Paper Piyush Pushkar
Manchester, United Kingdom
Keywords: violence, meaning, social defeat, structural oppression
Introduction
As clinicians, how do we conceptualise violence? Generally, we see it as a symptom or risk factor, or both. In short, it is a problem. For example, the Oxford Handbook of Psychiatry lists types of aggression:
instrumental/predatory and expressive/defensive, explains them in terms of universalising theories, e.g.
evolutionary or Freudian, and then describes therapeutic approaches to it.1 The anthropological position is somewhat different to the biomedical or even the biopsychosocial models, both generally and with regards to violence specifically. The key research method in anthropology is ethnography, a qualitative approach in which the researcher conducts participant observation. This involves spending significant amounts of time with informants, often living amongst them, doing what they do, and learning to live life as one of them, typically for months or years. As Alex Cohen describes it in one of the papers to be discussed,
We served as companions, confidants, and biographers. My colleagues and I shared meals, drank coffee, and hung out with informants; played cards and chess with them; listened with interest and made notes about or recorded our conversations both lengthy and brief. We visited informants in their apartments or hotel rooms during periods when they were off the streets. We took them out to eat at local restaurants. In short, we took an active part in their lives.2
For Cohen, this led to “rich, detailed understandings of their lives”, including hearing the voices of people who might have been excluded when using other methods of research. One of the pioneers of participant-observation, Bronislaw Malinowski, described its value in discovering the “imponderabilia of actual life”.3 From this, anthropologists are able to interpret the “webs of significance” that make up local cultures, and thus tell stories from the particular perspective of the informants themselves, considering what their behaviours mean for them.4 This leads to a different interpretation of violence which may be educative for us as clinicians.
In this essay, I will explore some of the anthropological literature on violence in the mentally unwell, in the hope of extracting some lessons for clinical practice. It will not be exhaustive of all the available ethnographic studies, but will draw a common thread between several interesting and significant works, concentrating less on self-harm and more on violence against others.
Review
All of the studies situate the behaviours of their subjects in their local environments, in many cases the same environments in which the anthropologists were living for the duration of the research. For the mentally unwell people studied, this environment is tough. They must tolerate poverty, joblessness, financial precarity, frequent homelessness, crime and drugs. In such environments, violence is frequently visible and takes on the appearance of normality. Philippe Bourgois’s In Search of Respect: Selling Crack in El Barrio, records extreme physical and sexual violence so often that he haltingly warns of the risk of the anthropologist “falling prey to a pornography of violence” in writing up his/her findings.5 Even when that violence does not directly involve the informant, its “traumatic nature and prominent public visibility contribute to a sense of an omipresent threatening reality that extend[s] far beyond the statistical possibility of becoming a victim”.6 Within this “culture of terror”,6 violence becomes a part of daily life, impossible to ignore and socialising those who witness it. For them it becomes normal.
Bourgois describes the systems, structures and cultural norms that support and allow this situation - so different from that which most of us would describe as normal or even acceptable - as an example of structural oppression, arguing that they influence and dictate the behaviours of those unlucky enough to be born into these situations such that they are unable to move away from them. In another study, Rob Whitley describes very similar circumstances as “social defeat”.7 He discusses the idea put forward by Selten and
Cantor-Graae that social defeat is a risk factor for developing schizophrenia. In their formulation, social defeat is defined as “a subordinate position or ‘an outsider status’”.7 They see many of the aspects of life mentioned above and in the ethnographies described as examples of social defeat: “homelessness, loneliness, unemployment”, etc.7
The purpose of this essay is not to explain violence away, nor to make the claim that there is a deterministic quality to acts of violence when they do occur. The point is to fully illustrate the answer to the question of what it means when it does occur. Experiencing “social defeat” does not necessarily lead to schizophrenia, and being surrounded by violence does not necessarily lead one to act in a violent manner oneself.
Whitley describes the idea of social defeat but actually takes issue with it for in his study; his informants are far from defeated. They resist the pervading fear of crime and violence against them by organising, by making improvements to their homes, and more importantly for this essay, by being prepared to confront people. This preparation includes carrying objects that may be used in self-defence, such as umbrellas and canes. Of course, being prepared for violence means that informants are sometimes involved in acts of violence, but what is important for Whitley is that this violence is not accepted passively, but instead resisted. In the model of social defeat as aetiological factor for schizophrenia, this means resisting not just the direct consequences of physical violence (i.e. physical harm to oneself), but also its indirect consequences as envisaged by the medical model. It means resisting mental illness itself. As such, they are
“active strategies of empowerment”,8 not only indicating, but in themselves also engendering “a sense of agency [and] confidence”.9
Bourgois takes a similar line in describing violent behaviour as a strategy to circumvent the circumstances of structural oppression. In essence, it is a strategy of survival. Below, I quote an exchange between two of his main informants, crack dealers in El Barrio who are also addicts themselves, describing why it is necessary not only to engage in violence, but to be seen to do so:
Primo: You could be a nice and sweet person in real life but you gotta have a little meanness in you and play street. Like, “Get the fuck outta my face.” Or “I don’t give a fuck.” That way you don’t let nobody fuck with you later...
Caesar: You’ve got to be a little wild for this neighbourhood, Felipe. [Gunshots] What did I tell you?
You can’t be allowing people to push you around, and then people think that you’re a punk and shit like that.10
Bourgois acknowledges that some of the acts of Primo and Caesar described in the text seem “irrationally violent” or “barbaric”.10 He writes of his own emotions in hearing their accounts of rape and bullying, his own profound dislike and disgust at Caesar in particular. In one episode, Bourgois writes of holding back tears as Caesar proudly recounts a beating he had perpetrated upon a child with cerebral palsy, having forgotten that Bourgois’ own child had recently been diagnosed with the same disorder. However, he uses his own emotion not to judge Caesar and Primo, but to further his analysis by “reinterpret[ing their actions]
according to the logic of the underground economy as judicious public relations and long-term investment in one’s ‘human capital development’”.10 In this way he is able to argue that structural oppression exists and shapes the lives of Primo and Caesar, but not that it determines their actions. They exhibit a contradictory agency which allows them to forge “strategies of resistance” like Whitley’s informants, many of which are violent.
Bourgois and Whitley’s arguments differ on the results of these strategies. For Whitley, the sense of empowerment gained in acts of social resistance contributes to recovery, particularly in the domains of existential and social recovery. For Bourgois, they fit into the cycle of structural oppression: “Caesar...
embod[ies] the social injustice of a nation that systematically chews up its most vulnerable citizens and spits them out onto inner-city streets where their desperate celebration of suffering terrorizes themselves, their neighbours, and their loved ones”.11 He goes further in adding a psychological aspect to his argument;
the inhabitants of El Barrio internalise an inner sense of worthlessness fostered by violence. This in turns leads to more violence, which further augments the sense of worthlessness, and so on.
While these two trajectories are different, they are not mutually exclusive. As Whitley notes, certain strategies of resistance can impact on other aspects of recovery as conceptualised by him, in particular, functional recovery. For example, carrying a knife may lend the carrier a sense of empowerment, of resisting
“social defeat”, but may also lead to arrest and prosecution which may then lead to unemployment, an aspect of “social defeat” in itself. The cyclical nature of structural oppression reveals itself again.
Alex Cohen discusses another typical aspect of life for the mentally unwell: boredom. Like the other studies mentioned so far, his is based in extreme circumstances. His research subjects are not just mentally
unwell, but also homeless, living precarious lives on Skid Row in Los Angeles, “a place where life was dominated by boredom and inactivity, only interrupted by brief periods of violence and terror”.12 Like Bourgois and Whitley, he notes unemployment, poverty and crime as aspects of normality for the people living on Skid Row. In his own life he finds meaning in his work and relationships, and is aware of how this is exhibited in the way he speaks and acts. He compares this to that which might be presented by the media in films and on television, how characters in soaps typically have jobs, families, projects, deadlines, etc.
He finds these tropes reappearing in the delusions of many of the people whom he interviews, who infuse their apparently repetitive lives with meaning by imagining themselves bound up with the lives of famous and important people such as Robert F. Kennedy and Mother Teresa. In this way, he argues, they replicate the “eventfulness” of the lives of people whom they see as normal.13 More relevantly for this paper, this is not just demonstrated in their delusions, but in their actual behaviours, i.e. they seek to alleviate the boredom of a life without close personal, family or work ties by pursuing drugs and its associated acts, some of which may include violence. As he writes, “The individuals we knew had few other avenues by which they could satisfy their need for meaningful social interaction and excitement”.13 Again, violence is understood as a possible response to social defeat. This response is one which not just has meaning, but actually creates it by virtue of its “eventfulness”, as interpreted by the perpetrator him/herself.
In a quantitative study, Mathias Angermeyer, a psychiatric sociologist, asks what this means not for the mentally unwell person him/herself, but for the general public (which, of course, includes many unwell people). He finds that there is an acute increase in the “social distance” between the mentally unwell and the general public after prominent acts of violence committed by people described as mentally ill.14 While he is careful to demarcate between schizophrenia and personality disorder, he points out that most journalists are not so careful. Instead, members of both groups are portrayed as mentally ill, and any crimes committed by them are prominently described as such. There were two highly publicised attacks on famous people in Germany in 1990, and one in 1993, the first two by people diagnosed with schizophrenia, the latter by a person with severe personality disorder. Following these events, random samples of people were surveyed, asking questions relating to the degree of intimacy and social involvement the respondents would be willing to enter into with a mentally unwell person. This included variables such as whether or not they would sublet their apartment to such a person, whether they would employ him/her, whether they would be happy for him/her to marry into their family, etc.
On all of these measures, the amount of people willing to enter into such relationships with mentally unwell people decreased after the 1990 violent attacks, and then rose again in the following years, before falling again after the 1993 attack. This is what he means by an increase in social distance. As such, what he describes as increased social distance sounds very similar to social defeat, i.e. an environment in which a person who is thought to have a mental illness can not find a home or a job, or enter into a meaningful long-term relationship. This returns us to Bourgois’s argument regarding the cyclical nature of structural oppression: a violent act is an agentic act in response to social defeat, but only serves to reinforce the social defeat against which it itself is a response.
Society makes little allowance for structural explanations of behaviour, instead treating individuals as agents responsible for their own actions. Therefore, a structural explanation of the origin or the meaning of a violent act has no truck. Instead the commission of an act which may be a strategy of survival becomes the very means by which its perpetrator is held down in an environment of social misery. That is, society notes the individual’s response to the situation, without taking account of the situation itself. The individual is punished or medically treated, or both, as appropriate, but no action is taken to treat the wider issues.
Conclusion
As clinicians, what can we learn from these studies? Since the environments studied in several of these papers are extreme, the relevance to our daily practice may be called into question. However, several aspects of life for our own clients may hold true. Certainly, we see the characteristics of social defeat regularly:
unemployment, degradation of social relationships, financial precarity, etc. The loss of meaningful social activity in one’s life to which this may lead can be easily understood and, I argue, should be more widely considered. However, boredom also has a more immediate and obvious relevance to inpatient practice, in which service users are kept in unstimulating environments for days, weeks, months or years, unable to work or build social relationships that have a non-institutional character.
One key lesson I hope to draw from these studies is theoretical: by understanding certain behaviours as symptoms rather than responses by human agents to complex and challenging environments, we run the risk of neglecting an aspect of their experience. However, if we simply allow ourselves to see behaviours
deterministically, as functions of structure and environment, this is equally dehumanising. Seeing a violent act as a response, imbued with meaning, to the particularities of a situation does not mean that it was the only possible response. Like those without mental illnesses, people with mental illnesses devise strategies for survival which are dynamic and contingent, aided by internal algorithms which are being continuously modified, both consciously and unconsciously. The meanings they draw from their actions are also dynamic and contingent, and may also be strategies in and of themselves. These behaviours not only find, but also create meaning as events in the lives of the mentally unwell.
Violent behaviour may benefit existential recovery, but is morally and practically undesirable, as well as leading to situations in which it hinders functional recovery, e.g. prosecution, arrest, further unemployment, etc. The cyclical machinery of structural oppression becomes visible as the actions of the mentally unwell, which are responses to their environments, serve to recreate those very same environments. Therefore, this raises questions regarding the wider responsibilities of the mental health worker in finding ways to alleviate structural inequalities. We must be more than clinicians serving individuals, as we serve those individuals better by devoting more time and effort to advocacy for and with the mentally unwell, to remove the factors of life that contribute to the social defeat of certain groups in society.
References
1. Semple D, Smyth R, Burns J, Darjee R, McIntosh A. Oxford Handbook of Psychiatry. Oxford: Oxford University Press;
2. Cohen A. The search for meaning: eventfulness in the lives of homeless mentally ill persons in the Skid Row district of Los 2005 Angeles. Culture, Medicine and Psychiatry 2001; 25: 277–296, p282
3. Malinowski B. Argonauts of the Western Pacific. London: Routledge; 2007, p18 4. Geertz C. The Interpretation of Cultures. New York: Basic Books; 1973, p5
5. Bourgois P. In Search of Respect: Selling Crack in El Barrio. Cambridge: Cambridge University Press; 1995, p18 6. Bourgois P. In Search of Respect: Selling Crack in El Barrio. Cambridge: Cambridge University Press; 1995, p34 7. Whitley R. Social Defeat or Social Resistance? Reaction to Fear of Crime and Violence Among People with Severe Mental
Illness Living in Urban ‘Recovery Communities’. Cult Med Psychiatry 2011; 35: 519–535, p520
8. Whitley R. Social Defeat or Social Resistance? Reaction to Fear of Crime and Violence Among People with Severe Mental Illness Living in Urban ‘Recovery Communities’. Cult Med Psychiatry 2011; 35: 519–535, p527
9. Whitley R. Social Defeat or Social Resistance? Reaction to Fear of Crime and Violence Among People with Severe Mental Illness Living in Urban ‘Recovery Communities’. Cult Med Psychiatry 2011; 35: 519–535, p529
10. Bourgois P. In Search of Respect: Selling Crack in El Barrio. Cambridge: Cambridge University Press; 1995, p24-25 11. Bourgois P. Confronting Anthropology, Education, and Inner-City Apartheid. American Anthropologist 1996; 98(2):
249-265, p256
12. Cohen A. The search for meaning: eventfulness in the lives of homeless mentally ill persons in the Skid Row district of Los Angeles. Culture, Medicine and Psychiatry 2001; 25: 277–296, p277
13. Cohen A. The search for meaning: eventfulness in the lives of homeless mentally ill persons in the Skid Row district of Los Angeles. Culture, Medicine and Psychiatry 2001; 25: 277–296, p284
14. Angermeyer M, Matschinger H. Violent attacks on public figures by persons suffering from psychiatric disorders: Their effect on the social distance towards the mentally ill. Eur Arch Psychiatry Clin Neurosci 1995; 245:159-164, p159
Correspondence
Piyush Pushkar
piyushpushkar@doctors.org.uk