced all over the world, from Africa to India to Native American cultures. Unfortunately I have not been able to read much on this topic beyond what has been written about these cults in Morocco (for a classic account, read Vincent Crapanzano’s work on the Hamadsha), but I can refer you to the work of scholars such as Gananath Obeyesekere, Melford Spiro, Janice Boddy, Erika Bourguignon, and George Devereux for accounts of practices elsewhere. The particulars of the way in which these cults are practiced varies widely, of course, but the general idea is fairly universal. In the most basic terms, communities in which such cults are practiced believe in the existence and presence of a certain kind of spirits, deities, or demons, who – at certain times, or for particular reasons – take possession of human bodies. Cults of possession prescribe certain treatments when this occurs. This may involve exorcism, but in a lot of cases it actually does not: rather, treatment consists of attempts, by healers and sufferer, to establish some kind of communication with the possessing spirit and subsequently transform the relationship between spirit and possessee into something more symbiotic – beneficial for both parties. As far as I know, communication with the spirit is in most cases established in ritual performances by inducing a kind of trance-state in the sufferer.
If exorcism is not always sought (even if that is the case because it is thought that exorcism is impossible), this means that spirit possession is not always absolutely negative. And in fact, you’ll often see that the healers in these possession cults are themselves involved in such a symbiotic relationship with a spirit, and that it is from this relationship that they derive their (positive) healing powers. Such healers work themselves into a state of trance to treat and assist supplicants who come to them with a wide variety of physical and social troubles. Many sufferers from possession go on themselves to become members of these cults, reinducing trance at frequent intervals to re-establish the relationship with their spirit.
Nevertheless, scholars of spirit possession mostly agree (as does the DSM-IV) that spirit possession is an expression of something psychologically pathological. In other words, the general consensus is that spirit possession is a culturally specific way of displaying symptoms of psychosis, dissociation, social anxiety, and such. That is, while a western psychotic may believe himself to be the reincarnation of Elvis Presley, a psychotic member of a community that believes in spirit possession may believe his body to be taken over by a demon.
The phenomenology of spirit possession is often described as episodes of a complete loss of control and consciousness – I imagine it as a sort of fainting or swooning – during which the spirit exerts complete power over the possessed body, displaying his (or her) control by making the body do extreme or inappropriate things (according to the standards of the cultural environment at hand). It is described by scholars as akin to what we in the world of the DSM and ICD know as an episode of dissociation – a state in which a person is so lost in internal goings-on that he or she loses touch with external reality. This becomes problematic when these episodes recur habitually, and do so outside of a person’s control. Dissociation often occurs in response to traumatic experiences, and may thus be a part of disorders like PTSD. Indeed, most possessees described in the ethnographic literature have experienced considerable (social) trauma in their lives leading up to the first experience of possessed trance (for some great ethnographic descriptions, see Obeyesekere’s Medusa’s Hair).
But while there is consensus on the pathology of spirit possession, there is disagreement about the purpose of these ritual performances. Specifically, there is disagreement about whether or not such performances – those ritual inductions of trance – work as a form of ‘treatment’, or whether they just allow the possessed person to express his or her symptoms. Chapin nicely lays down the point of contention in her article. Scholars like Mel Spiro believe that only western psychoanalysis can adequately treat symptoms of dissociation and/or psychosis. Ritual performances provide a space for a sufferer to express these symptoms, but that’s where it ends. For Spiro, the experience of spirit possession is a form of hallucination, and belief in its reality is pathological, because it shows an inability to distinguish between mental representations and actual reality. The cult lends cultural legitimacy to the symptom by ritualizing it – its expression thus gains a level of social acceptance. But because the cult ultimately reinforces this belief in the reality of possession, it only reinforces the pathology. No therapy is provided, because nothing is done to return the sufferer to reality.
Obeyesekere (and others with him, I’m sure, but Chapin – whose work I think relies heavily on his – mentions him as the representative of this viewpoint) disagrees. For him, the cultural meaning given to the symptoms actually carries the seed for resolution and catharsis. By providing the sufferer with culturally meaningful ways to express his or her inner conflicts, a kind of transformation becomes possible. When the mode of expression – the symbols used – are both deeply personally AND culturally meaningful, a connection between inner and outer worlds is established, the person is no longer lost inside himself but can reconnect; with this shared language, sense can be made of the experiences, control over one’s inner conflicts can be regained, and relationships with the outside world can be re-established.
Chapin, of course, sides with Obeyesekere, and provides an interesting ethnographic illustration of one woman ‘cured’ by her association with possession cults. What cures, she points out, reinforcing Obeyesekere’s arguments about “the work of culture,” is the cultural connection provided by these cults. For that cultural connection entails a few things that are crucial to catharsis. In a very simple sense, it provides an audience who understands. When you are able to express your experiences in words that make sense to your audience, those experiences don’t seem so anomalous and weird and ‘crazy’ anymore. They make sense, they can resonate with others’ experiences, or concepts and beliefs common to a cultural world. All this means that you have a basis to reconnect with your community. While psychiatric suffering often leads to marginalization and even ostracism, this kind of establishment of a shared language enables a re-integration.
But what “the work of culture” also effects – and this I think is very important – is a sense of control and mastery over one’s symptoms. In my research thus far, I’ve come to the belief that a loss of agency is a crucial element in suffering from a psychiatric disorder. It often goes along with an utter sense of having lost control over one’s mind, thoughts, and/or emotions. And, according to most scholars of possession cults as well as many scholars of mental illness in the west, the onset of such distress is often triggered by experiences of powerlessness (including trauma) in one’s daily life. Treatment, then, involves the regaining of control. Medication can regulate the chemical pathways in your brain, and you yourself can regulate the administration (dosage, timing) of medication. Alternatively, talk therapy can help you pinpoint exactly what’s gone wrong in your head (or behavior) – and once a problem is identified, a solution often becomes apparent. It’s Foucault’s power-knowledge: defining something means establishing control over it. Once you know something you can come to master it. The same is true of these possession cults. By lending meaning to one’s experiences, these cults help sufferers understand – come to know – what they are going through. Moreover, the ritualized performances provide a very overtly controlled way of giving expression to one’s experiences. In other words, these ritual performances allow the sufferer to regain some mastery over his inner conflicts, and thus enable him to resolve them. The trance – and loss of consciousness and control – that first occurs beyond the sufferer’s control – is transformed into a willfully and ritually induced state. A healer who him- or herself has a symbiotic relationship with a spirit, deity, or demon still experiences these trances, these episodes of dissociation. But the big difference is that now, they are deliberately induced in a very controlled fashion, and the individual remains in control of the experience – to the extent that he or she remains ‘present’ during the episode to effect healing cures through the power of the possessing entity.
In a sense, psychiatry works in the same way. I think that it, too, provides a culturally acceptable framework to understand one’s suffering – in this case, one that resonates with our beliefs in the truth of medical science and brain chemistry. Because it provides such culturally resonant meanings, the patient can re-establish a connection with the environment (it goes something like this: because it’s not him but a skewed brain chemistry, he’s not just acting out. It’s not his fault, so we can welcome him back into the family. There is, as you can see, a moral element involved here. That might be something for a future post). And, as already mentioned above, psychiatry provides ways for the sufferer to regain some control – whether it be chemical or psychodynamic.
My dissertation research will be comparing psychiatry to religious healing traditions in Morocco, exploring what makes individuals choose one form of treatment over the other, and the impact of that choice on their experience of illness. I base all this on the fundamental assumption that both are, in fact, valid forms of treatment, and on the assumption that both are forms of treatment that work because they attach some form of cultural meaning to an inner experience of suffering. I believe strongly in both assumptions, but I’m very glad that someone else does, too.
The article was interesting for me also because it brought up some issues that really intrigue me about spirit possession.
First of all, there is the question of what all this means for the definition of psychiatric illness and its treatment. If we believe that possession cults can treat (certain) psychiatric disorders, what does that imply for the nature of such disorders? For instance, does it deny a biochemical component? And if treatment is so culturally specific, what is the role of culture in the nature and experience of illness? If Spiro believes that only psychotherapy can treat psychiatric distress, even in areas of the world where this is not a common practice, this must mean that all psychiatric disorders everywhere are of similar nature. But if someone in Sri Lanka (in the case of Obeyesekere’s and Chapin’s work) responds to possession cults in the same way that a sufferer from PTSD responds to psychotherapy, does that mean that their illnesses are fundamentally different? Personally, I’m inclined to say no. I think that in the end, both biochemical and socio-psychological factors are involved in the development of mental illness. I think culture plays a huge role in our experience of such distress – because culture plays a role in shaping all of our mental activity. Anyone who has been used to speaking two languages from a young age will know that you think about things differently in different languages, because things are conceptualized differently. It makes sense, then, that the way you understand your inner conflicts should also be shaped by the meanings and beliefs prevalent in the culture you are a part of – and as such, it makes sense that each culture offers specific, culturally meaningful, ways of resolving those conflicts.
Chapin also brought up a few elements of possession that I have come across in my own research on these cults. My focus has been on Morocco, which is a literature that Chapin does not cite (it’s too outdated, probably), but the similarities with her discussion strike me. One such element is related to something I briefly mentioned above – the fact that spirit possession does not seem to be an absolutely negative phenomenon. When it takes you unawares, possession is a bad thing – that loss of control is undesirable, and the possessing spirit is depicted as a force of evil and maliciousness. Yet there is some seed of potential power in there, too. Possession can become a positive force of empowerment, too – it becomes a special connection with a spirit or deity, a link to the supernatural that lends one unique abilities such as that of healing. There seems to be a fine line, then, between the forces of good and evil. A possessing spirit can be both deity and demon, and possession can link you to the power of divine grace, or ensnare you in the temptation of a demon. Which way the scale tips, seems to be mostly up to you, and your ability to communicate with and control the spirit inside of you.
Another very interesting issue is the fact that possession always seems to carry a certain sexual charge. The relationship between spirit and victim always seems to carry certain sexual undertones – or a kind of gender-contrast, in the least. Chapin’s ethnography seems to draw attention to this, as did Obeyesekere’s. For the women who establish these intimate relationships with deities, it often means the renunciation of ‘earthly’ sex with her husband, and the symbols that express a woman’s relationship with a god are often sexual in a very Freudian way – phalluses everywhere. Moreover, most of the women described by Obeyesekere (and also the one described here by Chapin) have undergone rape, incest, or other kinds of forced sexual encounters, as part of the traumatic events of powerlessness that preceded their possession. It seems that sexuality (and perhaps there is a larger truth to that), like the spirits, can be both good and evil. For a woman, it can be synonymous with an ultimate powerlessness, the kind of serious trauma that would lead to dissociative symptoms. But of course, it can also be empowering, positive, the source of energy and life, the productive force one gains when a symbiotic relationship is established with a deity.
These accounts of women in Sri Lanka make me wonder how all this works for possessed women in Morocco. Vincent Crapanzano (1973, 1980) describes only men, but in his account too the gender contrast is important. He also identifies experiences of powerlessness as the source of the inner conflict expressed through possession. Crapanzano explains these experiences of powerless as a symbolic ‘feminization’ of the suffering man: because masculinity stands for dominance and femininity for submission, being possessed by a spirit means being deprived of one’s masculinity. Like it does in Sri Lanka, treatment involves the establishment of a more productive relationship with the spirit – the re-establishment of control over the relationship, the reclaiming of some dominance or autonomy, and as such, the reclaiming of one’s masculinity. Paradoxically and interestingly enough, the possessing agent is most often a female demon, a jinniyya. So it is a female force that deprives the man of his masculinity, that takes complete possession of a man and renders him unable to resist. To take this even further, Crapanzano suggests that treatment (the regaining of masculinity) must occur through infusion of the sufferer with the power of divine grace – a symbolic impregnation.
If it is a female force that takes possession of a man, femininity cannot stand simply for submission, it cannot simply be equated with weakness and dependence. It means that in fact, femininity is dangerously powerful. This idea is expressed forcefully by Fatima Mernissi, the well-known Moroccan feminist author who, in the days that she wrote about women and Islam, argued that Muslim women were not secluded in the harem because they are so weak, but because they are in fact so powerful that a woman’s simple gaze can send a man – and society as a whole – into frenzied chaos (another well-known feminist author – Nawal el-Saadaawi – makes similar arguments).
All this suggests to me that female participation in the possession cults of Morocco must be complex. I wonder how notions of gender and sexuality inform their experience of inner conflict, of possession, and of treatment. I wish I could end this post with some kind of answer to these questions, but I have none at the moment. All this is going to be a central pursuit of my dissertation research.
Sunday, July 13, 2008
Can Science withstand Capitalism?
Today I want to write about the connection between psychiatry, pharmaceutical research, and the drug industry. This is by no means a new issue – in fact, it’s been written about for years – but I came across a few discussions of it today and decided to take that as my cue to devote some space to this issue.
Of course there are links between psychiatric practitioners, researchers, and the drug industry. These three branches supposedly collaborate in the provision of adequate and effective drugs to the patients who need them. Researchers use their expertise on the brain to develop potent chemical agents to solve certain pathologies of the neural network. These drugs are manufactured and tested by the pharmaceutical companies, whose infrastructure helps deliver the drugs to the patient. But this distribution is mediated by the psychiatrist, whose clinical expertise and detailed knowledge of a drug’s effect is able to determine for which patient the drug is right. Ideally, each branch possesses a body of knowledge that is based on objective medical science, and is motivated in its pursuits by the ideal of helping a sick patient.
In reality, however, these links are much more complex. The bodies of knowledge involved are by no means objective, and the ideal of helping sick patients is pushed to the background by more immediate rewards.
The problem is that prescription is not guided solely by a doctor’s ‘neutral’ assessment of your symptoms; a doctor’s decision for a particular treatment plan emerges not just from clinical experience. It is driven also by the advertising for particular drugs that is directed at the doctor, and – more importantly – by the incentives a doctor receives from drug companies to prescribe particular drugs to his or her patients. Doctors get paid to prescribe certain medications, or to direct their patients to clinical trials testing a particular drug (which, of course, is another form of advertising). This simply leads to a bias that has nothing to do with clinical experience, and everything to do with money. There is an incentive in prescription for doctors that has nothing to do with actual efficacy.
The result? Doctors themselves often claim that they remain unmoved by the advertising directed at them by drug companies; they claim that their medical expertise withstands the lure of a marketing spin. Yet data speaks otherwise. Articles everywhere (this one, for instance) cite the New York Times’ analysis of data from Minnesota, which pointed out that doctors who received $5,000 or more from psychopharmaceutical companies were three times more likely to prescribe their drugs than doctors who had received no such incentives.
The problem is that in the end, the pharmaceutical industry is just that – an industry. Sure, their product may cure a debilitating disease, but ultimately, the industry’s goal is to sell its product and make money. They engage in the same strategies that any other product manufacturer would employ – advertising, marketing, PR. In other words: create news, promote positive stories about your product, encourage people to sell your product for you, and encourage consumers to ask for that product. The pharmaceutical companies do this in a variety of ways.
Advertising is a big deal. We’re all bombarded with commercials for new drugs on a daily basis. These are directed at doctors as well as consumers – that is, the patients. Ads for psychopharmaceuticals don’t just raise awareness for their product. They don’t just proclaim its miraculous effects. If you look closely, the ads for psychopharmaceuticals are not trying to sell you a pill; they’re trying to sell you a disease. These ads define an illness: they describe a set of symptoms and emphasize their debilitating nature, showing an individual in obvious distress. But, the ad then tells you, full of hope, there is a solution.
Exactly. Their drug.
The point is that these psychopharmaceutical advertisements change the definition of illness, usually by broadening its applicability. They alter our perception of our own experiences, and encourage us to see what used to be considered normal variation of the human condition as pathology. They create, in the words of Stefan Ecks, a “monoculture of happiness” (Ecks 2005:241), in which any sign of sadness is pathologized. This helps a company sell: the more often an illness is identified, the more often a drug linked to that illness will be prescribed. This is why the incredible rise in the incidence of depression in the past decades coincides with the introduction of antidepressant drugs like Prozac, and, as the New York Times argues, the increasing number of children diagnosed with pediatric bipolar disorder coincides with the introduction of new atypical antidepressants. This works on doctors, but on patients, too. The direct-to-consumer advertising encourages us all to wonder if Cymbalta may be right for us. After all, we all feel sad once in a while.
Another, very important, form of advertising for psychopharmaceutical companies consists of the funding of research, such as clinical trials. Abstractly speaking, this is commendable. More research is always good, and it is indeed sold as ultimately benefiting the patient, who will receive a drug whose efficacy and side-effects have been extensively tested. But the same problem emerges, because money and profits are involved: the point of these clinical trials is not to present ‘objective’ results. It is a form of marketing: the aim is to produce ‘scientific’ backing for the promotion of a particular drug. What this means: negative results are often ignored, while positive ones are often hyped up beyond all statistical validity and presented to medical professionals. Here, too, clinicians are paid to get involved. They are recruited to present the outcome of studies at conferences, or to ghost-write articles touting a drug’s miraculous efficacy. David Healy has written and spoken about this. At a lecture held at UCSD last year, he showed slides of pre-fab articles written by drug companies, that he was asked to claim authorship over in return for payment. For the drug company, such an agreement means scientific legitimacy for their study, and thus for their drug. For the psychiatrist, having such an article under one’s list of publications not only means financial boons, but also a reputation as a leader in the field. But the point, once again, is that all objectivity is gone. One might question the existence of objectivity in (biomedical) science altogether, and I usually do, but this is bias at a new level.
And in a sense, there’s nothing wrong with all this. The pharmaceutical industry is a manufacturer of products trying make money, just like any other company would do. It’s understandable, from a very detached point of view, that they do what they can to market their product. But what complicates matters is that in other cases – for those other manufacturers, of cosmetics, or macaroni, or air fresheners – their product is not something whose necessity for consumers is a matter of life or death (even if it’s symbolic death – the loss of ability or productivity). Advertising and marketing campaigns aren’t really fair (or ethical) when the need for a product is independent of a consumer’s buying power, susceptibility to advertising, and so on – and when unnecessary use of the product can be hazardous to one’s health. There is more involved with drugs than simple supply and demand.
All this is true for all areas of medicine, and all pharmaceutical companies are guilty of it. But it seems worse than normal in the case of psychiatry. Perhaps this is because psychiatric disorders are so much more elusive than any other disease. There are no simple, conclusive tests, and so the freedom of definition and diagnosis is much greater. Disorders like depression are diagnosed on the basis of observable symptoms, and rely very strongly on a doctor’s assessment of their impingement on normal functionality. There is a lot of room for interpretation. There is, in other words, much more space for the marketing and advertising of psychopharmaceuticals than there is for other drugs. An article on consumerist.com suggests, moreover, that psychiatrists are more susceptible to the financial incentives provided by drug companies because their base salary is generally lower than that of any other specialists.
So what do we do? Is there a solution here? Doctors are required to declare their income from pharmaceutical companies. Hypothetically that might work – if anything, to raise some awareness even on the part of the doctor that she’s being enticed to do certain things because of money. But other than that… does ‘transparency’ of financial connections and incentives really do anything? Even that aspect of awareness is questionable, I think. As I’ve mentioned, a lot of doctors will maintain that their medical objectivity is strong enough to withstand the force of financial incentives. The actual flow of money needs to be regulated in some way. I’m not suggesting that I have any ideas on how to do this, but something should be done. Perhaps limits on the amount of money doctors can receive from drug companies would work? Or, as is done in Europe, ban direct-to-consumer advertising of prescription drugs altogether. It makes no sense anyway. The government regulates the distribution of these drugs through prescription, yet entices everyone with it through advertising. Isn’t that unfair?
Of course there are links between psychiatric practitioners, researchers, and the drug industry. These three branches supposedly collaborate in the provision of adequate and effective drugs to the patients who need them. Researchers use their expertise on the brain to develop potent chemical agents to solve certain pathologies of the neural network. These drugs are manufactured and tested by the pharmaceutical companies, whose infrastructure helps deliver the drugs to the patient. But this distribution is mediated by the psychiatrist, whose clinical expertise and detailed knowledge of a drug’s effect is able to determine for which patient the drug is right. Ideally, each branch possesses a body of knowledge that is based on objective medical science, and is motivated in its pursuits by the ideal of helping a sick patient.
In reality, however, these links are much more complex. The bodies of knowledge involved are by no means objective, and the ideal of helping sick patients is pushed to the background by more immediate rewards.
The problem is that prescription is not guided solely by a doctor’s ‘neutral’ assessment of your symptoms; a doctor’s decision for a particular treatment plan emerges not just from clinical experience. It is driven also by the advertising for particular drugs that is directed at the doctor, and – more importantly – by the incentives a doctor receives from drug companies to prescribe particular drugs to his or her patients. Doctors get paid to prescribe certain medications, or to direct their patients to clinical trials testing a particular drug (which, of course, is another form of advertising). This simply leads to a bias that has nothing to do with clinical experience, and everything to do with money. There is an incentive in prescription for doctors that has nothing to do with actual efficacy.
The result? Doctors themselves often claim that they remain unmoved by the advertising directed at them by drug companies; they claim that their medical expertise withstands the lure of a marketing spin. Yet data speaks otherwise. Articles everywhere (this one, for instance) cite the New York Times’ analysis of data from Minnesota, which pointed out that doctors who received $5,000 or more from psychopharmaceutical companies were three times more likely to prescribe their drugs than doctors who had received no such incentives.
The problem is that in the end, the pharmaceutical industry is just that – an industry. Sure, their product may cure a debilitating disease, but ultimately, the industry’s goal is to sell its product and make money. They engage in the same strategies that any other product manufacturer would employ – advertising, marketing, PR. In other words: create news, promote positive stories about your product, encourage people to sell your product for you, and encourage consumers to ask for that product. The pharmaceutical companies do this in a variety of ways.
Advertising is a big deal. We’re all bombarded with commercials for new drugs on a daily basis. These are directed at doctors as well as consumers – that is, the patients. Ads for psychopharmaceuticals don’t just raise awareness for their product. They don’t just proclaim its miraculous effects. If you look closely, the ads for psychopharmaceuticals are not trying to sell you a pill; they’re trying to sell you a disease. These ads define an illness: they describe a set of symptoms and emphasize their debilitating nature, showing an individual in obvious distress. But, the ad then tells you, full of hope, there is a solution.
Exactly. Their drug.
The point is that these psychopharmaceutical advertisements change the definition of illness, usually by broadening its applicability. They alter our perception of our own experiences, and encourage us to see what used to be considered normal variation of the human condition as pathology. They create, in the words of Stefan Ecks, a “monoculture of happiness” (Ecks 2005:241), in which any sign of sadness is pathologized. This helps a company sell: the more often an illness is identified, the more often a drug linked to that illness will be prescribed. This is why the incredible rise in the incidence of depression in the past decades coincides with the introduction of antidepressant drugs like Prozac, and, as the New York Times argues, the increasing number of children diagnosed with pediatric bipolar disorder coincides with the introduction of new atypical antidepressants. This works on doctors, but on patients, too. The direct-to-consumer advertising encourages us all to wonder if Cymbalta may be right for us. After all, we all feel sad once in a while.
Another, very important, form of advertising for psychopharmaceutical companies consists of the funding of research, such as clinical trials. Abstractly speaking, this is commendable. More research is always good, and it is indeed sold as ultimately benefiting the patient, who will receive a drug whose efficacy and side-effects have been extensively tested. But the same problem emerges, because money and profits are involved: the point of these clinical trials is not to present ‘objective’ results. It is a form of marketing: the aim is to produce ‘scientific’ backing for the promotion of a particular drug. What this means: negative results are often ignored, while positive ones are often hyped up beyond all statistical validity and presented to medical professionals. Here, too, clinicians are paid to get involved. They are recruited to present the outcome of studies at conferences, or to ghost-write articles touting a drug’s miraculous efficacy. David Healy has written and spoken about this. At a lecture held at UCSD last year, he showed slides of pre-fab articles written by drug companies, that he was asked to claim authorship over in return for payment. For the drug company, such an agreement means scientific legitimacy for their study, and thus for their drug. For the psychiatrist, having such an article under one’s list of publications not only means financial boons, but also a reputation as a leader in the field. But the point, once again, is that all objectivity is gone. One might question the existence of objectivity in (biomedical) science altogether, and I usually do, but this is bias at a new level.
And in a sense, there’s nothing wrong with all this. The pharmaceutical industry is a manufacturer of products trying make money, just like any other company would do. It’s understandable, from a very detached point of view, that they do what they can to market their product. But what complicates matters is that in other cases – for those other manufacturers, of cosmetics, or macaroni, or air fresheners – their product is not something whose necessity for consumers is a matter of life or death (even if it’s symbolic death – the loss of ability or productivity). Advertising and marketing campaigns aren’t really fair (or ethical) when the need for a product is independent of a consumer’s buying power, susceptibility to advertising, and so on – and when unnecessary use of the product can be hazardous to one’s health. There is more involved with drugs than simple supply and demand.
All this is true for all areas of medicine, and all pharmaceutical companies are guilty of it. But it seems worse than normal in the case of psychiatry. Perhaps this is because psychiatric disorders are so much more elusive than any other disease. There are no simple, conclusive tests, and so the freedom of definition and diagnosis is much greater. Disorders like depression are diagnosed on the basis of observable symptoms, and rely very strongly on a doctor’s assessment of their impingement on normal functionality. There is a lot of room for interpretation. There is, in other words, much more space for the marketing and advertising of psychopharmaceuticals than there is for other drugs. An article on consumerist.com suggests, moreover, that psychiatrists are more susceptible to the financial incentives provided by drug companies because their base salary is generally lower than that of any other specialists.
So what do we do? Is there a solution here? Doctors are required to declare their income from pharmaceutical companies. Hypothetically that might work – if anything, to raise some awareness even on the part of the doctor that she’s being enticed to do certain things because of money. But other than that… does ‘transparency’ of financial connections and incentives really do anything? Even that aspect of awareness is questionable, I think. As I’ve mentioned, a lot of doctors will maintain that their medical objectivity is strong enough to withstand the force of financial incentives. The actual flow of money needs to be regulated in some way. I’m not suggesting that I have any ideas on how to do this, but something should be done. Perhaps limits on the amount of money doctors can receive from drug companies would work? Or, as is done in Europe, ban direct-to-consumer advertising of prescription drugs altogether. It makes no sense anyway. The government regulates the distribution of these drugs through prescription, yet entices everyone with it through advertising. Isn’t that unfair?
Thursday, April 3, 2008
Power & Control
Today’s interviewing class on the psychiatry ward felt very thematic, much more so than before. Perhaps my own particular research bias makes me see power issues everywhere, but today I got a very strong sense that the topic on the table was control. The class was led by what I eventually realized was a psychologist, not a psychiatrist, who spent the first half of the class talking mostly about the doctor-nurse relationship on the ward. The issue was how to help nurses deal with difficult patients. The psychologist saw an educational and managerial role for the doctor here: they were to explain to nurses how to cope with patients they disliked, and to manipulate the nursing schedule so that difficult patients were distributed evenly among the nurses. Interestingly, a slight disconnect occurred here: the residents unanimously expressed their disagreement with the psychologist’s view of the doctor’s role. They expressed a shared sense that in reality, they had no such power on the ward at all, and felt they had little influence on nursing practices. To this the psychologist responded by reclaiming that power: “you”, the residents, were the “supreme beings” on the ward and should claim authority over the day-to-day care of your patients.
I was even more struck by the psychologist’s stance once I realized she herself was not a doctor. She fully endorsed and pushed for a model of caretaking in which the doctor was the ultimate authority, and portrayed nurses as either uninvolved and ignorant (she suggested that nurses work on automatic pilot with little to no knowledge of a patient’s personal history or current pathology) or pathologically overinvolved (suggesting that nurses have a ‘baseline’, an MO of caring for others before caring for oneself, a tendency that can turn pathological and lead to ‘burnout’ and ‘compassion fatigue’. Doctors have that same tendency, she admitted, but in a different way. As in, not pathological?) caretakers. At first, assuming her to be a physician, I was unsurprised by her viewpoint, and the resident’s contestation of this sense of power actually struck me more. Most literature on psychiatric anthropology describes (and critiques) this sense of and claim to power by doctors on the ward. When I realized she had a PhD rather than an MD, the discrepancy felt even greater. But now that I am writing all this down, it seems to make more sense. The literature does actually describe the daily struggles for power that often go on among caretakers on a ward. The residents, as MDs, stand at the forefront of this conflict every day, which would explain – and make very understandable – their expressed sense that they feel a lot less powerful than the psychologist made them out to be. The psychologist, on the other hand, looks upon the medical profession from the outside and attributes to them the power that a medical degree confers in the popular imagination. She herself might be looking for that sense of power or authority on the wards, perhaps feeling like she has more to prove than a psychiatrist?
The purported topic of the day was Erikson’s developmental stages. Judged by the way in which the psychologist talked about developmental theories, and the way in which the residents then brought up Freud, I got the sense that none of the residents in the room knew very much about these psychoanalytic and psychodynamic theories, which surprised me. I wondered, then, on what they base their treatment. Because it does seem as though they engage in a lot of interpretive work with their patients; there is more involved in treatment at this hospital than pharmaceutical therapy, and there seems to be a lot of attention for patients’ background, goals, and social network.
In any case, the issue here was how to use these developmental stages in therapy. Erikson identifies the various developmental stages as a series of fundamental struggles or conflicts that have to be resolved before one can move on to the next stage. The first stage, for instance, constitutes the conflict between trust and mistrust: the developmental lesson here is to adopt a basic trust in others (one’s caretakers). If this goes awry, the result is either a ‘malignancy’ – that is, a failure to acquire trust, which leads to behavior of withdrawal – or an overcompensation; a pathological way of compensating for the failure to acquire basic trust, which results in delusional, or spoilt behavior. These developmental stages can be a tool in therapy by providing a framework to interpret the conflicts that underlie a patient’s behavior and/or pathology. The point of today’s class was to bring in a patient whose behavior could be attributed to a failure to resolve one of these conflicts, and to use one’s knowledge of this underlying struggle to help the patient move beyond it. One of the residents brought in one of his PTSD patients, who had come in with homicidal and suicidal ideations and uncontrolled episodes of rage. We had agreed beforehand that he most likely had failed to resolve the conflict between autonomy and shame/doubt, in which a toddler acquires a basic sense of self-control, and self-esteem as he acquires better motor coordination and learns to control his bodily urges. A failure to resolve this conflict can either lead to a self-limiting compulsion and lack of self-esteem, or an overcompensating impulsivity and recklessness – which could explain this man’s rage. We decided that control was probably an important issue for him, and so the psychologist explained that rather than interpreting his problems for him, she would try to guide him into a kind of self-realization, and ask permission before she herself provided any insight.
In my opinion she gave the man a lot less control than she had promised. She talked a lot, constantly reiterated what he said (which I understand is useful and may not necessarily be a form of claiming control, but putting myself in the man’s shoes I wondered if it would make me feel stifled), and did actually do a lot of interpreting. A resident later suggested all this, but stayed away from any notion of critique. In any case, it became clear that control and self-esteem were in fact a very big part of the problem for this man. His rage seemed like a way of compensating for an extreme sense of not having control (over others, and the effect of others on his own life), but simultaneously contributed to an extreme lack of self-esteem. In the way he talked about his wife, he portrayed himself as an utterly bad individual; the sense of having no control seemed to extend also to a failure to keep himself and his anger in check. His anger seemed like an externalized, projected form of anger toward the self. As the psychologist suggested, helping the man explore his internal response to feelings of betrayal and powerlessness would probably turn his homicidal ideation into suicidal ideation.
One of the residents brought up a good point here: anger is, essentially, what men are ‘supposed’ to feel when they feel conflicts of control. We (as in, our society, and many others) socialize men to deal with lack of control and insecurity by acting out, by being angry. What do we do with that, then? How do you help someone calm his rage without threatening his sense of masculinity? The resident brought up a good strategy: explore the man’s own ideals of masculinity, and try in some way to clarify the issue of degrees. Anger in itself is not always bad, but it should not be taken to extremes. As is the case with anything, of course. Questions of cross-cultural treatment come up here, I think – in the sense that different societies put forth different ideals of masculinity. A psychiatrist needs that awareness when treating someone like this, and I think the resident’s strategy of exploring the man’s own ideals is a good idea here. That way nothing is imposed, you allow the patient to establish the value framework within which his experience makes sense, and you can tweak your therapy and interpretation to match that framework, to make it make sense as well.
I was even more struck by the psychologist’s stance once I realized she herself was not a doctor. She fully endorsed and pushed for a model of caretaking in which the doctor was the ultimate authority, and portrayed nurses as either uninvolved and ignorant (she suggested that nurses work on automatic pilot with little to no knowledge of a patient’s personal history or current pathology) or pathologically overinvolved (suggesting that nurses have a ‘baseline’, an MO of caring for others before caring for oneself, a tendency that can turn pathological and lead to ‘burnout’ and ‘compassion fatigue’. Doctors have that same tendency, she admitted, but in a different way. As in, not pathological?) caretakers. At first, assuming her to be a physician, I was unsurprised by her viewpoint, and the resident’s contestation of this sense of power actually struck me more. Most literature on psychiatric anthropology describes (and critiques) this sense of and claim to power by doctors on the ward. When I realized she had a PhD rather than an MD, the discrepancy felt even greater. But now that I am writing all this down, it seems to make more sense. The literature does actually describe the daily struggles for power that often go on among caretakers on a ward. The residents, as MDs, stand at the forefront of this conflict every day, which would explain – and make very understandable – their expressed sense that they feel a lot less powerful than the psychologist made them out to be. The psychologist, on the other hand, looks upon the medical profession from the outside and attributes to them the power that a medical degree confers in the popular imagination. She herself might be looking for that sense of power or authority on the wards, perhaps feeling like she has more to prove than a psychiatrist?
The purported topic of the day was Erikson’s developmental stages. Judged by the way in which the psychologist talked about developmental theories, and the way in which the residents then brought up Freud, I got the sense that none of the residents in the room knew very much about these psychoanalytic and psychodynamic theories, which surprised me. I wondered, then, on what they base their treatment. Because it does seem as though they engage in a lot of interpretive work with their patients; there is more involved in treatment at this hospital than pharmaceutical therapy, and there seems to be a lot of attention for patients’ background, goals, and social network.
In any case, the issue here was how to use these developmental stages in therapy. Erikson identifies the various developmental stages as a series of fundamental struggles or conflicts that have to be resolved before one can move on to the next stage. The first stage, for instance, constitutes the conflict between trust and mistrust: the developmental lesson here is to adopt a basic trust in others (one’s caretakers). If this goes awry, the result is either a ‘malignancy’ – that is, a failure to acquire trust, which leads to behavior of withdrawal – or an overcompensation; a pathological way of compensating for the failure to acquire basic trust, which results in delusional, or spoilt behavior. These developmental stages can be a tool in therapy by providing a framework to interpret the conflicts that underlie a patient’s behavior and/or pathology. The point of today’s class was to bring in a patient whose behavior could be attributed to a failure to resolve one of these conflicts, and to use one’s knowledge of this underlying struggle to help the patient move beyond it. One of the residents brought in one of his PTSD patients, who had come in with homicidal and suicidal ideations and uncontrolled episodes of rage. We had agreed beforehand that he most likely had failed to resolve the conflict between autonomy and shame/doubt, in which a toddler acquires a basic sense of self-control, and self-esteem as he acquires better motor coordination and learns to control his bodily urges. A failure to resolve this conflict can either lead to a self-limiting compulsion and lack of self-esteem, or an overcompensating impulsivity and recklessness – which could explain this man’s rage. We decided that control was probably an important issue for him, and so the psychologist explained that rather than interpreting his problems for him, she would try to guide him into a kind of self-realization, and ask permission before she herself provided any insight.
In my opinion she gave the man a lot less control than she had promised. She talked a lot, constantly reiterated what he said (which I understand is useful and may not necessarily be a form of claiming control, but putting myself in the man’s shoes I wondered if it would make me feel stifled), and did actually do a lot of interpreting. A resident later suggested all this, but stayed away from any notion of critique. In any case, it became clear that control and self-esteem were in fact a very big part of the problem for this man. His rage seemed like a way of compensating for an extreme sense of not having control (over others, and the effect of others on his own life), but simultaneously contributed to an extreme lack of self-esteem. In the way he talked about his wife, he portrayed himself as an utterly bad individual; the sense of having no control seemed to extend also to a failure to keep himself and his anger in check. His anger seemed like an externalized, projected form of anger toward the self. As the psychologist suggested, helping the man explore his internal response to feelings of betrayal and powerlessness would probably turn his homicidal ideation into suicidal ideation.
One of the residents brought up a good point here: anger is, essentially, what men are ‘supposed’ to feel when they feel conflicts of control. We (as in, our society, and many others) socialize men to deal with lack of control and insecurity by acting out, by being angry. What do we do with that, then? How do you help someone calm his rage without threatening his sense of masculinity? The resident brought up a good strategy: explore the man’s own ideals of masculinity, and try in some way to clarify the issue of degrees. Anger in itself is not always bad, but it should not be taken to extremes. As is the case with anything, of course. Questions of cross-cultural treatment come up here, I think – in the sense that different societies put forth different ideals of masculinity. A psychiatrist needs that awareness when treating someone like this, and I think the resident’s strategy of exploring the man’s own ideals is a good idea here. That way nothing is imposed, you allow the patient to establish the value framework within which his experience makes sense, and you can tweak your therapy and interpretation to match that framework, to make it make sense as well.
Tuesday, April 1, 2008
Paranoia and Survival of the Fittest?
An article in Medical News Today (“Extent of Public Paranoia Revealed by Virtual Reality Underground Ride”) reported findings of a study on paranoia. The study sent a number of subjects on a virtual tour around the London Underground, examined their judgment of people around them, and concluded that paranoia is by no means limited to the severely mentally ill. The article quotes one of the investigators: “About one-third of the general population regularly experience persecutory thoughts. This shouldn't be surprising. At the heart of all social interactions is a vital judgment whether to trust or mistrust, but it is a judgment that is error-prone. We are more likely to make paranoid errors if we are anxious, ruminate and have had bad experiences from others in the past."
Naturally, given the current climate of global politics, the researchers link the presence of paranoia among subway users to general fears of terrorism. And in that way, the issue of inter-cultural or inter-ethnic conflict – and stereotypes – enter into this issue of social judgments. Perhaps in an effort to strike a positive note on these issues of conflict and mistrust, the researchers suggest that the existence of paranoid thoughts (and the social judgments to which it is linked) may be the only thing we all have in common as human beings.
I wrote an article, years ago, about the universality of the human need to define oneself in contrast with an ‘other’ (this, of course, being a big concept in anthropology. It is, for better or worse, our subject matter). I argued in this article that individuals and groups always need a contrast to paint themselves against; we do not know who we are if we cannot point to someone who is everything we are not. In that article I didn’t go into the possible evolutionary or biological reasons for this need – and I think it’s a murky subject, as anything related to evolutionary psychology is. But it seems to me that this need to contrast oneself to an ‘other’ is linked, conceptually, to these judgments, and to the paranoia engendered by those we judge untrustworthy. And it seems plausible that all that might be linked to some basic mechanisms for survival. I can imagine that in a world dominated by survival of the fittest, in which human beings need the help of others but also compete with them, snap judgments are sometimes necessary. Is this person going to help me survive, or will he threaten my right to live? And perhaps paranoia (or conflict, or prejudice – which I think can reasonably be linked to paranoia) is a mental mechanism that induces the individual to keep his distance from those deemed threatening.
But despite this potential universality, I’d be interested also in the cultural and gender variation in these judgments. Because there must be variation in these judgments: a woman will react differently to a particular man than another man will, and in the same way a Westerner ignorant of Middle Eastern cultures will react differently to an encounter with a man wearing a turban than a person from Calcutta will. And that’s interesting, because that suggests that universal, neurological mechanisms are shaped by culture and thus manifest themselves differently in people from different backgrounds. I wonder if this study looked into such variations at all.
Naturally, given the current climate of global politics, the researchers link the presence of paranoia among subway users to general fears of terrorism. And in that way, the issue of inter-cultural or inter-ethnic conflict – and stereotypes – enter into this issue of social judgments. Perhaps in an effort to strike a positive note on these issues of conflict and mistrust, the researchers suggest that the existence of paranoid thoughts (and the social judgments to which it is linked) may be the only thing we all have in common as human beings.
I wrote an article, years ago, about the universality of the human need to define oneself in contrast with an ‘other’ (this, of course, being a big concept in anthropology. It is, for better or worse, our subject matter). I argued in this article that individuals and groups always need a contrast to paint themselves against; we do not know who we are if we cannot point to someone who is everything we are not. In that article I didn’t go into the possible evolutionary or biological reasons for this need – and I think it’s a murky subject, as anything related to evolutionary psychology is. But it seems to me that this need to contrast oneself to an ‘other’ is linked, conceptually, to these judgments, and to the paranoia engendered by those we judge untrustworthy. And it seems plausible that all that might be linked to some basic mechanisms for survival. I can imagine that in a world dominated by survival of the fittest, in which human beings need the help of others but also compete with them, snap judgments are sometimes necessary. Is this person going to help me survive, or will he threaten my right to live? And perhaps paranoia (or conflict, or prejudice – which I think can reasonably be linked to paranoia) is a mental mechanism that induces the individual to keep his distance from those deemed threatening.
But despite this potential universality, I’d be interested also in the cultural and gender variation in these judgments. Because there must be variation in these judgments: a woman will react differently to a particular man than another man will, and in the same way a Westerner ignorant of Middle Eastern cultures will react differently to an encounter with a man wearing a turban than a person from Calcutta will. And that’s interesting, because that suggests that universal, neurological mechanisms are shaped by culture and thus manifest themselves differently in people from different backgrounds. I wonder if this study looked into such variations at all.
Monday, March 31, 2008
The Validity of Psychiatric Diagnoses
Two articles listed on Google news today address the issue of validity in psychiatry. That is, they deal with the question of how ‘real’ psychiatric disorders and diagnoses are. Both articles (“Psychiatry Confuses Distress with Disorder” in the Vancouver Sun, and “If Everyone is Ill, then No one is” in the Taipei Times) address the rapid increase in psychiatric diagnoses that has occurred during the last decades. The ‘bar’, or ‘threshold’ has been lowered, they contend: more and more people are being diagnosed not because mental illness is truly on the rise, but because the scope of pathology has been widened. In other words, what used to be considered normal variation in human behavior is increasingly medicalized and pathologized. The result is over-diagnosis and over-medication. The pieces don’t address the underlying causes for this medicalization (elsewhere, writers commonly attribute it to the power of the pharmaceutical industry, and consumers’ increased familiarity with the scope of psychiatric knowledge and treatment – the latter is actually suggested in the Vancouver Sun), but both trace it back to the rapid expansion of disease categories in the DSM and its attempts to increase its scientific and medical legitimacy.
Legitimacy, in this case, involves two things: reliability and validity. The DSM is a classificatory system that attempts to diagnose disorders on the basis of presented symptoms. In the absence of medical tests, diagnosis relies on a doctor’s interpretation of standardized lists of symptomatic criteria of which a patient must meet a specified number in order to classify as ill. Horwitz and Wakefield, the authors reviewed in the Vancouver Sun, accept the reliability of these standards (that is, they accept the idea that the same patient will be given the same diagnosis by any doctor who uses the diagnostic manual), but reject their validity, because the criteria disregard the various possible etiologies of disorder. That is, while a person mourning a recent loss (not only of a loved one, but of a job perhaps, or one’s good health) might display enough ‘symptoms’ of depression for a diagnosis, this diagnosis would not be valid, because this person’s sadness is not pathological (he has good reason to be sad). According to these two authors the problem, then, is that an emphasis on reliability has compromised validity, and consequently gives rise to over-medicalization. They suggest that a bit of subjectivity might solve much of the problem: a doctor who uses the manual would do well in keeping the patient’s background in the back of his mind and making an informed, unreliable but all the more valid, judgment on the basis of these personal considerations.
For Christopher Lane on the other hand, these ‘subjective standards’ are precisely the problem. He argues that overdiagnosis arises from the incorporation of subjective judgment into the diagnostic criteria of the DSM. Who has the authority, he claims, to determine what kind of symptoms ‘impair’ normal functioning? Who has the authority to judge what constitutes that normal functioning? His proposed solution involves setting the thresholds for diagnosis much higher, thus clarifying the line between ‘mild suffering’ and ‘disorder’. This, of course, never eliminates the ‘problem’ of subjective standards. How is a higher threshold any less subjective than a lower one and what makes this writer’s standards (being an English professor) any more authoritative or valid than that of any psychiatrist? Neither seems to me ideal – a higher threshold may eliminate over-medication, but will also deprive many people who legitimately suffer from any relief. Sure, Lane makes a valid point, and over-diagnosis is certainly a problem that must be addressed, but his call to set the thresholds higher is too simplistic.
Psychiatric diagnosis is difficult, and in the absence of medical tests these diagnostic criteria are all that doctors have to work with. Of course their validity and reliability are flawed, but any medical diagnosis is ultimately guesswork to some extent. The standards used to judge blood tests are not incontrovertibly valid, either. Just like psychiatric diagnoses, they were set, at some point, by doctors who decided that a certain concentration of a particular hormone constituted the threshold for pathology, and a certain amount of antibodies indicated the presence of disease. These, too, are random numbers designed to increase the reliability of a test. They are not necessarily biological givens.
And by means of update on the gendered thought processing issue I brought up a few days ago, Science Daily published a discussion of brain transformations in schizophrenia that actually brought up the existence of slight brain differences between men and women. These differences mostly involve the circuitry that processes emotion, which (of course…) are more elaborate in women. No mention of thought processes or rationality, and so this article is only tangentially related to my discussion earlier – unless we make use of cultural beliefs about the impact of emotion on rationality (‘you can’t think straight, you’re too emotional’. Or ‘you can think logically, you don’t let your emotions get in the way’), which are themselves to blame for the common judgment that women’s rationality is inferior to that of men. But either way, it might add something to the overall discussion… it suggests, in any case, that there might be some biological grounding for our culturally created differences in behavior.
Legitimacy, in this case, involves two things: reliability and validity. The DSM is a classificatory system that attempts to diagnose disorders on the basis of presented symptoms. In the absence of medical tests, diagnosis relies on a doctor’s interpretation of standardized lists of symptomatic criteria of which a patient must meet a specified number in order to classify as ill. Horwitz and Wakefield, the authors reviewed in the Vancouver Sun, accept the reliability of these standards (that is, they accept the idea that the same patient will be given the same diagnosis by any doctor who uses the diagnostic manual), but reject their validity, because the criteria disregard the various possible etiologies of disorder. That is, while a person mourning a recent loss (not only of a loved one, but of a job perhaps, or one’s good health) might display enough ‘symptoms’ of depression for a diagnosis, this diagnosis would not be valid, because this person’s sadness is not pathological (he has good reason to be sad). According to these two authors the problem, then, is that an emphasis on reliability has compromised validity, and consequently gives rise to over-medicalization. They suggest that a bit of subjectivity might solve much of the problem: a doctor who uses the manual would do well in keeping the patient’s background in the back of his mind and making an informed, unreliable but all the more valid, judgment on the basis of these personal considerations.
For Christopher Lane on the other hand, these ‘subjective standards’ are precisely the problem. He argues that overdiagnosis arises from the incorporation of subjective judgment into the diagnostic criteria of the DSM. Who has the authority, he claims, to determine what kind of symptoms ‘impair’ normal functioning? Who has the authority to judge what constitutes that normal functioning? His proposed solution involves setting the thresholds for diagnosis much higher, thus clarifying the line between ‘mild suffering’ and ‘disorder’. This, of course, never eliminates the ‘problem’ of subjective standards. How is a higher threshold any less subjective than a lower one and what makes this writer’s standards (being an English professor) any more authoritative or valid than that of any psychiatrist? Neither seems to me ideal – a higher threshold may eliminate over-medication, but will also deprive many people who legitimately suffer from any relief. Sure, Lane makes a valid point, and over-diagnosis is certainly a problem that must be addressed, but his call to set the thresholds higher is too simplistic.
Psychiatric diagnosis is difficult, and in the absence of medical tests these diagnostic criteria are all that doctors have to work with. Of course their validity and reliability are flawed, but any medical diagnosis is ultimately guesswork to some extent. The standards used to judge blood tests are not incontrovertibly valid, either. Just like psychiatric diagnoses, they were set, at some point, by doctors who decided that a certain concentration of a particular hormone constituted the threshold for pathology, and a certain amount of antibodies indicated the presence of disease. These, too, are random numbers designed to increase the reliability of a test. They are not necessarily biological givens.
And by means of update on the gendered thought processing issue I brought up a few days ago, Science Daily published a discussion of brain transformations in schizophrenia that actually brought up the existence of slight brain differences between men and women. These differences mostly involve the circuitry that processes emotion, which (of course…) are more elaborate in women. No mention of thought processes or rationality, and so this article is only tangentially related to my discussion earlier – unless we make use of cultural beliefs about the impact of emotion on rationality (‘you can’t think straight, you’re too emotional’. Or ‘you can think logically, you don’t let your emotions get in the way’), which are themselves to blame for the common judgment that women’s rationality is inferior to that of men. But either way, it might add something to the overall discussion… it suggests, in any case, that there might be some biological grounding for our culturally created differences in behavior.
Monday, March 24, 2008
The Gender of Rationality
Jill Lepore wrote an article in this week’s New Yorker (“Just the Facts, Ma’am: Fake Memoirs, Factual Fictions, and the History of History) about the difference between ‘history’ and ‘fiction’. Tracing the twin development of historiography and novels, Lepore’s main point is that the two genres are more similar than we would commonly believe – no more than two different kinds of history, each with its own form of truth. History books are, like novels, a form of “literary art” (pp. 80) and are never as ‘objective’ and unbiased as they claim to be; fictional stories on their part often convey larger truths about the human condition (they can ‘ring true’). What has separated them in the public mind has less to do with objective than with cultural standards of ‘truth’. Our standard looks for neutrality and empiricism: this means that we accept the outsider’s perspective and emotional distance of historiography as ‘fact’, while the personal perspectives and passions that take center stage in novels become its antithesis.
What is interesting to me is that this divide between two kinds of truth came to be drawn along gendered lines as well as literary ones. As Lepore recounts, the history of novels had by the eighteenth century become a women’s history. That realm of histories told through the eyes of individuals and through the stained-glass of affect and motivation, whose truths lie in the plausibility and universality of the experiences they recount, appealed to women’s processes of thought and experience. History, on the other hand, did not interest them – this ‘objective’, ‘neutral’ account of events that became men’s domain. Add to this, of course, the common rejection of novels as fancy and fantasy, the consequent fear of novels’ power to corrupt the minds of young women, and you not only ‘prove’ that men and women think differently, but also that women’s thought is somehow less true than that of men.
This is an incredibly interesting issue, but one I never know what to make of. These theories about gender differences in patterns of thought comes up in (cultural) psychiatry as well. It is invoked to explain gender differences in the prevalence and course of disease (are women more prone to depression or bipolar disorder because they are more sensitive to emotional mood swings?), and sometimes even factors into treatment decisions (as in, it informs the doctor’s goals of treatment. What is considered ‘normal’ affect for a man differs from what is considered ‘normal’ for a woman. An interesting discussion of this is Sara Starks & Joel Braslow’s historical overview of psychiatry in the post WWII-decades. They show that doctors were more likely to perform lobotomies on women because its side-effects interfered a lot less with women’s ideal behavior than with men’s).
No doubt there is some truth to all this – I am willing to accept the idea that women, in general, may tend to think more concretely and relationally than men do. I won’t bring up the critique of overgeneralization here, because as much as that critique should always be kept in mind, this article really does not intend to suggest that all women think in similar ways – and that they are categorically different from men. Nor, I think, do psychiatrists intend to do so (not all of them, anyway). But what I do want to bring up – because I think this article facilitates this question – is the issue of causality, or better said, the question of the chicken and the egg. That is, if these ‘generalizations’ are true, why are they true? What came first? Are women born with different wiring, that then gives rise to different ways of socializing and different domains of cultural activity (as some evolutionary psychologists would argue)? Or do culturally prescribed gender roles and expectations socialize men and women – born with equal potential – to develop their patterns of thought in different ways to match these expectations? Many anthropologists will argue that the impact of socialization is significant: women learn in large part to think more relationally and concretely because as girls they are socialized immediately into caretaking roles. They are taught to view the world and their actions in the terms of their relationships to others (a woman acts not just for herself, but for her children, and her husband), while a man is trained to pursue his own goals.
Even if there were some different wiring at birth – which I think we should not assume at all until it can be in any way ‘proven’ – the second scenario (the constructivist viewpoint) seems to me much more plausible and realistic. We are social beings who are not determined fully by our biology at all. We cannot disregard the incredible shaping force of our cultural environment. (Of course, much of my own work critiques this viewpoint, arguing that we are not fully or passively shaped by our environment. My point is that we are not passive blocks of clay but rather active intakers who confront and respond to the cultural environment in ways that are not always predictable. Nevertheless, a shaping influence is always there – that I assume to be true).
In any case, all this means that women did not ‘dislike’ history because they were born with a relational and concrete mind that eschewed ‘facts’, but rather because they were trained and expected to dislike it. Their consequent focus on novels as models of truth cannot have had a negligible effect on the solidification of even more relational, emotionally oriented, perspectives on ‘truth’ and ‘history’.
The article does not address this question directly – when I mentioned above that it facilitated the question, I meant to suggest that I think the article leaves the issue open. It does not unequivocally accept the idea that women are ‘naturally’ anything, and suggests through its wording and use of quotes that it disagrees, at least, with historical judgments of women as aversive to history.
Of course, the very reason for writing this article, as Lepore suggests, is the fact that these boundaries between history/men and novels/women have been blurring. Historiography has begun to tackle ‘alternative’ histories: personal accounts and relationships, the stories of subaltern populations, ‘social history’, ‘family history’, and so on. In other words, it has begun to tread back onto the territory traditionally claimed by novels. What hasn’t changed, according to the article, is the gender divide. Women still make up the bulk of fiction buyers, and men buy the bulk of history. What drives the changes in historiography, then, seems to have little to do with changing gender relations and patterning of thought. Lepore suggests that what is really going on is an emerging rejection of ‘objective’ and ‘neutral’ history altogether – that not only women, but men too, miss the element of storytelling, emotion, and personal accounts that novels provide. Can we conclude that men, perhaps, aren’t so different from women in their patterns of thought at all?
What is interesting to me is that this divide between two kinds of truth came to be drawn along gendered lines as well as literary ones. As Lepore recounts, the history of novels had by the eighteenth century become a women’s history. That realm of histories told through the eyes of individuals and through the stained-glass of affect and motivation, whose truths lie in the plausibility and universality of the experiences they recount, appealed to women’s processes of thought and experience. History, on the other hand, did not interest them – this ‘objective’, ‘neutral’ account of events that became men’s domain. Add to this, of course, the common rejection of novels as fancy and fantasy, the consequent fear of novels’ power to corrupt the minds of young women, and you not only ‘prove’ that men and women think differently, but also that women’s thought is somehow less true than that of men.
This is an incredibly interesting issue, but one I never know what to make of. These theories about gender differences in patterns of thought comes up in (cultural) psychiatry as well. It is invoked to explain gender differences in the prevalence and course of disease (are women more prone to depression or bipolar disorder because they are more sensitive to emotional mood swings?), and sometimes even factors into treatment decisions (as in, it informs the doctor’s goals of treatment. What is considered ‘normal’ affect for a man differs from what is considered ‘normal’ for a woman. An interesting discussion of this is Sara Starks & Joel Braslow’s historical overview of psychiatry in the post WWII-decades. They show that doctors were more likely to perform lobotomies on women because its side-effects interfered a lot less with women’s ideal behavior than with men’s).
No doubt there is some truth to all this – I am willing to accept the idea that women, in general, may tend to think more concretely and relationally than men do. I won’t bring up the critique of overgeneralization here, because as much as that critique should always be kept in mind, this article really does not intend to suggest that all women think in similar ways – and that they are categorically different from men. Nor, I think, do psychiatrists intend to do so (not all of them, anyway). But what I do want to bring up – because I think this article facilitates this question – is the issue of causality, or better said, the question of the chicken and the egg. That is, if these ‘generalizations’ are true, why are they true? What came first? Are women born with different wiring, that then gives rise to different ways of socializing and different domains of cultural activity (as some evolutionary psychologists would argue)? Or do culturally prescribed gender roles and expectations socialize men and women – born with equal potential – to develop their patterns of thought in different ways to match these expectations? Many anthropologists will argue that the impact of socialization is significant: women learn in large part to think more relationally and concretely because as girls they are socialized immediately into caretaking roles. They are taught to view the world and their actions in the terms of their relationships to others (a woman acts not just for herself, but for her children, and her husband), while a man is trained to pursue his own goals.
Even if there were some different wiring at birth – which I think we should not assume at all until it can be in any way ‘proven’ – the second scenario (the constructivist viewpoint) seems to me much more plausible and realistic. We are social beings who are not determined fully by our biology at all. We cannot disregard the incredible shaping force of our cultural environment. (Of course, much of my own work critiques this viewpoint, arguing that we are not fully or passively shaped by our environment. My point is that we are not passive blocks of clay but rather active intakers who confront and respond to the cultural environment in ways that are not always predictable. Nevertheless, a shaping influence is always there – that I assume to be true).
In any case, all this means that women did not ‘dislike’ history because they were born with a relational and concrete mind that eschewed ‘facts’, but rather because they were trained and expected to dislike it. Their consequent focus on novels as models of truth cannot have had a negligible effect on the solidification of even more relational, emotionally oriented, perspectives on ‘truth’ and ‘history’.
The article does not address this question directly – when I mentioned above that it facilitated the question, I meant to suggest that I think the article leaves the issue open. It does not unequivocally accept the idea that women are ‘naturally’ anything, and suggests through its wording and use of quotes that it disagrees, at least, with historical judgments of women as aversive to history.
Of course, the very reason for writing this article, as Lepore suggests, is the fact that these boundaries between history/men and novels/women have been blurring. Historiography has begun to tackle ‘alternative’ histories: personal accounts and relationships, the stories of subaltern populations, ‘social history’, ‘family history’, and so on. In other words, it has begun to tread back onto the territory traditionally claimed by novels. What hasn’t changed, according to the article, is the gender divide. Women still make up the bulk of fiction buyers, and men buy the bulk of history. What drives the changes in historiography, then, seems to have little to do with changing gender relations and patterning of thought. Lepore suggests that what is really going on is an emerging rejection of ‘objective’ and ‘neutral’ history altogether – that not only women, but men too, miss the element of storytelling, emotion, and personal accounts that novels provide. Can we conclude that men, perhaps, aren’t so different from women in their patterns of thought at all?
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