Season 02 - Episode 05: Care In/Out the Clinic (Feat. Carolyn Sufrin and Xochitl Marsili-Vargas)

In this episode, producer Diego Arispe-Bazan introduces two interviews. The first is between Penn grad student Josh Franklin and Professor Carolyn Sufrin. They discuss her recent book, Jailcare: Finding the Safety Net for Women Behind Bars (2017), interspersed with news clips and testimonials on the topic.

After a rare recorded quote by Sigmund Freud, Diego returns in the second half of the episode to talk with Xochitl Marsili-Vargas to discuss the ways that psychoanalytic discourse circulates outside of the clinic through questions such as “what you really mean is,” the kinds of conversations one might have with strangers, and reflect on the differences between mental health care in Argentina and the United States.

TRANSCRIPT:

Deborah Thomas: 00:00 Hello, my name is Deborah Thomas, editor-in-chief of American Anthropologist and this is "Anthropological Airwaves."

Diego: 00:22 Hello, this is Diego Arispe-Bazán, one of the co-producers of Anthropological Airwaves, and specifically producer of this episode. Today we discuss the contradictory intimacy of care within the US carceral system and how psychoanalysis as a method of care has gone far beyond the clinic in contemporary Argentina. Josh Franklin, PhD candidate at the University of Pennsylvania talks to Carolyn Sufrin about healthcare in a California jail. And I learned about the ways people listen for the unconscious in Buenos Aires from Xochitl Marsili-Vargas. And we end with a brief conversation on the differences between the visions of mental health and mental health care in each country.

Josh: 01:11 thanks so much for being able to talk about your book. I've been really looking forward to a chance to ask you some questions about the book, but maybe to start off with, it'd be really interesting for me to hear how you got into the project.

Carolyn: 01:22 Yeah, I'd be happy to talk about that and I'm, I'm thrilled to be having this conversation with you. Thank you for hosting me. So I'm a physician anthropologist and that certainly comes through in the book. And this project definitely has its roots in my clinical practice. And although I had a background in anthropology as an undergraduate major and, also had a masters degree, I really initially went on a clinical path. And along the way I developed an interest in working with incarcerated women that was actually very much driven by clinical experience, when I was a resident of delivering the baby of a woman who was shackled to the bed, which I'm sure it was exponentially more troubling for the woman herself.

Carolyn: 02:00 But for me as, as a caregiver, it was very unsettling: the violence that was happening, and my own complicity in it. And it very much also felt like Foucault was in the delivery room with me. You know, we had the politics of reproduction and sexuality and control and incarceration and that clinical moment got me interested in working with incarcerated women. And so after my clinical training, I pursued that interest and started actually working as a physician at the San Francisco jail. And, I hadn't really, I had never been inside a jail or prison until I started working there. I was really overwhelmed with the complexities and contradictions that I experienced. Here I was a caregiver in a space of punishment, in a space that's defined by violence. And what was I doing there? Trying to provide compassionate care. And that contradiction also is mirrored in this unusual legal and rights-based framework of healthcare for prisoners, which is that incarcerated are the only ones in our country with a constitutional right to health care, which is such a paradox, you know, in the United States that health care is not conceived of as a right, at least not formally.

Carolyn: 03:11 And then you've become incarcerated and part of the punishment is intentionally to remove most of your rights, yet you get, you gain this right to health care. And then I also observed that for so many of my patients, jail was actually the only place where they accessed healthcare. And this was also in San Francisco, a city that is known for having a robust safety net. And then a final contradiction or surprise that I experienced was I went in with a critical stance towards mass incarceration. And I had my assumptions about the people who would choose to work inside that they would all have a certain persona and the denigrating and you know, be using their position of power over the incarcerated people. And I certainly saw plenty of that. But I also saw that there were tremendous relationships of care and not only with healthcare providers but also with the guards.

Carolyn: 03:59 Um, and that came from, you know, a sense -- I later learned, as I did the research -- from a sense of familiarity that came through in recidivism. And I felt like there was some bigger story that was happening. And so I needed the tools of anthropology. And that's, I think one of the things we do best is we, you know, we, we, we gravitate towards the contradictions and what doesn't make sense at first glance and, and what requires suspension of your assumptions and questioning those. And so that's when I went back to graduate school and got my PhD in Anthropology and my dissertation fieldwork was at this jail and the spaces surrounding it. And that research is the basis for the book.

News Clip: 04:39 This all comes down to a moral and basic rights issue. Charles Ryan runs the Arizona Department of corrections and the judge deciding the case today that Ryan failed to improve health care for inmates. Now this all stems from a lawsuit filed back in 2014 where some prisoners claimed that their cancer went undetected, some even claiming that they were told to pray to be cured after begging for treatment. Now despite the ruling. The state continues to deny the claim that it provided second-rate health care to inmates and Governor Doosey stands behind Ryan.

News Clip: 05:10 Um, and you know, jail is where they hold you pretty much until you're sentenced. And so what I find with the jail systems is they don't really have a whole healthcare system in place for chronic care, chronic illness. So I find that a lot of complaints come out of jail, whereas in prison it's, it's really more of a systematic machine. And so I find a lot of times I have a lot of patients who will say that during the jail process of where they're waiting to get sentenced or cleared, it really is hard to get a chance to see a doctor.

Josh: 05:38 I really like what you said about looking to anthropology and it reminded me of something that you talked about in the end of the book, where you quoted at length from one of the deputies who had a really powerful and moving critique of the carceral state. So I wondered if you could talk a little bit more what that process was like, engaging with the nurses, the deputies, the inmates, healthcare workers in other settings and how that transformed the ways that you understood these contradictions.

Carolyn: 06:08 Even just the methodological, how do you even engage them in this research process? And granted this was the San Francisco jail. And in my particular case it was fairly straightforward because I had already been working there for several years and so they saw that I could play by their rules and they saw that I was there to care for the incarcerated people. So even just getting buy in from the people at the top and then, you know, I let everybody at the jail know that I was doing research. And many of them actually I think forgot after awhile and I, you know, I would position myself in spaces in the jail that I wouldn't otherwise have gone to where I not doing participant observation.

Carolyn: 06:49 So for instance, I would hang out with the deputies in the holding area, as they called it, where people would be in cells waiting to go to court or to the hospital, or to come back to jail. And I would hang out with them for a long time and got to know them. In any case, I think that that level of trust that I had built over the years made people actually very open to talking with me. And what I found when I would get some of the deputies or the guards, um, behind closed doors. And that's where this conversation with Deputy Alston unfolded. And she was someone, as I described in the book who on the surface and in her public persona in the jail, she's very curmudgeonly and, terse with the women. And I never saw her be physically abusive, but I never saw a real kindness or warmth in her and I wasn't expecting it.

Carolyn: 07:38 But when I got her behind closed doors and I asked her about her job and why she chose to work in this area and she just came alive in a different way. And she said in my, you know, dozens of years of working here, nobody has ever asked me any of these questions. And she had formed her her assessment and essentially makes the entire argument of my book, which is that jail has become part of the safety net because we have all these deficiencies in in our our social and medical safety net. And so by default, the way that we've invested in incarceration, jail has come to fill in this role and it should not be that way. And she said that too. And yet what she said was that she did not feel comfortable sharing that stance with her colleagues. But I heard other colleagues say similar things.

News Clip: 08:18 It's really sad in a sense, that 90% of people were incarcerated will at some point return home. And we have a choice in how we work on men and women back to our community. Once a person has served their time, that means that they should come out with a clean slate and an opportunity to start over.

Josh: 08:36 So in some sense the ethnographic work involves articulating or finding an outlet for a critique that's already imminent within the space and people who are practicing to find a voice and then become relevant to policy makers. Would you say that?

Carolyn: 08:50 Yeah, I think that's exactly it, it's one of the wonderful many wonderful tools, our discipline of anthropology, the action that it can do in real time. You know, and I didn't keep in touch with this particular deputy to know if the space for her to articulate her critique, how it changed the way she works. But um, to be able to share her observations, as someone who works inside the system, to be able to share that and say, you know, this is not just like prison abolitionists who are saying our system needs to change. These are people who work inside and see every day the destruction on human lives that it causes.

Josh: 09:27 Do you mind if I change gears a little bit? So, in the first part of the book, you give a really powerful critique of the state of mass incarceration and the conditions that that inmates face. And then the second half of the book, you introduce these themes of desire and intimacy. And I wondered if you could say a little bit more about what desire means in this context and what intimacy means, how you see that part of the work?

Carolyn: 09:52 Yeah. Both of those. They're signposts in a way for the contradictions that exist in incarceration, right? Because why should we be talking about desire in a space of punishment? Why should we be talking about intimacy in a place that is commonly talked about as dehumanizing? And so even just introducing those concepts as possible is a signal as a marker of these contradictions that were very real for the incarcerated women.

Carolyn: 10:22 And I talk about this, the woman whom I call Kima is, she said on a number of occasions, to me, "my worst day in jail is better than my best day on the streets. But I also hate it here." And so, you know, the desire for jail, especially the pregnant women and mothers whom I spent time with, it's full of contradictions. And for example, the women I call Evelyn, she knew that jail was the only place she could to access prenatal care. And so she turned herself in. She wanted to go to jail. And that's a really, that's really troubling to hear that her life on the streets was so precarious that jail felt a relative measure of, of safety. But it's also really troubling for people to say, oh well, people see jails as comfortable and good, which is not the case at all. It's jail.

Carolyn: 11:06 And so this desire is fraught with all kinds of complexity. It's the violence that's inherent in being able to desire a space of punishment, the intimacy that some incarcerated women feel in jail. And I'm not talking about romantic or sexual intimacy, but the intimacy of care-giving relationships, the intimacy that comes from recidivism and recidivism is a concept that is typically represented in statistical terms as a number, the percentage of people who get rearrested and come back. But what I learned from the ethnography, and again, this is what anthropology gives you, is you see that recidivism is actually full of relationships because going to jail for so many of these people is not a disruptive event. It is a chronic part of their everyday lives. And so the intimacy that gets cultivated through this familiarity of the space, the way time is structured, the people who work there, the other people who are incarcerated there, that familiarity breeds a sense of intimacy that can lead to feeling cared for. And so the intimacy, is, it's related to the desire, that the fact that someone can feel a sense of intimacy, through, through coming back to jail. But it's also fraught.

Josh: 12:20 I thought your comment about the absence or the relative absence of sexual and romantic intimacy from the spaces that you witnessed, was really interesting. It was something that I noticed in the book and I wondered what kinds of intimacy are emphasized, and which are eclipsed, and for what reasons. I wondered if you had any thoughts about the relative absence of that in the narrative.

Carolyn: 12:45 And I should also take, make a point that, sexual intimacy absolutely happens in jails and prisons. And in fact, during the time that I was there, there was a romantic relationship that unfolded between a female nurse and a male incarcerated person. And the nurse was promptly fired. And then there are also exploitative relationships, absolutely sexual violence that happens among incarcerated people from guards to incarcerated people. So the fact that in my research it did not emerge very much does not mean it doesn't happen. But that being said, the kinds of intimacy that did emerge worth, I mean, some of it was the clinical care giving moments like a nurse changing someone's dressing from an injury that she sustained when stealing someone's car, in a high chase speed accident, but that mundane act -- or mundane for a nurse changing someone's bandage -- was a moment away from the usual routine of being in the housing units, and it allowed for familiar conversation for them to talk about their children and those sorts of things.

Carolyn: 13:51 And that kind of intimacy is, it's unusual or it surfaces as unusual because you're in a space where you don't expect it. So, you know, that's one, one example, there's the intimacy of late at night. And I talk about this a little bit, Evelyn playing cards with a deputy. And both of them talking about their, their woes and the deputy who had herself had a chronic medical condition and Evelyn talking to her about that. And um, so there's, and there certainly was always a power dynamic in that. I don't know if it was this particular card game that she recounted it, but it had happened in the past where the deputy would wear gloves while playing cards with her. And so there's again, this contradictory intimacy of like, "Hey, I'm going to get to know you, but I'm going to keep my distance." So there are many ways in which intimacy, non-sexual, non-romantic, intimacy emerged. And this is, you know, I think something that I took a lot of inspiration from John Borneman's work on the different forms of care and the different kinds of kinship that emerge through care-giving relationships. There were all kinds of ways in which intimacy emerged. But again, it was always characterized by this contradiction and the fact that it arose in a space of violence, and in some ways emerged as intimacy because of how it was attached to violence.

Josh: 15:15 That's really interesting. Thank you for that and thank you for talking about the book and your work. It's been really wonderful.

Carolyn: 15:22 Oh well thank you so much. This has been a great conversation and thank you for your observations and perceptive questions about the book, this has been really enjoyable.

Sigmund Freud: 15:32 And in the end, I succeeded in dreaming up an international psychoanalytic association. But the struggle is not yet over.

Diego: 15:52 There is a lot of anthropological research that uses psychoanalysis as a tool for analysis. But what's interesting about your research is that you study psychoanalysis as a practice, as a clinical practice. And I was wondering if you could say a couple of things about that distinction.

Xochitl: 16:09 Well, yes, of course they are actually completely different in my book. Well, the one that I am writing right now, one part of it is dedicated to that a lot of people use psychoanalytic theory, especially the social science and the humanities in order to explain phenomena. And when you talk to analyst, the first thing that they're going to tell you is that that's not psychoanalysis that's using a particular framework in order to talk about a particular social object. But that's not psychoanalysis. And psychoanalysis is something very particular that only happens within the clinical setting. So psychoanalysis implies a private contract between an analyst and analysant. It implies transference and transference is involved with how we project some of our neuroses, fears, past, present. And that's why the analysts are supposed to be like a white canvas on which we as analysants drop everything.

Xochitl: 17:09 So it is a very different and very particular thing, psychoanalysis versus, it's a hermeneutic of take on the world. But again, some people say that this is a "psychoanalytic analysis of x." An analyst immediately would, you know, be like, no analysis is this. And what I'm interested in is how in Argentina, specifically in Buenos Aires, the country in the world with more psychoanalysts per-capita. How psychoanalysis has, as a discursive practice, left the clinic and has permeated to new practices, which is what I'm interested in.

Diego: 17:48 So it sounds a little bit like, and I think there are a lot of people know about this. There's this distinction that the practitioners make between, as you're saying hermeneutic tools or using psychoanalysis as a hermeneutic tool rather than as a clinical practice and the clinician seems like they're a little protective of that. Why do you think that they, they are so invested in making this distinction?

Xochitl: 18:11 Well, I think that... because, they are doing it because they believe it's a therapy. Maybe now that's not probably the right word, but the idea is that it's like when you go to the doctor, I mean, do you take a pill when you go... You have a broken leg? You go into treatment, that treatment. There you go. And it's a treatment that actually takes a long time. So, and there are different protective of their practice I guess. Right. So I remember when I interviewed, an analyst in Argentina and he was criticizing things like psycho-tarot or psycho-yoga or...

Diego: 18:49 What are those?

Xochitl: 18:49 Exactly. I mean, I don't know. I didn't really explore them in depth. Maybe I should have. But it's the idea that you have some kind of relation between psychoanalysis and tarot-reading, but he was criticizing, I think, this idea that the psy- stem can be attached to almost anything. And he was saying that he was completely against that. So the interesting thing I think is that for them then it's like, well this is our field. It's real. This is something that we do.

Xochitl: 19:19 And you have people doing psycho-tarot or you have people using it to analyze the unconscious practices of a nation. Well for them that's a metaphoric use of the world, but it's probably that's why they are so, so protected. Yeah.

Diego: 19:37 The way you describe it too is interesting because it seems like, as you said, it leaves the clinic and enters these other realms of social life. And so maybe the psychoanalyst community is saying, well, we don't want this to be commoditized as a means to sell other kinds of goods and services.

Xochitl: 19:54 Well let me, if you don't mind me interjecting, in one interview that I had with another analyst. He said, and it's also in my article, that he wanted to be a philosopher, but that that was not profitable economically. So therefore he said, well, I'm going to become an analyst so therefore I can actually read the people that I like and but still have an income, you know, and a steady income. So you see, so there's commodity already there. So it's not that they think that this is pure, but I think they believe in what they're doing, right, in this treatment. And as they also very well, we'll tell you, we're not curing people. We don't see people as sick, we see subjects who have some neurosis, some anxieties, and we are trying to help them live with them because they don't even, or at least the people that I work with, they don't believe that it's a treatment that, oh yeah, you go here two years, then you're going to solve all their problems and then you're going to be happy.

Xochitl: 20:54 No, they think we're going to help you manage some of your symptoms. So hopefully you can have a healthier life, but they don't talk about cure. And that's why they are very, very keen in talking about their analysantes or analysants, rather than patients. They don't use that word.

Diego: 21:13 Could you say more about some of these role designators, like this analysant/analysante distinction?

Xochitl: 21:20 So analysants, patients, are very different, because if you think about the word analysant or analyst, it just means that the person is seen as a text. That somehow you could analyze, and therefore your role as an analyst is to listen and suspend judgment and try to listen without paying attention to the words. And this is something that Freud called suspended attention. So basically, you are not focusing on referential content of the words, but you are just listening without paying much attention until there is something that caughts your attention.

Xochitl: 22:04 Lacan will call that a "node." What they're doing is a textual reconstruction of the psyche through the emergence of the unconscious, which is something that it's difficult to explain in words. And then the analysant is listening to himself or herself, but it's, it is the analyst's role to guide the conversation. So for example, if I say a word, so for instance, in one of my analytic sessions I was talking about something in particular and I said, "yeah, these people have helped me a lot." That's the only thing I said. And then they, I mean, sorry, the analyst stopped me right there and said "a lot -- mucho." There was a word that I used "a lot." And I said, yeah, they helped me a lot. And he's like, "I want to focus on a lot. How, how much or how so?" And then I started thinking about it, actually these people that I was talking about, hadn't helped me at all at that point! I remember I looked at him and I was like, "am I imagining that they are helping me?"

Xochitl: 23:06 And he smiled and said, well that's, we call that neurosis. And then he, I mean, and we shake hands and he's like, okay, that's the door. Kind of like, and then here's your insight. Exactly. And it was just one word. Right? Exactly. And yes, I mean later we kept talking about it, and I guess part of our self representation, we create this persona, right? That we want people to like us, to love us. And that's how neuroses, these anxieties, are there. So for me, I'm not saying I'm sold or whatever, but it was really an interesting moment and that's how I understood participant observation, how these things work in the clinic. And that's when I then understand that what, when people in Argentina say in casual conversations, "what you really mean is," trying to, you know, interpret your words, your utterances, what they're doing is trying to interpret, based on what they think psychoanalysis is, or based on their own experience as analysants.

Diego: 24:11 So it seems like these discursive partials serve to inform people's relationships with each other on an everyday basis. So I wanted to hear a little bit more about that, what the implications are for that.

Xochitl: 24:22 So the interesting thing about this recycling right, of this particular, "what you really mean is" forms, is that first of all, it happens between people that have no relation to each other, the taxi driver or the person at the store. I mean complete strangers will comment on your speech because they are fine socializing that way. And I feel that in the United States specifically, the sociability is very private. So what I think this shows is that sociability or social relations in Buenos Aires at least are shared. And it's okay. I mean, you don't have to be close to comment on somebody's personal life, which is something that I feel that in the United States it's very, it's a no-no. And part of my interest in this is this idea about that "what you really mean is," I mean, people born and raised in the United States, they were scandalized by it. It was like, "how dare they tell you what you think. Oh my God! If they say that to me, I will be so offended," but maybe I didn't answer your question.

Diego: 25:30 No, that was great! This leads me to another question. You know, it sounds like in Buenos Aires, these conversations about mental well-being are very active and happening all the time. The way you describe it to me right now, it seems like it's not just that they want to know about your personal life, but they're trying to enter your internal world how you think and feel. So if you could talk a little more about this attempt to enter into other people's internal worlds, as a social practice in Buenos Aires?

Xochitl: 25:57 I mean I think that one of the most important things is that they take at face-value. The idea of unconscious practices. And unconscious practices for psychoanalysis are not at all the same as for neuroscientists. So therefore, there seems to be, I mean we are guided by drives around unconscious impulses. We have traumas, and we have a lot of things going on inside our internal life that get represented through symptoms.

Xochitl: 26:27 The symptoms can vary in a lot of different ways. And again, the role of the analyst, or the friend when it is not in the clinic, is to try to understand those signs. Now in the United States, mental health is completely different, I think. I mean there is definitely a tradition of psychoanalysis, important in particular places, but it's too expensive. It's not covered by most insurance. So there is a huge... it's not an humanistic approach to the mind. It's a more, I dunno, biological approach to it. And that's why I think that mental health,

Diego: 27:06 You mean, this is general mental health practitioners?

Xochitl: 27:08 Yes, exactly. Or when you were talking about the media about mental health, what do they mean by that? Right. I mean, well I think that they mean that there are some imbalances or there are some... Yeah, can we call them? Or, or they do talk about behavior.

Xochitl: 27:23 Right. In the sense of like "they were loners," right. And "so they didn't have social network." I mean, in my experience in the United States, it's very tied to medication and and talk therapy. It's not considered as valuable, I think. Or it's become practice more for the middle classes. People who can't afford to go to therapy, have time, have the means to do it. And I feel that one of the main problems is also is the culture of instant gratification versus in Argentina, at least in terms of mental health, they understand, that this is a process that will take many years and they're not expecting to feel better after two times to have gone to see the psychologist-analyst or whatever. Versus in the United States in which people I feel are, I mean culturally they're not able to cope with uncertainty and they are always trying to calm the anxiety, those nervousnesses instead of seeing them as part of life.

Xochitl: 28:28 In Argentina. It's part of self care. Actually. If you don't go to analysis, people will look at you like you're not taking care of yourself. It's like you're eating junk food and not exercising. You will be like, do you know what? You should stop eating like that and exercise. Well, the same thing with, "oh, you haven't been to the analyst in 10 years? There's something wrong with you. Or are you afraid?" Then all of these different interpretations.

Diego: 28:51 Its like the dentist!

Xochitl: 28:51 Exactly. Exactly. And this is important to mention in Argentina because of the universal healthcare and because it has surpassed all of the different communicative spheres. This practice is actually, it's not only a middle-class or upper-middle-class practice. And to give you an example, the woman who cleaned the apartment that I was renting, she came from a really, really poor part of the city and she came to my house one day and she was limping.

Xochitl: 29:21 And when I asked her about it, she was like, "oh, don't worry about that. My stuff is psychosomatic." A woman that can barely read and write, but it's already in her discourse. Or a friend of mine who is a historian, who comes from humble beginnings. His dad was a construction worker, he already died. And his mom was a cleaning lady and when he, he kept peeing in his bed until he was 10 years old. That's what the Mother did, you know, I mean, she's like, "oh, so you have a problem, let's go see the psychologist." And again, of course they were poor, they went to the public hospital. But the idea that people who are, you know, not middle-class, reading existential theory as a form of self care.

Xochitl: 30:07 And the interesting thing there was, for instance, in 2001 there was a huge economic crisis in Argentina and so you have, you know, like all of these round tables of smart people trying to figure it out. There were a lot of economists and sociologists and an analyst of course, and they would be talking about the narcissistic nature of the Argentine. And so I mean, but they were seen as important as any economist who,, for me would be a more interesting analysis,because their economy just crashed.

Xochitl: 30:40 In the United States, going back to that, I mean again, I think that the main problem is it's, yeah, I mean the culture of the individual all that has been fostered here for so, so, so long. And then there are no social ties. In terms of mental health, I think that that for me is the most important aspect, that again because they don't think about mental health as self-care but more about a problem that needs to be solved. So maybe that's the main difference. Then, they don't see that sociability is part of good mental health. I think now the new discourses are about like, well you have to exercise, you have to eat healthy and you have to have friends. Right. I mean people are talking about the importance of having a social network in order to have mental health, but those are new things I think. And I don't do cross cultural analysis, so those are just thoughts.

Diego: 31:39 I mean, I think that was great! Thank you so much for chatting with us today.

Xochitl: 31:43 Thank you. No, thank you for the invitation, this was a pleasure!

Kyle Olson: 31:56 Thanks for listening to our episode on anthropology in, of, and beyond the clinic. Thanks to our interviewers, Josh Franklin and Diego Arispe-Bazan, and a special thanks to our guests, Carolyn and Xochitl. As always, if you like what you've heard, please rate and review us wherever you get your podcasts and tell a friend or colleague. If you have any questions or comments, you can email us amanthpodcast@gmail.com or look us up on Twitter and Facebook. We'd love to hear from you and we hope you tune in next time!