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Medical Humanities Online First

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Supple bodies, healthy minds: yoga, psychedelics and American mental health


Much discussion about mental health has revolved around treatment models. As interdisciplinary scholarship has shown, mental health knowledge, far from being a neutral product detached from the society that generated it, was shaped by politics, economics and culture. By drawing on case studies of yoga, religion and fitness, this article will examine the ways in which mental health practices—sometimes scientific, sometimes spiritual—have been conceived, debated and applied by researchers and the public. More specifically, it will interrogate the relationship between yoga, psychedelics, South Asian and Eastern religion (as understood and practiced in the USA) and mental health.

Optimal relief for pain at the end of life: a caregivers tale


The current opioid crisis—driven partly by medical overprescription and partly by illegal drug abuse—is a significant cultural and professional dilemma in the USA and elsewhere. It has produced a strong reaction in favour of restricting medical use of opioids for pain, especially chronic pain. The author for a quarter century has written about pain from a biocultural perspective, and in this essay—based on his experience as primary caregiver for his late wife—he approaches the question of appropriate opioid use at the end of life.

Women, 'madness and exercise


The positive relationship between exercise and mental health is often taken for granted in today’s society, despite the lack of academic literature evidencing this symbiosis. Gender is considered a significant determinant in a number of mental health diagnoses. Indeed, women are considered twice as likely as men to experience the most pervasive mental health condition, depression. Exercise for women’s mental health is promoted through various macrolevel charity, as well as microlevel, campaigns that influence government healthcare policy and National Health Service guidelines. Indeed, ‘exercise prescriptions’ in the treatment of depression is not uncommon. Yet, this link between exercise as a treatment for women’s mental health has not always been so pervasive. In fact, an examination of asylum reports and medical journals from the late 19th century highlights a significant shift in attitude towards the role of exercise in the treatment of women’s emotional states and mental health. This paper specifically examines how this treatment of women’s mental health through exercise has moved from what might be regarded as a focus on exercise as a ‘cause’ of women’s mental ailments to exercise promoted as a ‘cure’. Unpacking the changing medical attitudes towards exercise for women in line with larger sociopolitical and historic contexts reveals that while this shift towards exercise promotion might prima facie appear as a less essentialist view of women and their mental and physical states, it inevitably remains tied to larger policy and governance agendas. New modes of exercise ‘treatment’ for women’s mental health are not politically neutral and, thus, what appear to emerge as forms of liberation are, in actuality, subtler forms of regulation.

A moment for compassion: emerging rhetorics in end-of-life care


Compassion is an emotional response to the suffering of others. Once felt, it entails subsequent action to ameliorate their suffering. Recently, ‘compassion’ has become the flagship concept to be fostered in the delivery of end-of-life care, and a rallying call for social action and public health intervention. In this paper, we examine the emerging rhetorics of compassion as they relate to end-of-life care and offer a critique of the expanding discourse around it. We argue that, even where individuals ‘possess’ compassion or are ‘trained’ in it, there are difficulties for compassion to flow freely, particularly within Western society. This relates to specific sociopolitical structural factors that include the sense of privacy and individualism in modern industrialised countries, highly professionalised closed health systems, anxiety about litigation on health and safety grounds, and a context of suspicion and mistrust within the global political scenario. We must then ask ourselves whether compassion can be created intentionally, without paying attention to the structural aspects of society. One consequence of globalisation is that countries in the global South are rapidly trying to embrace the features of modernity adopted by the global North. We argue that unrealistic assumptions have been made about the role of compassion in end-of-life care and these idealist aspirations must be tempered by a more structural assessment of potential. Compassion that is not tied to to realistic action runs the risk of becoming empty rhetoric.

Using photography to enhance GP trainees reflective practice and professional development


The capacity and the commitment to reflect are integral to the practice of medicine and are core components of most general practitioners (GP) training programmes. Teaching through the humanities is a growing area within medical education, but one which is often considered a voluntary ‘add-on’ for the interested doctor. This article describes an evaluation of a highly innovative pedagogical project which used photography as a means to enhance GP trainees’ reflective capacity, self-awareness and professional development. Photography was used as a tool to develop GP trainees’ skills in recognising and articulating the attitudes, feelings and values that might impact on their clinical work and to enhance their confidence in their ability to deal with these concerns/issues. We submit that photography is uniquely well suited for facilitating insight and self-reflection because it provides the ability to record ‘at the touch of a button’ those scenes and images to which our attention is intuitively drawn without the need for—or the interference of—conscious decisions. This allows us the opportunity to reflect later on the reasons for our intuitive attraction to these scenes. These photography workshops were a compulsory part of the GP training programme and, despite the participants’ traditional scientific backgrounds, the results clearly demonstrate the willingness of participants to accept—even embrace—the use of art as a tool for learning. The GP trainees who took part in this project acknowledged it to be beneficial for both their personal and professional development.

At the intersection of self and not-self: finding the locus of 'self in autoimmunity


Individuals with chronic autoimmune disease experience a sense of vulnerability. In part, this relates to the struggle for finding the meaning of the illness. The consequent existential distress may manifest in an unseated sense of personhood. Insight into the mechanism of this state of powerlessness and of perceived loss of agency is central to establishing a supportive clinician–patient relationship. This present exposition underscores the concept of autoimmunity as one that represents a demarcation in the psyche: one that is not just a threat to our sense of self-hood but also to our humanity. Autoimmunity exposes the challenge imposed on the relating of the self to one’s own self and hence is an ontological challenge. The breach of the boundary between self and not-self that is caused by the autoimmune process culminates in feelings of alienation.

Paradigm shift? Purity, progress and the origins of first-episode psychosis


First-episode psychosis has garnered significant attention and resources within mental health services in North America, Europe and Australia/New Zealand since the 1990s. Despite this widespread embrace, little scholarship exists that examines underlying concepts, ideologies and imagery embedded within the early intervention paradigm. In this paper, I offer a sociohistorical analysis of the emergence of first-episode psychosis and early intervention as entities in psychiatry, drawing on contemporary philosophical thought to explore various concepts embedded in them. Although scattered references to ‘prodrome’ and ‘incipient cases’ exist in the historic psychiatric literature, the notion of first-episode psychosis as a distinct chronological stage emerged in the late 1980s. This occurred in response to a desire for a homogeneous, medication-naive population within schizophrenia research. Thematically, concerns regarding ‘purity’ as well as notions of ‘progress’ can be read off of the body of work surrounding the creation of the term and its development into a clinical organising concept. Furthermore, examining the sociohistorical context of the term demonstrates its entanglement with the course of atypical antipsychotic drug development, the expansion of clinical rating scales and wider neoliberal biopolitics within healthcare. Within psychiatry, the early intervention model has been termed a ‘paradigm shift,’ with the promise that earlier interventions will translate into shorter durations of untreated illness, improved utilisation of services and better prognoses for recovery. While these are laudable goals, they are tied to assumptions about biomedical progress and idealisations of clinical populations that feminist and disability critiques problematise.

Before narrative: episodic reading and representations of chronic pain


This article suggests that some illness experience may require a reading practice less concerned with narrative coherence or self-authorship, and more interested in the value of textual fragments, episodes and moments considered outside a narrative framework. Chronic pain can pose multiple challenges to the narrative orientations celebrated in both ‘survivorship’ discourse and classic medical humanities scholarship. In its recalcitrance to cure, its often mysterious aetiology and its complex blend of somatic, interpersonal and affective elements, representations of chronic pain can require a richer vocabulary of temporality. I draw on contemporary affect theory to augment the available critical vocabulary for the textual representation of protagonists’ temporal orientation within illness experience, identifying a language for the emergent present that resists a narrative form. Beyond identifying narrative ‘incoherence’, affect discourse gives a way to recognise the strained, equivocal labour of incoherence, of inhabiting a cryptic present moment. Affect theory’s attention to the emergent present may give a way to read incoherent ‘chaos’ outside from a narrative framework, not only as a dark, formless stage in a personal story. To expand our vocabulary for this position, I offer a term for a particular affective experience of the present amid repeated marginalisation: the temporality of thwarted connection. I illustrate how these concepts can enable an alternative reading stance by offering a brief analysis of Lous Heshusius’s hybrid autobiography and academic study, Chronic Pain from the Inside Out.

Blind alleys and dead ends: researching innovation in late 20th century surgery


This article examines the fortunes of one particular surgical innovation in the treatment of gallstones in the late 20th century; the percutaneous cholecystolithotomy (PCCL). This was an experimental procedure which was trialled and developed in the early days of minimally invasive surgery and one which fairly rapidly fell out of favour. Using diverse research methods from textual analysis to oral history to re-enactment, the authors explore the rise and fall of the PCCL demonstrating that such apparent failures are as crucial a part of innovation histories as the triumphs and have much light to shed on the development of surgery more generally.

Evidence and speculation: reimagining approaches to architecture and research within the paediatric hospital


As the dominant research paradigm within the construction of contemporary healthcare facilities, evidence-based design (EBD) will increasingly impact our expectations of what hospital architecture should be. Research methods within EBD focus on prototyping incremental advances and evaluating what has already been built. Yet medical care is a rapidly evolving system; changes to technology, workforce composition, patient demographics and funding models can create rapid and unpredictable changes to medical practice and modes of care. This dynamism has the potential to curtail or negate the usefulness of current best practice approaches. To imagine new directions for the role of the hospital in society, or innovative ways in which the built environment might support well-being, requires a model that can project beyond existing constraints. Speculative design employs a design-based research methodology to imagine alternative futures and uses the artefacts created through this process to enable broader critical reflection on existing practices. This paper examines the contribution of speculative design within the context of the paediatric hospital as a means of facilitating critical reflection regarding the design of new healthcare facilities. While EBD is largely limited by what has already been built, speculative design offers a complementary research method to meet this limitation.

Sing Your Heart Out: community singing as part of mental health recovery


This paper reports on a qualitative evaluation of a Norfolk-based network of community singing workshops aimed at people with mental health conditions and the general public. The aims of the study were (a) to evaluate the effectiveness of the Sing Your Heart Out (SYHO) project and (b) to identify the key features which made the project distinctive. The study draws on 20 interviews with participants, two focus groups with organisers and workshop leaders, and participative observation over a 6-month period. Interviewees all reported improvement in or maintenance of their mental health and well-being as a direct result of engagement in the singing workshops. For most it was a key component, and for some the only and sufficient component in their recovery and ongoing psychological stability. SYHO was regarded as different from choirs and from most other social groups and also different from therapy groups, music or otherwise. The combination of singing with an inclusive social aspect was regarded as essential in effecting recovery. The lack of pressure to discuss their condition and the absence of explicit therapy was also mentioned by most participants as an important and welcome element in why SYHO worked for them. The combination of singing and social engagement produced an ongoing feeling of belonging and well-being. Attendance provided them with structure, support and contact that improved functioning and mood. We conclude that the SYHO model offers a low-commitment, low-cost tool for mental health recovery within the community.