Medicalized Identities and Conditions

Social science critiques of medicalization, whether associated more closely with labeling theory and the social control of deviance, or with Foucaldian theory and the relationship of power to knowledge, have documented the way in which identities and subjectivity are shaped through this process. When individuals are publicly labeled as schizophrenic, anorexic, infertile, menopausal, a heart transplant, a trauma victim, and so on, transformations of subjectivity are readily apparent (Ablon, 1984; Becker, 2000; Estroff, 1993; Kaufman, 1988). At times medicalization may function to exculpate individuals from responsibility for being sick, and individuals may then actively participate in this process (Lock, 1990; Nichter, 1998).

A large body of anthropological research has focused on Zola's original intent in creating the concept of medicalization and has revealed how a range of behaviors and distress are constructed by the medical world as diseases. Robert Barrett shows how the institutional practices of psychiatry first created in the 19th century made possible the production of a new category of knowledge—schizophrenia. Prior to institutionalization, the kind of "crazy" behavior involving disorders of cognition and perception that we now associate with schizophrenia would have elicited a range of responses, not all of them indicating that pathology was involved. Barrett interprets schizophrenia as we know it today as a "polysemic symbol" in which various meanings and values are condensed, including stigma, weakness, inner degeneration, a diseased brain, and chronicity. Without this associated constellation of meanings, schizophrenia as we understand it would not exist. Barrett goes on to argue that the individualistic concept of personhood so characteristic of Euro-America has also contributed to our understanding of this disease. He shows how a theme of a divided, split, or disintegrated individual runs through 19th-century psychiatric discourse, and continues to the present day. Schizophrenia is not the only disease associated with splitting and dissociation, but it has been the prototypical example of such a condition. The perceived loss of autonomy and boundedness taken as characteristic of schizophrenia are signs of the breakdown of the individual, and thus of the person, and, further, the classification and treatment of schizophrenic patients as broken people with "permeable ego boundaries" profoundly influences the subjective experience of the disease (Barrett, 1988).

Barrett, himself a psychiatrist, argues that categorizing patients as suffering from schizophrenia implies a specific ideological stance which may highlight, prob-lematize, and reinforce certain experiences, such as auditory hallucinations, for example. Barrett's argument is neither one of simple social construction, nor of schizophrenia as a myth, but a more subtle argument in which he does not dispute at all the reality of symptoms, or the horror of the disease. He points out, however, that a careful review of the cross-cultural literature indicates that some of the constitutional components of what we understand as schizophrenia may be virtually absent in certain non-Western settings: "Thus, in some cultures, especially those that do not employ concept of 'mind' as opposed to 'body,' the closest equivalents to schizophrenia are not concerned with 'mental experiences' at all, but employ criteria related to impairment in social functioning or persistent rule violation" (Barrett, 1988, p. 379). Similar arguments to that of Barrett have been developed for clinical depression as it is currently defined, that is, as being a psychiatric ethno-category characteristic of Euro-America society (Kleinman & Good, 1985).

The literature of medical anthropology is replete with examples in which arguments about bodily ills are essentially moral disputes about the boundaries between normal and abnormal, and their social significance. Ong (1988), for example, interpreted attacks of spirit possession on the shop floors of multinational factories in Malaysia as complex and ambivalent, but not abnormal, responses of young women to violations of their gendered sense of self, difficult work conditions, and the process of modernization. The psychologization and medicalization of these attacks by consultant medical professionals permitted a different moral interpretation of the problem by employers: one of "primitive minds" disrupting the creation of capital.

Similarly, the refusal of many Japanese adolescents to go to school is labeled by certain psychiatrists in that country (but not all) as deviant, and as behavior that should be medicalized. In a few cases the children are clearly mentally ill, but this behavior can also be interpreted as an individualized, muted form of resistance to manipulation by families, peers, and teachers and to larger stresses associated with the education system and Japanese modernization (Lock, 1991). Similarly, Kleinman and Kleinman (1991) have analyzed narratives about chronic pain in China as in effect normal responses to chaotic political change at the national level. These changes are associated with collective and personal delegitimation of the daily life of thousands of ordinary people, and the subjective experience of physical malaise, that in the clinical situation are interpreted as and reduced to physical disorder. In a Brazilian shantytown, Scheper-Hughes interprets what she describes as an epidemic of nervoso as having multiple meanings: at times a refusal of men to continue demeaning and debilitating labor, at times a response of women to violent shock or tragedy, and also in part a response to the ongoing state of emergency in everyday life. The epidemic signals a nervous agitation, "a state of disequilibrium"—the only means of expressing dissent in a truly repressive society. Individuals are often quite conscious of the injustice of their situation, but at the same time exhibit ambivalence and describe their own bodies as "worthless" or "used up"

(Scheper-Hughes, 1992, p. 187). She concludes that the semi-willingness of people to participate in the medicalization of their bodies is the result of participating in the same moral world as their oppressors.

Swartz and Levett (1987, p. 747) note that, not surprisingly, "psychological sequleae" have been frequently reported in connection with the impact of massive long-term political repression of children in South Africa. They go on to argue that this psychologization is too narrowly defined, and that "the costs of generations of oppression of children cannot be offset simply by interventions of mental health workers." Further, these researchers argue, "it is a serious fallacy to assume that if something is wrong within the society, then this must be reflected necessarily in the psychopathological make-up of individuals" (p. 747, emphasis added). In common with those authors cited above, Swartz and Levett oppose the normalization and transformation of political and social repression into individual pathology, and its management solely through medical interventions.

Allan Young, researching the invention of posttraumatic stress disorder, shows just how powerful is the current psychiatric model in the creation of this new disease. Psychiatrists assume that the uncovering and reliving of a single traumatic episode during the course of therapy will open the door to relief from chronic debilitating stress and postulated pathological changes in the neuroendocrinological system (Young, 1995). Thus, even the atrocities of the Vietnam war and moral condemnation of them are individualized and depoliticized.

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