Propuesta de la mejora

This dissertation consists of three different parts. The first part offers a genealogy of

“specialized” mental healthcare and “immigrant suffering” in France. I argue that, in order to understand the contemporary relevance of the use of culture in mental healthcare and the distinct shape that it took in the French context, it is necessary to 1) understand how the concept of “culture” (preceded by the concept of “race”) became relevant in mental healthcare provision, and 2) trace the evolution of the cultural representations of immigrants in France—notably their impact in the healthcare context—and what led to an interest in “immigrant suffering.” In chapter 2, I analyze colonial psychiatry, the

collaboration between the scientific fields of psychiatry and anthropology, and how these were structured by the political context of French colonialism. Relying on biological racism, colonial psychiatry’s use of the concept of “race” in therapy contributed to the control of colonized populations. I then analyze how the transition to a different political context—that of decolonization and postwar internationalisms—positively impacted post-colonial psychiatry initiatives. I describe how a growing scientific interest in the cross-cultural variations in the expression of mental health disorders and their treatment inspired collaborations between Western psychiatrists and local healers. I show how these ultimately reify culture and depoliticize distress.

In chapter 3, I pursue the genealogy of “specialized” mental healthcare by tracing the mechanisms that eventually motivated an interest in “immigrant suffering.” I pay

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particular attention to the evolution of the cultural representations of immigrants in relation to France’s immigration policies. I analyze the reproduction of colonial representations of the “African Other” in the general field of public health in France at the turn of the nineteenth century. I look at the representations of distinct immigrant groups (North and sub-Saharan African successively), and how these impact their health and its management by French public health institutions. I focus on the naming of immigrants’ health issues by medical officials and how these naming strategies depoliticize the socioeconomic inequalities to which immigrants are vulnerable. In particular, I draw attention to the rhetorical shift from an emphasis on the infectious and malingering body of African workers (especially north-Africans), to an emphasis on the management of socially deviant and psychologically distressed African families

(especially West Africans), each corresponding to two general phases in the history of immigration: labor immigration and family reunification. Finally, I argue that this transition led to the first clinical ethnopsychiatry initiative for immigrants, and resulted from the need to institutionally manage immigrant families.

In the second part of the dissertation I analyze the institutional discourse of

“specialized” mental healthcare in contemporary France. In chapter 4, I analyze how, in the aftermath of Nathan’s ethnopsychiatry, the three specialized mental health approaches I have indentified have respectively re-formulated an expert discourse on “specialized”

mental healthcare delivery to immigrants in France. I suggest that these approaches have

“softened” their discourse on the relevance of cultural difference in mental healthcare delivery, mainly with the aim of securing institutional capital. In particular, I argue that by uncritically amending the overlap between cultural difference and socio-economic

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inequalities, and by developing technical lexicons that politically euphemize the

relevance of culture in discourse, they indirectly participate in de-politicizing the issue of immigration and the management of cultural difference in France altogether.

In chapter 5, I nuance this conclusion by introducing the internal complexities that characterize “specialized” mental health institutions. After establishing the structural features of the field they inscribe themselves into (the macro-context of my institutional analysis)—namely the close interaction between political conjunctures, immigration policies and racial/cultural discourses in particular, and the evolution of mental healthcare provision to foreign populations—I want to introduce the individual figures who

“perform the field.” Using the concept of reflexivity, I analyze how mental health experts and their trainees articulate their positionality in the field, where they identify

institutional contradictions, and how they make sense of them.

The last part of this dissertation analyzes clinical interactions and

cross-institutional referrals to “specialized” mental health centers, focusing on the identification and categorization of cultural difference. In chapter 6 (and in the third part of this

dissertation more broadly), I thus move beyond institutional discourse, and analyze filing and referring practices (the management of patients prior to consultation). I identify the coding of cultural differences, and how it creates tensions for health practitioners and staff in daily practice and interactions. Similarly, I study how referring institutional actors resort to a shared use of the concept of “difficulty” in order to avoid references to cultural difference. However, I suggest that the representations they help disseminate through the concept of “difficulty” simultaneously call for a pragmatic acknowledgement of cultural differences and an affirmation of their relevance both in their relation to the structural

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inequalities many immigrant families face, and to the expression of the mental suffering such inequalities produce. I argue that the aforementioned paradoxes echo France’s long-standing anxieties with naming identifiable immigrant groups, at the same time as its struggling with the necessity to structurally acknowledge them.

Chapter 7 analyses the clinical impact of the discursive ambivalences described in the previous chapter. In a first part, I focus on how specialized mental healthcare

practitioners manage the contradictions of their own institutional position, and

alternatively find avenues to contest it; the second part focuses on patients, the ways they put the regulative system to the test by directly contesting it, or by becoming socialized in it and finding ways to mobilize it to their own advantage.

Finally, chapter 8 re-emphasizes the tensions teased out in the previous sections, around naming and referring practices as regulative strategies in the management of immigrant families on the one hand, and their contestation in “specialized” mental

healthcare clinics on the other. The language of school referrals is particularly relevant as it most directly conveys definitions of what a “standard” socialization model and

“normal” behavior are. By examining how definitions of “normal” behavior are articulated through school referrals, I argue once again that “specialized” mental healthcare centers represent loci where essentializing representations of immigrants’

cultural differences are projected, and can be analyzed. Once again, I identify a language of “difficulty” – this time institutionalized by the national education jargon – in the identification of immigrant children’s behavioral problems and/or learning disabilities.

Theoretically, this dissertation contributes to social theory by proposing an analytical frame that measures the extent to which political discourse and public

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representations shape institutional practices by highlighting how social agents negotiate between the two. It thus contributes a model of institutional analysis that both delineates social frames and documents individual experience, through time and space. By doing so, it illustrates how anthropology may contribute to and praise the study of complexity of social life beyond the traditional structure/agency dyad.

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