Download Exercise 7_example 3

When a Framework Doesn’t Fit:
Considering the Transmissions and Flows of Knowledge in a Clinical Psychology Lecture Hall
At exactly 1:07 pm a powerpoint flickers on a screen in Sever 213 entitled “Eating
Disorders: I. PICA” with a bolded subtitle of “IA. DSM V DIAGNOSTIC CRITERIA”
immediately below it. “Today we are going to discuss the precursors, experiences, and
treatments for a variety of different eating disorders,” the Professor announces at a podium in the
front of the lecture hall. Students continue to file into the rows of seats in the hall, and hurriedly
take notebooks, pens, and laptops from their bags, jotting down the diagnostic criteria projected
on the screen.
Immediately after PICA is a slide with “EATING DISORDERS: II. ANOREXIA
NERVOSA” printed across the top and “IA. DSM V DIAGNOSTIC CRITERIA” immediately
underneath. Students continue to copy down the categorical requirements for diagnosis: a three
part list of core symptoms, specifiers to classify subtypes, and a rating for severity. The
following slide presents “EATING DISORDERS: III. BULIMIA NERVOSA” with “DSM-V
DIAGNOSTIC CRITERIA.” Next is a slide for “BINGE EATING DISORDER,” and finally,
“BODY DYSMORPHIC DISORDER.” The professor clears his throat and gives the class a
seven minute break. Students pull out their phones, stand up, and a few leave the room.
I was drawn to a developmental psychopathology course because of my interest in
medical anthropology. While I often consider mental health in terms of experience, I was curious
to understand how the stakeholders of mental health - those responsible for developing mental
health treatment interventions - consider, discuss, and teach. My inquiry was one driven by the
instruction of the course by a leading clinical psychologist. How does the person attributed with
a leading youth mental health program think about mental disorders, and moreover, how are
these considerations communicated and taught to a class of psychology students, potentially
progressing to become clinical psychologists or stakeholders in mental health themselves? It is in
this production and flow of knowledge in which my ethnographic inquiry can be placed.
The class is virtually silent throughout the first part of the lecture. There seems to be an
occupation with writing down the details of the disorder - with its categorical criteria, specifiers,
and severity levels, before the slide is removed from the monitor. A student in front of me holds
her head in apparent frustration and mutters “ugh” as the text disappears from the screen,
transitioning to the next slide.
Knowledge is curated on the powerpoint presentation. The considerations,
contemplations, and critiques of the professor - the working body of knowledge, or center of the
course’s information - finds itself in a static form. By fitting understandings onto the neat
template of the powerpoint, knowledge is presented in a way that can be directly assumed. With
a professor to read out what is printed on the slides, the students are able to write down the
information directly, without the interference of supplemental thoughts. The quick pace from
slide to slide apparently leaves little room for what is less than criticism, but a consumption, of
the information.
While the persistent silence and remote transcription in the first hour of the class could be
interpreted as a lack of engagement between the professor and student, and thus, an almost onedirectional transmission of knowledge from the authority to those learning, the second hour of
the lecture puts that assumption into question.
A young female student quickly throws up her hand as a slide entitled “Comparing
Anorexia and Bulimia” appears on the screen. “Is this similar to conduct disorders?” she asks.
“Like, can a patient transition from one to another? Are they necessarily separate?” Following,
another student raises his hand: “Well, I don’t think that would be the case, since so much of the
diagnostic criteria overlaps. If they didn’t have a separate diagnosis, how would they distinguish
them?”
Unlike the seemingly static flow of knowledge from the professor to the monitor to
students, the second hour of the course generates a multi-directional transmission, wherein
students question what is written before copying it for themselves. Raising questions creates a
break in the default flow of information, allowing it to proceed in the other direction.
Within the second hour, slides feature less text and more questions, such as “College
student examples. What casual factors and processes do you see?” and “Do you know someone
with a serious problem, but not officially diagnosed?” While these questions prompt a few
responses, from one to two students, the class-wide discussion seems to emerge from inquiries
raised by students themselves, as evident in the anorexia/bulimia comparison.
As a student of medical anthropology, I have grown familiar with critiquing the use of
diagnostic criteria and categorical portrayals of mental health. Extending from foundational
theories of medicalization, concepts in medical anthropology intend to destabilize the tidiness of
these categories, complicating them with lived experience to question their accuracy and
purpose. The image of a lecture hall of students transcribing diagnostic criteria directly from the
powerpoint into their notebooks fits nicely into this theoretical framework. The lack of
supplemental information from the professor himself or the virtual silence of the students in this
part of the class could support the idea of these categories as not only widely accepted, but
seldom questioned.
A framework of medicalization, however, would curate the class as neatly as the
powerpoint slides curate knowledge, without recognizing the competing moments in tension with
this theory. Was the direct transcription of diagnostic criteria from the slide to the notebook a
reflection of the unquestioned state of these categories? Or did students feel pressured by the
lack of time between the slides? Can these slides be found elsewhere, on a course site? What,
then, does this mean for the students: why is there a seeming need to transcribe?
What about the professor? What is the intention of presenting criteria in this way and
reading aloud what is written in text? Rather than assume he, too, is embedded in a structure of
these categories as given, perhaps this pedagogy was intentional. Were the categories to be
communicated as they typically are to the general public and to patients themselves, to then be
questioned via structured prompts and even fuller unstructured dialogue?
Hour three of the course dedicates itself to treatment, or, care for the illnesses presented
in the first part of class. After their seven minute break, students pile back into the classroom to
view a series of youtube clips of Alicia, a young girl suffering from anorexia nervosa.
The four-part clip begins by taking us into Alicia’s home life. Sitting with her mother and
father, she discusses feeling “disgusting” every time she eats and her fear of “growing up.” To
combat this inevitable process, Alicia avoids putting food into her mouth. The video then takes
us into a hospital-based treatment plan for Alicia, wherein she meets with psychiatrists and
mental health professionals with an intervention intended to “empower” Alicia to “re-feed
herself.”
A deep silence falls over the lecture hall at the conclusion of the clips. Students seem to
be drawn in by the images they just saw, rather than distracted by open emails or class notes. The
professor questions “What could have been done differently?,” to which a few students advocate
for family involvement or deeper treatment structure. At the conclusion of a conversation that
“will be continued next time,” students pile out of the lecture hall.
This last segment of the course demands deeper attention. My positionality as a medical
anthropology student carried with it a set of assumptions. Of these is the lack of attention thought
to be given to patient experience within psychologic and psychiatric discourse. Yet, the final
section of the course was dedicated to just that: the experience of a single patient as she
navigated treatment plans for her illness. Rather than take us into her understandings of anorexia
nervosa, or, what the illness meant for her, the video captured her engagements, including her
fears and frustrations, with a treatment plan.
While the video, and thus, the presented knowledge, does not consider how Alicia
understands or experiences her illness outside of a clinical setting, perhaps, despite the critique
common to medical anthropology, there is a value to privileging her interactions within that
setting. While diagnostic categories can be assigned a sense of passive acceptance - as evident in
their direct transmission from monitor, to the professor’s reading, to student notes - and privilege
diagnostic symptoms over patient experience - perhaps something is acknowledged in
exclusively considering experience in clinical settings.
It is in these biomedical spaces - that of the hospital, therapy office, and psychological
intervention - that a care can be provided. The privileging of interactions within this space
privileges a knowledge of the care that can be developed in the face of illness. Perhaps patient
experience is recognized, in the form of a few seconds of a clip, which can then open a wider
imaginary and catalyze the empathy and knowledge that medical anthropology intends to
generate. Perhaps, though, this knowledge is secondary to that at stake for both clinical
psychologists and patients alike, in developing an intervention to respond to that experience.
Attention to engagements in the clinical setting, then, has a stake for those in and in control of
clinical care.
Engagements with and attention to the flows and transmission of knowledge in a clinical
psychology lecture hall complicates the narrative of psychologic and psychiatric discourse as
reductive. Perhaps for the clinical psychologist leading the course, meaning can be found in that
which he holds an engagement with. In focusing on treatment experience, rather than subjective
illness understandings, the professor privileges what can be intervened - the lived experience of
the clinical setting and program - rather than that which is dynamic and subjective - inner
understandings with illness. Similarly, the tendency for students to question comparisons and
interventions, rather than diagnostic criteria, may exhibit less a passive acceptance of psychiatric
categories, but a recognition of their purpose, and to some extent, necessity. Perhaps, then,
meaning for eating disorders for them is held where they see questions as needed, yet not asked:
with identified faulty comparisons or alternative ideas for interventions.
Returning to my opening inquiry, the transmissions and flows of knowledge in a clinical
psychological setting seem unable to be understood as just that: a transmission or flow. Rather
than a process from professor to presentation to student, as was apparent in the first hour of the
lecture, or the probing of statements and concepts in the latter, the cycle of information in the
class seems unable to fit into a directional framework. While the diagnostic categories discussed
and learned omit patient experience, perhaps this limitation is recognized outside of
anthropological spheres. Perhaps practitioners recognize this limitation themselves, with the
intent to supplement this gap in what can be re-imagined: interventions in clinical settings and
discourse on interventions in clinical classrooms.