Elizabeth Anne Davis. Bad Souls: Madness and Responsibility in Modern Greece. Durham: Duke University Press, 2012. x + 331 pp. $94.95 (cloth), ISBN 978-0-8223-5093-4; $25.95 (paper), ISBN 978-0-8223-5106-1.
Reviewed by Noelle Mole (NYU)
Published on H-SAE (February, 2013)
Commissioned by Michael B. Munnik (Cardiff University)
The Ethical Onus of Psychiatric Care
In Bad Souls, Elizabeth Anne Davis examines how the treatment of mental illness in contemporary Greece hinges on an underlying conflict: navigating and diffusing the moral responsibility for care between patients, doctors, and the state, as well as families and communities. In Greek, a “bad soul” implies “a craven person disabled by moral cowardice and irresponsibility,” and so, too, the book probes the problem of how psychiatric patients become positioned--incompletely and unevenly--as atomized subjects, endowed with the capacity to self-manage their illness, treatment, and recovery (p. 20). Both theoretically rigorous and ethnographically nuanced, the book investigates the effects and erasures of current Greek psychiatry after a quarter century of reform, which adopted community-based care and dismantled and decentralized the state apparatus, especially for mandatory psychiatric institutionalization. For Davis, we must understand the “liberal ‘rights culture’ of personal responsibility” not merely as an effect of neoliberalism but rather as an emergent practice and value of Greek psychiatric reform (p. 123). Influenced especially by Italian Franco Basaglia’s deinstitutionalization movement, and the international turn toward community-based care in mental health, Greece--with significant assistance from the European Union--began reforming its infrastructure in the 1980s. As a whole, Davis accounts for how, within mental healthcare’s move away from dehumanizing institutional confinement, the apparatus came to promote and value patient self-care, if unevenly. She documents, for example, patients’ “countermoralism,” that is, the ways in which patients refuse--consciously and unconsciously, directly and indirectly--these collaborations and reroute the ethic of responsibility back to the doctor, the clinic, and the welfare state (p. 16).
Of its many distinguishing features, this ethnography investigates and theorizes various mental illnesses, including psychosis, paranoid schizophrenia, obsessive compulsive disorder, and bipolar disorder. She corrals the stories of many individuals--some of whom, however, disappear abruptly in ways that, perhaps, mirror the way patients enter and exit sites of care. Her approach, therefore, is quite unlike single-illness ethnographies (such as Junko Kitanaka’s Depression in Japan: Psychiatric Cures for a Society in Distress ; Emily Martin’s Bipolar Expeditions: Mania and Depression in American Culture ; and Jonathan Metzl’s The Protest Psychosis: How Schizophrenia Became a Black Disease . By calibrating our attention to the institutional, Davis successfully makes psychiatry and its attending practices and sustaining ethics her objects of study. The breadth of Bad Souls is quite spectacular as we come to inhabit multiple spaces within and adjacent to psychiatric institutions: mobile psychiatric units, case presentations, group therapy for psychotics, an immigration detention center, and numerous informal and formal interviews with doctors and patients both in hospitals and in private homes. At the same time, however, this necessarily means that questions about the particular qualities or symbolic manifestations of mental illness are not always explored with the same depth as single-illness studies. As an analytical strategy, however, it is this pan-illness lens that makes Davis uniquely able to bring this domain of knowledge--and the morally fraught micro-positionings of patients, doctors, and the state--into close relief.
Davis devotes the first section of the book to mapping how deception and “suspicions of lying” represent a central feature in the truth-making apparatus of diagnosis (p. 74). Often, she finds, this pivots on whether the patient is understood as deliberately lying and thus manipulating the doctor, as opposed to offering unreliable accounts or unintentionally omitting pertinent details of her or his history. To psychiatrists, the former kind of deception often represents either a “difficult” patient or, possibly, a symptom of personality disorders, which are understood as chronic and hard-to-treat conditions. Davis also reflects on how, in counterintuitive ways, these suspicions of deception actually suture the patient-doctor dyad and limit patients’ autonomous self-care; this represents, at least in part, patients’ “refusal” of this mode of discipline.
Davis’s ethnography is situated within Greece’s region of Thrace, borderland of Bulgaria and Turkey, and we learn that psychiatrists regularly treat minority patients--Gypsies, Turks, Pontii--and diagnose their illnesses as “cultural pathologies” (p. 4). She shows us that somatic symptoms have within Greek psychiatry become intertwined with the notion of “cultural” illness and aligned with psychoanalytic understandings of hysteria and conversion disorder. To intervening psychiatrists, women’s subordination, for instance, if expressed in bodily as opposed to psychic distress, serves as apparent proof of the patients’ “cultural difference” and, furthermore, their purportedly outdated expression of distress. Davis’s insights are exceptionally sharp here as she shows us that narratives of humanitarian psychiatric reform, together with cultural relativism, merge with the discourse of culture difference such that clinicians effectively become mobilized toward “urging clinical distresses out of the body and into the discursive domain of therapeutic persuasion” (p. 126). Davis uncovers the hidden logic: just as the traditional becomes modern and the hysteric precedes the depressive, so too, the rationale follows, must patients’ unconscious denial give way to individual responsibility.
In the third section of the book, Davis argues that treating severely ill patients as autonomous and capable of self-care can undermine their capacity to heal and receive effective treatment. For Davis, the shifted onus of moral responsibility onto patients is “more than a story of governmentality” (p. 15). By contrast, in a recent ethnography of Italy, The Moral Neoliberal: Welfare and Citizenship in Italy (2012), Andrea Muehlebach argues that portions of care work (for the elderly and the sick) now partially under the guise of volunteer workers represent a way in which the neoliberal state produces a “highly moralized kind of citizenship” (p. 6). Though the contexts are, of course, not symmetrical, it bears noting that Davis positions the cultivation of moral responsibility as more highly intertwined with the particular logic of Greek psychiatric reform than with neoliberal governance. Davis’s historical understanding of moral responsibility lives at the threshold of the political and the medical but does not, in ways that run counter to some debates on neoliberalism, theorize either the state or late capitalism as primary generators of citizens’ mandate to self-manage morally.
Bad Souls provides a compelling and detailed examination of ethics, relationality, medicine, and citizenship in modern Greece. This is also a story, a self-proclaimed study of “madness,” about the investigator’s ethical onus to attend carefully to human suffering and its complex formations and inexplicable silences. In Davis, we find an exceptionally graceful awareness of her quandaries and limitations as the critical investigator, as well as an ethnographic sensibility well suited to this complex material. The book deserves as much admiration and attention in the fields of psychiatry, anthropology, medical humanities, and European studies, as it does from scholars interested in ethics, governance, and citizenship.
: Madness and Responsibility in Modern Greece
. See for example Junko Kitanaka, Depression in Japan: Psychiatric Cures for a Society in Distress. (Princeton: Princeton University Press, 2011); Emily Martin, Bipolar Expeditions: Mania and Depression in American Culture. (Princeton: Princeton University Press, 2009); Jonathan Metzl, The Protest Psychosis: How Schizophrenia Became a Black Disease. (Boston: Beacon Press, 2011).
. Andrea Muehlebach, The Moral Neoliberal: Welfare and Citizenship in Italy. (Chicago: University of Chicago Press, 2012).
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