Outside the Asylum (book review)

I am continuing my research and public service on sharing reviews on aid worker memoirs.
Lynne Jones’ Outside the Asylum-A Memoir of War, Disaster and Humanitarian Psychiatry adds an important new aspect to the literature by focusing on an important, but often unnoticed aspect of humanitarian and post-conflict work.
Jones’ work as a mental health professional bridges the gap between international aid work and an increased focus on mental health and psychological well-being. Her work is not focusing on expat or local aid workers, but on local patients and newly traumatized in places as diverse as Bosnia, Kosovo, Iraq, Indonesia, Haiti, Mozambique, Philippines, Somalia and Ethiopia.

After leaving her work ‘inside the asylum’, the context of traditional psychiatric work in Britain of the late 1970s, her journey is driven by an imperative we often witness when medical or scientific knowledge is applied care- and respectfully to context outside traditional Western societies:

My work was as much about restoring respect for their views, their autonomy and their normal life as about dealing with intrapsychic angst (p.43).

Jones works in a particular tough environment: Mental health is not a priority in many countries and war and disasters often make a bad situation even worse. At the same time, caring for psychiatric patients is not exactly a priority for donors and on top of it, there is a heavy toll and her own personal life and well-being:

(Detachment) meant I could walk to work and sit in the social centres and cold welfare offices (in Sarajevo during the siege). I took obvious precautions like avoiding known sniper spots. (…) The worrying aspect was a kind of numbing. I could not shake off that feeling of detachment. The intake of breath still came if I heard someone killed, or saw a picture on the evening news, but the oddest thing was how the television footage of other people’s tragedies was somehow more real and upsetting than my own reality, which felt increasingly like a movie (p.61).

Based on my reading of other aid worker memoirs this is a common feeling, but also a state of mind that is now addressed better as discussions about mental health and well-being are entering discussions in the sector.

The importance and challenges of local talent
Lynne Jones highlights the importance of local assistance throughout her book. This is an important reminder that localisation efforts should not stop with program staff, but also include paying more attention (and possibly money) to the ‘fixers’ that often facilitate humanitarian work:

Translators are interlocuters with the community, cultural interpreters, co-therapists. They must have the ability to keep their thoughts to themselves and literally translate the person speaking-not easy when psychosis is concerned (p.69)

Jones’ take is more nuanced and when it comes to larger-scale behaviour change, local culture is often difficult to shift:

I asked what the long-term plans for the hospital were: “Deinstitutionalisation?” Dr B. laughed. “That is for the West. Here we institutionalise as much as possible. This society believes the mentally ill should be in an institution. We have no plans to put them in the community. Not here.” (p.159)

When traditional social norms, societal trauma and crises intersect, it is often people with mental health problems who suffer-even if this story has some kind of happy ending:

How to protect Annie and those like her from the abuses and torments of the crowd in the marketplace, in a country that had just crawled out of a twelve-year civil war? (p.205)
(…)
Annie came to me to tell me clients were buying her food. There is nothing as de-stigmatising as recovery (p.207)

Governmentality and mental health
An interesting theme that Jones’ includes throughout her book is the problem of ‘manualising’ mental health in humanitarian contexts, especially around the rise of PTSD as a catch-all diagnosis for many mental health problems.

PTSD gave psychiatrists a glamorous role in the emergency room and on the front line of disaster that had nothing to do with their usual emergency calls: calming and controlling a “crazy” person, listening to the miseries of a battered wife, arranging detoxification for someone high on amphetamines, or sorting out yet another teenager overdosing on paracetamol because of a bust-up with her boyfriend (p.79).
(…)
The trouble is that if you reduce the moral, social, economic and political complexities of a conflict to a disease category that can be universally applied, this appears to suggest that there is a simple medical fix to all the miseries caused (p.81).

The (bio)medicalisation of Western and Southern woes is certainly a much broader discussion and yet at the core of our modern development ideas that we can find technological fixes or medication for deep-rooted societal problems.

There is now a manual (…) called Psychological First Aid. My worry is that, by manualising this common-sense approach, we are undermining people’s trust in their own empathetic responses. We have again created a technology that people think they cannot deliver unless they are trained, rather than empowering people to do what seems natural and right in helping others in distress (p.295).

For someone who continues to come across ill-conceived volunteering schemes and outright terrible voluntourism ideas I am not entirely against ‘manualising’ certain aspects of best-practice work and provide training to a professionalizing group of concerned people who are interested in humanitarian or aid work. But I empathize with Jones’ frustrations about donor priorities, coordination meetings and global conferences to establish handbooks or manuals when caring, listening and providing basic comfort should not become too professionalised…

It is not the suffering that keeps me here. It is the proximity to courage. I hope some might rub off on me (p.100).

Outside the Asylum adds important nuances to the aid worker memoir genre and I can recommend it highly to medical students and professionals who are thinking about leaving their Northern ‘asylums’ and engage in humanitarian work. Jones’ writing, at times marked with her frustrations of the global aid industry and an almost constant neglect of some of the most vulnerable people in crises, creates an important niche: As a professional closer to the end of her career, I enjoyed her positionality between a space often occupied by younger female aid workers starting their careers and older men who reflect on their live and work well into their retirement.
Perhaps not exactly a ‘stocking filler’, but a suitable gift for those who enjoy critical reflections on helping others, staying sane and the complexities of the aid industry!

Jones, Lynne: Outside the Asylum: A Memoir of War, Disaster and Humanitarian Psychiatry. ISBN 978-1-4746-0575-5, 347pp, 14.99 GBP, London: Orion Publishing Group, 2017.