Open Encyclopedia of Anthropology - Depression

Affect

Rebecca Tishler — Wed, 26 Feb 2025 09:28:00 +0000

Detail of "The fallen Angel" (1847) by Alex Andre Cabanel, depicting the devil after being expelled from heaven. Picture by Wikipedia.

Daniel White Andrea De Antoni

University of Cambridge, Kyoto University

Initially published 26 Feb 2025

http://doi.org/10.29164/25affect

Abstract:

Affect refers to sensations and physiological shifts in intensity that may or may not formalise into conceptually distinct and collectively recognized feelings. Compared to emotions, which anthropologists see as feelings embedded in sociolinguistic concepts like love, anger, jealousy, han (Korean for sadness-grief), song (Ifaluk for justified anger), or hygge (Danish and Norwegian for cosiness), affects are conceived as more fluid. Although registered through biological and bodily sensation, affects are also culturally conditioned and can, in turn, strongly influence sociocultural dynamics. Anthropologists have long explored the varieties of emotional experience across cultures, from the analysis of different patterns of emotional behaviour in the early twentieth century to the linguistic comparison of different emotional expressions through the 1970s and 80s. Since around the 1990s, however, anthropologists began to shift their focus to the diverse ways that emotions also involve less linguistically determined but nevertheless socially conditioned bodily experiences they called ‘affect’. This entry documents early psychological and philosophical genealogies of affect; the relation of affect to anthropological studies of emotion; critiques of and counterpoints to the affect concept; and enduring themes in ethnographic studies of affect.

Introduction

An uneasy tingling of your skin when you pass through an unknown patch of forest; a sigh of comforting relief when you taste a familiar home-cooked dish after months away; the joyous energy of singing along with friends—word-for-word—the lyrics of a hit song; the high-intensity movements of a shamanic ritual; the low-intensity stillness of meditation; a dampness in the spleen; a longing in the heart; an ache. Many experiences are sensed but are not easily identified with a familiar emotion word like ‘fear’, ‘nostalgia’, ‘joy’, ‘transcendence’, ‘equanimity’, ‘worry’, ‘heartache’, or even ‘pain’. Moreover, feelings can often be surprising, arising at unexpected moments and carrying with them little indication of their origin or cause.

Although anthropologists have long been interested in these types of felt experiences, they have traditionally focused more explicitly on the public expression and symbolic display of feeling, which they called ‘emotion’. Since the 1990s, however, anthropologists in partnership with many others in allied social science and humanities disciplines began to explicitly emphasise the value of describing feelings that were sensed within and between bodies but did not always take linguistic or conceptual form. They called these ‘affect’.

Affect refers to a variety of bodily experiences, sensations, or simply perceived shifts in atmospheric intensities that, although conditioned through sociocultural environments, may not take form through culture-specific conventions and meanings. Despite their conceptual ambiguity, affects can feel sensorially distinct. They can feel strong, sharp, or subdued. Alternatively, they can also not feel like much at all, seemingly falling outside a person’s conscious perceptions. As an analytical concept, affect offers new ways to investigate what anthropologists have in the past variously referred to as ‘collective effervescence’, ‘sentiment’, ‘emotion’, ‘feelings’, ‘sensations’, and ‘the senses’. The broad semantic spectrum of these terms suggests not only that emotional experiences are diverse but so too are the conditions that shape them. The adoption of affect as a key conceptual tool was driven in part by a desire to address dimensions of experiences that eluded clearly circumscribed cultural frameworks and linguistic structures of meaning.

Affect theory brings together perspectives from psychology, philosophy, and several other fields such as gender studies, ethnic studies, and literature to explore the bodily and relational aspects of feeling. The following sections outline the development of the affect concept in anthropological theory. The first section traces influential genealogical roots for affect found within psychology and philosophy. The second highlights the relation between affect and earlier anthropological work on emotion. Section three evaluates critiques of and counterpoints to affect, given that the term is highly contested and debated within the emerging field of affect theory. The fourth section features distinctive features of the affect concept, and the conclusion considers enduring themes of affect studies, including implications for ethnographic method and disciplinary critique.

Psychological and philosophical forerunners to affect

Literature on affect in anthropology can be theoretical, abstract, and contested (see introductions to affect such as De Antoni 2019; Liljeström 2016; Rutherford 2016; White 2017). Therefore, it is helpful to outline key theoretical discussions in the past, which have traditionally emphasised Western traditions and that inform contemporary anthropological debates on affect. Two genealogies of this concept are particularly prominent, one psychological and the other philosophical. Each contributes distinct but complementary perspectives to shed light on how affect operates as an embodied and relational phenomenon. A common theme of this literature is a concern with how to relate somatic, or bodily, aspects of emotional processes (the ‘affective’) with its symbolic, conceptual, and representational components (the ‘emotional’).

Early psychological debates on affect adopted the worldview of Western science, which understood emotional energies as grounded in bodies and inherited through processes of evolution. As part of a natural continuum that humans share with non-human animals, according to Charles Darwin, emotional capacities could be identified through expressional behaviours, such as tendencies to bear one’s teeth when angry (Darwin [1872] 2018). This evolutionary view remained apparent in an early debate on the definition of emotion, which centred around a famous anecdote that questioned, for instance, whether fear is a condition that triggers one to run upon encountering a bear in the woods or is rather the post-hoc ascription of fear to an aroused body. Psychologist William James’ (1884) idea is that the ‘subjective experience [of sensations like] fear or disgust is the result of a process that unfolds after the alerting change in core affect’ (Beatty 2019, 202). In other words, although the common view sees emotion as a sensation that comes after one is ‘afraid’ (one sees a bear, becomes afraid, and runs away), James argued the reverse: that one is ‘afraid’ because of the physical experience of bodily sensations (one sees a bear, runs away, and finds oneself afraid).

These early debates on emotion became even more contested with the arrival of Freudian theory and the globalisation of discourses on instincts, Id, and the unconscious (W. Anderson, Jenson, and Keller 2011). With the spread of Freud’s idea that one’s psyche could be split between conscious and subconscious elements, scholars began to more commonly distinguish between feelings as containing both emotionally conscious and affectively un- or non-conscious components. Psychologist Silvan Tomkins (1962a; 1962b) expanded on these ideas, proposing a taxonomy of core affective instincts, such as interest-excitement, enjoyment-joy, or anger-rage. His work posited that while these states are universally shared, their expressions vary across cultural contexts. Early innovative essays in critical theory that began using the word ‘affect’ (Sedgwick and Frank 1995a; 1995b) revisited Tomkins’ theories, paving the way for a culturally oriented affect theory. For affect theorists today, this psychological lineage has inspired a set of questions focused on whether affect is universal or culturally distinct, to what degree it is grounded in bodies, minds, or both, and whether affect emerges before, simultaneously with, or after a conscious recognition of an experience of emotion.

Western philosophers also demonstrated an early interest in the relation between the somatic and ideological components of emotion. The philosopher Baruch Spinoza ([1677] 1994) defined affect (or what he called affectus) as the capacity to ‘affect and be affected’, a common phrase that many anthropologists would later cite. Spinoza described affect as ‘affections of the body by which the body’s power of acting is increased or diminished, aided or restrained, and at the same time, the ideas of these affections’ ([1677] 1994, 70, emphasis added). Spinoza’s view was that affect (bodily capacities) and emotion (‘the ideas of these affections’) are two dimensions of an inseparable single process, an argument which reflects his opposition to the mind-body dualism of his time.

Spinoza continues to inspire contemporary affect theorists who highlight the enduring open-ended, processual, and mutable qualities of the affective body as it exists in relation to different social and material environments. His ideas were rekindled in the widely read materialist philosophy of Gilles Deleuze, and popularised most prominently by the philosopher Brian Massumi (1995; 2002). From Massumi’s point of view, affect indicates pre-conscious modulations of ‘intensity’ moving through and between bodies (Massumi 1995; 2002). Emotion, on the other hand, is ‘qualified intensity’, its conceptual ‘capture’ in meaning, or the ‘socio-linguistic fixing of the quality of an experience which is from that point onward defined as personal’ (Massumi 1995, 88). From this perspective, affect could be understood as a kind of physiological flux of sensation that is registered in bodies and travels between them; emotion, on the other hand, is the conceptualisation of that sensation in a culturally shared and often linguistically coded meaning.

Within contemporary debates on affect, the philosophical idea that ‘arrangements’ (Slaby, Mühlhoff, and Wüschner 2017) of humans and non-human objects shape and are shaped by affect prior to affect’s capture in meaning became a popular and highly contested idea. Many contemporary scholars in the humanities and social sciences cite this particular philosophical genealogy of affect as influential, even if they are also critical of it (Ahmed 2004b; Berlant 2011; Berlant and Stewart 2019; Seigworth and Gregg 2010; Seigworth and Pedwell 2023). For example, some scholars argue that the terms ‘emotion’ and ‘affect’ identify qualitatively distinct experiences that follow ‘different logics’ and ‘pertain to different orders’ (Massumi 2002, 27). Other scholars see emotion and affect as existing along a continuum (Ngai 2005). Still others have proposed that the perception of an ‘affect-emotion gap’ is itself the product of particular discursive knowledge regimes, and varies based on different cultural, political, and socioeconomic applications of affect and emotion as technical terms (White 2017; 2022).

As a result of these debates, affect became a helpful conceptual lens through which ethnographers could focus attention on nuanced felt experiences that could exceed or precede cognition and language. It also provided a more fine-grained way to approach the contagious involvement and coordination of bodies that can be witnessed during rituals, political rallies, festivals, or in stadiums. In this regard, affect offered anthropologists more diverse and detailed perspectives on classic sociological theories of sentiment, such as Émile Durkheim’s notion of ‘collective effervescence’ (Durkheim [1912] 2008), which conveys a homogenisation of affects into one single group experience.

For example, ethnographic research on contemporary militarism in Pakistan demonstrates how the state can mobilise affect to sustain its authority over other political groups in society (Rashid 2020). Through a study of mourning rituals orchestrated by military personnel, anthropologists have shown how the military transforms grief into a resource for national solidarity. Ritual activities like public commemorations of martyred soldiers and state-sponsored funerals create ‘affective subjects’ who embody both personal loss and collective loyalty. Such examples show how affect operates not only as a homogenous collective force that can emerge through large-scale rituals but also as a constellation of complex feelings that can be specifically cultivated by certain social groups and selectively fostered or resisted by others.

Anthropologies of emotion

Anthropological work on affect builds closely on anthropological studies of emotions. These studies looked primarily to non-Western case studies of emotional experiences to examine how emotions varied from one context to another, providing evidence that challenged universal perspectives assumed by early research. Prominent works on this theme from the early twentieth century approached emotion as a marker of cultural difference. These works were influenced by psychological approaches and were later categorised under the label ‘culture and personality studies’. Representative studies depicted cultures as comparable through their dominant ‘patterns’ of dispositions, attitudes, beliefs, and personalities that make up a specific cultural entity (Benedict [1934] 2005). One influential study of the Japanese by Ruth Benedict, for example, juxtaposed individualistic ‘Americans’ motivated by emotional matrices of guilt and free expression with a more group-oriented ‘Japanese’, who were portrayed as motivated by shame, interdependence, and an obligation to different in-groups (Benedict [1946] 1974). In the case of interpersonal transgression, for example, ‘instead of accusing a man of being unjust, as an American would’, says Benedict, Japanese ‘specify the circle of behavior he has not lived up to’, and pointing to the particular ‘province’ or ‘code’ that was violated (195). Therefore, in cases of socially perceived bad behaviour, an American ‘may suffer from guilt’, whereas for ‘the Japanese’ ‘a failure to follow their explicit signposts of good behavior…is a shame’ (223–4).

In the 1970s and 80s, anthropologists reformulated these ideas of cultural difference imagined through constructs of emotion-based patterns and personality types, critiquing them as too rigid, culture-bound, and resistant to change. Instead, they focused on analysing emotional differences that could be observed through linguistic discourses and ‘emotional lexicons’ (Frevert et al. 2014). These anthropologists of emotion focused on cultural differences primarily by scrutinising emotion words in the languages of those they studied that did not neatly translate into English. This method offered insights into a broad human spectrum of emotional experiences existing both across and within different cultural groups.

For example, in a prominent 1980s study of the Ifaluk in Micronesia, based on fieldwork carried out in the late 1970s, anthropologists highlighted local words such as fago (loneliness/sadness) and song (justified anger) to build a critique of the ‘unnatural’ gendered division between reason and emotion in Western cultures (Lutz 1982; 1988). Other anthropologists working among the Pintupi of Australia examined emotions such as rarru (anger), which arose from threats to ‘shared identity or kinship’ (walytja) with others. These studies suggested that emotions emerge as semiotic—or meaning-making—practices rooted ‘in social life and its relationship to other signs’ (Myers 1988, 607). Among the Ilongot in the northern Philippines, strong feelings like liget resembled sentiments of anger and grief but did not have exact equivalents in Anglophone cultures, and appeared highly nuanced, complex, and variable (M. Rosaldo 1980, 1983, 143; R. Rosaldo 1989, 3; Spiegel 2017). These works demonstrated that emotions go beyond discrete bio-psychological categories and are embedded in social processes of language, meaning-making, and ethics (Lutz 1982; 1988; 2017).

Despite their innovative and nuanced approaches to emotion, some anthropologists perceived limits in what they saw as an increasingly outdated and culture-bound model of comparison. These critiques came in the wake of globalising processes that rendered the cultural boundaries of emotional words less distinct. Additionally, a theoretical turn in the 1980s emphasised a reflexive analysis of the Western literary conventions of anthropological writing, and challenged an ‘us-them’ model of culture (Clifford and Marcus 1986; Marcus and Fischer 1986). In light of their focus on culturally specific language and public symbols, previous studies of emotion were also criticised for overlooking aspects of bodily intensity that could exceed and confound language, potentially impacting bodies beyond conscious reflection.

These critiques grew throughout the 2000s, extending to disciplines beyond anthropology, and resulted in a theoretical shift away from the discursive dynamics of emotion toward sensations that did not neatly map onto emotional lexicons. Some scholars referred to this shift as the ‘affective turn’ (Clough 2007). Authors associated with this ‘turn’ sought to address more explicitly what language-centred analyses in the 1980s and 90s had partly and implicitly left out. Thus, affect theory provided alternatives to certain critiques made of the anthropology of emotion. Yet, it also became the target of new critiques, which argued that affect approaches overlook aspects of sociality in favour of describing bodily sensations, physiology, and abstract energetic processes of cultural dynamics.

Critiques of affect and counterpoints

With the rise of theoretical literature on affect, the term became increasingly targeted for critique and reformulation. For example, some critics took issue with an idea of affect as a field of ‘direct feeling’ that is supposedly distinct from the ‘conscious recognition’ of emotion (Ahmed 2004b, 39). They worried this approach risked universalising affect as a natural phenomenon disconnected from the socio-political forces that shape it. Related critiques argued that such a distinction even resembles a form of biological essentialism and reductionism, in which affect is treated as autonomous from ideology (e.g., Leys 2011, 2017).

Despite these on-going critiques of affect theory, some early studies of emotional and affective processes had specifically sought to show how social dynamics could shape physiological processes that were usually identified as purely biological or psychological phenomena. For instance, while a sensation such as pain may be commonly seen as an objective measure of a body’s biological response to a harmful stimulus, it can also be understood as operating through implicit value judgements of gender, ethnicity, and racial difference that ‘code’ pain in ways that register differently in the surfaces of skin. A study of an Australian government report on testimony of the separation of Aboriginal and Torres Straight Islander children from their families in Australia, for example, shows how historical narratives and contemporary legal practices can result in different effects upon the surfaces of bodies. While the report includes Aboriginal testimonies that read painfully to Indigenous communities, its suggestion that white Australians should acknowledge ‘national shame’ but not necessarily feel ‘personal guilt’ could be read as producing different affective results for readers with different skin colours: ‘Indigenous Australians tell their personal stories, but white readers are allowed to disappear from this history, having no part in what was done’ (Ahmed 2004a, 34–5). From this point of view, pain emerges as an immediate sensation, shaped through histories that read and feel differently for different people. Such studies show that ‘sensations are mediated, however immediately they seem to impress upon us’ (Ahmed 2004a, 30).

Although some studies like the above had directly addressed how bodily sensations could surface through social categories, other scholars still worried that broader trends in affect theory ignored how gender (Boler and Zembylas 2016; Thien 2005), ethnicity (Ramos-Zayas 2011), and racialisation (Berg and Ramos-Zayas 2015) shape and socialise affect. In adopting this perspective, affect theorists were entering territory covered by scholars of feminism, ethnic studies, and critical race theory. Some called for ‘critical examinations of “whiteness”’ (Berg and Ramos-Zayas 2015, 654) and sought to point out explicit examples from historical studies and queer theory that analyse the affective dimensions of racial dynamics. For example, historical studies of Latin American and Caribbean migrants in the United States have shown how certain depressive states were described by predominantly white mental health professionals through culture-bound taxonomies, such as familismo, fatalismo, or the ‘Puerto Rican syndrome’ (Berg and Ramos-Zayas 2015, 660; see also Muñoz 2006). Certain painful feelings tied to migration experiences, surfacing as uncontrollable screaming, trembling, or aggression in young women, were labelled as ‘abnormal’ and characterised through ethnic categorisations (Berg and Ramos-Zayas 2015, 660). Conversely, as other historical studies have shown, the perception of schizophrenia changed significantly in the 1960s from being seen as a ‘harmless’ condition primarily affecting white people to being viewed as a dangerous disorder characterised by anger and linked with the civil rights and Black Power movements (Berg and Ramos-Zayas 2015, 660; see also Metzl 2009). These studies show how institutional practices and ways of talking about race can condition negative affective states through racial frames.

Other critics argued that many affect studies ignored the role of history and place in conditioning affective responses, and offered compelling ethnographic examples as counterpoints. For instance, in a study on the ‘affective geographies’ of post-war Cyprus, after a 1974 partition of the island’s residents into a distinct northern Turkish-Cypriot and southern Greek-Cypriot territory, residents told stories of the melancholic feelings they encountered within ruined landscapes. Turkish Cypriots living in the abandoned homes of Greek Cypriots in the north faced an ‘atmosphere’ that ‘discharged a feeling of the uncanny, a strange feeling’ that was derived for some ‘out of a sense of impropriety, haunting, or an act of violation’ (Navaro-Yashin 2009, 11). Such studies raise the question of whether the feelings encountered in these landscapes are subjective, coming from the individual’s perception of a historically storied space, or the material environment itself, filled with abandoned objects and unkempt fields. Ethnographic evidence suggests that ‘neither the ruin…nor the people who live around it are affective on their own […] but both produce and transmit affect relationally’ (Navaro-Yashin 2009, 14). Detailed ethnographic studies of these socio-historical qualities of environments and space can help anthropologists unpack the multilayered impacts that some geographers have called ‘affective atmospheres’ (Anderson 2009).

Still other critics worried that philosophical oriented theorists of affect too heavily emphasise a ‘gap’ between the ‘signifying order’ and ‘affective order’; that is, between that which can be articulated and that which escapes linguistic expression (Martin 2013, S155; Ahmed 2004b; Berg and Ramos-Zayas 2015; Navaro 2017; Navaro-Yashin 2009). They wondered whether such a distinction was needed between emotion and affect at all. To this question, some of today’s affect theorists respond that neither early formative philosophical works on affect nor much of the affect literature that followed it subscribed to as hard of a break between affect and emotion as was characterised in some critiques of affect. As noted by Massumi in his popular work on affect, ‘The approach suggested here does not accept any categorical separation between the social and the presocial, between culture and some kind of “raw” nature or experience… The field of emergence is not presocial. It is open-endedly social’ (Massumi 2002, 9). Choosing to avoid this debate altogether, some scholars have advocated using the terms ‘affect’ and ‘emotion’ interchangeably (see Lutz 2017) or argued for ‘modal’ approaches that posit affect and emotion on a continuum, ‘whereby affects acquire the semantic density and narrative complexity of emotions, and emotions conversely denature into affects’ (Ngai 2005, 27).

Anthropologists of ‘embodiment’ have also contributed to discussions of how emotional and affective practices can exist along a continuum. These scholars argue that a focus on embodiment helps situate affect not as distinct from meaning-making processes, suggestive of body-mind dichotomies, but as something through which ‘dualities such as subject and object or meaning and the material world (evoking mind/body) can be collapsed’ (McDonald 2018, 187; also see Csordas 1990; 1993). For example, studies of exorcism rituals in Italy show how feelings and affects situated in embodied practices like prayer and touch constitute the basis for the experiential emergence of spiritual entities such as the devil. These felt experiences of the possessed person and the participants in exorcisms, in turn, contribute to the reality and the ‘capturing’ of particular entities into historicised, cultural structures of meaning—namely one demon or angel rather than another (De Antoni 2022). This ethnographically grounded approach to bodily feelings showcases what a focus on affect can offer anthropology.

Finally, some critics raised a methodological concern about philosophical descriptions of affect as an ‘escape’ from ‘perception’ (Massumi 2002, 36) or, in other words, as something that was difficult to articulate or ‘capture’ in language (see also Stodulka et al., 2019). For some ethnographers accustomed to describing their interlocutors through narratives, thinking of affect as that which always escapes its articulation has led to practical and methodological frustrations. It has also invited evocative experimental forms of writing about affect, such as works on everyday American life that attempt to capture the somatic contours of daily routines and ‘ordinary affects’ in poetic language that does not correspond to common analytical concepts (Stewart 2007, 1; also see Berlant and Stewart 2019). Many anthropological works on affect can be both highly theoretical and/or poetic in their approaches, and thus offer powerful insights through virtuosity in prose. At the same time, they can appear to some as overly abstracted from ethnographic contexts (Beatty 2019, 210–6). Thus, writing against the aforementioned critiques, many recent ethnographies analyse affect as situated in historical and cultural contexts (Ahmed 2004b; Berg and Ramos-Zayas 2015; Boler and Zembylas 2016; Muehlebach 2011; Muñoz 2006; Navaro-Yashin 2009; 2012; Newell 2018; Ngai 2005). Such works emphasise the simultaneously material, historical, social, somatic, and semiotic aspects of affect, and how these components relationally feed back into one another through dynamic ‘affective-discursive loops’ (Wetherell 2012, 7).

Indeed, some recent studies of affect have addressed the challenging question of how socio-material arrangements take on a force that is felt before it is conceived by revisiting classic arguments in social theory, such as in the popular discussion around mana (Mazzarella 2017a). Mana is a concept found throughout Polynesia that refers to a transhuman ‘force or efficacy’ that was ascribed to certain people or places that expressed palpable power and ‘vital energetics’ (Mazzarella 2017a, 1). Sociologist Émile Durkheim described mana as ‘at once a physical force and a moral power’ (Mazzarella 2017a, 1), resembling contemporary anthropologists’ interest in the relation between the emotional-conceptual and affective-somatic aspects of social processes. Such innovate reinterpretations of social theory show that what anthropologists today call ‘affect’ can be used to shed light on classic anthropological debates, resulting in a series of productive connections between anthropological studies of affect, emotions, mana, collective effervescence, and the ‘senses’ (Howes 2005; Pink 2009).

Advancing distinctive contributions of affect

Despite the many critiques of affect, including constructive suggestions to consider the overlapping territory between affect and emotion, there remain strong arguments for maintaining the distinctiveness of the term. For example, given that human acts of sensing or ‘feeling with the world’ (De Antoni and Dumouchel 2017) incorporate complex, fluid dimensions of both somatic and semiotic phenomenon, the word ‘affect’ can help disambiguate multiple processes. It can help anthropologists discern somatic processes that seem to function in part outside or below discourse more discretely, catalogue them more comprehensively, and add to ethnographic descriptions’ clarity, granularity, and sensitivity. This can sometimes require the modulation of the ethnographer’s own senses, which broadens previous conceptions of what makes for good ethnographic training.

For example, a case study of the French perfume industry demonstrates how affective capacities can develop through pedagogies of training, sensory exercises, and objects like an odour kit (Teil 1998). An odour kit is ‘made of a series of sharply distinct pure fragrances arranged in such a way that one can go from sharpest to the smallest contrasts. To register those contrasts one needs to be trained’ (Latour 2004, 207). In so doing, a perfumer, or an ethnographer studying perfume, must learn to ‘have a nose’ that allows one to inhabit a (richly differentiated odoriferous) world’ (207). New bodily capacities develop alongside encounters with objects that also operate affectively on the body. The result is that one develops a new, more discrete sensory capacity that at the same time unveils a more sensory-rich world particular to the modern French perfume industry.

Affect as a conceptual tool can also point to the experience of feelings that, while conditioned by cultural contexts, often misalign with or even challenge established cultural values. It can also help anthropologists articulate what happens in spaces of intimacy, whether of private homes or of selves, that do not fit—or fit only in queer relation—with established social values. In the Sindh Province of Pakistan, fakirs (meaning ‘beggars’ in Urdu and, in some cases, ‘transgenders’ in Sindhi) refer to persons who voluntarily take up poverty as a practice of ascetic devotion to Islamic saints, often motivated by ‘prophetic dreams and personal callings’ (Kasmani 2022, 8). Through devotional practices and mystical encounters with saints, some fakirs describe experiences of closeness and intimacy with saints that serve both as compelling testimonies of desirable affect for other ascetics and morally troubling stories for religious and political authorities. Thus, affects of ‘private feelings’ and ‘intimate relations with saints carry ramifications for broader regimes and critiques of power’ (10).

Another helpful approach to affect is a reflexive one, which subjects conceptualisations of affect, such as ‘the affect-emotion gap’ described above, to ethnographic observation. When doing so, it becomes clear how anthropologists’ practices of theorising affect can resemble those of their interlocutors. In national branding campaigns in Japan, for example, anthropologists noted how something like an ‘affect-emotion gap’ was also conceptualised by bureaucrats and national cultural policy makers. These officials observed an affective excitement among global consumers of pop-culture commodities produced in Japan and sought to convert it into an emotionally charged affinity for Japan itself. For example, through government-funded events promoting cultures of manga, to which many readers are attracted for its minor and counter-cultural themes, officials attempted to mainstream manga as a national cultural property of Japan. In this way, an increasingly global cultural commodity could be transformed into a potential national resource of soft power (Galbraith 2019; Leheny 2018; White 2022).

A similar process of gapping or splitting emotional processes can be observed within the global technological world of modelling affection, preference, and taste. For example, computer scientists at academic labs and corporate offices in the US who build taste recommendation algorithms for social media feeds presume that an affective appeal for a certain music style can be coded into numbers (Seaver 2022). Such a perspective splits a feeling of affection into the affective dimensions of personal experience and the emotional dimensions of ‘preference’ that can be computed. Similarly, engineers and computer scientists operating in the field of ‘affective computing’ (Picard 1997) at prominent labs at MIT and Cambridge rely on models that understand ‘affect’ as physiological changes in the body and ‘emotion’ as something codable in a machine system and translatable to humans interpreting those systems. Adapting work on affective computing to East Asian contexts, some robot engineers in Japan have experimented with building ‘affective engines’ into emotionally intelligent technologies, which could theoretically discern the affective states of people by reading the signal of an emotion, such as ‘happiness’, through the facial-expression recognition of a smile (see Fujita and Kitano 1998; White and Katsuno 2021; 2023). These examples illustrate how many specialists in the hard sciences are currently operationalising their own theories of affect to much greater impact than anthropologists. In fieldwork within rapidly changing technological worlds, the term ‘affect’ can therefore help anthropologists track significant transformations in the meanings, applications, and experiences of both human and more-than-human emotion.

Conclusions

As the above theoretical debates and ethnographic examples illustrate, studies of affect are diverse and contested. Nevertheless, enduring themes remain. Three are prominent. The first is the proposition that affect can point to feelings experienced beyond language or cognition—although not necessarily unaffected by them. Affect is indeed something more than just meaning. Rather, affect holds promise to add dimensionality to meaning, showing that meaning incorporates dynamic aspects of exchange between bodily experience and signification (Slaby and Röttger-Rössler 2018; Newell 2018; and Mazzarella 2009; 2017b). Affect points to somatic worlds in a way that is shared among others and consequentially entangled with semiotic concepts and conditioning. Bringing affect and semiotics together in this way can offer ‘improved understanding of both as the intertwined core of sociality itself’ (Newell 2018, 2).

A second enduring theme of affect is relationality. Although human bodies can be understood as individual sense-making and sense-registering entities, they are far from being merely an individuated product of established discourse. Rather, bodies can function as nodes that register, exchange, mediate, reciprocate, co-participate, and change in relation with other bodies or simply bodily parts—human or otherwise, living or inanimate (Navaro-Yashin 2009; Bennett 2010). This relationality of affect points directly to affect’s political dimensions and power dynamics, which incorporate aspects of race, ethnicity, gender, class, and several other theoretical concepts commonly used in socio-cultural anthropology (Berg and Ramos-Zayas 2015; Boler and Zembylas 2016).

Third, although affects may be distinguished by their uneasy alignment with conventional cultural categories, this by no means implies that affects are socially unconditioned. This point suggests that studies of affect hold potential to not only enrich previous anthropological studies of emotion but also to expand anthropologists’ understanding of the ‘culture’ concept on which the discipline still heavily depends. Through its ability to point anthropologists to the dynamic relation between public symbols and private feeling, the affect lens can unearth experiential dimensions of culture that have not been fully explored until recently.

Finally, beyond these enduring themes, affect may hold the greatest potential not in its theory-heavy analytics, which can draw disproportionately from the Western and philosophical traditions outlined above, but rather in its ethnographic applications in fieldwork. A growing collection of richly detailed ethnographies of religious practices, digital media, and human-nature interactions—many of non-Western contexts—show that affective practices exist in diverse and dynamic forms that don’t accommodate easily to established analytical theorising. For example, the deep cultivation of balanced states of feeling through Buddhist meditation in Thailand (Cook 2010); the pursuit of ‘queer companionship’ between Islamic saints and ascetics (Kasmani 2022); the mediation of the paranormal in Chile (Espírito Santo 2023); or the making of intimate and sometimes indifferent relationships with non-human others such as palms (Chao 2022), orangutans (Chua 2018; Parreñas 2012, 2018), mushrooms (Tsing 2021), and microbes (Benezra 2023): these innovative studies of affective themes diversify anthropology’s traditional understandings of culture; expand who speaks for and feels ethnographic knowledge; and offer reflexive resources for productively undoing and remaking the affective modes through which anthropological work is undertaken.

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Note on contributors

Daniel White is a research affiliate at the Leverhulme Centre for the Future of Intelligence at the University of Cambridge. His research examines emotion, politics, and emerging media technologies, with a geographic concentration on Japan and the Asia-Pacific. His recent book is Administering affect: Pop-Culture Japan and the politics of anxiety (2022, Stanford).

Daniel White, Associate Fellow, Leverhulme Centre for the Future of Intelligence. Level 1, 16 Mill Lane, Cambridge, Cambridgeshire, CB2 1SB, United Kingdom. Orcid ID: 0000-0003-2866-6587

Andrea De Antoni is associate professor in cultural anthropology at Kyoto University and Research Coordinator of the Italian School of East Asian Studies (ISEAS) in Kyoto. He specializes in anthropology of religion, experiences with spirits, spiritual healing in contemporary Japan and Italy, the anthropology of the body, affect, and emotions. He has published extensively about these topics in English and Japanese.

Andrea De Antoni, Associate Professor, Kyoto University, Graduate School of Human and Environmental Studies, Yoshida Nihonmatsu-cho, Sakyo-ku, Kyoto 606-8501, Japan. ORCID ID: 0000-0002-6480-0790

Editor:

Hanna Nieber

Diabetes

Rebecca Tishler — Mon, 01 May 2023 08:04:50 +0000

Person getting tested for high blood pressure and diabetes at Prince Mshiyeni Memorial Hospital in South Africa in 2012. Photo: GovernmentZA

Shir Lerman Ginzburg

Massachusetts College of Pharmacy and Health Sciences

Initially published 1 May 2023

http://doi.org/10.29164/23diabetes

Abstract:

Type 2 diabetes mellitus is a global disease that involves the body’s impaired ability to regulate blood sugar (glucose) due to malfunctioning insulin, a hormone produced in the pancreas which is responsible for transporting the glucose into the cells. Anthropologists have provided meaningful insights into the causes (aetiologies) and prevalence of diabetes, particularly focusing on the social, political, and economic factors that underlie the ways in which diabetes continues to afflict millions of people worldwide. As a chronic illness with no cure, diabetes poses unique challenges for people struggling to manage medications, food changes, and multiple medical appointments, particularly for those who are already suffering from other structural barriers to health. Furthermore, anthropologists have highlighted the importance of identifying the overlaps between diabetes and other chronic diseases in order to provide better treatment options and to understand the underlying structural conditions that contribute to diabetes, such as poverty and unemployment. The ‘syndemics’ framework is a useful tool for considering the multileveled approaches to diabetes aetiologies and preventions.

Introduction

Diabetes, a cluster of diseases that impact the body’s ability to process insulin, is well-established as a chronic illness, having been described as such as early as 1500 BCE, when an Egyptian manuscript described a ‘too great emptying of the urine’, although Apollonius of Memphis was the first to call the disease ‘diabetes’ in 250 BCE (Trikkalinou et al. 2017). Several centuries later, an unnamed seventeenth-century English surgeon called diabetes ‘the pissing evile’ due to the frequent urination common to people with the disease (Karamanou et al. 2016; Kelleher 1988). Unfortunately, most diabetes itself is rather less colourful, albeit equally dangerous if left unchecked. Diabetes is a chronic disease characterised by high glucose due to the body’s inability to produce and/or process insulin, a hormone that helps the body use energy (Carruth et al. 2019; Mendenhall et al. 2010; Schoenberg et al. 2005). People are clinically diagnosed with diabetes if their fasting glucose blood test levels are over 126 mg/L or have a three-month average hemoglobin (HbA1c) level of at least 6.0%.^[1] The number of adults (ages 20-79) worldwide living with diabetes reached 537 million people in 2021 and researchers estimate that by 2045, 783 million individuals worldwide will have diabetes.^[2]

Symptoms for diabetes include increased urination and thirst, unintentional weight loss, blurred vision, exhaustion, tingling hands and feet, and dry skin. Diabetes is sometimes called ‘the silent killer’ because these symptoms are so common that they are oftentimes attributed to other things, leading to worsening disease outcomes and decreased quality of life before a diagnosis is even made. Untreated diabetes can lead to coronary artery disease, renal failure, and blindness, and is correlated with high blood pressure (hypertension), high cholesterol (dyslipidaemia), arthritis, and depression (Mendenhall 2019; Trikkalinou et al. 2017).

Healthcare providers generally diagnose individuals as having one of three broad types of diabetes: type 1, type 2, and gestational. All three types share the same general symptoms and basic cause (a cellular inability to absorb glucose for fuel due to a failure to recognise insulin) but differ in the physiological details and cultural paradigms of aetiology and treatment. This entry will begin by outlining the three general types of diabetes and then discuss how anthropologists shed light on interacting cultural models of diabetes diagnosis, treatment, and long-term care.

Types of diabetes

Type 1 diabetes mellitus is an autoimmune reaction wherein the body’s defence system attacks the cells that create insulin, causing a severe insulin shortage in the body and allowing for a dangerous accumulation of glucose in the blood. Unchecked type 1 diabetes can contribute to nerve damage (neuropathy), kidney damage (nephropathy), eye damage (diabetic retinopathy), foot damage, heart disease, and skin infections.^[3] It is linked to both genetic and environmental factors, although the exact causes are not yet known and there is no known cure. Type 1 typically develops in children and young adults and requires individuals to inject insulin daily to remain healthy.^[4] Approximately 10% of people worldwide have type 1 diabetes as of July 2020.^[5]

Gestational diabetes develops in pregnant women who did not already have diabetes prior to pregnancy. This type of diabetes physiologically resembles the other types in that the body struggles to recognise insulin, which leads to higher levels of glucose in the bloodstream. While glucose levels generally return to normal after giving birth, women who have gestational diabetes are at higher risk for developing type 2 diabetes later in life.^[6]The precise origins of gestational diabetes are unknown, yet researchers suggest that the mother’s pre-pregnancy weight, physical inactivity during pregnancy, being of certain races or ethnicities (such as Black, Hispanic, and American Indian), having a family history of diabetes, and having polycystic ovarian syndrome are all contributing factors.^[7] Approximately 14% of women worldwide had gestational diabetes during pregnancy in 2021 (Wang et al. 2022).

Type 2 diabetes has become a pandemic, catching the attention of researchers and healthcare providers alike due to the urgent nature of its scope. Like the other diabetes types, type 2 involves high blood glucose levels, but unlike the other types, in type 2 the pancreas produces sufficient insulin. Instead, cells resist insulin’s efforts to transport glucose into the cells (insulin resistance), resulting in rising blood glucose levels and causing the pancreas to create more insulin. However, the cells continue to resist the insulin’s efforts, resulting in even higher glucose levels which can cause major health problems, such as heart disease, liver and kidney failure, and vision loss.^[8] Type 2 diabetes accounts for 95% of diabetes cases worldwide, with physical inactivity, being overweight or obese, and socioeconomic factors like poverty being major contributing factors.^[9]

This entry focuses on type 2 diabetes due to its overwhelming global prevalence and due to the biomedical focus on solely individual behaviours. Diabetes is commonly known among biomedical healthcare providers as the ‘lifestyle type’ due to its association with overconsumption and sedentary behaviours, which are generally blamed on individual patients (Carruth et al. 2019; Yates-Doerr 2011). However, this framing ignores the social, economic, and political contexts that impact the diabetes experiences of many patients. While anthropologists acknowledge the different clinical diabetes types, they also recognise the limitations of clinical diagnosis in getting to the deeper causes of diabetes.

Structural roots and barriers to care

Diabetes is what medical anthropologists term a ‘disease of modernisation’ due to its association with structural factors, such as poverty, unemployment, and colonisation (Baglar 2013; Ely et al. 2011; Mendenhall et al. 2010; Singer 2020; Wiedman 2012). At the same time, diabetes management has become exponentially more expensive due to the rise in transportation, housing, healthcare, and food costs, which negatively impact many peoples’ ability to consistently afford the many changes that are recommended by healthcare providers, particularly when many individuals are already struggling to pay for rent and other necessary living expenses (Mendenhall 2015; Thorsen et al. 2020; Vest et al. 2013; Weaver 2018). High costs of diagnosis and treatment contribute to diabetes being diagnosed later in its development and enable it to have more destructive effects.

Quality of life for people with diabetes depends on their financial resources, geographic proximity to healthcare services and social support networks, physical pain or discomfort levels, and dietary patterns. The uncertain, long-term benefits of living with minimal complications often conflict with the day-to-day difficulties of diabetes maintenance, which negatively impacts stress levels (Black et al. 2017; Speight et al. 2019). Anthropologists tend to note that not all populations experience the same quality of life in living with diabetes, as some communities face additional social, economic, and racial disparities on top of pre-existing health disparities that make a life of diabetes much harder (e.g. Rock 2003a; Wiedman 2021 and Weaver 2018). For example, Janet Page-Reeves and colleagues (2013) note that individual decisions and human agency is heavily constrained by social environments (structure) when it comes to diagnosing and treating diabetes. The social environment that Page-Reeves and others study is that of Hispanics in the state of New Mexico. They incorporate specific conceptual models of illness such as emotional regulation of symptom experience and biomedical diabetes aetiology, and core cultural values such as religiosity and prioritising the family to understand and deal with the disease. Page-Reeves and colleagues observe that in situations with limited economic resources, deciding where to spend money can be a difficult choice, particularly if family members with diabetes need to buy healthier (and more expensive) foods on top of multiple visits to the doctor.

The structural nature of diabetes reflects community-level inequalities in access to different foods, healthcare, education, and other necessary resources. While diabetes is currently present in all populations worldwide, it disproportionately affects low-income populations due to multiple factors that intersect with poverty, such as unemployment, food insecurity, unaffordable healthcare, and non-existent social support (Ferzacca 2012; Lerman Ginzburg 2020; Mendenhall et al. 2017; Rock 2003a; Solomon 2016; Weaver 2018).

A significant ethnography on the structural experiences of vulnerable populations with diabetes is Carolyn Smith-Morris’ 2006 ethnography of diabetes among the Akimel O’odham (colloquially known by outsiders as the Pima), a Native American tribe based by the Gila River in the state of Arizona and the northern Mexican desert. Smith-Morris found that the sweltering Arizona heat, unemployment, and poverty were all factors in the Akimel O’odham developing diabetes. Here, starkly high levels of unemployment and high reliance on government assistance coupled with limited economic resources, reduced physical exercise due to the heat, limited affordable healthy food options on the Pima reservation, and use of food as a comfort against daily struggles, were all contributing factors to developing diabetes. Although the Akimel O’odham have lived near the Gila River for centuries and are familiar with the high temperatures, their responses to it have changed in the past hundred years. As the Gila River has dried up, the Akimel O’odham lost their traditional farms and increasingly relied on government-subsidised foodstuffs (Smith-Morris 2006). Notably, the drying up of the Gila River was not a natural phenomenon, but resulted from the Arizona government’s extensive irrigation efforts as well as damming by non-Native farmers. However, policies of the US Department of Agriculture (USDA), which extended into the 1980s, forbade the Akimel O’odham from receiving help from agricultural loans. Combined with the loss of traditional food pathways, these policies forced the Akimel O’odham to obtain sedentary jobs and rely on high-calorie, poor-nutrition governmental food handouts (Booth et al. 2017; Smith-Morris 2006). Indeed, diabetes is so ubiquitous in the Akimel O’odham that participants in Smith-Morris’ research naturalised it more and more, observing, ‘it’s just how Pimas are’ (2006: 33).

Smith-Morris’s work with the Akimel O’odham highlights how political and economic factors contributed to diabetes aetiology in a population already facing racism and other abuses from the very government that was supposed to care for them. Recent work in Nepal supports these findings. Here, governmental inaction in the face of rigid social hierarchies and discrimination against the Dalits–members of the lowest social caste–creates structural situations of high diabetes risk (Thapa 2014). While caste-based discrimination is officially illegal in Nepal, social hierarchies forbid Dalits from participating in many social, religious, educational, and employment opportunities, forcing them into poverty, food insecurity, and occupational and housing uncertainty—all of which elevate diabetes risk. Given that existing social hierarchies are deeply entrenched, the Nepalese government has found it difficult to enforce anti-discrimination laws; in doing so, the Nepalese government failed to take care of its most vulnerable members and reduce Dalit diabetes risk. In this example, it is government negligence, rather than active mismanagement, that increases diabetes risk.

Additionally, colonisation is a structural factor that boosts diabetes risk, particularly as its effects continue for generations after the dissolution of the original colonising state. Indigenous communities that have experienced colonisation face extremely high diabetes rates due to a loss of traditional lands and food sources, cycles of food insecurity, and mental distress from oppressive regimes. In Canada, the diabetes prevalence rate is four times higher among Indigenous communities than in the general population due to decades of the Canadian government enforcing starvation, stress, food insecurity, and the environmental degradation of traditional food sources such as fishing (Temblay et al. 2021). Similarly, high diabetes rates in the Marshall Islands have been linked to the World War II-era devastation of breadfruit trees, which were a traditional food source for Indigenous communities (Duke 2017). The US began distributing canned meat and white rice when it colonised the Marshall Islands after the war. This abrupt change in food acquisition and preparation negatively impacted the Marshallese’s relationship with their environments and their bodies by increasing their reliance on imported canned foods, which are high in additives, rather than on fresh and local resources.

The geographic diversity of these case studies emphasises an urgent need for studying the complex historical, structural, and traumatic roots of diabetes in greater depth. Prolonged exposure to colonialism is associated with a profound loss of traditional food acquisition, preparation and consumption, and subsequently high levels of food insecurity and malnutrition even when a colonising regime no longer exists. The loss of traditional livelihoods and diminished community self-determination undermine socioeconomic development among oppressed communities. Particularly, it leaves rural communities in debilitating working conditions with only limited access to comprehensive primary care or physical activity options, like walking trails, that are weather-safe for year-round use (Rice et al. 2016; Tremblay et al. 2021).

The colonial roots of diabetes serve as a stark reminder that health is due as much to structural environments as it is to biology. As these and other ethnographies demonstrate, structural environments contribute to diabetes being a social disease as participants shared stories about their etiological foundations of diabetes and the ways in which adjusting to a new life required new perspectives.

Diabetes and biopower

Although, as the ethnographies above elucidate, anthropologists have studied diabetes susceptibility among different populations, anthropological literature has also cautioned against relying on rigid, overly simplistic ethnic categories to understand diabetes because they miss the nuanced biological human variations between and among ethnic groups that contribute to diabetes risk (Montoya 2007). Labelling individuals or entire populations as ‘at risk’ for diabetes based on easy single-gene categories risks ‘naïve genetic determinism’ that glosses over the need for deeper analysis of the social and environmental histories of different populations that shape their susceptibility to diabetes (Montoya 2007). Anthropologists have contributed valuable insight into the social, political, and environmental pressures that individuals and populations face, particularly by incorporating biopower—the regulation of human life at the population and individual body levels—and the politics of health, body image, illness metaphors, and explanatory models into the frameworks of diabetes aetiologies and lived experiences (Ferzacca 2012).

For example, research on the clinical encounters of diabetes highlights the difference between clinicians’ perspectives on diabetes and the perspectives of patients with diabetes (Guell 2011; Hernandez 1995; Hunt et al. 1998). Cheri Hernandez (1995), in an ethnographic study on the clinical parameters of diabetes management, observed that while healthcare providers emphasise maintaining acceptable glucose levels and adhering to medication and weight loss regimens, patients prioritise learning how to live with diabetes. Patients with diabetes often found biomedical explanations for diabetes to be insufficient and attributed their diabetes to personally-relevant triggering events and behaviours. Those who believed that their own behaviours were causes of diabetes tended to be more involved in their treatment; the act of being involved in treatment was associated with long-term behaviour change (Hunt et al. 1998).

While Hernandez and Linda Hunt et al. focused on the individual’s biomedical encounters for diabetes treatment, others have expanded this approach to the collective diabetes experience. Cornelia Guell (2011) draws attention to the conflicting hierarchies of diabetes knowledge in Germany that arose among Turkish migrants in Berlin. Tensions arose between Turkish healthcare providers and layperson self-help groups over conflicting values and knowledge hierarchies about diabetes. Along with fierce competition for limited funding for community diabetes clinics and health education classes, these differences in diabetes knowledge not only pitted the community and healthcare providers against one another but also created rifts in a community already facing severe marginalisation. Similarly, healthcare providers frequently place the responsibility for diabetes management squarely on the patient, making them ‘morally liable for their own ill health’, as Rebecca Seligman and colleagues have highlighted in their work on Mexican immigrants with diabetes in the city of Chicago (2015: 64). Many physicians believed that structural and social interventions were not part of their jobs, preferring to focus solely on clinical treatments without being concerned for the underlying social and structural roots of diabetes (Mendenhall et al. 2017). This arbitrary dividing of responsibility is harmful and perpetuates the deeper structures contributing to diabetes. It also conflicts with how people living with diabetes view their own diabetes aetiologies. Many people who spoke with Seligman et al. (2015) attributed their diabetes to structural factors, such as interpersonal violence, poverty, and unemployment, indicating that the biomedical emphasis on individual patient responsibility overlooks patients’ lived experiences with diabetes.

Diabetes management is complex and fraught with overlapping layers of meaning. A major theme in the anthropological literature on diabetes is that of responsibility and control over diabetic bodies. Biomedicine, in its fervent pursuit of individualised health, places the locus of control directly onto the patient to manage self-care; when diabetic bodies do not behave according to biomedically prescribed plans, the onus of responsibility falls squarely on the patient. Biopower, or the regulation of human life at the population and individual body levels, is used to discipline misbehaving bodies into docile conformity through state-controlled sites, such as schools, hospitals, and prisons (Foucault 1976). Bodies become political and economic battlegrounds between policymakers and healthcare providers as debates rage over the best ways to prevent and treat diabetes, while at the same time these forces exert control over the individuals who are inhabiting the very bodies at the centre of these debates (Gibson and Dempsey 2015).

One example of biopower in a colonisation framework is among Indigenous communities in Canada. Indigenous children at residential schools in Canada developed negative relationships with food due to malnourishment, abuse, punishment, and humiliation perpetuated in the residential school environment (Howard 2014). These collective traumas and negative lived experiences of residential school food were passed on to subsequent generations, where, aided by a loss of traditional food pathways due to aggressive colonisation by the Canadian government, they are embodied as diabetes among Canada’s Indigenous communities. Indigenous interactions with contemporary healthcare systems in Canada have reinforced colonisation through racism, stereotyping, and discrimination (Jacklin et al. 2017). Patients reported being repeatedly ignored or patronised at medical appointments despite having travelled long distances for check-ups. Physician shortages and geographic isolation from clinics contributed to diabetes mismanagement, as patients sometimes waited for several months without seeing a physician or having their medications refilled. In both cases, colonialism reinforced the stereotype of misbehaving diabetic bodies and placed the blame firmly on Indigenous communities for their own diabetes while diffusing blame from the state-sanctioned violence of colonisation that is responsible for diabetes perpetuation.

One of the most fundamental contributing factors to biopower and diabetes is the question of control over the very parameters of health. US doctors who led medical missions to Belize taught the locals that diabetes was the individual’s responsibility, rather than the doctor’s liability (Moran-Thomas 2019). This biomedical focus on patient responsibility for diabetes maintenance absolved doctors of the obligation to consider the roles of broader social, economic, and political milieus in which their patients lived. Doctors did not spend much time helping patients identify the early warning signs of diabetes but simply told them to lose weight and get more physical activity, despite limited access to healthy, affordable foods, safe infrastructure for outdoor activity, or disposable income for gym memberships. Amy Moran-Thomas notes that this lack of comprehensive medical care is notable because, as diabetes is not transmitted between people, there is less biomedical focus on the ways in which people’s interactions propagate the disease and more on the individual’s genetics and decisions that make someone more at risk for diabetes, despite the blatant social risk factors. As such, patients are blamed for noncompliance, frequently without evidence, despite the structural factors that exacerbate diabetes risk.

The physical body is also shaped by cultural metaphors of health and diabetes and naturalises certain cultural norms while stigmatising others (Martin 1987; Solomon 2016; Hardin 2018). This is evident in the ways in which diabetes is stigmatised due to its socially perceived associations with uncontrollable food consumption (Aghamohammadi-Kalkhoran and Valizadeh 2016; Broom and Whittaker 2004; Ferzacca 2012; Lee et al. 2015). For example, Amanda Willig and colleagues (2014) found that African American women with diabetes reported experiencing diabetes stigma when they were the only ones in their extended families with the disease, as they were perceived as having no self-control over their health and were treated as children without the ability to make decisions for themselves. Denise Bockwoldt and colleagues (2016) found that African Americans are less likely to adhere to insulin-based medication regimes due to a plethora of negative emotions associated with insulin, such as self-blame, frustration, fear of complications, and of being a burden on loved ones. Some study participants admitted to hiding their insulin from their loved ones so as to not be outed as insulin dependent. These results were replicated by Kryseana Harper et al. (2018), who found that family-based diabetes stigma was common in their mixed-gender African American cohort. This stigma both perpetuated a reduction in diabetes self-management and created resentment towards diabetes for the disruption it caused to peoples’ personal lives.

Additionally, healthcare providers sometimes stigmatise people with diabetes if they do not lose weight or adhere to their prescribed medication regimens, which further discourages people from visiting a healthcare provider (McNaughton 2013; Shahab et al. 2019). People with diabetes who need to inject insulin may also be mistaken for and stigmatised as drug users should they need to inject insulin in public (Balfe and Jackson 2007; Bock 2012). In the United States, a country in which productivity is highly valued, any loss of individual productivity is devalued and stigmatised, particularly if the cause of that loss is concealed or is a manageable disease, as diabetes is commonly thought to be (Ferzacca 2012; Hopper 1981; Shahab et al. 2019). External stigma over perceived loss of productivity and lack of individual discipline that are thought to contribute to diabetes become internalised among those living with diabetes or are involved in its treatment, and perpetuate individual and biomedical diabetes mismanagement (Aghamohammadi-Kalkhoran and Valizadeh 2016; Ferzacca 2012; Seligman et al. 2015).

Anthropologists reject the overly simplistic categorisations of diabetes as a disease of racial and genetic determinism, preferring instead to trace the overlapping intersections between biological pathways and structural factors. In her work with the Native community in Chicago, Margaret Pollak (2018) notes that anthropologists reject the thrifty genotype hypotheses, which speculates that people are biologically predisposed to diabetes, which is then triggered by social environments. Instead, the alarmingly high diabetes rates among certain communities are explored in relation to external influences, such as colonisation and land loss among American Indians in Chicago. Diabetes care is also a multigenerational, life-long social activity in Native communities, with friends and family helping one another inject insulin, manage medication schedules, and eat diabetes-friendly meals. In this way, diabetes is transformed from a biological disease into a form of social cohesion against colonial forces that attempt to destroy Native physical and collective bodies.

As these studies and ethnographies highlight, the biological and social spheres of diabetes consistently intersect, and these intersections manifest differently depending on the population and their social, psychological, and structural circumstances.

Syndemic interactions

In keeping with the anthropological emphasis on complex, multileveled interactions that underscore disease perpetuations, scholars have drawn attention to the ways in which structural factors exacerbate diabetes outcomes by focusing on parts of the world that have reported abrupt increases in diabetes prevalence (Mendenhall 2012; Weaver 2018).

The theory of syndemics has gained traction in anthropological diabetes research, as it provides a framework for understanding the social, political, and economic underpinnings of illness and disease interactions. Syndemics examines the concentration and deleterious interaction of two or more diseases or other health conditions in a population, particularly as a consequence of social inequality and the unjust exercise of power (Singer 2009: xv). Multiple anthropologists have observed that diabetes is a common component of syndemics research due to its increased incidence and prevalence (Everett and Wieland 2013; Lerman 2017, 2022; Mendenhall 2012; Ryan and Raja 2016; Weaver 2018; Weaver and Mendenhall 2014). Specifically, diabetes interacts synergistically with two other common occurrences: depression and food insecurity.

Research indicates that slightly over one-third of individuals with diabetes will develop depression and vice versa, and that individuals with diabetes are twice as likely as individuals without diabetes to develop depression (Gask et al. 2011; Katon et al. 2010; McSharry et al. 2013; Mendenhall 2012). While some evidence implicates depression as a precursor and major contributor to diabetes (Joseph and Golden 2017; Mendenhall 2015; Vrshek-Schallhorn et al. 2013), diabetes also increases the risk for developing depression (Katon 2010; Gask et al. 2011; Nash 2013). Depression, in turn, contributes to decreased diabetes self-care and access to healthcare, including decreased glucose monitoring, missed medical appointments, and increased likelihood of diabetes complications through diabetes mismanagement (Nash 2013; Weaver and Hadley 2011). Conversely, diabetes contributes to depression by deteriorating social networks, draining financial resources, and changing dietary patterns (Katon et al. 2010; McSharry et al. 2013). Food is a cohesive force: holidays, meetings, family meals, and casual gatherings often include food sharing (Lerman Ginzburg 2022b). When an individual cannot partake due to diabetes-related dietary limitations, the ensuing feelings of guilt or shame may provoke reluctance to attend the event, adding to social isolation. This is particularly true of women, who tend to be the primary cooks in their families and do not always receive support from their families to prepare healthier meals (Lerman Ginzburg 2022b).

The relationship between food insecurity and diabetes is rooted in structural factors. For example, Olayinka Shiyanbola and colleagues (2018) found that African Americans with diabetes attributed their disease outcomes to eating habits that were rooted in slavery and an ensuing consistent lack of healthy foods. Shiyanbola and colleagues’ work adds on to Lisa Sumlin and Sharon Brown (2017), who found that African American women attributed their diabetes rates to dietary patterns and cultural culinary practices that are grounded in slavery and expounded by centuries of poverty. Populations that have been abruptly introduced to and adopted Westernised dietary patterns, such as the Pima Native Americans in Arizona and the Nauruan Islanders in Micronesia, are exceptionally vulnerable to developing diabetes due to rapid changes in nutrition, through increased consumption of highly processed foods that are high in sodium, fats, and carbohydrates (Hardin 2015; Smith-Morris 2006; Solomon 2016; Weaver 2018). Western eating patterns were oftentimes forcibly imposed on unwilling communities, and these forced eating patterns went hand-in-hand with overlapping structural factors that accentuated the incidence of diabetes among the affected communities (Hardin 2015; Smith-Morris 2006).

Diabetes and food insecurity are also correlated with poverty, particularly in combination with the absence of affordable healthcare and housing (McNaughton 2013; Mendenhall 2015; Vest et al. 2013). In their study on diabetes among Canadians living in poverty, Dennis Raphael and colleagues (2012) found that since the government’s public policy dictates the incidence and experience of poverty, and that poverty and ensuing material deprivation are contributors to increased rates of diabetes, mitigating diabetes levels require changes at the government level, and not merely at the individual level. Studies such as these serve as a reminder that food insecurity cannot be attributed merely to individual-level food decisions, but also depends on government policies that impact access to financial assistance for low-income families. For example, my research in Puerto Rico explores participants’ experiences of eating whichever food was most easily economically and geographically accessible due to an influx of food taxes, high-end supermarkets in gated communities, and economic and political instability (Lerman Ginzburg 2022a). Thus, merely turning health and treatment into easy formulae ignores the agricultural, historical, social, and political specificities that are interwoven into food consumption (Emily Yates-Doerr 2015). This critical scholarship underscores the need for ethnographic research that situates food insecurity and diabetes not merely within biomedical milieus, but also as products of social, political, and economic forces.

Just as structural factors, such as interpersonal violence and poverty, are critical syndemic perpetuators, similarly community responsibility and collective care play a role in diabetes management. Jessica Hardin (2018), in her ethnographic work on cardiometabolic disorders in Samoa, highlights how healing is both individualistic and collective that both ‘transform individual bodies while impacting the broader community, making evident the problems of the collective in the bodies of individual Christians’, a process which she calls ‘embodied critique’ (5-6). Hardin found that her Samoan participants encouraged one another to link illness events with the state of their relationships. Concepts such as embodied critique move beyond individual bodies to encompass the broader community and the structural factors that underlie diabetes aetiology. While part of the responsibility was on the individual to manage their diabetes, including taking medications, structural factors like poverty and unemployment also contributed to diabetes, which made it harder for study participants to make the necessary changes.

In Puerto Rico too, the participants I worked with linked diabetes with broader socio-political problems, such as Puerto Rico's status as a US territory (Lerman Ginzburg 2017, 2022a). The 1917 Jones Act forced food shipped to Puerto Rico to be marked up in price to compensate for the shipping, but this cost is borne by Puerto Ricans. Their experiences of eating whichever foods were most easily economically and geographically accessible connected food insecurity and diabetes with US colonisation and political nepotism. People developed depression because of the high unemployment and crime rates, ate large quantities of cheap high-fat food because of food insecurity and food apartheid, and developed diabetes. Similarly, in tracing the syndemic underpinnings of diabetes and COVID-19, anthropologists like Merrill Singer (2020) have commented that NAFTA created ‘diabetes-inducing’ environments in Mexico by triggering a growing dependence on unhealthy food imports, mostly from the US, amid a national agricultural deficit that limited Mexicans’ access to the fresh produce grown in their own backyards. The rapid change in agricultural output and ensuing urbanisation created situations of stress, identity loss, and profound changes in dietary practices that contributed to diabetes risk.

Corporate influences on diabetes

Most of this entry has focused on the structural factors that impact the lived experiences of diabetes. However, there is also a corporate component to diabetes that impacts the quality of care. Medical anthropologists studying diabetes in the United States have argued that clinical care in the country is increasingly driven by large corporations, with a mounting emphasis on financial and managerial logics that reduce diabetes care to a narrow set of quantifiable metrics (Hunt et al. 2019). Healthcare providers measure successful diabetes management by monitoring glucose and HbA1c levels, medication regimen adherence, and significant weight loss, all of which are easily enumerated but difficult to achieve due to the multiple structural barriers associated with diabetes. Health insurance plans in the US use these quantitative parameters to determine approval of healthcare expenses while ignoring the underlying structural and social barriers that might prevent patients from managing their diabetes. Scholars also argue that screening, diagnosis, and treatment guidelines over the past forty years have changed under pressure from the pharmaceutical industry despite weak evidence of efficacy in order to benefit from promoting expensive medications to unsuspecting patients (Hunt et al. 2019). Additionally, easing the diagnostic criteria for diabetes means that more people are diagnosed with the illness, and therefore required to take medications. In tracing these linkages, scholars have recommended that individual vigilance over diabetes management be augmented with systemic surveillance by healthcare providers and by policymakers who are at the forefront of medical innovations, healthcare funding, and institutional policies (Rock 2003b). Such recommendations reiterate that structural factors that impact underserved populations with high diabetes rates are rooted in unjust policies that can only be remedied at a higher political level.

Conclusion

Diabetes continues to be a globally pervasive disease, particularly in low- and middle-income countries which are facing rapid changes in the mechanisation of labour, political stability, economic independence, and profound social unrest. Despite the advances in biomedical treatment options, diabetes continues to afflict millions of people around the world, which indicates that there is a pressing need for accessible treatment options. For example, the price of insulin is ten times more expensive in the US than in any other developed country, leading many people with diabetes to ration their insulin and risk their health if their health insurance doesn’t cover the cost (Rajkumar 2020). This travesty highlights the need for thorough healthcare reform in the US in particular. Furthermore, it is imperative that the structural factors underlying diabetes in societies throughout the world be considered during treatment. Multiple, overlapping factors, such as colonisation, poverty, and unemployment are inexorably linked to diabetes, and it is those factors which we must address as we move forward with diabetes treatment options. Thinking of syndemics is a useful way for digging more deeply into the aetiologies of diabetes, so that culturally-specific and affordable preventions might be developed and rapidly implemented.

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Note on contributor

Shir Lerman Ginzburg is an assistant professor of public health at Massachusetts College of Pharmacy and Health Sciences. Her research interests include mental health, diabetes, food insecurity, health disparities, Hispanics, obesity, syndemics, and colonisation. She earned her PhD in medical anthropology from the University of Connecticut. She practices yoga and meditation in her free time.

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[8] Harvard Medical School. 2022. “Type 2 diabetes mellitus.” https://www.health.harvard.edu/a_to_z/type-2-diabetes-mellitus-a-to-z. Accessed 29 November 2022.

[9] International Diabetes Federation. 2021. “Diabetes facts & figures.” https://www.idf.org/aboutdiabetes/what-is-diabetes/facts-figures.html. Accessed 18 January 2022.

Editor:

Riddhi Bhandari

Mental Health

Rebecca Tishler — Tue, 04 Apr 2023 15:25:29 +0000

"Be happy and live". Photo taken in 2021 by photographer and mental health activist Damilare Adeyemi.

Mikkel Kenni Bruun

King's College London

Initially published 4 Apr 2023

http://doi.org/10.29164/23mentalhealth

Abstract:

When we talk about mental health, we could seem to be talking about some self-evident reality. However, the very notion of mental health can be seen to both assume and require a specific vision of human interiority. The so-called ‘sciences of the soul’—or the ‘psy' disciplines—were particularly formative in defining this perceived interior selfhood through various scientific and therapeutic practices of inspection and introspection, through new constitutions, articulations, and regulations of what it means to be human. Mental health could be seen to be fundamental to our collective and individual ability as humans to think, feel, relate, interact with each other, sustain ourselves, and enjoy life. This entry explores some key theoretical and ethnographic interests, and their alignments and tensions, through which different anthropologies of mental health have taken shape. For example, social studies of mental health have been shaped by various engagements of ‘culture’ as a form of both contextualisation and critique. More recently, scholars have examined the political, ethical, and therapeutic processes by which people come to constitute themselves and others—for instance, through everyday practices of self-care or clinical diagnosis and treatment—as particular subjects of mental health. Anthropologists have described how people’s experiences of mental health and its associated afflictions are constituted relationally, in different ways, and with different social consequences around the world. The entry ends with a brief discussion of some current topics in anthropological studies of mental health, from the proliferation of mental disorders and the prevalence of neurobiological understandings of human distress to the increasing digitalisation of mental health. As these and other efforts imply, mental health is becoming a prominent field of enquiry in contemporary anthropology and one with renewed ethnographic salience for everyone involved.

Introduction: Situating mental health

The concept of mental health has drawn together a range of ideas and practices that have come to define, and intervene on, what it means to be human. In contemporary English-speaking societies, it is a concept which is often used to express a concern for human well-being in psychological terms. However, what counts as ‘mental health’ is a question of varied social significance as we move historically and ethnographically across time and space. Increasingly, mental health figures as a universal feature in conceptualising humans, and, conversely, mental ill-health is understood to affect humans globally, with an estimate of 970 million (or 1 in 8) people around the world considered to be living with a ‘mental disorder’.^{^[1]}

Some anthropologists have argued that mental illness is recognised in every culture, even if the ways in which people experience, treat, and make sense of psychological distress might differ considerably (see e.g. Luhrmann and Marrow 2016). Others have been sceptical of the very language of ‘mental health’ and ‘mental illness’, particularly where it has been deployed to pathologise or criminalise incongruent desires and bodies, as in the case of homosexuality for instance (Foucault [1961] 1988a), and to uphold systems of colonialism and racialisation (Fanon 1963). At the same time, the concept of mental health construed as a shared human condition of what it means to be psychologically well has been deemed important and needed; indeed, mental health has in recent decades come to be regarded as a ‘human right’ by the World Health Organisation (WHO).^{^[2]} Increasingly across different social worlds, from local healing practices and national health systems to everyday affairs of care and kinship, global health discourses, and beyond, mental health has emerged as something that ‘everyone has’. It is something that, for better or worse, warrants attention and action.

This entry provides a brief exploration of some theoretical and ethnographic interests that have been particularly instructive in anthropological studies of mental health. Before turning to anthropology, however, the entry suggests a way of situating mental health. This can only be done in very general terms here. One important point is that, despite its contemporary ubiquity and salience, mental health is a relatively recent concept that emerged in particular historical (and historiographical) circumstances, shaped by new psychological practices and institutions, through which new constitutions, articulations, and regulations of a ‘healthy mind’ were effected. Modern psychology now generally considers people to have something called mental health located in the putatively subjective interiority of the individual person, a human interiority which has become aligned with particular notions of ‘the mind’ or ‘the brain’ (Martin 2021; Rose and Abi-Rached 2013).

The concept of mental health reveals a complex historiography of social transformations over the past two hundred years, from the era of the asylums to the psychiatric hospitals and mental health services with which we are familiar today (Foucault [1961] 1988a; Unsworth 1993; Shorter 2007). It is a concept shaped particularly by two world wars and the emergence of welfare states with the monitoring of publics and populations (Fraser 1984; Busfield 1998; Marks 2017). Importantly, ideas of mental illness have also emerged in contexts of colonisation and decolonisation (Reyes-Foster 2018; Calabrese 2013; see also Fanon 1963). The historical precursor to the concept of mental health has been traced back to the efforts of the ‘mental hygiene movement’ that took shape in Europe and America during the nineteenth and early twentieth centuries (Bertolote 2008; Novella and Campos 2017). The idea of ‘mental hygiene’ gained traction in the second half of the nineteenth century and is often credited to the work of William Sweetser (1797–1875), who defined it as the science of preserving a healthy mind (Sweetser 1850). The mental hygiene movement sought to establish public health measures and interventions in the prevention and treatment of mental disorders. In the aftermath of the Second World War, however, the term ‘mental health’ gradually replaced the language of mental hygiene because the latter had become increasingly associated with Nazi eugenics.

When we move to present-day contexts of the cognitive sciences, mental health figures as a wide-ranging field of research, with several scientific and clinical definitions currently in circulation. The WHO offers the following:

Mental health is a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community.^{^[3]}

The WHO states further that ‘mental health is more than just the absence of mental disorders’. Conversely, according to this definition, mental ill-health implies that a person lies at a ‘negative’ end of a health continuum. For instance, mental health professionals might speak of ‘caseness’, of being ‘a clinical case’ (see e.g. Susko 1994), which means that a person who reports distress considered as pathologically significant is deemed to be suffering from mental ill-health. We see here that the very conception of mental health hinges on one of the key problems in psychiatry, namely the epistemic resolution of the ‘normal’ and the ‘pathological’—including that distinction itself (Canguilhem [1966] 1989; Foucault [1963] 1973). The various ‘psy’ sciences (Rose 1985) that emerged over the course of the nineteenth and twentieth centuries established themselves by claiming their ability to deal with a range of mental and behavioural phenomena deemed dysfunctional or abnormal. The concept of mental health was thus historically constructed around notions of pathology and the differentiation between normal and non-normal conduct.

Anthropological trajectories

Contemporary worlds of mental health can be seen to constitute a multitude of sciences, technologies, and professions, as well as involve a wide range of therapeutics and care practices within and beyond clinical settings. In the following sections, we are going to look at some key anthropological trajectories in relation to what has been collectively termed the ‘psy disciplines’, that is, psychoanalysis, psychiatry, and psychology. Anthropologists have increasingly come to treat mental health as an ethnographic topic of central rather than tangential interest. This entry suggests that we might think of different anthropologies of mental health, some of which have developed within specific subfields of social and cultural anthropology, such as medical anthropology, psychological anthropology, and cross-cultural or transcultural psychiatry. Since the early twentieth century, anthropologists have developed diverse ways of studying issues that we might, for the moment, summarise as concerning ‘mental health’. However, this term—and other related terms such as ‘well-being’—came generally much later in anthropology.^{^[4]}

Anthropological research on mental health has often focused on traversing or reconciling the disciplinary fields of anthropology and psychiatry. One key aim was to render anthropological knowledge applicable to clinical problems. To some, this meant accounting for ‘culture’ in psychiatry, particularly in terms of ‘cultural difference’ in the perception and experience of illness, and in the classification, diagnosis, and treatment of people (Kleinman 1980; Littlewood and Lipsedge 1997). Within anthropology, it is largely medical anthropologists who have been at the forefront of dealing with these issues in the context of psychiatry—a discipline that has tended to dominate anthropological studies of mental health both ethnographically and analytically (see, e.g., Sapir 1932; Opler 1959; Westermeyer 1976; Kleinman 1988; Luhrmann 2000; Littlewood 2002; Brodwin 2013; Jenkins 2018; Pinto 2020).

Ethnographic fieldwork encourages us to take seriously the experiential realities of those we study. Anthropologists might not always find it appropriate, therefore, to assume a particular definition of mental health but tend instead to be more interested in how the people they study are establishing and enacting their own definitions and self-defining worlds: for example, how people might understand, use, resist, and live ‘mental health’, and the consequences. As such, rather than taking mental health for granted as pre-given or self-evident, we can think of it as something that emerges relationally. This entry suggests that mental health comes to figure in multiple ethnographic senses: as a presumed universal feature of the human mind; a sense of self; a psychological state that can be intervened upon and taken care of; a measure for populations, groups, or individuals; an object of therapeutic enquiry; a matter of concern for those classified as patients; and so on. We could talk here of different 'definitional realities' of mental health that constitute its meaning (see Ardener 1982; Hastrup 1995; McDonald 2020). For instance, clinical evaluations of mental health are inevitably dependent on the conceptual definitions offered of that reality. Analytically, this means that ‘mental health’ does not figure as an a priori phenomenon anterior to its relations and articulations, but as a category in action. Some social scientists might want to talk here about the ontological multiplicity of mental health; for example, how it is enacted and coordinated as a matter of concern—similar to the ‘doing’ of disease in medical practice (Mol 2002).

The ‘social’ and the ‘psy’

The question of mental health has been shaped by various attempts to either separate or reconcile the social and the psychological. Such attempts were particularly influenced by anthropological studies of the so-called ‘primitive mind’, the 'personality of culture', and the nature of human cognition. Anthropology addressed mental health as an object of study, in an important sense, via the scientific ambitions of the early psy disciplines, notably late-nineteenth-century and early-twentieth-century psychoanalysis and experimental psychology. Yet mental health was often only implicitly dealt with, eclipsed by prevailing ambitions at the time to ascertain a universal human psychology—‘the generalised mind’—inspired in part by the German experimental psychologist William Wundt’s (1832–1920) ‘introspective’ methods, as well as by subsequent anthropological investigations into what was then seen as the ‘primitive’ or ‘savage’ mind (Martin 2021, 26–51; see also Rieber 1980; Mandler 2011). Influenced by Darwinian evolutionism and its underbelly of Victorian scientific racism, a widespread theory of human psychology claimed that so-called ‘primitive’ people lacked higher mental functions while they surpassed ‘civilised’ people in physical performance, because more energy was seen to remain devoted to their physicality as opposed to their mentality (Martin 2021, 37). This theory was put to test, and eventually challenged, by the 1898 Cambridge Anthropological Expedition to Torres Straits (Haddon 1901; Herle and Rouse 1998; Sullivan 2012), which also sought more generally to investigate psychological ‘introspection’, namely the inspection of one’s own internal mental processes. The expedition was influential in shaping both modern anthropology, and in bringing together psychology and anthropology with a common interest in what we might now want to see as an early version of mental health research.

However, the relationship between anthropology and psychology as exemplified by the Cambridge Expedition did not end in a happy marriage. On the contrary, in Britain and elsewhere, the social and cultural were in many ways further delineated in contradistinction to the psychological. During the early twentieth century, new disciplinary identities emerged as practitioners marked out social science (including anthropology) distinct from psychology and natural science. For example, the British anthropologist Edmund Leach treated psychology as a discipline against which social scientists are ranged. He asserted that ‘[the anthropologist] will be well advised to leave psychological matters to psychologists and stick firmly to the public sociological facets of the case’ (1958, 148). This was a disciplinary division of labour according to which the world was also divided into a presumed separation of the public and private, the collective and individual, the external and internal. One of the pioneers of British social anthropology, Bronisław Malinowski (1884–1942) effected his own disciplinary boundary-making by way of critically engaging with psychoanalysis. In Sex and repression in savage society (1927), Malinowski famously examined the Freudian ‘Oedipus complex’ in the context of Trobriand kin relations and child development, which led him to dismiss any notion of Oedipal universality claimed by psychoanalysts of the day. While Malinowski remained a critic of psychoanalysis and its ‘exorbitant claims’ throughout his career, he also contended that its ‘open treatment of sex […] is of the greatest value to science’ (Malinowski 1927, vii–viii). Although Malinowski and Leach, and, before them, Émile Durkheim ([1912] 2008), had long moved the ‘social’ away from the ‘psy’, the question of human interiority—for some the seat of cognition, emotion, and subjectivity, complete with an individuated mind or consciousness (indeed, what many today might think of as pertaining to mental health)—never completely disappeared from anthropology.

Influenced by the work of Franz Boas (1858–1942), another famous anthropological pioneer, developments in American cultural anthropology during the first half of the twentieth century offered a rather different engagement of psychological theories. The most prominent development came from the ‘culture and personality’ movement during the 1920s and 30s instigated by the work of Edward Sapir, Ruth Benedict, and Margaret Mead (all former students of Boas) and which subsequently fed into the American-bred field of psychological anthropology (Ingham 1996; LeVine 2010; see also Mead 1928; Sapir 1932; Benedict 1934). Applying their own critical reading of Freudian psychoanalysis, they argued that human behaviour is ‘culturally patterned’, just like speech is patterned by a particular language. The cultural patterns of childhood experience were thus considered to be the cause of adult personality characteristics, which in turn gave rise to culture-specific patterns of mental health and forms of psychopathology. The aim was for some to develop a generalised cultural description of mental health through ethnographic research on individual personalities and, by extension, the personality of cultures. For other anthropologists, however, such an ambition simply confirmed what they had previously suspected, that a psychologised version of anthropology was susceptible to reductionism and overgeneralisation (LeVine 2001).

It was only much later with the ‘cognitive revolution’ of the 1970s, that ‘psy’ gradually came to occupy another conceptual space among anthropologists as they began to move from the mythic and symbolic universe of structuralism (owed to the work of Claude Lévi-Strauss, and those who read him, see e.g. 1963) to the laboratory of cognitive science. New evolutionary theories equipped anthropologists with novel rethinkings of ‘cognition’ (e.g. Bateson 1972) that shaped the emerging subfield of cognitive anthropology (Blount 2011). Importantly, some anthropologists challenged what to them appeared to be their discipline’s ignorance of a properly scientific study of human mental life. Cognitive anthropology sought to put an end to the Durkheimian separation of the social from the psy that had informed so much of anthropology. However, mental health was still largely a taken-for-granted object in cognitive anthropology, which has tended instead to examine the transmission of cultural representations, Theory of Mind (ToM), innate modularity, and cognate ideas (see Whitehouse 2001; Bloch 2012; Irvine 2018). In all such endeavours, and in those that have come after, the concept of culture looms large.

Culture and mental health

Anthropological studies of mental health in the second half of the twentieth century have been driven by efforts to account for ‘culture’ and ‘cultural differences’ that came out of interdisciplinary borderlands between psychiatry and anthropology, sometimes referred to as ‘cross-cultural’ and ‘transcultural’ studies (cf. Opler 1959; Westermeyer 1976). Culture was also taken up as a language of anthropological critique. For example, the psychiatrist-cum-anthropologist Roland Littlewood has argued that the concept of culture remains ambiguous for psychiatry as it has tended to perceive it as secondary to a biomedical reality. He argued that psychopathology is inherently ‘local’, and that the discipline of psychiatry has its own tacit ‘culture’ (Littlewood 1996). Earlier work had already introduced the idea of ‘the cultural construction of clinical reality’ and encouraged ‘a clinical social science capable of translating concepts from cultural anthropology into clinical language for practical application’ (Kleinman, Eisenberg and Goods 1978, 140). Its authors urged a distinction between ‘disease’ and ‘illness’, as well as the concept of ‘explanatory models’ that sought to include and elicit the ‘patient’s experience’ of disease and treatment: how do people understand and live with mental illness? How is disease perceived in cultural terms? What or who caused it, and how? This work seemed in many ways novel and important, but it still took for granted many of the old dichotomies of medicine. For instance, Kleinman and his colleagues presented a scenario of doctors with scientific ‘knowledge’ and patients with culturally determined ‘beliefs’; with ‘disease’ (medical reality) on the one hand, and ‘illness’ (cultural experience) on the other.

The disease versus illness distinction has informed much research in the intersecting fields of anthropology and psychiatry, as well as beyond: it is now a common component of clinical education programmes where it features as a way of reinserting ‘the cultural context’ where such is deemed lacking or to acknowledge ‘the patient perspective’. Yet this conceptual binary can also imply a problematic separation of the physical versus the mental whereby the former is seen as underlying (biological) causation and the latter as mere (cultural) representation. This has tended to presuppose that neurobiology—as a seemingly culture-free reality—is the ontological foundation of mental health upon which perceptions and experiences of it are culturally or socially constructed. We can trace many contemporary versions of this type of social and cultural constructionism in anthropologies of mental health and related fields.^{^[5]}

The earlier work of Kleinman (1980; 1988) along with the anti-psychiatry movement of the 1970s (e.g. Szasz 1974) nevertheless had a significant impact in confronting psychiatry with ‘culture’, although their reasons for doing so differed greatly: anthropologists generally sought to improve psychiatry rather than dismantle it. Even so, anthropologists now seemed equipped to take apart the cultural preconceptions built into psychiatric diagnoses and treatments in a manner that exposed psychiatric conceptions of mental disorder as inherently ethnocentric, revealing underpinning cultural biases and assumptions (Littlewood and Lipsedge 1997). Anthropologies of mental health and illness have since been routinely embedded in constructs of ‘cultural difference’ or ‘different cultures’ (e.g. Littlewood and Dein 2000; Luhrmann et al. 2015; Onchev 2019). The language of culture has also been considered a worthwhile mode of contextualisation in a field of research that still tends to be dominated by biological determinism (e.g. Sargent and Larchanché 2009). Some anthropologists have found it compelling to talk of ‘the culture’ of the mental health clinic (Luhrmann 2000, 119–57); of differences in professional and therapeutic cultures, with diagnosis, treatment, and patients recontextualised. More recently, new interdisciplinary engagements between anthropology and psychology have described how different cultures ‘invite’ people to relate to their mind in particular ways, which in turn affects the kinds of mental experiences people have and how they make sense of them (Luhrmann 2020; Weisman et al. 2021). Understanding mental health here means grasping shifting cultural models of mind.

Historically, anthropologists have thus been largely responsible for introducing the concept of culture to the study of mental health (cf. Mead 1953; Opler 1959; Westermeyer 1976), although it did not always bring about the anthropological insights that occasioned it. For example, ‘cultural competency’ now regularly features as an important educational component of many mental health training programmes and services (e.g. Carpenter-Song, Schwallie and Longhofer 2007). But cultural competency efforts, despite their best intentions, can appear to treat culture simply as a variable to be accounted for. Different differences—what might be seen as pertaining to nationality, gender, ethnicity, race, and sexuality—are often brought together under a single denominator of the ‘cultural’, thereby eliding a range of experiences altogether.^{^[6]}

The concept of culture has in many ways effected its own problems. Introducing ‘culture’ in studies of mental health, as suggested above, meant introducing ‘context’ and then ‘meaning’. Yet, in these instances, culture is easily reified in ways that some anthropologists might find rather problematic (Strathern 1995; Fox and King 2002; McDonald 2012). For example, speaking about different cultures of mental health might imply an unhelpful normativity that requires further anthropological validation, and evoking culture as a mode of contextualisation and critique does not always differ significantly from people’s own self-understanding. Whitney Duncan (2017) explores this latter point in her ethnography of psychoeducation (psicoeducación) in Oaxaca, Mexico. Working with psychologists and patients in and around a psychiatric hospital, she describes how mental health practitioners come to understand culture as a barrier to mental healthcare. They strive to further ‘psy-globalisation’—the transnational flow of ideologies and practices around mental health. Practitioners see themselves as involved in a global and modernising movement to promote mental health but express frustration about how difficult this project is in Oaxaca, where ‘local culture’ prevents their efforts (Duncan 2017, 37). Mental health practice thus emerges as a project of what she terms ‘psychological modernisation’, a movement that is defined against its own perception of local culture (consisting of ‘traditional medicine’, ‘beliefs’, and ‘magical thinking’). It considers local culture to be incommensurable with global notions of mental health and a source of resistance to mental healthcare and its de-stigmatisation. Not only does psychoeducation in Oaxaca provide a means of self-understanding among professionals and patients alike in the context of modernity, Duncan argues, but it also actively seeks to produce the psychological conditions for modernity.

From governmentality to self-cultivation

Michel Foucault (1926–1984) has arguably been one of the most influential scholars in social studies of mental health and illness. It was the earlier body of his work on the history of madness and the birth of the clinic (Foucault [1961] 1988a; [1963] 1973) which initially inspired critical examinations of the psy disciplines—speaking of a ‘great confinement’ of the mad into asylums and new scientific ambitions that effected the authority of a ‘medical gaze’ (e.g. Hacking 1998; Rose 1989; Danziger 1998). These accounts have traced how, over the course of the twentieth century, psychological knowledge regimes have effected new forms of self-governance—what Foucault called ‘governmentality’—and political relations. The insight that whole populations and ‘life itself’ have become problematised as objects of management and regulation gave rise to the terms ‘biopower’ and ‘biopolitics’ (Foucault et al. 1991; Rose 2006).^{^[7]} In the formation of (neo)liberal democracy, Nikolas Rose (1996) has shown that diverse psychological knowledge practices require that we ‘invent our selves’ or constitute ourselves as if we were selves. The crux of the arguments that run through much of this and related Foucauldian scholarship is the contention that, in the name of expertise and well-being, the psy disciplines—their institutions, professions, technologies, and interventions—conceal and instil specific moral and political ideologies that shape the ways we come to know, relate to, and act upon ourselves and others. Constituted through discourses of individual autonomy, people are rendered responsible for their mental health—for instance, in everyday articulations and requirements ‘to take care of yourself’—in the name of their own freedom.

Anthropologists of mental health have also drawn from Foucault’s work on ‘subjectification’ (assujettissement) in examining the different modes and processes by which human beings are made into subjects. Subjectification refers not only to a mode of having power and control exercised over oneself (‘political subjection’) but also to modes of acting upon oneself and others that constitute one as a particular kind of subject (Foucault 1997). When applying this analytical lens to mental health, it can elucidate, for instance, the effects of people subjected to practices of diagnosis and treatment by which they are classified as distinct clinical cases (e.g. ‘a patient with anxiety disorder’), at the same time as they are required to take up particular subject positions (see Hacking 1985, on ‘making up people’). Consider as example the construction of ‘post-traumatic stress disorder’ (PTSD). Based on Vietnam War veterans’ reports of war-related trauma, PTSD was officially accepted in 1980 as a universal disorder, when it was included in the third edition of the American Psychiatric Association’s Diagnostic and statistical manual of mental disorders (DSM-III). This followed a political struggle by psychiatric workers on behalf of the large number of veterans who were seen to suffer from the psychological effects of traumatic memory (Young 1995). Contrary to the depiction of the disorder in psychiatric classification practices, PTSD may thus not be timeless, nor does it possess an intrinsic unity:

Rather, it is glued together by the practices, technologies, and narratives with which it is diagnosed, studied, treated, and represented and by the various interests, institutions, and moral arguments that mobilised these efforts and resources’ (1995, 5).

Young shows how clinicians in the US applied the diagnostic criteria to include people that they felt ought to be seen as mentally ill and shows the way patients in turn began to present themselves in such a way as to fit into the diagnostic categories of PTSD.

Moreover, some scholars have argued that psychiatry’s capacity to define the ‘mentally ill’ has been achieved partly through the making and remaking of the DSM (American Psychiatric Association 2013)^{^[8]} and through historical processes of institutional colonialism, market capitalism, and a medicalisation of human suffering (see e.g. Healy 1997; Kirk and Kutchins 1997; Borch-Jacobsen 2012; J. Davies 2021). This literature targets modern psychiatry and pharmaceutical industries in particular, and has echoes of earlier critiques that came out of the anti-psychiatry movement of the 1960s and 70s (e.g. Fanon 1963; Szasz 1974). This was a movement influenced by Foucault’s genealogy of madness, which appeared to expose psychiatry in many ways as a structural oppressor. Foucault’s scholarship thus had a significant impact on intellectual anti-psychiatry critics, many of whom held academic positions in psychiatry, although he often distanced himself from the direction in which they took his work.

Since the 1980s and 90s, then, social scientists have been ready to contextualise and deconstruct mental health within an analytical frame of ‘politics’. Neoliberalism—with its associated ideals of autonomy and individual responsibility (Ganti 2014)—has often been evoked as one such political frame within which to locate and critique mental health. Social scientists have pointed to the impact of neoliberal attitudes on social and economic stressors such as unemployment in relation to the rapid increase in ‘mental health problems’. Neoliberalism especially shapes depression and the growing ‘happiness’ industry (W. Davies 2015). At the same time, even putatively ‘neoliberal’ mental health initiatives might be seen to move beyond political agendas and logics with unexpected consequences. For example, some anthropologists argue that the self-governing practices of individuals required to ‘work on’ their mental health—and any process of subjectification this might entail—are not always sustaining any straightforward or self-explanatory neoliberalism (Cook 2016; Bell and Green 2016). It has also been common in social science studies of mental healthcare for ‘politics’ (neoliberalism or capitalism, for instance) to be seen and cited as a domain that gets in the way. By the same token, one common way of criticising care has thus been to situate it in the service of politics.

T.M. Luhrmann’s (2000) ethnography of American psychiatrists can be read as an objection to the kind of critical studies of the psy disciplines discussed above. Luhrmann refrained from situating her study of American psychiatry in terms of Foucauldian governmentality, deeming such social science perspectives a naive romanticism that does little justice to the suffering subjects:

Foucault did presume that madness had always existed, but he romanticised it in a way that, despite all his insights, did a terrible disservice to its pain. […] Madness is real, and it is an act of moral cowardice to treat it as a romantic freedom. (2000, 11–2).

Instead, Luhrmann identified two competing paradigms in psychiatry: the psychotherapeutic model (informed by psychoanalysis and psychotherapy) and the biomedical model (informed by neuroscience and pharmacology). Her ethnography provides a remarkable account of the epistemological conflicts between ‘talk therapy’ and ‘drug therapy’, and the medico-moral consequences of losing the former to the latter.

More recently, it is Foucault’s later writings on ethics and care (see e.g. [1978] 1988b; 1997) that have inspired anthropological perspectives on mental health. People who undergo mental healthcare, for example, can be understood as participating in active processes of self-cultivation through an ethical practice of ‘reflective thought’ (Laidlaw 2018). Here, one’s mental health is constituted as an object of reflection in order to change it, or one's relation to it. Practitioners of ‘mindfulness-based cognitive therapy’ develop a particular ‘distanced perspective’ as they are learning to cultivate a detached relation to thoughts and feelings: ‘I have thoughts, but I am not my thoughts’ (Cook 2015, 223–9). This seeming capacity for introspection, to take one’s ‘self’ as an object of inspection and reflection, is at once assumed and required in psychological therapies as practised in the UK and elsewhere (Bruun 2023). In the face of the promise of postsocialist democracy, the work of post-Soviet Russia’s psychotherapists can be understood as an ethical practice of freedom, but one that ultimately hinges on ‘an ongoing struggle between different assumptions about freedom […] that plays out through precarious care’ (Matza 2018, 241). The freedoms sought in post-Soviet Russia are less individualised and based instead on collective forms of ‘self-work’. Psychotherapists seek to cultivate mental health for themselves and their clients but are caught between psychology’s ambiguous care for the lives of two distinct groups of people—those who accumulated wealth and those who did not—following the collapse of the Soviet Union. There is no easy way out of biopolitics here, but the logics of psychotherapeutic care also enable new ethical orientations, new modes of caring for self and others.

Foucauldian notions of both governmentality and self-cultivation have encouraged anthropologists and mental health practitioners alike: not only have they provided important conceptual frameworks within which anthropologists might contextualise and critique psychological realities, but they have also informed mental health practitioners’ own critical assessments of their professional worlds.

Psyches, minds, bodies, and brains

Within the historiographical context of the sciences, mental health emerged in mutual distinction and self-definition: physiology dealt with ‘the body’; psychology with ‘the mind’ or ‘psyche’. The so-called ‘sciences of the soul’ were particularly formative in defining a perceived human interiority through different practices of inspection and introspection (Coon 1993; Danziger 1998; Vidal 2011). The modern disciplines of the clinic thus helped divide the human into the mental and the physical, the psychological and the physiological. We have largely inherited this and other dichotomies from the eighteenth and nineteenth centuries where also ‘subjectivity’ and ‘objectivity’ emerged in contradistinction (Daston and Galison 2007). New psycho-technologies and scientific methods of introspection helped constitute ‘the human mind’ as an object of both scientific observation and intervention (Rieber 1980; Green 2010; Martin 2021). Reified as empirical objects, ‘the mind’ and ‘the body’ established in turn universalising ideals about ‘mental’ and ‘physical’ health, including their demarcation and distinct disciplinary subdivisions and specialisms.

With the rise of neuroscience in the twenty-first century, some feel that mental health has finally been anchored in the physical reality of the brain (Rose and Abi-Rached 2013). Consequently, a biologically orientated psychiatry now tends to see the distressed mind as a result of a biologically dysfunctional brain. Focusing on the persuasive power of brain images as experienced by people suffering from mental ill-health, Joseph Dumit’s (2003) ethnography shows how neuronal connectivities and chemistries, such as neurotransmitters, come to be seen as the aetiology of distress. Through encounters with neuroscientific causation models where brain images (such as PET scans) play a key role, people come to understand themselves as having chemical imbalances in their brain that cause mental illness such as depression. Neuroscientific facts cast the afflicted person as a dysfunctional brain by which they acquire a sense that they are their brain. The persuasive idea here is that ‘the mind is what the brain does’. But this understanding of mental health, in which the person experiences distress because of their brain, also comes to sit in tension with people’s sense of an agentive self and a capacity for self-determination: ‘is it me or my brain?’ (Dumit 2003).

Neurobiological theories that envisage the brain as a chemical laboratory of mental health have, for a long time now, equipped mental healthcare systems with scientific rationales for the use of psychopharmaceuticals in the treatment and management of people who experience distress (Petryna, Lakoff and Kleinman 2006; Jenkins 2010; Oldani 2014). Biomedical models of mental health can thus appear to locate responsibility and agency elsewhere, namely in the biochemical constitution of brains. Conversely, anthropologists have also described how psychotherapists have tended to locate moral responsibility on the part of the afflicted person (Kirsner 1998; J. Davies 2009). Littlewood (2002) has construed this tension as ‘naturalistic’ versus ‘personalistic’ explanations of mental ill-health. For the biomedically-trained psychiatrist, however, mental illness was no longer anyone’s fault: people were instead suffering from discrete ‘disorders’ that could be detected neurologically and treated with drugs (Luhrmann 2012). By the 1980s, neuro- and cognitive scientists were throwing out the psyche and Freud had become a footnote in psychology textbooks as psychoanalytic theories and methods were largely discredited. Psychological scientists have since strived hard to situate mental health research in the scientific principles and measures of ‘real science’ on an equal footing with biomedicine, contending that their discipline could otherwise be lost to ‘pseudoscience’ (cf. Lilienfeld, Lynn and Lohr 2004).

Notions of the biochemical and genetic brain remain instructive in contemporary understandings of mental ill-health and its treatments (Rose and Abi-Rached 2013). It is partly through the persuasive notion of a universal human physiology that the concept of mental health has acquired its own universality. But it has also brought with it a biological understanding of minds and maladies. For some anthropologists, this entails a problematic reductionism which has caused a ‘psychiatric drug epidemic’ by way of pathologising human distress (J. Davies 2017). Over the past forty years, numbers of mental disorders have grown exponentially in the publications of international diagnostic manuals, resulting in a proliferation of psychopathologies and market-driven pharmaceutical treatments (Petryna, Lakoff and Kleinman 2006). In an age of psychopharmacology, the ‘pharmaceutical self’ (Jenkins 2010) continues to shape experiences of mental health with vast social, ethical, and economic effects.

Anthropology encourages us to treat the division of health into the ‘mental’ and ‘physical’ as a matter of ethnographic interest. It is, in other words, worthy of study to anthropologists that some people conceptualise health in terms of ‘mind’ and ‘body’, and that these divisions in turn mark out different realities deemed ‘psychological’ and ‘physiological’. More recently, the ‘biopsychosocial’ model, invented by the American psychiatrist George L. Engel (1977), has been an attempt to bring together different disciplines (biology, psychology, social science) alongside their associated realities (body, mind, society). Rather than treating these as separate phenomena, this model claims to further a more holistic and scientifically rigorous understanding of humans as biopsychosocial beings. In the context of mental healthcare, such an understanding has in turn encouraged a perspective on treatment in which it is no longer sufficient for interventions to consider only biological or psychological factors. Instead, treatment must include ‘the social’ in the sense of environment, context, and culture (see e.g. Álvarez, Pagani and Meucci 2012; Gask 2018). According to this model, mental health is not only a case of a biological body (a case of ‘brain chemistry’, for instance) existing anterior to its psyche, social relations, or environment, but of a whole body-mind-subject—biologically, psychologically, and socially constituted—in a particular cultural world. However, the anthropologist might wonder at the separations and connections that are sought here. We might ask, for example, if the tripartite differentiation put forward in the ‘biopsychosocial’ is still suggestive of a problem rather than offering a novel reconciliation.

The proliferation of mental health

Following the Covid-19 outbreak in 2020, an upsurge in mental ill-health around the world and its associated medical, social, and economic impacts, including an exacerbation of existing health inequalities, have been widely reported on in scientific journals (e.g. Moreno et al. 2020; Wu et al. 2021). The Covid-19 pandemic has reinvigorated mental health as a matter of concern, from local and national levels of concern—pertaining to ‘individuals’ and ‘populations’—onto a cosmopolitan scale as part of ‘global mental health’ efforts. Mental health perceived as a global phenomenon, which might require equally global intervention, seems now a well-established reality that has received further experiential confirmation by reports of a worldwide mental health crisis of depression and anxiety disorders caused by the pandemic (e.g. Santomauro et al. 2021). Anthropological investigations of mental healthcare in times of ‘crisis’ seem therefore both pertinent and needed (see e.g. Wright 2022).

An important trajectory of anthropological research in the field of mental health has focused on the production of neuroscientific facts (Cohn 2008, 2010; Dumit 2004), the effects of pharmaceuticals (Dumit 2012; Jenkins 2010; Petryna, Lakoff and Kleinman 2006), and the construction of ‘disorders’, such as bipolar disorder (Martin 2007), autism, depression (Kitanaka 2012), and schizophrenia (Luhrmann and Marrow 2016). Furthermore, the expansion of ‘evidence-based psychological therapies’, especially cognitive behavioural therapy and mindfulness, and a proliferation of mental health initiatives and psy professions around the world have been a recent focus of ethnography by which new accountabilities, healing modalities, and configurations of care and politics have been examined (Brenman 2021; Bruun 2023; Cook and Cassaniti 2022; Duncan 2018; Huang 2018; Long 2018; Matza 2018; Pickersgill 2019b; Vogel 2017; Vorhölter 2021; Zhang 2020). These studies deal diversely with issues of precarity and access to mental healthcare, the transformation of therapeutic practices within and beyond their particular cultural or clinical environments, and the social and ethical consequences of particular scientific, economic, and political framings of mental health.

Another recent direction of research explores the digitalisation of mental health. The proliferation of digital monitoring technologies and AI-assisted interfaces—such as computerised therapeutics, online clinical platforms, smartphone apps, and wearable self-tracking devices—has constituted new fields of digitised mental healthcare (see e.g. Birk and Samuel 2020; Brandt and Stark 2018; Fullagar et al. 2017; Minozzo 2022; Pickersgill 2019a; Trnka 2022). Self-monitoring of ‘mental well-being’ is now part of many people’s daily health regimen as everyday activities of eating, sleeping, work, and recreation have become digitalised objects of observation shaped by ambitions to ‘encode wellness’ and promote personalised forms of health surveillance (Cearns forthcoming; Bruun forthcoming). This move towards ‘digital psy’ presents us with ‘disparate subjects, practices, places and temporalities of sensing, predicting, diagnosing, or treating mental health’ (Bemme, Brenman and Semel 2020). New therapeutic socialities and relationalities have unfolded.

Conclusion

The anthropology of mental health has come a long way. This entry has shown how ‘mental health’ can figure both as an analytical category in anthropology and an object of ethnography. Ethnographies of mental health can help us grasp not only the structural features of healthcare systems but also the modalities of healing and care in and beyond the clinic (e.g. Meyers 2013; Patton 2010), the medical and moral complexity of psychological distress (e.g. Luhrmann 2000; Zhang 2020), and the experiential realities that take shape around these issues. Where issues of authority and mental illness come together, anthropologists have demonstrated how people might resist, reinvent, or transform the therapeutic worlds in which they live (e.g. Brodwin 2013; Calabrese 2013; Myers 2015). Ethnography also teaches us that people’s experiences of mental health are situated in their own and others’ classifications and understandings of it (Bruun and Hutten forthcoming). Mental health thus entails particular kinds of theories that people have about themselves and others and the world in which they live. Anthropology can help us better understand why and how people experience mental distress but also what well-being and happiness might mean and look like.

Mental health might be seen to have acquired a hard-won universality. While some find this universality compelling and needed, others are critical of the ubiquity of mental health as an organising concept with the capacity to both normalise and pathologise. Kleinman, among others, contends that the expansion of the category of mental health ‘seems to simultaneously trivialize the most serious medical conditions and to medicalize social problems’ (2012, 118). He suggests that ‘fifty years from now this category will have been abandoned’ (Kleinman 2012, 118). Meanwhile, the realities of people’s experiences of mental health are unlikely to go away any time soon. In many parts of the world, mental health is now something that ‘everyone has’. To have mental health everywhere brings home its ethnographic salience.

Note

The writing of this article was supported by the European Research Council (ERC) under the European Union’s Horizon Programme for research and innovation (project no. 947867).

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Whitehouse, Harvey, ed. 2001. The debated mind: Evolutionary psychology versus Ethnography. Oxford: Berg.

Wright, Fiona. 2022. “Making good of crisis: Temporalities of care in UK mental health services.” Medical Anthropology 41, no. 3: 315–28.

Wu, Tianchen, Xiaoqian Jia, Huifeng Shi, Jieqiong Niu, Xiaohan Yin, Jialei Xie, and Xiaoli Wang. 2021. “Prevalence of mental health problems during the COVID-19 pandemic: A systematic review and meta-analysis.” Journal of Affective Disorders 281: 91–8.

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

Zhang, Li. 2020. Anxious China: Inner revolution and politics of psychotherapy. Oakland: University of California Press.

Note on contributor

Mikkel Kenni Bruun is a Research Associate at King’s College London, where he currently works on the ERC SAMCOM project (https://samcom.uk). He also teaches anthropology at Cambridge University and is co-editing a volume on the anthropology of psychology. He holds a PhD in Social Anthropology from Pembroke College, Cambridge.

Dr Mikkel Kenni Bruun, Department of Digital Humanities, King’s College London, Strand, London WC2R 2LS, United Kingdom. kenni.bruun@kcl.ac.uk

[1] World Health Organization. 2022. “Mental disorders.” June 8. https://www.who.int/news-room/fact-sheets/detail/mental-disorders. Accessed 1 October 2022.

[2] World Health Organization. 2022. “Mental health.” June 17. https://www.who.int/news-room/fact-sheets/detail/mental-health-strengthening-our-response. Accessed 1 October 2022.

[3] World Health Organization. “Health and well-being.” https://www.who.int/data/gho/data/major-themes/health-and-well-being.

[4] Some early anthropological work that sought to study mental health explicitly is collected in the volume Culture and mental health, edited by Marvin Opler (1959). Many of its contributors were also professional psychiatrists.

[5] For a critique of cognitivist and cultural models in anthropology and psychology, see Toren 2012.

[6] A related issue concerns ‘structural competency’ efforts in the training of healthcare practitioners (Hansen and Metzl 2019). The ‘structural’ refers here to an analytical shift away from the level of the individual to examine institutional structures (clinical, educational, judicial, etc.) that underlie social determinants of health problems and access to care.

[7] It is important to note that Foucault was dealing mostly with the historiography of the ‘western’ subject. There are other histories and formations, of course. Recent anthropological writing on the relationship between the emergence of the psy sciences and colonialism has considered how we might think about presenting this history (Reyes-Foster 2018; see also Fanon 1963, on the ‘psycho-affective’ effects of colonisation). I am grateful to the anonymous reviewer for drawing my attention to this work.

[8] The DSM is currently in its fifth edition (DSM-5), published in 2013. It replaced the DSM-IV which appeared in 1994. For a critical review of the DSM-5, see Hacking (2013).

Editor:

Hanna Nieber

Depression

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

Junko Kitanaka Stefan Ecks

Keio University & University of Edinburgh

Initially published 30 Mar 2021

http://doi.org/10.29164/21depression

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.

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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).