Beyond ‘trauma’

Notes on mental health in the Middle East

Orkideh Behrouzan

09 Dec 2015

This special section includes some of the works presented in an interdisciplinary workshop entitled ‘Beyond “Trauma”: Emergent Agendas in Understanding Mental Health in the Middle East’, held in September 2014 in London. In the face of a pressing need to rethink the psycho-politics of well-being and mental health in the Middle East, the event raised questions about what is at stake – culturally, historically, and politically – when mental health becomes an area of inquiry and intervention. Specifically, we aspired to bring together viewpoints that go beyond the limits of dominant global health paradigms that are characterized by an individual-centred emphasis and approaches that focus on trauma and PTSD. We hope to engage in an ethical and pedagogical examination of what we assume we know, and to ask what happens to psychiatry and mental health care paradigms as they travel. At stake are a number of conceptual frames, both in the social sciences and in psychological disciplines, that no longer seem helpful, yet remain central in mental health care practice and policy making. A critical conversation about the cultural meanings and situated experiences of psychological conditions, as well as the appropriation of diagnostic categories and theories of trauma, seems to be long overdue.

In calling the project ‘Beyond “Trauma”’, we challenge the competing disciplinary assumptions that underlie the term and that pathologize and determine the parameters of ‘healthy’ reactions to ‘unhealthy’ conditions. One concern is that ensuing diagnostic labels (such as PTSD) and classifications (such as the DSM), themselves widely contested even in Western biomedicine, individualize and de-socialize experiences and phenomena that are fundamentally social and historical. We are also sensitive to the violence inherent in the very process of identifying trauma, which entails a politics of exclusion by applying taxonomies of experience. Such practices risk masking, erasing, and trivializing the experience of some while reinforcing the conditions that created the so-called trauma in the first place. This is not to overlook the individual burden and medical conditions that traumatic experiences inflict on individuals. As Veena Das puts it in her insightful commentary, ‘The issue here is not whether PTSD is real or not, but what forms do the relations among politics, law, and psychiatry take in different time-space configurations?’ I would add the question: What cultural and historical forces and moral tensions shape such reality?

The idea of the workshop arose in part from frustration with the extent to which communication across disciplines and areas of expertise remains blocked. While we all agree that interdisciplinary work matters, we have yet to overcome hierarchies of expertise and intellectual territories. Interdisciplinary work is continually challenged by competing rather than converging conceptual frameworks. One aim of the workshop was to achieve an interdisciplinary dialogue in which each participant could invite others to challenge their disciplinary assumptions, in which we could all display a willingness to face conditions beyond our grasp. This section is a showcase of that dialogue.  By the end of the workshop, a shared language had emerged built on mutual care and concerns. The participants came together around a deep sense of care and empathy for the human condition and the premise that health and well-being are shaped by both medical and sociopolitical forces, contexts, and histories. We believe that the tensions that different methodologies of research reveal between the mind-sets, narratives, and aspirations of different groups are valuable resources, rather than obstacles, for inclusive approaches to policy. We tried to illustrate, for example, why and how art, literature, cultural studies, and history are not only relevant to but in fact essential for informed mental health policy making, and why psychiatry cannot single-handedly deliver positive outcomes when it is divorced from politics, anthropology, and history. Mental health, in other words, is more than a clinical matter. Furthermore, clinical categorizations have implications beyond the clinical encounter.

When affliction occurs, it can provide the context in which certain forms of life become either valorised or pathologised. Depending on what gets pathologised and what gets valorised, institutions and politicians may create or instrumentalise certain strategies of living and political projects. From Hezbollah’s identity politics of solidarity in Lebanon, to Iranians’ mobilization of Shiite frameworks during the Iran-Iraq War, to European narratives of heroism in the First World War that inhibited the acknowledgement of psychic pain, institutionalized narratives often fluctuate between the extremes of heroism and victimhood. But the space ‘in between’ is where individuals carve out strategies of living and construct fragments of agency.

The pieces in this section thus turn to those spaces. In drawing on ethnographic fieldwork they share a bottom-up approach to psychological well-being that goes beyond individual clinical encounters. They illustrate how individual and social well-being are cultural, psychological, historical, and clinical constructions at once. They suggest interconnections between different locales, underscore existing institutional and professional frameworks, and highlight the challenges of multisited research. They also manifest the importance of moving away from analysis through the lens of ‘resistance’ in the Middle East and towards an understanding of political projects as ongoing strategies of ‘living through’. The scholars here look at both conflict-ridden and post-conflict parts of the region in order to parse out the human condition that characterizes each setting. Conflict often becomes a shorthand for other kinds of violence, as evident in the works of Omar Dewachi, Zuzanna Olszewska, and Hanna Kienzler and Zeina Amro, who locate violence in the complex politics of exclusion in ordinary life or around access to care. In Olszewska’s article, for example, there is no military conflict, but there are various forms of structural, gendering, and institutional violence and discrimination at play against and among Afghan refugees. Rather than perpetuating depictions of unending conflict, these studies suggest a focus on what it means to live in ecologies of uncertainty, testifying to the ongoing, unfinished, and stuttered nature of memory and experience.

What, then, are people’s strategies of ‘living through’? Whether it is medicalization (Behrouzan), cultural work (Olszewska), consolidation of specific therapeutic structures (Kienzler and Amro), or the reconfiguration of social relations that prevent the healing of the social wounds (Dewachi), the key task is to understand the cultural resources that individuals mobilize to create strategies for living. What means are available – culturally, clinically, or historically – for people to work with or through psychological pain? At issue is discerning what helps people sustain a moral life outside rigid clinical and cultural categories, while also acknowledging, respecting, and empathizing with people’s actual experiences. How can we incorporate, for example, collective acts of remembering and the powerful legacy of oral cultures into therapeutic interventions? What clinical possibilities do cultural analysis and historical accountability offer to practitioners and policy makers? Engaging with social sciences and humanities, we believe, contributes to therapeutic possibilities by helping us access the subjective experiences of inhabiting [ruptured] spaces of everyday life.

In order to access individuals’ experiences and the resources on which they draw, these pieces invite us to step outside of the clinical realm and enter the world of cultural work. Zuzanna Olszewska approaches poetry as a generative space that provides capacities for both experiencing and expressing. We hope to invite similar explorations on the interconnection between the personal and the political, the intimate and the shared, from the humanities and arts. Such capacities exist in art and literature precisely because they embody lived historical experiences and provide a window into different structures of feeling. Moreover, these spaces offer individual and collective capacities for the freedom of fiction and dreaming, which in turn make possible claims to historical experiences and demands for justice and accountability, while exploring what may come next. Artistic and literary expressions, filmic and visual mediations, activism, and various forms of cultural production allow for alternative individual and collective histories to evolve beyond institutional forms. In doing so, they offer possibilities for healing, community building, and re-assimilation. In this spirit, these pieces challenge several binaries – patient-practitioner, global-local, and cultural-biological – by incorporating the situated knowledge of practitioners, the understanding of whose experiences cannot be divorced from the conditions in which they live and work. A first step thus would be to evaluate the current state of mental health care systems that are in place, the struggles and opportunities of psychiatry’s interactions with various Middle Eastern societies and their medical pedagogies, and the ethical stakes of researching the pain of others. This requires a critical assessment of the role of the outsider in such ecologies of uncertainty.

These pieces also aim at shifting lenses and challenging stereotypical representations. Rather than understanding the region through the lens of ‘religion’ for instance, they focus on asking what parts of religious and cultural practices are mobilized to create moral frameworks, and why. Many of us share a disappointment with representations of the region in which it is repeatedly essentialized, misrepresented, and commonly reduced to ‘conflict’, and the ethics of engagement such representations engender. What do we even mean when we talk about ‘the Middle East’? How much do we know about its various health care infrastructures and diverse ways in which mental health and well-being are understood, practiced, and conceptualized? The speed with which the scene is changing, even since our London meetings in September 2014, both urges and warns against quick analysis. It calls for thinking about long-term, in-depth, and interdisciplinary approaches that go beyond analysing everything Middle Eastern through the lens of religion or conflict.

Sadly and inevitably, however, a portion of this project must engage with the afterlife of various wars in the region, many of which have turned from wars to prolonged states of endless chaos. The Iraq War, for instance, has become shorthand for the aftermath of an illegitimate invasion preceded by and extending earlier conflicts. Prior to 2003, Iraqi society had already been in a state of affliction for decades; the 1980 to 1988 Iran-Iraq War, the 1991 Gulf War, and decades of sanctions had created generations of lived war. Since 2003, alarming rates of mortality, disability, and displacement have been overshadowed by other catastrophes. It is estimated that over four million Iraqi children lost their parents after the 2003 invasion. More recently, millions of Syrian children have been displaced and left out of schooling. The condition of children alone qualifies as an emergency, a humanitarian crisis urging provisions for medium-term and long-term mental health care policies.

The ‘Beyond “Trauma”’ workshop was held in the immediate aftermath of the 2014 Gaza war. Over the past year millions of displaced refugees from and within Syria have suffered the loss of their homes, communities, and livelihoods. Rapid transformations in the region, including the entrenchment of the so-called Islamic State’s violent methods for obliterating cultural identity and inflicting atrocities upon civilians, only highlight the urgency of this conversation. There is a need for our sustained and committed attention to individuals’ and communities’ sense of well-being and integrity. Beyond the horror of these acts lie important reminders about what remembering and being remembered means when moral textures of societies are disrupted and structures of reverence and remembrance are obliterated.

At a more practical and immediate level, the question of humanitarianism is an urgent one that anthropologists and other scholars have investigated critically. At our event, we juxtaposed critiques of the humanitarian enterprise with the undeniable yet pragmatic need for it, as forwarded by practitioners Rita Giacaman and anthropologist Sa’ed Atshan, whose works are not included in this issue. But they enriched the ensuing debate by challenging the assumption in critical analysis that the humanitarian ‘gift’ is inherently oppressive; instead they highlighted its capacities for also creating solidarity. Hanna Kienzler and Zeina Amro further this critique by asking questions about transitioning from emergency interventions into long-term sustainable ones. We hope to advance this line of inquiry by inviting more scholars and practitioners to engage in critique while appreciating the complexities of practice. We were extremely privileged to have as our keynote speaker Jennifer Leaning, the distinguished human rights scholar and the director of the François-Xavier Bagnoud Center for Health and Human Rights at Harvard University. As an expert in public health rights-based responses to humanitarian crises, she addressed several key issues pertaining to practical predicaments, thereby complementing our debate by providing a situated insight into the ethics and complexities of humanitarian engagement. ‘The humanitarian enterprise is still necessary though deeply flawed’, said Leaning, setting the stage for a lively, critical, and truly interdisciplinary debate at our event. (Her keynote address is published in this special section as delivered in London on 27 September 2014.)

It is my hope that we grow in numbers, as this section reaches out and extends our call to more scholars, practitioners, PhD students and researchers, policy makers and others who share our concerns.[note 1]For more information about the workshop and its participants please see https://beyondtraumaproject.wordpress.com/2014/09/29/a-first-step-taken/
For now, I would like to thank the participants and contributors to the workshop: Nadje Al-Ali, Sa’ed Adel Atshan, Veena Das, Omar Dewachi, Rita Giacaman, Hanna Kienzler, Lamia Moghnieh, and Zuzanna Olszewska, as well as our wonderful audience and the academics, physicians, psychoanalysts, and students who joined us on the day. I would also like to thank Veena Das and Michael Fischer for their insightful commentary pieces published here. I am also grateful to the Wellcome Trust and the FXB Center for Health and Human Rights at Harvard University for funding the initial event that resulted in the publication of this collection, and for the support of Professor Nikolas Rose, the Head of the Department of Social Science, Health and Medicine (SSHM). We greatly appreciate the support and hard work of the editorial team of Medicine Anthropology Theory, particularly Vinh-Kim Nguyen, Eileen Moyer, and Erin Martineau, for their recognition of the urgency of this debate and for accommodating our section in this issue. We look forward to expanding this working group across sites and disciplines, and welcoming scholars, practitioners, and policymakers with expertise in different regions of the Middle East.