Open Encyclopedia of Anthropology - Drugs

Depression

Rebecca Tishler — Tue, 30 Mar 2021 18:40:59 +0000

Keio University & University of Edinburgh

Initially published 30 Mar 2021

Abstract:

Depression, which psychiatrists regard as a most common mental illness, has been examined by anthropologists especially closely since the 1980s. While most medical experts consider depression as a universal, neurobiological disease that requires a global public health intervention, anthropologists instead ask why the illness known in psychiatry as ‘depression’ appears to have been extremely rare in much of the world until very recently. They also investigate how a supposedly neurobiological disorder could possibly arise with increasing frequency in so many places in such a short time. Some anthropologists suggest that the apparent rise of depression is co-constituted by changes in diagnostic criteria, a medicalisation of normal distress, as well as the growing influence of the global pharmaceutical industry. They have questioned the assumption of a clear-cut border between normalcy and abnormalcy, illuminated depression’s social origins, and problematised the extension of medical power into spheres of life that used to lie beyond the reach of medicine. This entry shows how anthropologists investigated depression before and after its alleged global rise in the 1990s, and how this phenomenon can be understood as a cultural, historical product profoundly influenced by socioeconomic transformations of the current time.

Introduction

Depression, which psychiatrists define as a constellation of low energy, low self-worth, and low mood, has emerged as a global concern since the 1990s. Calculated in terms of disease burden through disability-adjusted life years (or DALYs), depression is deemed the world’s second most common disorder after cardiovascular disease (Murray et al. 2013). It reportedly affects more than 264 million people worldwide (Ritchie & Roser 2021). Most medical experts and epidemiologists consider depression to be a universal, neurobiological disease that requires a global public health intervention. Anthropologists, on the other hand, ask why the illness known in psychiatry as ‘depression’ appears to have been extremely rare in much of the world until very recently, and how a supposedly neurobiological disorder could possibly arise with increasing frequency in so many places in such a short time. Some anthropologists suggest that the apparent rise of depression is co-constituted by changes in diagnostic criteria, a medicalisation of normal distress, as well as the growing influence of the global pharmaceutical industry. Anthropologists tend to be critical of biologising perspectives that see moods and emotions as the same across the world, irrespective of cultural and social contexts (Ecks 2016).

This entry will survey some anthropological works on the subject before and after the alleged global rise of depression in the 1990s. The ascent of depression mirrors that of suicide, which was a global concern at the turn of the twentieth century, leading to its sustained epidemiological study and a theory of individual mental distress as a symptom of collective malady (Durkheim 1952 [1897]). The rise of depression at the turn of the twenty-first century has provided a fertile ground for new anthropological concepts and ethnographic approaches. This entry will show how anthropologists have frequently questioned the assumption of a clear-cut border between normalcy and abnormalcy, illuminated depression’s social origins, and problematised the extension of medical power into spheres of life that used to lie beyond the reach of medicine. Anthropologists tend to challenge biomedicine’s one-size-fits-all prescriptions for treatment and its underlying assumption that a person with symptoms of depression can be treated as an individualised and decontextualised being, cut off from social interactions and complex power relations (Kleinman & Good 1985). The entry also examines the historical implications of the current rise of depression by considering its relationship to wider socioeconomic transformations, including the neoliberalisation of selfhood.

Culture, gender, and situated biologies

If few psychiatrists dispute the universality of depression today, it was still a matter of debate in the mid-twentieth century, when the level of depression reported from most non-Western societies was low. Some psychiatrists even wondered if depression was a culture-bound Western illness, which they saw as reflecting a supposedly more mature and introspective Western self (see Littlewood & Dein 2000). This model of depression derives in part from the Western concept of melancholy that preceded it and that is rooted in Greco-Roman humoral medicine. Melancholy was not just a pathology, but was also seen as a source of reflexivity and creativity (Jackson 1986, Radden 2000). This line of thinking led some psychiatrists to assume that the relative lack of depression among non-Westerners was a sign of their immaturity and lack of insight, even a lack of Christian guilt, which made them immune to depression (see Littlewood & Dein 2000). One of them even echoed Jean-Jacques Rousseau's theme of ‘noble savages’ in claiming in a WHO report that Africans were not prone to depression because of their ‘lack of responsibility’ (Carrothers 1953, cited in Beiser 1985: 273).

Residue from these racialised and ethnocentric ideas continued to be found in later twentieth century psychological and psychiatric discussions that depicted Westerners as introspective and intellectually articulate ‘psychologisers’ and non-Westerners as unreflexive and more instinctual ‘somatizers’ (see White 1982). They explained the relative absence of depression among non-Westerners in terms of their alleged incapability in recognising psychological distress, which would instead be expressed as bodily symptoms (for criticism, see White 1982 and Kirmayer 1999; Ecks 2013, Kleinman & Good 1985). Women and the working class tended to be depicted as ‘somatizers’ well into the late-twentieth century (see Kirmayer 1999), speaking to the continuing presence of gender, class, and ethnicity biases in the psychiatric discourse about depression.

Anthropologists made a case against conventional psychiatry by arguing for the ‘work of culture’ (Obeyesekere 1985). They showed that local habits and traditions, such as Buddhism, can protect people from depression by transforming negative affect into publicly acceptable narratives and symbols. In an influential yet controversial article, Gananath Obeyesekere (1985) discussed the case of a Sri Lankan man whom psychiatrists would diagnose with depression but who, in a Buddhist context, was revered for achieving enlightenment because he saw the world as full of suffering. No society distinguishes categorically between mental illness and health (Keyes 1985). Sorrow and grief are often linked with inner depth and dignity, not pathology (also see Good, Good & Moradi 1985). Given these alternative perspectives of experiencing the world, some anthropologists argued that the high rate of depression in the US was a product of an American ethnopsychology that prioritises the constant pursuit of happiness as a basic aim of human existence (Lutz 1985).

One important instance of historical and regional variations of depression is its gender ratio. Although depression today is said to affect women twice as much as men, even in the West at the turn of the twentieth century, elite men used to be depicted as more prone to depression (as an illness of reflexivity) than women. For women, a diagnosis of hysteria was more likely (Showalter 1985; Raden 2000; see also Metzl 2003). Cultural perceptions of women in distress, and the ways in which people perceive and engage with these women, are associated with regional prevalence of depression, along with symptom-reporting and help-seeking behaviours. For example, postpartum depression is a major public health issue in the US and Europe, but it is not universally discussed or even recognised elsewhere. Anthropologists have found that a social and ritual structuring of the postpartum period protects women from depression. This structuring includes ‘1) protective measures and rituals reflecting the presumed vulnerability of the new mother; 2) social seclusion; 3) mandated rest; 4) assistance in tasks from relatives and mid-wives; and 5) social recognition through rituals, gifts, etc. of the new social status of the mother’ (Stern & Kruckman 1983: 1039). The authors also suggested that regional differences in prevalence might stem from the fact that most cases of postpartum depression are mild, not psychotic, and that such milder forms of depression are more easily shaped by cultural influences (Stern & Kruckman 1983).

In a study that introduced the influential concept of ‘local biologies’ (later redefined as ‘situated biologies’), Margaret Lock (1993) argued that experiences of disease and illness need to be understood as products of interplay between individual biology and sociocultural environment. Lock noted a statistical anomaly in the WHO’s cross-national depression survey, which reported that Japan not only showed lower rates of depression than its Western counterparts but that it was the only country included in the survey where slightly more men than women appeared to suffer from depression (Sartorius & WHO 1983). She explored this epidemiological puzzle by researching women at menopausal age in Japan and North America, and argued that an individual’s genetics, lifestyle (including diet), social environment, and culture interact to create vastly different experiences of aging. Combining epidemiological and ethnographic methodologies, Lock also showed that the lower rate of depression among menopausal Japanese women was because they did not recognise ‘depression’ as such, and regarded menopause as part of a natural aging process. Importantly, the women in Lock’s study, even those in trying socioeconomic circumstances, kept telling her that their suffering was insignificant, that they were even ‘fortunate’, when compared to their own mothers, who had survived WWII and its aftermath. This cultural, collective rendering of their suffering seemed to protect women from medicalisation, which would have turned natural processes of living and aging into matters for biomedical intervention.

The studies mentioned so far show that individual biologies are heterogeneous as they are formed out of particular local contexts, which also intersect with local politics of recognition and legitimisation of people’s distress. Examining how certain symptoms and certain types of suffering elicit more sympathy and concern from others, anthropologists help to explain differences in prevalence rates of depression as well as in health-seeking behaviours and care provision. In Lock’s study, for example, local politics that had an important, protective aspect for many women in distress also meant that the suffering of some other women, who did experience severe symptoms of menopause or depression, was often rendered invisible and left untreated, increasing their physiological and psychological pain. Given that cultural discourse can be a double-edged sword, anthropologists pay close attention to the fact that local forces do not have the same effects on all people. At the same time, reducing depression to these women’s physiological differences and/or neurochemical imbalances would be to omit, among other things, the socioeconomic environment and local gender politics that structure their distress in the first place^.[1]

Distress, misunderstandings, and the politics of psychiatry

Recognising that people in much of the world experience and express their distress by means other than the psychiatric concept of depression, anthropologists from the 1980s began employing the notion of ‘idioms of distress’ as culturally diverse ways of expressing psychosocial distress (Nichter 1981). This concept has proven highly productive for clinicians as well, as the term ‘idiom’ does not presuppose pathology and can be used to capture a wide range of local experiences, symptomatology, and help-seeking behaviours that might previously have gone unnoticed (see Lewis-Fernando & Kirmayer 2019). Mapping out regional idioms, anthropologists found depression-like experiences expressed in a wide range of descriptions of nervous conditions such as ‘nervos’ in South America, ‘nerve exhaustion’ in East Asia, as well as other psychophysiological idioms like ‘heart distress’ in the Middle East. They noted how common these depression-like symptoms were across cultures when they included somatic expressions of psychosocial distress, leading them to question the definition—based in Western psychiatry’s mind-body dualism—that defines depression predominantly as a disease of the mind (also see Marsella 1982, Kleinman 1988, Ecks 2021).

National politics and state medical systems also help shape distinctive forms of medicalisation. In a pioneering work on this topic, Arthur Kleinman’s ethnography of China (1986) showed how a particular Chinese usage of ‘neurasthenia’ (a psychiatric term for depression-like symptoms common at the turn of the twentieth century) emerged in the 1980s as part of a powerful, state-sanctioned discourse, unthreatening to the political status quo. Showing how people used this idiom to channel their anger against injustice suffered during and after the Cultural Revolution, Kleinman proposed an analysis of medicalisation that moved beyond the idea of a top-down process of labelling and social control by medical professionals. Instead, he demonstrated how medicalisation can be a bottom-up process, where people’s desire for social recognition of their suffering is intrinsically linked with state/biomedical legitimisation, which together produce an ambivalent form of liberation and empowerment for those in distress (cf. Yang 2018 on the official, individualising usage of ‘depression’ in China today).

Local notions of depression do not merely remain at the level of popular or folk knowledge but in fact shape and are shaped by professional psychiatry, which shows remarkable regional variation. This became apparent when a US-UK comparative study (Kendell et al. 1971) showed that, given the same set of symptoms, American psychiatrists were far more likely to diagnose schizophrenia while their British counterparts were more likely to diagnose manic-depression. Such differences in localised theories and practices are also expressed in the varying ‘prototypes’ of depression, or psychiatric ideas about what or who constitutes a ‘typical’ case (Young 1995). The typical subject of depression in Japanese psychiatric literature, which developed in close dialogue with the German psychiatric concept of typus melancholicus, has long been regarded as a burned-out white-collar worker, in sharp contrast to the North American psychoanalytic prototype of depression as an illness of melancholic housewives (Kitanaka 2012). Even at the level of hard scientific terms, depression is a malleable, multifaceted idea, and psychiatric language remains inextricable from the reality that it co-creates the illnesses it attempts to represent (Foucault 1973 [1961], Hacking 1999).

The heterogeneous nature of depression at the local level often goes unaddressed in biomedicine, in part due to the division between medical science and psychiatric practice (Young 1995, Luhrmann 2000). As Allan Young (1995) has shown, medical science, at its core, depends on a paradigmatic ‘style of reasoning’ (Hacking 1982) with a remarkably stable body of knowledge and ideologies about objectivity and universality; clinical medicine, on the other hand, remains protean and multiplicitous, working in tandem with local knowledge and discourse. A scientific style of reasoning provides practitioners with a sense of stability, order, and coherence via an understanding that not all scientific facts have equal ‘truth’ values (Gilbert & Mulkay 1984, Young 1995). Scientific psychiatry (i.e. research-based, academic psychiatry) emanates from only a handful of European and North American power centres and spreads to the ‘periphery’, while clinical psychiatry frequently remains a ‘local knowledge’, rarely traveling to the knowledge-production centres of scientific psychiatry (Cohen 1995). Communication is mostly unidirectional, and when medical science further distances the data from the world of local clinical practice, patients’ individual stories are replaced by fragments of voiceless material bodies in the laboratory. At this stage, the lack of dialogue between scientific psychiatry and local practice becomes more gravely problematic (Young 1995).

Given the power asymmetries in scientific psychiatry, ‘discovering’ depression in the non-West and imposing a decontextualised and universalised Western concept of depression on these societies may amount to a ‘category fallacy’. That is, it may give seemingly universal legitimacy to a culturally constructed concept and its use among those engaged in cross-cultural research (Kleinman 1977, Lutz 1985). Kleinman (1988) cites Obeyesekere (1985) in discussing the culture-bound syndrome among Southeast Asian men called dhat, a feared ‘semen loss’ that results in draining energy and weakness (Ecks 2013). Kleinman and Obeyesekere show how absurd it would seem to Westerners for psychiatry to adopt the concept, standardise it, train psychiatrists globally to correctly diagnose it, educate the public about it, and work with pharmaceutical companies to invent and market a drug for it. To most observers, this would create unnecessary anxiety and a desire for therapeutic treatment for an illness that does not exist as such. Yet when it comes to Western psychiatric concepts such as depression, a similar process is normalised and might even be praised as a form of medical humanitarianism. This is because depression is regarded by the Western psychiatric establishment as a ‘real’ phenomenon, but semen loss is not. Psychiatry has also been criticised for depending on databases mostly developed with and for the ‘mainstream population in Western societies’ (i.e. ‘middle class whites’) and naively applying it to all other people (Kleinman 1988: xii). Given such subtle but important power disparities, the anthropologist’s job is to attend to differences and ask how local knowledge is produced and what remains ‘local’, how local and global psychiatry might communicate with one another, and how local psychiatric concepts might influence the production of global and scientific psychiatric knowledge (Cohen 1995; also see Pentecost et al. forthcoming).

Globalised depression

Sensitivity to local differences has become more important than ever with the global rise of depression since the 1990s. Previously understood as a culture-bound syndrome of the West, depression has become regarded by many as a universal disease of epidemic proportions. This change was brought about partly by the broadening of the concept of depression in the DSM-III (The Diagnostic and Statistical Manual of Mental Disorders, Third Edition, published in 1980), the development and marketing of a new generation of antidepressants, and the movement for global mental health. As anthropologists working in places where depression used to be rare witnessed its sudden rise, they began documenting the ‘making of depression’ on the ground, or the process by which a constellation of low energy, low self-worth, and low mood comes to be regarded as a clinical symptom and then a disease. In analysing these processes, they have often used Ian Hacking's (1995) notion of a ‘looping effect’ in which people’s experience living with the label of depression alters how they experience the condition itself. As the label is more frequently applied, people appear to change in ways that affect both how depression is classified and how people describe and live with it (Hacking 1999). Such changes prompt us to wonder if psychiatric globalisation serves to erase regional theories and homogenises understandings of depression.

Initially, many social scientists, psychiatrists, and philosophers were particularly concerned about the global spread of antidepressants even to areas where depression had not been widely recognised. They noted that pharmaceutical companies carefully tailored their marketing strategies to cultural contexts by employing the most effective local idioms of distress in promoting antidepressants. Thus, they spoke of ‘mind food’ in India and of ‘a cold of the soul’ in Japan (Ecks 2013; Kirmayer 2004, Applbaum 2006). Critics worried that the aggressive marketing of pills like Prozac might serve to replace pre-existing local understandings with biomedicalised approaches to depression. This, they thought, might instil a concept of a neurochemical self (Rose 2007), making people think that ‘we are our brains’, possibly impoverishing our understanding of human nature (see Vidal & Ortega 2017; also see anthropological critiques of neurobiology and how to integrate it with an ecological perspective in Raikhel 2015). Such biological reductionism, occurring in the era of neoliberalism, might further create ‘happy’ productive workers, who voluntarily soothed their dissent with pills in exchange for the illusion of control.

However, anthropologists have since discovered that both lay people and diagnosed patients are usually not fully persuaded by such biological reductionism (Vidal & Ortega 2017, Elliott 2003). Therapeutic effects of drugs do not just rely on neurochemical change but also on cultural attitudes (Rose 2007: 100; Ecks forthcoming). While American discourse initially suggested that people could recover their ‘true selves’ through the use of antidepressant medications (Kramer 1993), in Argentina, antidepressants were offered as treatment for symptoms which were understood to be political and economic ills (Lakoff 2005). In India, psychiatrists linked antidepressants with widespread cultural notions around nutrition, digestion, and somatic balance, encouraging patients to see them as moner khabar (‘mind food’; Ecks 2013). In Pelotas, Brazil, economically-poorer youth tended to use antidepressants for longer periods and in a long-standing interpretive frame that encouraged them to subtly internalise the assumption that their psyches are inherently weak and immature. In contrast, middle-class youth used antidepressants to temporarily facilitate the crucial work of refashioning a resilient internal self. These different uses served to reinforce long-standing views of the psychological inferiority of marginalised populations (Béhague 2015). These wide-ranging discourses surrounding antidepressant use demonstrate that, despite its globalisation, depression continues to be a localised ‘polysemic symbol’ (Barrett 1988: 375) in which ‘various meanings and values are condensed into a syndrome’ (Lock & Nguyen 2010: 73).

Even in the US, where antidepressants like Prozac were initially hailed as magic happiness pills during the 1990s, scepticism grew about whether it was wise to even try to achieve such constant happiness. Leading psychiatrists began to debate whether the pharmaceuticalisation of everyday distress might render people less tolerant of negative emotions such as sorrow and grief, leading to what Allen Frances, the chairman of DSM-IV, called the ‘loss of sadness’ (Frances 2013). Many critics are concerned about how the loss of what was previously considered ‘normal’ sadness could weaken the traditional resources people have used to confront hardship or loss (for example Elliott & Chambers 2004). This debate was heightened when a crucial clause in the DSM-5, which used to make an exception for bereavement in the diagnosis of depressive disorder, was altered. Since 2013, even people dealing with a loved one's death can receive a diagnosis of depression (Ecks forthcoming). As Kleinman and others have argued, no reliable scientific evidence exists that can determine how long a 'normal' bereavement period should be (Kleinman 2012). These psychiatrists warn that when even grief is made an object of pharmaceutical intervention, resulting social pressure means pharmaceutical treatment of depression is normalised.

The recognition of the limitation of pharmaceutical cures has led to the flourishing of other psychosocial interventions and local reflections about the nature of depression. In post-dictatorship Chile, both antidepressants and group psychotherapies are offered to the poor as part of the National Depression Treatment Program, aimed to combat the world’s second highest prevalence of depression. Clara Han (2012) shows, however, that women living in poverty see such neuropsychological intervention as little more than a temporary respite with little efficacy for solving their everyday struggles. As these women bear the burden of redeeming themselves both from the nation’s traumatic past and the economic precarity brought on by radical monetary policies, they discuss depression as embodying the interconnectedness of domestic troubles, debts, and social insecurity, problems for which neuropsychology has little to offer (Han 2012). Similarly, in Iran, depression has served as an idiom for working through generational traumas, where the past memories of the revolution and international conflicts are woven together to express today’s collective and personal predicaments (Behrouzan 2016). The rise of psychotherapy in Mexico (Duncan 2018) and China (Zhang 2020) since the 2000s has helped cultivate people’s desire for an ‘entrepreneurial self’, even as it seems to also generate a space for reflecting on the psychological toll that this new self may bring. These regional discourses about depression suggest that medicalisation can provide a ‘structural possibility’ (Corin 1998) for people to detach from and reflect on pathogenic cultural expectations and to effect important social transformations.

Signs of profound structural changes can be found in areas where depression has been widely debated as an illness of labour and a problem of productivity at the national level (on economy and depression, see the classic sociological work by Brown & Harris (1978). The increasing number of distressed workers in Finland sparked a public concern as it was seen as a sign of the decline of the welfare state (Funahashi 2021). A diagnosis of depression has become a weapon of the weak for signalling their socioeconomic precarity and social pathology in Italy, where the debate about workplace bullying and workers’ psychopathology, including depression, arose. As people place the blame on neoliberalism, which they see as destroying their culture of safeguarded work, ‘mobbing experts’ are engaged to diagnose and intervene into the high stress level of the workplace, paving a way for a solution at an organisational, structural level (Mole 2010). The national debate regarding ‘overwork depression’ and ‘overwork suicide’ in Japan has turned these diagnoses into powerful tools workers and families can use to highlight the dire cost of work stress and emotional labour on their health. After medico-legal debates about the exact cause of depression—whether it is a problem of workers’ neuropsychological vulnerability or a pathogenic environment—the government has changed labour policies to remedy the psychologically toxic work environment. At the same time, work is seen as both a cause and a cure for depression, as new forms of surveillance technologies and occupational therapies have emerged as ways for managing and recovering the depressed (Kitanaka 2012; also see Bowen forthcoming on the near-absence of depression among ‘occupational mental disorders’ in Chile).

Global therapeutics: quantified selves, resilience, and anonymous care

The advent of digital psychiatry is shaping a global platform for the prevention of depression. This also raises concerns about novel forms of biomedical surveillance. While recording one’s moods has long been part of a psychiatric treatment for depression (Martin 2007), the accessibility of digital technologies today is encouraging more and more people to keep track of their biorhythms, cognitive patterns, behavioural habits, and moods (Ecks forthcoming). Digitalised neuropsychological management and interventions now include computer software that can quantify stress via heart rate through interaction with input devices. These prevention and early intervention technologies expand the number of people who begin to identify with the idea of the ‘quantified self’, which refers to both self-tracking technology and the community of users of such tools (Lupton 2016). While these tools can be empowering for those who want to be in control of their own health, such technologies might have the effect of taking depressed people out of the emotional realm and the particular social contexts where they feel their symptoms, and relocate them to the public, quantifiable realm of human engineering and rational management (Kitanaka 2015). Compared to previous forms of therapeutics technologies that often incorporate historical reflections on the nature of one’s predicament, these digitalised systems of state/corporate/market ‘care of the self’ (Foucault 1990, Foucault et al. 1988) are far from engaging with social origins of depression and largely remain at the level of merely encouraging individual transformation (cf. Borovoy & Zhang 2017). The spread of such therapeutic/surveillance technologies prompts us to ask whether they will end up reshaping social understandings of depression within the discursive limits of biopsychiatry, with its tendency to depoliticise illnesses and promote ideologies of individual responsibility and commodified health (cf. Comaroff 1982, Gordon 1988; also see Lovell & Susser 2014.).

Enhancement technologies for the depressed are another facet of emerging global therapeutics. To keep patients from developing depression and to help them recover from it, medical professionals based in the world’s power centres increasingly emphasise resilience, a seemingly benign concept, as well as ‘resilience training’, with the stated aim of rendering people better able to handle stress. Particularly in the US, the military promotes positive psychology through resilience training and encourages soldiers to adopt a positive attitude as a tool for becoming more psychologically ‘fit’ (MacLeish 2013). Resilience glamorises the individual’s transcendental power, which creates a potent lure for adopters. At the same time, it renders people’s ability to independently recover from distress and live healthy lives into a therapeutically managed process. Young points out that handling everyday stress is being redefined as ‘something to be achieved with the help of experts’, so much so that resilience might, before long, ‘displace effortless “normality” as the default condition of human life’ (2012, 2014). Emily Martin (2007) shows how even mania, the opposite pole of depression, is now fetishised and commodified in corporate America as a source of creativity and high productivity. As some companies offer training to boost both one’s manic power while maintaining healthy mood cycles, mood disorders like depression may become an entry point to one’s subjectivity for experts promoting the further corporatisation of psychological health (also see Chua (2011) on resilience training for suicidal youths in Kerala).

As suicide is said to kill one person every 40 seconds,^[2] treating depression as a way of preventing suicide has also become an urgent global issue. Globalising suicide prevention programs often take a universal form, despite the fact that their efficacy at the local level is often left unexamined. Problematising this and illuminating the high rates of suicide in the Canadian Arctic, Lisa Stevenson (2014) investigates the persistently high rate of suicide among Inuit youths, in particular, despite all the care that is given to them. Going beyond psychiatric conceptualisations of suicide and tracing Canada’s history of ‘welfare colonialism’, she identifies one problematic factor in care services driven by mechanical, bureaucratic rationality—what Stevenson refers to as ‘anonymous care’—whereby ‘it doesn’t matter who you are, just that you stay alive’ (Stevenson 2014: 7, emphasis in original). Questioning this form of humanitarianism, she criticises the global suicide prevention programs that seek to define at-risk populations and provide a set of protocols that would enable volunteer carers to deal with suicidal individuals at a distance, without needing to invest themselves in the specificity of those individuals’ suffering. The distance and anonymity afforded through this approach provides a certain freedom for both parties, but it also renders the suffering individual into a depersonalised ‘case’. Stevenson discusses how these Inuit youths, a group all too often regarded as a ‘problem’ to begin with and who are ultimately not well served by the humanitarian care provided to them, come to see in suicide a ‘leap into another way of being in time’ (Stevenson 2014: 147)—and asks how they can begin to reconstruct themselves in an alternative regime of life, one that recognises other ways of living and dying (also see O’Nell 1996; Davis 2012, Garcia 2010, Meyers 2013).

Depression and neoliberal selfhood

In asking what might be the universal implications of the global spread of depression, let us take a step back and ponder the broader historical meaning of the rise of the neuropsychological management of the self. Sociologist Alain Ehrenberg (2010) argues that depression is the typical disorder of the current era. Ehrenberg’s analysis focuses on understandings of mental illnesses from the 1900s to the 2000s. Social relations have changed from more hierarchical to more egalitarian, with a more equal distribution of wealth and status. In the 1900s, the prototypical mental conflicts came from struggles with authority and from deviance from clearly defined social norms. Conflicts lay between people. Since the second half of the twentieth century, flattening social hierarchies enhanced inner conflicts about motivation and decisiveness. Since then, conflicts lie within people's own selves. Ehrenberg describes how, today, all decision-making has to be done by oneself, within oneself. In other words, the rise of depression has to do with this fatigued self at a time one has to make so many decisions (Ehrenberg 2010: 223).

Building on Ehrenberg’s argument, Stefan Ecks (forthcoming) analyses the new regime of ‘neoliberal self’ that serves to extend market competition within the self. According to Ecks, neoliberalism accelerates the dual process of fewer social distinctions coupled with an intensified drive at self-enhancement and becoming an entrepreneur. In earlier forms of capitalism, the goal of all this striving was the accumulation of capital through ascetic self-denial (Weber 2010 [1904/05]). In neoliberalism, the goal is not self-denial but self-satisfaction, even its maximisation. Homo economicus replaces outside partners of exchange with his own inner self (Foucault 2008: 226; Rose 1990; Brijnath & Antoniades 2016; Hardt & Negri 2017; Martin 2007). As the self takes itself as its own competitor in a market for getting the best deal from every moment of life (Scharff 2016), this creates a pathogenic condition where one feels that one can never do enough, never improve enough. Slow or stalled decision-making becomes a dreaded symptom; inability to act becomes a pathology of the current era (Leykin & DeRubeis 2010), which may have contributed to the global rise of depression.

The global desire for therapeutics from depression is thus a search for a new form of psychological governance. Ecks (forthcoming) argues how depression’s main symptoms—of devaluing oneself, devaluing one’s life possibilities, and having no motivation or energy to enhance life—all go together in this new regime of self. He points out that, just as much as sadness, depression is associated with being numb and without emotional sensitivity. As emotions guide decisions, they literally move the person ‘out’ from where they are. The numbing of emotions makes deciding harder, not easier. To live is to value, and to value means to feel, with the whole body, that one thing is better than another thing (Ecks forthcoming). The numbness of emotion is also another symptom, where affective indifference can lead to indecisiveness (Ratcliff 2015). Thus a recovery from depression involves recovering emotions, and all forms of therapy involve giving people the belief that they can heal and that alternatives to the current impasse exist (Csordas 2002; Hinton & Kirmayer 2017). As the feeling of hopelessness is related to not being able to imagine a better future, or to believe that improvement could be possible, recovering from depression means regaining the ability to see different possibilities for action as possible. How such therapeutics can be made available is a question that needs further investigation.

Conclusion

The global medicalisation of the concept of depression points to the ‘maximum universality’ of depression, whereby it has become an object of biopsychological, scientific investigation. At the same time, it highlights depression’s extreme heterogeneity (Ehrenberg 2010: 74). As a result of the plasticity of the notion of depression, it has been subjected to widely varying local interpretations and responses. Psychiatry has largely aligned itself with the universalist stance, emphasising genetic and neurobiological research and promoting methodological individual reductionism. Anthropology, in contrast, illuminates the vast variation of depression experiences across time and space, thereby providing a key counterpoint to reductionistic psychiatric views on causality and personhood (Kleiman 1988, Kirmayer 1999). The fact that biomedicine as a whole has shifted away from simplistic models of genetic determinism (Lock & Pálsson 2016, Rose 2018) suggests possibilities for collaborative engagement between psychiatry and anthropology that may encompass both biological and sociocultural views of depression (Kirmayer et al. 2015).

Anthropologists, with their historically strong interest in local life worlds and native points of view, have shed light on dimensions of depression that may not be easily accessible through a psychiatric lens. Such perspectives are becoming more important than ever given the politics of medicalisation today, as a multiplicity of social actors and institutions including psychiatrists, lawmakers, governments, pharmaceutical companies, and NGOs all exert their own ideas as to the nature of depression and how best to respond to it. This heterogeneity of views on depression—and indeed on human nature—provide the backdrop to anthropological research on the subject that is at once multifaceted and nuanced. As depression allows no easy answers to questions about its causality or effective cures but seems to touch more and more people as part of the spread of capitalism, it will continue to be an important focus for further investigation and ethnographic engagement.

Note

Parts of this paper are adopted from Kitanaka (2012). Junko Kitanaka’s further research was funded by JSPS Grant-in-Aid for Scientific Research (C) 19K01205.

References

Applbaum, K. 2006. Educating for global mental health: the adoption of SSRIs in Japan. In Global pharmaceuticals: ethics, markets, practices (ed.) A. Petryna, A. Lakoff & A.Kleinman, 85-110. Durham, N.C.: Duke University Press.

Barrett R.J. 1988. Interpretations of schizophrenia. Culture, Medicine and Psychiatry 12, 357-88.

Béhague, D.P. 2015. Taking pills for developmental ails in Southern Brazil: the biologization of adolescence? Social Science & Medicine 143, 320-8

Behrouzan, O. 2016. Prozak diaries: psychiatry and generational memory in Iran. Redwood City: Stanford University Press.

Beiser, M. 1985. A study of depression among traditional Africans, urban North Americans, and Southeast Asian refugees. In Culture and depression: studies in the anthropology and cross-cultural psychiatry of affect and disorder (ed.) A. Kleinman, B.J. Good & B. Good, 272-98. London: University of California Press.

Borovoy, A. & L. Zhang 2017. Between biopolitical governance and care: rethinking health, selfhood, and social welfare in East Asia. Medical Anthropology 36(1), 1-5.

Bowen, S. Forthcoming. Depression and (expert) culture: psychiatric, regulatory, and moral frameworks underpinning the absence of depression in occupational health in Chile. In Etiopathogenic theories and models in depression (eds) J.P. Jiménez, A. Botto & P. Fonagy. New York: Springer.

Brijnath, B. & J. Antoniades 2016. “I'm running my depression:” self-management of depression in neoliberal Australia. Social Science & Medicine 152, 1-8.

Brown, G.W. & Harris, T.O. 1978. Social origins of depression: a study of psychiatric disorder in women (1^st American ed.). New York: Free Press.

Chua, J. 2011. Making time for the children: self-temporalization and the cultivation of the antisuicidal subject in South India. Cultural Anthropology 26(1), 112-37.

Cohen, L. 1995. The epistemological carnival: meditations on disciplinary intentionality and Ayurveda. In Knowledge and the scholarly medical traditions (ed.) D. Bates, 320-44. Cambridge: University Press.

Comaroff, J. 1982. Medicine: symbol and ideology. In The problem of medical knowledge (ed.) P. Wright & A. Treacher, 49-69. Edinburgh: University Press.

Corin, E. 1998. The thickness of being: intentional worlds, strategies of identity and experience among schizophrenics. Psychiatry 61(2), 133-46.

Csordas, T. 2002. Body, meaning, healing. Houndsmills: Palgrave Macmillan.

Davis, E.A. 2012. Bad souls: madness and responsibility in modern Greece. Durham, N.C.: Duke University Press.

Duncan, W.L. 2018. Transforming therapy: mental health practice and cultural change in Mexico. Nashville: Vanderbilt University Press.

Durkheim, E. 1952 [1897]. Suicide: a study in sociology (trans. J.A. Spaulding & G. Simpson). London: Routledge & Kegan Paul.

Ecks, S. 2013. Eating drugs: psychopharmaceutical pluralism in India. New York: University Press.

——— 2016. Ethnographic critiques of global mental health. Transcultural Psychiatry 53, 804-8.

——— 2021. Depression, deprivation, and dysbiosis: polyiatrogenesis in multiple chronic illnesses. Culture, Medicine and Psychiatry (available on-line: https://doi.org/10.1007/s11013-020-09699-x).

——— forthcoming (2022). Living worth: value in global mood medication markets. Durham, N.C.: Duke University Press.

Ehrenberg, A. 2010. The weariness of the self: diagnosing the history of depression in the contemporary age. Montreal: McGill-Queen’s University Press.

Elliott, C. 2003. Better than well: American medicine meets the American dream. New York: Norton.

——— & T. Chambers. 2004. Prozac as a way of life. Chapel Hill: University of North Carolina Press.

Foucault, M. 1973 [1961]. Madness and civilization: a history of insanity in the age of reason (trans. R. Howard). New York: Vintage.

——— 1990. The history of sexuality III: the care of the self (trans. R. Hurley). New York: Vintage.

——— 2008. The birth of biopolitics: lectures at the Collège de France, 1978-1979. Houndmills: Palgrave Macmillan.

———, L.H. Martin, H. Gutman & P.H. Hutton 1988. Technologies of the self: a seminar with Michel Foucault. Amherst: University of Massachusetts Press.

Frances, A. 2013. Saving normal: an insider’s revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma, and the medicalization of ordinary life. New York: Morrow.

Funahashi, D. 2021. Untimely sacrifices: death and work in Finland. Ithaca, N.Y.: Cornell University Press.

Garcia, A. 2010. The pastoral clinic: addiction and dispossession along the Rio Grande. Berkeley: University of California Press.

Gilbert, G.N. & M. Mulkay 1984. Opening Pandora’s box: a sociological analysis of scientists’ discourse. Cambridge: University Press.

Good, B.J., M.J. Good & R. Moradi 1985. The interpretation of Iranian depressive illness and dysphoric affect. In Culture and depression: studies in the anthropology and cross-cultural psychiatry of affect and disorder (eds) A. Kleinman & B.J. Good, 369-428. Berkeley: University of California Press.

Gordon D.R. 1988. Tenacious assumptions in western medicine. In Biomedicine examined (Culture, illness, and healing: studies in comparative cross-cultural research, vol. 4) (eds) M. Lock & D. Gordon, 15-69. Dordrecht: Springer.

Hacking, I. 1982. Language, truth and reason. In Rationality and relativism (eds) M. Hollis & S. Lukes, 48-66. Oxford: Blackwell.

——— 1995. The looping effects of human kinds. In Symposia of the Fyssen Foundation. Causal cognition: A multidisciplinary debate (eds) D. Sperber, D. Premack & A.J. Premack, 351-94. Oxford: University Press.

——— 1999. The social construction of what? Cambridge, Mass.: Harvard University Press.

——— 2002. Historical ontology. Cambridge, Mass.: Harvard University Press.

Han, C. 2012. Life in debt: times of care and violence in neoliberal Chile. Berkeley: University of California Press.

Hardt, M. & A. Negri 2017. Assembly. Oxford: University Press.

Hinton, D.E. & L.J. Kirmayer 2017. The flexibility hypothesis of healing. Culture, Medicine, and Psychiatry 41(1), 3-34.

Jackson, S.W. 1986. Melancholia and depression: from Hippocratic times to modern times. New Haven: Yale University Press.

Kendell R.E., J.E. Cooper, A.J. Gourlay, J.R.M. Copeland, L. Sharpe & B.J. Gurland 1971. Diagnostic criteria of American and British psychiatrists. Archives of General Psychiatry 25(2), 123-30.

Keyes, C.F. 1985. The interpretive basis of depression. In Culture and depression: studies in the anthropology and cross-cultural psychiatry of affect and disorder (eds) A. Kleinman, B.J. Good & B. Good, 153-74. Berkeley: University of California Press.

Kirmayer, L.J. 1999. Rhetorics of the body: medically unexplained symptoms in sociocultural perspective. In Somatoform disorders: a world wide perspective (ed.) Y. Ono, 271-86. Tokyo: Springer.

——— 2004. The sound of one hand clapping: listening to Prozac in Japan. In Prozac as a way of life (eds) C. Elliott & T. Chambers, 164-93. Chapel Hill: University of North Carolina Press.

———, R. Lemelson & C.A. Cummings 2015. Re-visioning psychiatry: cultural phenomenology, critical neuroscience, and global mental health. New York: Cambridge University Press.

Kitanaka, J. 2012. Depression in Japan: psychiatric cures for a society in distress. Princeton: University Press.

——— 2015. The rebirth of secrets and the new care of the self in depressed Japan. Current Anthropology 56(12), S251-S262.

Kleinman, A. 1977. Depression, somatization and the “new cross-cultural psychiatry.” Social Science & Medicine 11(1), 3-9.

——— 1986. Social origins of distress and disease: depression, neurasthenia, and pain in modern China. New Haven: Yale University Press.

——— 1988. Rethinking psychiatry: from cultural category to personal experience. New York: Free Press.

——— 2012. Culture, bereavement, and psychiatry. The Lancet 379(9816), 608-9.

——— & B. Good 1985. Culture and depression: studies in the anthropology and cross-cultural psychiatry of affect and disorder. Berkeley: University of California Press.

Kramer, P.D. 1993. Listening to Prozac. New York: Penguin Books.

Lakoff, A. 2005. Pharmaceutical reason: knowledge and value in global psychiatry. Cambridge: University Press.

Leykin, Y. & R.J. DeRubeis 2010. Decision-making styles and depressive symptomatology. Judgment and Decision Making 5, 506-15.

Lewis-Fernández, R. & L.J. Kirmayer 2019. Cultural concepts of distress and psychiatric disorders: understanding symptom experience and expression in context. Transcultural Psychiatry 56(4), 786-803.

Littlewood, R. & S. Dein 2000. Cultural psychiatry and medical anthropology: an introduction and reader. London: Athlone Press.

Lock, M. 1993. Encounters with aging: mythologies of menopause in Japan and North America. Berkeley: University of California Press.

——— & V. Nguyen 2010. An anthropology of biomedicine. Hoboken, N.J.: John Wiley & Sons, Inc.

——— & G. Pálsson 2016. Can science resolve the nature/nurture debate? Cambridge: Polity Press.

Lovell, A. & E. Susser 2014. What might be a history of psychiatric epidemiology? Towards a social history and conceptual account. International Journal of Epidemiology 43(Supplement 1), i1-i5.

Luhrmann, T.M. 2000. Of two minds: the growing disorder in American psychiatry. New York: Knopf.

Lupton, D. 2016. The quantified self. Malden, Mass.: Polity Press.

Lutz, C. 1985. Depression and the translation of emotional worlds. In Culture and depression: studies in the anthropology and cross-cultural psychiatry of affect and disorder (eds) A. Kleinman, B.J. Good & B. Good, 63-100. London: University of California Press.

MacLeish, K. 2013. Making war at Fort Hood: life and uncertainty in a military community. Princeton: University Press.

Marsella, A.J. 1982. Culture and mental health: an overview. In Cultural conceptions of mental health and therapy (Culture, illness, and healing: studies in comparative cross-cultural research, vol. 4) (eds) A.J. Marsella & G.M. White. Dordrecht: Springer.

Martin, E. 2007. Bipolar expeditions: mania and depression in American culture. Princeton: University Press.

Metzl, J. 2003. Prozac on the couch: prescribing gender in the era of wonder drugs. Durham, N.C.: Duke University Press.

Meyers, T. 2013. The clinic and elsewhere: addiction, adolescents, and the afterlife of therapy. Seattle: University of Washington Press.

Mole, N. 2010. Labor disorders in neoliberal Italy: mobbing, well-being, and the workplace. Bloomington: Indiana University Press.

Murray, C. J., A.D. Lopez & World Health Organization 1996. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020: summary (available on-line: https://apps.who.int/iris/bitstream/handle/10665/41864/0965546608_eng.pdf?sequence=1&isAllowed=y). Accessed 9 October 2019.

Neitzke, A.B. 2016. An illness of power: gender and the social causes of depression. Culture, Medicine and Psychiatry 40, 59-73.

Nichter, M. 1981. Idioms of distress: alternatives in the expression of psychosocial distress: a case study from South India. Culture, Medicine and Psychiatry 5, 379–408.

O'Nell, T.D. 1996. Disciplined hearts: history, identity, and depression in an American Indian community. Berkeley: University of California Press.

Obeyesekere, G. 1985. Depression, Buddhism, and the work of culture in Sri Lanka. In Culture and depression: studies in the anthropology and cross-cultural psychiatry of affect and disorder (eds) A. Kleinman & B. Good, 134-52. Berkeley: University of California Press.

Pentecost M. et al. Forthcoming. Global Social Medicine: Series Introduction. The Lancet.

Radden, J. 2000. The nature of melancholy: from Aristotle to Kristeva. New York: Oxford University Press.

Raikhel, E. 2015. From the brain disease model to ecologies of addiction. In Revisioning psychiatry: cultural phenomenology, critical neuroscience, and global mental health (eds) L. Kirmayer, R. Lemelson & C. Cummings, 375-99. Cambridge: University Press.

Ratcliffe, M. 2015. Experiences of depression: a study in phenomenology. Oxford: University Press.

Ritchie, H. & M. Roser 2021. Mental Health. Our World in Data (available on-line: https://ourworldindata.org/mental-health). Accessed 17 March 2021.

Rose, N. 1999. Governing the soul: the shaping of the private self. London: Free Association Books.

——— 2007. The politics of life itself: biomedicine, power, and subjectivity in the twenty-first century. Princeton: University Press.

——— 2018. Our psychiatric future. Cambridge: Polity Press.

Sartorius, N. & World Health Organization 1983. Depressive disorders in different cultures: report on the WHO collaborative study on standardized assessment of depressive disorders (available on-line: https://apps.who.int/iris/bitstream/handle/10665/37139/9241560754_eng.pdf?sequence=1&isAllowed=y). Accessed 9 October 2019.

Scharff, C. 2016. The psychic life of neoliberalism: mapping the contours of entrepreneurial subjectivity. Theory, Culture & Society 33(6), 107-22.

Showalter, E. 1985. The female malady: women, madness, and English culture, 1830-1980. New York: Pantheon Books.

Stern, G. & L. Kruckman 1983. Multi-disciplinary perspectives on post-partum depression: an anthropological critique. Social Science & Medicine 17(15): 1027-041.

Stevenson, L. 2014. Life beside itself: imagining care in the Canadian Arctic. Berkeley: University of California Press.

Vidal, F. & F. Ortega 2017. Being brains: making the cerebral subject. 1^st ed. New York: Fordham University Press.

Weber, M. 2010 [1904/05]. Die protestantische Ethik und der Geist des Kapitalismus. München: C.H. Beck.

White, G.M. 1982. The role of cultural explanations in “somatization” and “psychologization”. Social Sciences and Medicine 16, 1519-30.

Yang, J. 2018. ‘Officials' heartache’: depression, bureaucracy, and therapeutic governance in China. Current Anthropology 58(5), 596-15.

Young, A. 1995. The harmony of illusions: inventing post-traumatic stress disorder. Princeton: Princeton University Press.

——— 2012. Stress, cultural psychiatry, and resilience in the 21st century. Keynote presentation. Fukuoka, Japan: The Annual Meeting of the Japanese Society for Transcultural Psychiatry.

——— 2014. Resilience for all by the year 20–. In Stress, shock and adaptation in the twentieth century (eds) D. Cantor & E. Ramsden, 73-95. Rochester, N.Y.: University Press.

Zhang, L. 2020. Anxious China: the inner revolution and politics of psychotherapy. Berkeley: University of California Press.

Note on contributors

Junko Kitanaka, is a professor of medical anthropology in the Department of Human Sciences, Faculty of Letters, at Keio University in Tokyo. Her book Depression in Japan: psychiatric cures for a society in distress (2012, Princeton University Press) has won the American Anthropological Association’s Francis Hsu Prize in 2013 and has been translated into French. She has served on the Board of the American Society for Medical Anthropology and numerous editorial boards, including Cultural Anthropology. She is currently working on new projects on dementia, preventive psychiatry, and the medicalisation of the lifecycle.

Professor Junko Kitanaka, Department of Human Sciences, Faculty of Letters, Keio University, 2-15-45 Mita, Minato-ku, Tokyo 108-8345 Japan. junko.kitanaka@keio.jp

Stefan Ecks co-founded Edinburgh University’s Medical Anthropology programme. He teaches social anthropology and directs postgraduate teaching in the School of Social & Political Sciences. He did ethnographic fieldwork in India, Nepal, and the UK. Recent work explores value in global pharmaceutical markets, changing ideas of mental health in South Asia, poverty and access to health care, as well as multimorbidity. Publications include Eating Drugs: Psychopharmaceutical Pluralism in India (New York, 2013), Living Worth: Value and Values in Global Pharmaceutical Markets (forthcoming), as well as many journal articles on the intersections between health and economics.

Dr Stefan Ecks, School of Social and Political Science, University of Edinburgh, Chrystal Macmillan Building, 15a George Square, Edinburgh EH8 9LD, UK. secks@ed.ac.uk

[1] See Neitzke 2016 for a critique of the harm of biological reductionism in research on women and depression.

[2] Suicide: one person dies every 40 seconds. World Health Organization. News release. 9 September 2019 (available on-line: https://www.who.int/news/item/09-09-2019-suicide-one-person-dies-every-40-seconds).

Addiction

Rebecca Tishler — Wed, 21 Oct 2020 01:14:10 +0000

Joshua Burraway

University of Virginia

Initially published 21 Oct 2020

http://doi.org/10.29164/20addiction

Abstract:

What is addiction? As an umbrella term, addiction is often used to describe activities where there is an overwhelming drive to engage in destructive, distressing or compulsive behavioural patterns, including not just drug-taking and drinking, but gambling, eating, sex, video gaming, and even shopping. Whilst all these activities have generated rich fields of inquiry across the social science disciplines, this entry focuses primarily on the changing nature of substance addiction. Anthropology has played an important role in unpacking the multiple meanings contained within this phenomenon, tracking its expansion and enmeshment across a diverse range of human domains. The study of addiction encompasses anxieties regarding the changing nature of selfhood, control, and agency, as well as moral and political concerns relating to what counts as ‘proper’ versus ‘deviant’ behaviour. Since the turn of the twentieth century, addiction has increasingly become an object of both biomedical and criminal intervention. This shift has accelerated the birth of a therapeutic-carceral industry, where substance-users occupy the dual role of patient and criminal. This entry traces the development of anthropological thoughts on addiction, demonstrating how cultural approaches to non-Western alcohol use in the 1950s were adopted and expanded as Western social scientists sought more nuanced sociocultural models for understanding substance-use within their own societies. These developments fed into the tradition known as critical medical anthropology, which sought to join experiential accounts of suffering and illness to politico-economic approaches that examined the systemic conditions of inequality. The core contribution of anthropology in the study of addiction has been the generation of rich ethnographic data on the lived experiences and everyday realities of substance-users. This body of work has been instrumental in depathologising the lived world of addiction, demonstrating in vivid colour the complex sociality, cultural values, status dynamics, forms of intimate belonging, embodied experiences, and sociostructural inequities that lie at its heart.

Introduction

As a prism through which to contemplate the contemporary human condition, there are few phenomena that can rival addiction. Indeed, if anthropology is the study (logia) of man (anthrōpos), then addiction is more than a worthy object of investigation. In recent times, the category of addiction itself has expanded to include a far greater range of human endeavours than it has historically encompassed. Activities like sex, technology use, gambling, shopping and eating now sit alongside the more time-honoured activities of drug-taking, drinking and smoking. As Eugene Raikhel (2015) notes, the enlargement of addiction’s rubric to house this greater diversity hinges on the now-pervasive idea that these kinds of activities stimulate our brains in the same way as psychoactive substances do, paving the way for similar forms of self-destructive and compulsive behavioural patterns. Further on, this entry demonstrates some of the ways in which social science approaches to addiction have revealed problems with this brain disease paradigm, in particular the way in which it obfuscates addiction’s psychological, existential, cultural, economic and sociostructural determinants. Whilst this critical discourse applies to the full gambit of supposedly addictive activities outlined above, it is the use of and addiction to psychoactive substances that this entry focuses on, if for no other reason than their sheer ubiquity, contingency, and multiplicity across so many domains of human life.

As both a lived experience and an intellectual concept, substance addiction allows us to investigate diverse concerns such as morality, law, biology, neurochemistry, pharmaceuticalization^[1], agency, free will, and structural violence – to name but a few. And yet, it is also a relatively new object of human interest, grounded in late-nineteenth century Euro-American notions of health, illness, and individuality. As an anthropological concern, it is even newer – not truly capturing the discipline’s attention until the 1960s. Anthropology’s interest in addiction has, in large part, been stoked by major historical transformations in how society has come to understand and regulate the human consumption of psychoactive chemicals.

These transformations include how such chemicals have been culturally and medically conceived. Many contemporary ‘street drugs’, such as cocaine and opiates, for example, were often prescribed during the turn of the twentieth century as over-the-counter treatments for everyday maladies. They also reflect political changes, notably around interconnected themes of race, class, criminality, and power. As rising levels of socioeconomic and racial inequality in the West became tangled up with major public health concerns – such as the HIV/AIDS pandemic – the question of where and why substance-use patterns fitted into these crises became paramount. Addiction thus emerged as a central concept through which to consider the complex intersection between drug-use, therapeutics, epidemiology, and socio-political exclusion.

It quickly became clear that the consumption and circulation of psychoactive substances was no longer reducible to individual failings, be they biological, spiritual, or moral. Instead, social science explorations of addiction have clearly demonstrated the using and sharing of drugs to be intrinsic to local cultural systems, rooted in the social and economic dynamics of a particular place and time. Given that anthropologists have historically defined themselves in relation to the ethnographic study of society and culture, their late-in-the-day study of communities who use and share drugs is somewhat surprising. In point of fact, the now-burgeoning anthropological subfield that began in the 1960s has its roots in the innovative work of several sociologists. Using primarily ethnographic methods, these influential scholars argued not only that substance-use tends to be culturally constructed around local needs and concerns (Dai 1937, Lindesmith 1947), but that the pathologization narratives ascribed to substance-users are as well (Becker 1963). Pathologization refers to the process by which differences in human behaviour, especially those seen as sitting ‘outside’ of conventional moral and cultural norms, are converted into psychological and social aberrations that are seen as inherently destructive, something that increasingly happens through the language of biomedicalization.

Building on these formative ideas, the anthropological study of addiction has grown substantially. It cuts across a number of disciplinary subfields, notably medical, sociocultural, psychological, and political anthropology. Reflecting this boon in interest, a number of different explanatory approaches to addiction have emerged, all couched in their own particular intellectual traditions and scholastic genealogies. In what follows, this entry will first focus on three frameworks surrounding substance-use patterns that have been especially influential: a cultural approach, a subcultural one, and critical medical anthropology.^[2] The latter half of the entry will explore a selection of contemporary approaches to addiction that have emerged from the critical medical tradition. These include the study of differing therapeutic modalities, phenomenological analysis, and the role of temporality in questions of addiction and substance-use.

A cultural approach

Building on the work established by the aforementioned sociologists, the cultural model of substance-use can be traced to Dwight Heath’s (1958) work on alcohol consumption amongst the Camba, a horticultural people living in eastern Bolivia. Heath noted that most of the community’s adults would frequently drink vast quantities of rum during festival periods, sometimes remaining intoxicated for days on end. Rather than being viewed as pathological, though, this collective drunkenness – often to the point of passing out – held an enduring social and spiritual value. It reaffirmed bonds of solidarity as well as sustaining connections to those ancestral spirits who contributed to the health and fertility of the community. Heath’s observations essentially challenged the established orthodoxy that heavy alcohol usage was an intrinsically destructive behaviour. After all, the Camba drank huge quantities of distilled liquor during festive periods – the difference was that their drinking was embedded in a cultural, social, and cosmological context that imbued it with a set of meanings. It emphasised social cohesion over disintegration, collective identity over personal dissolution, and familial connection over breakdown (see also Van Vleet 2011).

In short, their drinking practices did not conform to the pathological model of addiction envisioned through a biomedical lens, in which excessive consumption is seen as intrinsically injurious to both the drinker and their surrounding community. This model, it should be noted, has been subject to a number of dynamic changes as new technologies. In particular neurological imaging techniques and advancements in psychopharmacology have reshaped how Western medicine conceptualises the relationship between behaviour, illness, and biology. The changing shape of biomedicine’s pathologising model, especially its increasing emphasis on the brain as the locus of addiction, continues to hold a profound grip on how substance-use is understood, experienced, and treated. Critically investigating the depth and reach of such pathologising understandings of addiction has become a core concern for anthropologists.

The core contribution of Heath’s cultural model was its capacity to destabilise existing projections of alcohol consumption as pathology. In the process, it shifted analysts’ focus onto emic (‘insider’) constructions of how substances were consumed in a local cultural context. Considering alcoholism to be merely a form of pathology runs the risk of being ethnocentric, that is of projecting one’s own cultural classifications onto the cultural settings of others. According to Arthur Kleinman, this constitutes a ‘category fallacy’. A seminal figure in medical anthropology and cross-cultural psychiatry, Kleinman cautions against the transplanting of Western-based categories to elsewhere places, especially psychiatric diagnoses. Exploring the way depression is expressed and negotiated in China via the moral dynamics of the family rather than the inner life of the individual, Kleinman makes the point that symptom expression is culturally variable, even for illnesses that may have a biological basis (see also Kirmayer & Young 1998). In this regard, Heath’s approach arguably foreshadowed important developments in medical anthropology, in particular the need to question whether Western diagnostic frameworks can be exported across socio-cultural settings, lest the nuances of non-Western lifeworlds thereby be eclipsed.

Heath’s approach, though, was not without its opponents, many of whom argued that anthropology’s tendency to downplay the issues associated with alcohol consumption in non-Western contexts married two of the discipline’s most problematic instincts: romanticization and exoticization (e.g. Room 1984). More broadly, his emic model failed to suitably account for the way in which major changes in the global politico-economic order have transformed and disrupted the shape and rhythm of traditional community life, something that Heath’s field site was certainly not immune from even in the 1950s.

To be fair to Heath, he did in his later work acknowledge how drinking practices amongst the Camba began to shift in relation to the socio-economic and ecological crises they suffered with the growth of the lumber industry in surrounding forests (Heath 1987). Dislocated from its formerly collective ethos, drinking and other forms of substance-use can rapidly become sites of relational breakdown, violence and interpersonal suffering (Quintero 2002). Indeed, anthropologists have observed that problematic forms of substance-use often emerge when social systems suffer major transitions in political organization, kinship, and economy (Frederiksen 2013; Pedersen 2011). The scale of problematic forms of substance-use amongst indigenous groups in the wake of colonial violence is testament to this observation. It reveals the way that historical trauma, dispossession, and social marginalization develop into disruptive drug-taking patterns (Jervis et al. 2003; Musharbash 2007; Spicer 2007; Stevenson 2014). The explosion of drug-related mortalities and other ‘diseases of despair’ throughout the deindustrialised heartlands of the modern West also speaks to the dangers of major socio-structural upheaval and the vacuums that such historical schisms leave behind (Anglin 2002; Billings & Blee 2000; Maggard 1994; Stewart 1996).

A subcultural model

In Heath’s work, heavy alcohol consumption was seen as an integral part of the prevailing moral and cosmological order. It was, in brief, a defining aspect of Camba culture, both as embodied practice and as system of meanings through which to relate to one another. To use the language of Ellen Corin (1995), drinking was central to social life, not peripheral. Over in the Western world, however, heavy forms of intoxication, be it through alcohol or other substances, have not historically been seen as something to be extolled or morally valued. The widespread and heavy-handed criminalization of drugs, the dominance of abstinence-based recovery programmes, and the pathologization of addiction as a psychiatric disorder all gesture to this fact. Accordingly, those who consume these substances are seen as troublesome to the dominant order. They exist on the peripheral edges of cultural norms and values. The drug addict challenges the very logic of Euro-American personhood, in particular the notion that healthy persons are those whose inner lives are stable and autonomous, uncorrupted by the enslavement and chaos of chemical dependency (Summerson Carr 2010). Addicts, then, unfitting of this cultural template, have consistently found themselves relegated to some social space outside of culture, defined primarily through the pathology of their condition.

Historically, these spaces, and the lives of addicts themselves, have been marked by narratives of deviance and exclusion, with little thought given to the complexities and intimacies that pervade them. The ‘subcultural’ thus emerged as an analytical frame through which to attend to them (see Becker 1963). Whilst the ‘sub-’ prefix (literally meaning ‘below’) arguably risks reifying hierarchical divisions of ‘good’ versus ‘bad’ forms of human social life, the purpose of this term was to call to attention the myriad ways that people on the periphery carve out ways of living that are at variance with the prevailing cultural centre. The so-called ‘underworld’ of drug addiction, in other words, is just that – a world; one teaming with complex forms of sociality that cannot be so easily explained away through the dehumanising language of deviance and moral decay.

Again, it was the sociologists who were first to the punch. The subcultural approach to substance-use emerged out of street-based research in America’s inner-cities. Seminal sociological accounts, in their rich descriptions of the selling, buying, sharing, and consumption of drugs, demonstrated these practices to be foundational to the daily lives of vulnerable and marginalised people (see Feldman 1968; Fiddle 1967; Partridge 1973; Sutter 1966). Particularly influential here was the work of Edward Preble and John Casey (1969), who described in intimate detail the social life of lower-class heroin users in New York City. For these users, tracking down and injecting heroin is understood as a ‘career’. It is a never-ending hustle that, from making money to buying the drugs, emerges as a full-time job that imbues each day with meaning, purpose, and business. A major contribution of this body of literature was to challenge entrenched myths surrounding drug consumption, especially intravenous usage, which had historically been viewed with high levels of moral panic. In many countries, notably in the US, the puritanical fear of needles remains ingrained in public health policy, with needle exchange programs regularly defanged or shut down out of the unfounded fear that they abet drug-use (Rhodes et al. 2005).

Unyoking drug-use from its historical associations with illness, social decay, and psychopathology shifted the emphasis of analysts from individual usage to the worlds in which such usage occurred. These worlds are marked by complex survival strategies, such as begging, panhandling, sex work, and petty crime. These strategies encompass sharing economies, rituals of socialization that initiate people into drug-using networks, and underground hustling practices that prop up multibillion-dollar narcotics economies. They include creating concealed urban spaces, such as shooting galleries and squats, that shelter ‘hidden’ populations unconnected to state services, as well as new linguistic forms of ‘street’ slang that are uniquely attuned to the conditions of scarcity, insecurity, and racialised surveillance that constitute everyday urban life in the poorest neighbourhoods. Ultimately, it was the long-term intimacy of the ethnographic method through which researchers could develop enduring relations of trust that provided access to these (under)worlds. The researchers’ emphasis on the emic perspectives, cultural order, and social meaning that were built into the fabric of these worlds serve to depathologise substance-use. Where the subcultural approach to addiction eventually succeeded was in its capacity to illuminate the complex arrangement of values, roles, and status dynamics that structure the daily lives of substance-using communities. What looked to the cultural centre like moral decay, pathology, and escapism, from within the periphery is experienced as meaningful activity. The pursuit, scoring, and taking of drugs serves here as the lifeblood of communal existence (see also Friedman et al. 1986).

Critical medical anthropology

Whilst the subcultural approach did much to enrich understandings of drug-using communities and to counter reductive and simplifying forms of stereotyping, a suspicion lingered that an over-emphasis on the ‘insider perspective’ risked a similar form of romanticising of which scholars such as Heath had been accused. The concern was that it might inadvertently deflect attention from the wider social, historical, and politico-economic forces that shaped patterns of drug-use and addiction. The response to such misgivings was the emergence of a critical medical anthropology in the 1980s, whose analytical goal was to fuse experiential accounts of suffering, illness, and wellbeing with politico-economic approaches that attended to the systemic conditions that drive institutionalised forms of inequality, racialised violence, carceral governance, and social control. The foundational figures of this approach, such as Nancy-Scheper Hughes (1990), Margaret Lock (1987), and Merrill Singer (1989), sought not only to reveal the structures underpinning the social determinants of ill health, but also to apply these critical frameworks in practical ways, collaborating with local communities so as to challenge and ultimately change existing healthcare systems.

A pertinent example of this tradition is the work of Philippe Bourgois (1995, 2009), who has conducted long-term ethnographic fieldwork amongst vulnerable drug-users in New York and San Francisco. Here, addiction is interpreted as a form of social suffering that is inexorably tied to the uneven distribution of wealth and power. In Bourgois’ eyes, America’s neoliberal market economy is rigged in favour of corporate power and special interest groups. Social care services are imbalanced and underfunded, while the principles of individual responsibility and entrepreneurial bootstrapism are still being championed. As a result, an ever-growing number of America’s indigent classes, a disproportionate amount of whom struggle with addiction issues, are turned into a ‘Lumpenproletariat’. This Marxist term historically refers to those people structurally positioned just below the wage worker, who prop up the economic system through irregular employment. In the context of addiction, it describes those vulnerable groups for whom punitive forms of disciplinary governance, such as through surveillance, policing, and incarceration, have become destructive and alienating. This occurs while other segments of the population, notably large corporations, continue to profit from these systems of abuse and punishment. Perhaps the most patent examples of this are the private prison system and the pharmaceutical industry, both of which generate billions of dollars of revenue each year.

The gaping health disparities we see between America’s upper and lower classes not only exacerbate the suffering of vulnerable groups and damage their bodies. They also reshape the bounds of their subjectivity to the point where everyday forms of systemic and intimate violence are experienced as the natural order of things. We see this frequently in cases where substance-users ‘blame themselves’ for the oftentimes brutal and discriminatory situations they find themselves caught up in. Such moments, as Bourgois demonstrates, point us to the way that marginalised people naturalise the structural forces that alienate them by internalising dominant cultural narratives around ideas of personal responsibility. They begin to believe that substance-users must be understood as the sole architects of their own downfall and, by extension, of their recovery as well.

Viewed through this critical lens, substance-use emerges as a form of self-medication through which to attend to chronic conditions of existential distress, powerlessness, and sociostructural alienation. It effectively provides a moment of escapist relief from the painful conditions of the user’s lifeworld. The irony, however, is that using illegal drugs as relief risks attracting exclusionary forms of social control that are likely to compound and amplify that person’s marginalization. Indeed, the ubiquitous forms of policing, punitive surveillance, mass incarceration, and disenfranchisement that underpin the US-led ‘war on drugs’ have turned already-precarious social spaces into what Jarrett Zigon (2019) has termed ‘zones of uninhabitability’. They are places where those who inhabit them suffer chronic conditions of isolation, cruelty, entrapment, and expendability. Since former US President Richard Nixon first declared illegal drugs “public enemy number one” in 1971, this now globalised and highly militarised crusade to eradicate this evil has ultimately become a war on already marginalised people (Zigon 2019). This is a war in which users and nonusers alike are trapped in zones of uninhabitability, made into internal enemies against which the ‘good life’ of the contemporary sociopolitical order can be defined, maintained, and protected.

The war on drugs in the age of the brain

The ongoing ‘war on drugs’ is couched in the notion that people are essentially powerless to resist the temptation that drugs offer. Labelled the ‘exposure’ orientation in clinical circles (Alexander 1982), this notion contends that mere one-time contact with certain drugs (especially opiates) is enough to trigger a self-destructive cycle of compulsive, ever-escalating usage. The addict, in other words, becomes a slave to their substance. This model is the foundation on which the idea of a chronic relapsing brain hinges. It holds that certain drugs ‘hijack’ the reward pathways in the brain – especially those responsible for producing dopamine, the neurotransmitter associated with feelings of pleasure and euphoria, among many other things. The formula ‘dopamine = pleasure’ has been refuted as a gross oversimplification, as the interaction between neurotransmitter production and subjectivity are far more nuanced and complex (Berridge 2007). Nevertheless, the broader paradigm that drugs cause a brain disease has shown itself to be pervasive, underpinning the prevailing idea that drug addiction is rooted in individual biology. In such a view, the addictive substance is seen as mounting a kind of hostile takeover of a person’s brain, in which the neurological mechanisms of reward, desire, and pleasure are systemically compromised.

Much of the empirical groundwork for the exposure orientation stemmed from experiments conducted on rodents in the 1960s. In these experiments, caged rats, who faced the options of drinking either water or an opiate solution, kept returning to the drug-laced bottle, oftentimes fatally. However, in the 1970s, psychologist Bruce Alexander noticed a key structural flaw in the experiments, specifically that the rats were all alone in the cage, with nothing to do but take the drugs on offer. Alexander hypothesised that it was the social isolation, and not the drugs, that sustained their desire to seek chemical relief. To test this hypothesis, he built ‘Rat Park’ – a sort of rodent utopia in which the rats had plenty of space to eat, run, and, most importantly, socialise. Despite facing the same two options, the rats hardly ever touched the drug-laced water, and none of them ever came close to overdosing. From this study and several variations, Alexander developed the ‘adaptive orientation’ view. It holds that addiction ‘is an attempt to adapt to chronic distress of any sort through habitual use’ (1982: 367). In other words, it is not the chemical that causes addiction, but the cages in which beings find themselves.

The extension of this idea is that a human being’s everyday reality can be experienced as cage-like. This chimes with broader anthropological investigations into the ways in which the uneven distribution of wealth, power, and resources has created conditions of extreme social isolation, chronic scarcity, and endemic precarity. These conditions are compounded through the exclusionary policies championed by drug war ideologues. Self-medication through drugs thus emerges as one of the few adaptive coping mechanisms available to deal with these cage-like conditions. This is because psychoactive drugs serve as a readymade shortcut to induce in the user alternative states of being. They may be brief and potentially costly, but they transport the user beyond the existential crises that are otherwise engulfing them.

Chemical interventions

The notion that psychoactive chemicals can act as transformational catalysts within broader healing rites has been noted across history and culture. In particular, hallucinogenic botanicals (such as ayahuasca, peyote, or iboga) have been used in ritual contexts in many small-scale societies to open up pathways between the human and the spirit world (Dobkin de Rios 1972). Taken in a collective setting and guided by ritual specialists such as shamans or other spiritual leaders, these substances open up new therapeutic pathways by reconfiguring the complex relation between self, ego, personhood, culture, and cosmology (Grob & Dobkin de Rios 1994). In the West, however, these institutionalised forms of ritual healing have been largely dismantled and disavowed over the course of modernity along with the stewards who sustain them. They have been replaced by an individualised, highly biologised therapeutic model that hinges on biomedical understandings of illness and disease (Kleinman 1988; Napier 1992, 2004). The modern pharmaceutical industry has emerged in lockstep with these historical changes, locating illness primarily in individual bodies and, in the case of mental health and addiction issues, the brain (see Raikhel 2015).

Whilst Western healthcare systems and certain ritual formats both incorporate chemical interventions into their modes of healing, there are crucial differences in how these substances are implemented, experienced, and conceptualised. For example, the Navajo, an indigenous people of the Southwestern United States, have long employed peyote in their healing ceremonies. Native to Navajo land, peyote is a small cactus plant that contains a hallucinogenic compound known as mescaline, which can profoundly alter a person’s sense of self and reality. According to anthropologist Joseph Calabrese, who took part in these rituals, peyote can be understood as a technology of consciousness modification that allows the sufferer to situate themselves in a broader arc of symbolic and spiritual healing. In other words, the visions, sensations, insights, interpretive activity, and encounters produced within what are known as Peyote Meetings are part of a deeper cultural narrative that reflects and responds to the Navajo cosmos. It is part of a universe that includes not just other humans but also non-human spirits, animals, and ancestors. For Navajo struggling with illness such as alcoholism or depression, taking peyote in ritual contexts opens up lines of communication with omniscient spiritual beings. Direct engagement^[3]with these spiritual entities can aid in the recovery process by providing deep personal insights that would otherwise remain hidden (Aberle 1991; Calabrese 2008).

As a collective cultural experience, the ceremonial distribution and ingestion of peyote differs radically from the clinical prescription of modern pharmaceuticals. In the latter context, the patient’s illness is located primarily in the brain’s faulty or damaged circuitry, while social and existential conditions are rendered peripheral to diagnosis and treatment. As psychiatry has become increasingly biologised (Luhrmann 2001), the result is that more and more mental health conditions are being designated as chronic (i.e. without end). Consequently, these afflictions require constant maintenance through on-going prescriptions and daily pharmaceutical intervention that operates on a molecular level.

Pharmakon dualities

We can learn more about the pharmaceutical approach to addiction by looking at the premise of opioid substitution therapy (OST) for those who are struggling with opioid dependency. OST is practiced in clinical settings across the globe. In it, the patient is prescribed a synthetic opioid such as methadone or buprenorphine that mimics the biochemistry of other opioids whilst suppressing euphoric sensations. By substituting one drug for the other, OST is designed to wean the addict off from the opioid they are perceived to be ‘abusing’, reducing cravings whilst staving off the physical and psychological symptoms of withdrawal. This idea of replacing ‘bad drugs’ with so-called ‘good medicines’ has been analysed as a site of profound contradiction by anthropologists. One prism through which a number of them have explored this idea is through the notion of the pharmakon – pharmacology’s etymological root, from the Greek. Pharmakon is a term used to describe things that hold a double valence as both cure and poison, something that has indivisibly positive and negative effects. Pharmaceutical opioids used in OST oscillate between the licit and the illicit (Bourgois 2000; Garriott 2011; Lyons 2014). They are thus an archetypal modern example of pharmakon, pendulating between being miracle cures and deadly poisons (see Biehl 2005; Meyers 2014).

Substances that carry these dual identities can radically blur the partition lines between therapeutic use and abuse. This has been shown by the unprecedented surge in morbidity and mortality associated with opioid pain relievers that has swept the United States in recent years. Aggressively marketed ‘miracle’ painkillers, such as the now-infamous Oxycontin, have flooded the US healthcare system. Their curative capacities soon turned poisonous as they took root within already-precarious communities which had been progressively compromised through the ‘perfect storm’ combination of deindustrialization, socioeconomic neglect, social safety net cuts, and mass unemployment (Dasgupta et al. 2018). Ironically, using OST as the predominant clinical response to the opioid crisis hinges on the same therapeutic logic that led to the proliferation of drugs like Oxycontin in the first place – namely that pain is a biological disorder (see Crowley-Matoka & True 2012). Addiction is here reduced to a set of individual withdrawal symptoms that emerge in relation to the internal dynamics of certain neurochemical pathways. It thus becomes unyoked from its social, political, and existential conditions. In America’s case, the conditions for the proliferation of opioid pain relievers were especially ripe. Pain relievers spread as part of an entrenched culture of pharmaceuticalization (Oldani 2014) that has been amplified by gaping disparities in health and wealth across the population, a rapacious health-care sector with huge barriers to treatment for those who cannot afford it, as well as a lack of unemployment support combined with an emphasis on the importance of maintaining work despite illness or injury.

Addiction, phenomenology and the temporal turn

To move beyond ‘neurocentric’ accounts and understand how wider structural conditions shape addiction, a number of scholars who identify with critical medical anthropology have turned to the philosophical field of phenomenology for inspiration. Simply put, phenomenology can be understood as a philosophical method that seeks to reveal the structure and conditions of lived experience by articulating how the world appears and is felt from an embodied perspective (see, for example, Good 1994; Csordas 1994; Throop 2007). Broadly speaking, then, phenomenological accounts consider a larger range of experiences than simply that of suffering and pathological compulsion. They describe the complex ways that pain intersects with pleasure, despair with hope, and creativity with destruction. At the same time, they hold that such complex forms of subjectivity are always already embedded in particular social, political, historical, and conceptual contexts (Mattingly 2019; Zigon 2018). For a number of scholars working in this subfield, much of the analytical emphasis has been on the way that substances are used as a means to alter temporality – the lived experience of time – under conditions of precarity.

This analytic move reflects broader discussions within the phenomenology of drugs that focus on their capacity to radically alter the subjective experience of time (Cope 2003; Deleuze 2004; Denzin 1987; Flaherty 1999; Hill 1978; Huxley 2004; Lapp et al. 1994; Klingemann 2000; Reith 1999; Shanon 2001; Smart 1968). For example, in her seminal work amongst Hispano heroin-users in New Mexico, Angela Garcia (2010) engages with melancholia, or endless mourning, as a way to articulate the historical dimensions of addiction and drug treatment in the region. For Garcia’s interlocutors, heroin use and the intimate losses it inflicts upon communities through incarceration and overdose deaths is experienced as indivisible from the long history of agricultural land dispossession, grinding rural poverty, and social abandonment. Addiction expresses loss and mourning for a past and a cultural identity that struggles for coherency in the face of widespread socioeconomic change. People here live in a purgatorial world where historical suffering meets clinical therapeutics and where each repeated descent into heroin usage fortifies the prevailing model of addiction as a chronic, ‘no exit’ disease.

My own work amongst London’s inner-city homeless has also engaged themes of temporality. It describes how rough sleepers use anaesthetic intoxicants such as alcohol, opiates, and pharmaceutical sedatives to induce blackout states. These provide a temporary reprieve from the chronic existential crises, painful memories, and deep boredom that undergird street living (Burraway 2018). Many of the homeless describe these blackout states in terms of ‘becoming somebody else’. Thereby, they experience the blackout as a paradoxical form of self-healing. It refashions the normal interface between self, memory, agency, body, and world. The blackout is paradoxical because it transports the homeless into a memoryless state where they are no longer burdened by the crisis of their own presence. Yet it also evaporates the moment the drugs wear off. In this regard, the blackout traps them in a Sisyphean loop in which the very experience of escape is forever held just out of conscious reach.

Approaching drug-use by focusing on how it alters people’s relationship to time has turned out to be a fruitful mode of inquiry, especially in social contexts marked by scarcity, precarity, and vulnerability. For example, in their ethnography of khat consumption among Ethiopian unemployed youth, Mains et al. (2013) note how finding the stimulant khat and then chewing it with others imbued the day with some kind of meaningful rhythm, in the process taking up time, of which there was plenty. So, rather than using psychoactive substances to annihilate the threat of an empty future by inducing anaesthesia – as was the case for my homeless interlocutors – these young Ethiopian men used khat’s stimulant properties to move towards an alternative vision of the future. They sought the psychoactive condition of mirqana, a state which moved them beyond the banal realities of the present and into dreams and hopes for a better time to come. Aligned with these studies is a large body of literature on the concept of waiting, which explores the various ‘time-killing’ strategies that people use to cope with economic stagnation, chronic joblessness, and deep boredom (Masquelier 2013; Harms 2013; Ralph 2008; Honwana 2012).

These studies also foreground that the body becomes central during periods of crisis. When the world feels as though it is spinning out of control, it is the body – people's foremost technical instrument (Mauss 1979) – that often becomes the new locus of control and transformation, a last resort of control in an otherwise-unmanageable world. This has been shown in ethnographic studies on topics as varied as homelessness (Bourgois & Schonberg 2009; Desjarlais 1997), eating disorders (Lester 2009), organ trafficking (Scheper-Hughes 2001), and prostitution (Day 2007; O’Neil 2015). The sad irony, however, as some have argued, is that the ‘resort’ to individual bodily techniques in times of crisis, such as through heavy drug-use, often ends up reproducing the very politico-ideological demands that the person in question seeks escape from. The imperative to take ‘personal responsibility’ for one’s own self-transformation has a decidedly neoliberal edge to it insofar as the locus of transformation is rooted in autonomous decision making rather than any kind of meaningful changes to the individual’s social and existential conditions.

Conclusion

The study of addiction is a messy and highly disjointed research field, described by some in terms of ‘conceptual chaos’ (Shaffer 1997). Much of this chaos can be seen as reflecting broader historical transformations in how Euro-American cultures have come to think about the human condition. Addiction has developed from being considered a spiritual affliction, conceived through Christian theology, to its present incarnation as a brain disease. Its study demonstrates the extent to which contemporary understandings reflect changing ideologies about the core elements of personhood, agency, and subjectivity. This path, though, is neither singular nor linear.

Anthropology has done much to parse out the complexity of addiction, which moulds and is moulded by the contexts in which it emerges (Raikhel & Garriott 2013). The discipline’s cross-cultural perspectives that allow for a more diverse body of thought on the topic challenge the hegemony enjoyed by neuroscientific approaches. While neuroscientific approaches do have merit, their virtues should not be extolled at the expense of alternative perspectives that may also be correct. It is for this reason that some scholars urge us to embrace analytic and interpretive multiplicity. They argue that a ‘vibrant epistemic pluralism’ (Raikhel 2015: 391) will provide a far richer and more nuanced conceptual vocabulary through which to make sense of addiction. Ethnography, which embraces human complexity at both the individual and structural level, has allowed anthropology to come up with many important insights since, its relatively late arrival to the addiction conversation. It has done this primarily by placing emic concerns and lived experience at the forefront of analysis. Ethnographic work emphasises the role of cultural mechanisms in shaping ideologies and experiences surrounding substances-use. It depathologises the social life of addiction amongst marginalised communities and problematises state institutions that effectively fuse therapeutic domains with criminal ones. Further, by moving the analytic lens beyond the individual user, anthropology has illustrated in granular detail that addiction cannot be uncoupled from history, policy, inequality, and political economy.

Addiction has also become a fundamental site for the production of theory, as it sits at the intersection of so many aspects of the human condition, which often stand in contradiction to one another. Thus, addiction is simultaneously an aspect of lived experience and an object of biomedical knowledge, a condition of therapeutic possibility as well as of penal coercion. It is a world of ecstatic pleasure and of debilitating pain, an escape route as well as a prison. Caught up in the swirls and eddies of this ambivalent churn are those who live with addiction each day, their on-going relationships with their chosen substances forcing us to rethink the boundaries of human agency. Above all, they highlight the need to avoid reductive accounts and to hold within our analytic frameworks multiple perspectives at once. To understand addiction, we must consider the structural in tandem with the experiential, the personal with the political, and the epistemic with the existential.

References

Aberle, D.F. 1991 [1966]. The peyote religion among the Navajo. Chicago: University Press.

Agar M. 1973. Ripping and running: a formal ethnography of urban heroin addicts. New York: Seminar Press.

Anglin, M.K. 2002. Lessons from Appalachia in the 20th century: poverty, power, and the "grassroots." American Anthropologist 104(2), 565-82.

Alexander, B.K. 1982. Opiate addiction: the case for an adaptive orientation. Psychological Bulletin 92(2), 367-81.

Becker, H.S. 1963. Outsiders: studies in the sociology of deviance. New York: Free Press.

Berridge, K.C. 2007. The debate over dopamine’s role in reward: the case for incentive salience. Psychopharmacology 191(3), 391-431.

Biehl, J. 2005. Vita: life in a zone of social abandonment. Berkeley: University of California Press.

Billings, D.B. & K.M. Blee 2000. The road to poverty: the making of wealth and hardship in Appalachia. Cambridge: University Press.

Bingham, D. 1937. Opium addiction in Chicago. Shanghai: The Commercial Press.

Bourgois, P. 1995. In search of respect: selling crack in el Barrio. Cambridge: University Press.

−−−−− 2000. Disciplining addictions: the bio-politics of methadone and heroin in the United States. Culture, Medicine & Psychiatry 24(2), 165-95.

−−−−− & J. Schonberg 2009. Righteous dopefiends. Berkeley: University of California Press.

Burraway, J. 2018. Remembering to forget: blacking-out in Itchy Park. Current Anthropology 59(5), 469-87.

Calabrese, J.D. 2008. Clinical paradigm clashes: ethnocentric and political barriers to Native American efforts at self-healing. Ethos: Journal of the Society for Psychological Anthropology 36(3), 334-53.

Carr, E.S. 2010. Scripting addiction: the politics of therapeutic talk and American sobriety. Princeton: University Press.

Cope, N. 2003. ‘It’s no time or high time’: young offenders’ experiences of time and drug use in prison. The Howard Journal of Criminal Justice 42(2), 158-75.

Corin, E. 1995. Meaning games at the margins: the cultural centrality of subordinated cultures. In Beyond textuality: asceticism and violence in anthropological interpretation (eds) G. Bibeau & E. Corin, 173-92. Berlin: Mouton de Gruyter Publishing.

Crowley-Makota, M. & G. True 2012. No one wants to be the candy man: ambivalent medicalization and clinician subjectivity in pain management. Cultural Anthropology 27(4), 689-712.

Csordas, T.J. 1994. The sacred self: a cultural phenomenology of charismatic healing. Berkeley: University of California Press.

Dasgupta, N., L. Beletsky & D. Ciccarone 2018. Opioid crisis: no easy fix to its social and economic determinants. American Journal of Public Health 108(2), 182-86.

Day, S. 2007. On the game: women and sex work. London: Pluto Press.

Denzin, N.K. 1987. The alcoholic self. Newbury Park, Calif.: SAGE.

Desjarlais, R. 1997. Shelter blues: sanity and selfhood among the homeless. Pennsylvania: University Press.

Dobkin de Rios, M. 1972. Visionary vine: hallucinogenic healing in the Peruvian Amazon. Prospect Heights, Ill.: Waveland Press.

Feldman, H. 1968. Ideological supports to becoming and remaining a heroin addict. Journal of Health and Social Behaviour 9(2), 131-9.

Fiddle, S. 1967. Portrait from a shooting gallery. New York: Harper and Row.

Flaherty, M.G. 1999. A watched pot: how we experience time. New York: University Press.

Frederiksen, M.D. 2013. Young men, time, and boredom in the Republic of Georgia. Philadelphia: Temple University Press.

Friedman, S.R., D.C. Des Jarlais & J.L. Sotheran 1986. AIDS health education for intravenous drug users. Health Education & Behaviour 13(4), 383-93.

Fuchs, T. 2005. Implicit and Explicit Temporality. Philosophy, Psychiatry and Psychology 12(3), 195-8.

Garcia, A. 2010. The pastoral clinic: addiction and dispossession along the Rio Grande. Berkeley: University of California Press.

Garriott, W. 2011. Policing methamphetamine: narcopolitics in rural America. New York: University Press.

Good, B.J. 1994. Medicine, rationality, and experience. Cambridge: University Press.

Grob, C.S. & M. Dobkin de Rios 1994. Hallucinogens, managed states of consciousness, and adolescents: cross-cultural perspectives. In Psychological anthropology (ed.) P.K. Bock, 315-29. Westport, Conn.: Praeger.

Harms, E. 2013. Eviction time in the new Saigon: temporalities of displacement in the rubble of development. Cultural Anthropology 28(2), 344-68.

Heath, D. 1958. Continuity and change in drinking patterns of the Bolivian Camba. Quarterly Journal of Studies on Alcohol 19(3), 491-508.

−−−−− 1987. Decade of development in the anthropological study of alcohol use: 1970–1980. In Constructive drinking: perspectives on drink from anthropology (ed.) M. Douglas, 16-69. Cambridge: University Press.

Hill, T.W. 1978. Drunken comportment of urban Indians: ‘time-out’ behavior? Journal of Anthropological Research 34(3), 442-67.

Honwana, A. 2012. The time of youth: work, social change, and politics in Africa. Sterling, Va.: Kumarian Press: Stylus Publishing.

Huxley, A. 2004 [1954]. The doors of perception: and heaven and hell. London: Vintage Classic.

Jervis, L.L., P. Spicer & S.M. Manson 2003. Boredom, ‘trouble,’ and the realities of postcolonial reservation life. In Ethos 31(1), 38-58.

Kirmayer, L.J. & A. Young 1998. Culture and somatization: clinical, epidemiological and ethnographic perspectives. Psychosomatic Medicine 60, 420-30.

Kleinman, Arthur. 1987. Anthropology and psychiatry: the role of culture in cross-cultural research on illness. British Journal of Psychiatry 151, 447-54.

−−−−− 1988. The illness narratives: suffering, healing and the human condition. New York: Basic Books.

Klingemann, H. 2000. ‘To every thing there is a season’—social time and clock time in addiction treatment. Social Science & Medicine 51(8), 1231-40.

Lapp, W.M., L.R. Collins, W.H. Zywiak & C.V. Izzo 1994. Psychopharmacological effects of alcohol on time perception: the extended balanced placebo design. Journal of Studies on Alcohol 55(1), 96-112.

Lester, R.J. 2009. Brokering authenticity: borderline personality disorder and the ethics of care in an American eating disorder clinic. Current Anthropology 50(3), 281-302.

Lyons, T. 2014. Simultaneously treatable and punishable: implications of the production of addicted subjects in a drug treatment court. Addiction Research and Theory 22(4), 286-93.

Lindesmith, A.R. 1947. Opiate addiction. Bloomington, Ind.: Principles Press.

Luhrmann, T.M. 2001. Of two minds: an anthropologists looks at American psychiatry. New York: Random House.

Maggard, S.W. 1994. "From farm to coal camp to back office and McDonald’s”: living in the midst of Appalachia’s latest transformation. Journal of Appalachian Studies Association 6, 14-38.

Mains, D., C. Hadley & T. Fassil 2013. Chewing over the future: khat consumption, anxiety, depression, and time among young men in Jimma, Ethiopia. Culture, Medicine & Psychiatry 37(1), 111-30.

Masquelier, A.M. 2013. Teatime: boredom and the temporalities of young men in Niger. The Journal of the International African Institute 83(3), 385-402.

Mattingly, C. 2019. Defrosting concepts, destabilizing doxa: critical phenomenology and the perplexing particular. Anthropological Theory 19(4), 415-39.

Mauss, M. 1979 [1934]. Techniques of the body. Economy and Society 2, 70-88.

Meyers, T. 2014. Promise and deceit: pharmakos, drug replacement therapy, and the perils of experience. Culture, Medicine & Psychiatry 38(2), 182-96.

Musharbash, Y. 2007. Boredom, time, and modernity: an example from Aboriginal Australia. American Anthropologist 109(2), 307-17.

Oldani, M. 2014. Deep pharma: psychiatry, anthropology, and pharmaceutical detox. Culture, Medicine & Psychiatry 38, 255-78.

O’Neill, B. 2015. Bored stiff: sex and superfluity in a time of crisis. Public Culture 27(2), 387-405.

Napier, D.A. 1992. Foreign bodies: performance, art, and symbolic anthropology. Berkeley: University of California Press.

−−−−− 2004. The righting of passage: perceptions of change after modernity. Philadelphia: University of Pennsylvania Press.

Partridge, W. 1973. The hippie ghetto: the natural history of a subculture. New York: Holt, Rinehart and Winston.

Pedersen, M.A. 2011. Not quite shamans: spirit worlds and political lives in Northern Mongolia. Ithaca: Cornell University Press.

Preble, E. & J. Casey 1969. Taking care of business: the heroin user’s life on the street. International Journal of the Addictions 4(1), 1-24.

Quintero, G. 2002. Nostalgia and degeneration: the moral economy of drinking in Navajo society. Medical Anthropology Quarterly 16(1), 3-21.

Raikhel, E. & W. Garriott (eds) 2013. Addiction trajectories. Durham, N.C.: Duke University Press.

Raikhel, E. 2015. From the brain disease model to ecologies of addiction. In Re-visioning psychiatry, cultural phenomenology, critical neuroscience, and global mental health (eds) L. Kirmayer, R. Lemelson & C. Cummings, 375-99. Cambridge: University Press.

Ralph, M. 2008. Killing time. Social Text 26(4), 1-29.

Reith, G. 1999. In search of lost time: recall, projection and the phenomenology of addiction. Time and Society 8(1), 99-117.

Room, R. 1984. Alcohol and ethnography: a case of problem deflation? Current Anthropology 25(2), 169-78.

Rhodes, T., M. Singer, P. Bourgois, S.R. Friedman & S.A. Strathdee 2005. The social structural production of HIV risk among injecting drug users. Social Science and Medicine 61(5), 1026-44.

Scheper-Hughes, N. 1990. Three propositions for a critically applied medical anthropology. Social Science & Medicine 30(2), 189-97.

−−−−− 2001. “Commodity fetishism in organs trafficking.” Body and Society 7(2-3), 31-62.

−−−−− & M.M. Lock 1987. The mindful body: a prolegomenon to future work in medical anthropology. Medical Anthropology Quarterly 1(1), 6-41.

Scherz, C. & G. Mpanga 2019. His mother became medicine: drinking problems, ethical transformations and maternal care in central Uganda. Africa: The Journal of the International African Institute. 89(1), 125-46.

Shaffer, H.J. 1997. The most important unresolved issue in the addictions: conceptual chaos. Substance Use & Misuse 32(11), 1573-80.

Shanon, B. 2001. Altered temporality. Journal of Consciousness Studies 8(1), 35-58.

Singer, M. 1989. The coming of age of critical medical anthropology. Social Science & Medicine 28(11), 1193-1203.

−−−−− 2008. Drugging the poor: legal and illegal drugs and social inequality. Long Grove, Ill.: Waveland Press.

−−−−− 2012. Anthropology and addiction: an historical review. Addiction 107(10), 1747-55.

Smart, R.G. 1968. Future time perspectives in alcoholics and social drinkers. Journal of Abnormal Psychology 73(1), 81-3.

Spicer, P. 1997. Toward a (dys)functional anthropology of drinking: ambivalence and the American Indian experience with alcohol. Medical Anthropological Quarterly 11(3), 306-23.

Stevenson, L. 2014. Life beside itself: imagining care in the Canadian Arctic. Berkeley: University of California Press.

Stewart, K.1996. A space on the side of the road: cultural poetics in an “other” America. Princeton: University Press.

Sutter, A. 1966. The world of the righteous dope fiend. Issues in Criminology 2(2), 177–222.

Throop, J. 2017. Despairing moods: worldly attunements and permeable personhood in Yap. Ethos 45(2), 199-215.

Van Vleet, K. 2011. On devils and the dissolution of sociality: Andean Catholics voicing ambivalence in neoliberal Bolivia. Anthropological Quarterly 84(4), 835-64.

Zigon, J. 2018. Disappointment: toward a critical hermeneutics of worldbuilding. New York: Fordham University Press.

−−−−− 2019. A war on people: drug user politics and a new ethics of community. Berkeley: University of California Press.

Note on contributor

Joshua Burraway is a cultural medical anthropologist whose research interests sit at the intersection between social and political theory, critical phenomenology, addiction medicine, and psychiatry. His research interests emerged from a long-term ethnographic study of homeless substance-users in inner-city London. Currently, he is carrying out research in rural Appalachia exploring deindustrialization, social trust, and the proliferation of opioids and other narcotics, such as methamphetamine.

[1] Broadly speaking, pharmaceuticalization refers to the reconfiguring of human realities, processes, and capabilities into opportunities for pharmaceutical intervention, augmentation, or enhancement.

[2] See Singer (2012) for a more exhaustive historical literature review of these approaches and several others.

[3] See also Scherz & Mpanga’s (2019) work in Uganda for how direct spiritual intervention can facilitate recovery from alcoholism.