Introduction to the Special Section: The Anthropology of Psychopharmaceuticals: Cultural and Pharmacological Efficacies in Context
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Psychopharmaceuticals have become a common means to treat mental distress in diverse contexts around the globe. In the past 20 years, the escalating global influence of biomedicine has led to the increasing presence of psychopharmaceuticals in the United States (Jenkins 2010a), Europe (Verdoux et al. 2008), Asia and the global south (Biehl 2010; Ecks 2010; Good 2010). Psychiatric drugs represent a multi-billion-dollar-a-year industry that promises to alleviate suffering (Petryna and Kleinman 2006) and, as part of the global economy, these drugs have transformed our sense of identity, agency, and affliction (Kirmayer and Raikhel 2009). While psychopharmaceutical interventions hold powerful promise for improving psychopathology, assessments of their successes or failures are ambiguous. Psychopharmaceutical treatments are not “magic bullet” cures, and each drug has multiple, potentially competing effects (Kirmayer and Raikhel 2009). These dynamics underscore the need to interrogate the meanings of psychopharmaceutical efficacy.
How is psychopharmaceutical efficacy defined, and by whom? How do individuals experience these drugs and interpret their effects in the contexts of their lives? Whyte et al. (2002b) stress that pharmaceutical treatments are “based on the principle that medicines have the same action in all patients: dosages are standardized … and the effects are considered to be universal. The underlying assumption is that biological bodies are the same in all settings, and that pharmacological action is located in the medical substance that is ingested” (33). Biomedicine generally considers the success of pharmacotherapies as based on pharmacological action, yet a significant and growing body of research reveals that pharmaceutical efficacy is not such a one-dimensional phenomenon, but is linked to multilevel, interwoven dimensions ranging from individual biology to sociocultural dynamics. Critiques of biologically reductionist orientations to psychopathology and its treatment stress that these approaches obscure matters central to illness experience, such as agency, morality, and social relationships (Jenkins 2010b). In response to these critiques, social scientists have increasingly explored psychopharmaceuticals in the complex, fluid contexts in which they exist and are ingested, contributing to understandings of the varied uses and experiences of these powerful agents.
Anthropological studies have been particularly central in describing the importance of context in shaping pharmaceutical efficacy. These studies reveal the ways in which diverse understandings of disease etiology and severity, healing processes, treatment modalities, and expected outcomes influence interpretations of pharmacologic interventions (Etkin 1988, 1992; Jenkins 2010a, b; Petryna and Kleinman 2006; Whyte et al. 2002). It is because of these complexities that there is a need for studies of psychopharmaceutical efficacy that pursue broad cultural analyses. However, such cultural analyses must not obscure lived experience. Biehl et al. (2007a) write that anthropology’s emphasis on cultural representation has minimized “the conceptual significance of lived experience, even when reports of experience are the major source of anthropological data” adding that, “a more substantial conceptualization of cultural experience is in order, one in which the collective and the individual are intertwined and run together and in which power and meaning are not placed in theoretical opposition but are shown to be intimately linked in an intersubjective matrix” (p. 14). Attention to the significance of lived experience of psychopharmaceutical use is particularly important, as this experience is one in which “nothing less than one’s view of self is at stake” (Karp 1996, p. 102). Yet, as Fox Keller (2007) stresses, we must also not ignore the biological body’s contributions to lived experience. These critiques underscore the need to understand psychopharmaceutical efficacy in relation to complex, interconnected biological, sociocultural, and structural factors that shape individuals’ responses to, and experiences and evaluations of, these drugs. Such a holistic perspective uncovers lived experiences of psychopharmaceutical use without isolating the biological body from cultural or structural realms.
The articles in this section contribute to this growing body of scholarship by exploring psychopharmaceutical efficacy using an anthropological lens. We emphasize the inter-connections between biology, sociocultural contexts, and structural dynamics. We explore how individual internal factors, psychosocial and cultural dimensions of everyday life, institutional power structures, and therapeutic paradigms and practices shape the lived experiences of persons taking these drugs. Through this lens, we expose the complex, contradictory, and often ambiguous nature of psychopharmaceutical effects. In this introduction we present an overview of the articles in this section, describing the novel ways that each author challenges narrow, pharmacologically reductionist notions of efficacy to illuminate how individuals experience and make sense of psychotropic drug use that is increasingly a part of people’s lives around the globe.
Background: Conversations on Meaning and Psychopharmaceutical Efficacy
The articles in this section represent the culmination of scholarship initially presented as part of The Anthropology of Psychopharmaceuticals: Cultural and Pharmacological Efficacies in Context panel at the Society for Psychological Anthropology’s 2011 Biennial Meeting. The conference theme, Subjects and their Milieux in Late Modernity: The Relevance of Psychological Anthropology to Contemporary Problems and Issues, inspired discussions of the increasing prominence of psychopharmaceuticals in mental health care and the complexities of the delivery and experience of this treatment. We explored how social forces that shape mental health care interact with individual characteristics and local contexts to influence the meanings of psychopharmaceuticals and their use for individuals who have much at stake in taking them, but whose experiences are often unknown or poorly understood. We were inspired by the power of psychological anthropology to bring to bear an experience-near approach and multi-level analysis to uncover the meanings of psychopharmaceutical use in the complex contexts in which psychiatric medication treatment occurs. Janis Jenkins’ scholarship stressing the dynamic reciprocal relationships between individual subjectivities and cultural imaginaries in the context of psychopharmaceutical use (Jenkins 1994, 2010a, b; Jenkins and Carpenter-Song 2005, 2008) inspired us to enlist her as discussant for the panel. It is Dr. Jenkins’ support and encouragement that ultimately compelled us to develop the papers presented at the conference into the articles published here.
Conversations on the complexities of psychopharmaceutical efficacy in dramatically distinct contexts—pharmacogenomics and ethnopharmacology (Ninnemann), co-occurring mental illness and heroin addiction (Schlosser and Hoffer), and psychiatric care in post-Socialist China (Ma)—uncovered fundamental questions in need of further exploration. In the following articles we strive to address these questions, asking: Who defines “efficacy” and by what criteria? How are interpretations of efficacy shaped by interconnected internal (e.g., biological) and external (e.g., sociocultural and structural) factors? and, How do the structural forces that shape everyday life influence the delivery and meaning of psychopharmaceutical treatment?
Interrogating Efficacy at the Nexus of Biological, Sociocultural, and Structural Dimensions
The three articles1 in this section each reveal diverse dimensions of these questions, challenging pharmacologically reductionist interpretations of efficacy. Through these critiques, the authors draw attention to how individuals experience psychotropic drugs at the intersection of biological, sociocultural, and structural influences that are too often considered in isolation.
Ninnemann’s “Variability in the Efficacy of Psychopharmaceuticals: Contributions from Pharmacogenomics, Ethnopsychopharmacology, and Psychological and Psychiatric Anthropologies” calls for anthropologically informed critiques of, and productive conversations with, the emerging fields of pharmacogenomics and ethnopsychopharmacology in response to the reification of pharmaceutical efficacy based on the assumed universal constancy of psychotropic medications. Ninnemann takes us to the frontiers of emergent genomic technologies in psychiatry that seek to find the “right” drug for the “right” patient at the “right” time (Reeder and Dickson 2003). Such individually tailored pharmacology is highly sought in contemporary psychiatric practice that is increasingly influenced by genomics, but too often overlooks the intricate and multifactorial connections between internal and external factors that shape drug effects. By drawing attention to the many environmental and cultural factors that interact with individual endogenous factors to shape psychopharmaceutical response, from diet to culturally specific measures of pharmacological efficacy (e.g., Hiyang in the Philippines), Ninnemann shows the complex, inter-connected links between genetic variability in the ability to metabolize psychotropic medications and environmental and sociocultural contexts that shape medication use and experience. These links necessitate anthropological understandings of efficacy that push beyond those centered on pharmacological action alone. Ninnemann challenges the fields of pharmacogenomics, ethnopsychopharmacology, and psychological and psychiatric anthropologies to move beyond disciplinary boundaries to understand both endogenous and exogenous factors influencing the use and experience of psychopharmaceuticals. Such a perspective demands that anthropologists and other social scientists attend to internal factors (e.g., genetic variability) that are often isolated from cultural analyses of psychopharmaceutical use and experience.
While Ninnemann provides a compelling argument for the need to integrate biological, environmental, and sociocultural contextual factors in interpreting psychopharmaceutical efficacy, Schlosser and Hoffer’s “The Psychotropic Self/Imaginary: Subjectivity and Psychopharmaceutical Use Among Heroin Users with Co-Occurring Mental Illness” and Ma’s “When Love Meets Drug: Pharmaceuticalizing Ambivalence in Post-Socialist China” present experience-near portraits of these dynamics through case studies that illuminate the intricacies of psychopharmaceutical effects.
By exploring psychotropic subjectivities of people managing co-occurring mental illness and addiction (CODs), Schlosser and Hoffer reveal interpretations of psychopharmaceutical efficacy that extend far beyond strictly pharmacological action. Subjectivity is complex, “neither reducible to the idea the person has of himself or herself nor necessarily an individual confrontation with the powers that be. Subjectivity is rather the material and means of a continuous process of experimentation—inner, familial, medico-scientific, and political” (Biehl et al. 2007b, p. 348). In addition, as we have stressed, the biological body contributes to subjectivity. Schlosser and Hoffer combine these orientations by drawing on the reciprocal psychopharmaceutical self/imaginary (Jenkins 2010a) to depict the nuance and complexity of psychopharmaceutical use among people with CODs, a highly vulnerable population that has gained significant concern from the psychiatric community for medication “non-compliance.” The experiences of people with CODs remind us that psychiatric medications do not exist in isolation from the myriad of other psychoactive substances increasingly present in cultural imaginaries and on the streets. Through the case of Susan, the authors describe how heroin addiction and its associated biological, sociocultural, and political-economic dynamics shape core conceptions of the “true,” “normal” self, making interpretations of psychotherapeutic efficacy and medication compliance evermore complex. Susan’s story reveals ongoing psychotropic drug experimentation within environments saturated with “good” medicines and “bad” drugs and cultural imaginaries that make drug self-modulation, and the hope for achieving one’s “true” self that it engenders, increasingly common. This analysis also underscores the inextricably entwined relationships between powerful biological realities of heroin addiction (e.g., tolerance and withdrawal) and structural forces (e.g., pharmaceuticalization and neoliberalism) that shape mental health treatment for individuals whose experiences are often alienated from biomedico-centric interpretations of psychopharmaceutical efficacy and medication “non-compliance.”
Biehl et al. (2007b) write that “life sciences and technologies are matters of intense negotiation; their local realizations are shaped by contingency, imagination, and uncertainty. Such realizations encode diverse economic and political interests as well as group and individual anxieties and desires” (344). Ma reveals these complex negotiations through the case of Mei, a woman psychiatric patient in post-socialist China. Mei’s story shows us that psychopharmaceutical efficacy must be understood not only as the product of pharmaceutical action, but also vis a vis changing socio-political contexts that shape individual anxieties and desires. By describing the ambivalent role that domestic intimacy holds in post-socialist China amidst rapid social change, Ma provides a window into the ways that shifting normative sociality shapes psychiatric care and the use and experience of psychopharmaceuticals. In this context, Ma asks, “Can pharmaceuticals, aside from affecting the individual’s body, generate interpersonal desire and transform intimacy?” Ma argues that socio-political life (bios) that conditions the expectation of constancy in intimate relationships, and the biological body (zoe) that drives the contingent desiring self, constitute and contradict one another in the socio-political context of post-socialist China shaped by biopsychiatry and neoliberalism. Here psychopharmaceuticals inhabit an ambivalent “zone of indistinction” (Agamben 1998) between bios and zoe. Mei, her intimate partner, and psychiatrists grapple in this zone as they engage with psychopharmaceutical treatment. The ways that these actors maneuver ambivalence in this zone reveal the multi-directionality of the biological body and socio-political life and both the somatizing and socializing potentials of pharmaceutical care. Thus, Ma cautions against focusing on “one way traffic” between the biological body and socio-political life and challenges us to resist traditional disciplinary orientations to confront complex bios-zoe tensions. Such endeavors will come closer to uncovering the meanings of psychopharmaceutical efficacy as experienced by individual biological bodies inextricably entwined with normative sociality in a world in flux.
In their work on subjectivity, Biehl et al. (2007a) emphasize that anthropological studies have repeatedly demonstrated the complexity of clinical psychiatric outcomes that are much more nuanced when “actually lived” as opposed to hypothesized and quantified (p. 12). In this section, we draw attention to the ways in which psychopharmaceuticals reflect and contribute to this complexity. Traditional approaches in biomedical psychiatry often regard individuals as static receptacles of drugs that are imbued with distinct and invariable pharmacological action and effects (Kirmayer and Raikhel 2009). However, the papers in this section expose considerable variation in individual responses to, and interpretations of, these drugs and their effects, demonstrating the multilayered and diverse sequelae of these powerful substances.
Using an anthropological lens, these papers highlight the ways in which psychopharmaceutical uses and effects interact with individual subjectivities. We demonstrate how such experiences are shaped by multiple factors ranging from individual biology to structural contexts. Ultimately, we aim to demonstrate how psychopharmaceutical drugs and their effects are experienced in real-world contexts, showing how, as Whyte et al. (2002b) stress, “different forms of efficacy, although distinguishable analytically, are experienced simultaneously … life is lived as a synthesis … Not only do efficacies tend to combine, but the acts of giving/taking medicine and looking to effects are integrated into the larger process of dealing with problems and living life” (36). The articles in this special section underscore the need to expand investigations of psychopharmaceutical efficacy beyond narrow, biologically reductionist definitions to understand psychotropic drug effects as complex, multi-layered phenomena. We urge scholars and practitioners to approach psychopharmaceutical efficacy with these complexities in mind, and to never neglect the lived experiences of individuals who take these powerful drugs.
The panel was comprised of five papers; two of these papers are not included in this section because they have previously been published in Culture, Medicine and Psychiatry. An article related to Stacey McKenna’s conference paper, “Social Problem vs. Cultural Symptom: The Construction of Amphetamine Use & Users in Popular Media,” was published in the March 2011 issue (McKenna 2011). McKenna’s conference paper explored the ways in which amphetamines are socially constructed in popular American fiction with methamphetamine users constructed as part of a social problem and prescription amphetamine (e.g., Ritalin, Adderall) users as symptoms of a culture of out control. McKenna’s paper added depth to our analysis of psychopharmaceutical efficacy by exploring how interpretations of drug users and drug effects are shaped not simply by a drug’s chemical composition and side and “sought” effects, but also by broader meanings of control, morality, and discipline. A similar version of Talia Weiner’s conference paper, “The (Un)managed Self: Paradoxical Forms of Agency in the Practice of Neurochemical Self-Management” was published in the December 2011 issue (Weiner 2011). Weiner’s conference paper explored the self-management practices of people with Bipolar Disorder and the possibilities for subjectivity and agency that are conditioned/foreclosed by psychiatry’s vision of the body as under the control of the intentional mind. This paper added depth to our conversation on the ways that therapeutic paradigms, and conceptions of the self based on these models, relate to the use of experience of psychopharmaceuticals.
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