Bad Souls: Madness and Responsibility in Modern Greeceby Elizabeth Anne Davis
Bad Souls is an ethnographic study of responsibility among psychiatric patients and their caregivers in Thrace, the northeastern borderland of Greece. Elizabeth Anne Davis examines responsibility in this rural region through the lens of national psychiatric reform, a process designed to shift treatment from custodial hospitals to outpatient settings./i>
Bad Souls is an ethnographic study of responsibility among psychiatric patients and their caregivers in Thrace, the northeastern borderland of Greece. Elizabeth Anne Davis examines responsibility in this rural region through the lens of national psychiatric reform, a process designed to shift treatment from custodial hospitals to outpatient settings. Challenged to help care for themselves, patients struggled to function in communities that often seemed as much sources of mental pathology as sites of refuge. Davis documents these patients' singular experience of community, and their ambivalent aspirations to health, as they grappled with new forms of autonomy and dependency introduced by psychiatric reform. Planned, funded, and overseen largely by the European Union, this "democratic experiment," one of many reforms adopted by Greece since its accession to the EU in the early 1980s, has led Greek citizens to question the state and its administration of human rights, social welfare, and education. Exploring the therapeutic dynamics of diagnosis, persuasion, healing, and failure in Greek psychiatry, Davis traces the terrains of truth, culture, and freedom that emerge from this questioning of the state at the borders of Europe.
"How to write a history of madness and a genealogy of ethics at the borders of Europe's psyche and within the complex confines of neoliberalism's demand that subjects govern themselves? Poetic in form and writing without ever loosening its grip of argument and analysis, Bad Souls is a searing ethnographic account of how mental health, Greek nationalism, and contemporary truth emerge in the fraught fault line between patients' struggles to maintain their minds and psychiatry’s struggle to maintain its therapeutic and diagnostic hold on the order of truth in the domain of the other."—Elizabeth A. Povinelli, author of Economies of Abandonment: Social Belonging and Endurance in Late Liberalism
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Bad SoulsMADNESS AND RESPONSIBILITY IN MODERN GREECE
By ELIZABETH ANNE DAVIS
Duke University PressCopyright © 2012 Duke University Press
All right reserved.
Chapter OneFalse Face
ON DIAGNOSIS AND METHOD
The process of mutually sustaining a definition of the situation in face-to-face interaction is socially organized through rules of relevance and irrelevance. These rules for the management of engrossment appear to be an insubstantial element of social life, a matter of courtesy, manners, and etiquette. But it is to these flimsy rules, and not to the unshaking character of the external world, that we owe our unshaking sense of realities. To be at ease in a situation is to be properly subject to these rules, entranced by the meanings they generate and stabilize; to be ill at ease means that one is ungrasped by immediate reality and that one loosens the grasp that others have of it. To be awkward or unkempt, to talk or move wrongly, is to be a dangerous giant, a destroyer of worlds. As every psychotic and comic ought to know, any accurately improper move can poke through the thin sleeve of immediate reality. —ERVING GOFFMAN, "Fun in Games"
On a late spring morning at the hospital in Alexandroupolis, I sat with Lina, a first- year psychiatric resident, and Dr. Angelidi, her supervisor, as they saw visitors to the outpatient clinic. A nurse called for the next patient, and two women entered the consultation room without a medical file that would indicate a history of treatment here. The older of the two, training her gaze at the floor rather than at the two doctors, did not speak as she awkwardly took a seat on the far side of their desk. Her young companion, when invited to join her, spoke out loudly: No, I'm not sick. Just write a paper [[TEXT NOT REPRODUCIBLE IN ASCII]] for this poor soul! They were seeking a certification of diagnosis ([TEXT NOT REPRODUCIBLE IN ASCII]).
Angelidi addressed the silent woman seated across from her: Tell me why you've come, dear. The young woman again spoke in her place, again loudly: Listen, first I'll talk, then you can talk. Lina shook her head and threw down her pen. They were off to a bad start.
Angelidi: Please sit down. I'm trying to talk to the patient.
Young woman (still standing): She doesn't talk. I told you, I'm doing the talking.
Lina (to the young woman): All right, then you can tell us what's wrong with the patient.
Young woman: She's sick [[TEXT NOT REPRODUCIBLE IN ASCII]] and she's stupid [[TEXT NOT REPRODUCIBLE IN ASCII]]. You give her a plate of food to eat and she just throws it on the floor. She can't do anything for herself.
Angelidi: But what's her diagnosis? What illness [[TEXT NOT REPRODUCIBLE IN ASCII]] does she have?
Young woman: I don't know. Look in her booklet and you'll see what medications she takes.
Angelidi: But that doesn't tell me what illness she has!
Young woman: Can't you tell from the medications?
Angelidi (reading through the prescription booklet): She sees a doctor at Komotini Hospital? Why didn't you take her there today?
Young woman: I don't know, I thought it was the same to come here.
Angelidi: No, it's not. The doctor in Komotini knows the patient already, and knows what illness she has. So that doctor can write her a paper with the diagnosis. I don't know her at all—I'd have to see her three more times before I could diagnose her for sure.
Young woman (pausing): Three more times we have to come back here?
Angelidi: It would be much easier for you to take her to her regular doctor in Komotini.
Young woman: Why can't you just write the paper for her? It wasn't easy for me to come here. This woman has no one, no family or friends to take care of her, she's poor, she has nothing. She's obviously very sick.
Angelidi: She may be sick, but I don't know how she's sick. That's what I have to write on the paper.
After another round of refusals, the two women left without a paper certifying the patient's diagnosis. Dr. Angelidi explained to me when they had gone that the young woman may have been attempting a scam: the patient, who was indeed "obviously sick," no doubt already had a certification from her doctor in Komotini. So maybe her friend was looking for another paper that she could put in a false name, Angelidi said. Then she could sell it, or use it herself, as a way to get disability income. For all parties to this encounter, diagnosis meant knowledge of disability, and thus official means for a patient who couldn't "do anything for herself" to earn support from the state. Withholding diagnosis was a way for Angelidi to avert deception on this score, even if the patient was, to her mind, legitimately ill. But while the conflict between the clinicians and the patient's advocate here may have arisen partly from this unspoken mistrust, it was elaborated in terms of incompatible conceptions of diagnosis. For Angelidi, diagnosis named a process of getting to know the patient over time, in order to determine the specific illness entity that disabled her. The young woman, by contrast, took diagnosis as knowledge of a general condition of illness: knowledge that could easily be deduced from medications, or from one look at the sick patient. This knowledge required an expert appraisal, but the young woman took that appraisal as a mere formality and an immediate entitlement for the patient.
Diagnosis derives from the Greek word diagignoskein (to discern, distinguish), comprising dia- (through) and gignoskein (to come to know, perceive): the art or act of identifying a disease from its signs and symptoms. In this section, I explore the manifold gnosis within diagnosis, and the arts of discernment on which that knowledge turned in the clinics of Thrace.
Games of Truth
In 1980, reflecting on the changing character of the social sciences "in recent years," Clifford Geertz named Erving Goffman the leader of a "swarm of scholars" contributing to "the game analogy" as an emerging genre of social theory. For Geertz, the versatile "gamelike conceptions of social life" that Goffman so voraciously deployed depended on a conception of social actors as strategists, committed to playing "enigmatical games whose structure is clear but whose point is not." It is this pointlessness that brought Geertz to discern, in Goffman's work, not only a nonhumanist approach but also a "radically unromantic vision of things, acrid and bleakly knowing ... but no less powerful for that."
Perhaps an unlikely comrade in other ways, Foucault meets Goffman on that terrain of games. He finds there a point that Geertz could not see in Goffman's depiction of social actors' "self-rewarding" submission to rules: namely, to maneuver around the effects of power on the field of truth. To an interviewer's question about access to "truth in the political sense," by which he meant a truth that, if aired, would break up the "blockages" of power, Foucault replied, "This is indeed a problem. After all, why truth? ... I think we are touching on a fundamental question here, what I would call the question for the West. How did it come about that all of Western culture began to revolve around this obligation of truth which has taken a lot of different forms? ... Things being as they are, nothing so far has shown that it is possible to define a strategy outside of this concern. It is within the field of obligation to truth that it is possible to move about in one way or another, sometimes against effects of domination which may be linked to structures of truth or institutions entrusted with truth." Foucault's response indicates that truth in the "political sense" that interests his interviewer promises only a delusory liberation from power. He proffers the alternative notion of truth as a game, radically circumscribed by its implication in power. He defines truth game as "a set of rules by which truth is produced ... a set of procedures that lead to a certain result, which, on the basis of its principles and rules of procedure, may be considered valid or invalid, winning or losing." Since there is no effective strategy of thought outside the "field of obligation to truth," critique can be achieved "only ... by playing a certain game of truth," but "differently," at a distance.
Likewise, truth games for Foucault are not just "concealed power relations"; thus one can examine power relations in the truth game of psychiatry, for example, without "impugning [its] scientific validity or therapeutic effectiveness." Rather than being falsified by its alliance with power, it is precisely in this alliance that truth becomes a strategic possibility. Foucault defines strategy as the rationality by which an end is sought; as the seeking of advantage in relation to an opponent's strategy; and as the means of obtaining victory, particularly when it is a matter of depriving an opponent of those means. These three definitions, he says, "come together in situations of confrontation—war or games." Since they are played according to rationalities, principles, and rules, I will observe—and this is a point about psychiatry that I will demonstrate ethnographically throughout this book—that if truth games, like wars, may be declared won or lost only once they are over, they can also be conducted badly and interminably.
In this book, I treat clinical diagnosis as a truth game, not only at the level of institutionally legitimized power indicated in Foucault's definition, but also at the level of confrontation between parties to the diagnostic encounter—a confrontation between discrepant strategies of truth. This second level of the truth game is the object of Pierre Bourdieu's theory of practice: a theory, as he proposes in The Logic of Practice, of "what it is to be 'native.'" This is to be the player of a game—to be engaged in the "real play of social practices" such as ritual, gift exchange, and work. Bourdieu mobilizes game-playing as a metaphor for the kind of knowledge employed in these practices, in order to evoke the "practical sense" manifested in a player's "skill, dexterity, delicacy, or savoir-faire" in a game, or the "feel for the game" implied by "native membership in a field." In "actual" games, like chess, he argues, the game is "clearly seen for what it is, an arbitrary social construct"; but in the social practices that he treats as metaphorical games, players remain unaware of the constructed nature of the stakes and presuppositions. Game-playing in this sense requires "self-deception" of a particular kind, which Bourdieu labels the illusio of the game—the player's interest, his or her investment in what is at stake, as opposed to the objective truth of the game's social function. Nativity entails having already passed through the gradual process of initiation by which the disposition to play the game is learned and its objective truth repressed. It means having a body that "takes metaphor seriously" and "believes in what it plays at."
Bourdieu's theory of practice as native game-playing is a sharp tool for analyzing the unconscious nature of strategy, without hypostatizing any particular unconscious—least of all, perhaps, the one modeled by psychoanalysis. This theory of practice makes sense of the fact that certain kinds of questions "never arise" when players are "caught up in the game." Questions about the coherence of the game, broached by contradictions between its theoretical and practical elements, remain unasked by players because they play the game over time, rather than within the totalizing temporality of the synchronic model. As opposed to this theoretical logic of the model, Bourdieu describes the logic of practice as "fuzzy," "convenient," "easy to master and use," "poor and economical": in the temporality of action, its loose and imperfect nature does not impeach its coherence. Theoretical questions about coherence are not, for Bourdieu, of the same order as those "excluded" as "unthinkable" by the logic of practice—those that expose the objective truth of the game, which is to say its social function, and the relations of domination hidden within it that naturalize and legitimize the strategies of the privileged.
In the next section, I turn to the former questions—those that "never arise" in practice—to analyze clinical diagnosis. My procedure is to discern the moral judgments expressed in diagnostic practice, as articulated by experts, and to assemble these judgments into something like a logic of the diagnostic truth game. This logic is a "common sense" that I believe clinicians, as its more privileged players, might recognize if asked, but that they are not disposed to articulate, since what this logic is transparent to is not their practice but my critical inquiry.
Yet this threshold of transparency is the point at which Bourdieu ceases to guide my approach to the practice of clinical diagnosis. For Bourdieu, practice itself and theoretical knowledge about practice occupy discrepant orders of logic. They may be reconciled only through the conceptual instrument of habitus—both the "embodied history" of practice and the "immanent law" that regulates and describes it functionally. 18 The moral judgments that I present in this text, on the other hand, are of the same logical order as the diagnostic practices in which they are embedded, as well as the order of my own analysis and the critical responses of patients. My position as an outside observer therefore does not confer an essentially special capacity to perceive the logic of this game. It is entirely possible for a player to see this logic at work in clinical practice, to assimilate it theoretically, and to speak with me about it. I imagine that such a conversation could take place without creating a logical impasse—and certainly without, as Bourdieu puts it, "totally breaking the spell" of practice.
Likewise, I cannot describe psychiatric practice as a habitus of "learned ignorance." This practice, like my own clinical work, is a matter of theoretical second-order reflection that participates in the development of theory about itself, and that is therefore permeable to reflection about it. What differentiates my intervention from the clinical practice of psychiatrists, then, is not a special claim to objective description, but rather its alliance to a different goal: not therapy, but critique.
It is in light of this transparency of practical logic to itself that I characterize the clinical encounter as a game—although not metaphorically, as Bourdieu would have it, since its constructedness is very much in play. This game does not exclude as "unthinkable" questions about its ultimate truth. In their everyday confrontation with patients, the clinicians I cite here were well aware of disputation over the truth of diagnosis, and thus over the legitimacy of their authority to practice it. Far from being uncritical automatons caught in illusio, these clinicians self-consciously operated in a space of play, where they occupied a variety of moral positions within and between partial regimes of truth. Like Quesalid, the unhappy shaman depicted by Claude Lévi-Strauss in "The Sorcerer and His Magic," they were ethically engaged in a conscious deliberation on the truth of their practice, often becoming convinced in the process of its efficacy, yet finally unable to determine their own good faith. They were aware that the apparatus of clinical diagnosis naturalized their privilege and authority, which arose from grounds additional to their mere expertise; and that the truths it yielded were inconclusive, unstable, and strategic. In practice, as I observed it, this awareness was voiced—not as transcendental truth, but as context-specific doubt—in consultations and arguments among clinicians, in their negotiations with patients, and in my conversations with them. It is this lack of scientific and moral certainty in the clinical orientation to truth—this witting absence of secure grounding, often expressed in the mode of irony—that leads me to view diagnosis as an "actual" game.
The practical logic of clinical diagnosis thus comprehends its own strategy, even as it reproduces that strategy. My attention to communicative disruptions in diagnostic encounters is intended to shed light on this double consciousness by which clinicians speak the discourse of truth while, in its margins, speaking a discourse of doubt. This double consciousness does, as Bourdieu predicts, yield an impasse—but this impasse is not located where he finds it, between theoretical and practical logic. Rather, as the renowned activist psychiatrist Franco Basaglia insisted, it resides in the "social fabric" and in the political economy that promote a humanitarian ethics for psychiatry but withhold the resources and confound the reorganization of governance that might allow this ethics to materialize in practice. As I showed in the prelude to this text, Greek psychiatrists perceive this impasse as a moral as well as a governmental deficit, expressed in a rhetoric of backwardness—a rhetoric that orients itself to the fantasy of truth symbolized by modern, Western, progressive medicine, and more specifically, by scientific advances in biopsychiatry.
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The critique of psychiatry as a discourse of truth is a fertile and crowded field, both within psychiatry itself and in associated disciplines in the social sciences. One approach, arising with the early phases of international psychiatric reform, voiced a denunciation of institutional psychiatry from a position of explicit moralism. The foundational thought of Basaglia in Italy, of R. D. Laing in Great Britain, and of Thomas Szasz in the United States, among others, sought to reveal the construction of psychiatric truth through coercive power, both to liberate patients from their institutional domination and to develop new therapeutic avenues to the truth of madness. In its more strident moments, this critique of psychiatry appears as precisely the sort of delusory emancipatory project that Foucault dismantles with his analytic device of the truth game. Goffman, in his work on asylums, redirects this critique toward a different objective: he evacuates the unmasking process of its therapeutic mandate, revealing the psychiatric institution as a field of power that mirrors social relations outside the institution, particularly hierarchical "service relations." But since mental illness, from this point of view, can only provide a framework for status-seeking strategies inside the institution, Goffman declines to account for madness as a question of truth.
Excerpted from Bad Souls by ELIZABETH ANNE DAVIS Copyright © 2012 by Duke University Press. Excerpted by permission of Duke University Press. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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Meet the Author
Elizabeth Anne Davis is Assistant Professor in the Department of Anthropology, in association with Hellenic Studies, at Princeton University.
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