In the Journals

In The Journals – November

Hello trusty readers. Check out November’s haul for “In The Journals,” and be sure to check out the special issue of Science, Technology, and Human Values: Feminist Postcolonial Technosciences.

 

American Ethnologist:

Memory, body, and the online researcher: Following Russian street demonstrations via social media (open access)

Patty A. Gray

The Moscow street demonstrations of 2011–12 were the largest public gatherings in Russia since the collapse of the Soviet Union. They were also the largest-ever gathering of Russians on social media. While using the Internet to follow such large-scale social movements remotely, researchers experience social media as a context in which anthropology happens. They may think about “being there” in new ways that shift their focus to their own processes of memory making and sense of bodily presence. Experiencing and remembering social media in the body challenges the distinctions we might otherwise make between virtual and physical encounters.

Royal pharmaceuticals: Bioprospecting, rights, and traditional authority in South Africa

Christopher Morris

The translation of international biogenetic resource rights to a former apartheid homeland is fostering business partnerships between South African traditional leaders and multinational pharmaceutical companies. In the case of one contentious resource, these partnerships are entrenching, and in some instances expanding, apartheid-associated boundaries and configurations of power. The state and corporate task of producing communities amenable to biodiversity commercialization and conservation is entangled with segregationist laws and spatial planning. Rather than exclusion and the closure of ethnic boundaries, resource rights in this context foreground forced enrollment and the expansion of indigenous group-membership as modes of capitalist accumulation in an extractive economy.  

Atmosphere: Context, detachment, and the view from above Earth

David Valentine

Since the 1950s, views of Earth from above have been critiqued for provoking detachment from and decontextualization of human, terrestrial concerns. These critiques thus establish Earth’s enveloping atmosphere as the ultimate context for meaningful and grounded accounts of humanness, and outer space as a site for abstract, generalizable knowledge. But in outer space, the explanatory work done by “context” is put in question, because spacefaring humans must attend to basic and constantly shifting conditions for life that lie beyond “context” on Earth, including breathing. Attention to humans in real and speculative space environments reveals context as a naturalizing device that establishes universal nature/culture distinctions through recourse to grounding terrestrial ontologies.

 

Configurations:

Disappearing Bitches: Canine Affect and Postcolonial Bioethics

Hyaesin Yoon

This article engages with the animal bodies that haunt the transnational pet-cloning industry: the “used-up” surrogate-mother dogs said to be returned to dog-farms and slaughtered for human consumption in South Korea. I explore how “Western” criticisms that reduce the problem to Korea’s dog-eating culture and lack of bioethics—interlocking with nationalist and cultural relativist responses among Koreans—reiterate postcolonial relations within transnational bioethics, further pushing these animals into the shadows. I trace shame and disgust (as affective remainders of canine bodies) as a way to critically examine the bioethicalization of animal welfare as an operation of the biopolitical order of things among human and nonhuman bodies in the field of transnational biotechnology, in an effort to remind us of the canine others within us.

  

Cultural Anthropology:

Practicing Uncertainty: Scenario-Based Preparedness Exercises in Israel

Limor Samimian-Darash 

Excerpt:

In this article, I examine the scenario-based exercise as a central technology within Israel’s preparedness apparatus. Drawing on my ethnographic research in NEMA and the Turning Point administration, I analyze how the scenario event works as a technology-based uncertainty, both in its conceptualization of the future and, especially, in its enactment. As Barak argued, the exercise narrative is a chosen event, one that does not replicate the past or attempt to predict the future. Though designed to challenge responders, the scenario represents not a worst-case event but a plausible one. Moreover, although the scenario is based on a preselected, well-designed event, I argue that once practiced, it is actualized as a multiplicity of subevents, or incidents, that the various participants sometimes enact with unexpected consequences. With this technology, the Israeli preparedness system is directed neither toward producing specific responses nor toward discovering the best solutions for an unknown future. Rather, the technology generates uncertainty through its execution, from which new problems are extracted.

You-Will-Kill-Me-Beans: Taste and the Politics of Necessity in Humanitarian Aid

Micah M. Trapp

Excerpt:

In my work in the Buduburam Liberian refugee camp, located forty kilometers west of Accra, Ghana, I have sought to understand how refugees’ demand for food with what they consider to be good taste is configured in equations of who is deserving, or in need of, humanitarian aid. My questions have centered on how the politics of necessity shape food provision as humanitarian aid. Central to these inquiries are the critical opportunities afforded to refugee subjects by the aesthetics of taste—how cooking and taste reveal forms of refugee subjectivities that counter the humanitarian politics of necessity.

 

Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine  

Fragmentation in Australian Commonwealth and South Australian State policy on mental health and older people: A governmentality analysis (open access)

Candice Oster, Julie Henderson, Sharon Lawn, Richard Reed, Suzanne Dawson, Eimear Muir-Cochrane, and Jeffrey Fuller

 Mental health care for older people is a significant and growing issue in Australia and internationally. This article describes how older people’s mental health is governed through policy discourse by examining Australian Commonwealth and South Australian State government policy documents, and commentaries from professional groups, advocacy groups and non-governmental organisations. Documents published between 2009 and 2014 were analysed using a governmentality approach, informed by Foucault. Discourses of ‘risk’, ‘ageing as decline/dependence’ and ‘healthy ageing’ were identified. Through these discourses, different neo-liberal governmental strategies are applied to ‘target’ groups according to varying risk judgements. Three policy approaches were identified where older people are (1) absent from policy, (2) governed as responsible, active citizens or (3) governed as passive recipients of health care. This fragmented policy response to older people’s mental health reflects fragmentation in the Australian policy environment. It constructs an ambiguous place for older people within neo-liberal governmental rationality, with significant effects on the health system, older people and their carers.

Legitimating the illegitimate: How doctors manage their knowledge of the prestige of diseases

Marit Haldar, Eivind Engebretsen, and Dag Album

Although the sociology of medicine has developed a rich body of research on patients’ experiences and how they handle their illnesses, few analyses have examined doctors’ concepts of disease. Building on previous research findings that doctors consider some diseases to be more worthy than others, this article focuses on how these differences in disease prestige are articulated and made logical. We presented a focus group panel of doctors a table of 38 diseases rank-ordered by prestige according to the results of a previous quantitative study of doctors. We prompted a lively discussion among the doctors by asking them whether they were familiar with this rank order. In analysing how they managed the prestige knowledge presented to them, we focused on how they handled the value conflict between this informal rank order and the formal value of equality of treatment. Using positioning theory as a theoretical premise and a methodological tool, we found that the focus group participants created positions in their conversations that allowed them to present and discuss views on disease prestige that would be considered illegitimate if they were declared directly. However, they were able to do so without being forced to take a personal stand. Thus, we demonstrate how informal disease rankings can be produced and reproduced.

Life according to ME: Caught in the ebb-tide

Olaug S Lian and Frances Rapport

In this article, we explore the role of ‘place’ in shaping people’s illness experiences through a data-led inductive case-study based on experiential data from people living with myalgic encephalomyelitis (ME) in Norway. Our main aim is to understand how they experience, interpret and attach meaning to various places in which they reside, and how they construct the course of a life influenced by chronic illness. The study is based on stories containing photographs and written texts, received from 10 women and men. In their stories, they describe those places where they experience their illness in the least and most taxing ways. Through a narrative and photographic analysis of their stories, we explore how they perceive the relationship between place and illness as experienced, managed and endured. Our analysis is based on a place-sensitive sociology, in which we approach place both as physicality and a symbolic construction. The participants describe how a wide range of places are intimately linked to their illness experiences, and they interpret these links by referring to both physical and symbolic factors. They describe their lives in terms of a need for equilibrium between activity and rest. Risk is a strong underlying theme: whatever they do, they risk losing something. Most of all, the participants describe how they are looking for places to escape to and from. Places to escape to are those places where privacy and peace can be found, which primarily revolve around being at home. Places to escape from are those places that make their energy ‘slowly ebb away’.

Narrative as re-fusion: Making sense and value from sickle cell and thalassaemia trait

Simon M Dyson, Waqar IU Ahmad, and Karl Atkin

The moral turn within sociology suggests that we need to be attentive to values and have a rapprochement with philosophy. The study of illness narratives is one area of sociology that has consistently addressed itself to moral domains but has tended to focus on stories of living with genetic or chronic illness per se rather than liminal states such as genetic traits. This article takes the case of genetic carriers within racialized minority groups, namely, those with sickle cell or thalassaemia trait, and takes seriously the notion that their narratives are ethical practices. In line with the work of Paul Ricoeur, such storied practices are found to link embodiment, social relationships with significant others and wider socio-cultural and socio-political relations. At the same time, such practices are about embodying values. These narratives may be considered as practices that re-fuse what genetic counselling has de-fused, in order to make sense of a life in its entirety and to strive ethically and collectively towards preferred social realities.

New Age in Israel: Formative ethos, identity blindness, and implications for healthcare

Dalit Simchai and Yael Keshet

This article presents a critical analysis of New Age culture. We draw on two empirical studies conducted in Israel and show that the lofty notions about freedom from the shackles of socially structured identities and the unifying potential this holds, as well as the claim regarding the basic equality of human beings, are utopian. Blindness toward ethno-national identity reinforces identification with a self-evident hegemonic perception, thereby leading to the exclusion of peripheral groups such as indigenous populations. This exclusion is manifested in the discourse symbolically as well as in the praxis of complementary and alternative medicine, which is one of the main fields in which New Age culture is involved. Thus, the unifying ethos in the New Age culture becomes an illusionary paradise. This article contributes to the study of power relationships between New Age culture in diverse Western countries and the native and peripheral populations of these countries, and to the sociological study of complementary and alternative medicine incorporated into health organizations.

Nursing futility, managing medicine: Nurses’ perspectives on the transition from life-prolonging to palliative care

Alex Broom, Emma Kirby, Phillip Good, and Zarnie Lwin

The shift from life-prolonging and palliative care can be fraught with interpersonal complexities as patients face dilemmas around mortality and the dying process. Nurses can play a central role in managing these moments, often with a focus on promoting and enhancing communication around: the meaning of palliative care, the nature of futility and the dying process more broadly. These sites of nurse–patient communication can be highly charged and pose unique challenges to nurses including how to balance nursing perspectives versus those of other stakeholders including doctors. Here, drawing on interviews with nurses, we explore their accounts of communication about futility and the process of transitioning to palliative care. The interviews reveal nurses’ perspectives on the following: the art of conversing around futility and managing patient resistance, the influence of guilt and individual biographies in shaping communication, the importance of non-verbal and the informal in communication, the impact of conflicting organisational expectations on nurses and the process of learning to effectively communicate. We argue that these transitional moments articulate important, and at times problematic, aspects of contemporary nursing and nurse–medical relations.

  

Health and Place:

Three modes of power operation: Understanding doctor-patient conflicts in China’s hospital therapeutic landscapes

Peiling Zhou, Sue C. Grady

  • Hospitals are described per spaces, decorations, doctor-patient power relations and discourse between medical encounters.
  • Spatial and temporal arrangements of these environments shape doctor-patient relationship to enhance or reduce conflicts.
  • Adaptations to improve hospital therapeutic environments for patients and doctors are provided.

 

Health, Risk & Society:

‘Because I’ve been extremely careful’: HIV seroconversion, responsibility, citizenship and the neo-liberal drug-using subject

Andrea Krüsi, Ryan McNeil, David Moore & Will Small

In this article, we examine how injection drug users who do not attribute their HIV infection to engaging in HIV risk behaviours take up and critique discourses of individual responsibility and citizenship relating to HIV risk and HIV prevention. We draw on data from a study in Vancouver, Canada (2006–2009) in which we interviewed individuals living with HIV who had a history of injection drug use. In this paper, we focus on six cases studies of participants who did not attribute their HIV infection to engaging in HIV risk behaviours. We found that in striving to present themselves as responsible HIV citizens who did not engage in HIV risk behaviours, these participants drew on individually focused HIV prevention discourses. By identifying themselves in these ways, they were able to present themselves as ‘deserving’ HIV citizens and avoid the blame associated with being HIV positive. However, in rejecting the view that they and their risk behaviours were to blame for their HIV infection and by developing an explanation that drew on broader social, structural and historical factors, these individuals were developing a tentative critique of focus on individual responsibility in HIV transmission as opposed to dangers of infection arising from the socio-economic environment. By framing the risk of infection in environmental rather than individual risk-behaviour terms, these individuals redistributed responsibility to reflect the social-structural realities of their lives. In this article, we reflect on the implications of these findings for public health measures such as risk prevention messages. We argue that it is important that such messages are not restricted to individual risk prevention but also include a focus of broader shared responsibilities of HIV.

 

Philosophy, Ethics, and Humanities in Medicine (open access):

Failed surrogate conceptions: social and ethical aspects of preconception disruptions during commercial surrogacy in India

Sayani Mitra and Silke Schicktanz

During a commercial surrogacy arrangement, the event of embryo transfer can be seen as the formal starting point of the arrangement. However, it is common for surrogates to undergo a failed attempt at pregnancy conception or missed conception after an embryo transfer. This paper attempts to argue that such failed attempts can be understood as a loss. It aims to reconstruct the experiences of loss and grief of the surrogates and the intended parents as a consequence of their collective failure to conceive a surrogate pregnancy.

 

Social Science and Medicine

Common or multiple futures for end of life care around the world? Ideas from the ‘waiting room of history’

Shahaduz Zaman, Hamilton Inbadas, Alexander Whitelaw, David Clark

Around the world there is growing interest in the manner in which care is delivered to people at the end of life. However, there is little unanimity on what constitutes a ‘good death’ and the appropriate societal responses to the issue of delivering culturally relevant and sustainable forms of end of life care in different settings are not subjects of broad agreement. In this critical conceptual paper we focus on the emerging narratives of global palliative care and offer an assessment of their implications. We relate this to calls to improve end of life care across jurisdictions and settings, attempts to map and grade the development of palliative care provision, and to the emergence of a widely recognised global ‘quality of death index’. We consider an alternative approach to framing this debate, drawn from a subaltern and post-colonial studies perspective and suggest that adopting a truly global perspective will require acceptance of the plurality of past and present local problems and issues relating to end of life care, as well as the plural possibilities of how they might be overcome. In that context, we would not aim to universalise or privilege one particular global future for end of life care. Instead of homogenising end of life interventions, we seek to be open to multiple futures for the care of the dying.

Constructing embodied identity in a ‘new’ ageing population: A qualitative study of the pioneer cohort of childhood liver transplant recipients in the UK

Karen Lowton, Chris Hiley, Paul Higgs

Medical innovations have created a future of survivorship for many groups of people with a variety of conditions that were previously untreatable or untreated. This has led not only to an expansion of medical activity in a whole variety of new areas but also to the emergence of new groups of individuals defined or defining themselves through their experiences, diagnosis and treatment. Through analysis of in-depth interviews with 27 of the now-adult survivors of the pioneer cohort of children receiving liver transplants in Britain in the early 1980s and 1990s, this paper presents how this group not only illustrate the capacities of modern medicine and healthcare to transform the survival prospects of a more diversified population, but also create new narratives of embodied identity. Specifically, we examine how childhood identities were shaped in three settings; home, hospital and school. At home, parents appeared to shape their child’s identity through controlling tightly a daily medical regime focused on the concept of ‘body as machine’, celebrating their survival as a transplant recipient, yet at the same time socialising their child as a ‘normal’ child, albeit one who had a serious illness. The hospital appeared instrumental in shaping parents’ focus on their child’s body, and offered a way, through other patients with liver disease, for children to feel ‘normal’ in their difference. It was in school, through interaction with ‘healthy’ children and teachers, that corporeality and embodiment appeared most salient, and where social identity was negotiated and more often held in contention. Adult survivors of childhood liver transplant straddle the different discourses of normality and difference as their embodied experiences shape their narratives of identity and shed light on an underexplored aspect of the relationship between medicine and society.

Reconciling community-based Indigenous research and academic practices: Knowing principles is not always enough

Melody E. Morton Ninomiya, Nathaniel J. Pollock

Historically, Indigenous health research in Canada has failed to engage Indigenous peoples and communities as primary stakeholders of research evidence. Increasingly, research ethics and methodologies are being positioned as tools for Indigenous self-determination. In response, mainstream institutions have developed new ethical principles for research involving Indigenous people. While these transformations are necessary steps towards re-orienting research practices, they are not prescriptive. In this paper, we make visible three dilemmas from a case study in which Indigenous health research frameworks provided limited guidance or were unclear about how to balance community priorities with Indigenous research principles. We also discuss the strategies used to resolve each of these dilemmas.

We draw examples from a project that examined the lived experiences of children and youth living with FASD and their caregivers. This project was conducted in collaboration with Sheshatshiu Innu First Nation, an Indigenous community in Labrador, Canada. In doing so, we argue that knowing the key guiding principles in Indigenous health research is not always enough, and that the ‘real-world’ context of practices and relationships can lead to conflicts that are not easily resolved with adherence to these principles.

Two approaches, one problem: Cultural constructions of type II diabetes in an indigenous community in Yucatán, Mexico

Sarah M. Frank, T. Elizabeth Durden

The emerging epidemic of obesity and type II diabetes in Mexico has recently propelled the nation into the public health spotlight. In the state of Yucatán, the experience of diabetes is greatly impacted by two cultural constructions of disease. In this setting, elements of Yucatec Mayan health practices as well as the biomedical model affect the approach to type II diabetes. Both frameworks offer unique understandings of the etiology of diabetes and recommend different ways to manage the condition. Based on in-depth and semi-structured interviews with both community members and clinicians, the present study seeks to understand how diabetes is understood and treated in indigenous settings in rural Yucatán. We explore the context in which community members navigate between locally available healthcare options, choose one over the other, or incorporate strategies from both into their diabetes care regimens. The tension between indigenous community members and their biomedical healthcare providers, the changing food environment of this community, and the persistence of traditional gender constructions affect the management of type II diabetes and its associated symptoms.

 

Social Theory & Health

Trust matters for doctors? Towards an agenda for research

Tom Douglass, Michael Calnan

Sociological research offers crucial understanding of the salience of trust for patients in mediating a plurality of healthcare activities and settings. Whilst insights generated surrounding the salience of trust for patients are important, other trusting relations within healthcare have largely been neglected. This paper focuses on the significance of trust for doctors, arguing that trust is salient for doctors in facilitating their professional role, in the management of complexity and uncertainty in contemporary medical practice, and is a key mechanism underpinning professional identity. As such, the paper develops a preliminary conceptual framework for researching trust by doctors built upon the idea of a ‘lattice’ of doctor trust relations in various entities and at various levels that may be interconnected. The lattice of doctor trust comprises four primary conceptualisations – trust in patients, self-trust, workplace trust and system trust. The paper explores the notions of doctors’ need to trust patients to provide accurate information and to commit to certain treatment pathways; the relationship between the self-trust of the doctor, clinical activity and trust in others; the need for doctors to trust their professional colleagues and the broader organisational setting to ensure the smooth running of services and integration of care; and notions surrounding the complexity of the broader systems of modern (bio)medicine and the role of trust by doctors to facilitate system functioning.

Bureaucratically distorted communication: The case of managed mental health care

Jeremiah C. Morelock

Mental health treatment providers today are subject to insurance company regulation. Using grounded theory to analyze 33 interviews of treatment providers, I portray this regulation as a form of surveillance that operates through discourse, and ask how treatment providers communicate with and through this system. My findings reveal that mental health treatment providers are required to deliver information to insurers within a rationalized medical discourse that is supposed to represent treatment, but is inadequate for the task. I argue this bureaucratic system demands that providers communicate with insurers in a distorted way. These findings are theorized in dialogue with Habermas’ communication typology and his theory of lifeworld colonization. I argue that the case of managed mental health care presents an arena of communication and colonization which is best suited by building from the Habermasian framework. Colonization occurs, yet on within a specific channel of communication, despite pretensions of thoroughgoing colonization. Systematically generated communicative distortions occur, but often without necessarily involving self-deceptions or strategic private agendas. This paper contributes to Habermasian theory by suggesting it could be further elaborated upon to account in for forms of colonization and distorted communication that occur in varied social contexts.

The birth of mindpolitics: understanding nudging in public health policy

Rik Peeters, Marc Schuilenburg

This article addresses the question: ‘In what ways have nudging and other behavioural techniques entered the realm of policymaking for public health and what does that mean for the way contemporary society is governed?’ In our genealogy of Dutch public health policy, we have identified four periods: ‘rational persuasion/individual responsibility’ (‘70s), ‘welfarist emancipation’ (‘80s), ‘neo-liberal regulation’ (‘90s), and ‘management of choice’ (now). We show how a different type of technique, which we call ‘mindpolitics’, has slowly complemented the biopolitics of public hygiene and health care. We argue that to think in terms of biopolitics today means to think of its relation to a world in which public health is managed through architecture of choice and the way individuals are nudged into making better decisions.

 

Society and Mental Health

The “Work” of Workplace Mental Health: An Institutional Ethnography

Cindy K. Malachowski, Katherine Boydell, Peter Sawchuk, and Bonnie Kirsh

This article employs institutional ethnography (IE) inclusive of its distinctive epistemological stance to elucidate the institutional organization of the everyday work experience of the employee living with self-reported depression. The study was conducted within a large industrial manufacturing plant in Ontario, Canada. We discuss three institutionally organized processes that play a dominant role in coordinating the experiences of employees with self-reported depression: (1) employees’ work of managing and negotiating episodes of depression, (2) managers’ administrative work of maintaining privacy and confidentiality, and (3) the administrative work of authorizing illness. We shed light on how confidential medicalized disability management programs render managers ill prepared and inadequately trained to provide mental health support to their employees. Our findings inform advocacy efforts and facilitate both organizational and policy change to enhance services and supports for employees.

Depressive Symptoms and Electronic Messaging with Health Care Providers

Celeste Campos-Castillo, Daniel J. Bartholomay, Elisabeth F. Callahan, and Denise L. Anthony

Recent health policies encourage electronic messaging with providers to potentially improve health care. It is unclear whether the same potential exists for individuals with mental health symptoms. Whereas these individuals appear interested in such technologies, they may also be concerned about privacy and security risks. To clarify this ambiguity, we conceptualize electronic messaging as an impression management tool for individuals with depressive symptoms, who risk devaluation from others. Consequently, factors that increase the perceived risk of devaluation in face-to-face clinical encounters may increase the likelihood of electronically messaging providers. We empirically examined two factors: depressive symptom severity and trust in physician confidentiality, which is the expectation that one’s regular physician uses personal health information appropriately. We found that reporting severe depressive symptoms increased the likelihood of electronically messaging providers but only among respondents who lacked trust in physician confidentiality. Electronic messaging is potentially a means to reach this underserved population.

 

Sociology of Health & Illness

Speculating on health: public health meets finance in ‘health impact bonds’

Rachel Rowe and Niamh Stephenson

Where modern public health developed techniques to calculate probability, potentiality, risk and uncertainty, contemporary finance introduces instruments that redeploy these. This article traces possibilities for interrogating the connection between health and financialisation as it is arising in one particular example – the health impact bond. It locates the development of this very recent financial innovation in an account of public health’s role within governance strategies over the 20th century to the present. We examine how social impact bonds for chronic disease prevention programmes bring two previously distinct ways of thinking about and addressing risk into the same domain. Exploring the derivative-type properties of health impact bonds elucidates the financial processes of exchange, hedging, bundling and leveraging. As tools for speculation, the functions of health impact bonds can be delinked from any particular outcome for participants in health interventions. How public health techniques for knowing and acting on risks to population health will contest, rework or be subsumed within finance’s speculative response to risk, is to be seen.

Parental involvement in neonatal critical care decision-making

 Chloe Shaw, Elizabeth Stokoe, Katie Gallagher, Narendra Aladangady and Neil Marlow

The article analyses the decision-making process between doctors and parents of babies in neonatal intensive care. In particular, it focuses on cases in which the decision concerns the redirection of care from full intensive care to palliative care at the end of life. Thirty one families were recruited from a neonatal intensive care unit in England and their formal interactions with the doctor recorded. The conversations were transcribed and analysed using conversation analysis. Analysis focused on sequences in which decisions about the redirection of care were initiated and progressed. Two distinct communicative approaches to decision-making were used by doctors: ‘making recommendations’ and ‘providing options’. Different trajectories for parental involvement in decision-making were afforded by each design, as well as differences in terms of the alignments, or conflicts, between doctors and parents. ‘Making recommendations’ led to misalignment and reduced opportunities for questions and collaboration; ‘providing options’ led to an aligned approach with opportunities for questions and fuller participation in the decision-making process. The findings are discussed in the context of clinical uncertainty, moral responsibility and the implications for medical communication training and guidance.

Repertoires of responsibility for diabetes management by adults with intellectual disabilities and those who support them

Lorna Rouse and W.M.L. Finlay

The limited existing research on diabetes management and intellectual disabilities (ID) highlights the need for further exploration of the concept of responsibility. This study explored repertoires of responsibility in accounts of managing diabetes for adults with ID. Fourteen semi-structured interviews were conducted in the UK with seven adults with mild/moderate ID and type 1 or 2 diabetes and seven people who they nominated as supporting their diabetes management. A discursive psychological analysis found that interpretative repertoires relating to competence, independence and accountability were drawn on to construct multiple and sometimes conflicting versions of responsibility. Within these repertoires people with ID were positioned in conflicting ways; as competent, personally responsible, and entitled to independence and choice, but as also lacking competence, dependent on others and incapable of overall accountability. People with ID often took up empowering positions defending against an incompetent identity. Supporters built accounts which negotiated dilemmatic repertoires on the dual responsibilities of empowering adults with ID to self-manage and managing risk to support good and safe care. The implications of available discursive resources and the ways in which they are mobilised are considered.

 

Transcultural Psychiatry

Healing through giving testimony: An empirical study with Sri Lankan torture survivors

Teresa S. Puvimanasinghe and Ian R. Price

Sri Lanka has recently emerged from a three decade long civil war between government forces and the Liberation Tigers of Tamil Eelam. Behind the actual arena of conflict, forms of organised violence were often perpetrated on ordinary Sri Lankans who came into contact with law enforcement officials and other state authorities. The effects of these encounters on mental health, well-being, and community participation can be severe and long-lasting. Considering the generally poor availability of mental health services in many low-income countries, brief efficient interventions are required to enhance the lives of individuals and their families affected by torture, trauma, or displacement. In this context, the present study evaluated the effectiveness of testimonial therapy in ameliorating the distress of Sri Lankan survivors of torture and ill-treatment. The results indicated that over a 2- to 3-month period, psychosocial functioning was significantly enhanced in the therapy group compared to the waitlist control group. The general benefits of testimonial therapy, the ease with which it can be incorporated into ongoing human rights activities, and its application by trained nonprofessionals encourage greater use of the approach.

Indigenous identity transformations: The pivotal role of student-to-student abuse in Indian Residential Schools

Kimberly Matheson, Amy Bombay, S. Alexander Haslam, and Hymie Anisman

Embracing a shared social identity typically serves to protect group members in the face of threats. However, under some conditions, intragroup dynamics are diverted so that instead, they contribute to disturbances in collective well-being. The present analysis applies a social identity framework to understand how intragroup processes elicited in Indian Residential Schools (IRS) altered the capacity of Indigenous peoples to overcome damage to their identity and collective functioning. With the alleged goal of assimilating the Indigenous population, residential schools in Canada entailed the forced removal of Indigenous children from their communities. A Truth and Reconciliation Commission established in 2008 confirmed the extensive abuse perpetrated by IRS staff, but also raised awareness of the pervasiveness of student-to-student abuse. Supported by qualitative analyses of the reports of social service providers working with IRS survivors (N =  43), it is argued that a key part of the dynamics in the IRSs was the subversion of intragroup processes among Indigenous children in attendance. Understanding intragroup dynamics provides a basis for recognizing the persistent effects of IRSs, and for identifying strategies to heal and reclaim a positive collective identity.

How patients and clinicians make meaning of physical suffering in mental health evaluations

Nicholas J. Carson, Arlene M. Katz, and Margarita Alegría

Clinicians in community mental health settings frequently evaluate individuals suffering from physical health problems. How patients make meaning of such “comorbidity” can affect mental health in ways that may be influenced by cultural expectations and by the responses of clinicians, with implications for delivering culturally sensitive care. A sample of 30 adult mental health intakes exemplifying physical illness assessment was identified from a larger study of patient–provider communication. The recordings of patient–provider interactions were coded using an information checklist containing 21 physical illness items. Intakes were analyzed for themes of meaning making by patients and responses by clinicians. Post-diagnostic interviews with these patients and clinicians were analyzed in similar fashion. Clinicians facilitated disclosures of physical suffering to varying degrees and formulated them in the context of the culture of mental health services. Patients discussed their perceptions of what was at stake in their experience of physical illness: existential loss, embodiment, and limits on the capacity to work and on their sense of agency. The experiences of physical illness, mental health difficulties, and social stressors were described as mutually reinforcing. In mental health intakes, patients attributed meaning to the negative effects of physical health problems in relation to mental health functioning and social stressors. Decreased capacity to work was a particularly salient concern. The complexity of these patient–provider interactions may best be captured by a sociosomatic formulation that addresses the meaning of physical and mental illness in relation to social stressors.

Political and economic transformations in Ukraine: The view from psychiatry

Shelly Yankovskyy

This article examines contemporary Ukrainian psychiatry through the voices of patients, practitioners, and advocates, focusing on shifting objects of knowledge, interventions, and institutional transitions. Currently, we are witnessing the reconfiguration of psychiatry on a global scale through neoliberal rhetoric combined with the call for global mental health. The goal of the movement for global mental health is to scale up psychiatric treatments through greater access to psychiatric drugs, justified through the framing of distress as an illness. Neoliberal rhetoric suggests that cutting social service expenditure through the privatization and decentralization of the health care system will stimulate economic growth and, in the long term, combat poverty. This paper traces how these dynamics are playing out in Ukraine, drawing on ethnographic fieldwork conducted at a psychiatric hospital in south-central Ukraine from 2008–2010, while working with a non-governmental organization

Contextualizing Afghan refugee views of depression through narratives of trauma, resettlement stress, and coping

Qais Alemi, Sigrid James, and Susanne Montgomery

This qualitative study explored how Afghan refugees conceptualize frames of mind that may reflect depression in general and as it relates to trauma they experienced. We performed in-depth interviews with 18 Afghans residing in the San Diego area. Views regarding the causes, symptoms, and perceived treatments of depression were gathered through free-listing techniques, and supplemented with narratives relating to pre- and post-resettlement stressors and coping mechanisms. Data were analyzed with standard qualitative content analysis methods. Items endorsed with relation to depression causality included pre-migration war traumas, notably separation from family, and post-migration stressors including status dissonance and cultural conflicts that ranged from linguistic challenges to intergenerational problems. Depressive symptoms were viewed as highly debilitating, and included changes in temperament, altered cognitions, avoidance and dissociative behaviors, and somatic complaints. Relief was sought through family reunification and community support, reliance on prayer, and the academic success of their children in the US. The findings underscore the need for practitioners to take into account situational stressors, cultural aspects of mourning and symptomatology, and existing coping mechanisms in developing interventions that are based on refugees’ articulated needs.

Does culture impact on notions of criminal responsibility and action? The case of spirit possession

Ayesha Ahmad and Simon Dein

Multicultural societies such as the United Kingdom are host to people with diverse belief systems and behavioral norms. Whilst a country requires that all members of society conform to standardized legal requirements, cases arise that involve certain complexities related to the cultural or religious context in which a certain action was committed. This paper addresses the impact of culture on notions of criminal responsibility and action. Through a case study of a recent event in the United Kingdom, we explore whether a cultural defense is relevant for contextualizing incidents in which an individual commits a criminal action during an alleged period of spirit possession From this analysis, we suggest that using a cultural defense can aid understanding of an individual’s relationship to the society that he or she identifies with and facilitate the practice of justice in a multicultural society.


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