Life after armed group involvement in Nepal: A clinical ethnography of psychological well-being of former "child soldiers" over time.

Little is known about the longitudinal effects of early age involvement of young people in armed groups and their well-being as they return to strongly affected, politicised communities. Current research and policy are often driven by the assumption of a causal relationship between participation in this war experience and psychological damage. This article explores the role of young people's armed group experience during the Nepal People's War, compared with post-conflict stressors, in shaping intra-psychic impact and distress, and which processes enable well-being and resilient functioning. Findings are reported from an 18-month clinical ethnography of a cohort of 17 Nepalese young subjects, where participant-observation methods were used to explore their daily lives after exiting the armed group and follow-up research conducted six years later. The findings highlighted limited evidence for on-going intra-psychic impact and distress related directly to their armed group experience; when such distress occurred, it appeared to be generated more by the structural violence of their environments. The key constituents determining their well-being included: a sense of closeness through emotional connectedness with their family, ideological proximity with the values of the armed group, closeness in their bond with the community, and the social-emotional-economic capital available to them to navigate the harsh structural constraints of post-conflict life. These data further challenge the prevailing assumption that this war experience inevitably leads to psychological damage, and the article argues that structural violence often plays a predominant role in cases where psychological distress does arise.

Meaning in hoarding: perspectives of people who hoard on clutter, culture and agency.

Hoarding has become increasingly prominent in clinical practice and popular culture in recent years, giving rise to extensive research and commentary. Critical responses in the social sciences have criticised the cultural assumptions built in to the construct of 'hoarding disorder' and expressed fears that it may generate stigma outweighing its benefits; however, few of these studies have engaged directly with 'hoarders' themselves. This paper reports on in-depth, semi-structured interviews with 10 individuals living in England, who received assessment and intervention for hoarding from Social Services. Their narratives drew on the cultural repertoire of values and discourses around waste and worth, the mediation of sociality and relationships through material objects, physical constraints on keeping order and the role played by mental health. Analysing these perspectives anthropologically shows how dominant models of hoarding, such as the DSM-5 paradigm, potentially lend themselves to reductionist understandings that efface the meaning 'hoarding' may have and thereby deny agency to the person labelled as 'hoarder'. More culturally informed analysis, by contrast, affords insights into the complex landscape of value, waste, social critique, emotion, interpersonal relationships and practical difficulties that may underlie hoarding cases, and points the way to more person-centred practice and analysis.

Ethnographic perspectives on global mental health.

The field of Global Mental Health (GMH) aims to influence mental health policy and practice worldwide, with a focus on human rights and access to care. There have been important achievements, but GMH has also been the focus of scholarly controversies arising from political, cultural, and pragmatic critiques. These debates have become increasingly polarized, giving rise to a need for more dialogue and experience-near research to inform theorizing. Ethnography has much to offer in this respect. This paper frames and introduces five articles in this issue of Transcultural Psychiatry that illustrate the role of ethnographic methods in understanding the effects and implications of the field of global mental health on mental health policy and practice. The papers include ethnographies from South Africa, India, and Tonga that show the potential for ethnographic evidence to inform GMH projects. These studies provide nuanced conceptualizations of GMH's varied manifestations across different settings, the diverse ways that GMH's achievements can be evaluated, and the connections that can be drawn between locally observed experiences and wider historical, political, and social phenomena. Ethnography can provide a basis for constructive dialogue between those engaged in developing and implementing GMH interventions and those critical of some of its approaches.

Carers' responses to shifting identity in dementia in Iris and Away From Her: cultivating stability or embracing change?

An emphasis on supporting and maintaining self-identity in people who have dementia for as long as possible has gone hand in hand with the revitalisation of dementia interventions, services and empowerment. However, recognition of the need for change, adaptation and personal growth is as necessary when living with dementia as at any other time in people's lives. Those who care for people with dementia must constantly navigate this tension between continuity and change within the context of memory loss, knowing when to respond by reinforcing the 'self' they have known over time, and when it may be better to respond by acknowledging the changes that have taken place in that 'self'. The creative arts are avenues for the exploration of the caring relationship under these conditions, conveying the challenges and stimulating audiences to ask how they themselves might choose to respond in a similar situation. This article considers how the scenarios of two noted films, Iris (dir. Richard Eyre, 2001 UK)) and Away From Her (dir. Sarah Polley, 2006 Can), present the dilemmas of identity and caring. In both, a husband cares for a wife experiencing cognitive decline, but responds differently in each to her shifting needs and experience of identity. We argue that the two films reveal complementary and provocative perspectives on this situation. They offer no easy answers, but provide insights into the everyday decisions characteristic of caring for someone who has dementia.

"Now he walks and walks, as if he didn't have a home where he could eat": food, healing, and hunger in Quechua narratives of madness.

In the Quechua-speaking peasant communities of southern Peru, mental disorder is understood less as individualized pathology and more as a disturbance in family and social relationships. For many Andeans, food and feeding are ontologically fundamental to such relationships. This paper uses data from interviews and participant observation in a rural province of Cuzco to explore the significance of food and hunger in local discussions of madness. Carers' narratives, explanatory models, and theories of healing all draw heavily from idioms of food sharing and consumption in making sense of affliction, and these concepts structure understandings of madness that differ significantly from those assumed by formal mental health services. Greater awareness of the salience of these themes could strengthen the input of psychiatric and psychological care with this population and enhance knowledge of the alternative treatments that they use. Moreover, this case provides lessons for the global mental health movement on the importance of openness to the ways in which indigenous cultures may construct health, madness, and sociality. Such local meanings should be considered by mental health workers delivering services in order to provide care that can adjust to the alternative ontologies of sufferers and carers.

Patterns of persistence amidst medical pluralism: pathways toward cure in the southern Peruvian Andes.

When mental illness and related conditions strike among the Quechua-speaking peasant population of southern Peru, they open wide the question of who is best placed to offer the healing that families seek for their afflicted relative. Biomedical doctors and the traditional healers known as yachaqs are the two most commonly consulted sources of help. Yet most families show different patterns of persistence with each; they frequently give up on biomedical assistance after the initial intervention but continue to consult a succession of yachaqs over considerable periods of time, even if the former has had some limited success and the latter virtually none. I draw on ethnographic fieldwork to show that explanations based on inaccessibility, cultural incongruence between patient and clinician, or stigma are ultimately inadequate; rather, it is necessary to delve into fundamental differences in how the two fields of healing are conceptualized by those negotiating them.

The pursuit of certainty in diagnosing dementia: cognitive testing, childishness and stress in two British memory clinics.

By often taking as its focus the experience of illness in itself, medical anthropology has sometimes neglected the meanings that patients may assign to the diagnostic procedures that they are expected to undergo. This paper puts into anthropological perspective the author's experiences working as an assistant psychologist in two British memory clinics for the detection and treatment of dementia, using comments by patients to illustrate the significance that one aspect of these procedures--cognitive testing--had for them. These comments suggest that the meanings that patients construct with regard to such testing are complex and cannot be understood if one persists in seeing it as a neutral diagnostic tool without broader implications. It is argued that a strong association made by many patients between the cognitive tests and their childhood school experiences informs their reactions for better or worse. It is important to acknowledge the implications of this active interpretation of medical procedures if the memory clinic experience is not to become an alienating and infantilising one.