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?This will clear your mind?: The use of metaphors for medication in psychiatric settings
Abstract
Psychiatric medications are an important part of the interaction between patients and clinicians in psychiatric settings. This article examines metaphors used by patients and clinicians to talk about the effects of antipsychotic medication. Metaphors provide a way to communicate about issues of identity and change involved in giving and taking medication. Although metaphorical language can contribute to misunderstandings between patients and clinicians, metaphor is also a major way in which clinical experiences are given shared meanings.
... Left undiscussed is whether effects these decisions have on the health and health noncompliance occurs when medicines are self-precare of the population (Etkin and Tan, 1994; Nichter scribed. How are decisions about self-regulation and Vuckovic, 1994; van der Geest and Whyte, 1989 ). reached in these circumstances? ...
... According to Bourdieu (1990) , practical logic sitivity to medicines, immediate needs, or immanifests a "kind of stylistic unity" which is percepti-pressions of medicine strength? ble to the observer, but does not contain the coherence found in "the concerted products of a plan"patients' metaphorical explanations of their effects necessitated by a visit to the doctor (Leibowitz, (Helman, 1981; Montagne, 1988; Rhodes, 1984; 1989). Research among low income households Rhodes-Amarasingham, 1980). ...
... At the same time, other con(van der Geest, 1988 ). This in turn fosters increased sumers respond to advertising claims that multimedicine demand (Kieinman, 1980; Nichter, 1989; symptom formulations are stronger by questioning van der Geest and Whyte, 1989). their relative safety. ...
In the United States, contradictions related to medicine use abound in a social environment in which the pursuit of health has become a cultural project. In a marketplace where over half a million health products are available, choices at once seem to foster agency and encourage dependency on medical fixes. The aggressive marketing of medicines as indispensable commodities co-exits with rising concerns among the lay population about what is safe in the short- and long-term. In this paper we broadly consider medication-related practice in the United States as it is affected by social, cultural, and political-economic factors. We direct attention to changes in medicine use related to product proliferation, lowered thresholds of discomfort, the economics of health care, and a revival of the self-help ethic. We also consider the manner in which the demand for and use of medications reflect deeply embedded cultural ideals and emergent perceptions of need. We juxtapose two trends in American thinking about medicines: (1) the perception that "more is better," associated with cultural impatience with illness; and (2) a growing doubt about medicine necessity, safety, and efficacy.
... Treatments to improve metaphorical discourse, where the clinician actively works with the patient to develop the language used to describe their experience, may be a particularly valuable therapeutic target in such cases. There is considerable research on different methods of effectively using metaphors in clinical practice, including its applications to numerous psychotherapeutic modalities and medication management settings (99)(100)(101), as well as randomized controlled trials across different populations and a variety of medical conditions (102)(103)(104). More broadly, possible existing clinical approaches have included working from the patient's own metaphors (such as changing a patient's own "metaphorical kernel statement") or introducing novel cliniciangenerated metaphors which are then co-elaborated (105,106). ...
Explanatory models of the mind inform our working assumptions about mental illness with direct implications for clinical practice. Neurobiological models assert that the mind can be understood in terms of genetics, chemistry, and neuronal circuits. Growing evidence suggests that clinical deployment of neurobiological models of illness may have unintended adverse effects on patient attitudes, public perception, provider empathy, and the effectiveness of psychiatric treatment. New approaches are needed to find a better language for describing (let alone explaining) the experience of mental illness. To address this gap, we draw upon interdisciplinary sources and semiotic theory to characterize the role of metaphor in the conceptualization and communication of psychopathology. We examine the metaphors recruited by contemporary neurobiological models and metaphor’s role in facilitating descriptive clarity or evocative creativity, depending on intention and context. These multiple roles reveal the implications of metaphorical reasoning in clinical practice, including cognitive flexibility, personalized communication, and uncertainty tolerance. With this analysis, we propose a clinical approach that embraces the meta-process of ongoing novel metaphor generation and co-elaboration, or languaging metaphors of psychopathology. Our goal is to bring attention to the value of employing ever-evolving, shapeable metaphorical depictions of psychiatric illness: metaphors that enable a capacity for change in individuals and society, reduce stigma, and nurture recovery.
... The metaphoric movements of medicines in relation to psychiatric conditions are particularly revealing, because such conditions are especially difficult to communicate. Rhodes (1984) describes how psychotropic drugs are said to "clear the mind," "to straighten one's thoughts," or "to keep one's thoughts together." But for Rhodes, describing the metaphoric concreteness of the action of drugs is only a stepping stone to a more general conclusion: drugs are themselves strategies of concretization. ...
... Un hecho revelador es que la medicación antipsicótica 2 es uno de los pocos tratamientos cuya administración puede ser obligada por un juez a tomar de por vida en muchos países (Inchauspe y Valverde, 2017). Una extensa literatura en ciencias sociales ha mostrado que el diagnóstico de psicosis, especialmente de esquizofrenia, suele tener un impacto devastador en la vida de las personas afectadas (Estroff, 1985;Jenkins, 2015;Jenkins y Carpenter-Song, 2008;Martínez-Hernáez 1998;Rhodes, 1984). Los sujetos con este tipo de diagnóstico ven cercenadas sus posibilidades de acceso al mercado de trabajo, su red de relaciones sociales claramente disminuye tras este, usualmente se tornan dependientes de sus familiares, sufren marginación, estigma e incomprensión social y sus derechos se ven limitados, incluyendo las decisiones sobre su propia salud. ...
... Un hecho revelador es que la medicación antipsicótica 2 es uno de los pocos tratamientos cuya administración puede ser obligada por un juez a tomar de por vida en muchos países (Inchauspe y Valverde, 2017). Una extensa literatura en ciencias sociales ha mostrado que el diagnóstico de psicosis, especialmente de esquizofrenia, suele tener un impacto devastador en la vida de las personas afectadas (Estroff, 1985;Jenkins, 2015;Jenkins y Carpenter-Song, 2008;Martínez-Hernáez 1998;Rhodes, 1984). Los sujetos con este tipo de diagnóstico ven cercenadas sus posibilidades de acceso al mercado de trabajo, su red de relaciones sociales claramente disminuye tras este, usualmente se tornan dependientes de sus familiares, sufren marginación, estigma e incomprensión social y sus derechos se ven limitados, incluyendo las decisiones sobre su propia salud. ...
(From Introduction)
Ángel Martínez-Hernáez y equipo (Andrea García-Santesmases Fernández, Asun Pié Balaguer, Deborah Bekele, Elisa Alegre-Agís, Martín Correa-Urquiza, Mercedes Serrano-Miguel, Nicolás Morales Sáez y Xavier Cela Bertran) abordan los conflictos entre pacientes, profesionales y cuidadores respecto a la medicación neuroléptica o antipsicótica en el tratamiento de las esquizofrenias y de otros trastornos psicóticos. El capítulo está basado en una investigación etnográfica y de acción participativa en Cataluña sobre la gestión colaborativa de la medicación. Esta orientación es la expresión local de la iniciativa desarrollada en Canadá y Brasil, para democratizar la práctica clínica, específicamente en relación a los derechos de los pacientes respecto al acceso de la información, participación y educación sobre los medicamentos, y la escucha de sus experiencias de sufrimiento. Los resultados señalan ciertas disonancias que dificultan cualquier alianza terapéutica, en relación con las necesidades de las personas para la vida y no para la gestión de los trastornos, que tematizan los efectos adversos de la medicación, la conciencia de la enfermedad y las relaciones coercitivas.
... The scenario is further constrained by obstacles in the social and psychosocial sphere that have been identified in the anthropological literature, both in earlier work dealing with first-generation antipsychotics (Estroff, 1985;Rhodes, 1984) and in later studies about recovery and second-generation antipsychotics (Brown, 2019;Jenkins, 2015;Choudhury et al., 2015). Jenkins (2015:65) and Jenkins and Carpenter-Song (2008:381) identify the two "paradoxes of lived experience" labelled "recovery without cure" and "stigma despite recovery." ...
Video resulting from the Collaborative Management of Medication in Mental Health project. Link:
https://www.youtube.com/watch?v=RNHe2LFdvNg&feature=emb_logo
... The scenario is further constrained by obstacles in the social and psychosocial sphere that have been identified in the anthropological literature, both in earlier work dealing with first-generation antipsychotics (Estroff, 1985;Rhodes, 1984) and in later studies about recovery and second-generation antipsychotics (Brown, 2019;Jenkins, 2015;Choudhury et al., 2015). Jenkins (2015:65) and Jenkins and Carpenter-Song (2008:381) identify the two "paradoxes of lived experience" labelled "recovery without cure" and "stigma despite recovery." ...
Video resulting from the Collaborative Management of Medication in Mental Health project. Link:
https://www.youtube.com/watch?time_continue=14&v=4luEoiI37f8&feature=emb_logo
... The scenario is further constrained by obstacles in the social and psychosocial sphere that have been identified in the anthropological literature, both in earlier work dealing with first-generation antipsychotics (Estroff, 1985;Rhodes, 1984) and in later studies about recovery and second-generation antipsychotics (Brown, 2019;Jenkins, 2015;Choudhury et al., 2015). Jenkins (2015:65) and Jenkins and Carpenter-Song (2008:381) identify the two "paradoxes of lived experience" labelled "recovery without cure" and "stigma despite recovery." ...
Antipsychotic medication is the primary treatment for psychotic conditions such as schizophrenia and schizoaffective disorders; nevertheless, its administration is not free from conflicts. Despite taking their medication regularly, 25–50% of patients report no benefits or perceive this type of treatment as an imposition. Following in the footsteps of a previous initiative in Quebec (Canada), the Gestion Autonome de la Médication en Santé Mentale (GAM), this article ethnographically analyses the main obstacles to the collaborative management of antipsychotics in Catalonia (Spain) as a previous step for the implementation of this initiative in the Catalan mental healthcare network. We conducted in-depth interviews with patients (38), family caregivers (18) and mental health professionals (19), as well as ten focus groups, in two public mental health services, and patients' and caregivers' associations. Data were collected between February and December 2018. We detected three main obstacles to collaboration among participants. First, different understanding of the patient's distress, either as deriving from the symptoms of the disorder (professionals) or the adverse effects of the medication (patients). Second, differences in the definition of (un)awareness of the disorder. Whereas professionals associated disorder awareness with treatment compliance, caregivers understood it as synonymous with self-care, and among patients “awareness of suffering” emerged as a comprehensive category of a set of discomforts (i.e., symptoms, adverse effects of medication, previous admissions, stigma). Third, discordant expectations regarding clinical communication that can be condensed in the differences in meaning between the Spanish words “trato” and “tratamiento”, where the first denotes having a pleasant manner and agreement, and the second handling and management. We conclude that these three obstacles pave the way for coercive practices and promote patients' de-subjectivation, named here as the “total patient” effect. This study is the first GAM initiative in Europe.
... Metaphors were used to convey an experience-near understanding of the patient's problem and imply the set of actions needed to counter this problem or to acknowledge the frustrations related to the problem, cf. (Rhodes 1984). The patient's speech and thoughts were reported by means of indirect speech representation at both wards. ...
This Ph.D. thesis was aimed at gaining insight into mental health nursing practices by focusing particularly on nurses’ communication with each others. Starting from a general concern for the complex ways in which mental health institutions create ideas and facts about patients, different areas of mental health nurses’ mutual communication was examined in de- tail: nursing records, nurses’ shift reports, interdisciplinary conferences, and the continuous everyday interactions. The analysis was based on a social constructionist tenet: knowledge is a receptor of social meaning rather than a passive reflector of reality. Therefore, the analysis was focused on social and linguistic conventions in the everyday practices that mediated the production of clinical knowledge, such as: decision making; recording; gossiping; informal debates; formal meetings, etc. The empirical analysis combined an anthropological fieldwork study with a detailed discourse analysis. Fieldwork took place at two Danish mental health hospital ‘special observation’ wards for six and four months respectively. Data were systematically construed by means of continuous fieldnote writing, by transcribing audio-recordings of recurring meetings, by photocopying material written by the nurses and, finally, by continuously back- ground-interviewing the nurses. The analysis followed the outline for discourse analysis set by N. Fairclough who had developed an integrated analysis of the textual organisation of written texts, of interactional dynamics of verbal communication, and social practices.
The major results were: 1. In their mutual communication, the nurses used everyday language with the occasional use of technical words or words with special local connotations. For outsiders, this language use was difficult to understand, because it lacked textual cohesion and descriptions seemed idiosyncratic. However, the language use appeared perfectly coherent for the nurses, because they both mastered the particular genre and had prior knowledge of the conversational topics. Most of the linguistic activity types at the wards were everyday activities, such as telling stories, debating, persuading, etc.
2. Clinical knowledge was mediated by social processes; explicit knowledge of the clinic was produced, negotiated, and interpreted among the nurses in the clinic. This production of clinical knowledge was particularly influenced by hierarchical positioning among the nurses. The nurses needed social skills for participating in the processes of producing and negotiating clinical knowledge and these skills had to be learned by newcomers at the wards. The everyday language was well suited to the everyday practices on the wards. Many assumptions remained implicit in the nurses’ communication and only rarely did the relatively low level of explicit and concise clinical knowledge lead to obvious misunderstandings among the nurses. The ability to sum up clinical experiences in telling expressions was a sign of status; the opposite situation, to be found ignorant by peers, was avoided by the nurses.
3. The nurses’ daily language use was constrained by an ‘institutional order of discourse’ which comprised a managerial discourse and a medical-psychiatric discourse. The managerial discourse demanded visibility and control of the nurses’ activities, and it forced the nurses to put their experiences into writing. The genre of recording was tight, using simple and effective means for short and concise linguistic expression. The medical-psychiatric discourse was evident in the collaboration between the professional groups at the interdisciplinary treatment conferences. Through the turn take system a medical reading of the clinic dominated and the interactions re-enacted the hierarchical differences between the professions.
4. The nurses’ production of clinical knowledge did not follow a particular discursive format. The nurses described everyday happenings and events using an informal logic which reflected their engagement in the commonsensical everyday world. The everyday world’s unstructured demands for action were evident in the nurses’ communication. Further, the analysis of communication between the nurses indicated that the interpretative frame for producing clinical knowledge about the patient was the commonsensical everyday world. In this sense, the nurses’ production of clinical knowledge was not just constrained by an institutional order of discourse, but also by the internalisations of social structure that gave the nurses their commonsensical orientation to the clinic.
The results were used to recommend an outline for future research and clinical changes.
... Ce que ces travaux désignent par le terme de point de vue du patient est un ensemble de réponses à des questions fermées standardisées, qui sont ensuite transformées en variables discrètes, placées sur une échelle, et généralement couplées à un recueil des mêmes données auprès d'un tiers, soignant ou enquêteur. Comme le note Rhodes (1984), ces approches considèrent « le point de vue comme une 'chose' que les patients 'ont' ou 'n'ont pas' » (p. 68), c'est à dire comme un attribut. ...
Qu'y a-t-il de commun entre les traumatismes résultant de la catastrophe d'AZF à Toulouse, les actes incivils et la déscolarisation de certains jeunes des quartiers populaires, la violence larvée et/ou effective dans certaines relations sociales et institutionnelles, les tentatives de suicide chez des adolescents, les logiques de dépression et d'alcoolisation des individus confrontés à la disqualification et à l'isolement, les "passages à l'acte" de personnes qui n'en peuvent plus de souffrir et de vivre dans le dénuement, la tuerie insensée de Nanterre et le développement de multiples conduites dites addictives ? A priori rien, si ce n'est l'existence de détresses et de souffrances, mal, ou pas du tout prises en compte par notre société et notre système sanitaire et social. L'ouvrage rassemble les contributions nécessaires pour penser les conditions qui font aujourd'hui de la santé mentale une véritable question de santé publique.
... Van Dongen (1990), qui décrit le rôle des médicaments aux Pays-Bas dans les pavillons psychiatriques pour les patients chroniques, présente une autre sorte de «non-conformité». Dans une relation ambiguë entre le personnel et les patients, les médicaments remplacent les mots dans la communication (voir aussi Rhodes 1984 L'ambiguïté des médicaments -oscillant entre contrôle social oppressif et maîtrise de soi-même-se manifeste notamment dans le principal remède qui traite 1' alcoolisme au Danemark, 1' Antabuse (ce médicament interfère avec la décomposition de l'alcool dans le corps et cause des effets secondaires désagréables). Les personnes qui luttent contre leurs problèmes d'alcoolisme peuvent choisir de se soumettre à l' Antabuse ; mais d'autres subissent des pressions de la part de la famille, des employés, des autorités judiciaires et du Bien-être social pour suivre le traitement (voir aussi Steffen à paraître). ...
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... In anthropology and sociology, there has been a similarly persistent call for more attention to the meaning of medication, both in general health care as well as in psychiatry. More than twenty years ago, Rhodes' (1984) classic study looked at patient-staff communication and the use of metaphors to describe medication experiences. She analyzed the verbatim transcripts of interviews with thirty patients and fifteen staff to create an interesting typology of seven types of images and metaphors used in the clinical encounter (e.g. ...
Background and Purpose: Researchers in social work and beyond have urged those in mental health to more fully embrace research into the subjective experience of pharmacotherapy among people with serious mental illness (Floersch et al., 2007, Jenkins et al, 2005; Mintz, 2001). Often using symbolic interactionism as a theoretical frame, previous studies have examined, for example, patient-staff communication (Rhodes, 1984), the use of metaphors (Helman, 1981), issues of self-identity (Carder et al, 2003), medication as a symbol of hope, struggle, and control (Usher's 2001), and, importantly, as an avenue to normality (Knudsen, Hansen, Traulsen, & Eskildsen, 2003). This study attempts to build on that body research with a specific client group served in a local community program, and then immediately transform the findings into program enhancement.
This community-based qualitative inquiry asks: what is the meaning and impact of taking psychiatric medications in the lives of people with severe mental illness living in a residential program. The specific study objectives are (1) to create a typology of meaning and (2) use the findings to enhance specific programming to better reflect the role and importance of medication issues in the everyday lives of residents.
Method: Consistent with related inquiries, the research derives from an interpretive paradigm and relies on a thematic analysis of semi-structured interview data. A staff-resident Advisory Panel guided the research. Participants were 21 adults with extensive histories of mental illness, numerous hospitalizations, currently taking multiple medications. In addition to the interviews, participants each created a color drawing related to their experience with medication, which they titled and interpreted themselves. In addition to a member check, a peer consultant supervised the audit trail of data reduction to support rigor.
Findings: The main results are the distillation of themes into a typology of meaning with 7 dimensions:
Psychiatric medication as
1. a positive force across several dimensions of experience.
2. as tolerated fact of life.
3. as primarily an internal and individual experience.
4. as a prominent part of the story and evolution of one's mental illness.
5. as basis of gratitude and source of victory over past struggles.
6. as necessary for prevention of relapse and protection of humanness.
7. as a symbol of differentness and dependency.
Conclusions & Implications: Among this group of residents, it is clear that taking medication is not a benign act. Rather, taking psychiatric medication is something that incites meaning, influences identity, and impacts life. There is also conundrum: medication can be an avenue to full humanness and a more positive life experience, but also can be the source of felt differentness, resignation and melancholy. The Advisory Panel generated 12 different initiatives for program change, currently being implemented. These include sponsoring a Summer Book club for staff and residents, publishing a collections of life stories, conducting skills training sessions on how to talk with your prescriber about psychiatric medication, and changing intake assessment forms to allow new residents to talk more about their experience with medications and the evolution of their mental illness.
... Podem, mas não necessariamente o fazem, incluir uma tentativa de compreensão das causas das doenças. 39 Relacionam-se freqüentemente às concepções de tratamento e funcionam como elementos de controle e avaliação da evolução dos processos vividos, tanto para significá-los como para tentar predizer seu desfecho. ...
Family concepts of a relative’s illness are an important part of the coping process and reveal the cultural construction of the experience of illness. As part of a qualitative study conducted in the Schizophrenia Outpatient Clinic of the Department of Psychiatry, Escola Paulista de Medicina - UNIFESP, 14 relatives of eight outpatients diagnosed with schizophrenia were interviewed and invited to talk freely about their ideas and feelings concerning their relative’s problem. Qualitative analysis was used to identify categories of illness representations. Three main categories were discussed, including Problema de Nervoso, Problema na Cabeça and Problema Espiritual (Problem of the Nerves, Problem in the Head and Spiritual Problem). The authors present evidence of these categories as cultural constructions, and discuss the relevance of popular notions of illness to the understanding of the course and outcome of schizophrenia, and the planning of culturally meaningful interventions.
... Each of these examples highlights the extent to which metaphors are embedded in how we talk about health and illness. Metaphors have been documented in the descriptions of a wide variety of medical issues and experiences including pulmonary diseases, 1 hypertension and cardiovascular disease, 1-3 strokes, 4 measles, 5 AIDS, 2,6 psychiatric disorders, [7][8][9][10][11] and, most popularly, cancer. 1,2,[12][13][14][15][16][17][18][19][20][21] Given the prevalence of metaphor use when describing health and illness, can metaphors also influence how we think and make decisions about our health? ...
Metaphors influence judgments and decisions in nonmedical contexts.
First, to investigate whether describing the flu metaphorically increases an individual's willingness and interest in getting a flu vaccination, and second, to explore possible mediators and moderators of the effect that metaphors might have on vaccination intentions. Materials and METHODS: Three studies, each using a between-subjects manipulation in which the flu was described literally (as a virus) or metaphorically (as a beast, riot, army, or weed), were conducted. A total of 167 psychology undergraduates (study 1) and 300 and 301 online participants (studies 2 and 3, respectively) were included. Studies 1 through 3 examined vaccination behavioral intentions, absolute risk, comparative risk, perceived flu severity, and recent flu and flu vaccination experience. Studies 2 and 3 assessed vaccination e-mail reminder requests and global affect. Study 3 evaluated affective reactions, personal control, and understanding of the flu.
Describing the flu metaphorically increased individuals' willingness to get vaccinated (studies 1-3), while the impact of metaphors on requests to receive an e-mail reminder to get vaccinated was unclear (studies 2 and 3). These results were moderated by vaccination frequency in study 2, such that the effects were found among individuals who occasionally receive flu vaccinations but not among individuals who never or always receive flu vaccinations. Metaphor use did not significantly impact any of the hypothesized mediators: perceived absolute risk, comparative risk, flu severity, affect, personal control, or understanding of the flu. Limitations include convenience samples and measuring behavioral intentions but not actual vaccination behavior.
Describing the flu virus metaphorically in decision aids or information campaigns could be a simple, cost-effective way to increase vaccinations against the flu.
... In anthropology and sociology, there has been a similarly persistent call for more attention to the meaning of medication, both in general health care as well as in psychiatry. More than twenty years ago, Rhodes' (1984) classic study looked at patient-staff communication and the use of metaphors to describe medication experiences. She analyzed the verbatim transcripts of interviews with thirty patients and fifteen staff to create an interesting typology of seven types of images and metaphors used in the clinical encounter (e.g. ...
This community-based qualitative inquiry asks: what is the meaning and impact of taking psychiatric medications in the lives of people with severe mental illness living in a residential program. Participants were twenty-one adults with extensive histories of mental illness, numerous hospitalizations, currently taking multiple medications. In addition to a thematic analysis of semi-structured interviews, participants each created a color drawing related to their experience with medication, which they titled and ‘interpreted’ themselves (see http://blog.vcu.edu/kbentley/). The main finding is a distillation of themes into a seven dimension typology of the meaning. A staff-resident Advisory Panel guided the research, and final results take into account participant feedback and member checking. Included here are plans and hopes for using the findings to enhance specific programming at the residential program to better reflect the role and importance of medication issues in the everyday lives of residents.
... One fascinating aspect of labeling drug effects is the use of metaphors by drug takers to describe and com-prehend the effects they experience. Studies have shown how these metaphors, especially at the societal level, can influence perceptions about the benefits or dangers of drugs (38,39). These labels are often drawn from information provided through drug advertising (7,40,41), as well as from literary accounts (42). ...
Social pharmacology is the study of the influence of social and cultural variables on drug effects and use. It considers concepts and variables that in the past have been called “nonspecific” or “nonpharmacological” in nature. Social pharmacology refers to those variables that are not pharmaceutical in nature, but that still can have a profound influence on drug action and the occurrence of specific drug effects as perceived and interpreted by the user. Research on these variables, such as suggestibility, knowledge and information, user set, setting, and attribution, has been conducted for many years.Social pharmacology provides a framework for identifying and classifying variables and how they function to modify drug action to produce drug effects in humans. It is the primary approach for integrating pharmaceutical variables with social and cultural variables to assist in explaining and understanding user-generated descriptions of their drug experiences, with the goal of improving outcomes of patient drug therapy.
... Here it was hoped that with the injection the client would take showers, clean his apartment, and demonstrate clear thinking. With respect to grid participant expectations of desired effects, Lorna Rhodes has identified the cultural implication behind the metaphor "clear the mind," which was in common use among practitioners and patients in our study (Rhodes, 1984). ...
This article reports on two research projects and argues that current medication management research and practice does not represent the complexity of community-based psychotropic treatment. Ethnographic findings are used to demonstrate that a social grid of man- agement exists to negotiate medication 'effect' interpretation. Anthropo- logical and semi-structured interview data are used to illustrate patient subjective experience of atypical antipsychotic treatment. It is argued that 'active' and 'passive' management relationships are produced by the myriad ways individuals manage the gap between the desired and ac- tual effects of medication. It is shown that psychological and cultural 'side effects' are as common as physical 'side effects.' (Article copies available for a fee from The Haworth Document Delivery Service:
... Van Dongen (1990), qui décrit le rôle des médicaments aux Pays-Bas dans les pavillons psychiatriques pour les patients chroniques, présente une autre sorte de «non-conformité». Dans une relation ambiguë entre le personnel et les patients, les médicaments remplacent les mots dans la communication (voir aussi Rhodes 1984 L'ambiguïté des médicaments -oscillant entre contrôle social oppressif et maîtrise de soi-même-se manifeste notamment dans le principal remède qui traite 1' alcoolisme au Danemark, 1' Antabuse (ce médicament interfère avec la décomposition de l'alcool dans le corps et cause des effets secondaires désagréables). Les personnes qui luttent contre leurs problèmes d'alcoolisme peuvent choisir de se soumettre à l' Antabuse ; mais d'autres subissent des pressions de la part de la famille, des employés, des autorités judiciaires et du Bien-être social pour suivre le traitement (voir aussi Steffen à paraître). ...
... The use of analogy, such as this, is typically a means into the worldview of the other, a way of using the imagination to communicate with. Doctors connect with patients when explaining diagnoses, for instance (Rhodes 1984). We think figuratively and communicate through analogy according to Fernandez (1986, 6-7) who is continuing Lakoff and Johnson's (1981, 6, authors' emphasis) thesis that 'human thought processes are largely metaphorical'. ...
This article looks at the difference between scientists' written reports and their oral accounts, explanations and stories. The subject of these discourses is the eruption of Mount Chance on Montserrat, a British Overseas Territory in the Eastern Caribbean, and its continued monitoring and reporting. Scientific notions of risk and uncertainty which feature in these texts and tales will subsequently be examined and critiqued. Further to this, this article will end by pointing out that, ironically, the latter – the tale – can in some cases be a more effective and approximate mode of communication with the public than the former – the text.
... They can be given in friendship or controlled restrictively in order to maintain authority. As noted above, in the communication between a patient and practitioner, or between a patient and his environment, a medicine--even before it is used---can be more convincing and more effective than words in communicating knowledge and emotion (166,168,185). ...
▪ Abstract This review discusses pharmaceuticals as social and cultural phenomena by following their “life cycle” from production, marketing, and prescription to distribution, purchasing, consumption, and finally their efficacy. Each phase has its own particular context, actors, and transactions and is characterized by different sets of values and ideas. The anthropology of pharmaceuticals is relevant to medical anthropology and health policy. It also touches the heart of general anthropology with its long-time interest in the concepts of culture vs nature, symbolization and social transformation, and its more recent concerns with the cultural construction of the body and processes of globalization and localization. The study of transactions and meanings of pharmaceuticals in diverse social settings provides a particularly appropriate empirical base for addressing these new theoretical issues.
... Charmaz suggests the onset of longterm illness itself compels a heightened selfconsciousness in response to unfamiliar bodily symptoms and their intrusion into everyday life from which emerges a dialectic process of reasoning and logic-making as the person seeks to understand what is going on. Similar personal challenges to manage and control multiple sclerosis or other longterm illnesses is evident in peoples narrative accounts in other studies (Amarasingham, 1984;Fitzgerald & Paterson, 1995;Huttlinger, Krefting, Drevdahl, Tree, Baca, & Benally, 1992;Robinson, 1990). In a study of men and women with multiple sclerosis, Robinson observed how commonly peoples autobiographical accounts of their life embodied notions of positivity and optimism as they strove for mastery over an otherwise unpredictable disease trajectory. ...
This paper presents one interpretive element of a qualitative study aimed at understanding the lived experience of women with multiple sclerosis. Data were gathered from 16 women by way of a focus group interview (six women) and ten semi‐structured individual interviews. Symbolic interactionism was used to build a theoretical foundation for interpreting the day‐to‐day dynamic relationship between the person, the symbolic meaning of their illness, and their occupations. Narrative quotes have been used in the text to illustrate how the raw data informed the interpretive process. People often use metaphors when it is hard to depict the subjective meaning of things in everyday words. As women in this study talked about living with multiple sclerosis, they crafted narrative images richly embroidered with metaphor. The women's engagement in the intuitive occupations of storymaking and storytelling reveals a rich use of analogies and metaphors to make meaning of and to develop occupational strategies for managing the intrusiveness of their illness in their everyday lived world.
... (For a convincing and very detailed argument on this last point, see Medicating Schizophrenia: A History by Sheldon Gelman, 1999.) When Rhodes (1984) examined the talk of psychiatric staff and patients about medication issues, she found their discourse marked by metaphor that could persuade, and could communicate experience or expectation, but that, just as often, confused each other and entangled issues. Rhodes found that communication about medication was most successfully managed by those who were willing to adopt the point of view and idioms of the person with whom they were conversing. ...
The author draws on her personal experience as the family member of an individual with mental illness, on her anthropological research and on that of others to argue that medicalizing madness can be counterproductive to recovery. The medical model is sometimes used in a way that strips away the meaning of the illness experience. Analogies drawn to diseases do not help the understanding of mental illness. Psychiatry is a social practice embedded in a social milieu and that renders it less than objective. It is useful to recognize that the experiences called symptoms have meaning and may have positive and pleasurable aspects.
... We discuss the practice relevance of contemporary psychiatric research. Residents are asked to consider what basic science constructs mean for their patients (24) and to consider how they will use evidence in practice. Treatment researchers define clinical targets using laboratory-based measurement techniques, but research constructs are rarely comparable to patient-care scenarios (25). ...
Education in Psychiatry, like Treatment in Psychiatry, begins with a case vignette to illustrate an important problem in clinical psychiatry. However, the goal of Education in Psychiatry is to present and evaluate methods to teach students, trainees, and other psychiatrists how to treat patients with these problems.
... Drawing on what they perceive to be a widely shared faith in the objective facticity and authority of Science, the advertisers invoke a reified "medical model of mental illness.., by bringing mind (or behavior, or personality), viewed now as a substance, under the sway of medical technics" [25, p. 86]. At the same time, these advertisers realize that "mind, the location of the illness (in our culture), is also the perceived location of the interface between self and medication which can be made concrete only by imagining 'mind' in... terms of some other domain, something more imaginable" [30]. Hence, they rely on abstract visual metaphors to evoke the relationship between mental states and medication. ...
Advertisers have adopted the use of highly abstract visual metaphors and symbols in addressing physicians about antidepressant drugs. Campaigns built around an abstract visual aesthetics are designed to generate cognitive connections between named drug entities and the meaning of abstract visual images: these connections are called 'carry-over symbols'. In this study we critically dismantle and analyze the encoding practices used in two recent ad campaigns for antidepressants. In addition to asking what the ads mean, we ask how they mean it. This analysis is joined to a comparison of the information provided by these ads with the pharmacological and therapeutic properties of the drugs themselves. Our analysis suggests this style of drug advertising produces, as a social side-effect, a reified and medicalized account of psychiatric illness (depression). It also poses an obstacle to scientific discourse and understanding; privileges certain types of social knowledge concerning mental illness, psychiatric patients, and drug taking; and discourages professional d debate regarding therapeutic approaches to treating illness. These ads reflect a positivistic conceptualization of mental illness and doctoring as mind mechanics.
In the early 1990s, while I was conducting an ethnographic study in a psychosocial rehabilitation center in Barcelona for people suffering from psychosis, a patient and informant gave me four letters that he had supposedly sent to various recipients. Only recently did I discover that these letters, which warned of terrible catastrophes, were related to the Marian apparitions of Garabandal in the 1960s in Spain, and that their recipients had all been involved in this amazing event. This discovery led me to attempt an ethnographic reparation, and to reconsider the letters as a way of inhabiting the world. With this objective and drawing on Ernesto de Martino's concept of "crisis of presence," I propose to understand the informant's experience as an extreme example of the porosity of presence. I conclude that the letters can be understood as the affected person's struggle for being in a human history. [crisis of presence, Garabandal apparitions, reflexivity, schizophrenia]
Category labels affect people’s judgments regarding mental disorders which are unknown to them. Descriptions of these ‘unknown’ disorders that do have a name, are assumed by people to be more stable and having reasons to exist, when compared with the same descriptions of disorders - without a specific name [3]. However, it is not clear whether this effect can be evoked by other linguistic parameters, for instance, by metaphors. We hypothesized that including a metaphor in the description of a mental disorder would lead to the same effect even without a category name. We replicated a study by Giffin and colleagues’ and added a new experimental condition in which participants read texts with the descriptions of a person’s unusual behaviour without the disorder's name, but with its metaphoric description. After reading the texts, participants assessed a few statements concerning some characteristics of the disorder. The results showed that the effect of a category label was replicated, and the metaphoric description also evoked a significant effect, but it was found in judgments of different characteristics of the disorder.
This paper examines the dialogue which occurs between physicians and patients in response to nervios (nerves), the presenting complaint in 30% of general medicine consultations and 50% of psychiatric consultations observed in urban outpatient clinics of San José, Costa Rica (Low 1981). Nervios is both a common, culturally acceptable distress symptom, that is, a sign of psychosocial discomfort, and a syndrome, that is a local medical concept which identifies and gives meaning to a group of anxiety-related symptoms. It is a particularly interesting example of a folk illness that has no clear biomedical diagnosis or description, yet is normally presented to a physician in the clinic setting by a variety of patients searching for a cure or symptom alleviation. Physicians whom I observed respond to these requests positively in so far as they rarely question the use of the term nervios and usually take part in a discussion of the medical, social and family concerns of the patient. The physician often prescribes a pill, a tranquilizer or anti-depressant as part of the treatment. This “treatment” of talking and medication reflects cultural agreement on the part of both physicians and patients as to their expectations of the consultation and the cultural meaning of nervios.
The ready availability and extreme popularity of Western pharmaceuticals in developing countries poses important general issues for medical anthropology. In attempting to explain why medicines are so attractive in so many different cultures, this article suggests that they facilitate particular social and symbolic processes. The key to their charm is their con-creteness; in them healing is objectified. As things, they allow therapy to be disengagedfrom its social entanglements. Medicines are commodities which pass from one context of meaning to another. As substances, they are “good to think with” in both metaphoric and metonymic senses. They enhance the perception of illness as something tangible, and they facilitate communication about experiences that may be difficult to express. In the course of their transaction, they bear with them associations to authoritative professionals and the potency and potential of other cultural contexts of which they once were a part.
In this article, we examine the regulation of psychiatric patients becoming intoxicated from drinking excessive amounts of liquids at a large psychiatric asylum in Canada. We analyze how medical staff created a formalized diagnostic category and a specialized ward for its treatment. We consider the institutional context in which “water intoxication” was developed as a diagnostic category and we examine the impact of this diagnosis on the regulation of asylum patients. Finally, we discuss the patients’ opposition to treatment as well as the impact of “water intoxication” on their self-identity and institutional status.
Résumé
Les auteurs de cet article discutent de deux points de vue différents sur les médicaments. Leurs propres recherches ainsi que d’autres études indiquent une grande popularité des médicaments dans les sociétés prospères comme dans les sociétés pauvres. Ils sont parvenus cependant à constater en même temps une attitude plus sceptique et réticente vis-à-vis des médicaments pharmaceutiques. Ils perçoivent ce scepticisme comme l’expression émergente d’une sorte de politique médicinale, qui se formule en termes de catégories individuelles et culturelles. Cette étude examine les raisons de la popularité mondiale des médicaments, et suggère ensuite que certains de ces mêmes facteurs peuvent aider à comprendre certaines réticences dans d’autres circonstances.
A elaboração de um significado para a compreensão e a convivência com a esquizofrenia constitui uma das maneiras de os familiares lidarem com a doença e a evidencia como um fenômeno culturalmente constituído. A partir de uma abordagem antropológica, este estudo entrevistou 14 familiares de 8 pacientes com diagnóstico de esquizofrenia, buscando formular uma compreensão da esquizofrenia através dos conceitos e imagens do universo cultural e social familiar. Os dados produzidos foram analisados segundo metodologia qualitativa. Três categorias de concepção de doença são discutidas, Problema de Nervoso, Problema na Cabeça e Problema Espiritual. Argumenta-se que as concepções analisadas podem ser compreendidas como construções culturais e discute-se a importância desta abordagem para a compreensão da evolução da doença e para a elaboração de programas de intervenção culturalmente apropriados.
Over the last ten years a new approach to psychiatric knowledge has developed under the influence of social anthropology. Its origins, assumptions, methods, achievements, and limitations are reviewed.
A conceptualization is presented which encourages a renewed exploration of the way in which psychiatric patients discuss their medications in the group therapy setting. It is suggested that process-oriented group therapists tend to harbor subtle prejudices which may inhibit examination of this material. If we listen to medication-related discourse more carefully, we find that patients disclose important information about hopes and fears about treatment, self-efficacy, attitudes about control and authority, and other sensitive or disowned parts of experience. The process of interactions about medicines often reveals interpersonal difficulties, particularly around intimacy. Suggestions for intervening more effectively with this type of material are presented. The importance of medication attributions in revealing curative fantasies is discussed.
Much of what has been written about how psychiatric hospitals change a patient's self-image has been written from the perspective
of the hospital and related social forces. Little has been done to explain the patient's perspective and role in this process.
This study examines the process from that essential perspective, using both qualitative and quantitative methods. The results
suggest that both frequency and duration of exposure to psychiatric hospitals, as well as a past history of hallucinations,
are important variables in determining engulfment in the patient role. The process of engulfment appears to be a developmental
sequence with important transitional events (e.g., hallucinations, Supplemental Security Income, repeated hospitalizations)
demarcating and pushing forward the process, and shifting beliefs and definitions associated with each developmental stage.
What seems to underlie this process is patients' need to maintain a positive view of themselves as competent.
The chronically mentally ill tend to receive inadequate medical care for nonpsychiatric illnesses and to have poor health care status. Their medical problems lead to excessive morbidity and mortality and adversely affect their adjustment to psychiatric illness. The authors argue that many of the barriers to medical care for these patients can be overcome by using case managers as "culture brokers"-persons who provide bridges between the worlds of the chronically mentally ill and medical providers. This paper presents the culture broker model and its roots in anthropology, and illustrates its application to the medical care of the chronically mentally ill with case examples.
An inquiry into the role metaphor plays in personal and societal conceptions of drugs and drug taking reveals that drug metaphors and symbols are quite pervasive in individual thinking, social discourse, and the cultural media. They appear to influence beliefs and attitudes regarding drugs, the nature and meaning of drug experiences, and the reasons behind drug-taking behaviors. Some drug metaphors are common to different cultures and historical periods, while others are specific and exclusive to particular individuals and groups or drug-taking situations. These metaphors can carry positive as well as negative connotations. Further study is needed to delineate the metaphorical structuring of our thinking about drugs, and the process whereby these metaphors are generated and spread throughout society.
How can we know whether people who have been treated for an illness or been helped with a problem have indeed regained their health or solved their problem? Is "health" an objective condition-something that is observable, visible, perhaps even measurable? This article discusses these questions with the help of an analysis of the account given by a patient in psychotherapy regarding her recovery from a problematic life situation. The point of departure here is that recovery from illness or from a condition of ill-health should be understood as a reorganization of cultural, social and psychological elements which together are able to convey the picture that treatment has been successful and full recovery has been achieved. What the patient presents is not a "report" on an "actual" transformation process, nor is it an accumulated description. Rather, the patient presents a narrative, shaped by and created out of her own life situation and the interview situation in which she is engaged. It is a narrative that highlights certain aspects of a course of events and which arranges the pieces of the puzzle in such a way as to convey a picture of transformation and recovery.
A biocultural study of the side effects of chronic lithium treatment among 70 Hong Kong Chinese psychiatric patients, using a self-report 33-item checklist and semi-structured interviews, revealed an imperfect correspondence between biomedically prescribed and culturally endorsed psychotropic side effects. Although polidipsia and polyuria (47%) were the biomedically most ‘real’ side effects, they were not usually regarded as bothersome or translated into metaphors to express undesirable side effects.
Complaints such as tiredness (38%), drowsiness (36%) and poor memory (31%) were also common but their frequency was significantly lower than that of normal control subjects. The item ‘loss of creativity’ had no conceptual equivalent in Chinese and was usually misinterpreted. As no patient was aware that lithium was a metal, the side effect ‘metallic taste’ was variously labelled. Contrary to Western findings, complaints of ‘missing of highs’, loss of assertiveness and fear of weight gain were rarely encountered. Active elicitation was required for indigenous complaints, with 38% of patients considering lithium to cause mild “hotness.” This was readily neutralized by drinking more water which had a “cooling” effect. Expectedly, concurrent neuroleptics and antidepressants amplified most lithium side effects.
This study affirms Western data on the biomedically universalizable effects of chronic lithium treatment, but also supports the thesis that culturally constituted cognitive styles affect patients' recognition, labelling, experiencing and reporting the total drug effect. Further, it demonstrates that the lived experience and clinical negotiation of lithium associated side effects reproduce, authenticate, and at times critique, core cultural and moral premises of Western and Chinese societies.
Metaphors and related tropes, explicit or implied, are ubiquitous in our daily lives. Rereading the first paragraph of this article will demonstrate how pervasive metaphors are in our ordinary language (e.g., 'world of anesthesia,' a 'fueled' debate, 'medicine' has a 'fringe element'). Metaphors are not merely ornamental; metaphoric thinking is integral to how we perceive our environment and process our experiences. Anesthesia patient care, monitoring, research, subspecialties such as pain management, and the economics of anesthesia care are examples of areas replete with metaphors. Because language affects our perceptions, phrases such as 'under anesthesia,' which evoke vast metaphoric relationships, have profound implications. Some metaphors can be harmful or pointless. For instance, metonymic references to patients and other jargon provide a verbal shorthand, but may be unintentionally hurtful. Metaphors, such as those in scientific theories, can hide truths as well as reveal them. Unlike literary metaphors, scientific metaphors need to be consistent with observation and measurement. Although we need not return to Lockean distrust of tropes, over-adorned or flowery phrases are usually inconsequential or self-mocking. We are a species that can think metaphorically; it would be artificial, and indeed impossible to ban metaphors from the practice of anesthesia. Instead, we must recognize that metaphors exist in anesthesia and acknowledge their implications. Metaphors are powerful tools. By transforming the intangible to the tangible, metaphors may enhance and direct our understanding of anesthesia. Elucidating the metaphors that underlie difficult and multifaceted concepts can help clarify those concepts. Furthermore, creativity, whether it be in patient care issues or research, may be enhanced by a conscious effort to conceive new metaphors or combine existing ones in novel ways.
Substance abuse treatment programs in the United States frequently incorporate self-help approaches, but little is known about the use of self-help groups by individuals with dual disorders. This paper brings together several current studies on the role of self-help programs in treating substance use disorders among individuals with severe mental illness. These studies indicate that only a minority of individuals with dual disorders become closely linked to self-help. Psychiatric diagnosis and possibly social skills are correlates of participation. Dually disorders consumers often experience the use of 12-step philosophy and jargon by mental health professionals as alienating and unempathic. The authors propose suggestions for incorporating self-help approaches into the comprehensive community care of individuals with dual disorders.
Ethnographic research in a forensic psychiatric hospital demonstrates a prevalent ambiguity about the relationship between emotion and reason and a suspicion that many inmate-patients are not mentally ill. Nonetheless, central to the discourse and method of inmates and staff are skills in suppressing one's own emotions and in producing and manipulating others' emotions. Drawing upon Foucault's insights, the author suggests that practices in American penal and forensic psychiatric contexts shed light on the wider culture's surreptitious ideologies of emotion and interpersonal dynamics.
Psychiatrists, though they occupy relatively high status positions, are nevertheless individuals whose motives and attitudes are in large part culturally determined and whose choices are culturally constrained. This paper examines cultural factors that may contribute to the tendency of psychiatrists at two general hospitals in northern India to rely heavily on multiple drug prescriptions and on electroconvulsive therapy (E.C.T.) in the treatment of their clients. What the author describes as an "epidemic" view of psychiatric pathology, the political economy of psychiatric care in India, the need to "sell" psychiatry as a legitimate kind of medicine by satisfying client expectations, and psychiatrists' relationship to other actors in India's pluralistic medical system are all presented as factors that encourage a reliance on pharmaceutical or somatic interventions in psychiatric settings.
Our understanding of the psychosocial and cultural dimensions of disease and illness is limited not merely by a lack of empirical knowledge but also by an inadequate medical semantics. The empiricist theories of medical language commonly employed both by comparative ethnosemantic studies and by medical theory are unable to account for the integration of illness and the language of high medical traditions into distinctive social and symbolic contexts. A semantic network analysis conceives the meaning of illness categories to be constituted not primarily as an ostensive relationship between signs and natural disease entities but as a 'syndrome' of symbols and experiences which typically 'run together' for the members of a society. Such analysis dirests our attention to the patterns of associations which provide meaning to elements of a medical lexicon and to the constitution of that meaning through the use of medical discourse to articulate distinctive configurations of social stress and to negotiate relief for the sufferer. This paper provides a critical discussion of medical semantics and develops a semantic network analysis of 'heart distress', a folk illness in Iran.
The now-classic Metaphors We Live By changed our understanding of metaphor and its role in language and the mind. Metaphor, the authors explain, is a fundamental mechanism of mind, one that allows us to use what we know about our physical and social experience to provide understanding of countless other subjects. Because such metaphors structure our most basic understandings of our experience, they are "metaphors we live by"--metaphors that can shape our perceptions and actions without our ever noticing them.
In this updated edition of Lakoff and Johnson's influential book, the authors supply an afterword surveying how their theory of metaphor has developed within the cognitive sciences to become central to the contemporary understanding of how we think and how we express our thoughts in language.
Any good doctor knows … that the patient’s complaint is more extensive than his symptom, and the state of sickness more comprehensive than localized pain or dysfunction. As an old Jew put it (and old Jews have a way of speaking for the victims of all nations): “Doctor, my bowels are sluggish, my feet hurt, my heart jumps — and you know, Doctor, I myself don’t feel so well either.” (Erikson 1964:51)
At the Annual Meeting in May 1974, the American Academy awarded its first Social Science Prize to Clifford Geertz for his significant contributions to social anthropology. Mr. Geertz has taught at Harvard University, the University of California at Berkeley, and the University of Chicago; in 1970 he became the first Professor of the Social Sciences at the Institute for Advanced Study in Princeton. Mr. Geertz' research has centered on the changing religious attitudes and habits of life of the Islamic peoples of Morocco and Indonesia; he is the author of Peddlers and Princes: Social Changes and Economic Modernization in Two Indonesian Towns (1963), The Social History of an Indonesian Town (1965), Islam Observed: Religious Developments in Morocco and Indonesia (1968), and a recent collection of essays, The Interpretation of Cultures (1973). In nominating Mr. Geertz for the award, the Academy's Social Science Prize Committee observed, "each of these volumes is an important contribution in its own right; together they form an unrivaled corpus in modern social anthropology and social sciences." Following the presentation ceremony, Mr. Geertz delivered the following communication before Academy Fellows and their guests.
Implicit images of human behaviour influence most research endeavours. Studies of patients' “compliance” with doctors' instructions have generally used an ideal image of the patient as a passive, obedient and unquestioning recipient of medical instructions. Divergence from this ideal—“defaulting”—is seen as irrational in the light of medical rationality. The blame for “default” is seen as lying with the patient. The research problem is then to find out what there is about the patient that makes him a defaulter. This is a view of the problem from the point of view of the medical profession. An alternative approach from the perspective of the patient is suggested. The focus is then on the social context in which illnesses are lived and treatments used. A more active view patients is entailed in which patients have expectations of the doctor, evaluate the doctor's actions, and are able to make their own treatment decisions. Rather than “defaulting” being found in certain types of individuals, almost anyone can be a “defaulter” at some time or another.
Psychoanalyst, teacher, and scholar, Heinz Kohut was one of the twentieth century's most important intellectuals. A rebel according to many mainstream psychoanalysts, Kohut challenged Freudian orthodoxy and the medical control of psychoanalysis in America. In his highly influential book The Analysis of the Self, Kohut established the industry standard of the treatment of personality disorders for a generation of analysts. This volume, best known for its groundbreaking analysis of narcissism, is essential reading for scholars and practitioners seeking to understand human personality in its many incarnations. âKohut has done for narcissism what the novelist Charles Dickens did for poverty in the nineteenth century. Everyone always knew that both existed and were a problem. . . . The undoubted originality is to have put it together in a form which carries appeal to action.ââInternational Journal of Psychoanalysis
The appropriateness, efficacy, and morality of treatment of schizophrenics and other seriously mentally ill persons in community settings rank very high among the many controversial issues generated by public mental health policies. The public also seems concerned that such patients may present dangerous potential for committing crimes, especially of a violent nature. Reflecting these apprehensions, considerable controversy now revolves around the wisdom of community mental health policies and the adequacy of resources available for community treatment programs. Over the past decades, the recognition that total institutions were failing the goals society set for them indeed, that their intrinsic structures tended to undermine their avowed purposes-has spurred three kinds of change: (1) internal reorganization which has promoted greater personalization and the "therapeutic community"; (2) advocacy and some measures toward deinstitutionalization; and (3) the introduction of new techniques of behavior control, capable of both enhancing individual change and permitting release from closed institutions. Reforms of the first two sorts have been made more possible by the last, but, paradoxically, technology has generated its own new problems. Without social regulation, the threat technology poses may be unacceptable to society. Also, within the mental health profession, there are corresponding differences of opinion as to the adequacy of the evidence for the deinstitutionalization policy and for the scientific basis of community mental health programs. The fear is that drugs and other behavior control technologies, if not controlled and regulated, combined with the anomie and isolation of urban life, will convert our communities into the ultimate total institution, a totalitarian society. The dilemma is that without new technologies, long-term changes in the mental health system are unlikely, and the creation of new community alternatives will depend upon the availability of new technologies. Thus, the issue of community treatment of the mentally ill is not only scientific and professional, but also social, ethical, and political in the broadest and most humane sense of those terms. (PsycINFO Database Record (c) 2013 APA, all rights reserved)
Medical anthropologists spend most of their time eliciting and interpreting people's statements about sickness and health. For this task, they make certain assumptions about the importance of language and reason. In this paper I argue that their assumptions are tailored to fit an hypothetical Rational Man rather than real people. The concept of ‘explanatory models of sickness’ is used to illustrate this point.
My critique begins by drawing attention to two non-cognitive determinants of people's statements: their degree of emotional arousal and their capacities for discoursing on medical subjects. These determinants are briefly discussed and then set aside, to make room for the paper's argument proper. This starts with the observation that medical anthropologists tend to overlook the fact that they have established a cognitive no man's land stretching between their informants' statements and the cognitive structures which are supposed to generate these statements.
I survey this void, using a five-fold model of medical knowledge. People use one kind of knowledge to organize their medical experiences and perceptions. In Rational Man writing, this form of knowledge is considered equivalent to cognitive structures (e.g., causal models, classificatory schemes), but I argue that it also includes knowledge of prototypical sickness events and knowledge that is embedded in actions, social relations, and material equipment. The theoretical implications of the five-fold model are outlined.
This is followed by an analysis of the reasoning processes in which people use medical knowledge to produce the statements whose meaning we wish to learn. I demonstrate the importance of being able to distinguish operational and monothetic forms of reasoning from pre-operational and polythetic ones. Rational Man writers are described as ignoring the latter pair. The concept of ‘prototypes’ is reintroduced to illustrate these points.
Sinhalese patients in Sri Lanka have a variety of practitioners to choose from in seeking treatment for illness. The include: Ayurdevic physicians, Western physicians, and ritual practitioners. This paper traces the movement of a single patient seeking treatment for pissu (madness) from a number of healers. It is suggested that this movement of the patient among a variety of treatment systems allows a fluidity of diagnosis which prevents any one explanatory system from dominating her perception of her illness. It is also argued that treatments are linked by an underlying continuity of process, in which the personal antecedents of the illness are reinterpreted in terms of public representations of affliction and in which all treatments phrase illness most basically in terms of excess and imbalance.
Persuasions and Performance: Of the Beast in Everybody and the Metaphors of Everyman
- J W Fernadez
- J. W. Fernadez
The Art of Medicating Psychiatric Patients
- J R Lion
- J. R. Lion
The Social Use of Metaphor
- J D Sapir
- J C Crocker
- J. D. Sapir
Models of Madness, Models of Medicine
- M Siegler
- H Osmond
- M. Siegler