Milena Bister, Institut für Europäische Ethnologie, Humboldt Universität zu Berlin
How psychiatric health care interferes with social life has been an issue on the agenda of various disciplines for several decades. Whether driven by a historical, sociological, medical or anthropological perspective these studies have broadly contributed to the cultural understanding of mental disorders and their related actors and institutions. In this context the interdisciplinary workshop aimed to situate the influence of psycho-pharmaceuticals on the changing modes of psychiatric classification, therapeutic practices and mental illness experiences. The workshop was funded by the ESF research networking programme “Standard drugs and drug standards” (DRUGS, Institute for the History of Medicine, Charité – Universitätsmedizin Berlin) and by the DFG project “The production of chronicity in mental health care and research in Berlin” (Institute for European Ethnology, HU Berlin).
In the first paper of Panel I STEFAN WEINMANN (Eschborn/Berlin) set out to emphasize the importance of psychiatric medication on diagnostic work. In arguing that diagnosis is a fundamental source for professional knowledge, communication and hence for the arrangement of treatment guidelines, Weinmann indicated the role of the pharmaceutical industry not just in making their drugs and evidence based trials popular, but in the establishment of diagnostic consensus about diseases among professionals as well. Through this fundamental involvement of pharmaceutical companies, diagnosis and medication might be seen as mutually co-constitutive practices highly entangled with the politics of evidence based medicine.
Taking the two German states from the 1950s to the 1980s as an example, VIOLA BALZ (Berlin) discussed how psycho-pharmaceuticals had contributed to the need for realigning clinical classification systems. To allow the “effectiveness” of drugs to arise as a new category in clinical recordings, a symptom oriented assessment had become crucial. Even though in the DDR a more syndrome-oriented classification system had been developed, symptoms gained greater importance in both states as they came to be allowed to be treated independently, without assigning them to a nosology. Subsequently the interaction between the professional and the patient transformed into an interrogation of symptoms.
In commenting the two contributions JEAN PAUL GAUDILLIERE (Paris) pointed to the implicit argument of both papers that there were a specific problem with, and maybe a kind of failure of standardization in psychiatry. He suggested approaching standardization in psychiatry through engaging with the analytic question of if and how the significance of “the case” is specific to the psychiatric field. Gaudilliere urged an awareness of the fact that most of psychiatric care happens in mental health services outside clinics and in contact with professionals other than psychiatrists.
Panel II started with STEFAN ECKS (Edinburgh) and his research focus on the applications of cultural explanatory models in psychiatry. Drawing on a case study in India, Ecks developed a metaphorical analysis of the term “moner khabar” (food for the mind), which had been frequently used by one psychiatrist in the field to describe pills to the patients. Just as with other commonly used metaphors, connotations of “moner khabar” led to the patients' compliance by making the intake of pills an ordinary everyday activity, not something specific to the ill. Through referring to common-sense reasoning psychiatrists might achieve compliance in the short run, but Ecks suggested that sooner or later the practice of keeping patients ignorant about drugs and treatments could add to the country’s “treatment gap”.
The issue of how compliance with medication be understood not as an end in itself but as a marker of therapeutic relevance, had been risen by MARTINA KLAUSNER (Berlin). By examining social psychiatry in her current PhD project Klausner focused on the specific interplay of words and pills in an environment that clearly privileged social relations as the source of mental suffering. In this context “taking pills” was considered a sign of good behaviour and compliance was interpreted as an indicator of recovery. While words were clearly treated as having the most potential in therapy, social psychiatrists employed pills as a means to not only deal with long-term illnesses but also to balance the ward as a highly precarious social space. Thus prescribing psycho-pharmaceuticals was as much a plural practice as receiving and taking pills.
The context of the latter had been taken into focus by NICOLAS HENCKES (Paris). He drew attention to the dimensions of hope entangled with pharmacological promises and biomedical research in the social lives of families with mentally ill children. Henckes analysed the care work undertaken by parents who were mostly organized in parents' unions that promoted biomedical research in France in the 1960s and 1970s. For them hope for curability was very important in dealing with the sick child on a daily base. Through hope the family turned into adjuncts of psychiatry: Whereas the clinic “stabilized” the (not cured and not ill) patient and subsequently released her from hospital, the family had to maintain “stability” with its permanent threads of relapse.
In her commentary of the panel MAGALY TORNAY (Zürich) acknowledged the focus of all three papers on the 'oral' as a practice with specific qualities as opposed to the 'written' or the 'formal'. Further she encouraged active research into temporalities as the work of the three panellists had shown plenty of empirical incentives to engage with the cyclic dimensions of temporality.
With an empirical ethics approach ILINA SINGH (London) opened the discussion of Panel III. She presented a study that investigated children’s perspectives on Attention Deficit/Hyperactivity Disorder (ADHD) and their handling of the diagnosis in UK schools from 2004 to 2011. In the children’s accounts ADHD was qualified as a “disorder of anger” and as a somatic experience, of which they could also make social use by making it an excuse for “bad behaviour”. Children in this study experienced medication as an aid to behave well and self-controlled especially in an aggressive school environment. Interestingly they appreciated that medication did not impede pretence of bad behaviour, which they saw as necessary in cases where friendships needed to be defended. With this context Singh advocated a serious debate about what medication is a solution for in aggressive school environments and what it is a problem of for social scientists.
In her subsequent talk JANIS JENKINS (San Diego) continued with the focus on person-illness-medication interactions, presenting some major theses published in her recently edited book “Pharmaceutical Self” (SAR Press, 2010). In particular Jenkins advocated a divergent perception of the ways in which these interactions occur, and suggested approaching them by reflecting on narratives at the level of verbs (what medication does) and pronouns. In her research an analysis of the same has shown that a concern with subjectivity is but one perspective when it comes to the usage of psycho-pharamceutical drugs. Further Jenkins reported that social response to psychoses made a huge difference in who recovered and who did not, and in what was possibly understood as “illness”, “recovery” or “cure”.
General practitioners (GPs) are part of this social response in rural areas of France, as was shown by CLAUDIE HAXAIRE (Paris), who investigated the GPs' prescription practices of psychotropic medication. Here the physicians' knowledge of the social situation of the patient and her family had turned out to be of utmost importance for the GPs in deciding the prescription and dosage of psycho-pharmaceuticals. In contrast classifications of symptoms and related evidence based guidelines had a minimal impact. Nevertheless the social reflections still remained implicit during prescription, or at least the GPs did not consider them to be intrinsic to their medical care practices. As prescribing psychotropic drugs was part of the daily business of the so called “family doctors”, Haxaire favoured further research into the professional domain of GPs.
Last but not least ANNE LOVELL (Paris) highlighted in the final commentary during the workshop that the psycho-pharmaceutical continued to be understood as a system of exchange and circulation between multiple spheres and groups. She stressed that being aware of this should prevent a reinforcement of the bias in anthropology and the social sciences of investigating the effects of diagnoses, prescription and medication on 'the individual'. In a lot of cases the individual user logic only applied to middle-class consumers who clearly did not represent the majority of patients. Instead in most cases families or community groups were the vis-à-vis of medical action. Lovell then set out to underscore the analytical productivity of temporality in studying the psycho-pharmaceutical endeavour. Among others she spotted drug development, advertisement and commercialisation, hope and disappointment, lifetime and child development as well as the effects of drugs on experience itself as versatile axes of temporality worthy of scrutiny in their historical dimensions. Based on this, Lovell encouraged remaining sensitive to the socio-temporal specificities of different psycho-pharmaceutical substances.
To sum up, the workshop gave a broad overview on topics currently relevant to anthropological, social and historical studies of the mental health care system. Through engaging in an interdisciplinary debate on empirical grounds the complexities of the psycho-pharmaceutical were successfully taken into account. Due to the fact that most of the contributions dealt with local experiences, at the end of the workshop the question came up as to why 'the global' scarcely appeared in the discussion. Was this a problem of the paper selection? A problem of methodology? Or a problem of the psycho-pharmaceutical drug more general? Ilina Singh thoughtfully suggested that it might not be 'a problem' of the pills but rather of what pills address, namely deeply local issues like the brain or the social. Local interventions thus remain ever essential in a globally connected world. To grasp 'the global' therefore requires explicit conceptual and methodological attention. Plain extrapolation of 'the local' or a random comparison of local studies will not do the job. In the end the workshop emerged as a kick-off meeting for further interdisciplinary dialogue on the infrastructures of the global.
Jörg Niewöhner (Berlin): Welcome and Introduction
Panel I: Classificatory Systems and The Production of Evidence
Stefan Weinmann (Eschborn/Berlin): Diagnoses and Medications – Producing Evidence and Reaching Consensus
Viola Balz (Berlin): The Emergence of a New Concept of Effectiveness
Commentary on Panel I by Jean Paul Gaudilliere (Paris)
Panel II: Therapeutic practices in different settings
Stefan Ecks (Edinburgh): “Mind food“ - Interrupted Looping Effects in Depression
Martina Klausner (Berlin): Of Words and Pills - Producing the Stable Patient in a Social Psychiatric Clinic in Berlin
Nicolas Henckes (Paris): Reshaping Chronicity - Neuroleptics and the Changing Meaning of Therapy in French Psychiatry
Comment on Panel II by Magaly Tornay (Zürich)
Panel III: Patterns and Experiences of Use
Ilina Singh (London): A Disorder of Anger and Agression - ADHD in the UK
Janis Jenkins (San Diego): Pharmaceutical Self & Imaginary
Claudie Haxaire (Paris): From the Doctor's Psychotropic Medication to the Patient's Remedies, or Subversion of Medicalisation
Final Commentary by Anne Lovell (Paris)