The Infernal Alternatives of Corporate Pharmaceutical Research: Abandoning Psychiatry

ABSTRACT

What happens when health research is measured by market size? How does this change the dynamics of medical research, and how is its growth envisioned and managed? In this article, I build on my arguments in Drugs for Life: How Pharmaceutical Companies Define our Health, which focused primarily on the development and marketing of mass medications for heart disease and I examine the market dynamics that are used to drive research into and out of psychiatric and other neuromedicines, such as the closing of mental health research at most major pharmaceutical companies. Industry compares entire sectors of medical research to evaluate their relative chances of profits and growth; it is willing to sacrifice a whole region of effective and profitable medicine if it can grow profits more in other regions. Baudrillard, Pignarre, and Stengers are used to consider whether this situation can best be described as one of infernal alternatives, and how to analyze the responses of psychiatric leaders.     

Cultivating the Therapeutic Self in China

ABSTRACT

Facing intensified market competition and rapid social change, many Chinese are experiencing increased mental distress. In this article, I examine how psychological training and interventions play a vital part in cultivating a new self among urban middle-classes. I ask how the Chinese notion, ziwo (self), is turned into an object of intense inquiry and how therapeutic techniques are deployed for self-development. The new forms of the self, however, continue to intersect with and complicate the existing social nexus, cultural sensibilities, and notions of personhood. My ethnography explores how this therapeutic work contributes to intricate forms of subject-making that challenge such conceptual binaries as the private versus social self, the inner versus outer life, and psychological versus social problems. Thus, what is emerging is not a usual “neoliberalism” story of self-advancement, but a more complicated picture based on assemblages.     

Domestic Moods: Maternal Mental Health in Northern Vietnam

ABSTRACT

In this article I propose the notion of domestic mood as an important concept for mental health research. Drawing on ethnographic fieldwork conducted among women living in Hanoi, Vietnam, I explore the maternal mental health problems that the women reported, focusing particularly on the household tensions and conflicts that made the entry into motherhood a distressful experience. To develop the concept of domestic mood, I draw on Martin Heidegger’s work, particularly his claim that human being is always a being-with. Comprehending maternal mental health problems, I argue, requires that we pay attention not only to individual states of mind, but also to the ways that domestic environments shape people’s moods. Taking this analytical approach, I show how the mental health states of pregnant women and new mothers in Vietnam were inseparable from their husbands’ structural vulnerabilities within kin groups.     

Task-Shifting in Community Mental Health in Kerala: Tensions and Ruptures

ABSTRACT

Based on an ethnography of community mental health programs run by two NGOs in Kerala which have associated themselves with preexisting, locally grown, community-based palliative clinics, this article explores how professional NGOs bring a new culture to volunteer-based programs. Professionalizing volunteers through task-shifting results in the transformation of their philosophy of community care, which constrains and narrows understandings of mental health care. The state, in alliance with psychiatric NGOs, front-stages development through aggressive task-shifting which we argue is a socio-politico-moral process, disrupting the shared consciousness between volunteers and their own communities with fatal consequences for their most vulnerable citizens.     

Spaced learning using emails to integrate psychiatry into general medical curriculum: Keep psychiatry in mind

Objectives: Traditionally, medical students on clinical rotations receive instruction on principles of mental health only during the psychiatry clerkship. We used emails to insert teaching of psychiatric concepts beyond the psychiatry clerkship into other rotations using the method of spaced learning, the delivery of brief morsels of information repeated over time intervals. We predicted that the intervention would improve attitudes and confidence towards the integration of psychiatry and knowledge retention.

Methods: We developed and distributed a series of emails relating key psychiatric concepts targeted to the other core clerkships.

Results: In a cluster-randomized trial over one academic year (intervention group n?=?71, control group n?=?61), scores on the Attitudes and Confidence in the Integration of Psychiatry scale and on the knowledge quiz did not differ significantly. Students who actively engaged with the emails demonstrated significantly higher scores on the knowledge test. Email users valued the timing, format of delivery and application of psychiatric principles outside the psychiatric setting. Participants recommended simplifying the format and previewing the benefits of spaced learning to increase utilization.

Conclusion: Delivering spaced learning through emails, within a curriculum designed to foster engagement, may provide an efficient means of addressing the widely-recognized but elusive goal of integrating teaching across medical disciplines.     

Political Therapeutics: Dialogues and Frictions Around Care and Cure

ABSTRACT

In 1978, Italy passed a law establishing the abolition of the mental hospital. Up to that time, the traditional asylums were still governed by the 1904 law that positioned psychiatry within the criminal justice system by assigning it the function of custodia (control, custody) rather than of cura (care). In the 1960s and 1970s, Italian psychiatrist Franco Basaglia initiated a movement of de-institutionalization of the mentally ill that revolutionized psychiatric care in Italy. It also had a deep impact on restructuring the psychiatric system in other European and Latin American countries. In this article, I discuss the different psychiatric practices and imaginaries that resulted from the movement of democratic psychiatry and Basaglia’s visions for a community-based and diagnosis-free care of the mentally ill. I ethnographically trace what I call the “Basaglia effect” in today’s psychiatric practices, and focus on ethnopsychiatry as a counter clinic that emerged from Basaglia’s legacy. I reflect on the frictions between care and cure that ethnopsychiatry re-articulates and works with in the context of contemporary migrations to Europe.     

Neoliberal Optimism: Applying Market Techniques to Global Health

Global health and neoliberalism are becoming increasingly intertwined as organizations utilize markets and profit motives to solve the traditional problems of poverty and population health. I use field work conducted over 14 months in a global health technology company to explore how the promise of neoliberalism re-envisions humanitarian efforts. In this company’s vaccine refrigerator project, staff members expect their investors and their market to allow them to achieve scale and develop accountability to their users in developing countries. However, the translation of neoliberal techniques to the global health sphere falls short of the ideal, as profits are meager and purchasing power remains with donor organizations. The continued optimism in market principles amidst such a non-ideal market reveals the tenacious ideological commitment to neoliberalism in these global health projects.     

Duties toward Patients with Psychiatric Illness

Patients with psychiatric illness feel the brunt of the intersection of many of our society's and our health care system's disparities, and the vulnerability of this population during the Covid-19 pandemic cannot be overstated. Patients with psychiatric illness often suffer from the stigma of mental illness and receive poor medical care. Many patients with severe and persistent mental illness face additional barriers, including poverty, marginal housing, and food insecurity. Patients who require psychiatric hospitalization now face the risk of transmission of Covid-19 due to the inherent difficulties of social distancing within a psychiatric hospital. Patients whose freedom and self-determination have been temporarily overruled as they receive involuntary psychiatric treatment deserve a setting that maintains their health and safety. While tele-mental health has been rapidly expanded to provide new ways to access psychiatric treatment, some patients may have limitations in technological literacy or access to devices. The social isolation, economic fallout, and potential traumatization related to the current pandemic will disproportionately affect this vulnerable population, and society's duties to them must be considered.     

Adaptive expertise in medical decision making

Abstract

Aim: Recently, a growing awareness has developed of the extraordinary complexity of factors that influence the clinical reasoning underpinning the diagnostic process. The aim of the present report is to delineate these factors and suggest strategies for dealing more effectively with this complexity.

Method: Six major clusters of factors are described here: (A) individual characteristics of the decision maker, (B) individual intellectual and cognitive styles, (C) ambient and homeostatic factors, (D) factors in the work environment including team factors, (E) characteristics of the medical condition, and (F) factors associated with the patient. Additional factors, such as health care systems, culture, politics, and others are also important.

Results: A review of the literature suggests that most clinicians trained under existing methods achieve a level of expertise presently referred to as “routine” or “classic.” The results of studies of diagnostic failure, however, suggest that this level of expertise has proved insufficient. A growing literature suggests that more effective clinical decision might be achieved through adaptive reasoning, leading to enhanced levels of expertise and mastery.

Conclusions: It is proposed here that adaptive expertise may be achieved through emphasizing additional features of the reasoning process: being aware of the inhibitors and facilitators of rationality; pursuing the standards of critical thinking; developing a comprehensive awareness of cognitive and affective biases and how to mitigate them; developing a similar depth and understanding of logic and its fallacies; engaging metacognitive processes such as reflection and mindfulness; and through approaches embracing creativity, lateral thinking, and innovation.     

Fighting Novel Diseases amidst Humanitarian Crises

The Democratic Republic of the Congo is facing two crises: a potentially explosive Ebola epidemic and a major insurgency. But they are not wholly distinct from each other: the first is intertwined with the second, and public mistrust and political violence add a dangerous dimension to the Ebola epidemic. The World Health Organization and other health emergency responders will increasingly find themselves fighting outbreaks in insecure, misgoverned or ungoverned zones, possibly experiencing active conflict. Yet the WHO has neither the mission nor the capabilities to navigate these security threats. We cannot expect that the usual public health strategy will succeed when health workers’ lives are directly imperiled and community resistance runs deep. Tackling health emergencies amidst complex humanitarian crises requires fresh thinking. Here, we offer a blueprint for fighting diseases in complex humanitarian emergencies. The building blocks of security and trust include high‐level political support, street‐level diplomacy, community engagement, enhanced funding, and protection of health professionals working in conflict or disaster zones.     

Psychiatry,Sex, and Science: The Making of “Adolescent” Motherhood in Southern Brazil

ABSTRACT

Research linking teen motherhood to psychoneurodevelopmental causes and pathologies has proliferated in the past two decades. In Brazil, a psychodevelopmental project of teen motherhood has gained traction despite many experts’ long-standing commitment to psychodynamic psychiatry and social epidemiology, generating epistemic tension rather than substitution. Drawing on historical ethnography conducted in Southern Brazil, I explore how this project materialized through the co-production of epistemic struggles, remedial interventions, and ontological politics. In showing how this co-production became interwoven with incremental changes in young women’s emotions, sexualities, relationships, and bodies, I describe how one particular “kind” of teen motherhood emerged and became entangled with both psychiatric knowledge-production and the angst of working-class political agency. In giving women a contested psychiatric language with which to rework their social–moral worlds, I argue that science did more than conceptualize teen childbearing in pathological terms; it contributed to its troubled transformation.     

State propaganda and mental disorders: the issue of psychiatric casualties among Japanese soldiers during the Asia-Pacific War

This article explores the politics of Japanese wartime medical policy, demonstrating how state propaganda about the people and their armed forces influenced authoritative views on health and what might endanger it. By focusing on the obstacles faced by psychiatrists trying to promote more official concern for mental health issues, it challenges the validity of figures indicating a low incidence of psychological trauma among the country's soldiers. Civilian psychiatrists had to contend with the threat of censorship and arrest for even discussing war-induced mental disorders; at the same time, army psychiatrists as military insiders were pressured to convince their patients that their conditions were not serious and did not merit compensation. While discussing the neglected topic of Japanese psychiatric casualties, an attempt is made to provide a comparative approach by referring to the state of military psychiatry in other national settings.     

Twelve tips for establishing a new medical school

Abstract

Many new medical programs have been established during the last 20 years, and this trend seems set to continue as the health care needs of the world’s populations become more complex and demand increases for more physicians to provide the necessary health care. In this paper, we address how best to establish a new medical school, based on our experiences in new ventures in several countries. Success requires a combination of boldness of vision, support from many stakeholder groups, adequate financial and human resources, educational expertise, confidence, patience, and persistence.     

Fog of War: Psychopharmaceutical “Side Effects” and the United States Military

ABSTRACT

The unprecedented reliance today on psychiatric drugs to maintain mission readiness in war and to treat veterans at home has been the subject of ethical debate in the United States. While acknowledging these debates, I advocate for an ethnography of how US soldiers and veterans of the Iraq and Afghanistan wars themselves articulate political and ethical tensions in their experiences of psychiatric drug treatment. Detailing one army veteran’s interpretations of drug effects as narrated through the lens of his current antiwar politics, I examine the radicalizing transformations of self and subjectivity that he attributes both to his witnessing drug use in Iraq and to the neurochemical effects of his own medications. Playing on the biomedical notion of “side effects,” I highlight surprising political and ethical openings that can surface when psychopharmaceuticals and war intersect. Psychotropic medication use offers a critical realm for furthering the ethnographic study of the lived tensions and contradictions of military medicine and medicalization as revealed in militarized embodied experience.     

Tattered Textures of Kinship: The Effects of Torture Among Iraqi Families in Denmark

ABSTRACT

Drawing on ethnographic fieldwork in Denmark, primarily among Iraqi women and secondarily among Iraqi men who are either direct or indirect victims of torture, I explore how the memories of torture are distributed in the everyday lives of Danish families originating from Iraq. I argue that torture is folded into kin histories and the everyday work of bearing and resisting painful memories. Consequently, torture affects not only the mental and physical health of the singular survivor, but also the entire texture of kin relatedness around him or her, to the extent that kinship normativity may be disrupted. Leaning on the metaphor of a rugged cloth, I conclude by arguing that the way in which torture makes and unmakes kin relatedness congeals in what I term tattered textures of kinship.     

Psychology and learning: The role of the clinical learning environment

Abstract

The clinical learning environment for the postgraduate education of physicians significantly influences the learning process and the outcomes of learning. Two critical aspects of the learning environment, when viewed through a psychology lens are (1) constructs from psychology relevant to learning, such as cognitive load theory and learner self-efficacy; and (2) psychological attributes of the context in which learning occurs such as psychological safety and “Just Culture”. In this paper, we address selected psychological aspects of the clinical learning environment, with a particular focus on the establishment and sustainment of psychological safety in the clinical learning environment for physicians. Psychological safety is defined as individuals’ perceptions that they can speak out in the learning or working context without consequences for their professional standing or risks to their status on work teams or groups. We close with seven critical strategies for use by educators, learners, health systems leaders, and other stakeholders to contribute to a clinical environment that optimizes learning. These dimensions can also provide avenues for future research to enhance the community’s understanding of psychological constructs operating in the clinical learning environment.     

Mental Health and the Maintenance of Kinship in South Africa

ABSTRACT

At the turn of the millennium, people with mental disturbance often lived in circumstances of economic marginalization in South Africa. The historical material of one low-income urban area reveals the place of kin relations and reciprocity in enabling negotiation of a more fluid set of responses to mental illness. In this sociocultural context, “stigma” was not an inevitable reaction to mental illness, and a more complex set of social dynamics could mitigate marginalization. Research on how changing informal care practices relate to state-based community care continues to be important to inform contemporary health reforms.     

Humanitarianism from Below: Sowa Rigpa,the Traditional Pharmaceutical Industry,and Global Health

ABSTRACT

In this article I explore, for the first time, the relationship between Sowa Rigpa (Tibetan medicine) and global health, tracing “the global” in ethical discourses and pharmaceutical innovation practices of Tibetan medical practitioners. I argue that Sowa Rigpa’s engagement with the world and its global health activities outside China can be understood as a form of “humanitarianism from below,” while its industrialization in China aligns with global health in different ways. In providing new insights into recent developments of Sowa Rigpa, I aim to decenter the notion of humanitarianism and contribute to a broader understanding of global health.     

Yields and Rabbit Holes: Medical Students’ Typologies of Sufficient Knowledge

ABSTRACT

Given the vastness of bioscientific knowledge and regular changes in evidence and protocol, how do individual clinicians make decisions about what to know and what to ignore? In this article I identify a process termed “sufficient knowledge:” the prioritizing of medical knowledge perceived as most important, while ignoring information that is not deemed essential or applicable. Drawing on 14 months of ethnographic fieldwork at an allopathic medical school in the American Midwest, I describe three typologies of sufficient knowledge that medical students devised to distinguish what to know and what to ignore or deemphasize: high yield knowledge, low yield knowledge and “rabbit holes.” I aim here to contribute to a growing topical and theoretical discussion of ignorance by social scientists, especially to generate a more balanced picture of physician training and practice beyond depictions of knowledge and expertise.     

Much More than a Clinic: Chicago’s Free Health Centers 1968-1972

ABSTRACT

Drawing on archival evidence, I document the emergence and florescence of three free health clinics in Chicago in the late 1960s. I trace the centers’ forceful removal by the city’s Board of Health, and their subsequent replacement by Federally Qualified Health Centers (FHQCs). I argue that the demise of the free centers is exemplary of a broader trend in US health policy of regulating and diminishing the health care options of poor Americans. By highlighting the stark contrast between Chicago’s free health centers of the 1960s and the health care services offered by contemporary FQHCs, I reveal a gradual shift from health care rights to accessing care in the US health care safety net.