Notably, although recruited from across the United States, nearly all participants were sheltering in place at the time of study enrollment due to the COVID-19 pandemic, which may have affected substance use patterns and mood as well as interest in a digital health intervention. Notably, however, alcohol sales in the United States increased during the COVID-19 pandemic. The primary outcomes of substance use, cravings, confidence, mood, and program acceptability were standard measures with demonstrated validity and reliability. The limitations were that all were self-reported, and acceptability measures were not open-ended or qualitative. Few participants were misusing opioids, likely due to study exclusion designed to mitigate risk, namely, the requirement of engagement with medication-assisted treatment and no history of opioid overdose requiring Narcan . Notably, nearly 1400 people with interest in a program for those with substance use concerns were excluded due to low severity on the CAGE-AID screener. Worth testing is the utility of digital health programs for early intervention on substance misuse that is sub-syndromal. Building upon the findings of this study, future research will evaluate W-SUDs in a randomized controlled trial with a more racially or ethnically diverse sample,vertical plant growing balanced on sex and primary problematic substance of use; will employ greater strategies for study retention ; and will be conducted during a period with less restrictions on social contacts and physical mobility.
Randomized controlled evaluations of conversational agent interventions relative to other treatment modalities are required. Self-cutting can be understood clinically as a symptomatic behavior, on the one hand, and as a bodily practice embedded in a cultural imaginary and identity on the other. It is present in a variety of ways including the 1993 memoir of Susanna Kaysen “Girl, Interrupted” , the 1995 acknowledgment by Princess Diana that she identified herself as a “cutter,” and the 2011 video “F**kin’ Perfect” by the pop music performer Pink. The Internet has become a massively popular resource for cutters to share information , and one study identified more than 400 message boards about cutting generated via five search engines . Youths may identify with “Emo” or “Goth” culture which lionize depression and cultivate self-cutting as a cultural practice . Popular concern about perceived dangers of self-cutting has at times been heightened to the point that one cultural historian suggested that “Cutting has become a new moral panic about the dangers confronting today’s youth” . Anthropology has not been disposed toward addressing cutting as a problematic cultural or clinical phenomenon given the disciplinary propensity to understand body mutilation and modification in terms of rituals and cultural practices. This is perhaps because ritual meaning is not so dependent on distinguishing whether harm is inflicted by others or by oneself or on differentiating cultural practice from psychopathology.
These distinctions are clear in one of the rare instances in which an anthropologist has addressed the issue of self-injury, here in the context of commenting on an article relating it to borderline personality disorder.One other anthropological observation has been provided by Lester, who notes that current explanations of self-harm can be grouped into four categories: communicating emotional pain, emotional or physiological self-regulation, interpersonal strategy, and cultural trend. She notes that these categories share the idea that self-harm manifests individual pathology or dysfunction, with the cultural assumption of the individual as a rational actor. In contrast, an anthropological perspective emphasizes the “cultural actor who embodies and responds to cultural systems of meaning to internal psychological or physiological states” . Emphasizing the powerful symbolic significance and long cross-cultural record of self-harm and blood shedding as ritual and even therapeutic practices, she suggests that contemporary cutting may be seen as privatized and decontextualized social rituals affecting transformation parallel to collective initiation rituals that operate in a cycle of self-harm and repair, especially in the case of adolescent girls struggling with the aftermath of sexual abuse and/or with contradictory gender messages . Sociocultural characteristics of a typical “self-cutter” emerged in the 1960s as Euro-American, attractive, intelligent, and possibly sexually adventurous teenage girls, that Brickman claimed was partially taken up in medical discourse in a manner that “pathologizes the female body, relying on the notion of ‘femininity as a disease’” . Gilman took exception to assumptions of pathology with the provocative claim that “self-cutting is a reasonable response to an irrational world” .
From a clinical vantage point, self-cutting is often viewed as a type of injury or harm to the self. The historical backdrop to this development can be traced to Menninger’s attention to self-mutilation as distinguished from suicidality. The distinction between “delicate” and “coarse” self-cutting was made by Pao , with Weissman focusing on wrist-cutting syndrome and Pattison and Kahan proposing the existence of a deliberate self-harm syndrome. Favazza provided cases of extreme and highly unusual forms of self-mutilation in excruciating detail, with an attempt to classify types based on severity. With the provisional emergence of non-suicidal self-injury disorder criteria in the fifth version of the Statistical and Diagnostic Manual of Mental Disorders DSM-V ,1 the distinction between self-harm as within a normative or pathological range remains equivocal. This is illustrative of the manner in which conceptualizations of self-cutting continue to be embedded in a complex cultural history of changes in the incidence, popular awareness, and social conditions in which such phenomena occur.While it is possible to find clinical, psychometric, survey, and historical approaches to the phenomenon of self-cutting, we lack an ethnographic account with a substantive locus in the interactions of individuals, grounded in the specificity of bodily experience and the immediacy of struggle in the face of existential precarity . In this article, we take a step toward such an account with a discussion situated at the intersection of two anthropological concerns. First is the ethnographic understanding of experiential specificity through anthropological adaptation of phenomenological method . Drawing on this approach, we understand experience as meaningful sensory perception in temporal context and within particular cultural, social, and interpersonal settings and subjectivity as the more or less enduring structure of experience. With respect to mental illness, this approach invites anthropological recognition of struggle as a fundamental human process that comes to light in the context of lived experience.
Second is the ongoing anthropological concern with adolescence as a stage in the life course at which identity is consolidated and people approach full cultural membership but which is also fraught with challenges to well-being that anthropology can contribute to understanding in a way relevant to mental health policy and practice . The contemporary anthropological approach to childhood is strongly influenced by child standpoint theory that aims at an account of society from where children are socially positioned and in which they are not passive social “others” but agentive participants in social life,growing strawberries vertically hence co-constructors of social knowledge and by extension of knowledge generated by research2 . In particular, anthropologists have taken up the idea that “children have agency and manifest social competency” . Guided by these concerns, we will focus specifically on self-cutting among a group of adolescents who have been psychiatric inpatients; by attending to experience and subjectivity articulated in the youth’s own voices, we will come to understand self-cutting as a crisis of agency enacted on the terrain of their own bodies. There is scant literature on how young people conceive and understand mental health , let alone experiential accounts of adolescent mental illness from the standpoint of the child . In addressing the experience of cutting among a clinically defined and diagnosed group of youth, our stance is not to fall prey to accepting a false dichotomy between ethnographic and clinical sensibilities; that a young person is following a regimen of psychotropic medication is as much an ethnographic as a clinical fact, and that a young person lives in a fragmented family environment may have clinical as well as ethnographic implications. Self-cutting can be understood as a troubling symptomatic behavior or as a creative struggle for agency and may exhibit elements of both pathological obsession and ritual transformation, but in either case it is an enactment of a vexed relation between body and world.This discussion is based on SWYEPT, our study of youth in New Mexico who were inpatients in the state’s flag ship Children’s Psychiatric Hospital at the University of New Mexico .
New Mexico is a state whose total population according to the 2010 United States Census was 2,059,179. In 2010, according to the US Census Bureau’s categories, by race the largest population proportions were designated “white” and American Indian/Alaska Native , with 23 federally recognized Indian tribes in the state comprising various groups of Pueblos, Navajos, and Apaches; other racial categories were minimally represented. By ethnicity, Hispanics or Latinos accounted for the largest single block , while among non-Latinos the largest blocks identified themselves as generically white or American Indian . New Mexico is one of the poorest states in the nation. According to the US Statistical Abstract, as of 2008 the median household income was $43, 508 or 44th among the 50 states, and the proportion of persons living below the poverty level was 17.1% or 5th in rank among the states. New Mexico ranks as one of two states within the United States hardest hit by child poverty, with the rate of 30% in New Mexico . Relatedly, home foreclosures have also been inordinately high. Along with poverty comes a serious drug problem, with parts of the state severely afflicted by heroin and methamphetamine use, and the presence of violent gangs, with one anti-gang website listing 178 in the Albuquerque area. The SWYEPT study examines cultural meaning, social interaction, and individual experience among adolescent patients and their families, with the long-term goal of producing knowledge of broad use to those concerned with the treatment of adolescents suffering from mental illness in the context of significant cultural differences. The aspects of this knowledge include: types of problem, illness, or psychiatric disorder experienced by afflicted adolescents; trajectories of adolescent patients from the community into treatment and back into the community; patient experience of therapeutic process and family response to that process; alternative and complementary resources brought into play by families on behalf of patients; difference between the experience of afflicted adolescents and that of counterparts who have not been diagnosed or treated for emotional disturbance. Notably for present purposes, ours was not explicitly a study of self-cutting or self-harm, but cutting emerged within the ethnographic interviews as a theme deserving of the particular attention we devote to it here. We recruited participants for the study with the assistance of three clinicians at Children’s Psychiatric Hospital who referred to us patients aged 12–18 they judged as not so severely cognitively disabled or developmentally impaired as to be unable to participate in interviews and not so emotionally fragile or clinically vulnerable that their participation would be unduly stressful. We obtained informed consent from youth and their parent or primary guardian based on these referrals, recognizing the ethical responsibility of respecting the vulnerabilities of individual patients and the need for continued rapport in the relationship between therapists and families, as well as the importance of our respect as researchers for the clinical expertise of the referring therapists. All participants entered the project as inpatients at CPH. Assisted by a team of graduate student ethnographers and clinically trained diagnostic interviewers, we conducted ethnographic interviews covering life history and experience with illness and treatment with the young people and their primary parent/guardian three times at approximately six months’ intervals.During this period, we also conducted the child version of the Structured Clinical Interview for DSMIV, a clinician-administered research diagnostic interview , the Adolescent Health Survey , and the Youth Self Report and Child Behavior Check List for children and their parent/guardian respectively. Although initial interviews occasionally took place in the hospital, it was rare for a participant still to be there at the time of the second and third ethnographic interviews. Yet it was not always the case that they were at home, since it was not uncommon for them to be placed instead at another treatment facility of in-treatment foster care. This often led us far afield from the hospital in Albuquerque, such that our ethnography ranged across the entire state of New Mexico and occasionally beyond. In this respect, our work was not strictly speaking a clinical ethnography in the sense of ethnography primarily situated in a clinical context that focuses on the institutional cultural milieu and interactions among patients and staf .