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Book Review: Balint Matters

20 Jun, 17 | by amcfarlane

Balint Matters: Psychosomatics and the Art of Assessment by Jonathan Sklar, London: Karnac, 2017, 254 pages, £27.99.

Reviewed by Dr Neil Vickers.

Michael Balint is mentioned in medical humanities circles as a revered ancestor, much as one might talk about William Empson as a significant figure in the history of English literary criticism. Everyone knows they’re important but surprisingly few people read either writer today or even know why they should. (An important exception is Josie Billington’s superb Is Literature Healthy? – reviewed here – which devotes a chapter to Balint.) Empson did theory before Theory, and Balint did narrative medicine before Narrative Medicine. Both men were at least as interesting as what came after them and yet both have become unduly sepia-tinted with the passage of time. Part of the reason for this fading in Balint’s case has to do with the fact that his clinical examples are firmly rooted in the sociological reality of the 1940s and 50s. The world Balint describes is hidebound by class. As a psychoanalytically-minded medical humanist, I occasionally press a copy of Balint’s classic, The Doctor, the Patient and the Illness (1957) on M.Sc students, but always with the caveat about his antiquated case material. ‘Someone should update it,’ I whisper, as they saunter out of the room.

Now someone has updated it. In his new book, Balint Matters, Jonathan Sklar, psychiatrist, psychoanalyst and leader of Balint groups (as well as a leading scholar of Ferenczi’s thinking) has produced a masterly summary of the Balint technique, along with a history of Michael Balint’s contribution to the theory of the doctor-patient relationship in collaboration with his wife, Enid. The second half of the book, entitled ‘Assessment’, which I won’t discuss here could be published as a volume in its own right. Assessing a patient for psychodynamic treatment is a topic on which surprisingly little has been written.

Michael Balint was born Mihály Bergsmann in Budapest in 1896. His parents were descendants of German-Jewish families who had been in Hungary for only two or three generations. (This German-Jewish world of Leopoldstadt is described in a wonderful series of autobiographical interviews that Georg Lukacs gave towards the end of his life, published as Gelebtes Denken). In 1916, young Mihály took the momentous decision to abandon Judaism in the hope of eluding the anti-Semitism that was still rife in Austro-Hungary and changed his name to Bálint (which means ‘Valentine’ in Magyar). He first came into contact with psychoanalytic ideas while a medical student in Budapest. His fellow-medical student and first wife, Alice Szekely-Kovacs, was one of Sándor Ferenczi’s analytic patients. Balint himself held off from having analysis with Ferenczi at first, and following the overthrow of the Hungarian Soviet Republic (which had bestowed a public professorship of psychoanalysis on Ferenczi, a world first) Michael and Alice fled to Berlin in 1919 to train as analysts at the Berlin Psychoanalytic Institute, where both had analysis with Hans Sachs, and where Michael did a PhD in chemistry and physics. The couple went back to Budapest in 1924 and became patients, colleagues and friends of Ferenczi. Balint became Ferenczi’s literary executor and the chief exponent of his thinking in the international psychoanalytic movement for decades. If the rediscovery of Ferenczi has reinforced the air of ‘always the bridesmaid, never the bride’ hanging over Balint, so has the explosion of interest in Winnicott, with whom he has so much in common.

Balint’s main contributions lie in two areas: psychosomatics, understood holistically as the study of the relationship between mental and physical disturbances; and the uses of therapeutic regression, which he explored in his other great book, The Basic Fault (1967). Sklar’s concern is with the first and specifically with the work Balint developed at the Tavistock Clinic in the 1940s and 50s with his third wife, Enid (Alice having died shortly after they arrived in England, to escape the Anschluss). Balint focused his attention on how the doctor’s attitudes and approach affected the course of an illness, and suggested that ‘the most frequently used drug in general practice was the doctor himself, i.e. it was not only the bottle of medicine or the box of pills that mattered, but the way the doctor gave them to his patient—in fact, the whole atmosphere in which the drug was given and taken.’

Sklar offers a number of clinical vignettes from Balint groups he has facilitated, describing how this works in practice. These case histories for me formed the heart of the book. I won’t spoil the reader’s pleasure by describing too many of them but among those that stood out for me was the case of a 70-year-old woman who was addicted to dihydrocodeine, a strong opioid analgesic. The woman had complained of a pain in the hip but a scan revealed only minor osteoarthritis. Her condition never seemed to improve. She made occasional visits to a cousin who lived far away and would ask her doctor for a bumper supply of painkillers to get her through. Then, much against the patient’s will, her daughter visited the GP and told her that her mother never went to see a cousin, and that the story was just a ruse to get more prescription opioids. The GP was appalled to realise that in the course of the previous year she had prescribed more than 3,000 dihydrocodeine tablets to this woman. In discussion with the group, the GP realised she knew nothing about her patient’s history. With a bit of help from Sklar, the group discussion included the following ideas: 1) the patient had an addictive relationship to the doctor; 2) the doctor felt depressed on behalf of the patient; 3) the doctor was unconsciously acting as a container for aspects of her patient’s mind, perhaps playing the part of a distant depressed mother, who gave her daughter ‘the wrong medicine.’ Feeling, noticing and understanding these projections didn’t cure the patient but they did give her doctor more freedom in the way she related to her. Addiction could now be seen as a way of representing early childhood deprivation.

Balint groups have also been used with psychiatrists. Sklar is fascinating on the attempts by some trainees to use Balint groups as a covert form of personal analysis. This arises not least because of the peculiar pressures of working with severely disturbed patients. The kinds of problems many of the trainee psychiatrists brought had to do with the ways in which they were made to carry aspects of their patients’ mental disturbances. Again, to pull out just one example, Sklar describes the case of a young psychiatrist, Dr L, overwhelmed by the suicide of a male patient who had been admitted at his mother’s request, shortly after the latter’s recent remarriage. Dr L bitterly regretted not administering ECT. Perhaps it would have saved him? She was also worried about the effect of the suicide on the other patients on the ward where the man was being treated. The nurses had suggested that a community ward meeting should be convened to break the news. The group listened to Dr L’s anxieties and asked for information about the patient’s history. It turned out that his biological father had killed himself by electrocution. Sklar asked how the ward meeting had gone. It had been fine for the most part though a psychotic woman had to be removed. This woman had told the meeting she was the angel of death and that there would be more deaths. Somewhat to the group’s surprise, Sklar observed that the psychotic woman had voiced what was in effect Dr L’s own worst fear about herself. Here was an instance of the need to listen to the very mad, as barometers of the most split-off emotions in the room. The psychotic woman had been excluded because she was voicing the emotions that were most unacceptable to the group. Dr L then remembered that her patient had killed himself on his mother’s birthday and that her recent marriage was to an electrician. These snippets, combined with the knowledge of the patient’s father’s suicide, shed new light on the hopes she had placed in ECT. They amounted to a re-enactment of the patient’s deep upset over his father’s suicide and at the same time offered a means to shut out and ignore the meaning of the mother’s marriage to an electrician. As a result of this meeting, Dr L softened down her until-then vigorously-asserted opinions about psychiatry’s exclusively organic basis.

For me, the most moving chapter in the book describes Sklar’s work in the early 2000s at a hospital in an unnamed city in South Africa. In 2007, it was estimated that nearly 6 million South Africans had HIV or AIDS, or 12 per cent of the population. This was overwhelming to the medical professions attempting to offer treatment at a time when antiretrovirals were beyond most people’s reach. Thabo Mbeki’s refusal to believe that HIV had anything to do with AIDS licensed widespread denial of the natural history of the disease and its behavioural causes. Of course, the doctors knew how AIDS was commonly transmitted but the overwhelming nature of the incidence of the disease and the need to shield families from stigma meant that patients were often treated as if they were just medically irrelevant dying people. The doctors for whom Sklar acted as a Balint facilitator told him of their anger at the way AIDS patients were treated as undeserving and subhuman. But they also described the primitive fears the disease evoked in the workplace. The whole practice of medicine was at risk of becoming warped by the cultural phantasies surrounding it.

Sklar’s book deserves to be read by anyone who wants to know how to listen to patients with an analytic ear, how to understand the dilemmas of clinical practice analytically, or why psychoanalysis still has so much to offer physical medicine. As his title makes clear, Balint matters, particularly in an environment where doctors and patients are urged to forget about the whole person and focus instead on gross symptoms and quick fixes. As a result of his endeavours, it should be easy for most readers to imagine a Balintian response to many clinical dilemmas. It is even possible that this brilliant exposition of Balint’s thought will initiate a new phase in the reception of this underrated and very fertile thinker, and bring about further extensions of the Balint model of the kind Sklar himself has achieved here.

Book Review: Eros and Illness

13 Jun, 17 | by amcfarlane

Eros and Illness by David B. Morris, Cambridge: Harvard University Press, 2017, 368 pages, £31.95.

Review by George Derk, PhD (gtd2gu@virginia.edu)

With the provocative pairing in the title of his new book, David Morris sets himself the task of dramatically altering the perceived relation between these two terms. As he contends, there exists less of an opposition and more of an affinity between them than we are usually willing to admit. At times, they even seem like bedfellows rather than rivals: “eros and illness both usually send us under the bedcovers” (27). Professor Emeritus of English at the University of Virginia, Morris began his academic career focusing on eighteenth-century literature before turning his attention to the medical humanities. In some ways this new book is a follow-up to and an elaboration of a couple of his previous ones, including The Culture of Pain (1991) and Illness and Culture in the Postmodern Age (1998), but at least one significant difference sets this recent work apart from the rest. Morris draws from his personal experience as caregiver for his wife, Ruth, after she was diagnosed with early-onset Alzheimer’s. It is this model of care, where provider and patient are the most intimate of partners, that allows Morris to explore the neglected dimension of eros in illness.

Morris begins by developing a capacious interpretation of eros, one that cannot be reduced to sexual activity nor to the Roman equivalent of Cupid. He instead derives his understanding of the concept from both the French philosopher Georges Bataille and the Canadian poet Anne Carson, and while he carefully stipulates that eros resists any easy definition, the word that comes closest to naming it is desire. He proceeds with a thorough examination of desire in the context of health care—or what he calls “medical eros”—mostly through illness narratives and doctors’ memoirs. He occasionally supplements these primary texts with analysis of literature and the other arts, as when he discusses the waiting involved in caregiving as akin to the waiting depicted in Samuel Beckett’s most famous play, or as when he finds an affirmation of eros in a series of nude portraits that Amedeo Modigliani painted while suffering from a terminal illness in wartime Paris. What he eventually uncovers amounts to an alternative medical genealogy, a recovery of the ancient figure of Asklepios as the embodiment of the obscured tradition of eros in Western health care. For Morris, the dominant stature of the other ancient healer, Hippocrates, and what he represents—biomedicine, or what Morris terms “medical logos”—has resulted in a reduction of the pluralism of healing practices, inhibiting the effectiveness of treatment for chronic illness.

From a certain angle, the book falls into a recognizable pattern of decrying how science-based, data-driven medicine has lost sight of its core humanistic principles, which I suspect would prompt many health care professionals to respond that the realities and demands of the job only allow for so much empathy and compassion. However familiar Morris’s argument may sound, the frequency with which medical logos runs up against its own limits warrants reiteration. If medical eros seems like some New-Agey solution to the problems of modern health care, it does a lot more good than some of the other reactions, such as over-treatment, that occur when doctors confront uncertainty or a lack of options. Perhaps the more insightful and original contribution of this book, though, is less its appeal to humanize medicine and more its belief that anyone can learn how to care for those who fall ill. Indeed, as Morris suggests with his own transformation from English professor to fulltime caregiver, the innate capacity to provide humane care stems from the eros that one already bestows onto his or her loved ones. The relative absence of Ruth’s story further underscores that this book chronicles the experience of illness not from the perspective of the patient but from that of the caregiver, although at times the boundary blurs. Morris himself becomes a patient after suffering a heart attack, which he attributes to the stress of providing care and which he takes as an example of a “supradyadic effect,” or how one’s health is interdependent on the health of those in one’s social network.

The book, overall, reads like part Bildungsroman of a caregiver and part philosophical treatise on the nature of caregiving. Morris strives to preserve the desire that drew him to Ruth in the first place and sustained them through three decades of marriage. In the face of regret at not recognizing Ruth’s symptoms earlier, guilt for his irritability towards Ruth’s increasing debility, and, most of all, anguish at the terrible inverse logic of dementia (“she was fading emotionally, just when I felt in greatest need of her ordinarily loving expressiveness”), Morris maintains that eros doesn’t necessarily have to evaporate altogether and may actually serve as the greatest resource when medical logos has no answers (39). Along with the personal experiences that he relates, the case for eros is strongest when grounded in specific instances wherein biomedicine finds itself ill-equipped. Morris’s inclusion of the writings from people with non-normative identities—such as the African-American, lesbian poet Audre Lorde who claims in The Cancer Journals (1980) that the “love of women healed me”—proves particularly effective in this regard. Dwelling on the accounts from those at the margins testifies to the potential of medical eros to help remedy the imbalance of treatment for underserved communities. In addition to the benefits made available by eros, the cost of not acknowledging its contributions equates to an egregious oversight. Morris cites an estimate by the American Association of Retired Persons that within the U.S. 36-38 million family caregivers provide $350 billion (approximately £270 billion) in unpaid labor annually.

Yet counterexamples exist to raise questions about this book’s insistence, in its more unrestrained moments, on championing eros as a possible panacea. The anti-psychiatry movement, which Morris overlooks, would seem to embody many of the characteristics of medical eros. For all the necessary reforms that it has lead to, it has arguably been too successful in undermining biomedical treatments for psychiatric ailments. While the dismantling of mental health care results more directly from draconian cuts to funding than from this particular movement, the U.S. continues to live with the legacy of an impaired system of psychiatric care. That said, Morris anticipates an objection such as this by advocating for a balance between eros and logos. His goal, as he states it, is for biomedicine “to recognize eros and to deal with it—the good and the ill—mindfully” (13).

The principal testament to eros that Morris offers may ultimately be the fact that he managed to write this book. While caring for Ruth, Morris admits to feeling drained of his normal passion for writing: “I could write, but writing lacked all pleasure, joy, and desire” (251). As the examples curated by Morris attest to again and again, illness throws eros into disarray. One of the more telling instances in the book involves the poet Jane Kenyon, suffering from end-stage leukemia, who is reminded by her husband that the bed she lies on is the same site of their countless sessions of lovemaking over the years. This is the type of recognition that Morris prescribes, an awareness of how a bed, as object and symbol, stands for the underlying bridge between eros and illness. The challenge of the latter consists of finding new ways to realize the former. The strength of Eros and Illness resides in how Morris models the counteracting of illness by eros through his writing, eloquently giving voice to Ruth, who lost hers, and rediscovering his own in turn.

After the Storm: Liberation and Hope in Later Life

6 Jun, 17 | by amcfarlane

After the Storm (Kore-eda Hirokazu, Japan 2016), in UK Cinemas from 2nd June 2017

Reviewed by Khalid Ali, Screening Room editor

Japan is well known for its relatively traditional social structures, a predetermined life course that heavily influences career choices. Kore-eda Hirokazu’s latest film After the Storm explores those paradigms through the story of Ryota (Hiroshi Abe), a hapless man in his late 40’s who won a major award for The Empty Table, a novel he wrote as a child. However, his adult life is plagued with failure; he is divorced, falling behind on paying his son’s school fees, and abuses his day job as a private detective by blackmailing his clients. Still, his worst enemy seems to be a gambling addiction; a trait he inherited from his recently-deceased father. In contrast, his elderly mother, Yoshiko (Kirin Kiki), is a feisty, strong woman who is trying to get her son’s life back together by scheming to bring him closer to his wife and son. Yoshiko is the perfect model of ‘successful ageing’; she is not a victim of loneliness or social isolation, in spite of being a widow living alone in a council flat. She spends her time listening to music in weekly classes and practises Tai-chi in neighbourhood group sessions; in short she is content with her own company, wisely commenting, ‘Making new friends with people of my age only means more funerals’.  The contrast between the positive life-approach the old woman adopts, and her son’s self-destructive behaviour and bitterness, is remarkable.  The inter-generational bond between Yoshiko and her grandson, Shingo (Taiyo Yoshizawa), is another factor in Yoshiko’s well-being until a typhoon brings the family members together under one roof to candidly face their hidden secrets and prejudices.

Continuing his fascination with ‘father-son relationships’ which was a prominent theme in Like Father, Like Son, Hirokazu delves deeper into negative personality traits such as gambling, contemplating whether inheritance or environmental factors play a more prominent role in the vertical propagation of addictive and compulsive behaviours. Ryota’s father was a pathological gambler who taught his son the rules of buying winning lottery tickets, and Ryota is following in his father’s footsteps by doing the same with his son Shingo as a bonding exercise.

Full of astute observations on ageing, the film upholds family values; having a role in the upbringing of grandchildren is an important dimension contributing to well-being in later life. A study comparing older Japanese and American people showed that personal growth and positive relations with others were highly rated amongst older Japanese people as important factors in psychological well-being. (1)

When asked whether the character of Yoshiko is representative of old people in Japan, Hirokazu states: ‘I try not to think about such big themes when I am making movies. It’s just that the grandmother is a fairly accurate portrayal of my own mother. I wasn’t consciously making her happy, but I was trying to show how she dealt with her “unfulfilled dreams” by “loving the present/now”, and how that was different from the protagonist, Ryota, in dealing with his aborted dreams. I don’t think the elderly people in Japan are happy. When I visit European countries, I always feel that old people there seem so much happier’.

In spite of its focus on positive trends in old age, After the Storm does not shy away from exploring darker subjects such as financial abuse of old people by their close relatives in Ryota’s scams to embezzle money from his mother. Hirokazu thinks that some older people are resourceful enough to deal with such issues in talking about Yoshiko: ‘Knowing she has been lied to, she still goes along with it; that is how she deals with her son. Life is more complicated than simply labelling people as “black or white”. As a director I do not have bad characters, and others who are very critical of them.  I make sure that there are other characters in the story that understand the motivations of the “bad ones”. I think of human beings’ short comings in gradual steps when writing their traits for the screen, so that the audience can warm up to them through a flaw they can relate to. The filmmaker’s position is not to forgive someone’s flaws or empathise with them blindly, but also to be able to laugh at them from a distance.’

After the Storm is a beautiful gem that shines a light on the factors that make some people happy and content; Yoshiko does not dwell on her bereavement; she even breathes a sigh of relief being liberated from her gambling deceased husband.  Her perpetual sense of hope and positivity brought to my mind Emily Dickson’s poem ‘Hope’:

‘Hope’ is the thing with feathers-

That perches in the soul-

And sings the tune without the words-

And never stops- at all….

Address for correspondence: Khalid.ali@bsuh.nhs.uk

Reference

  1. Kaasawa M, Curhan KB, Markus HR, et al. Cultural perspectives on aging and well-being: A comparison of Japan and the USA. Int J Aging Hum Dev 2011; 73 (1): 73-98.

Does Narrative Medicine Have a Place at the Frontline of Medicine?

30 May, 17 | by amcfarlane

This guest blog post is by Liam Dwyer, a postgraduate medical student at Trinity College, Dublin, where medical training encompasses medicine and health as well as humanities, provoking students to conceptualise medicine differently; not simply as a clinical science, but with a more holistic perspective. Here he explores the role of narrative medicine, both in medical training and its practicality in a clinical setting.

While medicine has always encompassed a narrative form, it is only in the past two decades that the study of humanities has begun to eclipse medical training (1–5). It represents a means of developing a skill in interpretive, relational and reflective areas otherwise difficult to teach (6). As espoused by Dr. Rita Charon, it ‘enlarged the evidence available on which to base our clinical actions and the grounds for our therapeutic affiliation’ (7), yet whether its basis represents clinical idealism rather than clinical realism entails further inquiries into the nature of such skills.

It cannot be denied that narrative medicine is met with some opposition. It stems from realistic concerns about the management of time, especially in terms of accessibility for patients. In the current situation, even large university hospitals have systems of managing the multiply-injured patient comparing poorly to international standards (8). Morris et al. reports the rooted dubiety of clinicians about narrative medicine. ‘”What you say about narrative is very interesting,” He has heard repeatedly. “Thanks so much for coming. But I have seven minutes per patient.” End of story’ (9). Furthermore, many patients, especially those who are well-informed, prefer a ‘no-nonsense’ physician who holds the answer (9). Narrative infers an expurgation of professional distance and authority.  A clinician conveying such intimacy may step over the line between paternalism and patient-centred care (10).

A significant discussion surrounding narrative medicine was Dr. Charon’s 2001 article in JAMA, asserting that narrative medicine is a form of knowledge, in terms of being a source and an instrument (11). As a source, it represents something clinically relevant to numerical data of an arterial blood gas. As an instrument, requiring skillful technique for its implementation, like a scalpel (9). Dr. Charon wants certified professional competence and medical training in narrative, advocating ways of thinking about knowledge that are bound to inspire resistance. A biomedicine potentially reformed by narrative medicine is right to see its menacing identity and power. Unlike biomedicine, narrative medicine entirely depends on the concept of inter-subjectivity (9). For narrative medicine to warrant space in JAMA, it needs to accentuate its claim to knowledge, which in the last few years, it has achieved to some extent (12–16). Physicians are beginning to accept the value of what’s absent by the accredited biomedical narrative forms (12–16). Not only medicine but also nursing, law, religious studies, and government have recognized the value of narrative knowledge (11,17).

Medical narrative forms have been established for exploring novel styles of interactions with patients (18). Even clinical trials have begun to be formulated around narrative medicine (19). Numerous teaching programmes have recently been created to enhance narrative competency, such as those at Columbia or  King’s College London, with experts in the area of narratology demonstrating its therapeutic role for patients (9). Authors such as Bury proposed that illness of any kind is a disruption, an adjournment of an on-going life (20,21). When an individual faces an illness, they need to adapt their life story. In this milieu, narrative provides a voice to that disruption (20). Anatole Broyard, a prominent writer for the New York Times, delineated the story of his illness, affirming ‘storytelling seems to be a natural reaction to illness. People bleed stories, and I’ve become a blood bank of them’ (20,22).

Narrative medicine aids doctors in appreciating styles of thought and interaction in medicine that go beyond disease-framed, chronological history-taking (5,23,24). They have been shown to play a key role in making diagnostic assumptions and developing care pathways (25), especially in comprehending the story of those with cancer (26), acute coronary syndrome (ACS), and those with other chronic diseases (25,27). Recently, Gargiulo et al. investigated the psychosocial and organizational aspects of the patient’s journey whilst undergoing hematopoietic stem cell transplantation (HSCT) through various narrative interviews (25). Psychological issues (‘I met many people who are now dead, each person is unique… unfortunately that’s life…’), and clinical issues (‘you might get infected… you might have stomach ache, backache. I had to take many pills every day. I could not eat… I lost 22kg… ‘) were highlighted, leading to more effective care plans for the patients (25).

Yet for narrative medicine to be implemented at the frontline of medicine, its idealistic expectations must be re-evaluated. A number of problems relating to Charon’s way of thinking have been raised. Angela Wood’s essay contests the rationale of the concept of narrative self through her discussion and use of Galen Strawson’s seminal ‘Against Narrativity’ (28,29). It asserts that storytelling is not the sole or most valuable method by which to highlight an individual’s suffering. It calls for the reassessment of the role of the narratee in the narrative process permitting scholars to re-evaluate what it is we do with stories of illness (29).  Also, to think on methods in which narrative may be employed to understand illness and suffering in medical humanities contexts.  Narrativity should be broadened to encompass forms of expression as even non-verbal expression needs language and narrative ordering in the development of expression. In each effort made to elicit an expression of suffering, we demand a cognitive engagement that requires the ordering information into narrative (29). As eloquently put by McKechnie, ‘We seek out communication; we desire the transmission of an idea. This is narrativity and it takes a myriad of forms’ (29). Furthermore, Dr Charon’s development of the parallel chart (30) is a practical and essential part of medical training, designed to increase the student’s capacity for effective clinical work. However, to employ parallel charts in an acute clinical context is far from practical. This method asks doctors, in addition to maintaining traditional records on their patients’ progress, to monitor the emotional toll of the hospital experience. As the healthcare environment speeds up, practice will also speed up, and therefore inter-professional healthcare teams will need a more powerful framework to achieve empathetic and effective collaborative relationships.

Narrative medicine is a promising addition to the current training strategies to prepare medical students for effective performance as resident physicians and practising clinicians, but its effective implementation in an acute setting is a challenging feat. Indeed, resistance to narrative medicine does exist, both with patients and physicians, and will not dissipate. Narrative medicine has gained enough traction that the present time seems appropriate to confront its internal differences. This self-assessment assures not just clarification of its principles, but also of the benefits that extend beyond improved patient care for doctors.

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  28. Strawson G. ‘Against Narrativity’. Ratio. 2004; XVII(December): 428–52.
  29. McKechnie CC. ‘Anxieties of communication: the limits of narrative in the medical humanities‘. BMJ Medical Humanities. 2014; 119–24.
  30. Weiss S, Midelfort L. ‘Narrative Medicine: Honoring the Stories of Illness’. JAMA. 2006; 296: 2622–3.

Death By Suicide: The Beginning After the End

23 May, 17 | by amcfarlane

The Levelling, directed by Hope Dickson Leach

On general release in UK cinemas now

Review by Professor Robert Abrams, Weill Cornell Medical College, New York

Even before you view The Levelling, a film written and directed by Hope Dickson Leach, its title gives off a disquieting aura; you feel you are about to enter the maelstrom of a fearsomely destructive force. And so you are. The word “levelling” itself connotes complete destruction or possibly rageful retribution. One can only hope that there might also be a corresponding coda of reconstruction and healing.  The viewer of this film is ultimately witness to both: a saga of suffering known to clinicians as complicated grief, and its protracted resolution, of which some of the details will be outlined here.  But the viewer’s worst fears are realized at the beginning, in the primal mayhem of a drunken party that plays along with the opening credits.

In the next scene a young woman, Clover Catto (Ellie Kendrick), is returning home to the family dairy farm from University for the funeral of Harry (Joe Blakemore), her younger brother. Harry shot himself to death, even though their father Aubrey (David Troughton) insists it was an accident after a night of drinking. Aubrey is indeed a difficult man, described with considerable understatement as “not an easy father.” He is neglectful of animals and indifferent to people, especially it seems, to his daughter. Whenever confrontation with emotion becomes unavoidable, he recoils: “You have to get up, get out of bed, and milk the bloody cows.”

Determined to understand what happened, Clover surveys the flood-ruined wreck of a farmhouse in search of memories. She blames her ostrich-like father for her brother’s unexplained changes of personality, but Aubrey is inured to any suggestion of feeling or loss.

At least in one way her father had got it right. Clover is not a good fit for farm life. She cannot abide the killing of animals or cruelty; she cannot eat them, either; a commercial cattle farm is no place for a person with these sensibilities, even for one training to be a veterinarian. No respect for any form of life and no emotional attachments, whether human or bovine, are allowed in Aubrey’s world.

Father and daughter have been divided, one might say imprisoned, by a mutual feeling of abandonment and injustice. But Aubrey is still the most important man in Clover’s life, hate becoming psychologically equivalent to love once the algebraic negatives are removed. In the Catto family’s no-communication bubble, Clover had hoped for nothing as keenly as to be loved by her father; her father had privately yearned for her to be the one to initiate a rapprochement, had wanted Clover to want to return home, to support her troubled, probably mentally ill brother, and to shore up Aubrey himself as well.

What is the relevance of this film for readers of Medical Humanities? The Levelling deals with a conundrum seen often enough in clinical practice—and also in life: the consequences of suicidal death for the living. Death by suicide entails a double death, exactly as described by the clergywoman-therapist in the film, encompassing both the death of the person and the death of the “person you thought you knew.”  Healing is necessarily intricate, and it is accurately and sensitively presented in this otherwise disturbing film.  The Levelling can be summed up as a chilling depiction of what psychiatrists now consider to be “complicated grief.”  Complicated grief is a syndrome of greater severity, complexity and persistence than ordinary grief.  It is a condition in which the circumstances of the death interfere drastically with mourning.  Thus the survivors must deal first, before anything else, with the traumatic aspects of loss, with shock, anger, and their own sense of injury; this principle applies to the aftermath of a suicide or to any premature or unnatural death. Acknowledging the traumatic aspects of the event itself and then the personal meaning of the death is a foundational precondition for any meaningful process of bereavement.  For now, the clergywoman-therapist tells Clover, “This is about you.”

The melancholic beauty of the music in The Levelling and the camera’s focus on an untidy farm are fitting backdrops to a messy, circuitous and wrenching emotional path to healing from complicated grief. The brilliance of the film lies in its measured manner, the way we slowly become privy to the source of the characters’ anger and sorrow, their journey from death and destruction to a long-delayed but never-too-late recognition of their love for each other. “Levelling” in the end implies a new beginning on an even playing field.

Address for correspondence: rabrams1717@gmail.com

New Editor for Medical Humanities

18 May, 17 | by amcfarlane

BMJ, a leading medical knowledge provider, is pleased to announce Brandy Schillace PhD as the new editor of Medical Humanities.

Dr Schillace is Senior Research Associate and Public Engagement Fellow for the Dittrick Museum of Medical History, College of Arts and Sciences, at Case Western Reserve University, US. For ten years, she managed the medical anthropology journal, Culture, Medicine, and Psychiatry, and edited its first medical humanities special issue. An accomplished medical humanities scholar, speaker and author, she continues to serve as chief editor of the medical humanities and review blog MedHum | DailyDose. Her recent books include the co-edited collection UNNATURAL REPRODUCTIONS, on “monstrous” birth across time and genre (Cambria), DEATH’S SUMMER COAT, exploring cultural approaches to death and dying (E&T UK, Pegasus US), and CLOCKWORK FUTURES, a social history of technology and the “steampunk” aesthetics of invention (Pegasus, US). In all her work, Dr Schillace seeks to uncover the human stories at the centre of science and medicine.

Dr Schillace will take over as editor from Deborah Bowman from 1 July 2017. Welcome to Dr Shillace and thank you to Professor Bowman for all of her excellent work on the journal.

Stories From the Birthing Room

15 May, 17 | by amcfarlane

Sue Wiseman, Professor of Seventeenth Century Literature at Birkbeck University of London, is organising an event entitled “Stories From the Birthing Room” during Birkbeck’s annual Arts Week. Here she discusses the event and some of the issues that she hopes will be open for discussion.

‘I wil not use any kind of sorcery or incantation at the time of travail [labour] of any woman; and .. .I will not destroy the child born of any woman, nor cut, nor pull off the head therof or otherwise dismember or hurt the same’ (Evenden, 2000, appendix A). This was the oath sworn by Eleanor Paed in sixteenth century Canterbury and, notwithstanding the scenes of carnage conjured here, she was a woman’s friend in time of trouble – a midwife. What do texts like these begin to tell us about the early modern birthing room? “Stories From the Birthing Room” combines a seminar and scripted performance to analyse what we can learn when we combine law, myth, life-narrative and theatre as they disclose what was at stake in birth.

A woman’s lying-in was a complex time in early modern England. It was both a time of ritual and celebration and, potentially, a time at which soci0-economic ruptures and tensions could be made discomfortingly, even murderously, real. Perhaps paradoxically, given that it was expected to be a time of sequestration and secrecy (some midwives’ contracts specified secrecy from men), the lying-in process also generated a plethora of complex meanings. From the knives that might be used to cut the woman, or to cut free a dead foetus, to the midwife or to any appearance of a man, most presences in the birthing room were imbued with significance, uncertainty, and often conflict. Accordingly, what happens in the secrecy of the birthing room has left a large textual corpus.

For many years scholarship was, in many ways, dominated by the single issue of men versus women as controllers of birth. This debate focussed on the gradual masculine takeover of the birthing chamber in the eighteenth century. At first it was shaped by scholars’ “uncritical acceptance” of the self-interestedly negative image of midwives presented by the men who superseded their authority, and then characterised by scholarship vigorously and effectively challenging that account (2000, p. 1). The past two decades have seen a shift in interests with more research focussing on the seventeenth century and earlier, and a welcome diversification of topics and approaches. For example, Doreen Evenden has made a detailed study of the licensing of London midwives and tracked many of their lives and, setting the lying-in chamber in the context of court testimony, Laura Gowing has illuminated what was at stake in that room and how economic and legal forces, as well as powerful feelings, shaped women’s relationships to each other (Evenden, 2000; Gowing, 2003). Thus, it is clear that some of the information that discloses men’s rise to power over both birth and the way it was recorded in writing can tell us about other aspects of society too, and that we can also use fresh sources and begin to consider togther texts scholars usually divide up along disciplinary boundaries – such as strictly medical, legal texts, theatre texts, and case notes.

Stories From the Birthing Room’ starts with the all-female space of the chamber of birth to show afresh the many ways it radiated significance in early modern England. Putting beside each other texts from very distinct spheres of writing – legal, theatrical and medical – we hope to show the power of women’s secrets to generate revealing responses in many kinds of writing. At the same time, the seventeenth century is not well served by resources on the birthing room and we will make these some of these stories lastingly available to a wider audience by dramatizing and filming them.

The event’s hypothesis is that uniting the archives and approaches usually used by social historians, historians of medicine, literary scholars and practice-led theatre researchers would be likely to extend our sense of the ways the stories of lying in were told and potentially point to new approaches. So, we open with a seminar held by London Renaissance Seminar at which Dr Leah Astbury will discuss preparations for birth. Dr Adrian Wilson, following up his path-breaking work on women and obstetrics, turns his attention to birth and myth, exploring the myths surrounding the Caesarian section of Jane Seymour, mother of Henry VIII’s male heir – who died soon after his birth. Dr Isabel Davis asks about the medical and political implications of Mary Tudor’s expected, celebrated, but never delivered, infant. The second part of the event brings together texts from the courtroom, case history and theatre chosen by scholars in different disciplines. Thus, building on her research in Common Bodies Professor Laura Gowing has chosen texts from case papers and legal testimony. Dr Isabel Davies, drawing on her work on conception which involves both pre-modern texts and collaboration with artist, Anna Burel, speaks on legal and religio-politcal texts on Mary’s pregnancy. Susan Wiseman, exploring the elite and the non-elite in seventeenth-century England, selects texts from case notes that in telling birth narratives shape a life-story for women whose lives are rarely written – the vagrant, the disabled, the domestically abused. Crucially, Dr Emma Whipday, playwright, theatre director and academic, has brought together her roles by selecting theatre texts that tell, but also question, the scene of birth.

Considering together legal, theatrical and ‘medical’ texts generates both findings and questions. For example, if we see theatre, court and case history together it is immediately clear that voice was important, and often authoritative, in seventeenth-century oral-literate culture. Eleanor Paed’s oath was both oral and textual, acknowledging the diverse literacies present, but it was not part of a residual culture in being heard. Rather, it was part of a culture simultaneously spoken and written; though it can be approached diachronically as shifting in balance towards the prioritisation of the written, it is also the case that the definitive shift took place in the eighteenth century. As Adam Fox puts it, in sixteenth- and seventeenth-century England “the three media of speech, script and print infused and interacted with each other in a myriad ways” (Fox, 2000, 5). In the texts we explore, women’s voices appear in the trial testimony, yet of course they are changed by the process of recording; in seeing women’s agency in such testimony how should we balance the fact that they record public testimony actively made against masculine and institutional shaping? How should we understand female voices on the stage? In what ways, if any, should we hear the voicing of women’s experience by a female playwright as distinct from the male playwright’s texts about lying-in? If, in the astrological notebooks and case notes on troubled people of practitioner Richard Napier’s, women outnumber men and many of these were suffering problems that sprang from lying-in, how far can we consider ourselves having access to the thoughts of the poorer women of Buckinghamshire and Northamptonshire who told him their stories of “dangerous labours” (MacDonald, 1981 38)?

Thus, in an exchange we will hear during Emma Whipday’s performance, in Margaret Cavendish’s play The Convent of Pleasure (1668) a character asks if a midwife has come to attend her lady. She hasn’t because “she cannot come, for she hath been with a Lady that hath been in strong labour these three days of a dead child, and ’tis thought she cannot be delivered”. However, when the midwife suddenly does arrive it is because the earlier woman “could not be delivered, and so she died”. “Pray tell not our Lady so”, replies the first “for, the very fright of not being able to bring forth a Child will kill her”. (Cavendish, 1668, scene ix). Such material presents a scenario strikingly similar to that found in legal papers when birth goes wrong, in case notes and apparently in women’s testimony. It has the strong appearance of being a record of speech, yet, of course, it is a prescription for speech – a play (although, in fact, a play we think was not performed at the time of its composition and publication). So, as we see, seventeenth-century England was not operating with a sense of an original ‘voice’; if plays and case records don’t give us access to an unmediated subject that is something they share with other texts of the period, yet, at the same time, in many cases it is a female voice that has been heard or imagined, in a public situation.

While if we ask which text – play, oath, ballad or case note – gives greatest access to the lying-in room, we can give no definitive answer; they tell us different things – and often ones which exist in contradiction. Yet, putting together a range of sources is likely to tell us much more than looking at a single kind of text.

References

Cavendish, Margaret. Plays, London, 1668

Evenden, Doreen.  The Midwives of Seventeenth-Century London, Cambridge: Cambridge University Press, 2000.

Fox, Adam. Oral and Literate Culture in England 1500-1700, Oxford: Oxford University Press, 2000.

Gowing, Laura. Common Bodies: Women, Touch and Power in Seventeenth-Century England, New Haven and London: Yale University Press, 2003.

MacDonald, Michael. Mystical Bedlam: Madness, Anxiety, and Healing in Seventeenth-Century England, Cambridge: Cambridge University Press, 1981.

Book Review: Notes From the Sick Room

9 May, 17 | by amcfarlane

Notes from the Sick Room by Steve Finbow, London: Repeater Books, 2017, 343 pages, £8.99.

Reviewed by Alan Radley, Emeritus Professor of Social Psychology, Loughborough University

This is a book about sickness, more specifically about the illnesses of a number of well-known artists and philosophers. It is also about the illness history of the book’s author, Steve Finbow. He uses his own experiences of illness (and they are many and varied) to introduce the reader to the travails and writings of the individuals whose sickness he explores. The word ‘travails’ is apposite here as it suggests that illness can be, if not a life’s work, then a determining factor in how people live their lives, as well as rendering their experience meaningful through writing and other forms of art. Key to this is the idea that being trapped in a diseased body opens up the possibility of escape through self-examination, issuing in a productive outcome. To make this argument Finbow explores in detail the circumstances and reflections upon illness of several artists and writers. He introduces us to cancer in the life and death of people such as J G Ballard, Iain Banks, Christopher Hitchens and John Diamond. Finbow details the sufferings of Frida Kahlo after the bus crash that severely damaged her pelvis; the effects of being shot upon Andy Warhol and his art; the denials of illness that were part of Bruce Chatwin’s extensive travelling; and the descriptions of and insights into illness offered by writers such as Katharine Mansfield and Virginia Woolf.

How should one tackle a subject like sickness while providing detailed biographical detail about one’s own and others’ illness, at the same time weaving a complex argument drawing upon philosophers such as Nietzsche and Foucault? Finbow achieves this by treating the book as a virtual hospital – a clinical space – populated by celebrity patients and some celebrity doctors (e.g. Susan Sontag). The entries and exits from the various departments to which he escorts the reader are managed in part by introducing us (in detail) to his own medical history. These extend from a pain in the buttock to severe pancreatic necrosis and a spell in intensive care, all illuminated by details from his medical notes. In the case of the pain in the buttock, Finbow uses this as an approach to the question of whether cancer is alien to or part of the self and, in the case of the latter, how it might become so. Turning on the issue of denial, he argues that the denial of disease (“flight to sanity”) is not healthy, but that health tolerates disintegration and, by implication, transforms it through art and writing.

The idea that illness and the state of being sick can be the bases of productive art is expressed in a quote that Finbow provides, in which John Berger says of Frida Kahlo: “The capacity to feel pain is, her art laments, the first condition of being sentient. The sensitivity of her own mutilated body made her aware of the skin of everything alive – trees, fruit, water, birds, and, naturally, other women and men. And so, in painting her own image, as if on her skin, she speaks of the whole sentient world” (322). By drawing attention to this Finbow is agreeing with Nietzsche and Foucault that art is an act of freedom-making borne of suffering. This extends to the person’s life – including their art – so that what is rendered is expressive of a way of being rather than illness per se. It is perhaps for this reason that he objects to Susan Sontag’s attack on the use of metaphor as aestheticizing the “what should not be imagined”  – the abhorrent disease that is cancer. To this Finbow replies, “what nonsense”, and argues that when Sontag wrote about cancer in her book Illness as Metaphor (1978) she was, in effect, aestheticizing it.

The problem here is that there is a difference to be made between aesthetics and aestheticization. Aestheticizing, at its root, directs the viewer/reader to the artist/author rather than the object. An artwork is the product of a transformation that directs our attention to the ineffable; it is this that, in part, gives it aesthetic value. This is not always an easy line to draw, but it matters in this book because Finbow treats of both aesthetics and aestheticization in the course of his descriptions and discussions. By dramatising the artists and writers he discusses as either patients or doctors, Finbow risks muddling this distinction. So, for example, he writes: “Dr Sontag sits back in her chair, her fingers pyramided above the desk, the silver streak (poliosis) in her hair illuminated by the overhead fluorescent strip lights”. And later, “She closes the book, gets up, takes me by the crook of the arm and says authoritatively, ‘Let’s go to your office. I think we need to have a little chat’” (300). For this reader at least, these passages had the effect of displacing attention from the book’s argument about illness to the author’s interest in his subject matter, which at times I found unhelpful.

In terms of the book’s overall aim Finbow goes some way to demonstrating that illness improves the work of the artists considered, though he does not show exactly how art draws upon illness. Instead, the book remains a bricolage of ideas that coheres as a sort of image, a story of the necessity of ill health in our lives. Its overall message – drawn from Nietzsche – that life needs illness, is incomplete without it, is an important one. Health is not separate from illness, and a deeper understanding of health includes the idea that it can be strengthened by illness. And for that, and its historical and biographical detail, Notes from the Sick Room makes for a most useful and interesting read.

Alan Radley is the author of Works of Illness: Narrative, Picturing and the Social Response to Serious Disease. Ashby-de-la-Zouch: InkerMen Press, 2009.

Auditory Hallucinations, Agoraphobia and Extremism as Portrayed by Actor Ahmed Magdy

3 May, 17 | by amcfarlane

In this podcast, our Screening Room editor, Khalid Ali, explores the role of film in shining a light on mental illlness, dysfunctional families, and the rise of religious fanaticism with Egyptian director Ahmed Magdy.

Recently introduced to acting, Ahmed talks about his portrayal of three challenging characters: a young man imprisoned in his mother’s house in Gate of Departure (Karim Hanafy, 2014), an extremist who converts from Islam to Christianity in The Preacher (Mawlana) (Magdi Ahmed Ali, 2016), and a man troubled with persistent auditory hallucinations and a legacy of inherited mental illness in Ali, the Goat and Ibrahim (Sherif El Bendary, 2016).
Ahmed Magdy studied Law in Ain Shams University, but pursued his passion for film by taking part in Egypt’s independent cinema scene since 2008. He produced and directed a couple of independent films, and directed his own short, Caika Bel Crema (A Cream Cake, 2008).

Book Review: Deleuze and Baudrillard: From Cyberpunk to Biopunk

25 Apr, 17 | by amcfarlane

Deleuze and Baudrillard: From Cyberpunk to Biopunk by Sean McQueen, Edinburgh: Edinburgh University Press, 2016, 288 pages, £70.

Reviewed by Dr Anna McFarlane (University of Glasgow)

Sean McQueen’s first monograph ambitiously aims to create “a cognitive mapping of the transition from late capitalism to biocapitalism” (1) and to do this through tracing trends in science fiction from the cyberpunk movement of the 1980s and early 90s through to a subgenre only recently designated as ‘biopunk’. Following Fredric Jameson, a scholar known for his analysis of postmodernism and Marxism in late capitalism, McQueen argues that cyberpunk is the quintessential literature of late capitalism and therefore a fitting place to begin his analysis of this recent cultural movement from late capitalism to biocapitalism which, McQueen argues, “is the frontline of capitalism today, promising to enrich and prolong our lives, whilst threatening to extend capitalism’s capacity to command our hearts and minds” (1-2).  In McQueen’s schema this is a transition from the ‘control’ of late capitalism to the ‘contagion’ of a biocapitalism that he argues is an increasing threat to individuality and the autonomy of the body.

The book’s title belies its contents to some extent, given that the first half of the book does not focus on texts from cyberpunk’s ‘canon’, such as it is, but focuses on the ‘cyber-‘ aspect of cyberpunk to investigate texts that engage with the concept of control. Anthony Burgess’s A Clockwork Orange (1962) is not generally considered cyberpunk-proper in reviews of the genre, but its themes of control, and of the renegade individual fighting subjection by the state, certainly resonate with the work of figures in the cyberpunk canon such as William Gibson and Pat Cadigan. Another of McQueen’s chosen texts, JG Ballard’s novel Crash (1973), has been subject to debate about the extent to which it can be considered science fiction, let alone cyberpunk. Such deviations from the ostensible theme may be traces of the monograph’s origins as McQueen’s PhD thesis, but their reworking in this monograph is satisfying for those coming to the book for considerations of Deleuzian and Baudrillardian thought, who might consider the texts to which their philosophies are applied a secondary consideration. McQueen successfully cuts through the archaeology of decades of readings and misreadings of these two thinkers, often with a sharp word for scholars who come to the original philosophy with their own preconceptions, and hence leave it repeating unjustified or inconsistent critiques of these two thinkers. His own readings come across as fresh and new, perhaps because he works against a backdrop of scholars who have become too accustomed to invoking the names of Deleuze and Baudrillard without putting in the time to tackle their complex bodies of work first-hand.

The primary interest in the book for scholars of the medical humanities comes in the latter half, where McQueen turns to biopunk. This is a relatively new term in science fiction scholarship (following in the -punk traditions of cyberpunk, steampunk, and dieselpunk, to name but a few), but McQueen finds the term’s origins in classic science fiction, such as Mary Shelley’s Frankenstein (1818, commonly considered science fiction’s foundational text) and HG Wells’s The Island of Dr Moreau (1896). The first example of contemporary biopunk McQueen draws upon is Vincenzo Natali’s 2009 film Splice, in which a couple who work for a pharmaceutical company use DNA to create a hybrid creature.

The film draws on the tradition of Frankenstein to express fears of uncontrollable technological change, while also specifically critiquing a biocapitalism guided primarily by profit margins, rather than by philosophical or ethical considerations about the effects of its research.

McQueen’s readings of Deleuze and Baudrillard focus on some of these thinkers’ key concepts, how these have been relevant to cyberpunk and its investigation of ‘control’, and how they might function in contemporary debates about the ‘contagion’ that McQueen finds characteristic of biopunk. He contrasts Deleuze’s concept of the ‘body without organs’ with Slavoj Žižek’s ‘organs without a body’, both of which attempt to offer a representation of desire without the restrictions of hierarchy (to draw on only one valency discussed in the book). Žižek provides something of a bridge between Deleuze and Baudrillard here, as his Lacanian impulses are echoed in Baudrillard’s attempts to consider psychoanalysis, and how it might function in a society defined by the imaginary realm of consumption and consumer fetishism. Under biocapitalism, the consumption impulse could quickly move towards the point where the market’s freedom to use cells and discarded bodily tissue for profit is in tension with the long-held belief that it is immoral to profit from the cells of organs – as argued by Marlon Rachquel Moore in a recent article for BMJ Medical Humanities, “Opposed to the being of Henrietta: bioslavery, pop culture and the third life of HeLa cells”, which teases out the historical racial injustice that is now being relived, without hope of reparations, by the family of Henrietta Lacks whose ‘immortal’ cells continue to be the basis for untold profit in the biotechnology industry. The move from co-opting the labour of classes of the population under slavery, and later forms of capitalism, to co-opting the use-value of the body itself is the journey with which McQueen engages here as he moves from readings of Karl Čapek’s R.U.R. (Rossum’s Universal Robots) (1921), the science fiction play that brought the word ‘robot’ into English usage, and Eric Garcia’s The Repossession Mambo (2009, filmed in 2010 as Repo Men) which sees a biounderclass fitted out with artificial organs and forced to pay crippling interest rates or face having their organs repossessed – and dying in the process.

The electronic copy of this book, from which I reviewed, leaves something to be desired. Like many academic books, it uses endnotes which cannot be easily referenced as one reads in the electronic form, and the book’s use of abbreviations for the major works of Deleuze and Baudrillard exacerbate this problem as the reference list at the beginning of the book cannot be easily consulted. This makes for particular difficulties when quotes from the major texts are picked out as introductory to chapters and their sections, leaving the reader occasionally unsure as to which of the theorists is being quoted. However, the content of the book ultimately extends the case for considering biopunk as a unique and important subgenre of science fiction that, in turn, deals with the unique and important development of biocapitalism. McQueen’s readings of Baudrillard and Deleuze manage to scrape away some of the sedimented assumptions and misreadings of the past and offer exciting new ways to consider their work. His reference to both major and minor texts from both thinkers will introduce readers to insights they had not previously considered – again, especially relevant to students of the medical humanities might be Baudrillard’s comparison between cancer and capitalism in The Transparency of Evil (1990), the biopolitics of organ transplantation in Kazuo Ishiguro’s Never Let Me Go (2005), or Thierry Bardini’s account of subjectivity after bioengineering, Junkware, which McQueen turns to in his final chapter reading of Brandon Cronenberg’s Antiviral (2012).

As I pointed out above, McQueen’s book does not always stick to the limits laid out in his title, (for example when he reads texts that are not considered archetypically ‘cyberpunk’ under that rubric, or in the latter half of the monograph where Foucault’s thought is just as crucial to his argument as that of either Deleuze or Baudrillard), and his book should come with a warning for those who have never tackled Deleuze or Baudrillard before, given the slew of concepts that are not fully unpacked here for beginners. However, the book that emerges is cohesive and amounts to an often passionate argument for considering class consciousness in the era of bioengineering, biohacking, and biopolitics.

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