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Ashe, Leah M. (2017). “Knowing violence: Psychiatric hegemony and the corruption of care.

” Presentation at the European


Association of Social Anthropology - Medical Anthropology Network Conference, Lisbon, Portugal, 5-7 July 2017. Video at
https://youtu.be/K32VKm2MgTM.

[OPEN Powerpoint and press Start Show.]

Knowing Violence:
Psychiatric Hegemony and the Corruption of Care

Preface
I’m a newcomer this year to the field of medical anthropology: My postgrad work was in critical approaches to food security and
cultural food studies, and this past year I’ve joined the center for science, technology, and society at the University of Notre Dame.
This was my academic entrée into medical anthropology; but my interest in the field originated in my own extraordinary experience
with medicine. Thus my perspectival and analytical stances negotiate the emic/etic complementarity in a very particular way.
Certainly mine is a testimony of embodied experience; it’s also one that, in its critical formation, is (I think) distinct from the thrust of
other such voices. I acknowledge from the very first instance that these particularities of position lend evident and unavoidable
elements of particularity to my analysis that seem at once both unsophisticated and, in their way, also privileged. I hope that, whatever
its limitations, the richness of my experiential knowledge might – I hope – also capacitate a rich theoretical one, and in that spirit I
offer this work.

[NO IMAGES]

Intro
In this paper, I’m going to propose that we think about the relationship between care and violence differently and more tentatively
than we, even and perhaps especially we in the academe, conventionally do. Of course the attempts to theorize each concept are
profuse in number and superabundant in content. Here, rather than grasping at some particular aspects of these conceptually opulent
spaces, I will take care and violence on their very roughest terms. So if care might be “theoretically slippery” enough to be understood
in many dimensions (feeling, act, relationship, practice and many more) (e.g., Abbots 2017; Fassin 2008; Mol 2008; Tronto 1993);
and violence can likewise be understood in many dimensions (physical; social; cultural; epistemic; narrative; discursive) (e.g., Asad
2015; Bourdieu 2001; Cover 1986; de Sousa Santos 2015; Escobar 1995; Fanon 2004; Fricker 1999, 2007; Galthung 1969, 1990;
Grosfoguel 2012, 2013); I propose that it’s most helpful to think of care and violence, at least in this analysis, each as “fully” as we
can. What we lose in precision and focus I hope we’ll win in space for the problematization of their relationship – which is, in the
end, what I hope to achieve in this paper.

[NO IMAGES]

Part I: Narrativity and Translation


Fassin (2011) has emphasized the importance of “the trace” of violence as that which transforms it from a phenomenologically real
but politically nonviable experience to one that, by way of its inscription on and in the body, can be inscribed also in the formality of
law and procedure and so transferred to the realm of public intelligibility. These questions of visibility, translatability, and
intelligibility lie at the core of the relationship between violence and care that I approach here; and hence matters of narrativity and
perlocutionary consequence turn essential. But if Fassin’s insight of the trace regards that which can translate the violence of the
experiential and the physical into political effect, I want to suggest a similar sort of translation, but one that translates not from the
phenomenological to the political but rather to what we might think of as the metaphysical or the cosmic.

Cover’s (1986) seminal Violence and Word articulates the violence inherent to the act of legal interpretation, to law. Of course this
connection itself isn’t original (Weber’s notion of the state’s aspirational monopoly on violence figures widely into social and political
criticism, of course), but Cover’s emphasis on the translation, the act of translation, of law into violence comprehends this
mechanism more meticulouslessly. He articulates the consequentiality inherent to law’s systematized operation by socially invested
people acting at each of its cogs: in the sentencing act, for example, the judge unleashes a whole chain of what can only be construed
as violent events. As a result of the judge’s interpretation, he writes:
1
Ashe, Leah M. (2017). “Knowing violence: Psychiatric hegemony and the corruption of care.” Presentation at the European
Association of Social Anthropology - Medical Anthropology Network Conference, Lisbon, Portugal, 5-7 July 2017. Video at
https://youtu.be/K32VKm2MgTM.

Somebody loses his freedom, his property, his children, even his life. … When interpreters [of the law] have finished their
work, they frequently leave behind victims whose lives have been torn apart by these organized, social practices of violence.
(1601)

I think you can begin to see how Cover’s explication of law’s perlocutionarity might be mapped onto care. This is the point I want to
situate, then: that law, and all those nomoi that work as its socially administrable proxies and analogs, entails violence. Whether or
not these might be justifiable violences are another question; that they are violences, and that they unleash chains of violences, is what
I want to name and make central here.

If care takes its form as something that both exists within a particular meta-nomos and installs its own internal nomos, then care
might, like Cover’s law, hold within it the seeds and the structures for inducing and effecting extraordinary chains of violence. In
other words, it might be the case that care can act, quite the opposite of responding to violence, as I think we intuitively
understand it to do, in precisely the contrary way.

[NO IMAGES]

Part II: The empirical case


I am the empirical case. As I prefaced, I approach this paper and my analysis with all the reflexivity I am able to summon; still, it is
my story, I am invested in it, and, if I do not in any case accept any thinker’s claim to objectivity, I certainly make no such claim here.
I want to situate My Particular not as A General, but as a real incidence and coincidence of persons, events, actions, and
circumstances that comprise a part of this reality whose real particularity we have to acknowledge if our epistemopoetic gestures are to
be good ones. So: the empirical.

[POWERPOINT: CLICK]

For about twelve years, I’ve suffered serious gastrointestinal problems; in real terms, I have a lot of stomach pain and produce a lot of
diarrhea. In 2005, I was diagnosed with Crohn’s disease following a begrudgingly tolerated colonoscopy. After several years of trying
different medications and getting the pain and supermotility more or less under control, I “opted out”: I didn’t want to regularly
consume pharmaceuticals or have to visit the doctor each month, and I preferred to treat myself with simplicity and without the
intervention of modern medicine: I ate plenty of good food, I got exercise and fresh air, and I generally tried to “live well.” At the
same time, I moved overseas, and the good Mediterranean “environments” of my new contexts kept me generally in good health for
most of the next decade. In 2014, however, while working on my Ph.D. through Cardiff University in the UK, I suffered what
gastroenterology frames as a bout of “active” Crohn’s: eight continuous months of increasingly severe pain and daily, massive
episodes of diarrhea. Finally I went to a doctor (in the UK). He suggested that a colonoscopy was in fast order and recommended that I
wait in the hospital for the first opening; the first bookable appointment, if I chose to instead wait, lay six months into the future. I
took his advice and waited in the hospital for an opening; it was a decision, a bad decision, that utterly transformed my existence, my
being, my understanding of the world, and my entire scope of capabilities and possibilities.

To make gross elision to a long, bad, detail-laden story: In the filthy hospital ward filled with many people, few nurses, fewer doctors,
and no soap in the soap dispensers, I immediately caught several infections, each worse than the previous, and soon I began to lapse
into and out of consciousness. I’m a former elite athlete (in rowing and running), and my heart rate is, like that of many athletes, very
low. This made the heart monitor sound too regularly for the nurses’ liking, and they disengaged the monitor; I had a cardiac arrest;
the hospital staff failed to recognize it; and my heart totally stopped for 20 minutes. That’s an amount of “dead time” usually
understood to lie at the very limits of revivability. I did return to Life, as it were, by way of a long coma; when I “woke up,” a month
or so later, I discovered that I could not move my body and that I was in any case fastened to the bed by all numbers of devices and
tubes. I also discovered an intensity of pain that I had never before even the capacity to imagine – and I say this (1) having suffered
from major attacks of Crohn’s or, given my now wholesale skeptical appraisal of medical knowledge and nosology, as it were, at least
from whatever excruciating stomach-region problems really did and do continue to afflict me; and (2) having performed as an elite
athlete accustomed to body-wrenching limit performances.

[POWERPOINT: CLICK]

One of the new pains I discovered upon waking was in my legs and feet: it turns out that no carer had thought it proper – proper – to
move my body while I was comatose, nor to help afterwards when I discovered that I could not move it myself. Neither did they care

2
Ashe, Leah M. (2017). “Knowing violence: Psychiatric hegemony and the corruption of care.” Presentation at the European
Association of Social Anthropology - Medical Anthropology Network Conference, Lisbon, Portugal, 5-7 July 2017. Video at
https://youtu.be/K32VKm2MgTM.

to prop my feet upright so that they did not atrophy, flopped, in something of a technomodern foot binding that leaves me still with
what I euphemistically call a “falling problem.” Doctors, it turns out, had authoritatively declared physical therapy of any kind to be
out of the question.

[POWERPOINT: CLICK]

A second pain I discovered upon waking was the volcanic eruption at the entrance to my stomach: one of the tubes attached to me shot
a constant jet of high-speed liquid – “food” – into it for fifteen hours each day, and the point where this jet entered my already pained,
damaged viscera excruciated in a way that words fail. At the same time, my body reacted to this visceral assault by rejecting its
contents in extraordinary, and pained, flows of diarrhea.

The “carers,” as they were, refused to change either of these circumstances, and I soon found out why. While I’d been comatose,
doctors had convened to establish and declare from among themselves the truth of what had caused my sudden deterioration and
cardiac arrest. Surely, they reasoned, it could not relate to the eight months of diarrhea and pain with which I’d reported to the
hospital, as that seemed too simple a thing. More surely still it could not relate to the nosocomially produced sequelae I suffered
following my decision to “wait in the hospital” for that advertised colonoscopy. The only reasonable explanation, they concluded
authoritatively, was that I must be responsible for it myself. That is, while I was in a coma and with no positive evidence at their
hands whatsoever, the doctors diagnosed me: surely, they reasoned from their seats of absolute epistemic omnipotence, I must be
anorexic, I must be the cause of these terrible outcomes. And accordingly, of course, I must be punished for it. That I managed to lose
20 pounds more while in the hospital, tethered to a bed, assaulted by a jettisoned delivery of 2500 calories per day – not food, to be
sure, but calories – first while comatose and then while functionally paralyzed, lent no uncertainty to their diagnosis. They knew, in
their privileged scientific access to Truth and Knowledge, that I was anorexic. (In their words, as conclusive and certain as they were
accusative, What else could it be?)

[POWERPOINT: CLICK]

What I see in this scenario is a major problem of scientistic hegemony: a medicine without the epistemic capacity for diagnosis,
perhaps even a medicine that generates from within itself real consequences of sickness and death, cannot lay claim to well
legitimated certitude, knowledge, or the social privileges that these invoke. In order to constitute itself, Medicine must Know. So it
did.

To elide the saga from this point even more tremendously: After five months of so-construed care in the general hospital, the doctors
sentenced me – legally, to return more directly to my opening comments on Cover’s portrayal of legal violence and the not distant
relation of these practices from ones of care – to a prison, to a carceral detention center for anorexics, which they named in
sociopolitically approbated form as a psychiatric hospital, and where I was abused for five months more. In Roman terms, I moved,
legally, from sui iuris to alieni iuris: I did not belong to myself. I belonged to The Doctor, to The Hospital, to The State. The doctor
owned me.

Doctors force fed me, to my protest, for five months total: absurdly, while making the claim that I was anorexic, they would not allow
me to eat. Watchers Watched me – capital-W, capital-W – 24 hours per day at a distance of no more than one arm’s length from my
body. And they could not figure out why I weighed so little – I denied vomiting, I denied having ever not-eaten, I denied everything
they accused me of because I did not do, had never done those things; and, upon Watching me, capital W, they discovered that indeed
I did not vomit, I did receive a continual flow of forced calorie-fluid shot into my esophagus, and I had very limited use of my body.

They Watched me, they surveilled me, at every moment of the day. To be surveilled while I lay on the sheets or sat on the toilet and
generated extraordinary, pained expulsions of diarrhea; to be surveilled when my body reflexively convulsed in pain as the jets of
high-speed liquid shot through my esophagus; to be surveilled as I tried to reach for my feet to soothe their fiery pains: I don’t think I
understood how these banal acts of surveillance, of being watched, could have acted on me with such cosmic consequence. When I
rolled over in the middle of the night, unable to sleep in the constant light and noise, or when I awoke suddenly from a nightmare, I
discovered that there was always there a Watcher Watching. And in her watching she reminded me constantly of the surreal absurdity
of it all: all night long the Watcher munched on pretzels that I could not eat because that was not allowed but they could munch and
crunch and have a phone conversation about picking up the kids and a little extra money in the next paycheck. And I could only lie
there, convulsing in pain, jets of liquid shooting into me, eyes Watching me.

[PAUSE]

3
Ashe, Leah M. (2017). “Knowing violence: Psychiatric hegemony and the corruption of care.” Presentation at the European
Association of Social Anthropology - Medical Anthropology Network Conference, Lisbon, Portugal, 5-7 July 2017. Video at
https://youtu.be/K32VKm2MgTM.

Again eliding tremendously: After many months, a herculean personal labor of physical habilitation, and a long tactic of prudent
obeisance, I escaped, went directly to the airport, fled the country, and spent the next year re-learning to do all the things they’d taken
from me: to walk, to climb stairs, to type at the computer, to use RefWorks, to finish my Ph.D. To sit in the sunshine. To breathe fresh
air. To eat real food, with friends, untimed, and from a shared loaf of bread.

I want to speak more about many aspects of this horror …


[POWERPOINT: CLICK]

I want to speak more about force feeding: about how it’s rightly recognized in international law as an impermissible torture; about
how it is used historically and actually to intimidate and violate prisoners. I want to make visible the real horror of the practice and its
real use not only on hunger-striking freedom fighters – though here too it is indefensible – but also on skinny women and old people
in hospitals. I want to point out the absurd incompatibility of illegalizing foie gras production but condoning, endorsing, and indeed
sponsoring the same abuse upon people. I’m drawn here to the writings of the suffragettes and prisoners who suffered and suffer the
practice historically and contemporarily. (See, i.a., Animal Protection and Rescue League; ICRC 2013; JewishNews-Ben 2017;
Lazarus 2013; Miller 2016; WMA 1975, 1991)

I want to speak more about the metaphysical effectiveness of surveillance, of Watchers and Watching. To see, to look at, and to
watch are different things; I’m drawn here to Illich’s writings on the eyes and the gaze. (See, e.g.,; Illich 1995a,b; 2005);

I want to speak more about the epistemic hegemony of scientistic medicine, and the violence this does in and of itself to the
mystery of the person. I want to speak about possibilities for not knowing, not understanding in a modern, modernized world
governed by a nomos of knowability and by the sanctioned knowers who are authorized to know. (On the mystery of the person, the
contingency of the event, and the freedom of the response, see especially Illich and Cayley 2005; on scientism, see Boatella 2013; de
Sousa Santos 2015; Fricker 1999, 2007; Grosfoguel 2013; Lander 2000; Mayes 2015; Robinson 2015; Sorrell 1991.)

And of course I want to speak more about the many specific practices of so-construed care and examine the chains of effect that these
practice and unleash – chains that I suspect are, as in Cover’s formulation of law, often violence-laden.

I will speak more about these things – in another moment. Here I want only to broach them, to bring them to your medical
anthropologists’ table and invite you to partake. I’ll finish for the moment by way of some conceptual propositions.

[POWERPOINT: CLICK]

Part III: Corruptio optimi pessima and the unpersoning effect


(Now.) It is not only that that these medical practitioners dominated me; that they disabled me; that they imprisoned me; that they
violated me. It is that they exacted their violences from within the discourse of care, from within the sanction of society, from
within the doctor’s profession of trust and my credence in it. In their unmaking of my world (to use Scarry’s (1985) words), they acted
in perfect conformity with the legal and moral parameters that located theirs. To follow Illich (see, e.g., Illich and Cayley 2005;
Cayley 2011; Illich 1976, 1992, 2008); here, it is precisely this zenith of corruption, of perversion, that makes their acts, and the
consequences of those acts, so exquisitely degrading and so effectively consequential. It is the perversion of care into violence, of
carers into violators, of moral existence into moral extinction that makes this sort of violence so utterly grotesque and so
metaphysically powerful. It is a case of corruptio optimi pessima, the corruption of the best become the worst.

I propose to understand this experience (for me) and this act (for the many carers who performed it) in terms of
UNPERSONING. I want to be as precise as I can and insist on using this word more to articulate the act of demotion from person to
something other than person; whether this is a demotion from subject to object, from agent to thing, or from person to “non-person,
almost-person, temporary person or anti-person” (Esposito 2016, 26; see also Esposito 2015), what I want to emphasize here with
unpersoning is the demotional experience and the demotional act (rather than the new status itself).

Of course Esposito argues that the “dispositive of the person” is as problematic as it is pervasive in the modern West (Esposito 2012,
2015, 2016); this is a much bigger problem. For now all I want to recognize is that this dispositive of the person exists and that it
4
Ashe, Leah M. (2017). “Knowing violence: Psychiatric hegemony and the corruption of care.” Presentation at the European
Association of Social Anthropology - Medical Anthropology Network Conference, Lisbon, Portugal, 5-7 July 2017. Video at
https://youtu.be/K32VKm2MgTM.

saturates our thoughts; that is, whatever we might think about it, the dispositive of the person locates and saturates the reality in which
most of us here live. I’ll say at least that it saturates mine. For now, then, I want to sidestep the problematization of personhood itself
and emphasize the practices of distinction that it requires us to continually negotiate. In other words, insofar as the person exists, he
exists because he is categorically different than some other collection of beings – the non-persons and almost-persons and so on. In
short, “what is included is that which is not excluded” (Esposito 2015, 73), and to include a being in the category of persons means
identifying that justifying reason why he is not excluded. What I want to emphasize is the act of demotion from the first of these
categories to the second one: from person to … something other than person.

To return to the particular, I claim that the act of attributing a mental health diagnosis upon someone makes at least a first move in the
practical operation of such a demotion. Perhaps there are grades and degrees and gravities of the unpersoning act. Among the acts I
would claim to be an act of full and complete unpersoning is that of torture, a category that is itself of course construable and
contestable, but let us say at least there are some classes of violence that are graver than others and that torture is what lies at the
extreme. What Medicine delivered to me was certainly violence, and I would claim that it also had aspects to it – force feeding is one
– of violence in its gravest form. The fullness of its deliveries to my body transformed not only my body but also, with it, that very
fundamental identity I’d earlier enjoyed: that of person.

The act of provoking, of generating, of delivering this monumental transition is what I propose as UNPERSONING. And it is this
act-cum-experience, UNPERSONING, that Care-turned-Violence, Corruptio Optimi Pessima, has the capacity to deliver.

How, then, might we begin to understand more meticulously this concept of unpersoning? At this point I merely float the idea, and
there remains the great work of fleshing out its many-layered detail. Several thinkers’ conceptual formulations might enter neatly into
this labor; now I’ll only broach them.

First:
Esposito’s articulation of the dispositive of the person names the singularity and evitability of the person concept and insists
on the precariousness of its ascription. If one is not a person but must be defined to be, understood to be, a person, his status
as such is likewise not immutable. (See, i.a., Esposito 2012, 2015, 2016)

Second:
In a related sense, Agamben’s (1998) portrayals of the Roman homo sacer and of the concentration camp Muselman
emphasize the demotional aspect that I want to capture in unpersoning: it is not only that there is a distinction, that we make
a distinction, between the person and the less-than-person, but that the transfer of a being from bios to zoe is a specifically
demotional move.

Third:
Fricker’s (1999, 2007) conceptualization of epistemic violence, particularly in the medical encounter’s regularized practice
of it; Dworkin’s more radical writings on the translation of physical violence into an existential or metaphysical one; and
Scarry’s (1985) articulation of the capacity for torture to make and unmake worlds each help point to how this demotional
movement of the self – which, we must remember, is also a demotional act performed by the so-construed carer – happens.

Fourth,
On an even more metaphysical plane, Buber’s (1937) writings on the differences that demarcate an I-Thou relation from an
I-It one, and Illich’s (i.a. 1992, 2005) insistence on the contingency, mystery, particularity, and freedom inherent to the
Samaritan relation or to the Samaritan “response” are, I think, crucially insightful for appreciating the not wholly knowable,
and certainly not generalizable, aspects of the person’s being that we might try to capture as “cosmic.”

Here, then, I’ve done no more than raise my real experience of care-turned-violence as a subject worthy of more contemplation; and
I’ve raised it here because I think medical anthropology has a privileged place from which to contemplate it. Your wide berth of
conceptual resources; broad cache of research and analytical practices; sensitivity to hermeneutic juncture; and appreciation for a
diversity of epistemic actors and acts give anthropology a fullness of vision that most disciplinary traditions preclude. I invite medical
anthropologists, then, to take up more robustly these questions that I broach: How might we understand and problematize the different
combinations of relationships, practices, and effects possibilized within this care/violence matrix, as it were? How might medical
anthropologists act, in a “barefoot” sense, as it were (Scheper Hughes 1992, 1995), to make visible the normalized practices of care-
turned-violence that, as in my case, remain concealed, obscured, denied, and invisible?

5
Ashe, Leah M. (2017). “Knowing violence: Psychiatric hegemony and the corruption of care.” Presentation at the European
Association of Social Anthropology - Medical Anthropology Network Conference, Lisbon, Portugal, 5-7 July 2017. Video at
https://youtu.be/K32VKm2MgTM.

And what is it about the perversion, the corruptional aspect, of this care-turned-violence, this corruptio optimi, that makes it so
especially violating?

The questions are yours for the thinking. Thank you.

6
Ashe, Leah M. (2017). “Knowing violence: Psychiatric hegemony and the corruption of care.” Presentation at the European
Association of Social Anthropology - Medical Anthropology Network Conference, Lisbon, Portugal, 5-7 July 2017. Video at
https://youtu.be/K32VKm2MgTM.

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Ashe, Leah M. (2017). “Knowing violence: Psychiatric hegemony and the corruption of care.” Presentation at the European
Association of Social Anthropology - Medical Anthropology Network Conference, Lisbon, Portugal, 5-7 July 2017. Video at
https://youtu.be/K32VKm2MgTM.

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