Social defeat and the culture of chronicity: or, why schizophrenia does so well over there and so badly here

Dissociation and misdiagnosis of schizophrenia in populations experiencing chronic discrimination and social defeat

As recently as the late 20th century, Schizophrenia, a category of mental illness with widely varying phenotypic symptoms, was believed by psychobiologists to be a genetically based disorder in which the environment played a limited etiological role. Yet a growing body of evidence indicates a strong correlation between schizophrenia and environmental factors. This theoretical paper explores the relationship between highly elevated rates of schizophrenia in some low-income minority communities worldwide and trauma-related dissociative symptoms that often mimic schizophrenia. Elevated rates of schizophrenia in racially and ethnically isolated, inner-city Black populations are well documented. This paper contains evidence proposing that this amplification in the rate of schizophrenia is mediated by childhood trauma, disorganized attachment, and social defeat. Further, evidence demonstrating how these three variables combine in early childhood to incubate dissociative disorders will also be conveyed. The misdiagnosis of dissociative disorders as schizophrenia is theorized to partially mediate the increased rate of schizophrenia in communities that experience high levels of racial/ethnic discrimination. It is argued that this misdiagnosis is often attributable to cultural misunderstanding and/or a lack of knowledge about dissociative disorders.

The Experience of Psychosis in Psychiatric Inpatients During the COVID-19 Pandemic Among Unhoused Individuals

This research investigates the impact of Coronavirus-2019 on individuals without housing and experiencing psychosis using semi-structured qualitative interviews and a case study format. We found that for our participants, life in the pandemic was generally more difficult and filled with violence. Further, the pandemic seemed to impact the content of psychosis directly, such that in some cases voices referred to politics around the virus. Being unhoused during the pandemic may increase the sense of powerlessness, social defeat, and the sense of failure in social interactions. Despite national and local measures to mitigate virus spread in unhoused communities, the pandemic seemed to be particularly hard on those who were unhoused. This research should support our efforts to see access to secure housing as a human rights issue.

Is it Still Ok to be Ok? Mental Health Labels as a Campus Technology

This article uses ethnography and coproduced ethnography to investigate mental health labels amongst university students in the UK. We find that although labels can still be a source of stigma, they are also both necessary and useful. Students use labels as 'campus technologies' to achieve various ends. This includes interaction with academics and administrators, but labels can do more than make student distress bureaucratically legible. Mental health labels extend across the whole student social world, as a pliable means of negotiating social interaction, as a tool of self-discovery, and through the 'soft-boy' online archetype, they can be a means of promoting sexual capital and of finessing romantic encounters. Labels emerge as flexible, fluid and contextual. We thus follow Eli Clare in attending to the varying degrees of sincerity, authenticity and pragmatism in dealing with labels. Our findings give pause to two sets of enquiry that are sometimes seen as opposed. Quantitative mental health research relies on what appear to be questionable assumptions about labels embedded in questionnaires. But concerns about the dialogical power of labels to medicalise students also appears undermined.

The Shaman and Schizophrenia, Revisited

This paper presents evidence that some-but not all-religious experts in a particular faith may have a schizophrenia-like psychotic process which is managed or mitigated by their religious practice, in that they are able to function effectively and are not identified by their community as ill. We conducted careful phenomenological interviews, in conjunction with a novel probe, with okomfo, priests of the traditional religion in Ghana who speak with their gods. They shared common understandings of how priests hear gods speak. Despite this, participants described quite varied personal experiences of the god's voice. Some reported voices which were auditory and more negative; some seemed to describe trance-like states, sometimes associated with trauma and violence; some seemed to be described sleep-related events; and some seemed to be interpreting ordinary inner speech. These differences in description were supported by the way participants responded to an auditory clip made to simulate the voice-hearing experiences of psychosis and which had been translated into the local language. We suggest that for some individuals, the apprenticeship trained practice of talking with the gods, in conjunction with a non-stigmatizing identity, may shape the content and emotional tone of voices associated with a psychotic process.

Making meaning of trauma in psychosis

Background

Finding new meaning and identity in the aftermath of trauma has been identified as a key process of mental health recovery. However, research indicates that this meaning-making process is compromised in people with psychosis. Considering the high prevalence, yet under-treatment of trauma in people with psychosis, it is urgent to gain insight into how their meaning-making process can be supported.

Aim

To gain insight into how people with psychosis make meaning of trauma and identify barriers and facilitators in their meaning-making process.

Methods

Qualitative inquiry of N = 21 interviews transcripts from the Dutch Psychiatry Storybank. We included interviews of people who (a) lived through multiple psychotic episodes, and (b) spontaneously addressed traumatic experiences in a low-structured interview. Storyline analysis was performed to gain insight into the meaning-making of trauma within their self-stories. Psychosocial conceptualizations of narrative identity were used to inform the analysis. A data-validation session with four experts-by-experience was organized to check and improve the quality of our analysis.

Results

We identified four different story types: (1) Psychiatry as the wrong setting to find meaning; (2) The ongoing struggle to get trauma-therapy; (3) Exposure to trauma as a threat to a stable life, and (4) Disclosure as the key to resolving alienation. Each story type comprises a different plot, meaning of trauma withing the self-story, (lack of) integration and barriers and facilitators in the meaning-making process. Overall, barriers in the meaning-making process were mostly situated within mental healthcare and stigma-related. People felt particularly hindered by pessimistic ideas on their capacity to develop self-insight and cope with distress, resulting in limited treatment options. Their process of adaptive meaning-making often started with supportive, non-judgmental relationships with individuals or communities that offered them the safety to disclose trauma and motivated them to engage in a process of self-inquiry and growth.

Conclusion

The outcomes illuminate the social context of the meaning-making challenges that people with psychosis face and illustrate the devastating influence of stigma. Our outcomes offer guidance to remove barriers to adaptive meaning-making in people with psychosis, and can help clinicians to attune to differences in the meaning-making of trauma.

They have taken out my spinal cord: an interpretative phenomenological analysis of self-boundary in psychotic experience within a sociocentric culture

INTRODUCTION

In the tradition of phenomenological psychiatry, schizophrenia is described as a disturbance of the minimal self, i.e. the most basic form of self-awareness. This disturbance of the minimal self at the individual level is assumed to precede the intersubjective disturbances such as boundary weakening. However, the role of intersubjective disturbances in the emergence and recovery of schizophrenic experience still remains an open question. This phenomenological study focuses on how encounters with others shape self-experience during from psychosis by analyzing this process from the perspective of cultural differences, which in current research is especially under-researched. While most phenomenological accounts are based on first person-accounts from Western, individualist cultures where the self is conceived and experienced as separate to others, the present study qualitatively investigates psychotic experiences of patients from Jaffna, Sri Lanka.

METHOD

Semi-structured interviews were conducted with three participants with a diagnosis of schizophrenia or first episode psychosis. The interviews were transcribed and analyzed using interpretative phenomenological analysis (IPA). Eight group experiential themes were identified across interviews.

RESULTS

The data suggest that intersubjective processes of boundary weakening such as invasiveness and hyperattunement may shape minimal self-experience and more specifically contribute to a mistrust of the own senses and to hyper-reflexivity. Interestingly, boundary weakening yields pervasive emotions and can be experienced as a threat to the whole social unit. On the one hand, the strengthening of self-other-boundary was achieved through opposition, closedness and withdrawal from others. On the other hand, this study suggests that the re-opening of self-other-boundaries in response to the crisis may help establish connectedness and may lead to recovery.

Schizophrenia: A Review of Social Risk Factors That Affect Women

Social risk factors are long-term or repeated environmental exposures in childhood and youth that change the brain and may, via epigenetic effects, change gene expression. They thus have the power to initiate or aggravate mental disorders. Because these effects can be mediated via hormonal or immune/inflammatory pathways that differ between men and women, their influence is often sex-specific. The goal of this narrative review is to explore the literature on social risk factors as they affect women with schizophrenia. We searched the PubMed and Scopus databases from 2000 to May 2023 using terms referring to the various social determinants of health in conjunction with "women" and with "schizophrenia". A total of 57 studies fulfilled the inclusion criteria. In the domains of childhood and adult abuse or trauma, victimization, stigma, housing, and socioeconomics, women with schizophrenia showed greater probability than their male peers of suffering negative consequences. Interventions targeting appropriate housing, income support, social and parenting support, protection from abuse, violence, and mothering-directed stigma have, to different degrees, yielded success in reducing stress levels and alleviating the many burdens of schizophrenia in women.

The contagion of mental illness: Insights from a Sufi shrine

In this article, an anthropologist and a psychiatrist examine a Sufi shrine-based concept of affliction known as asrat (an "effect" in Hindi-Urdu, "difficulty" in Arabic) and related practices of healing in urban north India. Rather than being located in an individual body, asrat afflictions are shared, most often within a household or kinship group. Through surveys, clinical assessments, and ethnographic work, we track three different ways in which afflictions move between bodies, and the mechanisms at work in asrat healing processes. Rather than a "collectivist" concept of the psyche, we suggest that a key role of shrine-based therapeutic processes is to manage a "suspicion system," related to experiences of psychic and economic injuries and conflict between intimates and kin. Through a multi-sited research design that moves across a leading Sufi shrine, an urban poor neighborhood in Delhi, and one of India's leading psychiatric facilities, we argue that within asrat-related processes, psychic vulnerabilities are addressed by "re-combining" relations through forms of inter-subjective attunement within a smaller segment of the kin group, potentially making symptoms and the burden of care and conflict more livable. We suggest that shrine-based concepts and practices may be cross-culturally significant, even for secular understandings of the inter-subjective dimensions of mental illness.

Psychiatric genomics, mental health equity, and intersectionality: A framework for research and practice

The causal mechanisms and manifestations of psychiatric illness cannot be neatly narrowed down or quantified for diagnosis and treatment. Large-scale genome-wide association studies (GWAS) might renew hope for locating genetic predictors and producing precision medicines, however such hopes can also distract from appreciating social factors and structural injustices that demand more socially inclusive and equitable approaches to mental healthcare. A more comprehensive approach begins with recognizing that there is no one type of contributor to mental illness and its duration that should be prioritized over another. We argue that, if the search for biological specificity is to complement the need to alleviate the social distress that produces mental health inequities, psychiatric genomics must incorporate an intersectional dimension to models of mental illness across research priorities, scientific frameworks, and clinical applications. We outline an intersectional framework that will guide all professionals working in the expanding field of psychiatric genomics to better incorporate issues of social context, racial and cultural diversity, and downstream ethical considerations into their work.

The Limits of Knowing Other Minds

New care workers in Britain typically struggle to understand, on their initial encounters, people who communicate atypically due to their intellectual disabilities. But they are required to provide care that is attuned to these individuals’ desires and intentions. Why, then, does a care organization called L’Arche UK make it harder for carers to learn what is going on inside these people’s minds? I argue that doing so does not prevent the acquisition of essential knowledge, but rather trains new carers to relate to those with intellectual disabilities as opaque. This creates a more involved relationship that opens up the possibility of forms of status and intimacy otherwise closed to such people—thereby raising questions about the supposedly fundamental role that transparency and knowledge play in knowing others.

The Limits of Knowing Other Minds

New care workers in Britain typically struggle to understand, on their initial encounters, people who communicate atypically due to their intellectual disabilities. But they are required to provide care that is attuned to these individuals’ desires and intentions. Why, then, does a care organization called L'Arche UK make it harder for carers to learn what is going on inside these people's minds? I argue that doing so does not prevent the acquisition of essential knowledge, but rather trains new carers to relate to those with intellectual disabilities as opaque. This creates a more involved relationship that opens up the possibility of forms of status and intimacy otherwise closed to such people—thereby raising questions about the supposedly fundamental role that transparency and knowledge play in knowing others.

Becoming a complementary health practitioner: The construction of alternative medical knowledge

Complementary and alternative medicine (CAM) has become widely popular in many countries, yet little is known about the actual training of CAM practitioners. This article employs ethnographic research methods to closely examine the meaning-making processes used in such training at a complementary and alternative medical college. It delineates how CAM practitioners in training, specialising in naturopathy, make sense of alternative medical knowledge and transform it into medical truth. The study indicates that the core of CAM training rests on overturning the biomedical epistemological hierarchy between the objectification of disease and the experience of illness through extended intersubjective sharing by instructors and students. This study therefore adds to the extensive CAM literature by carefully examining the way naturopathic knowledge is inculcated during practitioner training. The emerging insight is that introspection and the search for authenticity, a central narrative of modernity, have become powerful resources in CAM’s construction of alternative medical truth.

Relegating Psychosis: Blood Work and "Routine Connection" in the Clozapine Clinic

This paper attends to the sociality available in the clozapine clinic regimen and suggests that the social dimensions of clozapine treatment may be as important as the biochemical efficacy of clozapine. The clozapine clinic is where people diagnosed with chronic schizophrenia who take the antipsychotic clozapine go for routine monitoring of clozapine side effects, particularly haematological effects. Psychopharmaceutical treatments are often criticized for being reductionistic and dehumanizing, but clozapine clinics offer increased clinical contact in the age of deinstitutionalization. The inadvertent social benefits of biomedically reductive treatments have not previously been ethnographically attended to in the clozapine-only context. Drawing on 18 months of ethnographic fieldwork with 43 clozapine clients and 16 clinical caregivers in two clozapine clinics in the United Kingdom in Australia, I argue that routine clinical attachments in the clozapine clinic can serve a therapeutic role in terms of providing opportunities for clients' health agency, social competence and accountability. This socio-therapeutic quality appeared to be available because the clinical emphasis was not on psychotic illness. It depended, however, on reliable and familiar social exchanges inside the clinic and on the predictability of clinical activity. The importance of unemotional but unfailing relationships and rhythms in the clozapine clinic context echoes cross-cultural findings about how schizophrenia is managed more productively in environments that invite more neutral and equal social exchanges.

The social utility of community treatment orders: Applying Girard's mimetic theory to community-based mandated mental health care

Serious mental illness (SMI) has long posed a dilemma to society. The use of community treatment orders (CTOs), a legal means by which to deliver mandated psychiatric treatment to individuals while they live in the community, is a contemporary technique for managing SMI. CTOs (or a similar legal mechanism) are used in every province in Canada and in many jurisdictions around the world in the care and management of clients with severe and persistent mental illness (most frequently schizophrenia) who have a history of treatment non-compliance and subsequent relapse. Although there is ongoing controversy around CTOs, their use continues to be on the rise. René Girard's mimetic theory, in which he posits the social utility of the scapegoat mechanism, may shed some light on how established cultural patterns contribute to contemporary responses to SMI: how culture depends on the reproduction of certain narratives, and how these act to shape the identity of those involved. The CTO specifically can be seen to act as a scapegoating mechanism, wherein, by singling out and controlling individuals who appear to threaten social order, social order is restored. This paper reviews Girard's theory, looks at how it has been applied to SMI, and then considers how it may illuminate the social role of the CTO. This examination may provide mental health nurses with insight into the constructed identities of their patients, as well as the role of mental health care within broader cultural narratives.

What does it mean to be exposed to suicide?: Suicide exposure, suicide risk, and the importance of meaning-making

Current research indicates that exposure to suicide is a risk factor for suicidality; however, we know little about the mechanisms through which exposure confers this risk. In this study, we address this gap by examining the role of meaning-making after a suicide death in moderating individual's vulnerability to suicide. We draw on interview data with suicide bereaved individuals in the USA (N = 48), the majority of whom engaged in intense meaning-making processes after their loss. Many reported an increased awareness of suicide as a 'something that actually happens,' a realization that impacted their lives and relationships with others (N = 37). For 7 participants, all women, their loss appeared to trigger increased suicidality, as they not only felt overwhelmed by grief, but also came to see suicide as something they, too, could do. However, for 19 participants, witnessing the profound impact of suicide on others made them feel that suicide was something they could never do. Thus, in our data, how exposure impacted vulnerability was tied to how individuals made sense of and experienced their loss. For some, suicide was re-framed as more of an option, while for others it was re-framed as not just the killing-of-oneself, but as the harming-of-others through grief and trauma, which in turn diminished their view of suicide's acceptability. Collectively, our findings suggest that exposure to suicide itself is not inherently risky, though it may be inherently distressing; instead, whether it results in increased vulnerability depends on the meaning an individual makes of the experience and likely the context surrounding the death. We discuss the implications of our findings for theories of suicide contagion, suicide itself, and suicide prevention.

De-othering “schizophrenia”

Do psychiatry and clinical psychology have an “other”? This article critically addresses the clinical-scientific fascination with diagnostic challenges and other psychiatric mysteries, focusing on the example of “schizophrenia,” often seen as the most severe and enigmatic of all mental disorders. Over a century of clinical and scientific discourse on schizophrenia has painted a portrait of something indecipherable at the very foundation of psychiatric inquiry. Despite entrenched beliefs, mounting evidence from both qualitative-phenomenological and quantitative research suggests that the experience of psychosis can be meaningfully understood. Further, there is a wealth of data indicating that persons with lived experience of psychosis can lead self-actualized lives, and new studies have revealed that psychotic experiences are common in non-clinical populations. Yet traditional views of psychosis persist in the face of this mounting evidence. I suggest that the key to de-othering schizophrenia may lie in an emerging body of research on “social defeat,” marginalization, and alienation. More specifically, the experiences and behaviors commonly designated as psychosis arise in social and interpersonal contexts that are distinctly alienating, including the psychiatric encounter. It follows that schizophrenia may not be the elusive empirical object of debates about unintelligibility or “ununderstandability,” but rather a social configuration that is manifest within the deadlock of this debate itself.

Extraordinary Care for Extraordinary Conditions: Constructing Parental Care for Serious Mental Illness in Japan

This article presents an account of how Japanese parents in a family support group for mental illness constructed understandings of care for adult children with serious mental illness, primarily schizophrenia. I build from Janis H. Jenkins's research on the "extraordinary condition" of schizophrenia to discuss "extraordinary care," which parents practiced as a way to refute cultural and clinical beliefs about pathogenic families and degenerative diseases. Parents' accounts of extraordinary care revealed a reliance on biomedical knowledge to treat the symptoms of mental illness coupled with an ongoing determination to improve children's lives beyond what psychiatry could offer. Extraordinary care thus points to the therapeutic limits of biomedical psychiatry while also reinforcing the significance of social relations as families work toward recovery.

"If One Does Not Fulfil His Duties, He Must Not Be a Man": Masculinity, Mental Health and Resilience Amongst Sri Lankan Tamil Refugee Men in Canada

Refugee men face unique mental health stressors in the pre- and post-migratory periods. However, there has been little in-depth research on the mental health of refugee men in Canada. Given this situation, the overall aim of this study is to explore the psycho-social experience of Sri Lankan Tamil refugee men in Canada. Particular objectives include better understanding any inter-relationship between war-trauma, migration, concepts of masculinity and mental health. The study employed a two-phase participatory action research design based on the grounded theory approach. Phase 1 involved an 8-month ethnography conducted in Sri Lanka. Phase 2 consisted of qualitative interviews with 33 Sri Lankan Tamil refugee men living in Canada. Consistent with grounded theory, analysis was conducted inductively and iteratively. Four specific themes emerged from the data (i) gendered helplessness of war: participants commonly reported ongoing negative rumination regarding experiences where they were unable to adequately protect loved ones from physical suffering or death; (ii) reduced capacity: participants frequently felt unable to fulfill culturally sanctioned duties, such as supporting their family, due to ongoing pre- and post-migratory stress; (iii) redundancy: many participants felt that they were useless in Canada, as they could not fulfill typical masculine social roles (e.g. provider) due to factors such as unemployment and underemployment; (iv) intimate criticism: some participants reported that their spouses would often attempt to 'shame' them into greater achievement by constantly reminding them of their 'failures'. Many found this distressing. These various failures culminated in a state that we label "depleted masculinity", which participants linked to emotional and behavioural problems. Participants reported that they actively tried to rebuild their masculine identity, for example by adopting leadership roles in community organizations, which fostered resiliency. Results suggest a need to review and rebuild masculine identity to support the mental health of refugee men.

Care Wounds: Precarious Vulnerability and the Potential of Exposure

What does it mean to offer care when the act of caring is wounding to its giver? For peer specialists-individuals with lived experience as patients in the psychiatric system-this question shapes how they use their own histories to provide support for individuals experiencing psychiatric crisis. Peer support is unique in the way it draws on empathetic resonance and depends on carefully deployed vulnerability; where one connects with others through the recognition of shared experience and mutual hurt. For peers, care works when this guidance, reassurance, and "being with"-all of which draw upon their own stories of traumatic history and variegated suffering-mitigate the present crisis being experienced by another. Drawing on twenty-eight months of fieldwork with a peer-staffed crisis respite center in the eastern United States, I argue that the peer specialist becomes the embodiment of a novel intersection of intimacy and compensation; one that poses vulnerability not as a consequence, casualty, or risk factor in the commodification of care, but as its principle vector of resonance and the assumption on which it is based. For peers, care that works-in that it creates a mutual resonance for the recipient-becomes simultaneously care that wounds its giver.

Idling in Mao's Shadow: Heroin Addiction and the Contested Therapeutic Value of Socialist Traditions of Laboring

The Chinese government has come under attack by international critics for forcing drug users to labor in the name of treatment. While joining these activists in criticizing conditions in compulsory labor centers, former detainees who congregated at a drop-in center in southern Yunnan also defended the therapeutic potential of socialist legacies of laboring. Shuttling between laboring in state compulsory centers and idling in a market economy, long-term heroin users saw their difficulties in recovering from addiction as inextricably linked to their inability to find suitable work opportunities. Certain drop-in center attendees maintained that earlier Communist laboring projects had helped wayward citizens, including drug addicts, "merge into" society as productive workers. This group evoked the stable long-term jobs and benefits once provided by local state-owned enterprises and the radical revolutionary power of "remolding through labor" they imagined to have existed in the first years of the People's Republic as powerful alternatives to their recent crisis of idling. The nuanced ways that drop-in center regulars revisited the potential healing power of earlier traditions of socialist laboring as remedies to their contemporary struggles complicates long-standing debates about coercion in treatment and the responsibility of the postsocialist state towards marginalized workers.

Does culture create craving? Evidence from the case of menstrual chocolate craving

Craving is considered a key characteristic of diverse pathologies, but evidence suggests it may be a culture-bound construct. Almost 50% of American women crave chocolate specifically around the onset of menstruation. Research does not support popular accounts implicating physiological factors in menstrual chocolate craving etiology. We tested the novel hypothesis that greater menstrual craving prevalence in the U.S. is the product of internalized cultural norms. Women of diverse backgrounds (n = 275) reported on craving frequency and triggers and completed validated measures of acculturation. Foreign-born women were significantly less likely to endorse menstrual chocolate craving (17.3%), compared to women born to U.S.-born parents (32.7%, p = .03) and second generation immigrants (40.9%, p = .001). Second generation immigrant and foreign-born women endorsing menstrual chocolate craving reported significantly greater U.S. acculturation and lower identification with their native culture than non-menstrual cravers (all p < .001). Findings inform our understanding of food cravings, with important implications for the study of cravings in other domains.

Does Employment Promote Recovery? Meanings from Work Experience in People Diagnosed with Serious Mental Illness

Employment has been highlighted as a determinant of health and as an essential milestone in the recovery process of people with serious mental illness. Different types of programs and public services have been designed to improve the employability of this population. However, there has not been much interest in the meanings attributed to these experiences and the negative aspects of work experience. In this research, we explored the meanings that participants attributed to their work experience and the impact of work on their recovery process. Research participants lived in Andalusia (Spain), a region in southern Europe with a high unemployment rate. Two versions of a semi-structured interview were designed: one for people who were working, and one for unemployed people. Participants' narratives were categorized according to grounded theory and the analyses were validated in group sessions. Apart from several positive effects for recovery, the analysis of the narratives about work experience outlined certain obstacles to recovery. For example, participants mentioned personal conflicts and stress, job insecurity and meaningless jobs. While valid, the idea that employment is beneficial for recovery must be qualified by the personal meanings attributed to these experiences, and the specific cultural and economic factors of each context.

Case Manager Perspectives on the Role of Treatment in Supportive Housing for People with Severe Mental Illness

OBJECTIVE

Growing recognition exists of housing as a social determinant of health, and thus, health care reform initiatives are expanding the reach of health care beyond traditional settings. One result of this expansion is increased Medicaid funds for supportive-housing programs for people with severe mental illnesses. This qualitative study explores the ways in which case managers working in a supportive housing program approach treatment and how their approach is influenced by both program requirements and their beliefs about mental illness.

METHOD

The study is part of a longitudinal qualitative study on recovery for people with severe mental illnesses living in supportive housing. Multiple interviews (n = 55) with 24 case managers from a residential-continuum supportive-housing program were conducted over 18 months. To provide an in-depth view of case manager perspectives, the study uses thematic analysis with multiple coders.

RESULTS

Overall, case managers understand supportive housing as being a treatment program but predominantly characterize treatment as medication management. The following themes emerged: believing medication to be the key to success in the program, persuading residents to take medication, and questioning the utility of the program for residents who were not medication adherent.

CONCLUSIONS

Case managers understand supportive housing to be a treatment program; however, given the external constraints and their own beliefs about mental illness, case managers often equate treatment with taking medication. Study findings demonstrate the need to train case managers about mental health recovery and integrated health care. The findings also have implications for policies that tie housing to services.

Well-being in clozapine-treated schizophrenia patients: The significance of positive symptoms

OBJECTIVES

Well-being perception is seldom explored in schizophrenia patients. Recurrent limitations, such as the questionable applicability of gold standard definitions of health and well-being, and fewer tools available to assess well-being, are pronounced in this subpopulation. This cross-sectional study sought to explore potential clinical factors that may predict subjective well-being scores in chronic schizophrenia patients (N=142) receiving clozapine treatment.

METHODS

The Short Warwick-Edinburgh Mental Well-being Scale (SWEMWBS) was used to measure well-being. We correlated SWEMWBS scores and 27 clinically recognized factors, spanning socio-demographics, symptom severity scores, physical health diagnosis, clozapine side effects, habits and prescribed medication. Factors with a p<0.2 correlation were included as a predictors in a linear regression model.

RESULTS

Ten factors were included in the linear regression model, however only positive symptom severity was a significant predictor of SWEMWBS score (p<0.0001).

CONCLUSIONS

We suggest that greater levels of clinical attention given to positive symptoms compared with other symptoms and aspects of well-being, during biomedical treatment for chronic schizophrenia, may partially explain the finding that only positive symptoms significantly predicted patient perceptions of low well-being.

"No One Ever Even Asked Me that Before": Autobiographical Power, Social Defeat, and Recovery among African Americans with Lived Experiences of Psychosis

Our article draws on ethnographic research with African American males diagnosed with a psychotic disorder in a high-poverty urban area of the northeastern United States. Our participants frequently described the ways public mental health services led them to experience a paralyzing erosion of autobiographical power, which we define as the ability to tell one's own story and be the editor of one's own life. We identified three important points when the loss of autobiographical power seemed to perpetuate social defeat or a sense of social powerlessness (Luhrmann 2007) for our participants during their interactions with public mental health care. We invite further inquiry into the loss of autobiographical power in settings of public mental health care, the sense of social defeat it seems to perpetuate, and the impact of these on mental health recovery, especially for people living in contexts of persistent social adversity.

Effect of a socıal defeat experıence on prefrontal actıvıty ın schızophrenıa

The social defeat (SD) hypothesis of schizophrenia posits that repeated experiences of SD may lead to sensitization of the mesolimbic dopaminergic system and to precipitation of psychosis. Based on previous definitions adapted to a human experimental paradigm, we prepared a computer simulation of SD to mimic this subjective experience. We measured prefrontal cortex (PFC) activity in subjects with schizophrenia and healthy controls during exposure to a single SD experience with functional near infrared spectroscopy. PFC activity declined in both groups. Compared with the control condition, SD exposure was associated with a broader decline in left ventromedial, right medial and right lateral PFC activity in healthy controls (n=25), and a sharper decline in right ventrolateral PFC activity in subjects with schizophrenia (n=25). The activity in the right ventrolateral PFC, was significantly lower in patients compared with controls. This may be due to a deficiency in emotion regulation or self-control, or it may be related to impaired empathy in schizophrenia. Different patterns of brain activity during the SD experience in subjects with schizophrenia versus healthy controls may provide indirect evidence regarding the SD hypothesis of schizophrenia.

Transatlantic variation in the attributed etiology of psychosis

BACKGROUND

Differences in transatlantic perception of psychosis have been reported in the historical psychiatric literature.

AIMS

This study aims to determine if articles in the American Journal of Psychiatry (AJP) are more likely to attribute biological factors to the etiology of psychosis than those of the British Journal of Psychiatry (BJP).

METHODS

A systematic MEDLINE search for articles in the AJP and BJP from 2005 to 2007 identified 360 abstracts with psychosis and etiology-related words. Chi-square analyses were used to test differences in the proportion of attributed biological or psychosocial etiology of psychosis in each journal.

RESULTS

A greater proportion of abstracts (83/87) in the AJP attributed biological etiology of psychosis (χ(2) = 12.33, df = 1, p < 0.001), while a greater proportion in the BJP (16/44 abstracts) attributed psychosocial etiology (χ(2) = 19.76, df = 1, p < 0.001).

CONCLUSIONS

The AJP tends to publish biomedical explanations of psychosis, while the BJP shows a relative preference for psychosocial theories.

Family influence in recovery from severe mental illness

The aim of this study was to investigate the perceived influence of family on recovery from severe mental illness. 54 semi-structured interviews were conducted with a diverse sample of people with severe mental illness living in Montreal. Results indicated that family both facilitated and impeded recovery processes. Specifically, family facilitated recovery through providing (a) moral support, (b) practical support and (c) motivation to recover. However family impeded recovery through (a) acting as a stressor, (b) displaying stigma and lack of understanding, and (c) forcing hospitalization. The study indicates the importance of family psychoeducation in promoting recovery.

Time seizures and the self: institutional temporalities and self-preservation among homeless women

This article documents temporalities of homelessness as experienced by many homeless people today, those living in the midst of an urban "services ghetto"-where social service organizations abound, but such organizations fail to coordinate the provision or timing of services, producing an incoherent multiplicity of offerings and schedules. I analyzed distinct but related temporal modes by which institutional timetables controlled homeless women's existence, what I call empty time and overscheduled time. The paradoxes of institutionalized waiting and strict yet inconsistent timetables exacted profound material and psychological tolls. For homeless women in Chicago, many of whom experienced symptoms of severe mental illness, simply securing their daily needs was such a time-consuming endeavor that they had to focus on short-term self-preservation rather than seeking stable employment or housing. Using anthropological theories of self and subjectivity, I argue that what was at stake for many women was more than the exhaustion of shelter life-negotiating institutional timetables also threatened their sense of dignity and humanity. Through the everyday patterning of women's time, non-profit agencies whose stated aim was to eliminate homelessness paradoxically frustrated women's efforts to escape life on the streets. I conclude the analysis with policy suggestions to address these problems.

A Bayesian Approach to Latent Class Modeling for Estimating the Prevalence of Schizophrenia Using Administrative Databases

Estimating the incidence and the prevalence of psychotic disorders in the province of Quebec has been the object of some interest in recent years as a contribution to the epidemiological study of the causes of psychotic disorders being carried out primarily in UK and Scandinavia. A number of studies have used administrative data from the Régie de l'assurance maladie du Québec (RAMQ) that includes nearly all Quebec citizens to obtain geographical and temporal prevalence estimates for the illness. However, there has been no investigation of the validity of RAMQ diagnoses for psychotic disorders, and without a measure of the sensitivity and the specificity of these diagnoses, it is impossible to be confident in the accuracy of the estimates obtained. This paper proposes the use of latent class analysis to ascertain the validity of a diagnosis of schizophrenia using RAMQ data.

Narrative Exposure Therapy for Treating PTSD With Psychotic Features

Posttraumatic stress disorder (PTSD) with secondary psychotic features is a syndrome that comprises PTSD symptoms followed in time by the additional appearance of psychotic features. Although diagnostic criteria for this condition are not available, the clinical description of this condition has been described especially in individuals who have experienced severe, chronic, multiple traumatic events. This case study presents the treatment of a survivor of torture with severe PTSD and concomitant psychotic features using the psychosocial approach as a theoretical framework of the clinical presentation and narrative exposure therapy (NET) as a psychotherapeutic intervention. NET could be a useful psychotherapeutic tool in relieving symptoms related to severe PTSD with secondary psychotic features. The overall implications involved in working with survivors of torture are also discussed.

Fear and loathing in New England: examining the health-care perspectives of homeless people in rural areas

Little anthropological research has been conducted on the health care perspectives of homeless people in rural areas. The aim of the present study is to elicit health-care beliefs, and examine overall health experience among a sample of current or recently homeless people in rural New Hampshire. Thirteen qualitative interviews were conducted, 11 with single men. Interviews were audio-recorded and transcribed, and analyzed using thematic analysis. Despite a massive burden of disease and illness, almost all participants reported an abiding aversion to doctors, hospitals and professional health care. Participants reported numerous negative encounters with doctors and health care professionals, often of a demeaning and disparaging nature. Participants noted that these encounters resulted in frequent cases of misdiagnosis and iatrogenesis. In contrast, participants spoke more fondly of other social and voluntary services, for example homeless organizations. Like other rural New Englanders, participants made their own individual efforts to maintain and promote health, for example by pursuing hobbies or prayer. The findings are contextualized within literature suggesting that these perspectives are generally shared by other poor rural people. Consistent with this literature, the findings suggest that homelessness in rural areas is often temporary and episodic. As such, this paper brings into question the distinctiveness and overall utility of the concept: 'the rural homeless'. The key determinant of negative attitudes to health care may not be recent homelessness. It may be entrenched socio-economic marginalization, and the resultant social stigma, that are shared amongst the rural poor, regardless of their current housing status.

Beyond critique: rethinking roles for the anthropology of mental health

The current supremacy of the 'bio-bio-bio' model within the discipline of psychiatry has progressively marginalized social science approaches to mental health. This situation begs the question, what role is there for the anthropology of mental health? In this essay, I contend that there are three essential roles for the anthropology of mental health in an era of biological psychiatry. These roles are to (i) provide a meaningful critique of practices, beliefs, and movements within current psychiatry; (ii) illuminate the socio-cultural, clinical, and familial context of suffering and healing regarding emotional distress/mental illness; and (iii) act as a catalyst for positive change regarding healing, services and provisions for people with emotional distress/mental illness. My argument is unified by my contention that a credible anthropology of mental health intending to make a societal contribution should offer no opposition without proposition. In other words, any critique must be counter-balanced by the detailing of solutions and proposals for change. This will ensure that the anthropology of mental health continues to contribute critical knowledge to the understanding of mental suffering, distress, and healing. Such social and cultural approaches are becoming especially important given the widespread disenchantment with an increasingly dominant biological psychiatry.

Childhood attachment and schizophrenia: the "attachment-developmental-cognitive" (ADC) hypothesis

Schizophrenia is a complex psychiatric syndrome whose exact causes remain unclear. However, current scientific consensus has highlighted the importance of neurodevelopmental and neurocognitive processes in the development of schizophrenic symptoms. Research over the past three decades, motivated by the findings of the World Health Organization's large-scale studies, has highlighted the importance of psychosocial adversities - including childhood abuse and neglect - in this disorder. In this paper, I propose a hypothesis based on John Bowlby's framework of attachment theory, which I have termed the attachment-developmental-cognitive (ADC) hypothesis. The ADC hypothesis integrates recent developments related to (1) existing models of schizophrenia, (2) studies examining the effect of attachment on brain biology and cognitive development, and (3) various known facts about the course and outcome of this disorder. In doing so, it explains how disturbed childhood attachment leads to core psychological and neurochemical abnormalities which are implicated in the genesis of schizophrenia and also affect its outcome. The ADC hypothesis compasses and expands on earlier formulations, such as the "social defeat" and "traumagenic" models, and has important implications regarding the prevention and treatment of schizophrenia. Ways of testing and refining this hypothesis are outlined as avenues for future research. Though provisional, the ADC hypothesis is entirely consistent with both biological and psychosocial research into the origins of schizophrenia.

Keep your sunny side: a street-level look at homelessness

This opinion piece considers my personal experiences of poverty, homelessness, loss, and physical disability in relation to recent discussions of social defeat and resistance among permanent supported housing tenants with physical and mental illnesses. By drawing attention to the onslaught of deprivation and humiliation that generally comes with the territory of poverty and homelessness in the United States, I hope to influence the ways in which clinicians, social service providers, and scholars think about specific instances of social defeat and resistance. My basic point is that any specific experience of resistance or defeat cannot be adequately understood in isolation. Rather, such experiences must be understood in relation to individual life histories of defeat and resistance, and to the symbolic and material sources of success and failure available to citizens who occupy a particular section of social space in a given society.

The phenomenon of social isolation in the severely mentally ill

PURPOSE

The phenomenon of social isolation is closely linked with the experience of having a severe mental illness (SMI). This paper offers scholarly perspectives and analyses of the phenomenon of social isolation as it applies to people with SMI by highlighting relevant definitional, historical, theoretical, and conceptual understanding surrounding this phenomenon.

CONCLUSIONS

Stigma, alienation, and existential loneliness when taken together provide an understanding of the multidimensional problem of social isolation for people with SMI.

PRACTICE IMPLICATIONS

Mental health services should be provided which take into account the importance of human contact and social connection for people who live with SMI. Services can be offered which are designed to develop social skills, as well as to create opportunities for social connection and community involvement.

Making God real and making God good: some mechanisms through which prayer may contribute to healing

Many social scientists attribute the health-giving properties of religious practice to social support. This paper argues that another mechanism may be a positive relationship with the supernatural, a proposal that builds upon anthropological accounts of symbolic healing. Such a mechanism depends upon the learned cultivation of the imagination and the capacity to make what is imagined more real and more good. This paper offers a theory of the way that prayer enables this process and provides some evidence, drawn from experimental and ethnographic work, for the claim that a relationship with a loving God, cultivated through the imagination in prayer, may contribute to good health and may contribute to healing in trauma and psychosis.

Social defeat in recovery-oriented supported housing: moral experience, stigma, and ideological resistance

Drawing from ethnographic observations and interview data gathered during 6 months working as a home caregiver at the Pinewood Apartments, a recovery-oriented supported housing community in Texas, I demonstrate how stigma and social defeat were moral and social processes that pervaded life for all involved, including service providers. Yet, because of the extreme power differentials that characterized tenant-staff relationships, the assault of stigma and social defeat was much more frequent, existentially intense, and morally and materially consequential for certain tenants, whose attempts at ideological resistance were delegitimized by service providers, including myself, who were backed by the authority of dominant psychiatric and moralistic discourses concerning the inherent irrationality and irresponsibility of people with severe mental illness. Nevertheless, due to the indeterminate and at times inharmonious nature of moral experience, it is not my intention to portray tenants as wholly defeated. Rather, individual tenants often exhibited defeat and resistance simultaneously.

Association between degrees of social defeat and themes of delusion in patients with schizophrenia from immigrant and ethnic minority backgrounds

Immigrants have a heightened risk of developing schizophrenia, suggesting that social factors play an important role in the pathogenesis of schizophrenia. This study aimed to examine the relationship between degrees of social defeat and themes of delusion in patients with schizophrenia from immigrant and ethnic minority backgrounds. Retrospective chart review was conducted. Patients' psychosocial history, particularly employment history, level of education, and subjective feelings of societal integration before and after immigration, were compared to determine the degree of social defeat. It was found that delusional themes of psychological persecution, such as control and reference, were more common in those with either moderate or severe degrees of social defeat.

The zone of social abandonment in cultural geography: on the street in the United States, inside the family in India

This essay examines the spaces across societies in which persons with severe mental illness lose meaningful social roles and are reduced to "bare life." Comparing ethnographic and interview data from the United States and India, we suggest that these processes of exclusion take place differently: on the street in the United States, and in the family household in India. We argue that cultural, historical, and economic factors determine which spaces become zones of social abandonment across societies. We compare strategies for managing and treating persons with psychosis across the United States and India, and demonstrate that the relative efficiency of state surveillance of populations and availability of public social and psychiatric services, the relative importance of family honor, the extent to which a culture of psychopharmaceutical use has penetrated social life, and other historical features, contribute to circumstances in which disordered Indian persons are more likely to be forcefully "hidden" in domestic space, whereas mentally ill persons in the United States are more likely to be expelled to the street. However, in all locations, social marginalization takes place by stripping away the subject's efficacy in social communication. That is, the socially "dead" lose communicative efficacy, a predicament, following Agamben, we describe as "bare voice."

"I want the one that will heal me completely so it won't come back again": the limits of antipsychotic medication in rural Ghana

Campaigns to scale up mental health services in low-income countries emphasise the need to improve access to psychotropic medication as part of effective treatment yet there is little acknowledgement of the limitations of psychotropic drugs as perceived by those who use them. This paper considers responses to treatment with antipsychotics by people with mental illness and their families in rural Ghana, drawing on an anthropological study of family experiences and help seeking for mental illness. Despite a perception among health workers that there was little popular awareness of biomedical treatment for mental disorders, psychiatric services had been used by almost all informants. However, in many cases antipsychotic treatment had been discontinued, even where it had been recognised to have beneficial effects such as controlling aggression or inducing sleep. Unpleasant side effects such as feelings of weakness and prolonged drowsiness conflicted with notions of health as strength and were seen to reduce the ability to work. The reduction of perceptual experiences such as visions was less valued than a return to social functioning. The failure of antipsychotics to achieve a permanent cure also cast doubt on their efficacy and strengthened suspicions of a spiritual illness which would resist medical treatment. These findings suggest that efforts to improve the treatment of mental disorders in low-income countries should take into account the limitations of antipsychotic drugs for those who use them and consider how local resources and concepts of recovery can be used to maximise treatment and support families.

Social defeat or social resistance? Reaction to fear of crime and violence among people with severe mental illness living in urban 'recovery communities'

This article is propelled by recent theory positing that 'social defeat' is a common experience for people with severe mental illness, potentially affecting course and outcome. The primary objective is to investigate how far fear of crime and violence contributes toward 'social defeat' among people with mental illness. This is done through examining 6 years of ethnographic data collected from a sample of urban-dwelling people with severe mental illness, all securely-housed in apartments located in small scale "recovery communities." Findings suggest that many participants living in the highest crime neighborhoods report that they deliberately restrict their temporal and spatial movement as a consequence of such crime. This hinders aspects of their recovery. Nevertheless, participants actively confront the nefarious affects of neighborhood crime by engaging in various empowering strategies of resistance. These include confronting disruptive people, fortifying homes, moving around the neighborhood in small groups and carrying objects such as umbrellas and canes that can be used in self-defense. Some reported that fear of crime directly contributed to the development of a rich and gratifying domestic life, centered on hospitality and religion. I conclude that participants partake in valiant and durable "social resistance," and may better be perceived as imaginative and resourceful resistors, rather than passive victims of "social defeat." An influential factor fostering such resistance is the "recovery community' itself, which creates secure and reliable housing within a micro-community in which participants could thrive.