Duke University Press, 2012
344pp., US $25.95 paperback
Psychiatric care seems to be ever marred by the problematic and contingent relationships it fosters. Patient and physician, nurse and therapist, administration and action snag on the ideals and shortcomings of each other’s missions. In Elizabeth Anne Davis’ haunting ethnography, Bad Souls: Madness and Responsibility in Modern Greece, these snags complicate treatment and treatment seeking while Greece struggles to reform their psychiatric system to meet the needs of a diverse patient population. An ethnography of “kinds of subjects” (4), Bad Souls grapples with the moralistic underpinnings of taking care of mentally ill subjects and the moral and ethical parameters of patienthood under reform era ideology. With a nod to ancient Greek philosophy of the psyche, Davis explores Greece’s psychiatric establishment, through an outpatient behavioral health focused association and a university hospital psychiatric clinic in the Thrace prefecture, as it takes up the more Platonic based theory of the psyche as integrated into the conscious, and therefore responsible, self. All too often, however, treatment frames patients in the Homeric sense; psyche is not more than a shadow that survives the death of the body here. As psychiatry goes, and Davis illustrates, this problematization of the psyche can have devastating consequences when treatment is provided on the implicit condition that there is no wall separating madness from sanity; madness is simply sanity behaving poorly.
Drawing from Foucault’s work on the genealogy of ethics (12) the patients and clinicians in Thrace demonstrate what Davis terms a “fundamental asymmetry in therapeutic relationships”(13) wherein the patient is framed by morality, symptomology and responsibility, with the three perilously overlapping. Divided into three parts, Bad Souls takes into consideration conflicting personal and political responsibilities as they shape the meaning of being mentally ill in Modern Greece.
Part 1 looks at deceptive practices, blind deceits that are generated by the ethical expectations of patients in relation to their illness. Driven by the patients’ needs of ownership of diagnostic language and certification for state support and care, clinicians in Thrace navigate not just the dishonesty that arises naturally from such a situation but the “peculiar intimacy” (4) that comes from such therapeutic relationships that are built upon needs and authorization, with therapists negotiating “a shaky ground between guidance and coercion”(14). These complex negotiations of character the mentally ill and their therapists must manage in order to carry out and receive psychiatric care demonstrate where ethical tensions come into being when either party communicates poorly thereby breaking character. Davis describes the “self-presentation” the patients must develop to fill their role in the therapeutic relationship and the diagnosis the therapist must generate to complete the dyad as “distancing maneuvers” that create the autonomous yet congruent positions in the therapeutic relationship (72).
Part 2 takes into consideration the “local cultures of deception”(121) that are linked to the cultural minorities of the Thrace prefecture, framing diagnosis as dependent more upon cultural knowledge than of the more broadly accepted standards of diagnosis. The need to perform the role of qualifying patient (one eligible for state support) gives way to forms of deceit that bridge the gap between accepted “rights culture” (126) of the reformed psychiatric system and the peculiarities of the minority cultures, making salient the ethical tensions that arise between access and provision of care. Among the pathologies the minority cultures displayed there was Muslim conservatism, disallowing women patients from open and honest communication with the clinician and the often-constant presence of a husband, hesitant and shameful Turkish patients who require all the more prodding to open up and other forms of minorities that, presenting conversion symptoms of mental distresses, tended towards a more “somatic rubric” in clinical encounters (127). This “reordering of body and language”, left conversion disorders on the “surface of the body” (138), unable to penetrate down to the soft, morally implicated Self in the interior. These practices of deception, whether agentic or not, found their way into the communities’ clinical profiles; deviant social behavior, chronic suicidality and incessant delusion all can be said to characterize not just discrete diagnostic categories but cultural minority markers as well. Much like the “rhetorical terrain of madness (τρελλα)”(173) Davis found deep within the social milieu of a Pontian settlement, mental illness lends itself to a theory of interpretation, of deciphering, of discerning. Little can be implicated from clinical symptomology alone; in Davis’ view, diagnosis takes a kind of acrobatics of cultural sensitivity attuned towards the diverse ethnologic landscape of the Thrace prefecture.
Part 3 questions the humanitarian concerns of reform era Greece, which leave many of the most severely mentally ill without the support reform had aimed to establish. Reform discourse theoretically moved patients from the long-term institutional stays in psychiatric hospitals and psychiatric wards of general hospitals to the community for community-based care and support from family members and other caregivers with short term inpatient stays reserved for severe cases. This reform, Davis notes, acts “as both a paradigm and an allegory of modernization”(26). Modernization had the intent of reestablishing patient dignity and autonomy but ironically does some backtracking in this territory, providing more opportunities for patients to fail themselves and their state-caregiver. Kleandis, a patient Davis illustrates in part 3, tested the weakness of the system as his diagnosis of obsessive-compulsive disorder (OCD), a neurotic disorder that is typically thought of as well-managed through out-patient care and very amenable to therapy, resisted countless attempts at rehabilitation he had undergone over the years. Kleandis’ OCD was severely disruptive and the psychiatric system he was subject to was not designed to treat neurotics long-term, causing Kleandis to rotate throughout different stages of the system like an aimless pin-ball. Reform language stressing the importance of both community-based care and sufficient provisions for the most-helpless resulted in a contestation of worlds where patients like Kleandis are never situated on one side of the agent/agentless binary and so never fall into a care routine that is efficacious enough for recovery. His failure to find himself in situ of this “care and control”(194) of the system makes the almost “pathological sense of responsibility”(235) OCD generates all the more tragically ironic. Unable to take clinical responsibility for his illness, Kleandis fell into therapeutic suspension, prostrate under the burden of full responsibility for his life.
To conclude psychiatric care in modern Greece is a negotiated practice of making responsibilities known and provided for. “Here, psychiatrist and patient negotiated their responsibilities in different, perhaps incommensurable registers”(9). These registers imbricate upon the already established modes of recognition and responsibility that patient and practitioner are commissioned with understanding and wielding to their advantage. In this sense, the psychiatric reform in Greece holds responsible its citizens for their care, regardless of mental capacity but not without consideration of diagnosis, which seems to frame as much as set free psychiatric patients. The patients’ “exile to a liberal landscape where they had either to take responsibility for themselves or to craft pathological modes of dependency”(6) was indeed indicative of this hold reform held over some of Greece’s most vulnerable citizens. Though some could benefit from the liberal models of care espoused by the reform, emphasizing self-control and accountability, “these therapeutic techniques required an ontological freedom that eluding many patients, addressing them in vain as autonomous subjects who could choose to become responsible”(18). To become a psychiatric patient in modern Greece, therefore, is to become a powerful and crafty player in one’s own treatment, rendering helplessness and complete illness incompatible with the accepted modes of care and assumed ‘goods’ of autonomy and personal freedom. This means that ““wild” madness” is no longer a viable role for even the most severe of cases (19), thus placing mental illness closer to a pathology of character and will than of genes. The therapists and clinicians working under this command know this model is faulty but at least one that enables a mobilization of modernity and democratization. Still, some patients are lost somewhere between autonomy and dependency, unable to fully actualize either character to the tune of the state’s expectations as set forth by therapeutic goals. Patients and therapists meet somewhere near this stop-gap, engaging not just diagnostics and therapy but the shared humanity of the divide between sickness and health. To Davis, this is “a story about collaboration between patients and therapists, and the impasses of their collaboration”(15). This collaboration is the salvaging of a nation-state’s broken account of psychiatric illness, an account that reveals the strengths and weaknesses of psychiatric care in modern Greece and the wider discourse on human dignity.
Erica Rockhold will be beginning her masters in anthropology at Northern Arizona University this fall.