Drawing on this approach, we understand experience as meaningful sensory perception in temporal context and within particular cultural, social, and interpersonal settings and subjectivity as the more or less enduring structure of experience. With respect to mental illness, this approach invites anthropological recognition of struggle as a fundamental human process that comes to light in the context of lived experience . Second is the ongoing anthropological concern with adolescence as a stage in the life course at which identity is consolidated and people approach full cultural membership but which is also fraught with challenges to well-being that anthropology can contribute to understanding in a way relevant to mental health policy and practice . The contemporary anthropological approach to childhood is strongly influenced by child standpoint theory that aims at an account of society from where children are socially positioned and in which they are not passive social “others” but agentive participants in social life, hence co-constructors of social knowledge and by extension of knowledge generated by research. In particular, anthropologists have taken up the idea that “children have agency and manifest social competency” . Guided by these concerns, we will focus specifically on self-cutting among a group of adolescents who have been psychiatric inpatients; by attending to experience and subjectivity articulated in the youth’s own voices,hydroponic system for cannabis we will come to understand self-cutting as a crisis of agency enacted on the terrain of their own bodies. There is scant literature on how young people conceive and understand mental health , let alone experiential accounts of adolescent mental illness from the standpoint of the child .
In addressing the experience of cutting among a clinically defined and diagnosed group of youth, our stance is not to fall prey to accepting a false dichotomy between ethnographic and clinical sensibilities; that a young person is following a regimen of psychotropic medication is as much an ethnographic as a clinical fact, and that a young person lives in a fragmented family environment may have clinical as well as ethnographic implications. Self-cutting can be understood as a troubling symptomatic behavior or as a creative struggle for agency and may exhibit elements of both pathological obsession and ritual transformation, but in either case it is an enactment of a vexed relation between body and world.This discussion is based on SWYEPT, our study of youth in New Mexico who were inpatients in the state’s flagship Children’s Psychiatric Hospital at the University of New Mexico . New Mexico is a state whose total population according to the 2010 United States Census was 2,059,179. In 2010, according to the US Census Bureau’s categories, by race the largest population proportions were designated “white” and American Indian/Alaska Native , with 23 federally recognized Indian tribes in the state comprising various groups of Pueblos, Navajos, and Apaches; other racial categories were minimally represented. By ethnicity, Hispanics or Latinos accounted for the largest single block , while among non-Latinos the largest blocks identified themselves as generically white or American Indian . New Mexico is one of the poorest states in the nation. According to the US Statistical Abstract, as of 2008 the median household income was $43, 508 or 44th among the 50 states, and the proportion of persons living below the poverty level was 17.1% or 5th in rank among the states. New Mexico ranks as one of two states within the United States hardest hit by child poverty, with the rate of 30% in New Mexico . Relatedly, home foreclosures have also been inordinately high. Along with poverty comes a serious drug problem, with parts of the state severely afflicted by heroin and methamphetamine use, and the presence of violent gangs, with one anti-gang website listing 178 in the Albuquerque area.
The SWYEPT study examines cultural meaning, social interaction, and individual experience among adolescent patients and their families, with the long-term goal of producing knowledge of broad use to those concerned with the treatment of adolescents suffering from mental illness in the context of significant cultural differences. The aspects of this knowledge include: types of problem, illness, or psychiatric disorder experienced by afflicted adolescents; trajectories of adolescent patients from the community into treatment and back into the community; patient experience of therapeutic process and family response to that process; alternative and complementary resources brought into play by families on behalf of patients; difference between the experience of afflicted adolescents and that of counterparts who have not been diagnosed or treated for emotional disturbance. Notably for present purposes, ours was not explicitly a study of self-cutting or self-harm, but cutting emerged within the ethnographic interviews as a theme deserving of the particular attention we devote to it here. We recruited participants for the study with the assistance of three clinicians at Children’s Psychiatric Hospital who referred to us patients aged 12–18 they judged as not so severely cognitively disabled or developmentally impaired as to be unable to participate in interviews and not so emotionally fragile or clinically vulnerable that their participation would be unduly stressful. We obtained informed consent from youth and their parent or primary guardian based on these referrals, recognizing the ethical responsibility of respecting the vulnerabilities of individual patients and the need for continued rapport in the relationship between therapists and families, as well as the importance of our respect as researchers for the clinical expertise of the referring therapists. All participants entered the project as inpatients at CPH. Assisted by a team of graduate student ethnographers and clinically trained diagnostic interviewers, we conducted ethnographic interviews covering life history and experience with illness and treatment with the young people and their primary parent/guardian three times at approximately six months’ intervals.
During this period, we also conducted the child version of the Structured Clinical Interview for DSMIV , a clinician-administered research diagnostic interview , the Adolescent Health Survey , and the Youth Self Report and Child Behavior Check List for children and their parent/guardian respectively. Although initial interviews occasionally took place in the hospital, it was rare for a participant still to be there at the time of the second and third ethnographic interviews. Yet it was not always the case that they were at home, since it was not uncommon for them to be placed instead at another treatment facility of in-treatment foster care. This often led us far afield from the hospital in Albuquerque, such that our ethnography ranged across the entire state of New Mexico and occasionally beyond. In this respect, our work was not strictly speaking a clinical ethnography in the sense of ethnography primarily situated in a clinical context that focuses on the institutional cultural milieu and interactions among patients and staff . Our focus was instead on the experience and subjectivity of the troubled youth along their trajectory back to their families, back again to the hospital, to other institutions, or to treatment foster care. Whenever possible we conducted interviews in participants’ homes both for their convenience and so that interviewers could conduct ethnographic observation of the domestic environment and neighborhood setting. Our primary ethnographic locus was thus the family rather than either the clinic or the community, following the methodological premise that families are the principal formative inter subjective locus for adolescents and for the mentally ill,indoor hydroponics cannabis no less for mentally ill adolescents . Given these caveats, our work could be described as clinical ethnography in a different sense, insofar as it synthesizes clinical and ethnographic sensibilities and approaches . This means not only a balanced attention to diagnostic profile and life experience, but recognition that narrative data generated by diagnostic and ethnographic interviews can be complementary by identifying different kinds of experientially relevant events and themes . The participants constituted an ethnically diverse group including New Mexican Hispanics and Latinos of Mexican descent, Anglo-Americans, and Native Americans. While an ethnically diverse group of youths whose economic and residential conditions vary, the life situations of most are shaped by features of structural violence . Of the 47 adolescents who participated in the research, 57% reported having cut or harmed themselves at some time, comparable to 61% among adolescents hospitalized for psychiatric problems in a previous study by DiClemente, Ponton, and Harley in another North American location. This rate can be understood against the background of a reported rate of 1–4% of self-injurious behavior in the general population , while the rate among adolescents has been placed by various researchers as ranging between 1 and 39% . Let us now take a closer look at cutting among several of these young people in order to get a sense of how they talk about it and what it means to them, its place in the overall configuration of their experience, and the similarities and differences among them that might allow us to characterize cutting as a crisis of agency.
SWYEPT participants represent a wide range of diagnostic profiles from a clinical standpoint and a diversity of life experiences from an ethnographic standpoint , but our purpose here is to present a series of vignettes that summarize the range of experiences and utterances centered around the phenomenon of cutting. Lacking space to present full case studies, we briefly examine how they describe their own cutting behavior and what that behavior means in the context of their troubled lives and in the constitution of their subjectivity. We have selected these instances and interview excerpts based on the young person’s relative ability and/or willingness to elaborate on how cutting has been a part of their lives. Each profile includes the biographical and ethnographic context of the young person’s experience, their diagnostic and functional status, medication history, their own experiential commentary, and a brief interpretative commentary. We first met Maria, a Hispanic 17-year-old female, when she was living in a ranch style home in a lower-income neighborhood that was bustling with the activities of her extended family and infant son. During the course of the study, she later lived in an apartment with her son, boyfriend and mother, moving again two years later into a very small apartment with her toddler. Maria was the youngest of three daughters to a single mother with multiple boyfriends and father figures. She bore the physical and emotional marks of a major arm injury in mid-childhood from a car accident in which her extremely drunk mother was driving, as well as enduring severe and catastrophic stressors related to abuse, neglect, and sustained psychosocial instability in her early life. While Maria is close to her older sisters, they were not a significant source of personal or financial support and held an anti-psychiatric opinion about how Maria did not need medication. She relayed that she had to “grow up fast” since her mother had severe problems with alcohol. Indeed, her mother’s alcohol abuse severely affected their relationship. Maria was sexually assaulted at the age of 11 by her mother’s ex-boyfriend, which disturbed her greatly; she marks this as a time of pain and confusion. She grew up believing her adoptive father was her biological father, but when Maria was 15, her father went to fight in Iraq. While in Iraq, he wrote her two letters saying that she was not his biological daughter, and he was getting remarried and could not support her financially or otherwise. She said she was devastated by this, by the fact that he would “cut me out of his life.” Maria responded by cutting on herself. In this instance, we have a patent metaphoric and literal alignment of psycholinguistic and palpablebodily expression. These events have created major emotional and psychiatric challenges for Maria. When Maria began the study, she had been admitted for a suicide attempt and ongoing postpartum depression. Prior to being admitted, she had an eating disorder, along with self-harming and abusing cannabis for two years. Her SCID diagnosis shows mood disorder due to a general medical condition, postpartum major depressive disorder, brief psychotic disorder related to postpartum depression, separation anxiety disorder, PTSD, alcohol abuse, cannabis dependence, and an eating disorder.We have presented and analyzed these vignettes with an emphasis on experiential specificity and on the importance of youth’s own voices under conditions of structural violence.