The Psychotropic Self/Imaginary: Subjectivity and Psychopharmaceutical Use Among Heroin Users with Co-Occurring Mental Illness

Many people diagnosed with mental illnesses struggle with illicit drug addiction. These individuals are often treated with psychiatric medications, yet little is known about how they experience this treatment. Research on the subjective experience of psychiatric medication use highlights the complex, contradictory, and ambiguous feelings often associated with this treatment. However, for those with mental illness and addiction, this experience is complicated by the need to manage both psychiatric medication and illicit drug use. Using ethnographic data from a study of heroin use in Northeast Ohio, we explore this experience by expanding the pharmaceutical self/imaginary (Jenkins, Pharmaceutical Self: The Global Shaping of Experience in an Age of Psychopharmacology, School for Advanced Research Press, Santa Fe, NM, 2010b) to include psychopharmaceuticals and illicit drugs, what we call the psychotropic self/imaginary. Through this lens we explore the ways participants interpret and manage their psychotropic drug use in relation to sociocultural, institutional, and political–economic contexts. This analysis reveals how participants seek desired effects of legally prescribed and illicit drugs to treat mental illness, manage heroin addiction, and maintain a perceived “normal” self. Participants manage their drug use using active strategies, such as selective use of psychiatric medications, in the context of structural constraints, such as restricted access to mental health care, and cultural contexts that blur distinctions between “good” medicines and “bad” drugs.     

Criminal Law as It Pertains to Patients Suffering from Psychiatric Diseases

The McNaughton rules for determining whether a person can be successfully defended on the grounds of mental incompetence were determined by a committee of the House of Lords in 1843. They arose as a consequence of the trial of Daniel McNaughton for the killing of Prime Minister Sir Robert Peel’s secretary. In retrospect it is clear that McNaughton suffered from schizophrenia. The successful defence of McNaughton on the grounds of mental incompetence by his advocate Sir Alexander Cockburn involved a profound shift in the criteria for such a defence, and was largely based on the then recently published “scientific” thesis of the great US psychiatrist Isaac Ray, entitled A Treatise on the Medical Jurisprudence of Insanity. Subsequent discussion of this defence in the House of Lords led to the McNaughton rules, still the basis of the defence of mental incompetence in the courts of much of the English-speaking world. This essay considers one of these rules in the light of the discoveries of cognitive neuroscience made during the 160 years since Ray’s treatise. A major consideration is the relationship between “the power of self-control” and “irresistible impulse” as conceived by Cockburn on the one hand, and by cognitive neuroscience on the other. The essay concludes with an analysis of the notion of “free will” and of the extent to which a subject can exert restraint in the absence of particular synaptic connections in the brain.     

From “Lists of Traits” to “Open-Mindedness”: Emerging Issues in Cultural Competence Education

The incorporation of “culture” into U.S. biomedicine has been increasing at a rapid pace over the last several decades. Advocates for “cultural competence” point to changing patient demographics and growing health disparities as they call for improved educational efforts that train health providers to care for patients from a variety of backgrounds. Medical anthropologists have long been critical of the approach to “culture” that emerges in cultural competence efforts, identifying an essentialized, static notion of culture that is conflated with racial and ethnic categories and seen to exist primarily among exotic “Others.” With this approach, culture can become a “list of traits” associated with various racial and ethnic groups that must be mastered by health providers and applied to patients as necessary. This article uses an ethnographic examination of cultural competence training to highlight recent efforts to develop more nuanced approaches to teaching culture. I argue that much of contemporary cultural competence education has rejected the “list of traits” approach and instead aims to produce a new kind of health provider who is “open-minded,” willing to learn about difference, and treats each patient as an individual. This shift, however, can ultimately reinforce behavioral understandings of culture and draw attention away from the social conditions and power differentials that underlie health inequalities.     

The Patient’s View: Issues of Theory and Practice

Almost all the knowledge now produced about psychiatry includes what is called “the patient’s or client’s perspective.” This paper analyzes how this notion has been framed in the discourses on mental health over the last two decades, particularly in mental health research and in anthropology. The very concept of the “patient’s perspective” is a social and historical construct. Despite its remarkable prevalence, the notion remains vague. Mental health research pictures it as a stable attribute of the individual. Anthropologists integrate the contextual nature of the patient view; but they still largely envision the psychiatric patient as a rational actor producing narratives based on common sense. However, in psychiatric practice, the client’s perspective is not something the patient individually produces; it is rather shaped by and in a context. To explore this process, my research investigated interactions between staff and patients in a French community mental health center, and showed that the client’s perspective is the result of a collective process. Further analysis demonstrates that eliciting or producing the patient’s view is sometimes considered a therapeutic goal in itself, since being granted the status of a rational and narrative actor gives access to the most valued model of care, one that is based on partnership. Being an outcome that is negotiated between patients and care providers, the “patient’s view” then becomes a new resource in mental health settings.

J D Bernal (1901–1971) in perspective

Conclusion We must conclude that the sub-title of Bernal’s “The Social Function of Science” — “What science does: what science could do” is still the relevant challenge and indicates Bernal’s chief contribution, besides the foundation of molecular biology to our civilization. It is manifest that resources spent on armaments are a monstrous pathological symptom of our social structure. The ancient problem of “what is property” and what may be “owned” and by whom or by what organs of society is awakening.     

Social Defeat or Social Resistance? Reaction to Fear of Crime and Violence Among People with Severe Mental Illness Living in Urban ‘Recovery Communities’

This article is propelled by recent theory positing that ‘social defeat’ is a common experience for people with severe mental illness, potentially affecting course and outcome. The primary objective is to investigate how far fear of crime and violence contributes toward ‘social defeat’ among people with mental illness. This is done through examining 6 years of ethnographic data collected from a sample of urban-dwelling people with severe mental illness, all securely-housed in apartments located in small scale “recovery communities.” Findings suggest that many participants living in the highest crime neighborhoods report that they deliberately restrict their temporal and spatial movement as a consequence of such crime. This hinders aspects of their recovery. Nevertheless, participants actively confront the nefarious affects of neighborhood crime by engaging in various empowering strategies of resistance. These include confronting disruptive people, fortifying homes, moving around the neighborhood in small groups and carrying objects such as umbrellas and canes that can be used in self-defense. Some reported that fear of crime directly contributed to the development of a rich and gratifying domestic life, centered on hospitality and religion. I conclude that participants partake in valiant and durable “social resistance,” and may better be perceived as imaginative and resourceful resistors, rather than passive victims of “social defeat.” An influential factor fostering such resistance is the “recovery community’ itself, which creates secure and reliable housing within a micro-community in which participants could thrive.     

Moral Agency,Identity Crisis and Mental Health: An Anthropologist’s Plight and His Hmong Ritual Healing

During anthropological fieldwork, the author had a serious accident on the outskirts of a Hmong village in the highland of Laos. However, this dramatic incident turned out to be the occasion of his ritual initiation into the local village community. An analysis of narratives of the incident reveals Hmong conceptions of the anthropologist’s physical, mental and moral affliction, its causative concomitants and his ritual healing. Hmong mental health and identity are situated in a moral space of exchange relationships to significant others, challenging basic assumptions of concepts of the person widely held in psychiatry and beyond. The healing ritual transformed the author’s being from indeterminate “other,” in a life-threatening state of identity crisis, to a wholesome Hmong “self,” in a state of health and moral agency. This exemplary rite de passage highlights the affinity of ritual healing and constitution of self in a moral space. The underlying relational concept of the person is in sharp contrast to psychiatry’s concepts of the person, which are deeply shaped by values of individualism. Psychiatric services must accommodate substantial differences in the concepts of the person when treating Hmong migrants from Laos.     

Social defeat and the culture of chronicity: or,why schizophrenia does so well over there and so badly here

The history of the way schizophrenia has been conceptualized in American psychiatry has led us to be hesitant to explore the role of social causation in schizophrenia. But there is now good evidence for social impact on the course, outcome, and even origin of schizophrenia, most notably in the better prognosis for schizophrenia in developing countries and in the higher rates of schizophrenia for dark-skinned immigrants to England and the Netherlands. This article proposes that “social defeat” may be one of the social factors that may impact illness experience and uses original ethnographic research to argue that social defeat is a common feature of the social context in which many people diagnosed with schizophrenia in America live today.     

The Ethical Self-Fashioning of Physicians and Health Care Systems in Culturally Appropriate Health Care

Diverse advocacy groups have pushed for the recognition of cultural differences in health care as a means to redress inequalities in the U.S., elaborating a form of biocitizenship that draws on evidence of racial and ethnic health disparities to make claims on both the state and health care providers. These efforts led to federal regulations developed by the U.S. Office of Minority Health requiring health care organizations to provide Culturally and Linguistically Appropriate Services. Based on ethnographic research at workshops and conferences, in-depth interviews with cultural competence trainers, and an analysis of postings to a moderated listserv with 2,000 members, we explore cultural competence trainings as a new type of social technology in which health care providers and institutions are urged to engage in ethical self-fashioning to eliminate prejudice and embody the values of cultural relativism. Health care providers are called on to re-orient their practice (such as habits of gaze, touch, and decision-making) and to act on their own subjectivities to develop an orientation toward Others that is “culturally competent.” We explore the diverse methods that cultural competence trainings use to foster a health care provider’s ability to be self-reflexive, including face-to-face workshops and classes and self-guided on-line modules. We argue that the hybrid formation of culturally appropriate health care is becoming detached from its social justice origins as it becomes rationalized by and more firmly embedded in the operations of the health care marketplace.     

“Not <Emphasis Type="Italic">Here</Emphasis>”: Making the Spaces and Subjects of “Global Health” in Botswana

This essay argues that what makes “global health” “global” has more to do with configurations of space and time, and the claims to expertise and moral stances these configurations make possible, than with the geographical distribution of medical experts or the universal, if also uneven, distribution of threats to health. Drawing on a study of public–private partnerships supporting Botswana’s HIV/AIDS treatment program, this essay demonstrates ethnographically the processes by which “global health” and its quintessential spaces, namely “resource-limited” or “resource-poor settings,” are constituted, reinforced, and contested in the context of medical education and medical practice in Botswana’s largest hospital. Using Silverstein’s work on orders of indexicality, I argue that the terms of “global health” are best understood as chronotopic, and demonstrate how actors orient themselves and others spatio-temporally, morally, and professionally by using or refuting those terms. I conclude by arguing that taking “global health” on its own terms obscures the powerful forces by which it becomes intelligible. At stake are the frames within which medical anthropologists understand their objects of study, as well as the potential for the spaces of “global health” intervention to expand ever outward as American medical personnel attempt to calibrate their experiences to their expectations.     

Species of thought: A comment on evolutionary epistemology

The primary outcome of natural selection is adaptation to an environment. The primary concern of epistemology is the acquistion of knowledge. Evolutionary epistemology must therefore draw a fundamental connection between adaptation and knowledge. Existing frameworks in evolutionary epistemology do this in two ways; (a) by treating adaptation as a form of knowledge, and (b) by treating the ability to acquire knowledge as a biologically evolved adaptation. I criticize both frameworks for failing to appreciate that mental representations can motivate behaviors that are adaptive in the real world without themselves directly corresponding to the real world. I suggest a third framework in which mental representations are to reality as species are to ecosystems. This is a many-to-one relationship that predicts a diversity of adaptive representations in the minds of interacting people. As “species of thought”, mental representations share a number of properties with biological species, including isolating mechanisms that prevent them from blending with other representations. Species of thought also are amenable to the empirical methods that evolutionists use to study adaptation in biological species. Empirical studies of mental representations in everyday life might even be necessary for science to succeed as a normative “truth-seeking” discipline.     

Climate Change and Global Health: Quantifying a Growing Ethical Crisis

Climate change, as an environmental hazard operating at the global scale, poses a unique and “involuntary exposure” to many societies, and therefore represents possibly the largest health inequity of our time. According to statistics from the World Health Organization (WHO), regions or populations already experiencing the most increase in diseases attributable to temperature rise in the past 30 years ironically contain those populations least responsible for causing greenhouse gas warming of the planet. Average global carbon emissions approximate one metric ton per year (tC/yr) per person. In 2004, United States per capita emissions neared 6 tC/yr (with Canada and Australia not far behind), and Japan and Western European countries range from 2 to 5 tC/yr per capita. Yet developing countries’ per capita emissions approximate 0.6 tC/yr, and more than 50 countries are below 0.2 tC/yr (or 30-fold less than an average American). This imbalance between populations suffering from an increase in climate-sensitive diseases versus those nations producing greenhouse gases that cause global warming can be quantified using a “natural debt” index, which is the cumulative depleted CO₂ emissions per capita. This is a better representation of the responsibility for current warming than a single year’s emissions. By this measure, for example, the relative responsibilities of the U.S. in relation to those of India or China is nearly double that using an index of current emissions, although it does not greatly change the relationship between India and China. Rich countries like the U.S. have caused much more of today’s warming than poor ones, which have not been emitting at significant levels for many years yet, no matter what current emissions indicate. Along with taking necessary measures to reduce the extent of global warming and the associated impacts, society also needs to pursue equitable solutions that first protect the most vulnerable population groups; be they defined by demographics, income, or location. For example, according to the WHO, 88% of the disease burden attributable to climate change afflicts children under age 5 (obviously an innocent and “nonconsenting” segment of the population), presenting another major axis of inequity. Not only is the health burden from climate change itself greatest among the world’s poor, but some of the major mitigation approaches to reduce the degree of warming may produce negative side effects disproportionately among the poor, for example, competition for land from biofuels creating pressure on food prices. Of course, in today’s globalized world, eventually all nations will share some risk, but underserved populations will suffer first and most strongly from climate change. Moreover, growing recognition that society faces a nonlinear and potentially irreversible threat has deep ethical implications about humanity’s stewardship of the planet that affect both rich and poor.     

Science through the internet: Researching, evaluating and citing websites

This article attempts to convey the joys and frustrations of skimming the Internet trying to find relevant information concerning an academic’s work as a scientist, a student or an instructor. A brief overview of the Internet and the “do’s and don’ts” for the neophyte as well for the more seasoned “navigator” are given. Some guidelines of “what works and what does not” and “what is out there” are provided for the scientist with specific emphasis for biologists, as well as for all others having an interest in science but with little interest in spending countless hours “surfing the net”. An extensive but not exhaustive list of related websites is provided.     

Spiritist Psychiatric Hospitals in Brazil: Integration of Conventional Psychiatric Treatment and Spiritual Complementary Therapy

In Brazil, during the XX century, dozens of Spiritist psychiatric hospitals emerged seeking to integrate conventional medical treatment with complementary spiritual therapy. This combined inpatient treatment is largely found in Brazil, where many psychiatric hospitals stem from the Spiritist movement. The present report describes the use of these spiritual practices, their operating structure, health professionals involved, modalities of care, and institutional difficulties in integrating spiritual practices with conventional treatment in six leading Brazilian Spiritist psychiatric hospitals. These hospitals combine conventional psychiatric treatment with voluntary-based spiritual approaches such as laying on of hands (“fluidotherapy”), lectures regarding spiritual and ethical issues, intercessory prayer, spirit release therapy (“disobsession”) and “fraternal dialogue”. The non-indoctrination and optional nature of these spiritual complementary therapies seem to increase acceptance among patients and their family members. In conclusion, the Spiritist psychiatric hospitals in Brazil have, for more than half a century, provided an integrative approach in the treatment of psychiatric disorders, associating conventional and spiritual treatments, more specifically Spiritist therapy. The lack of standardized treatment protocols and scientific studies remain a barrier to assessing the impact of this integrative approach on patients’ mental health, quality of life, adherence, and perceived quality of treatment.     

A reexamination of Gilligan’s analysis of the female moral system

Gilligan’s (1982) refinement of Kohlberg’s theory on moral development operates on two theses: (1) females, more so than males, reach moral decisions based on the personalities of the relevant individuals; and (2) female behaviors stemming from moral decisions are based upon “care” and “responsibility for others.” This article accepts the first thesis but argues that the second is incorrect. That is, self-interest—i.e., aiding “blood” kin and/or carefully monitoring reciprocity—rather than “altruism” is argued to be the operant dynamic in forging distaff morality and resultant behavior. Six empirical examples are presented as contraindicative of Gilligan’s second thesis. Finally, it is suggested that selection for the psychological traits of independence and the mastery of subtle social chess yielded ancestral females who had more descendants—us—than did females with alternative profiles. Nancy S. Coney is a professor at Western Illinois University and is interested in both clinical and nonclinical aspects of women’s psychology. Wade C. Mackey is interested in biocultural anthropology and has authored two books on fathering:Fathering Behaviors (Plenum, 1995) andThe American Father (Plenum, 1996).     

The Charms of Nature: Darwin on Meaning and Value

I review George Levine’s provocative and highly original book Darwin Loves You. Levine, whose “home discipline” is English Literature, offers a compelling interpretation of Darwin’s works, evaluating their content and Darwin’s prose style to identify a distinctly Darwinian attitude toward nature as a source of meaning and value. Levine believes that Darwin exemplifies the capacity to feel “enchantment” about the natural world, suggesting that, if Darwin’s example were followed, a “Darwinian re-enchantment of the world” would be brought about. This would offer a secular, non-supernatural basis for purpose, meaning, and value. I conclude with a few critical remarks about the scope and cogency of Levine’s proposal.     

Joseph Hooker Takes a “Fixed Post”: Transmutation and the “Present Unsatisfactory State of Systematic Botany”, 1844–1860

Joseph Hooker first learned that Charles Darwin believed in the transmutation of species in 1844. For the next 14 years, Hooker remained a “nonconsenter” to Darwin’s views, resolving to keep the question of species origin “subservient to Botany instead of Botany to it, as must be the true relation”. Hooker placed particular emphasis on the need for any theory of species origin to support the broad taxonomic delimitation of species, a highly contentious issue. His always provisional support for special creation waned during the 1850s as he lost faith in its expediency for coordinating the study of plant geography, systematics and physiology. In 1858, Hooker embraced Darwin’s “considerable revolution in natural history,” but only after Darwin had carefully molded his transmutationism to meet Hooker’s exacting specifications.     

What is the best approach to treating schizophrenia in developing countries?

BACKGROUND TO THE DEBATE: Schizophrenia affects an estimated 25 million people in low- and middle-income countries, with an average lifetime risk of about 1%. The illness is associated with excess mortality from a variety of causes. A 2001 Institute of Medicine report on mental illness in developing countries found that in 1990, over two-thirds of people with schizophrenia in these countries were not receiving any treatment (http://www.nap.edu/catalog/10111.html). The report found no evidence that the proportion of treated people in the developing world had increased since 1990. There is now a debate among mental health professionals in low-income countries over how best to improve patient care. In this article, three psychiatrists give their different viewpoints on the current status of treatment efforts for schizophrenia in the developing world and the measures that can be taken to increase the proportion of patients receiving treatment.     

Employment of 16S rDNA gene sequencing techniques for improved identification of difficult-to-identify bacterial veterinary pathogens

To employ 16S rDNA PCR and automated sequencing techniques to identify a collection of bacterial veterinary pathogens from avian, equine, canine and ovine sources, that have proven difficult to identify, employing conventional cultural techniques. Universal or “broad-range” eubacterial PCR was performed on a collection of 46 difficult-to-identify bacterial isolates originating from clinical veterinary specimens. 16S rDNA PCR was performed using two sets of universal primers to successfully generate a composite amplicon of 1,068 bp, which was sequenced to obtain each isolate’s identity. Sequence analysis was able to identify all isolates examined with relative ease. Where the use of molecular identification methods is justified, such as in outbreak control or bioterrorism in animal health, employment of partial 16S rDNA PCR and sequencing employing universal or “broad-range” 16S rDNA, provides a valuable and reliable method of identification of such pathogens.     

Personal Experience of Schizophrenia and the Role of <Emphasis Type="Italic">Danwei</Emphasis>: A Case Study in 1990s Beijing

Danwei as a cornerstone of Chinese urban society has received great research attention. The relationship between the Danwei and psychiatric patients, however, remains unclear. This article aims to shed light on the subject with an integrated micro–macro approach. It introduces a historical understanding of mental health in urban China under the “economic state in transition” framework. A detailed case study in clinical sociology is provided to reveal the many social factors affecting the experience of a schizophrenic patient and his significant others. A changing role of the Danwei is hypothesized and validated with qualitative data. The Danwei was shown to have changed significantly before the mid-1990s, yet it still played a major role in urban workers’ lives, including those of psychiatric patients, and even more so in people’s expectations. This lends support to the need for a more responsive public policy to address various social issues brought about by economic reform, with the learning of worldwide experiences including “community care,” “social support” and “social rehabilitation.” Implications for social research, policymaking and professional practice are discussed.