In Conversation with Neil Armstrong

Interviewed and edited by Gloria Bhiziki and Elise Lee following Dr Neil Armstrong’s Friday Seminar on  'What Does Anthropology Have to Offer Mental Health Research?”

Neil is a member of SOAS’s Centre for Anthropology and Mental Health Research in Action (2022).

Elise: We’ve been reading a book by Langlitz (2012) in one of our courses, Mind and Society. Pointing out problems of biomedical randomised experiments, the book suggests instead a biocultural model that considers individuals' cultural backgrounds. Instead of the neuroscientific biochemical model, should we have biopsychosocial experiments that account for individuals' social and cultural backgrounds?

Neil: I suppose you’re asking if it’s possible and preferable. It’s possible to do a randomised control trial (RCT) of an intervention that took the social and the culture seriously. Already, even mainstream RCTs control what they think of as demographic information, so it could be an extension of that. I don't see why not, but broadly there are also limitations of RCTs. It’s not so much whether interventions play out differently for different sorts of people but also whether you even should be using different sorts of outcome measures. Normally, we've got a standardised intervention that your standardised outcome measures, so the data can be somewhat comparable. If you want to take cultural differences seriously, you might want a different kind of intervention with a different group and a different way of understanding the outcomes of different groups. If that were the case, you might want to enhance the way you think about demographic populations, but the endpoint might be more radical than that.

Gloria: In addition to that question in the book, neurosciences seem to be somewhat obsessed with schizophrenia as the epitome of psychosis. Why do you think that is?

But that's kind of fading now, you say the book’s 2012. For a while, they were super excited because people diagnosed with schizophrenia were seen as being in a sense the most “mad” (I know that's not the perfect way of putting it), but I think it's been a shift now partially because that research didn't lead to anything particularly new. 

Gloria: Yes, a lot of research in the book didn’t lead to anything. 

There are atypical antipsychotics like olanzapine that are broadly the same as the antipsychotics that they replaced. They may be preferable in some respects but basically, no one came up with much so far. I think there's been a shift towards things like neurodiversity. This is a business they're trying to charge; you’re doing loads of research on a new product or problem because this is a business. There's been a move towards people who are, let’s just say, not as distressed. A lot of people with schizophrenia are not holding down full-time employment and sometimes go through very difficult situations; but if you have different sorts of populations–let's just say you are functional and are earning lots of money–you might have nonetheless become a potential new market for new kind of treatment, that might be “exciting”. I know a lot of psychiatrists are quite sceptical about some of the categories now popular in research like ADHD, neurodiversity, this sort of thing. People feel that sometimes there's an increasing bias in research towards less serious middle-class things.

Elise: In consideration of bureaucratic surveillance, do you think psychiatric hospitals still have a place in the treatment of mental illness, particularly due to the history of asylums, eugenics and ableism?

Yeah, I do actually. I think that sometimes people go “mad”. A lot of my friends and myself too used to be a service user in hospitals several times. Sometimes it's not a bad idea in my view. The word “coercion” is probably overused sometimes. A friend of mine, who kept being admitted to the local mental hospital, was all over the place. At that point, he couldn’t look after himself and was gripped by preoccupations. It's okay to, and he would say the same thing, it was helpful. That's not to say what happens in those hospitals is ideal but I’m not against the idea of compulsory treatment sometimes for some people.

Elise: Considering that you say compulsory treatment or mental health hospitals are useful for some people, then how could we address their problems?  

I think partially what we ought to do is think about ward cultures. We're starting on some research at the Centre about this now. You can create wards that are more compassionate, open to distress, and humane, but less pathologising. I think that if staff didn’t have to spend a lot of time tick-boxing and producing notes, they might talk to patients a bit more, but I don’t think that’s the whole solution. You may have to change how their jobs are structured, the risk culture and who’s accountable for what, so they can have more time for informal ad-hoc connections. I also think to some extent what we at the moment expect professional services to deliver might be better thought of as something people could do themselves. I’m involved with service user organisations which is not so much like, “Here's a distressed person who needs to be cared for,” but more like, “Here's a group of people who are facing distress in various kinds of ways who might be able to understand and help each other,” which I think is often better. One of the worst things that can happen to someone if they're a long-term service user is that they are always a recipient of care, they have nothing to offer. Those people walk around having a sense that “I’m a problem that needs to be fixed” but in fact, I get to know people like this who can also support others and listen in a way that clinicians are not good at. If we could create institutional conditions, you might need professionals too, but it might just be that some of the things we want to do in a clinical ward might in future be done in patients-run organisations.

Gloria: You point out how people tend to feel they are the problem that needs to be immediately fixed by the system. But, there’s an opposite of that kind, where we use a biological explanation that removes responsibility for and externalises the harm from you. It’s like, “Oh, this is just how I’m built” and results in the desire to use medicine to treat it. I think we do need a balance.

Yeah, I’m totally with you there. Sometimes people’s absolution of saying, “My brain’s circuitry is faulty and there’s nothing I can do,” may undermine people’s agency. Sometimes people want to be told, “None of this is your fault, none of this is even about you, and this just happens to you.” One of the drivers for highly bureaucratised and highly biological care is not just structures, it’s also where people experiencing distress want to be innocent victims of injustice as if their neurocircuitry is being visited by aliens. Of course, you need to be compassionate, you need to see how people are often going through adversity, people experience trauma or difficulties often in early life, but still, you have agency. I think trying to develop that sense of agency is helpful. A psychiatrist can’t say something inappropriate like “You should get your act together” to a patient, but I have been a patient, among friends, we trust each other, and it might be helpful. 

Gloria: You mentioned aliens and that reminds me of another book we did for this course. Lepselter (2016) looks at UFO abductees. They kind of control the situation by suggesting there’s an apocalypse coming and they remove responsibility for the situations they are in, not only from themselves, but also place it on the state. I guess we do need a balance where you also consider helping yourself. They do build communities, but in a negative way where the world is ending.

Interesting. A friend of mine works with a group of UFO believers and a lot of them have been abducted. He feels that it can become very harmful to people as they become very preoccupied. On the other hand, maybe we all want to be abducted a bit. There are days when I won't mind being abducted for days or weeks. You could see drinking and drugging as a kind of abduction, waking up not knowing what exactly happened last night. I like the poet John Burnside, he had a massive drink and drug thing going on and he would sometimes write incredibly beautifully about it all. He had been “abducted” by alcohol perhaps.

Elise: How does place-making differ between psychiatric wards, rehabilitation centres, mental health institutions, and labs where researchers conduct experiments for the neuropharmaceutical industry? Gloria:  It’s the place where the researchers conduct experiments on rats and mice in comparison to the place where it is put into practice in psychiatric wards. How are these places made and why are they so different although they influence the same kind of industry? 

When I speak to researchers whether in bench or clinical studies, they often don’t directly see chosen patients and are unaware of what it’s like to be a front-line clinician. A lot of front-line clinicians don’t read the research because they just think these researchers don’t know. It’s annoying because sometimes high-end research people were once psychiatrists who saw more patients but they've advanced by publishing a lot of research rather than by helping more with the front line because of how career structures work. In mental health, treatment success isn't highly measurable. No one talks like, “This psychiatrist, his patients all get away, he’s amazing”. Likewise, in a way nobody says their work becomes widely respected, people may say it has been adopted by hospital managers and made into policy, but that’s slightly different. So, the links are quite loose between sitting in an NHS clinic and some guy doing some work on rats.

Elise: Following up on place-making, what kind of bureaucratic processes are required to make these spaces? Are there bureaucracies behind buying the furniture, installing different windows and painting the walls in psychiatric wards?

There are, but they're not standardised. At least for NHS trusts, they're quite separate, they do things like that variously. I find a lot of patient art in psych hospitals patronising; they are selected patients' paintings, and of course, they’re not pictures of psychiatrists mistreating people. Maybe a room like this (an LSE classroom) is created by bureaucracy. Maybe a committee made all the decisions to decorate it, but it’s probably maintained by different disconnected teams, like cleaners and the IT people. Nobody is ultimately responsible, the ultimate responsible person may be quite separated from those people who touch it.

Elise: Do you think how the place is made will influence the experiences of service users?

Yes. I think you can design for surveillance, for example, some of the older hospitals have very long corridors. They are not necessarily great for creating circumstances that make it easy for patients to informally interact in spontaneous ways, but you can alternatively design for this too. In the psych wards, there are often thoughts about security. I have to say the idea that someone watching you doesn’t necessarily make you as a patient feel annoyed because some wards can have an atmosphere where other patients can be scary; sometimes patients don’t think of each other as comrades.

Gloria: In consideration of people publishing articles and acknowledging one person contributing to it, I guess that’s like how science works, demystifies itself and doesn’t want to change the entire system. It also goes back to nobody responsible for anything.

No (agreeing). If you want to think about what might be the change in healthcare, you might want to have the moment, like “hang on a moment, psychosis might be one form of healing that might not need to be treated, or maybe bipolar disorder is habitus”. You might want to work with their tastes, values and commitments rather than treating them as victims of having a faulty brain. It might be a matter of, first, speaking to senior clinicians who might start to change policy, but it needs either interventions or institutional change and that's quite a long process. It requires us to yet follow through on all things, not just having a nice idea that we can discuss in a seminar with people. It's like NHS bosses don't know what people say in LSE seminars or any other seminars. 

Elise: Laura Bear, who is teaching us the course is also involved in the Centre at SOAS. You mentioned how university seminars obviously won’t have any direct effect on anything, what may the Centre do then?

We hope the things we do will bridge the gap between the interesting ideas and actual lived experiences of mental healthcare. Some of that is collaborating with other researchers to introduce ethnographic methods into what they're already doing. Let's say you have a group of people within the NHS who are trying out a new kind of treatment. To show the full benefits of the innovative treatment style, you might need to have that kind of subtlety and flexibility of ethnography. If they build into our analysis, then we might change the things that we judge as being a success or a failure. We're also trying to produce some kind of training for peer support workers. The NHS now employs a lot of people with lived experience of distress and they are backed differently in different trusts but they are a part of care. The problem is that lived experience is one thing, but it's in a sense not a form of expertise, so the tricky thing is sometimes I can see situations where a lived-experience person says, “I have this experience”, but the clinicians feel, “I have loads of patients why do I care about this one?” What I think anthropology can offer is that this one person is a way of theorising so that the systematic and the rigorous start to view it as valid data rather than just a personal anecdote. We’re developing the training now and we hope to deliver them next year. In that case, we think simply having some anthropological training could lead to changes in the balance of power and discussion. 

Elise: The anthropological training is to the peer supporters, right?

Yes, perhaps we will teach them re-theorising experiences. They had training, but we think a lot of the training was for them to anticipate a medical response to distress. We're not saying it’s wrong, but we’re saying there might be other frames too. In particular, their lived experience may not have translated very well into a medical model. It might be much easier to articulate your own experience if you have access to theoretical resources.

Gloria:  There was a piece of work of yours on “public silliness”. Do you think we have to increase the aspect of play not only in universities but also in general life? (See our last article: In Conversation with the Teaching Creativity Team)

Yes. One of the things I've found sad is how extremely humourless a lot of mental health care is. I think humour is such a part of surviving the less fun bits of life, and I regret it's not just part of more daily life. We’re doing the silliness workshops. So much mental health is about things like self-monitoring and self-management–planning, taking time off, being kind to yourself, working out what you can and can't do. I'm not saying there’s anything wrong with that but that can lead to a very buffered individualistic kind of sense. I think people need connections, and I don’t think you self-manage your way into connections. I think actually you often need to stop thinking. There are various ways to stop thinking but in our social workshops, we’re doing it in a very safe way. People mock a bit, they're facilitated, thinking in quite a skilful way, just by being spontaneous, playful, non-competitive, not worrying too much about what it’ll look like in pictures tomorrow, relax a little bit, and get over themselves a little bit. 

Gloria: There’s the narrative that the 90s is the “decade of the brain”, said President George Bush, do you think any decade is or could be the “decade of mental health”?

I hope not. It feels like it's just more and more predominant in universities and broadly in life. It’s not that all mental health care is bad or counterproductive. I don't want to tear everything down, but I think often we do better by thinking about it in non-medical terms like “loneliness” and the best way to generate community is not to think it's a mental health disorder. Say, I've got some students who seem to be impervious to loneliness but they’re not the healthy ones to me whereas the people who say “I feel lonely” to me know in their mind that there isn't enough community in their world and they feel the adverse effects of it– that's not pathology; the pathologist is outside of them, it's not in them. I think treating it as a mental health thing just seems to me to be the wrong way to go about it and I feel like quite a lot of forms of distress are like this. I think we're too quick to pathologise and medicalise. 

Elise: When you mention “pathologising”, do you mean something like imposing labels and categories on people of different kinds of mental disorders like “bipolar”? It’s like if you’re labelled, you feel the need to fit into that label, and there’s a looping effect. Do you think these labels and categories are still useful? Earlier, we talked about how compulsory treatments in psychiatric wards might still be useful for certain people despite their problems.

Yes, but to some extent it's not for me to say whether the terms are useful because I'm not a psychiatrist, a psychologist or a nurse. I sense that the problem is more that the institution can only read those categories and I would like institutions to read other categories too. At the moment, most hospitals just organise around the medical bureaucratic categories, which seems problematic; they can be narrow and reductive, but maybe the category is useful anyway. I think some people seem to experience distress which perhaps goes beyond what you might expect even knowing things about their backgrounds, networks, social situations and context. Maybe there’s something that might have to do with the brain or the gut– I don't see why one would close the door there. I don't think the existing categories are likely to be durable, they’re constantly evolving. In a way, not only anthropologists, but most clinicians I know are already thinking that. For the most part, there isn’t a wrong thing called “schizophrenia”, there isn’t a wrong thing called “bipolar”. Maybe the diagnosed categories attached to the treatments continue to be helpful in mental health care, I don’t see why not.

Elise: It seems that there is a paradox that when you want to care about people who are distressed or lonely, there’s always a risk of pathologising everything and turning it into a crisis, like the “mental health crisis”, then it may be problematic.

Yes. I think not everything we’re doing is working. There’s never been so much mental health care. When I was an undergraduate, there was hardly any mental health care for students but I don’t think we were super depressed or anxious, to some extent, I think maybe we were happier, partially because we were less serious. I think we’ve been more exposed to more psychology which may be individuating, problematising and pathologising. It seems to me that psychological assumptions and ways of thinking are permeating into schooling in a way that I think can be potentially harmful. In the meantime, a lot of the interventions are not effective.

Gloria: I feel like the hyper-awareness of everybody being connected and constantly perceived also pathologised everything.

You guys are living in this world where everything is documented. There’s no forgiveness. I think of it almost in theological terms like you are living in a religion where there is no forgiveness whereas for us we could have committed all sorts of indiscretions and there is no record. It’s not just a way of enabling some kind of moral misbehaviour, it's also not having to think so much about how things look to other people. We were just able to be spontaneous, like in our silliness workshops. There are no accounts, it’s temporary, and we’re playing. Now, everything is documented and there’s a problem there. 

Bibliography

Langlitz, N. 2012. Neuropsychedelia: the revival of hallucinogen research since the decade of the brain. University Of California Press.

Lepselter, S. 2016. Resonance of unseen things. University Of Michigan Press.

SOAS 2022. Dr Neil Armstrong. SOAS (available on-line: https://www.soas.ac.uk/about/neil-armstrong, accessed 26 January 2025).