Prozak Diaries: Psychiatry and Generational Memory in Iran

Orkideh Behrouzan

Stanford University Press, 2016, 328 pages

 

Orkideh Behrouzan’s first ethnographic endeavor, Prozak Diaries (2016), explores a question that has provoked much interest in the Middle East in recent years: what’s with all the talk about depression nowadays? The influence of Western clinical psychiatry seems to traverse language: the Farsi word afsordegi, for example, is often substituted by ‘depreshen.’ Prozak Dairies is a multifaceted exploration of the pervasiveness of depreshen talk, or the use of psychiatric language more generally, in Iranian society. The main thrust of Prozak Diaries considers the extent to which modern clinical psychiatric language has become vernacular—gradually normalized within Iranian popular culture and public discourse and co-constitutive with trends in psychiatric treatments and scholarly debates. Behrouzan identifies depreshen, as well as other psychopathologies such as attention deficit hyperactivity disorder (ADHD) and post traumatic stress disorder (PTSD), as diagnoses that have grown in popularity over the past three decades. She then follows the many elusive manifestations of psychiatric discourses and therapeutic practices amongst Iranians. Behrouzan asks questions that are not only relevant to Iranians but which also reflect global trends pertaining to increased rates of prescribing and consuming psycho-pharmaceuticals, an adoption of American clinical language, and an acceptance of an agenda standardized by American pharmaceutical companies. How, she asks, has the normalization of the psychiatric vernacular engendered new ways “of knowing, interpreting, and perceiving oneself in the world?” How might the contemporary psychiatric vernacular open up new ways of expressing mental or emotional conditions in Iran? In what ways has this vernacular replaced older forms of expression; and how might it preclude alternative avenues of self-expression (p. 24)?

Orkideh Behrouzan is a doctor of psychiatry as well as a medical anthropologist. Her scholarship is principally interdisciplinary, an approach which Behrouzan argues is under-practiced yet “crucial” to understanding and engendering “new, culturally appropriate space for conceptual and practical innovations in mental health care” (p. 217) In this sense, Prozak Diaries is a milestone for its approach to understanding contemporary trends in mental health practices and discourses, in the Middle East and beyond. Behrouzan speaks to patients and clinicians. She examines debates among practitioner-academics of psychiatry as well as debates that take place on social media platforms. She outlines trends in the psycho-pharmaceutical industry and reads these trends alongside media and cultural analysis. She examines the role of mental illness “anti-stigmatization,” “education,” or “awareness” campaigns. She recounts personal narratives and testimonies told to her by people who self-identity as suffering from mental illnesses; she also includes stories of people who write about their own struggles with mental health in the Iranian blogosphere—what Behrouzan calls Weblogestān. In this sense, Behrouzan weaves together, “anecdotes, life stories, dreams, interviews, and past and present narratives” so as to provide better insight into individual experiences with mental health and emotional struggles. She represents individual experiences and insights in juxtaposition with larger trends in political-economy, social theory, and institutional trajectories. Clearly influenced by Veena Das’ approach to ethnographic writing, the stories and expressions that take center stage in Prozak Diaries stand in as an alternative to an authorial master narrative based on epidemiological data (p. 7). The interlocutors, characters, and stories that enliven Prozak Diaries span generations, expertise, political and economic positions. In this sense Behrouzan does a good job studying “up, down and sideways” so as to capture various generational, geo-political, economic and sociocultural positions, as well as how power and control operate across them (Nader 1972).

The book begins with a short account of the project from the perspective of the anthropologist; each subsequent chapter concludes with a similar account from the perspective of the interlocutors that give the book vitality: the Poet-Satirist, Freud, The Counselor, the Student, the Blogger, the Mother, and the Medical Intern. The first chapter is a general overview defining the contours and questions that are guiding Behrouzan’s project. Chapter two is a comprehensive historical account of Iranian institutions that chronicles major events, debates, and pedagogical shifts which occurred within Iranian hospitals and universities. These shifts and debates demonstrate the extent to which academic theories and medical therapies shape how psychiatry in Iran is understood and represented in mass. Behrouzan discusses at length the ways in which contrasting and oftentimes conflicting orthodoxies play out within Iranian institutions and among prominent public intellectuals, clergy, and mental health practitioners. The chapter begins with the seeds of modern psychiatry that were planted in Ruzbeh Psychiatric Hospital during the 1930s and 40s. There was nothing particularly special about the introduction of psychoanalytic theory and the absorption of clinical psychiatric practices and therapies in Iran. The phenomenon in Iran coincided with the emergence of new theories that were being developed and tested by European psychoanalysts such as Sigmund Freud and Carl Jung around the same time. The intellectual and practical implications of European psychoanalysis inevitably engendered vigorous debate in Iran. Scholars, physicians, and public intellectuals began to explore and contend with clinical psychiatry models emerging from Euro-American contexts in relation to Shi’ite doctrine and ritual which, according to Behrouzan, tendered to valorize sacrifice, stoicism, and martyrdom. Clinical models were also explored in relation to poetic or Sufi renderings of madness, asceticism and transcendence—mystical and alchemical traditions deeply rooted in Persian literature and the Islamic philosophical sciences.

In chapter three Behrouzan describes how seemingly incommensurable values and worldview are presented as such and how they play out in actuality. This chapter gives a rundown of how psychiatric illness has been represented over the last three decades in five domains: (1) in mass education or public awareness campaigns, (2) in the media and in particular in mental health talk shows national television, popular television shows, (3) in statistical or epidemiological research, (4) in public policy, and (5) in prescription drug patterns and marketing. The minutia of the contradictions outlined in the first three chapters of the book are clearly analyzed in chapters four and five. Chapter four explores how individuals express their own political and psychiatric subjectivities. What shines most through chapter four is how individuals use public forums to justify, legitimize or make peace with medicating—how people may be critical of privilege and take counter-hegemonic stances while also conceding that they are taking advantage of a privileged position and benefiting from a hegemonic pharmaceutical industry. Chapter five delves into an analysis of collective versus individual pathologies, dystopia and melancholia. This chapter contends with the limitations of the Diagnostic and Statistical Manual of Mental Disorders (DSM); it also shows, through examples, the extent to which Iranian mental health practitioners and the general public began to adopt methods, concepts, and terminology from the DSM since the 1979 Revolution. Again, Behrouzan does not try to iron out the paradoxes of the 1979 Revolution and how it marked, at least on a symbolic level, a qualitative shift where criticism of Western or imperialist sentiments became the new convention. Rather, Behrouzan shows that while Iranian intellectuals and public figures fashioned themselves as a counter force to Western imperialism they were simultaneous adopting discourses (in this case the medical the clinical psychiatric frameworks like the DSM) that make possible a reliance Western free market logics (in this case psychopharmacological therapies). The importation of these frameworks necessitated that categorization of psychopathologies be narrowly applied to individuals. Chapter five explores how individuals who are dependent on mental health medications internally grapple with the external contradictions of how mental health is discussed and understood in their society.

One of the most profound undercurrents in this book is the subtle suggestion that Western psychoanalytic paradigms do not hold open enough space to account for collective dysphoria. Behrouzan provides many examples of how poetry and philosophical texts written in the past call attention to modes of expression that were once capable of epitomizing collective sentiments about loss, dysphoria, or melancholia. However, Behrouzan also provides many examples of how references to these texts have been appropriated for marketing purposes, how they that been utilized to support interests that ally with neoliberal or transnational economic interests. In this economy, outwardly discussing and representing ones’ individual struggle with depression is often advertised as a brave or courageous act precisely because it is considered taboo. What is considered “taboo” becomes folded into a kind of marketing strategy that celebrates confessional narratives about suffering through mental health pathologies. The individual act of discussing ones’ depression in the public sphere is plugged into a framework that characterizes mental health issues as taboo and characterizes discussing taboos as brave – this framework prioritizes individuals and their role in destigmatizing psychopathologies like depression (pp. 21, 81,106, 107, 117). The ability to speak of a larger collective dysphoria or a longer continuum of loss and pain, however, is lost within this framework. Individuals who are taking mental health medication and telling their stories in the book do express a kind of meta-awareness of this phenomenon; for them, they realize that underneath their individual diagnosis and the medication they use to treat it “lingers the ghost of collective losses, of loved ones, of integrity, of the social fabric of life itself.” (p. 117). Ultimately, these middle chapters of the book argue convincingly that, since the late 1930s, major pedagogical shifts, ideological positions, discourses and orthodoxies about psychiatric practice and theory in Iran occurred parallel to, and as a result of, geo-political, economic and cultural changes and interests.

For example, in chapter two Behrouzan considers the years leading up to and following the 1979 Revolution, the religious codes of conduct and a Shi’ite moral order in society since the late 1970s, the Iran-Iraq War (1980–1988), and economic sanctions imposed by Western governments. While Behrouzan shows how these events were profoundly influential in steering the direction of modern Iranian psychiatry, she is careful not to make simplistic causal claims. There is no over-determined superstructure, no inescapable imperial influence, hegemonic sovereign power or all-powerful state apparatus—there are no non-agentive bio-political colonized subjects, no voiceless protagonists resisting one thing or another. It is extraordinary how Behrouzan connects dots in a messy field of shared interests, convergences, and divergences. One key point in Prozak Diaries that is repeatedly emphasized is that while modern Iranian psychiatry as a scientific discipline began to calcify in the 1930s in conjunction with Freud’s influence worldwide—the subject of psychiatry, or viewing mental and emotional health as a key aspect of biomedical health, was always already configured prominently in Persian traditions as well as in the Islamic medical and philosophical sciences. Indeed, some of the earliest work about psychiatry was written in Persian dating back to the ninth century which draw upon the Greek medical texts written seven centuries before. Prozak Diaries engages incisively in a field where what seems like paradoxical positions meet—in a messy reality which cuts through stereotypical binaries. The ways in which Freud or critiques of Freud, religious doctrine or secular critiques of religious doctrine, western influences or critiques of western influences, are leveraged or welded in personal and political justifications for one thing or another makes Prozak Diaries special.

In the spirit of Ian Hacking, Behrouzan demonstrates how understandings and recognition of mental health disorders such as PTSD, ADHD, and depression have evolved, “looped,” and shifted overtime—marking or depending on dominant generational and moral orthodoxies. The two concluding chapters circle back to debates, tensions, and contradictions outlined particularly in chapter two: tensions and distinctions that seem naturally oppositional are showed by Behrouzan to be anything but. West vs. east, religious vs. secular, scientific vs. mystical, worldly vs. ascetic, all of these essentialisms are blurred amongst two primary approaches to psychiatry in Iran. On the one hand, there is the psychodynamic approach which emphasizes psychotherapy and considers familial, social, and environmental considerations in diagnosis and treatment. On the other hand, there is the biomedical approach which emphasizes neurochemical considerations and is thus more supportive of psychopharmacological treatments (pp. 210-215). Behrouzan’s analysis does not take Iranian culture as the primary subject of inquiry per se. Instead Prozak Diaries turns the mirror upon the discipline and practice of psychiatry itself, and situates it particularly within Iran; thus Behrouzan offers a portable story that may be culturally specific but nonetheless analyzes the culturally specific context as it is informed and constructed by the assumed universality of psychiatry’s reach. In this sense, Behrouzan does not explicitly call for an “alternative,” “non-western,” or “anti-colonial” genealogy (see Navaro 2017). Rather, Behrouzan simply provides the genealogy itself without a pretense or normative call to write against or diversify. Behrouzan blends deep historical insights that are indigenous to the region with “imports” and insights that were as relevant in 9th and 10th centuries are they are today. She blends English and Persian. She blends biomedical and poetic language, cultural and political references, illustrating how physiology manifests itself in “interpersonal relationships among couples, individuals, and society at large.” By any standard, Prozak Diaries is meticulously crafted and exceptionally well-executed. Behrouzan’s medical training, deep historical perspective, cultural analysis, and careful ethnographic writing illuminate a way of thinking about the Middle East that is often lacking.

It is hard to think of anything too critical about this book, except perhaps that it is geared towards a narrow audience with specific interests and it might be inaccessible to those who are otherwise uninterested in psychiatry and Middle Eastern Studies. The only slight miscalculation that comes to mind is that Behrouzan makes specific choices as a writer, she provides examples and multiple perspectives for a reason, and the reasons underlying her choices may not be clear to the nonspecialist reader because she does not explain her choices, except perhaps, till the very end of the book in the endnotes. While some discussion is provided in the endnotes along with almost all serious engagements with critical social theory and intellectual genealogies; I would have liked to read more about, for example, why Behrouzan organized the chapters the way she did, why she steers away from using an omniscient authorial voice, or why each chapter seems to be organized around different subject positions. Indeed, readers are not able to fully appreciate the depth and scope of Behrouzan’s expertise unless they dig through the endnotes which, for many readers, are an optional augmentation to the text itself. The endnotes however, are where the most compelling and sophisticated discussions in the book take place. I can only speculate that the reason why Behrouzan reserved serious engagement with theory for the endnotes is because she wanted the text as a whole to be accessible for non-specialists. Given the rigor of the text, Prozak Diaries is not particularly accessible to the nonspecialist reader anyway. This is why it was bit of an oversight for Behrouzan to underplay her command of social theory and psychoanalytic literature within the text itself. The full extent to Behrouzan’s contribution may go unnoticed to readers; with exception those of us who enjoy the footnote/endnote trenches. So if you do read the book, which I highly recommend that you do, delve into the endnotes, you won’t regret it!

This small criticism is not intended to suggest that non-specialists should not bother to read Prozak Diaries. On the contrary, it should be considered an invaluable ethnography for all medical students, medical and psychological anthropologists, those interested psychoanalytic theory, and those studying the Middle East, Central Asia, or the Muslim World in general. It would interest mental health care practitioners who work in and study the MENA region as well as those interested in emerging literature considering deep historical accounts of societies in and around the Caspian, Black, and Mediterranean Seas. Indeed, Prozak Diaries illustrates how, despite dominant narratives that claim a natural incommensurability between Western and Eastern world-views—cross-cultural and ideational enmeshment and exchange is a matter of historical fact and continues to be up to the present day.

 

Works Cited

Nader, L. 1972. ‘Up the Anthropologist: Perspectives Gained from ‘studying up’’pp. 284–311 in D. Hymes (ed) Reinventing Anthropology. New York: Random House

Navaro, Y. 2017. “Diversifying Affect.” Cultural Anthropology 32(2).

 

Dina Omar is a doctoral candidate at Yale University in the department of Anthropology. She has joint appointments in Women’s Gender and Sexuality Studies, and Middle Eastern Studies. Her research focuses on histories and trajectories of mental health institutions and therapies in and around Israel and Palestine as well as the politics of mental health in areas or extreme surveillance.