Paper short abstract:

Drawing on fieldwork in an eating disorder facility in Italy, the paper argues that treatment here rests on an operationalization of kinship care, but that the time chronic patients need in treatment generates a dangerous mix between what is seen as ‘functional’ and ‘dysfunctional’ in kinship care.

Paper long abstract:

Drawing on fourteen months of fieldwork in a public residential facility for eating disorders in central Italy, this paper examines treatment at the intersection of professional and family care practices. In arguing that ‘chronic cases’ put into question the specific kind of kinship care that is at the basis of treatment, this paper both draws on and goes beyond anthropological works that, by looking at kinship in practice, have usefully highlighted the potentially harmful side of kinship – including those works that have explored how kinship can be framed as a source of mental distress and at the same time a vehicle for remedy. In addition to all of these aspects, kinship here becomes a risky therapeutic tool, because professionals need to borrow from kinship practices in their own work with patients, balancing those with the necessary clinical detachment. The paper argues that the time chronic patients need in residential treatment generates a particularly dangerous mix between what is seen as ‘functional’ and what is seen as ‘dysfunctional’ in kinship care. This is because the ‘efficacy’ of the kind of kinship work that is at the basis of treatment rests on that being partial and temporary. Long term care in the facility complicates what otherwise allows clinical detachment: the treatment team ends up literally substituting the patient’s family, with professional care and family care mixing ‘too much’ with one another.

Paper short abstract:

Based on field research in inpatient psychiatric care, I adopt the lens of sensory ethnography to the experience and treatment of psychiatric illness. I discuss, how encounters of "resonance" beyond dualist, medicalized concepts of illness create fleeting moments of care within austere institutions.

Paper long abstract:

Based on fieldwork in an inpatient psychiatric clinic in Switzerland, I examine different practices and ontologies of care, experienced and navigated within institutionalized care. I trace sometimes competing notions of personhood, wellbeing and illness among different actors (patients, medical staff, spiritual care, movement therapists). I illustrate how some patients associate healing with interpersonal relationships, being listened to and “being seen”. This need for social resonance can be at odds with different aspects of institutionalized psychiatry – often medical ontologies that prioritize a dualistic, biochemical model of health. Similarly, institutional hierarchies can degrade multisensorial, spiritual, embodied therapies such as art and movement therapy as mere “pastime” or subsume them as “unspecific therapies”. Adopting a phenomenological perspective based on sensory ethnography, I illustrate how different professional ontologies of care and wellbeing co-exist within clinical settings and how interpersonal resonance, as well as therapeutic human-nonhuman-relationships emerge in sometimes unexpected settings. In order to grasp the ephemeral, I examine vignettes from the field through the lens of spatiality and temporality. I discuss, how alternative, sometimes hardly visible encounters of care emerge at the margins of a scarce institutional landscape that is exceedingly marked by austerity and shortage of staff. Thereby I complicate the picture of the biomedically dominated psychiatric clinic by illustrating, that healing is not an isolated biochemical phenomena, but a lived experience that involves embodied, affective and societal dimensions. I propose an extended notion of therapeutic “resonance” that includes also human-nonhuman-relationships such as human-animal encounters, architecture, atmosphere, natural environments and spiritual practices.

Paper short abstract:

The paper explores tensions between care and control in the community-based psychiatric care under the reform of psychiatry. It shows the importance of human connection allowed in the community setting and the need for continuous ethical consideration if control is not to take over.

Paper long abstract:

The ongoing reform of psychiatry in the Czech Republic introduced mental health centres as a new form of mental healthcare intended to provide treatment mainly outside institutions. One of the reform's aims is to "humanize" psychiatric care, in the system still largely based on big inpatient facilities, criticized by both users/survivors and professionals for violent or even inhuman conditions. Based on the ethnographic research in a new facility, where I worked as a psychologist in the past, the paper explores dynamics of caring and controlling. Assuming they may be both present in any form of psychiatric practice, I intended to investigate what sort of care is taking place in new services and how it interacts with control (and surveillance). Based on the experience of nurses who moved from inpatient to community-based setting, I will show the potential for developing a different kind of relationships to clients in the community. Analyzing several situations from centre's practice, involving practitioners of various professional background, I will show the urgent need for ethical consideration of every step taken by the centre towards clients as the centre's controlling role can easily take over. However, the need for reflection is not always recognized by practitioners. Person in a client role is often seen as not responsible for themself at the moment while practitioners adopt an either-or attitude towards responsibility. I will suggest that aplying rather a both-and attitude brings the space for dialogue that invites reflection and opens much broader field of possible actions.

Paper short abstract:

This paper discusses advocacy for Open Dialogue, a model of psychiatric care that is often framed as a more ‘human’ alternative to conventional treatment. It explores how supporters of this approach have embraced human limitations – vulnerability, fallibility – as conditions of effective caregiving.

Paper long abstract:

Open Dialogue is an innovative model of psychiatric crisis response informed by systemic family therapy and service user/survivor movements. It strives to upend entrenched hierarchies within the clinical encounter, placing the client in the driver’s seat of a transparent, non-pathologising, and dialogical therapeutic process. In recent years, Open Dialogue has captured the imaginations of activists, clinicians, and people using services in the UK, where it is currently subject to a randomized controlled trial. Those advocating for the approach consistently describe it as a more ‘human’ alternative to conventional mental health services. This paper draws on 16 months of clinical ethnography to explore the multivalent notion of the human that is mobilized in such claims. It considers how human care came to be defined in relation and juxtaposition to anonymous and bureaucratic regimes of care within the UK’s National Health Service. Yet whereas anthropologists have often highlighted the social capacities of human beings (e.g., empathy, connection) relative to impersonal bureaucracies, Open Dialogue supporters frequently emphasized human limitations. The human, in this context, was fallible, uncertain, and, often, wounded. Interestingly, these qualities were construed not as barriers to high-quality service delivery, but as preconditions to high-quality therapeutic relationships that made space for clients’ own expertise and agency. In this way, I suggest, Open Dialogue advocates encourage a radical rethinking of caregiving that has implications both for anthropological theory and for a public mental health system in crisis.

Paper short abstract:

This paper examines how CHWs in north India address social dimensions of mental health. CHWs displayed culturally nuanced relationship skills and contextual knowledge. They deployed relationships and knowledge to social analysis of their client's lives and to implement bespoke micro-innovations.

Paper long abstract:

Community-based workers promote mental health in communities yet little attention has been given to the ways they operate and the strategies used. For example, how do they translate biomedical concepts into frameworks that are acceptable and accessible to communities? How do micro-innovations lead to positive mental health outcomes, including social inclusion and recovery? The aim of this study was to examine the types of skills and strategies to address social dimensions of mental health used by community health workers (CHWs) working together with people with mental health problems. We interviewed CHWs (n=46) about clients with psychosocial disability who were randomly selected from 1000 people registered with a local non-profit community mental health provider. Notes taken during interviews were cross checked with audio recordings and then coded and analysed thematically. CHWs displayed culturally nuanced skills in forming trusting relationships and in-depth knowledge of the context of their client's lives and family dynamics. They used this information to analyse political, social and economic factors influencing mental health for the client and their family members. The diverse range of analysis and intervention skills of CHWs built on contextual knowledge to implement micro-innovations in a be-spoke way, applying these to the local ecology of people with mental health problems to address social determinants that shaped the mental health of clients.

Paper short abstract:

This paper explores how people in Scotland with experiences of suicidality are designing community-based peer-support initiatives in place of failing statutory mental health services that have become overwhelmed austerity cuts and COVID-19 lockdowns.

Paper long abstract:

This paper presents on-going ethnographic research with people who have attempted, been bereaved by, or work in areas that respond to suicide. Drawing from anthropology (Kleinman, 1988; Chua, 2012; Jenkins 2013) and critical suicidology (Marsh, 2010; Chandler, 2020), this paper outlines tensions that arise as peer led responses to suicide work with and challenge clinical forms of mental health care.

For over a century, suicide has been largely constructed within the epistemology of psychiatry. People who experience suicide attempts are seen as pathologically ill and irrational (Tack 2019; White et al. 2016; Marsh et al., 2021). Statutory responses to suicide reflect contradictory logics of care and control. They focus on individual interventions like pharmaceutical medication, psychological therapies, or in some cases techniques of surveillance and restraint, which are delivered by psychiatrists, GPs, the police, and suicide prevention organisations.

The often brutal, legalistic ways that people who have attempted suicide are treated by law enforcement and hospitals has motivated Scottish citizens to launch peer-led responses that engage in social and community-based care. These lived experience-led groups challenge dominant discourses that frame grief and suicidality as departures from, rather than part of, normal life, by conceptualising suicide within both discourses of mental illness as well as the affective, social and cultural worlds in which they take place. Statutory services have an ambivalent relationship to these peer-led responses just as community-based organisations harbour resentful attitudes towards state mental health care which they see as neglectful and sometimes abusive.

Paper short abstract:

Based on fieldwork in England & Kenya, I examine settings where community—i.e., experiences of mutual responsibility, reciprocal care, belonging—is core to treatment. Here mental healthcare is reframed as a social accomplishment rather than technology of the self: community is both context and cure.

Paper long abstract:

The late-20th c. deinstitutionalization of psychiatric treatment in North America and Western Europe was based on the premise that it would be more cost-effective and more humane to have mental patients live in their own home, replacing confinement within the “total institution” of the asylum (Goffman 1961) with one-to-one outpatient treatment, family reunification, and—ideally—social reintegration. In Thatcher’s UK, this approach became known as “care in the community”, conjuring images of support, communal engagement, and belonging. While the term persists, its promise has not: disproportionate numbers of people living with mental illness are profoundly socially isolated, often with little amelioration of their symptoms (Leff 1997). However, the rise of medical research into health impacts of loneliness and recent experiments in “social prescribing” suggest a different role for (the) community in mental healthcare. Based on fieldwork in the UK and in Kenya, this paper explores a series of settings in which community itself—i.e., the subjective experience of collective being-in-relation, including mutual responsibility, reciprocal care, and intersubjective belonging—forms a core element of treatment. In the logic and practice of such therapeutic communities, mental healthcare is reframed as a social accomplishment rather than a technology of the self: far from a mere setting for treatment, here community emerges as both context and cure.

Paper short abstract:

With a critical medical anthropological gaze, a tragic public death of a man in the street of Oslo in 2021 is analyzed. The ethnographic story disentangles the context of sociality and cultural competence to explore the use of lay competence within the clinical mental health services.

Paper long abstract:

This paper analyzes the tragic public death of a young man in Oslo, Norway back in November 2021. The tragic event allows us to explore how professional and lay people can collaborate in the mental health treatment process. Following this, the paper explores the interface between mobility, migration, substance abuse and mental illness practices within the mental health care systems. The personal story reveals ways a man can succeed in mobility as a personal carrier, from the country of origin, following the process of making a life in Norway with mother and aunt, and later on establish a new family, new identity with friends, and lastly being admitted to the Oslo National Academy of Arts. The life-story enhance both successes and situations of substance abuse and psychosis symptoms. The tragic event allows us to explore how professional and lay people can collaborate in the mental health treatment process. The story reveals limitation in the treatment process, and this paper discuss how the complex context of human sociality could have been acknowledged in the treatment process and ways that could have contributed to a more holistic understanding of the person in context. The event reveals a tension within the mental health services and involving relationships within the clinical setting. The paper explores these practices in the light of the concepts of embodiment (Csordas, 1994) and ethics of care, concepts of autonomy and inter-dependency (Tronto, 2020). Hence the paper discusses models of care that open up for practices of sociality that incorporate social relations and cultural competence - approaches that open up for lay counselling and peer support within the mental health care system (e.g., Kleinman’s explanatory models and the Cultural Formulations Interview that build culturally sensitive services and is integrated into mental health care services. (L,J Kirmayer et al.2020, American Psychiatric Association, ICF ).