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300 Medical Anthropology Quarterly

and their mentally ill patients (i.e., “the sub- jects”).

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Lakoff uses the object of bipolar disor- der, specifically a French biotech company’s (Genset) quest to obtain blood samples of patients diagnosed with bipolar disorder for genetic sequencing, to explore what he describes as the “epistemic milieu” of the “Argentine mundo-psi”(p. 4)—a native term never fully explicated, but discussed at several points in the text in reference to Argentina’s unique cosmopolitan mixture and intellectual history of psychodynamic approaches to treating the mentally ill both in private and public health settings (e.g., p. 16–17). The problem Lakoff exposes in Argentina is that, depending on one’s psy- chiatric training and orientation, bipolar disorder exists as a collection of observ- able symptoms that present in patients who have a distinct genotype and are ready for pharmaceutical treatment (e.g., biopsychia- try), or that bipolar disorder is a “fiction” of biopsychiatry and patients must be re- cast (i.e., rediagnosed) through the prism of psychodynamics and enter into psychother- apy or analysis with or without the aid of psychotropic medication (e.g., Lacani- ans). Lakoff notes that, according to Tanya Luhrmann (Of Two Minds: The Growing Disorder in American Psychiatry, Knopf 2000), Freudian psychiatry in the United States was basically dead—or at the very least running a distant second when compet- ing (and compared) with global biopsychia- try. But in Arentine mundo-psi, Lakoff finds a site where these competing paradigms con- tinue to battle.

Lakoff is very successful in moving the reader through detailed ethnography and a sophisticated grasp of psychiatric history as well as critical theory, how these dueling paradigms require certain forms of “sub- jectivity” (or personhood) to function. He spent time talking with and interviewing psychiatrists and psychoanalysts as well as observing case presentations at several pub- lic hospitals. Specifically, his work at Hos- pital Romero on both the “women’s ward” (ch. 3, “The Lacan Ward”) and the “men’s ward” (e.g., the biopsychiatric ward) was

especially fascinating and at times quite disturbing. A psychology resident provides a concise description of the dilemma: “In this point the two discourses are incom- patible: in how to understand the subject. [Bio]Psychiatry thinks it knows and the pa- tient doesn’t, whereas psychoanalysis says the patient is the one who knows” (p. 85).

Lakoff, like Lacanians (and interpretive anthropologists alike), provides several case studies so that readers can clearly see the processes and discussions he observed in ac- tion (“thinking in cases,” p. 87). For ex- ample, on the women’s ward a Lacanian- trained resident presents to a mixed group of biopsychiatrists and psychoanalysts the case of a 53-year-old suicidal women who was hearing voices of “birds” telling her to “kill herself,” and a typical argument ensues. Some are skeptical about the “reality” of the hallucinations. Some think that the hal- lucinations tranquilize her fear—the delu- sion may be “restitution.” At the time, the patient would not talk to the resident and refused psychotherapeutic interventions. A (bio)psychiatric resident also working with the same patient felt her “silence” was a side effect of powerful antipsychotic med- ications: she was “neurolepticized.” After several weeks in the women’s ward there was little progress. The patient seemed “im- penetrable.”

However, the first resident had been able to construct a history through the woman’s case file of various traumatic events, includ- ing attempted rape, a troubled marriage, and her son’s departure for the Malvinas war. This resident presents her information to a senior Lacanian.

The senior Lacanian then tells the resi- dent that he is going to “make a hypothesis, to invent a meaning.” There must have been some kind of catastrophe, perhaps a bomb, leaving a hole—“an agujero.” An event, a moment: the three days of the 1955 Rev- olution of Liberty, in which people had to flee. The senior Lacanian explains that there was a saying in this period—“the birds are coming”—which referred to planes com- ing with bombs. “Something concrete hap- pened in the Real.”



Book Reviews 301

He then tells the resident that these “signs, hieroglyphics” (e.g., the suicide at- tempt) are not nothing. For the patient, killing herself would be the highest expres- sion of “staying put,” in the place with the “agujero, the hole.” The patient was there- fore unassociative, with no possibility for transference (key to Lacanian psychoana- lytic work). The senior Lacanian concludes: In psychoanalysis “one tries to bring the subject near the catastrophe, to the Real, whereas she is trying to flee the catastrophe” (p. 89). He proposes that the resident “con- struct a text with the patient.” The resident asks him if it will be possible to make a diag- nosis. He says: “What matters is the making of a historia.” Thus, the patient remains in the hospital, within an intertreatment (and epistemic) psychiatric limbo.

Lakoff skillfully presents an archaeol- ogy of how this current state and form of Argentine mundo-psi came to be. In partic- ular, the Argentine history of psychoanal- ysis and its current association and home within public (mental) health hospitals fas- cinates. In the 1940s psychoanalysis was re- served for the private treatment of neurosis of the educated classes. However, the polit- ical situation of Argentina in the 1950s and 1960s provided the right conditions for psy- choanalysis to enter the public hospital and salud mental was born—a progressive re- form movement for the treatment of mental health.

Some scholars and clinicians feel strongly that the Lacanians, through their inability to treat the psychotic, were creating a public health disaster in Argentina (i.e., large num- bers of patients being sedated and institu- tionalized). Nevertheless, followers of both psychiatric paradigms see themselves as pro- ponents of “social justice.” Lacanians in particular see themselves as fighting for “the human”—for subjectivity itself—preserving the depth of the subject (vs. treating the surface symptomatology through biopsy- chiatric means). Yet, through Lakoff’s ob- servations of mundo-psi realities and his critical interrogation of current global lit- erature regarding psychiatry, science, ne-

oliberal movements, and pharmaceutical sales practices, we come to see the short- comings and ethical quandaries of both paradigms.

Nevertheless, Lakoff leaves the reader with the sense that, with the current state of global capitalism and psychopharmaceu- tical marketing dominance, pharmaceutical reason may just win out. In fact, pharma- ceutical reason has evolved over time as (mental) illnesses gradually came to be de- fined in terms of that to which they respond (i.e., the drugs). Taken to its full extent, this reason has fueled the field of “phar- makogenetics.” In his final chapter, Lakoff shows the reader how the genetic sequenc- ing work of Genset (in collaboration with Jansen Pharmaceuticals) may erase the sub- ject altogether. Psychiatric categories will continue to be broken down in terms of “medication response,” so that neither La- canians nor biopsychiatrists will need to ask diagnostic questions like “Is it bipolar disor- der or schizophrenia?” But instead the clin- ician (or gene sequencer) will ask, “Is it a lithium or an olanzapine response profile?”

Lakoff’s work should be essential read- ing for graduate students of both medical anthropology and science and technology studies as well as critical pharmaceutical studies.

Upper-level undergraduate students will find portions of the text difficult without proper supplemental instruction. However, Lakoff has the ability to concisely and effec- tively explain complicated intellectual ter- rain (Lacan, Canguilhem, Deleuze, Rabi- now, Rose, etc.) because of the way he inter- weaves background theory (and discussion) with ethnographic observation. In short, he tells a compelling and important story of contemporary psychiatry and provides a model for future anthropological study.

Multiple Medical Realities: Patients and Healers in Biomedical, Alternative and Tra- ditional Medicine. Helle Johannessen and Imre Lázár, eds. New York: Berghahn Books, 2005 xiii + 202 pp.



302 Medical Anthropology Quarterly

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