Music Asylums: Wellbeing Through Music in Everyday Life

Tia DeNora

• Publisher: Routledge
• Year: 2016
• ISBN:
  9781317092131
• Edition: 1
• Topic: Mezzi di comunicazione e arti performative
• Subtopic: Etnomusicologia

Taking a cue from Erving Goffman's classic work, Asylums, Tia DeNora develops a novel interdisciplinary framework for music, health and wellbeing. Considering health and illness both in medical contexts and in the often-overlooked realm of everyday life, DeNora argues that these identities are by no means mutually exclusive. Moreover, she suggests that the promotion of health and more specifically, mental health, involves a great deal more than a concern with medication, genetic predispositions, clinical and neuro-scientific procedures. Adopting a holistic, interactionist focus, Music Asylums reconnects states of wellness and wellbeing to encounters with others and - critically - to opportunities for aesthetic experience. Building on DeNora's earlier work on music as a technology of self in everyday life, the book presents music as an active ingredient of action, identity, capacity and consciousness. From there, it suggests that access to, and evaluation of, music is an important ethical matter. Intended for scholars and practitioners in psychiatry and psychology, palliative care, socio-music studies, music psychology and the allied health professions, Music Asylums showcases music's role in the existential project of being and staying well, mentally and physically, from moment-to-moment and across all realms of social life.

Chapter 1
In Sickness and in Health:
Defining the Ecological Perspective

In Anna Karenina, Tolstoy wrote that happy families are all alike but that each unhappy family is unhappy in its own way (2004: 1). As with happiness, health is often assumed to be an unproblematic state, the absence of disease, something easily assessed and universally unvaried. By contrast, the forms of suffering associated with illness are seen to be diverse. In this book, my aim will be to challenge these assumptions. I will suggest that health and illness are not opposing conditions but are fused together in complex ways and experienced as multi-dimensional degrees of wellbeing. I will also suggest that this experience takes shape or is figured in relation to things outside of individuals, ecologically, and in ways that amalgamate people, practices, culture and things. One of those things, as I will describe in some detail, is music.

To lay the groundwork for this project and to consider specifically music’s role in relation to health and wellbeing, in this chapter, I consider illness as it is manifest in everyday life. To that end, I will introduce a perspective that conceptualizes health and illness as a pragmatic, temporal and ecological production. In describing this production, I will also dispense with the mind–body dichotomy implicit in so much of our everyday discourses of health/illness. Thus, and taking my cue from the World Health Organization’s motto, ‘There is no health without mental health’, I will develop the argument that the seemingly specific case of mental health can be used as a case in point for health in general, the idea being that consciousness and orientation mediates illness (identity and symptoms) and that bodily symptoms interact and can be altered in relation to mind ecologically conceived. This perspective is by no means equivalent to the suggestion that, ‘a broken leg is a state of mind’, but it points to ways in which we may learn a great deal about health/illness in general by considering mental illness from a socio-ecological perspective.

More specifically, and to foreshadow the theoretical line I shall be developing, the social phenomenon of mental illness and the seemingly inextricable mind–body–culture entanglements attendant with it, offers support for a non-reductionist, anti-mechanistic focus on health and illness. This anti-reductionist focus in turn offers real potential for novel and, arguably, more sustainable means by which to address illness/wellness. To what extent, for example, might the so-called myth of mental illness be but the tip of a much larger phenomenon, namely, the myth of individualized and mechanistic conceptions of health and illness writ large? To broach this question, and primarily for readers unfamiliar with the literature on health/illness as construction, I begin with a brief review of the fundamentally social and emergent character of health and illness.

The Cultural and Technical Mediation of Health and Illness

The very terms, ‘health’ and ‘illness’ are elusive. While it seems to be a universal fact that human beings exhibit physical symptoms such as congestion, immobility or fever, how these conditions come to be experienced, identified and treated is culturally specific. The cultural specificity of health/illness is, moreover, consequential for our experience of being well or ill and for the quality of social arrangements that surround this experience: for example, socially distributed opportunities for inclusion, exclusion and care. So, for example, diseases are eradicated and curtailed in relation to cultural–technical interventions – drugs and antibiotics, surgery and sanitation, but also bio-feedback and belief – and in relation to social decisions about where our health priorities lie and what should receive attention, when and how.

Medical historians chronicle the paths of diseases as they rise, fall and are reconfigured across time and place. It is no longer possible, for example, to be diagnosed with green fever or puerperal insanity nor, to my knowledge, is there a medical model of cancer in our time that invokes the idea of blood letting to release the ‘morbid humors’ (Diamandopouls 1996; Kardinal and Yarbro 1979). Women are no longer burned at the stake for exhibiting symptoms that are today associated with hysteria or epilepsy (Chodoff 1982; Risse 1988). Conversely, prior to the 1970s, 1980s and 1990s, there was no Lyme disease, no AIDS, no West Nile virus. There were, to be sure, people who suffered from symptoms associated with all of these maladies as there were (and are) people suffering from symptoms of maladies at one time unknown or that today continue to exist in the dappled world between official recognition and disavowal – ME or myalgic encephalopathy is a striking example (Wallace 1991).

Tracing the careers of diseases in these ways thus highlights the complex processes by which categories of diagnosis, prognosis, etiology, treatment and cure are configured within medical classification schemes. It also highlights the processes by which these schemes are linked to institutional practices of health provision. These processes are of course interrelated with a host of mediating factors and the history of medicine offers numerous cases where this shaping is contentious and – most interestingly – knowledge-based. In the nineteenth century, for example, puerperal insanity was the subject of rival knowledge claims between two groups, both with vested interests and both concerned to secure authority and economic dominion (Marland 1999, 2004). On the one hand, midwives advocated keeping the patient at home and thus out of the grasp of the then-emerging specialists in ‘mental alienation’ (early psychiatry), on the other, mental alienists advocated relocating the mentally unwell to lunatic asylums and, thus, under their own auspices.

In the twenty-first century, the factors that mediate definitions of health and illness most often include techniques and technologies, research funding priorities, lobby groups, policy cultures, systems of belief, discursive categories and iconic depictions in the media and the arts. Other factors include a widening raft of powerful players adjacent to the medical-industrial complex – health maintenance organizations, pharmaceutical companies and insurers. In relation to these factors, the medical, paramedical and non-medical, the economic, the technical and the socio-cultural are often so mutually inflected that disentangling them is impossible.

Moreover, in our time, perhaps as never before, new categories of disease are emerging. This emergence is both symptom and cause of a medicalized culture in which increasing numbers of human conditions are pathologized (Conrad 1987, 2007). Some observers link this trend to what they call, ‘disease mongering’, the widening or the boundaries of treatable illness so as to generate new markets for medical goods and services (Moynihan Health and Henry 2002). But the growth of medical conditions is also fuelled by the fears and desires of healthcare consumers, a process bolstered by a 1985 FDA ruling permitting direct-to-consumer ‘ask your doctor’ drug advertisements (Herzberg 2008; Menand 2010), internet search engines and the plethora of on-line advice for the ‘worried well’. Indeed, at least one study has suggested that doctors are more likely to prescribe a medication if the patient requests it (Kravitz et al. 2005).

Most recently, medicalization has been further propelled by biometric technologies in ways that are transforming the practice of medicine (Clarke et al. 2010). At the heart of this transformation is an issue that deserves sociological attention: the emergence of so-called personalized, predictive medicine and its reorientation of the temporal conceptualization of illness and disease.

Personalizing Medicine?

In the nineteenth and twentieth centuries and earlier, the medical gaze focused upon illness as it became manifest through pathological matters. The gaze was, in other words, retrospective, in response to and dealing with, the onset of illness and with the aim of cure or palliation. Rarely was it concerned with health conditions that might occur. By contrast, in the twenty-first century, a trend has emerged that shifts the temporal focus of the medical gaze. What was retrospective is now also in part prospective, a focus linked to and facilitated by the development of new ‘predictive’ technologies, in particular genetic screening and, most recently, neuro-imaging. These new technologies are, moreover, personalized: individuals’ unique bio-markers are interpreted as probability indicators of the risk of contracting one or another form of illness in the future. These bio-markers are also often used to assess individuals’ degrees of receptivity to particular drug therapies. This personal, prospective approach, along with its associated technologies, is increasingly hailed as an emerging new paradigm in medical science and clinical practice (Issa 2007; Hobson 2009). A journal devoted to the subject was founded in 2004 (Personalized Medicine) and new, public–private partnerships devoted to bio-marker research are on the rise (Cooper 2012). Increasingly, moreover, personalized diagnostic technologies are marketed for over-the-counter sales drawing predictive clinical authority into the domestic sphere and the culture of everyday life. The push is accompanied by bullish economic rhetoric – in 2009 the core segment of the personalized medicine market – medical devices and diagnostics – was estimated at $24 billion annually and predicted to rise by 10 per cent a year until 2015 (PricewaterhouseCoopers LLP 2009). Despite the fact that, in 2011, growth has slowed (Tufts Center for the Study of Drug Development 2011), there is, nonetheless, much at stake here of a non-medical nature.

It is worth pausing to consider the significance of the term ‘personalized’ in ‘personalized medicine’ and beyond the realm of mental health. The term is not used, for example, to indicate a concern with the lived experience or biographical contingencies of individual patients. Rather, it refers to the collection and use of unique biological information – the individual’s biological ‘fingerprint’ (the discourse is important here) as revealed by biometric scans. The courses of action implied by this information are in turn relatively generic – pharmaceutical and/or surgical. So, to take one of the more dramatic (and least complicated) examples, if it discovered that a patient has the genetic mutations BRCA1 and BRCA2 associated with breast or ovarian cancer, she may be advised to undergo preventative surgery. Similarly, the quality and quantity of protein enzymes are being used to tailor courses of drug therapy for other cancer patients. At the same time, as some observers have noted, personalized medicine does not involve so much a form of individual bespoke tailoring as a more coarse attempt to differentiate between rough treatment groups, a kind of ‘small, medium or large’ form of allocation for drug therapy (Hedgecoe 2004).

While, on the one hand, the science of personalized medicine may add some nuance and precision to diagnosis, treatment and prevention of disease (or at least this is the aspiration); on the other, it can sidestep many other features of health and illness such as patients’ behaviour, beliefs, aspirations, socio-economic circumstances and – critically – the physical and social environment. In this sense, personalized medicine furthers a medical model of disease and, in the process, can be subject to critique. This critique throws into relief the politics of medicine (Hedgecoe 2004; Rothstein 2003), in particular the way in which the social relations of illness are narrowly conceived when viewed through the lens of personalized medicine. Within the personalized medical purview, expert clinicians, technologically assisted, provide accurate diagnoses, perform medical procedures and/or prescribe effective pharmaceuticals, to patient-recipients, who are sometimes counselled by specialist counsellors about the risks associated with bio-markers, drug therapies, clinical procedures and, sometimes, social and socio-biological practices (such as, in certain situations, whether or not to procreate).

Beyond the professional–lay relations associated with the medical model, there is yet a further set of relations that is also unduly narrowed by predictive medicine. This is the set of relations between illness and those who have it. To consider this set of relations is to consider the ontology of illness itself. If, on the one hand, illness is genetically preordained, if it is intracellular, independent of and latent in the patient, then there is or can be little or no mutual influence between the patient, her/his disease and her/his biological makeup. In its extreme form, personalized medicine transforms illness into a statistical probability: illness becomes an intrinsic and preordained statistical trait of the organism and in the organism. If, on the other hand, one maintains that environmental factors are also involved (in the oft-quoted words of Judith Stern, ‘all illnesses have some hereditary contribution. Genetics loads the gun and environment pulls the trigger’), then (and depending upon how the term ‘environment’ is defined) illness is never entirely distinct from the consciousness and lived experiences of those whom it afflicts, and biological determinism is insufficient as an explanation and basis for treatment options. Thus strongly biologically determined perspectives constrain ontologies of health and illness in ways that preclude more nuanced and perhaps more empirically accurate accounts of how we become and stay healthy and/or ill.

Much hinges on the focus on bio-markers, avenues are closed and avenues are opened. The bio-marker focus closes pathways into critical theory and the critical history of science and technology, in particular on perspectives that seek to investigate connections between illness and (a) the environment (environmental pollutants, toxins and stress factors), (b) the economy (social class and illness), (c) agency (can individuals be empowered in their own healthcare beyond merely choosing from medical menus or opting in or out of tests and procedures?), (d) socio-cultural conventions (are there ways of arranging social life in which illness conditions might be transcended?) and (e) faith (is there any way that incorrigible belief [in something] can be beneficial or harmful to health?). Turning its back on these questions, the focus on bio-markers opens new avenues to enhanced medical authority, specifically to a materialist conception of illness, whether physical or mental (for the distinction between them is diminished), as independent from culture and as immured from contingency. The aetiology of illness, it is implied, is linked to chromosomes, biochemistry and an individual’s preordained chances. According to this aetiology, the pathways to treatment are prescribed: when illness manifests itself (when the trigger is pulled), it is best dealt with through resort to the latest advances in the medical and pharmaceutical arsenal. Thus, locating illness inside individuals has important social implications. It absolves all others from a shared – communal, moral – responsibility for the social distribution of illness and health. Simultaneously it elides alternative responses to diagnoses and illness identities (for example, one might decide, for various reasons, to live with a condition, diagnosis or risk). Linked to these forms of narrowing, the treatment pathways associated with predictive medicine implicitly also prescribe and endorse an ontological stance. Matter triumphs over mind, culture and environment and in a way that reasserts biology as destiny, but this time with destiny cast as something science and technology can at least in part redirect.

Still Crazy After All These Years?

Nowhere, arguably, is the burgeoning paradigm of personalized medicine more prevalent than in psychiatry (Singh and Rose 2009: 202–3). Articles devoted to correlations between particular genetic bio-markers and mental disorders such as schizophrenia, bipolar syndrome, ADHS and antisocial behavior have multiplied since the early 1990s. More recently, work on neuro-imaging techniques has highlighted correlations between psychiatric disorders and features of brain function. As a report on the research in Science Daily described it:

According to previous research, normal interaction between the amygdala and the VMPFC may underlie the proper adaptation of levels of the stress hormone cortisol on a daily basis. These levels do not vary as widely in people with major depressive disorder; future research may now be able to clarify the mechanism that underlies this aspect of depression. It could also examine the possibility of using measurements of activity in the amygdala to predict the effectiveness of treatments for depression such as cognitive behavioral therapy. (Society for Neuroscience 2007)

Similarly, the Director’s Blog, on the National Institute for Mental Health website describes the drive toward prospective diagnosis:

As NIMH research increasingly reveals the brain circuitry for various forms of mental distress, our hope is that we can look forward to a classification system validated by a deep knowledge of both the genetic risks and neural basis of mental illness. This approach could transform not only diagnosis but treatment. We know from studies of neurologic disorders, such as Parkinson’s disease and Huntington’s disease, that behavioral signs and symptoms are late manifestations of the underlying brain disorder. Imagine the impact of identifying the neural basis of schizophrenia or mood disorders before the onset of disabling behavioral symptoms so that clinicians would regularly intervene to preempt psychosis or depression. (Insel 2010)

This screening boom and the arguments in favour of mandatory screening have been met with criticism from within the psychiatric field (Lehrman 2006). In relation to mental health conditions the ethical issues linked to these developments are urgent. For while the illness status of mental disorders remains hotly contested even within psychiatry itself (see below), individuals identified as at risk (prior to any onset of symptoms) may (perhaps unnecessarily) be subject both to drug treatments (at pre-symptomatic stages) and to social stigma still sadly associated with treatment for mental health concerns (Singh and Rose 2009: 204).

The adage, ‘don’t fix it, if it isn’t broken’ might seem applicable here, since drug therapies often bring with them new problems in the form of side-effects and counter-indications. While such side-effects might be acceptable and, indeed, but a small price to pay (by whom and for what reasons is of course an issue), there are some further, and serious issues at stake, namely the reality status of mental illness – even in the most real and serious of cases. For these reasons, it is evermore urgent that interdisciplinary expertise is pooled to consider, from as many angles as possible, the complex and often contradictory ways in which the ontology and aetiology (the reality status and causes) of mental illness are, have been and might be conceptualized. This investigation needs, moreover, to consider conceptions of mental illness in terms of their impacts and prerequisites across a variety of domains, social, economic, technical, ethical, institutional, political and cultural.

Conceptualizing mental illness has, since 1957, been dominated by the Diagnostic and Statistical Manual of Mental Disorders, or DSM. A highly contested tome, the DSM illustrates the social, cultural and technical mediation of disease categories over time and place. Various ‘illnesses’ have been dropped from DSM over time – homosexuality being perhaps the most notorious example. But other currently well-ensconced categories only emerged in recent times (bipolar syndrome in 1980, for example) and debates continue over the aetiology/causes and reality status of various categories within DSM (Alloy et al. 2005).

Indeed, the most current published version of DSM (American Psychiatric Association 2000) is now undergoing wide-ranging process of revision and debate. The new DSM (DSM-5) is scheduled for release in 2013. The full first draft was released in 2010 (American Psychiatric Association 2010). In the decade between the revised edition of DSM-IV and 2010, two critical and related trends have emerged, both in relation to growth of interest in and publicity for predictive medicine’s focus on bio-markers. Both of these trends have been noted by a number of highly established, internationally prominent, psychiatrists (one of whom was at the time the president of the American Psychiatric Association [see Kirsch 2010; Sharfstein 2005]). The first trend is that, according to some of the proposed criteria for DSM-5, a growing number of so-called normal conditions are being hailed as psychiatric conditions – shyness, for example, as ‘social anxiety disorder’ and cigarette addiction as ‘nicotine use disorder’. The second, and related trend, is that these disorders are medicalized and treated, increasingly, with drugs (paxil or seroxat the recent drug for ‘shyness’, for example). In short, the explosion of new kinds of mental ‘illness’, combined yet again with a growth in screening practices of personalized medicine, adds up to an exponential growth in new cases. In 2004, the World Health Organization’s Global Health Observatory Data suggested that there were nearly 200 million cases of mental disorder worldwide (WHO 2004). In 2010, they estimated the number as nearer 450 million (WHO 2010). The fact that cases of mental illness have been on the rise since the economic crisis of 2008 is of course an important part of this global picture, as is the fact that mental illness rates are highest in countries where income inequality is high (Wilkinson and Pickett 2007), and I will return to these socio-economic, ecological conditions below. Unlike mining for minerals, where supply exists independently of demand or exploration, mental health is a different sort of phenomenon, at once more specu...