Keeping Our Mouths Shut: The Fear and Racialized Self-Censorship of British Healthcare Professionals in PREVENT Training Abstract The PREVENT policy introduced a duty for British health professionals to identify and report patients they suspect may be vulnerable towards radicalisation. Research on PREVENT’s impact in healthcare is scant, especially on the lived experiences of staff. This study examined individual interviews with 16 critical National Health Service (NHS) professionals who participated in mandatory PREVENT counter-radicalisation training, half of whom are Muslims. Results reveal two themes underlying the self-censorship healthcare staff. The first theme is fear, which critical NHS staff experienced as a result of the political and moral subscript underlying PREVENT training: the ‘good’ position is to accept the PREVENT duty, and the ‘bad’ position is to reject it. This fear is experienced more acutely by British Muslim healthcare staff. The second theme relates to the structures which extend beyond PREVENT but nonetheless contribute to self-censorship: distrustful settings in which the gaze of unknown colleagues stifles personal expression; reluctant trainers who admit PREVENT may be unethical but nonetheless relinquish responsibility from the act of training; and socio-political conditions affecting the NHS which overwhelm staff with other concerns. This paper argues that counter-terrorism within healthcare settings may reveal racist structures which disproportionality impact British Muslims, and raises questions regarding freedom of conscience.

Identity, Subjectivity, and Disorders of Self in Psychosis Abstract Alterations in self-experience are increasingly attended to as relevant and important aspects of schizophrenia, and psychosis more broadly, through a burgeoning self-disorders (SD) literature. At the same time, issues of self, subject, and subjectivity within schizophrenia-spectrum illnesses have also gained attention from researchers across the social sciences and humanities, and from ethnographic research especially. This paper examines the subjective experience of disruptions in self-identity within a cohort of first episode psychosis (FEP) service users, critically engaging with the SD literature and bringing it into conversation with social sciences and humanities scholarship on self and schizophrenia. Drawing findings from an ongoing ethnographic study of young peoples’ experiences with psychosis, we explore meanings of mental distress relating to psychotic episodes and attend to issues of self, identity, and subjectivity. We critique the division between “normal” and “pathological” self-experience that is endorsed within the SD literature, arguing against the notion that fragmentation of self-experience in schizophrenia-spectrum illnesses is indicative of psychopathology. We highlight how experiences categorized as psychosis are also important and complete aspects of one’s social world and inner life and explore the ways in which at least some aspects of disruptions of self-identity stem from clinical situations themselves—in particular, from asymmetries of power within the mental health system. Relating our findings to feminist, postcolonial, and disability studies’ approaches to the “self,” we emphasize the complex interplay between interpersonal, cultural, and structural aspects of self-experience within FEP.

Overlaps and Disjunctures: A Cultural Case Study of a British Indian Young Woman’s Experiences of Bulimia Nervosa Abstract Eating disorder diagnoses are characterised by a pattern of disordered eating behaviour alongside symptoms such as body dissatisfaction and preoccupation with food, weight or shape (APA in Diagnostic and statistical manual of mental disorders, DSM-5, APA, Washington, DC, 2013). Incidence rates for eating disorders have increased during the last 50 years. However, epidemiological studies have suggested that such trends may not be a true representation of the occurrence of these illnesses in the general population, with figures underestimated due to reduced help seeking and poor access to care, particularly amongst ethnic minorities. This case study explores the experiences of a young British Indian woman with bulimia nervosa. Arising from an in-depth semi-structured interview, analysed with interpretative phenomenological analysis, her narrative offers a critical lens onto how diverse fragments of cultural practices and meanings come together to produce the clinical category of ‘bulimia.’ It thereby offers an alternative portrait of relationships between eating disorders and ‘culture,’ one that goes beyond a framing of these illnesses as culture inscribed on the body. Interrogating relationships between culture and the development, expression and maintenance of bulimia is suggested to be key to forging culturally-sensitive understandings of this illness; this paper begins to provide the evidence base for the design and development of appropriate support services, thereby aiming to contribute to a reduction in health inequalities and barriers to treatment.

Technologies of the Social: Family Constellation Therapy and the Remodeling of Relational Selfhood in China and Mexico Abstract In this article, we investigate how an increasingly popular therapeutic modality, family constellation therapy (FCT), functions simultaneously as a technology of the self (Foucault, Technologies of the self: a seminar with Michel Foucault, University of Massachusetts Press, Amherst, 1988) as well as what we here call a “technology of the social.” In FCT, the self is understood as an assemblage of ancestral relationships that often creates problems in the present day. Healing this multi-generational self involves identifying and correcting hidden family dynamics in high-intensity group sessions where other participants represent the focus client and his/her family members, both alive and deceased. Drawing on ethnographic data collected in multiple FCT workshops in Beijing, China and Oaxaca City, Mexico, we show how FCT ritually reorganizes boundaries between self and other in novel ways, creating a collective space for shared moral reflection on troubling social, historical, and cultural patterns. By demonstrating the ways in which FCT unfolds as both a personal and social technology, this article contributes to ongoing conversations about how to effectively theorize sociality in therapeutic practice, and problematizes critical approaches emphasizing governmentality and commensuration (Mattingly, Moral laboratories family peril and the struggle for a good life, University of California Press, Oakland, 2014; Duncan, Transforming therapy: mental health practice and cultural change in Mexico, Vanderbilt University Press, Nashville, 2018; Matza, Shock therapy: psychology, precarity, and well-being in postsocialist Russia, Duke University Press, Durham, 2018; Pritzker, Presented at “Living Well in China” Conference, Irvine, CA, 2018; Mattingly, Anthropol Theory, 2019; Zigon, “HIV is God’s Blessing”: rehabilitating morality in neoliberal Russia, University of California Press, Berkeley, 2011).

Traditional Chinese Medicine Explanatory Models of Depressive Disorders: A Qualitative Study Abstract Traditional Chinese medicine (TCM) is an alternative medical system utilised by many Chinese. However, the knowledge of TCM concepts of depression is limited amongst clinicians with training in Western biomedicine. The purpose of this study was to obtain a better understanding of the conceptualisation of depression from a group of TCM practitioners. Semi-structured interviews in Chinese were carried out with 10 TCM practitioners in Hong Kong. A case description of major depression disorder (MDD) was used as a basis. Interview texts were transcribed, translated and analysed using qualitative content analysis. Most informants identified the case as a depression pattern, a term that lacked clear definition and standardised criteria. The mechanism of disease for MDD symptoms were regarded to be liver-qi dysregulation and an imbalance of yin and yang. The TCM practitioners implemented individualised diagnosis, treatment, and a holistic concept without clear distinction between the mind and the body. This contrasted with the biomedical tradition of separating psychologisation and somatisation. The meanings given to the concept of depression did not correspond with current DSM or ICD definitions, and the TCM normativity can result in variations in explanatory models.

Initiating Change: Negotiations of Subjectivity in a Danish Activation Programme for Young Adults with Psychosocial Problems and Common Mental Disorders Abstract An increasing number of young adults in Denmark experience difficulties in completing their education and holding down a job. Many of these young adults have psychosocial problems and common mental disorders. To retain public income support they must attend education and work-directed activities, known as ‘activation programmes’. Based on ethnographic fieldwork, this study presents an analysis of how one such programme unfolds in practice and how the participants engaged with the activities and negotiated the underlying rationales. We argue that the activities involved in the programme constitute ‘biographical techniques’ that entail a configuration of the participants as being responsible for their own biographies and having the capability to solve their problems themselves. The participants challenged this configuration of subjectivity by recounting complex or immediate problems that could not be solved through biographical techniques and by refusing to deal with their life stories as a way of configuring their futures. Biographical techniques limited the possibilities for grappling with the complexity of the participants’ problems. We conclude that the participants are therefore subjected to biographical coercion because forms of subjectivity other than biographical subjectivity are disregarded.

“How Can We Help You”: Mental Health Practitioners’ Experiences of Service Provision in Northern Namibia Abstract Although 12–13% of Namibians are reported to struggle with psychological distress, very few practitioners are available to provide mental health services in Namibia. Those practitioners who are available are often trained from Western counseling and psychiatric perspectives that may not readily align to beliefs about illness held constructed in Namibian cultures. Institutional effort is invested in the education and use of mental health practitioners, including counselors, social workers, nurses, psychologists, and psychiatrists. However, little is known about the experiences of these providers. Therefore, this study, a grounded theory ethnography, was undertaken as part of broader ethnographic work to understand how mental health practitioners (N = 7) in Northern Namibia view their work with Aawambo Namibians given that Namibian mental health practitioners are few but embedded in the country’s health care system. Four categories were identified in analyses: Provision of Mental Health Services in the North, Practitioners’ Conceptualizations of Psychological Distress: Western and Aawambo Influences, Beliefs about Mental Health Services in the North, and Integration of Traditional Treatment and Counseling. Results are discussed with respect to cultural competence in Namibian mental health practice and potential for integrating traditional practices and mental health services.

From Treatment to Containment to Enterprise: An Ethno-history of Therapeutic Communities in Puerto Rico, 1961–1993 Abstract Unpaid work is now a central therapy in Puerto Rican therapeutic communities, where substance users reside and seek to rehabilitate each other, often for years at a time. Once a leading treatment for addiction in mainland United States, therapeutic communities were scaled back in the 1970s after they lost federal endorsement. They continue to flourish in Puerto Rico for reasons that have less to do with their curative powers than with their malleability as multi-purpose social enterprises and their historical co-option by state, market and family actors who have deployed them for a variety of purposes. Their endurance from the 1960s to the neoliberal present obliges us to recognize their capacities as what Mizruchi calls abeyance mechanisms whereby ‘surplus’ populations, otherwise excluded from labor and home, are absorbed into substitute livelihoods. Having initially emerged as a low-cost treatment, in a context of mass unemployment and prison-overcrowding they now thrive as institutions of containment and informal enterprise.

Giving a Voice to Gambling Addiction: Analysis of Personal Narratives Abstract Gambling addiction (GA) is now considered a worldwide health issue. Although the topic of disorder awareness is a central issue in clinical practice, there are few studies examining this dimension in relation to GA. To bridge this gap, we conducted a qualitative study, administering interviews focused on awareness of GA and eliciting narratives of both the disorder and the whole life of participants. We adopted both qualitative and quantitative methods of research, using computer-aided content analysis. We administered to a sample of 15 treatment-seeking gamblers the Psychiatric Interview for Gambling Addiction and performed a qualitative analysis of the text using the T-Lab software. Five main thematic domains and four factors emerged, shedding light on specific aspects underlying the development of and recovery from GA. Specifically, the results suggested that dissociation processes, materialistic thinking and difficulties in social achievement underlie the subjective experience of GA. Moreover, closeness in interpersonal relationships and awareness of the disorder emerged as core features in the process of change. As a whole, the results highlight the specificities of disorder awareness in addicted gamblers. We discuss these results within the context of previous research and suggest clinical implications for the treatment of GA.

Finding “What Works”: Theory of Change, Contingent Universals, and Virtuous Failure in Global Mental Health Abstract Global Mental Health has developed interventions that strive to work across great difference—variously conceptualized as cultural, socio-economic, geographic, or pertaining to the characteristics of health systems. This article discusses how the evaluation framework Theory of Change (ToC) facilitates the production of ‘global’ knowledge across such differences. Drawing on 14 months of multi-sited fieldwork among Global Mental Health actors in Europe, North America and South Africa, it traces the differential use of ToC in GMH interventions. While much critical scholarship of Global Health metrics holds that techniques of quantification rely on universals that necessarily betray the “real world”, ToC unsettles these critiques. It comes into view as an epistemic and relational device that produces ‘contingent universals’—concepts that are true and measurable until they stop working in the field, or until the parameters of ‘what works’ shift to a new iteration. As such, Theory of Change produces actionable—rather than true—knowledge attuned to open-ended change, both desirable (impact) and unforeseen (adaptation). Its effects, however, are ambiguous. ToC presents us with a horizoning technique that enables what I call “virtuous failure” within the evidence-based paradigm. It may equally harbor the potential to disrupt distinctions such as bricolage (tinkering) and design (planning) and their respective politics, as it may tie neatly into audit cultures, depending on its use. The article analyzes the novel stakes of reflexive evaluation techniques and calls on anthropology and critical Global Health for renewed empirical engagement.