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MME1

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Rebecca Lester

on 15 October 2015

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Transcript of MME1

Introduction
Me, Myself, and ED
New therapy technique for EDs
that enables pastiche subjectivity
as healthy self
Allows clinicians and clients to mediate contrary models of the subject
But adaptation to a non-neutral
system that keeps people sick
Part of a long-term ethnography at an American ED clinic
Changing complexion of illness and health against backdrop of managed care, where issues of agency and subjectivity become entangled with economic expediency
Ecology of illness CONCEPTS and illness EXPERIENCES
Therapeutic Mechanisms as mediating macro and micro
Therapists as Brokers
Window into struggling out forms of subjectivity and expeirence within complext systems
EDs challenge divisions between body/mind, health/illness, individual/culture, etc.
GENDER as central language for articulating cultural anxieties about these ambivalences
Assumptions about motivations
Models of healthy subjectivities
Developmental frameworks
Devemopmental Theories
Assumptions about Motivations
Models of Healthy Subjectivity
Institutions as laboratories for understanding processes of subjectivity
Specific practices by which people are supposed to change, ways of knowing if this has "really" happened, guiding forces for all of it.
Implications for Theory
Systems that bridge inside/outside
Hegemony/resistence/agency/networks
Selves as process vs object
Ecology of illness CATEGORIES
Implications for Practice/Methods
Clinician/ethnographer
Policy- and intevention-relevant research
Introduction
New therapy technique for EDs that enables pastiche subjectivity as healthy self.

In the context of managed care, allows for a distributed model of agency that bridges "rational actor" and "irrational patient" positions.

Allows clinicians and clients to invoke contrary models of the subject in ways that increase access to care.

While this allows adaptation within the healthcare system, it reproduces neoliberal conditions within the psyche itself, concealing the degree to which these conditions contributed to the illness in
the first place.
The broader project
What this talk is about
Institutions as laboratories for understanding
processes of subjectivity

Processes and practices that connect multiple ecologies at multiple levels (ecologies of knowlede <- -> ecologies of "self")

Local practices through which people are supposed to change

Specific mechanisms through which biopolitical and
bioethical systems co-constitute subjects deserving
of care as subjects of neoliberalism.

Methodological Implications

developmental concerns
assumptions about motivations
indicators of recovery
Relevance to anthropology
Low rate of success, high rate of relapse
(30/50/20)
Therapists can't give (and clients can't get) treatment that works
Profit-driven healthcare system
What strategies do clinicians and clients use to make sense of what they're doing in treatment?

Are these strategies effective? If so, in what ways? And to what (and whose) ends?

What can this tell us about processes of subjectification, agency, and meaning making within complex ecologies of knowledge / practice /experience?
Diagnoses
Dangers of EDs
Anorexia
Bulimia
Binge Eating Disorder
EDNOS
Medical monitoring
Psychotherapy
Nutritional support
Inpatient/Residential
Day Treatment
Outpatient
"Best Practices"
Quantifiable data
Discrete treatment
episodes
Treatment
The Research
The Clinic
Private cLinic
Opened 2001
Exponential growth
Residential
Day Treatment
Outpatient
Interdisciplinary Team
Methods
Given this...
Up to 24 million people in the United States experience an eating disorder.

Only 10 percent of men and women with eating disorders obtain treatment.

Just 35 percent of people with eating disorders that receive treatment do so from a specialist eating disorder treatment centre.

Roughly 80 percent of females who receive treatment for their eating disorder do not get the intensity of treatment needed in order to stay in recovery.

Patients released from treatment while their weight is still below 85 percent of what is considered normal, have a relapse rate of 50 percent.
(The Refrew Center for Eating Disorders)
50% of all diagnoses. Not covered by insurance.
Medical management
Individual therapy
Group therapy
Family therapy
Individual meal plans and dietary support
Multiple levels of care

Long-term ethnography in American ED clinic

EDs and cultural anxieties / ambivalences

Ecology of illness CONCEPTS and EXPERIENCES

Psychotherapeutic interventions and techniques mediate macro and micro ecologies.

Therapists as brokers

Window into struggling out forms of subjectivity and expeirence within complex systems.

Managed Care and the
(Moral) Liberal Subject
Rebecca J. Lester
Department of Anthropology
Washington University in St. Louis
Mosaic Minds, Managed Care, and Everyday Ethics in an American Eating Disorders Clinic
Managed Care
Eating Disorders
Benefits management
EBP and cost-effectiveness
Measurable data
Relationships between symptom and cause
Rational Actor
Sick Role
You paid for the benefits...
but do you get the care?
1990s
Commodification of health / care
Profit-driven
Consumer "choice"
Cultivates / disallows certain forms of subjectivity
Orientation to our own and others' bodies and well-being
Moral/ethical implications
The right kind of sick
Overview
"Wal-marting healthcare"
The wrong kind of sick
How can you be the right kind of patient
if you're the wrong kind of sick?
Don't want to get better
Non-compliant with caregivers
Responsible for illness
Rights:
Exempt from normal roles
Not responsible for illness
Obligations:
Want to get well
Seek help and follow
recommendations
of company
of plans
of behaviors
of providers
biological / body
psychological / mind
Questions of agency

How can you be a rational actor if you are, by definition, "not in your right mind"?
Rational actor still in-tact and in charge
"fundamental clash between psychodynamic culture and the culture of managed care" (Cohen, Marecek, and Gillham 2006).
Conclusions:
So What?

Self-system is multiple and constantly shifting

Networks of distributed volition, agency, and moral responsibiltiy

Rehabilitates the always healthy Self from a system that is out of whack

Allows a doubling of the subject: client is simultaneously rational actor AND "the wrong kind of sick"

What's Next?
Theorizing Agency and Moral Personhood
Theorizing Biopolitical and Bioethical Processes
Bridging Psychological nd Cultural Theories of Subjectivity
Through IFS and the model of Self-leadership, clients learn to inhabit a liberal moral subjectivity characterized by rational choice, ////

The work of IFS in the clinic ends up being less about curing the ED and more about making clients acceptable subjects of managed care
and this...
Becoming "Self-led"
IFS , Mosaic Minds, & Managed Care
Key Questions
2002-2008

Benefits of local fieldsite

Standard P/O

Chart and document review

Clinical training and practice
practicum student
team therapist
ongoing private practice

Special ethical concerns
Might help people get better care!
Full transcript