Cultural and Political Ecologies of Persons, Families, and Psychotropics
The widespread dispensing of psychotropic medications is typically practised with the idea that these drugs, as bioactive compounds, do not require cultural consideration. Closer inspection shows that this is definitely not the case (Jenkins 2010; Ecks 2013; Ecks and Basu 2009; Basu 2014). First, there can be no doubt that psychopharmaceutical treatment concerns subjective experience and cultural interpretation of illness and healing. This necessitates treatment practices that are guided by a contemporary understanding of culture. What is therefore required is an appreciation of culture in non-reductive terms (Martinez 2000; Jenkins and Barrett 2004; Biehl et al. 2007; Parish 2008). Culture is not a factor, but rather a pervasive process at work in nearly every aspect of mental health and illness, including psychopharmaceuticals. As there are many definitions of culture, it is useful to provide our theoretical formulation of culture with attention to lived experience:
Culture is not a place or a people, not a fixed and coherent set of values, beliefs, or behaviors, but an orientation to being-in-the-world that is dynamically created and re-created in the process of social interaction and historical context. Culture has more to do with human processes of attention, perception, and meaning that shape personal and public spheres in a taken for granted manner. What do we pay attention to and how? What matters, and what does not? (Jenkins 2015a, p. 9)
This approach takes as fundamental the inevitability of multiple, competing perspectives (vs. one-sided accounts of “clinical facts” or “noncompliant patients,” for example). Attention to the multiplicity of perspectives leads to an appreciation of the reality that the experience of giving and taking medication is neither straightforward nor unilateral.
Second, anthropological attention to gender, class, and ethnicity is clearly integral to interpreting these perspectives. For example, appreciating gendered differences in a specific cultural environment is key for communicative clarity in healthcare encounters, as well as aetiology. Worldwide, women and girls disproportionately struggle daily against affronts to psychic integrity that may be conducive of serious conditions such as depression, trauma, and psychosis (Jenkins and DelVecchio Good 2014). These may also alter women’s ability to seek treatment. Likewise, class and socio-economic status are widely recognized as a social determinant of mental health status (WHO 2014). Ethnicity among low-income minorities in countries with vast economic inequality (such as in the United States or China, for example) is marked by a “greater exposure to racism and discrimination, violence, and poverty, all of which take a toll on mental health. Living in poverty has the most measurable impact on rates of mental illness. People in the lowest stratum of income, education, and occupation are about two to three times more likely than those in the highest stratum to have a mental disorder” (U.S. Surgeon General 2001; also discussed in Institute of Medicine 2013; Kleinman 1986; How et al. 2011). Understanding the toll that ethnicity and socioeconomic condition, like gender, take on persons’ capability to act, and designing GMH interventions with them in mind, will allow researchers and healthcare workers to provide treatment that persons have the power and desire to access.
Third, in-depth empirical attention to the perspectives of persons and families living with mental illness is a surprisingly neglected area of research (Jenkins and Karno 1992; Hinton et al. 2015); but, available ethnographic accounts show that these persons and their families are grappling with distressing conditions and the complexity of taking medications. They do so, by and large, with little clinical or social support. In both low- and high- resource settings, the taking of psychotropic drugs invariably entails considerable cultural conflict, social stigma, and paradox for persons and their families (Whyte et al. 2002; Jain and Jadhav 2009; Jenkins and Carpenter-Song 2005, 2008; Dumit 2012; Read 2012). Analytical attention to how these cultural forces impact the course and outcome of treatment will be critical to formulating successful GMH interventions.
Finally, patient-provider relationships are often culturally defined by power and embedded in hierarchical social relations of difference. Properly understood, prescribing and taking medication is as a collaborative undertaking that requires negotiation and renegotiation over time. Though not often practised, there are fruitful models to draw upon, such as those pioneered by Partners in Health (Farmer 2015; PIH.org) and the international Hearing Voices Movement (Woods et al. 2013); maximal healthcare efficacy in terms of psychopharmaceuticals requires maximal collaborative partnership. Yet, in terms of serious mental illness, GMH has little to show that would constitute the fruits of such a collaborative approach. Many GMH care providers and others believe that serious mental illness necessitates the use of psychotropics, and we do not dispute this claim. Yet, for psychopharmacological treatments to remain both valid and efficacious on a global scale, providers must work to transcend the notion that the primary “problem” is patient “compliance” or “adherence.” This simplistic view of a patient’s relationship with their medication fails to take into account their subjective illness experience, their interpretation of the problem, as well as their own agency and desired outcomes. When “compliance” and “adherence” are the starting points (and often the endpoints) in clinical thinking, it should be little wonder that they are also often the stopping point for patients in resource-poor and affluent settings alike. Without discounting the importance of adherence to psychopharmaceutical regimens, the giving and taking of medication would more productively be conceived as a collaborative process of engagement that only occurs as part of a cooperative effort based on engaged listening.
Thus, our research experience suggests that treatment via psychopharmaceuticals must be approached through a fine-tuned engagement that seeks to take into account (1) the social, cultural, and psychological contexts of mental illness and its treatment, and (2) the ecological features of environments with respect to socioeconomic and political conditions that may predispose persons to mental illness through entrapment in precarious situations. Our argument is that GMH must proceed with an understanding of these dual sets of intersecting factors bound together “extraordinary conditions” of affliction and precarity (Jenkins 2015a). We intend these observations to be a critical locus for making meaningful differences for the course and outcome of mental illnesses worldwide.