Prozak Diaries: Psychiatry and Generational Memory in Iran - Softcover

Behrouzan, Orkideh

Softcover

ISBN 10: 0804799415 ISBN 13: 9780804799416

Publisher: Stanford University Press, 2016

Synopsis

Prozak Diaries is an analysis of emerging psychiatric discourses in post-1980s Iran. It examines a cultural shift in how people interpret and express their feeling states, by adopting the language of psychiatry, and shows how experiences that were once articulated in the richly layered poetics of the Persian language became, by the 1990s, part of a clinical discourse on mood and affect. In asking how psychiatric dialect becomes a language of everyday, the book analyzes cultural forms created by this clinical discourse, exploring individual, professional, and generational cultures of medicalization in various sites from clinical encounters and psychiatric training, to intimate interviews, works of art and media, and Persian blogs. Through the lens of psychiatry, the book reveals how historical experiences are negotiated and how generations are formed.

Orkideh Behrouzan traces the historical circumstances that prompted the development of psychiatric discourses in Iran and reveals the ways in which they both reflect and actively shape Iranians' cultural sensibilities. A physician and an anthropologist, she combines clinical and anthropological perspectives in order to investigate the gray areas between memory and everyday life, between individual symptoms and generational remembering. Prozak Diaries offers an exploration of language as experience. In interpreting clinical and generational narratives, Behrouzan writes not only a history of psychiatry in contemporary Iran, but a story of how stories are told.

About this title

About the Author

Orkideh Behrouzan is Assistant Professor at SOAS University of London, and a 2015-16 Fellow of the American Council of Learned Societies. She is the winner of the 2011 Kerr Award from the Middle Eastern Studies Association.

Excerpt. © Reprinted by permission. All rights reserved.

Prozak Diaries

Psychiatry and Generational Memory in Iran

By Orkideh Behrouzan

STANFORD UNIVERSITY PRESS

Copyright © 2016 Board of Trustees of the Leland Stanford Junior University
All rights reserved.

ISBN: 978-0-8047-9941-6

Contents

Note on Transliteration, 
Abbreviations, 
Introduction: Ethnographic Experiments across Sites and Disciplines, 
Chapter 1: Mapping Prozak Diaries and Medicalization, 
Chapter 2: Pedagogical and Cultural Histories of Iranian Psychiatry, 
Chapter 3: An Emerging Psychiatric Discourse in Five Frames, 
Chapter 4: Depreshen Talk, the Pill, and Psychiatric Subjectivities, 
Chapter 5: Material Remains, Cultural Aesthetics, and Generational Forms, 
Chapter 6: Tending ADHD, Shifting Moralities, and Generational Perceptions, 
Chapter 7: The Many Minds of Psychiatry, or Psychiatry as Cultural Critique, 
Conclusion: Reflections on Mental Health and Interdisciplinary Conversations across Cultures, 
Acknowledgments, 
Notes, 
References, 
Index, 

CHAPTER 1

Mapping Prozak Diaries and Medicalization

MEDICINE HAS SEVERAL LIVES; it gains a new life in each language and creates new cultural forms in each temporality. In 1990s Iran, a cultural shift took place in public articulations of psychological well-being, manifest in the evolution of a psychiatric discourse in the media and a rise in psychiatric talk among people. By the end of the 1990s, a Persian psychiatric vernacular had emerged in society: afsordegi(depression), depreshen, dep zadan (becoming depressed), toroma (trauma), esteress (stress), bishfa'ali (hyperactivity in children), and the Persianized catchall term for antidepressants, Prozak. This shift toward a clinical and psychiatric discourse for talking about psychological distress was indeed part of a broader historical and cultural change. Traditionally, one discussed psychological and psychiatric pathologies primarily in a concealed, private, poetic, or religious language. After all, in Persian poetics, Sufi traditions, and the Shi'ite ethos of conduct, stoicism had an elevated status. Far from medicalized, melancholic gravitas signaled depth of character achieved through spiritual transcendence, unrequited love, and unshaken faith. Within the medical establishment too, psychiatry had historically been seen as the unwanted child of medicine, its image marred by its allegedly less scientific foundations and the close proximity many of its key figures had to the world of letters and the humanities — if not the stigma of madness itself. Throughout the twentieth century, Islamist and Marxist ideologies too had further regarded psychiatry and particularly its psychoanalytical legacies as Western constructs that contradicted the ethos and priorities of the revolution. But this was all to change.

In the late 1980s, a psychiatric discourse began to enter the media; a space emerged where psychiatrists and psychologists began educating the public about mental health. They introduced signs and symptoms of mood and anxiety disorders, as well as clinical and diagnostic frames with which people could understand their psychological experiences. This was a new opportunity for psychiatry, as a discipline, to be claimed in a specifically Iranian context. Psychiatric talk was now public and explicit.

When we find ourselves embracing a particular form of knowledge — in this case, psychiatry — it is tempting to assume that certain forms of illness must have become either more common or more efficiently diagnosed than before. Real life is more complex. The narratives and languages we choose have as much, if not more, to say about the world we have lived in than about what we are telling. Our choices — of languages, of concepts, of frameworks, of the bodies of knowledge we draw upon — are truly ours only insofar as we choose from what is culturally, scientifically, psychologically, and historically legitimate, accessible, and available to us. The internalization of new articulations necessitates, and reflects, the internalization of mindsets that have made that particular language intelligible and instrumental for us. In doing so, it reveals historical, cultural, and epistemological possibilities and impossibilities that have made a particular form of knowledge fit for a particular people at a particular time and place. This book is meant to describe some of those possibilities and impossibilities that might easily be overlooked by purely biomedical explanations.

Indeed, recent developments of medical disciplines need to be situated in several historical contexts, including that of the Iran-Iraq War (1980–1988). Shortly after the 1979 Revolution, Iraq invaded Iran and ignited a destructive eight-year war that resulted in a large number of casualties and adverse health conditions, as elaborated in numerous studies conducted by Iranian clinicians and researchers who have documented the physical and mental health impact of the war among veterans and civilians alike. The postwar years were also marred by economic sanctions imposed by Western governments, many of which continue to this day with health-care-related implications. Yet the Iran-Iraq War (officially, in Iran, the Sacred Defense) also engendered new societal norms and solidarity; it mobilized, through educational and media campaigns, the Shi'ite ethos of endurance and sacrifice for justice.

For clinicians and policymakers, wartime concerns with post-traumatic stress disorder (PTSD) and anxiety disorders were replaced, in the 1990s, with concerns about depression and dysphoria. A discourse of mental health (salamat-e ravani) began to emerge, with the primary focus on raising awareness about and destigmatizing psychological disorders. Gradually, growing numbers of mental health talk shows and newspaper columns on psychiatric topics introduced a new clinical vernacular that gave people a way to discuss the very real pain that lingered from the war. This clinical language was both validated and welcomed by doctors as well as policymakers because and insofar as it fit several other paradigms in the late 1980s. The biomedical, authoritative, and symptom-centered language of psychiatry indicated that the malaise so many were experiencing resided in the purview of medicine. In the absence of an alternative public discourse, psychiatry and disorder provided society with a legitimate language to channel psychological and social experiences after the war. However, while the war is an important historical context, it does not solely explain the growing popularity of psychiatric discourses among people.

As psychiatric terminologies and diagnoses moved outward from the privacy of clinical encounters, a shift began to appear in language. People began to speak more publicly and commonly of their prescriptions for ghors-e a'sab (nerve pills) and of depreshen, jokingly, as an "epidemic," a "crisis," or a "national trait." Everyone allegedly knew someone who was depress. Depreshen became street slang, and gradually it became less surprising to hear individuals talk about depression or call themselves depress, or afsordeh. Media, art, literature, and blogs adopted an explicitly medicalizing discourse of afsordegi/depreshen and statistical reports on mental health began circulating in the media. By the early 2000s, websites and blogs dedicated to mental health flourished among Iran's growing educated and urban population.

This, of course, was in part an outcome of media and educational campaigns for destigmatizing mental illness (particularly mood disorders); but a certain kind of receptivity and readiness for this language ought to have been in place among people and practitioners alike. A decade after the end of the war, reports emerged of a surge in antidepressant (and later Ritalin) consumption. Doctors both welcome this as a step forward in raising awareness (and better illness detection) and speculate about possible overmedication, but explain that medication is usually the first line of intervention for a number of practical reasons: the lack of a well-funded mental health care infrastructure, the arbitrary distribution of patients among specialties, the lack of patients' compliance with psychotherapy, and a culture of quick fixes, as well as what they perceive as a clash of tradition and modernity. But they still advocate medication and insist that it provides relief, destigmatizes psychological problems, eliminates guilt, and projects modernist and educated attitudes. Above all, it provides hope.

Although these cultural shifts remained gradual and largely unacknowledged, a discourse of salamat-e ravani (mental health) was palpable in the 1990s. Psychiatrists were now provided with a platform to educate the public and to introduce a fluent psychiatric language into people's daily lives. The discourse was also implied in parallel shifts in mental health policy and the institution of new legislation, as well as in public policy behind television programs, city planning, and education reforms that aimed to reintroduce splashes of color and joy into the daily life of citizens. When addressing alleged mental health problems, experts and officials alternated between different and at times competing rationalizations. Whether explaining them in terms of neuropathology or lack of religious integrity, they were nevertheless participating in a public discourse on mental health and psychological well-being, albeit in a sanitized clinical language. Most important was the very emergence and existence of a medico-rational attitude toward governing society's mental health and well-being; its presence validated the predicament to which psychiatry was trying to respond. And in this emerging public discourse, pathology was increasingly becoming a given. The gradual normalization of this new psychiatric vernacular further created a new way of knowing, interpreting, and perceiving oneself in the world.

Of course, we do not need to look further than news headlines to notice a palpable increase in psychiatric diagnoses (particularly depression and ADHD) and medication in Iran and around the globe since the 1990s. Worldwide, there are cautionary discussions about the psychological impact of communication technologies, psychopharmacological interventions, and the changing psychological landscapes of family and interpersonal relations. Is it possible, one might ask, that urban lifestyles or shifting gender roles are leading to more dysphoria everywhere? Maybe. Is it scientifically imaginable, as some neuroscientists suggest, that the adverse effects of the war might leave a genetic imprint across generations? Maybe. Could Iranian children too be more prone to hyperactivity and inattention as a result of shifting familial, gender, and technological patterns? Perhaps. Would that mean their brains are changing in ways that lead to psychiatric diagnoses such as ADHD? Maybe and maybe not. Is it possible that not everyone who calls herself depress or takes antidepressants is clinically depressed? Yes.

While these questions are fascinating in their own right, they are not the focus of this book, nor are causal claims about mental illness, questions of whether depression has increased in society, or epidemiological surveys of psychiatric diagnoses. These questions could not be asked, much less answered, until concepts such as depreshen are clinically and culturally analyzed in their Iranian contexts. To investigate depreshen, attention to its psychological detailing is necessary. But so is an anthropological understanding of its historical and cultural trajectories.

What We Mean When We Talk about Depreshen

It is misleading to assume that the rise in depreshen talk or alarming statistics means that people must be clinically depressed. Medical anthropologists have always been interested in the meaning of illness and how patients account for their illness experience or their identification with it, thus creating a legacy of studying "illness narratives" that, in its initial formulations, aimed to confront the hegemonic universality of "explanatory models" that Western biomedicine provided. Narratives of illness also reveal the historical and cultural trajectories that underlie health conditions. On the one hand, the political economy of health has become the focus of a critical branch of medical anthropology that asks how illnesses evolve, medically and socially, and what sociopolitical contexts and material conditions of power or inequality underlie their social construction. On the other hand, influenced by anthropological traditions of cultural analysis and hermeneutics, another branch of medical anthropology has focused on an interpretive anthropological investigation into how illness experiences are culturally shaped, experienced, and made sense of by individuals. Narratives are equally instrumental in understanding the subjective experience of illness, a topic of interest shared today with the fields of medical humanities and narrative psychiatry, both of which have successfully brought patient narratives to the attention of clinicians. Both disciplines are, however, situated in wider Western traditions that tend to regard the self as a universal, whole entity. Anthropologists, instead, regard the self as situated in historical contexts and therefore subject to diverse interpretations of selfhood. Anthropology also cautions against the tendency to essentialize and universalize individual narratives of illness and suffering, and deems it important to appreciate the messiness and (dis)order of such narratives in order to grasp the ethical implications of clinical decisions. "The disordering of narrative," writes anthropologist Veena Das in her book Affliction, "is part of the sense of bewilderment about what it means to have this illness in this body," and in this moment.

Four decades ago, a classic study by anthropologists Byron Good and Mary-Jo Good and their colleagues laid the groundwork for analyzing how Iranians experienced depressive illness as an interpreted disorder whose symptoms were situated in the cultural context of Iranian affect. B. Good's earlier work on narahati, depression, and anxiety (experienced as heart distress in the 1970s) had already shifted the conventional focus from cultural responses to illness toward its cultural interpretations and semantic networks — that is, experiences associated with illness through networks of meaning and social interactions. Importantly, in approaching narratives of illness, Good went beyond the narrative structure to explore how cultural and linguistic contexts shape our experience of a particular illness. "As new medical terms become known in the society," Good argued, "they find their way into existing semantic networks" and shape medical rationalities. Among Iranians, these semantic networks are informed not only by medical rationalities, but also by traditions that include, but are not limited to, Zoroastrian, mystic, and Shi'ite symbolism. The work of anthropologist Michael Fischer in the 1970s identified the cultural cues and linguistic references for such rationalities by unpacking Shi'ite symbolism and its various cultural, psychological, and political interpretations of Iranian affectivity. Fischer also provided a genealogy of the Iranian revolution and its emotional residues, followed by Fischer and Abedi's analysis of depression and cultural articulations of feeling blocked, caught, and suspended (avareh) between cultures, as was the fate of many Iranian émigrés in the United States. These studies, alongside Lotfalian's research on psychological conditions among Iranian émigrés in California in the immediate postrevolutionary period, laid important ground for my work.

Today, Iranian medical rationalities have changed immensely. What was once communicated in the double entendre of unrequited love in mystic poetry, sacrificial ethos in Shi'ism, self-denying melancholy in mysticism, or even clandestine political rebellion, can now be part of a public discourse of psychological and psychiatric distress. After almost four decades, I pick up where the above scholars left off, starting with an examination of the cultural and historical semantics of depreshen among Iranian youth. Another way of posing the question might be to ask how depreshen differs from clinical depression, and what the difference can tell us about Iranian society.

Iranian psychiatrists and general practitioners — who often fill in where there is no referral system from primary care to mental health specialists — use the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as their gold-standard diagnostic tool. In the DSM, a time frame is set for the duration of symptoms. If a number of symptoms such as depressive mood persist beyond a certain period of time and cause functional impairment, diagnosis is confirmed. The DSM also regards loss as marked by a singular event; to be diagnosed, the patient ought to have experienced a particular number of symptoms for longer than a particular period (beyond what is considered "normal" reaction to the stressor), and ought to have experienced an impairment of function because of those symptoms. In Iran, generally speaking, a depression diagnosis often means that medication will follow.

But the DSM, embedded in a very specific American biomedical epistemology, takes for granted function as universal, time as linear, and loss as singular. It sees contextual factors as secondary to the essence of the illness. At best, when considering the cultural aspects of illness, biomedical psychiatry treats culture as a static and secondary variant that intervenes upon the already-formed illness. But cultural, historical, and social contexts are not located outside of the realm of illness. Rather, illnesses are both biologically and socially constructed; their cultural contexts shape how we experience and relate to them.

(Continues...)

Excerpted from Prozak Diaries by Orkideh Behrouzan. Copyright © 2016 Board of Trustees of the Leland Stanford Junior University. Excerpted by permission of STANFORD UNIVERSITY PRESS.
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Edition details

• Publisher: Stanford University Press
• Publication date: 2016
• Language: English
• ISBN 10: 0804799415
• ISBN 13: 9780804799416
• Binding: Paperback
• Edition number: 1
• Number of pages: 328