Biopolitics and Psychosomatics: Participating Bodies
8 July 2016, University of Cambridge
Darin Weinberg, University of Cambridge
Monica Greco, Goldsmiths, University of London
Robbie Duschinsky, University of Cambridge
Michael Schillmeier, University of Exeter
Can we think of our living bodies as involving forms of social intelligence, agency, and power? And if so, how might this proposition transform the ways in which we consider the possibilities and politics of patient participation? These were the questions at the core of the intellectual agenda of the conference “Biopolitics and Psychosomatics: Participating Bodies”, held on 8 July 2016 at the Centre for Research in the Arts, Social Sciences and Humanities (CRASSH) at the University of Cambridge. The event—co-convened by Monica Greco (Goldsmiths), Darin Weinberg and Robbie Duschinsky (University of Cambridge) and Michael Schillmeier (University of Exeter)—aimed to reclaim the term ‘psychosomatic’ from the reductive and polemical forms of engagement in which it is often caught, and use it as a springboard for reframing questions of agency, embodiment, responsibility, power and choice in the context of current challenges facing state-sponsored service provision in Europe and the US. The spirit of the conference was explicitly exploratory, more concerned with creating space for a new type of conversation than to provide direct answers to the many questions raised. Despite a last-minute cancellation by Laurence Kirmayer, who was scheduled to deliver the closing keynote, the conference proved successful, stimulating discussion and debate about these important and timely questions, on practical, political and intellectual levels.
After Darin Weinberg’s welcome address Monica Greco’s introduction outlined the multiple connotations of the term ‘psychosomatic’ and the striking contrast between them. Despite designating a thriving interdisciplinary research field (‘psychosomatic medicine’) that, in the course of its history, has articulated in multiple ways how culturally mediated social relations might get ‘under our skin’ to produce both physical and mental ill health, the adjective ‘psychosomatic’ also routinely carries the reductive and offensive connotation of designating illnesses as being ‘all in the mind’. For some, this might be reason enough to abandon the concept, but for Greco the value of the term lies precisely in the ‘awkward’ way in which it forces us to confront uncomfortable questions around the value of illness and the active powers of the body. If these questions are not crudely reduced to instruments for blaming and stigmatizing patients, Greco proposes they hold potential for rethinking biopolitical issues which concern social inequality and responsibility for health. These questions become particularly relevant in societal contexts of participation where service users are encouraged to be active partners in care. They hold the potential for rebalancing the rather ‘disembodied’ way in which existing narratives and practices of participation conceive patients. Informed by Michel Foucault’s genealogy of how biological life became an object of government to be known, fostered, and administered, Greco raises questions of how a socially and historically engaged concern with psychosomatics might re-configure how we think about biopolitics. These are big and bold questions that demand creative interdisciplinary attention, hence the selection by the convening group of speakers and discussants spanning a range of disciplinary, conceptual and methodological perspectives.
Following the programme order I offer summaries of the contributions given by the speakers. I also summarise participant discussions, and conclude with a brief reflection on the day.
The conference’s keynote by Felicity Callard examined how psychiatrists Donald Klein and Max Fink observed and evaluated the effects of drugs trialled on psychiatric hospital ward patients in the 1950s and 1960s, looking carefully at how attributions of agency for different effects were made. Later, in the 1980s, Klein would join the taskforce for the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), which would be published to include the category of panic disorder for the first time. One of Callard’s key arguments was that Fink and Klein’s early experiments were central to the forging of this category and its eventual establishment in American and international psychiatry.
In contrast to today’s more standardized and controlled procedures for clinical psychiatric research, Callard described how Fink and Klein had advocated open creative experimentation using numerous, and seemingly ‘messy’, measures. However, whilst data collected included assessments of drug action from a wide range of actors in a variety of settings, Callard paid attention to the ways some interpretations were prioritized, while others were de-selected. Notably, this was illustrated by examining the kinds of observations that were given credence by Fink and Klein, in particular regarding assessments of the authenticity of patients’ outward expressions of their inner states. The views of psychoanalytic therapists based on talk with patients, and explanations from patients themselves, were predominantly judged as erroneous, whereas observations of patients’ behaviours and affects by clinical researchers and nurses in the ward were held to be of higher accuracy. This latter group were also credited as especially expert at assessing the effects of drugs on patients put in a ‘somatizing’ set—a group Fink and Klein characterized as inauthentically presenting bodily symptoms of illness. Callard discussed how interpretations of patient bodies as authentic or inauthentic were closely tied to active debates about how to attribute agency.
Callard ultimately proposed that what had been at stake in these early experiments was not necessarily a purely empirical trial of drug action as Fink and Klein had claimed, but, more fundamentally, questions about how to judge agency and determine pathology in clinical psychiatric research. The ways Fink and Klein had addressed these, Callard argued, had significant implications for the professional standards used to define, identify and treat mental disorder to this day.
An academic psychiatrist himself, Michael Sharpe discussed his experience of leading two high-profile clinical trials, one on the impact of treating depression in cancer patients, and the other on the efficacy of psychological treatments for Chronic Fatigue Syndrome/myalgic encephalomyelitis (ME). While both studies were published in The Lancet, and concluded with comparable findings—that psychological treatments had positive effects on the conditions—the reception of the two studies, both by the press and by patient advocacy groups, was very different. Whereas the ME trial was strongly dismissed by patient groups, and was stated by one group as the main reason for deciding to withdraw from a decade long relationship with a university’s Cognitive Behavioural Therapy (CBT) department, recommendations from the cancer study were swiftly taken up by a major national cancer support charity, and had an overwhelmingly sympathetic response in the media.
Reflecting on this, Sharpe considered a contrast between cancer, which he proposed might be regarded a ‘gold standard’ legitimate illness, and the conflictual history of disputes over the validity of ME as a genuine illness. Specifically, Sharpe compared debates about whether the basis for ME is mental disorder, with medical orthodoxies about cancer having clear and undisputed physical causes. He considered the potential applicability of Laurence Kirmayer’s argument about underlying values in biomedicine whereby the mental symbolises the intentional and voluntary, in contrast to the physical, or bodily, signifying the involuntary and accidental.
Focusing on the field of psychoanalysis, Patrizia Giampieri-Deutsch considered bases for the take-up of short-term psychodynamic and manualised treatments, such as Short Psychodynamic Supportive Psychotherapy (SPSP), over long-term psychotherapy. Giampieri-Deutsch discussed external drivers, including the economic priorities of service providers and health insurers considering financial and time costs, as well as current debates around standards of evidence for judging the efficiency, efficacy and effectiveness of treatments and also underpinning funding decisions. In this context, the need for evidence was highlighted as a challenge facing classical psychoanalysis. Giampieri-Deutsch presented this as a paradox, with reference to the Helsinki Psychotherapy Study Group which had found longer-term psychotherapy performed better than short-term treatments, resulting in stable transformations of personality, and not just symptomatic improvements in controlled trial settings. Nonetheless, a continuing dispute, both inside and outside psychoanalysis, remained the use of mainly third person knowledge from therapists in psychoanalytic studies.
Participation and patient choice of treatment types was also discussed. A practicing psychoanalytic therapist and researcher in Vienna, Giampieri-Deutsch had observed that whilst some patients seem to seek out psychoanalysis and look for Freud’s “talking cure”, today less seem prepared to dedicate time to their mind, particularly in comparison to their body, hence possibly being more inclined to select short-term therapies.
Next, Hanne Knudsen delivered a paper which explored questions of responsibility in the ambitions of current public health programmes in Denmark. In particular, Knudsen considered the focus on the responsibilization of individuals in the use of ‘health dialogues’ and ‘health games’. These involved target citizens being invited to discuss their personal responsibilities regarding healthy lifestyles with public health professionals. Knudsen argued that a core governance challenge these attempted to meet was one of ‘heterophony’, that is, how public health may depend not only on health per se, but also on factors such as the economy and education. However, in practice, her research had found that attempts to mobilize personal responsibility had opened up new heterophonic spaces and potential responsibilities, leading to greater uncertainty regarding outcomes and accountability for public health programme providers. Knudsen argued that to understand this unanticipated problem, the concept of personal responsibility requires examination. Drawing on the thinking of philosophers Søren Kierkegaard and Jacques Derrida, she outlined a tension or paradox built-in to the term. In particular, Knudsen proposed that exercising personal responsibility requires two sets of simultaneous actions that are incompatible, namely: making nominally free individual choices, as well as having and fulfilling externally-set societal obligations. Her contribution therefore opened up questions about how this tension plays out and is sought to be managed in a context of responsibilization, and in relation to the conference theme of participation.
Concluding the speaker panels, Martin Savransky aimed to contribute to debates around the concept of ‘participation all the way down’, exploring how bodies might be thought of as participating in socially intelligent and intelligible ways. Based on the proposition that to participate involves some form of acting based on thinking, Savransky examined how bodies might be considered to think, a proposal at odds with the Cartesian logic of a sentient mind and a passive material body, but, drawing from another historic tradition of thought, pan-psychism.
Savransky outlined that the basic idea of pan-psychism is that everything which exists has a mind or mind-like qualities. However, inspired by particular schools of thought in this tradition, namely those of William James and of Alfred North Whitehead, he suggested that a more fruitful approach would be to start with the proposition that everything thinks, rather than possesses a mind. On this basis, thinking would need not be limited to consciousness, or cognition, but could take various forms, such as sensory awareness, or the discernment of relevance and feeling. Hence, thinking bodies, Savransky argued, could be seen to be at the very core of experiences of health and illness, such as at times when bodily forms disrupt and medical services are sought in reaction.
Darin Weinberg followed up these presentations with a discussion of overarching themes and contributions. He started by considering the relevance of normative standards for identifying illnesses as denigrated in status or as disrespected disorders. In particular, he reflected on his research in the field of addiction in America. Here Weinberg described how the authority of doctors to interpret thought, feeling and mood was being de-stabilised. Biomedical expertise now had to contend with other kinds of expertise, such as the experience based knowledge of people who are clean and previously had drug and alcohol addictions. He considered these shifts as part of wider neo-liberal drivers of the marketization of knowledge.
Turning attention to the relationship between mind and body, Weinberg outlined the uses of historical genealogies for addressing important questions, such as understanding how bodily materiality came to be a pervasive marker of illness legitimacy in Europe and the US. He also drew attention to the need to attend to how such legitimacies come to be sustained, including questions about the maintenance of professional credibility in medicine. In addition, Weinberg argued for being open to contingency, including historically and contextually specifying not only how, but also when and if the body is invoked. Regarding attempts to get around mind-body dualism, Weinberg noted Savransky’s paper, and also highlighted the contributions of Maurice Merleau-Ponty, Pierre Bourdieu, and Bruno Latour. Rather than focussing efforts on trying to overcome presupposed mind-body relations solely through theory, Weinberg advocated empirical grounding to either re-stabilise or re-articulate them.
Weinberg also discussed further problematizing the concept of participation. He explored questions surrounding the navigation of tensions between expertise and democratic inclusion, including how knowledge claims are adjudicated. He discussed limitations to liberal orientations to participation that can prioritize voice and choice over care, drawing on his ethnographic research finding interactional difficulties arising from a political parliament initiative for people with learning disabilities in the UK.
Chaired by Maryon McDonald, the final panel question and answer session addressed the topic of the politics of mind-body relations, continuing on from Darin Weinberg’s discussion as well as Q&As throughout the day.
Alongside more well-trodden ground, such as how dualism informs healthcare practice and the stigmatisation of mental illness relative to physical illness, less familiar connotations of the term psychosomatic were also picked up in relation to the conference themes. It was noted that ‘lifestyle’ illnesses could be thought of as psychosomatic, opening up questions about how social dynamics might play a role in producing them. Also raised was the question of how illness might represent a value – not only for an individual (as a less costly form of social suffering, for example), but also for a social ‘system’ or socio-economic configuration.
Ways to get around prefigured mind-body relations were further debated. For example, Robbie Duschinsky proposed considering possible uses of the language of stress on the basis of its polyvalence, prompting conversation about everyday colloquial uses and medical discourses. Additionally, Patrizia Giampieri-Deutsch proposed re-examining how the mind is conceptualised. Drawing on Freud’s notion of psyche, she proposed models of the mind needed to concentrate not only on functional or intentional thinking and cognition, but also on feelings and affects.
Finally, the panel considered current concerns and challenges facing state-sponsored service provision. Delegates discussed the interests of states in policing who is ill and who is not, and in judging agency and designating responsibility for illness in relation to controlling access to rights-based entitlements to publicly funded healthcare and welfare services. Alongside this, biopolitical concerns about keeping governed populations healthy were also highlighted, and current challenges to this considered. For instance, Monica Greco proposed that states seem to be finding that the models of subjectivity on which service provision are based are not working while the prevalence of chronic illness continues to rise.
The character of this conference was questioning and rather brave. Participants took intellectual risks; they engaged with psychosomatics as a multi-faceted conceptual resource in a challenging and diverse interdisciplinary forum. As a result, they started a conversation with potential to help move forward debates on current challenges facing service provision, particularly about the important issue of patient participation.
Arguably, the inevitable limitation of the exploratory orientation taken was that this event opened up more questions than there was scope to critically develop and answer. Nonetheless, the enthusiasm generated will surely have paved the way for future work which further updates not only how the critical questions of agency, embodiment, responsibility, power and choice are framed, but also how they are addressed.
Alev Sen is a PhD candidate at the Department of Sociology, University of Cambridge and an ESRC Doctoral Training Centre student. She is researching experiences of living with rare diseases in the UK. Her research explores engagement with publicly funded healthcare services with a focus on people with Alkaptonuria.
 The conference was sponsored by the Centre for Research in the Arts, Humanities and Social Sciences (CRASSH), the Wellcome Trust, and Goldsmiths, University of London.