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Bad Souls: Madness and Responsibility in Modern Greece

0 Comments 🕔14.May 2014

As its title suggests, the focus of anthropologist Elizabeth Anne Davis’s book, Bad Souls: Madness and Responsibility in Modern Greece, is on how to reconcile the relationship between madness and responsibility in the context of national psychiatric reform in Greece. This is a process set in motion as part of a humanitarian condition of Greek accession to the European Union in the early 1980s, and was largely funded and mandated by it. Based on extensive ethnographic research in Thrace, which is located by the northeastern borderland with Turkey and is Greece’s poorest region, Davis intersperses descriptions of policies and political history relating to psychiatry and the rights of the patient with case studies of selected patients she encountered during fieldwork in two psychiatric hospitals and one psychiatric association. Responsibility is a thorny and complex issue in the field of psychiatry and is often beset with subjective quandaries that complicate the delivery of care and the question of the patient-physician relationship. This is well illustrated in Davis’s statement: “Like their fellow citizens, patients are expected to function as responsible members of the community, but unlike them, many patients are ascriptively or subjectively disabled from the capacities and desires that define responsible citizenship. This disjunctive demand for patient responsibility inaugurates a collaborative mode of ethics by which therapists in a sense complete the subjectivity of their patients as they enlist them in treatment.” Therapists are caught between the need to foster responsibility in patients and, at the same time, afford them the freedom they are entitled to as citizens. It is a wiggly tightrope act that often ends up in failure of treatment.

A number of themes are intertwined in the dense description of the reform process that the book provides us with: freedom, truth, ethics, alienation, persuasion, healing, subjectivity, and cultural diagnostics. The story that emerges is one that is so typical of many similar processes implemented in other European countries where reform has been aimed at shifting treatment from the institutional setting of custodial hospitals to outpatient settings: when patients are cared for in outpatient settings they struggle to function in communities that often are the sources of their mental pathology, as well as being sites of respite and refuge. The book itself is structured according to three intertwined themes: truth-telling in the psychiatric encounter, culture, and diagnosis; freedom of the patient in terms of the juxtaposition of protection; and liberation of the patient.

The chosen region is particularly intriguing due to its sparse population, which includes cultural minorities that to a large part are separated from Greek society, and Muslim communities of Gypsies, Turks, and Pomacs. It is this cultural diversity that causes ambiguous reactions and actions in the therapists that care for patients belonging to these minorities; it gives grounds for suspicion regarding the truthfulness of patients’ claims of illness and thus their needs for financial assistance and state-subsidized care. These patients’ social positions are precarious, as they struggle against what Davis terms a ‘folk genetics of madness’ that makes them a social liability to their families and gives them a stigmatized identity in the community. The absence of cultural beliefs and practices that could render illness and healing comprehensible outside of the biomedical paradigm further adds to their vulnerable status.

This is an educational book in many senses; well researched and spanning a breath of knowledge combined with solid, long-term fieldwork that has produced a wealth of empirical material. The author’s background as a scholar of Hellenic studies brings additional credibility to her familiarity with Greek culture, history, philosophy, politics, and society. The contextualization of the issue of psychiatric reform and moral dimensions of responsibility is not only couched in the cultural particularities of a specific country context, but also in detailed descriptions of psychiatric terms, patient-physician communication, and the central ideological streams of Greek psychiatry. Davis is well versed in the central figures of Greek social psychiatry and their major works, in part gained through in-depth interviews conducted with these persons.

After telling us the story of two psychiatric hospitals and one psychiatric association, Davis recounts selected patient case histories. This is the most interesting and appealing part of the book, because in these ethnographic sections of the book Davis traces the complex, multifaceted meanings of responsibility and mental illness for the people caring for individual patients, as well as patients’ own view of their situation. These sections provide the reader with detailed descriptions of patient-psychiatrist interactions, psychiatrists’ interpretations of the care rendered, the patients’ conditions, and Davis’s personal discussions with patients. She provides us with a multifaceted perspective of how psychiatric therapy is enacted, and also how the issue of responsibility is negotiated between patient and psychiatrist. Voices and faces are given to patients who often remain nameless in accounts of therapy and are at the margins of the official story of reform processes. By providing the reader with medical histories that include information on the social conditions under which these patients live, in communities characterized by violence and destitution, it is easy to see the challenges faced in terms of providing good care and safeguarding patient well-being. The psychiatrists’ engagement is noteworthy; most of them go beyond their call of duty with follow-up and forms of assistance. The influence of social psychiatry on the therapists’ attitudes and manner of working with patients is central. Through this multi-pronged approach the author helps us see how patients tell different stories about their condition and its background than the psychiatrists that care for them, but also that these stories sometimes converge. Davis illustrates that there is cultural meaning in the patient-physician interactions and that psychiatrists use cultural diagnostics when giving illness labels to their patients. Throughout these descriptions she seeks to provide a balanced picture of the challenges faced by both patients and psychiatrists and how these challenges are dealt with.

The book also provides descriptions of Thrace’s historical development and the region’s migration history that clearly outline how the Greek government sought to attract these populations to immigrate to Greece, but then, for the most part, forgot about them and left the impoverished region to its own devices. Based on Davis’s account of the practical implementation of psychiatric reform in Greece, it is easy to extrapolate that the process should also entail social reform and structural support to individuals so that they can live decently and safely in the community. Democratic reform of psychiatry needs to extend far beyond clinic walls to social reform, and should also include structural support to these culturally and socially marginal individuals. It is this abject poverty and violence that jars one’s sense of justice; how can responsibility be addressed when the most basic conditions of life are not fully met?

Although the author is successful in identifying and tackling a range of issues, the book would have benefitted from a section outlining the motivations for the methods chosen and the advantages of the ethnographic method in researching this particular subject matter. It would have been equally interesting to know why the author chose to conduct research on this subject. Davis uses a very creative solution in the manner in which she divides up the book and titles each individual part, but this does to some degree make it difficult to interpret what she is exactly dealing with in each section. The section headings are poetic, but a quick glance of the book’s contents page does not immediately reveal what the book is about. Another issue that she does not sufficiently address is that of ‘bad souls’. This concept is sparsely mentioned in the book, but as it features in the title one expects to find it treated in the book more thoroughly. In addition, it is an interesting concept that would have merited further investigation and explanation.

It is debatable whether the format she has used – where background information is interspersed with factual information on policy and history of psychiatric reform with ethnographic vignettes – is the most effective and reader-friendly manner of presenting the material. It no doubt enlivens the reading experience and provides rhythm to the text, but perhaps a more straightforward division of facts and history in one section and ethnographic descriptions in another section would be more pedagogical. Above all, the rich use of ethnographic material points to the advantage of using qualitative methods and ethnographic accounts in unearthing the aspects of the field of psychiatry that are taken for granted for and hidden, as well as the field’s  implementation in the community.

Taken as a whole, this volume should appeal to a specialist audience interested in delving into the history and culture of psychiatric reform and how it plays out in a specific region at the margins of Europe. It should also interest scholars and policymakers working in the field of psychiatry and psychiatric reform. Overall its straightforward and simple language makes for an engaging read and its fascinating subject matter also makes it an ideal teaching tool for courses on health and illness from a variety of disciplinary perspectives.

Without denying the need to address responsibility as a central pillar in the care process or romanticizing the patient-physician relationship, Davis’s research on this issue shows that anthropologists can recognize and document processes of care as they evolve, and are part of the everyday life of patients and physicians alike. In a succinct manner we are reminded of a significant point: that policy documents and legislation are always interpreted and subjectively shaped by various actors in charge of caring for patients. They are filtered through the professional experiences and ideological concerns of these individuals and the many particularities of local conditions and personal histories that they have to take into account when judging what is best for the patient. Throughout the book, Davis demonstrates how the reformed system of psychiatric care in Greece is beset by an inadequacy of both medical care and legal protection to foster the well-being of a great number of patients. She states: “This impasse between humanitarian psychiatry and intractable pathology determines the ethics of responsibility for mental illness in Greece – for patients, doctors, communities and the state. Well-being emerges on one side of this impasse; asylum persists on the other.” This is a statement that one hopes will stimulate debate on the relationship between policy implementation, psychiatric reform, and the central issues of responsibility and freedom in Greece and beyond. All in all, the author has been successful in fulfilling the aim of embarking on a journey to examine the Greek psyche as a seat of ethical subjectivity and responsibility, and doing so in an engaging and thorough manner.

She ends with a last description of the new wave of immigrants who flood in to the local detention center from Asia, Africa, and the Middle East. They have arrived in Greece with the same hopes that immigrants before them have entertained and hope for a peaceful and better life in this new country, despite the heavy traumatic experiences they have lived through in their countries of origin. History repeats itself, and local therapists will have to take on the challenge of helping these individuals help themselves.

Reviewed by Susanne Ådahl, University of Turku

Bad Souls: Madness and Responsibility in Modern Greece
edited by Elizabeth Anne Davis
Duke University Press
Paperback / 344 pages / 2012
ISBN: 978-0-8223-5106-1

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