Straining Psychic and Social Sinew: Trauma among Adolescent Psychiatric Patients in New Mexico

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Title:
Straining Psychic and Social Sinew: Trauma among Adolescent Psychiatric Patients in New Mexico
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Medical Anthropology Quarterly (MAQ).
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Jenkins, Janis H.
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Adolescent
Mental health
Trauma
PTSD
New Mexico
Lived experience

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Abstract:
Drawing on data from a longitudinal study of 47 adolescents of diverse ethnic backgrounds hospitalized for psychiatric disorder in New Mexico, the article critically examines the relevance of post-traumatic stress disorder (PTSD) to address anthropological questions of how to define the problem. Factors include the utility/limitation of psychiatric diagnostic categories, the lived experience of severe distress, the socioeconomic and political conditions of suffering, and reciprocal relations between immediate and remote social institutions. I discuss the mental health care system for adolescents and present two case studies of young inpatients, emphasizing the need for dual specification of the conditions of trauma and the structure of experience. I argue for understanding patterns of abandonment that shape the raw existence of young people at both the personal and collective levels to apprehend their depth and durability.
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Collected for University of Florida's Institutional Repository by the UFIR Self-Submittal tool. Submitted by Yasemin Akdas.
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(Citation/Reference) This is the author's post-print. Please cite the final version of the article, available from the link on the cover page.

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! Janis H. Jenkins Department of Anthropology University of California at San Diego (E mail: jhjenkins@ucsd.edu) Straining Psychic and Social Sinew: Trauma among Adolescent Psychiatric Patients in New Mexico ################################################# #################################### Drawing on data from a longitudinal study of 47 adolescents of diverse ethnic backgrounds hospitalized for psychiatric disorder in New Mexico, the article critically examines the relevance of post traumatic stress disor der (PTSD) to address anthropological questions of how to define the problem. Factors include the utility/limitation of psychiatric diagnostic categories, the lived experience of severe distress, the socioeconomic and political conditions of suffering, and reciprocal relations between immediate and remote social institutions. I discuss the mental health care system for adolescents and present two case studies of young inpatients, emphasizing the need for dual specification of the conditions of trauma and th e structure of experience. I argue for understanding patterns of abandonment that shape the raw existence of young people at both the personal and collective levels to apprehend their depth and durability. [adolescent mental health, trauma, PTSD, New Mexic o, lived experience] ##################################################################################### Over the last two decades, attention to the mental and behavioral health of children and adolescents has intensified global ly ( Anderson Fye and Lin 2009 ; Carpenter Song 2009a, 2009b; Csordas 2013; Hoagwood and Olin 2002 ; World Health Organization 2005). Anthropological accounts of adolescent mental health are needed to determine the cultural contours and situational specificity of the lives and health status of contemporary youths afflicted with mental illness. Such accounts are a vital complement to descriptions in clinical diagnostic terms, on the one hand, and critiques of medicalization, on the other. Ethnographic data are likewise needed as a corr ective to rhetoric and practice that seek either to minimize problems as nothing more than normative struggles or blame them on unruly youthful provocateurs. These are the data of palpable suffering in the form of suicide and self injury, pain and rage ov er the constriction o f life sustaining possibilities and collective betrayal by the state, communities and kin who do not meet basic needs for care and protection. On a global scale, they are among the many aspects of turbulent lives that may be manifeste d in a variety of forms that are as socially serious as they are symptomatically severe ( Merikangas et al. 2010 ). In this article I take initial steps toward an anthropological study of psychic trauma among youths at personal and collective level s The p rimary goal of the analysis, derived from a larger research project, is to examine the phenomenological, social, and situational features of trauma as lived experienced of children and adolescents. 1 While adaptation in the aftermath of warfare is intricate we know far less about the process of defense and adaptation of children who are repetitively exposed to traumatic events as the everyday condition of their lives. For the cases of trauma in the present study there is a patterning of conditions of aband onment and neglect that make events o f trauma all but routine The conditions provide the occasion for regular violation of the dignity and integrity of vulnerable teenagers Comprehending this problem, in my view, requires a clear recognition of this soci al historical

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! $ pattern as a type of structural violence (see Farmer 2004) that conduces to a reciprocal shaping of subjective experience and social structural relations Although such levels of analysis entail what may arguably appear as intangibles in the abstract particular forms of their convergence can create inarguably tangible forms of mental anguish and psychic suffering as a matter of lived experience. The WHO (2005:7) reports a n overall 20% prevalence rate of me ntal disorders for children/ adolesce nts. C ommunity studies are greatly needed, but a summary of available epidemiological studies by P atel and colleagues (2007) provide transnational data for overall prevalence of mental illness that indicate a range of 8 29%, with rates of 13% in Brazil and India, 18% in Ethiopia, an d 27% in Australia Recent reports of mental illness from the United States among teenagers between the ages of 13 and 18 are 21% overall ; the comparable figure for the adult population is reported as 26.2% reporting symptoms of a diagnosable mental disorder in any given year (NIMH 2012). Southwest Youth Experience of Psychiatric Treatment (SWYEPT Study) T his article draws on data collected from a n interdisciplinary research project on adolescent mental health carried out 2005 2011 and funded by the National Institute of Mental Health 1 T he study ( Southwest Youth and the Experience of Psychiatric Treatments [SWYEPT]) was based in the Albuquerque metropolitan area, but for practical reasons there is a high degree of residential mobility among the youths studied the research was carried out across the S tate of New Mexico. Conducting a study of persons and institutions in motion does not resemble the more traditional anthropological approach of staying put in one locale or neighbor hood as the site of culture and place (Gupta and Ferguson 1997). D uring the course of this six year study the research team ventured out across the state largely as "road warrior s, given the great distances traveled to get to wherever the adolescents re sided following their discharge from the hospital. Not infrequently, these sites were unstable by virtue of changes of family residence or aftercare clinical placements In this respect, the research was conducted as mobile anthropology now common for wor k in mental health and global medicine ( Desjarlais et al. 1996 ; Good et al. 2006; Ward 2003). Members of the research team were positioned in relation to study participants as recruitment encounters and initial interviews often took place in the inpatient setting. The research rather than clinical function of team members was reinforced by our subsequent following of patients and families beyond the hospital over several visits to their homes and across other clinical facilities. The collaborative nature o f the research was emphasized for both participants and researchers by the fact that different team members conducted different interviews at different times (ethnographic, clinical diagnostic), so that participants often inquired about team members they h ad met previously, and team members consulted with one another about aspects of their respective encounters with participants. W e were able to visit homes and residential facilities t o conduct ongoing interviews and observations for an average of 13 month s but the range was between three months and two years. 3 The research team would meet with the adolescent and his or her family (separately, usually) in the home setting although in some cases we met in coffee shops or the homes of other relatives where the adolescents were not residing. The homes were typically low income housing with few amenities and little space (apartments, trailers, small homes).

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! % T he types of mental health problems with which people grappled wer e by no means minor Problems far exc eeded Attention Deficit Hyperactivity Disorder (ADHD) depression, or any one type of problem Diagnoses included a full range of seriou s and usually multiple problems of anxiety disorders, eat ing disorders, and psychos e s. A n abbreviated examination of tra uma in relation to post traumatic stress disorder ( PTSD ) as a diagnostic category is discussed below, but more e xtended discussion of the fuller clinical picture along with the utility and limitation of psychiatric diagnostic categories is beyond the scope of this article. O verall, during the course of our fieldwork, we were struck by the palpable personal anguish and the cultural, social, and economic particularities that seemed implicated in their creation Notable for many individua ls was a constant ins tability of social settings including hospitals and clinics, kin based households, foster homes, hospitals, schools, and neighborhoods Beyond the more circumscribed situations of trauma examined here, we are attempting to understand these youths' lives i n terms of what Korsgaard (1996) has developed as a model of practical identity defined in terms of valuing oneself, action, and life as worthwhile. In situations of exposure to repetitive or sustained traumatic events and conditions, persons might be expe cted to fundamentally call into question an existential description of life worth living ( Nietzsche 1967) Indeed, in this study many of the admitting incidents were suicide attempts. Trauma and Trouble in the Land of Enchantment The wide g eographic swa th of the state of New Mexico self described as the "Land of Enchantment," 4 is well known as a multicultural mŽlange of Hispanic, Native American and Anglo American population s Through the 1980 s, Hendren and Berlin (1991) provide d an excellent account o f this ethnic diversity in relation to clinical care of children in the state. However, the current situation for ethnicity in New Mexico has perhaps become more complicated today as a matter of cultural identities in relation to complex "hyperdiversity" ( Good et al. 2011). The dominant cultural and global imagination of this rural state as one of beautiful expansive landscapes and a cosmopolitan tourist mecca in Santa Fe is far less recognized for its exceptionally high rates of child poverty and historica lly produced institutional subjugation that is anything but beautiful Our research team is concerned with the mental health consequences of growing up under adverse economic and social conditions that in th is case includes inpatient psychiatric treatment Ethnographic interviews and observations, along with research psychiatric diagnostic criteria, provide evidence of the prominent place of trauma in the lives of many of the adolescents. Traumatic events and conditions are numerous includ ing direct viole nt assaults of all sorts, witnessing deaths, suicide attempts or violent a ttack s by family and friends, shocking revelations and betrayals (e.g., being disowned or learning of sexual abuse), abrupt residential moves (adolescent ejected or removed from home family eviction or flight), encounters with police and the juvenile justice system, drug related violence, hospitalization, among many others. Although initially encountered in an inpatient psychiatric facility the majority of the ethnographic and psych iatric d iagnostic work was carried out in homes. Anthropological interviews and observations were completed for parents, siblings, therapists, doctors, and operators of residential facilities We also collected ethnographic observations of neighborhoods a nd communities. The goal was to visit with adolescents and parents and to conduct interviews at various intervals over a period of one to two years.

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! & As of 2010 the U.S. Census reports the population of New Mexico as just over two million residents. This r epresents a 13.2% growth from the previous decade. T he most populous metropolitan areas are Albuquerque and Las Cruces (primary sites of the study), but the rural character of the state overall is noteworthy compared to the rest of the nation (17 vs. 87.4 persons per square mile). Census data show the population as predominantly Hispanic (46.3%) followed by Anglo American (40.5%) and Native American (9.4%). A national survey in association with the U.S. C ensus finds a rate of child poverty at 20% and highe r for 24 of the 50 states. The highest rates nationwide are for New Mexico at 30% and Mississippi at 32.5% ( Macartney 2011:6). Adverse conditions for survival are longstanding in this locale although they have been exacerbated under the press of the Great Re cession in the U nited S tates that has cut a deep and broad incision in the form of job losses home foreclosure s and radical curtailment of health services beginning in 2008 The lives of adolescents in this study are by and large marked by residential instability and familial fragmentation. For the most part they live in low income households with some living on the rough edge of survival. C onditions include d high unemployment the presence of gangs, violent crime, and a scarcity of social and educat ional resources One commodity for which there is no shortage is an array of street drugs. As Garcia (2010) has poignantly captured, New Mexico has the inauspicious distinction of the highest per capita rate of heroin related deaths in the nation. Overall drug related overdose s in New Mexico w ere recently reported as the leading cause of unintentional death (New Mexico Department of Health 2011). Use of cannabis, alcohol, methamphetamine, and cocaine, among other drugs, is common among New Mexican adolesce nts ( U.S. Department of Health & Human Services 2011) Mental Health Care in New Mexico: 2005 2011 Although our study of adolescents who had inpatient psychiatric treatment includes a comparison group of non hospitalized children, this article draws onl y from the clinically related component. The primary hospital from which research participants were drawn was Children's Psychiatric Hospital (CPH), a large university based children's psychiatric hospital in Albuquerque. During the five year period of the SWYEPT study (2005 2011) we saw the length of inpatient stay and clinical services sharply curtailed, to the dismay of clinicians, patients and families alike. From a statewide New Mexico perspective an ethnographic study of mental health professional s (Kano et al. 2009 ; Watson et al. 2011 ; Willging and Semansky 2010 ; Willgin et al. 2009 ) examine s the pragmatic, institutional and policy effects of behavioral health care reforms underway during the course of our research. These findings are fully in ac cord with our observations and interaction with staff at CPH The radical curtailment of services coincided with the centralization of all mental or behavioral health services managed by Value Options, the largest privately held health care corporation in the country at the time. The Southwest Youth Experience of Psychiatric Treatment Study The SWYEPT project included 47 youths (25 boys and 22 girls ) between the ages of 13 and 17 Participants were roughly equally distributed across ethnically hybrid gro ups of mostly Hispanic, Anglo American, and Nati ve American heritage On average, the teens were 14 years old. Among the Hispanic group (36.2%), all were born in the U nited S tates ( primarily New Mexico)

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! and predominantly speak English with limited facility in Spanish, al though several reside in households where Spanish is spoken by grandparents or parents. Almost three quarters had been hospitalized previously on multiple occasions. T he youths had commonly committed violent or suicidal acts, experienced rec ent deaths of loved ones, and had experienced heavy use of drugs and alcohol, legal troubles, physical and/or sexual abuse, and routine self cutting. Data from the Structured Clinical Interview for DSM IV ( in the version for children known as the KID SCID ) administered by one of two members of the team (a child psychiatrist and clinical psychologist both trained specifically to reliably administer this research diagnostic interview) are impressive in terms of the co occurrence of multiple psychiatric dia gnoses. While thirteen (27.7%) made full criteria for PTSD, the diagnosis was more likely for girls in our study (8 of 22 or 36.4%) compared with the boys (5 of 25 or 20%). It is c ritical to bear in mind that in any examination of a particular type of men tal illness, persons commonly have diagnostic criteria for more than one disorder. This is particularly true for PTSD, a disorder commonly correlated with majo r depression/ dysthymia C onsidering all disorders, in the present study PTSD and depression were nearly always observed to co occur (91.7%) among girls (all) and boys (save one) (This can be contrasted with depression in which 44.4% of the girls and 20% of the boys also made criteria for PTSD). Thus it is important to remember the close correlation of PTSD and depression not only as a matter of phenomenological experience but also in theorizing about the social determinants of t hese concurrent disorders. Anthropological Specification of Psychic Trauma and PTSD Currently, there is a vast literatu re on the often destructive impact of trauma on the self and others ( e.g., Breslau 2004; Henry 2006; Hinton et al. 2012 ; Jenkins 1996 a, 1996 b ; Quesada et al. 2011 ) Further there is the question of how to conceptualize psychic trauma in a way deepened by a framework that takes into account the reciprocal shaping of social institutions and personal subjectivity ( Fassin et al. 2009 ; Jenkins 1991 ). In examining these questions there is by now a well known anth ropological skepticism surrounding psychiatric di agnostic categories as historical inventions, biologically reductive, lacking in cultural validity, biased in relation to gender, ethnicity, and social class, an d products of medicalization ( Kleinman 1988 ) I concur with the position outlined by Good (199 2 ) that for anthropologists working in this field psychiatric diagnostic categories provide a useful starting point for comparison. That is, at the most rudimentary level of comparing constellations of symptoms that tend to go together it makes empiri cal sense to consider these on a preliminary basis. That said, and knowing the foregoing findings in terms of diagnostic categories, my research experience leads me to more questions regarding these categories than any other study that I have conducte d Th e co occurrence of disorders e.g. depression + PTSD + psychosis confers a degree of complexity that is dizzying. How to account for this? Might some measure of the complexity be due to developmental issues insofar as these are adolescents in (relatively) earlier stages of the onset of illnesses that have not yet fully coalesced in a (relatively) more coherent clinical picture? Crises and Conditions of Trauma as Extreme, Recurrent, and Unending On the other hand, is this co morbidity better understood a s a mirror of the severity of the charred social, economic, political, and psychological realities as a matter of lived experience? If

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! ( so how should we think about such totalizing forces that produce subjectivity? We have several candidate concepts. There is the notion of the "apparatus" (Foucault 1980:194) as "a thoroughly heterogeneous ensemble consisting of discourses, institutions, architectural forms, regulatory decisions, laws, administrative measures, scientific statements, philosophical, moral and philanthropic propositions." Notions of violence have figured in prominently in anthropological thinking about disease. Scheper Hughes ( 1993 ) has written of th e violence of food scarcity configured as a madness of impossible choices for maternal decision m aking. Das has written on subjectivity and violence as "conceptual structures of our discipline" that are necessary yet problematic insofar as they are a "professional trans formation of suffering (1995:175). I have elaborated a "political ethos" conceive d as the cultural organization of feeling and sentiment pertaining to social domains of power and interest for examination of "the nexus among the role of the state in constructing a particular political ethos, the personal emotions of those who dwell in t hat ethos, and the mental health consequences of inhabiting such a milieu" ( Jenkins 1991:140 ). Farmer (2004) has argued the utility of a broadly encompassing notion of "structural violence" ( built into institutions, practices, and presuppositions) and Que sada et al. (2011) sought to delimit the potentially over inclusive term to structural vulnerabilit y." Lovell (2012) has provided an elegant formulation of "extraordinary circumstances" such as what transpired during and in the aftermath of Hurricane Katr ina to take into consideration pre existing psychiatric vulnerability and yet a remarkable capacity for action and agency in the face of necessity. Lovell (2012) offers an appealing notion of "precarity" that holds particular value by encompassing an exper ience near quality of danger while preserving human sociality under the press of extreme and life threatening circumstances. 5 In an effort to link long term stress associated with loss of family, j obs, and community, Adams and colleagues (2009:615 ) coined the term "chronic disaster syndrome" to draw together the long term effects of personal trauma, the social arrangements in which disaster is a way of life In such formulations the potential problem is not a myopic individualism mired in the complexity of comorbidity but an unwieldy mŽlange of everything that begs the question of how a multiplicity of factors and levels of analysis are interrelated. In short, our studies require a dual specification of the situations and conditions of trauma in cultural, social, and human development as well as appreciation of trauma as a complex attunement to the reality of the modulation of raw existence and the structure of experience. Struggles to conceptualize what is at once totalizing and pervasive having no "post" (or even "pre") to "the" (singular) "traumatic" event or collective traumatic conditions pose threats to the very structure of meaning. Structural si tuations of Gregory Bateson and colleagues (1956) notion of the "double bind" present themselves in ironic and fragmentary form as "continuous crisis" and repetitive and predictable cycles of disbelief that defy human cultural and psychological expectations of the possible. In the present study, for example, a broad range of experiential questions eme r ged that preoccupied the adolescents in relation to existential, cultural, and psychological development. F or example, what are the cultural meaning s and expectation s concerning a mother or a father? What psychological development and transformation occurs when a mother doesn't bake cookies because she was high on meth for three days and gone without notice for months at a time? How does a girl organize psychologically around the need for a father who has been in prison her entire lifetime yet she feels she "needs" him now she is "getting older" ( 17 ) and will graduate from high school, get married, become a mother herself?

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! ) Case Studies To take an initial step toward illustrating this point in relation to existential features of psychic trauma that I am interest e d in here, I briefly describe th e situations of Luke and Alisa ( pseudonyms). While each case has unique qualities, the two presented here are representative of a pattern of precarious relations that I define below holds for the 12 adolescents diagnosed wit h PTSD. Luke Scott Luke was 15 years old and in ninth grade He lived in a low income neighborhood outside Albuquerque with his mother, two younger sisters, and brother, all of who m have different biological fathers. Luke has received outpatient psychiat ric treatment since kindergarten; he was diagnosed at the time with ADHD Since th en he has had seven in patient hospitalizations for episodes of explosive anger and was diagnosed with PTSD and oppositional defiant disord er. A recent hospitalization duri ng which we encountered him occurred in the wake of a physical fight with his sister for whom Luke's mother called the police, who offered either to arrest him or take him for psychiatric hospitalization. When we met Luke in the hospital, he was quite med icated but managed an apparently well practiced firm handshake and direct look in the eye. Although chatty and personable he was easily distracted and could be fidgety. Luke's mother, Martha Ruiz is Anglo American and divorced from Luke's father, who is of Mexican origin. She receives unemployment assistance through a housing subsidy. She has had a series of live in male partners T he most recent of them is Chuck wh o Luke considers a "cool guy a full time truck driver A previous partner, Kent, biologic al father of Luke's younger brother, lived with the family from 1998 to 2005. Luke recalled : F or seven years, I thought I loved him as my father." Thus it was crushing to Luke to have his younger sisters divulge in 2006 that for a period of approximately four years (when Luke was 9 13 years old), his stepfather Kent had sexually abused them. More, Kent handcuffed Luke to a bed and beat him, allowing Kent opportunities to abuse Luke's sisters without Luke's knowledge or interference. Luke struggled with th e handcuffs, breaking some of the bars on his bed but not the thicker ones Following his sister's revelations of sexual abuse, Luke demanded that they tell his mother because he refused to keep such a terrible secret. In the wake of that telling, Kent was arrested and held in custody, pending a trial that particularly preoccupied Luke at the time we met him. Asked what he thought of his hospitalization, Luke said he was there for his "anger, mostly my anger, I have big, erratic blow ups. I go from flat lin e to straight up." During his diagnostic interview w ith the project psychiatrist, Luke said, "( T )he only reason for my anger is I need to distract myself." He is unwavering, however, in his conviction that his problems started with the trauma inflicted on him and his sisters by Kent. Luke was reflective about trying to manage his anger but still convinced that his stepfather's abuse was the source of his and his family's troubles, that he simply could not "let it go," and that to do so would be a problem since he says "I don t want to let go of this thing" because "that day may come when I need it, and if I don t have it then, I'll have to revert it, something that I don't like to do. Use weapons. Because I don t like using weapons in fights." Luke is full y aware that he retains his anger not only as a defensive strategy that keeps him

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! vigilant but also as the fuel for his wish for violent retribution as he grow s into becoming a physically capable, stronger young man. Alisa Sanchez The second example of psychic trauma is illustrated by the life of a 17 year old girl of mixed Hispanic heritage with the pseudonym of Alisa. Alisa has scarcely managed to sustain her life in the face of economic hardship and destructive parents who neither understood her nor were concerned with her needs. Suffering numerous insults to the integrity of her development, she struggles with the pain and confusion of a shattered psyche and limited resources for the crafting of a satisfying life. She had been hospitalized eight time s since the age of 13 Shortly after turning 17 she gave birth to a healthy baby boy. Yuma, an Isleta Native American and boyfriend of two years, was an active father in the months immediately following the birth. In the initial telling of what led to he r hospitalization, Alisa was adamant that she had been devastated to receive a letter from her father then serving in Iraq that informed her that he wasn't her biological father and had decided to disown her. After h e return ed to the Albuquerque area, she attempted to contact him by telephone to no avail. S he felt that hi s refus al to take the call was the last straw, reporting that she "freaked out" and began to cry, feeling abandoned. This experience was the immediate precursor to one of her several hospit alizations. She likewise had several clinical diagnoses over the years but the central and enduring one was PTSD. The acuity of the loss of her relationship to this father figure unfolded in the context of a history of having suffered multiple instances of sexual molestation by her mother's boyfriends or partners. The first she recalled had occurred at age 11 when she was sleeping in the same bed with her mother and her partner at the time while her mother was either asleep or drunk. Adding to the horror o f that assault was her family's response to the event for which she felt "blamed and unsupported," with her mother and other relatives trying to minimize what had occurred. It was immediately after this event that she began self cutting on the advice of a friend who had been raped by her father. This became a regular habit in the wake of a subsequent sexual assault as a young teenager by a boy she h ad "trusted (and) he took advantage of me." By the time of her father's rejection, her narrative draws the co nnection all too clearly, and literally: H e (her father) cut me out of his life and she "started cutting" not only to take away the pain but also in a desperate attempt to draw him back into her life. Alisa was open about the relentless buffeting of he r identity and evolutio n as a child with multiple father figures and abuse by some of the unsavory ones. Still, the most profound insult to her, the renunciation by her adoptive father, loomed largest. She pined for some resolution. The diagnosing research psychiatrist thought perhaps this played into some of her experiences with the need to connect with her boyfriend at the time and the trouble that ensued with their subsequent breakup. Confessing to her boyfriend that she had a friendship with another boy he became enraged and broke off the relationship. In response, she swallowed a bottle of Seroquel (antipsychotic medication) and at 17 was hospitalized again. Just as she intended the cutting as a means of bringing back her father, she admitted that th e overdose was intended to get her boyfriend to return. Her mother's severe problem with alcohol was a lifelong source of torment for Alisa. At around age five, she suffered a major injury in a car accident when her mother was driving while intoxicated. In deed, Alisa's right arm was very nearly severed. A pretty young girl with long

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! + dark hair and striking brown eyes, she was also notable not only for being overweight but also for the long, deep scars that ran the length of her arm. Dealing with her mother's alcoholism from an early age, she says she had to "grow up early" and be "the adult" from the age of six. Being the adult involved making sure at times that her mother was still breathing and being exposed to what she describes as her mother's "bringing d ifferent men in the house, being very promiscuous in front of me." With sadness she relayed that she knew all about sex from the age of four and had nightmares of her mother being brutalized by the men she brought home. According to SCID research crit eria, Alisa's current diagnoses were enduring PTSD and depressive disorder with psychotic features. The latter diagnosis was for a condition that developed post partum. While breastfeeding she experienced sexual stimulation that, although not uncommon, te rrified her. It brought back her own sexual molestation some years back. Unlike Luke, Alisa did not accept easily the diagnosis of PTSD. At the time she was given that diagnosis, she had had several previous clinical diagnoses and experienced this one as c onfusing and having been "thrown" at her. During the following year, she was clinically diagnosed with p sychosis, which she experienced with both relief and shame. S he felt relief in that the diagnosis made sense to her since she had had frightening halluc inatory experiences. She felt shame particularly in relation to her two older sisters who alternately doubted or derided the diagnosis. Her mother, Ramona, a large and rough hewn w oman of Hispanic heritage with dark hair, had a difficult life herself, gro wing up in a family of eight where beatings were routine. Her small home was provided to her through a housing subsidy. Ramona has a history of alcohol and drug abuse for which she has been in court mandated rehabilitation programs using the treatment mode l from Alcoholics Anonymous. She relayed that she was raped as a child and that her family did not care about her. Ramona sees t his lack of care and protection as intergenerational and repetitive: I look at cycles it keeps repeating itself through the g enerations and I want it to stop. I've seen cycles my whole life that's what I saw my mother do." In the wake of the accident involving drunken driving that se verely injured Alisa, the judge mandated a court ordered residential rehabilitation program for Ramona. She was allowed only supervised visits with Alisa for several months. During that time, Alisa lived with her uncle and elder sister. Even though Ramona completed a rehabilitation program following the car accident, she could not maintain her so briety. Given the need to become "the adult" at age six, it is to Alisa's credit that she appeared as a precocious, contemplative, and empathetic person. Two years after we met her, she had moved out of her mother's house, having been ousted, and was livin g in a small, messy apart ment with her boyfriend and two year old son. Even though she was wracked by anxiety, she passed her GED requirement in lieu of having completed high school. She was in the process of enrolling in courses at the local community col lege, and was interested in becoming a counselor. Patterns of Precariousness: Trauma and Social Danger The problem of PTSD has been acknowledged as often not reducible to a single event but rather as a response to recurrent threats to the bodily and psy chic integrity. Analysis of the foregoing cases, in accord with others diagnosed with PTSD according to research criteria, reveals a pattern with respect to the conditions in which these youths find themselves, a pattern of precarious conditions that lay t he grounds for the transpiration of traumatic events. 5 Identification of such a pattern of instability constitutes a parallel if wider ranging diagnosis of social, psychological, cultural processes in political and historical context. The in depth intervie ws provide experience

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! ", near accounts of conditions of existence made perilous by abandonment or inadequacy of parental and state protection Many of the parents in this group have themselves have had chaotic childhoods ravaged by poverty, drug and gang viol ence, par ental neglect or maltreatment. Although a fuller discussion is beyond the scope of this article these problems need be traced to take into account New Mexico 's colonial history of brutal subjugation and domination of local populations (Chavez 20 06 ; Sanchez 1996 ). In identifying problem s within th e proximal space of the family, such relations can be configured within a broader framework of interge nerational and colonial legacy of some five centuries of conflict among Spanish, Native American, Mexi can, and Anglo American s in contrast to the relatively recent geopolitical designation of New Mexico as part of the American Southwest. This complicated historical situation involves an intricate set of connections that must be considered in order to theor ize the precarious conditions that transcend individual or familial households. The political and cultural instability in the region is manifest in families and communities as the collective casualty of colonial and postcolonial conflict. A s the work of G arcia (2010) has elegantly portrayed New Mexico's colonial history is deeply implicated in the psychic trauma of many of its residents. 6 To interpret social inattention and abdication of moral obligation for the provision of protection and care the legac y of historical trauma, including unconscious residues of subjugation and violation, must be considered together with the contemporary conditions of structural violence ( Anderson et al. 2011 ; Capra 2000 ). The absence of parental protection may occur in rel ation to instability of residence and partner, severe drug and alcohol abuse, and emotional volatility. Taken together, these conditions make possible the many forms of abuse and neglect of children from parental unavailability and lack of care. Individual agency and responsibility in the ethics of care under such conditions are hazy at best although the children in this study demonstrated considerable confusion about security, attachment, and who if anyone was morally accountable for such a precious exist ence. Luke met the lack of protection from his mother wi th the creation of a self system in which anger is readily and reliably available. His anger protects him even if his mother and her various boyfriends will not. The emotional response to exposure to life threatening events under conditions of the absence of parental protection is anger at the most visible level. More tender emotions of fear and trembling, and even grief over how alone in the world he is when it comes to his own protection, are camouf laged by barefaced and dramatic displays of anger. Yet Luke has done far more than devise an elaborate self system of anger that is at once protective and destructive. As we have seen, his interests in astronomy and having a girlfriend helped protect an es timable if fraught capacity for development, resilience, and even idealism. That he has crafted these under conditions of psychic trauma and adversity appeared extraordinary. Alisa's life is no less poignant with respect to breakdown in the provision of p arental protection as the ground s for sustained and repetitive events that for her have created deep and enduring psychic trauma. In addition to the serious injuries sustained (as for Luke albeit even more life threatening), she could not rely on a famili al safety net in the face of unrelenting familial crises and residential moves. Alisa's overt problem is not anger but more of one of being lost in an arid sea of misery and misjudgment. Navigating a parched and unreliable social landscape, she has remarka bly managed to muster personal resources without succumbing to an otherwise arguably warranted resentment. She lives a mix of sadness and loss that she could not save her relationship with her mother without surrendering her sanity. She has her child and h erself to care for and this self created system of protection is what she has.

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! "" Identifying Phenomenological Dynamics of Trauma A primary intent of this article is the exploration of trauma as experienced by adolescents In sum, I see the s triking elem ents of shared phenomenological lifeworlds of these youths as follows : alternating modes of attention that can be characterized as a kind of "hiding" or social withdrawal, on the one hand, and furious if anxious insistence on attachment and connection, on the other. Equally notable are conflicts over the sense of erasure and non recognition of self and other that similarly contributes to an objectified invisibility. Most striking to me, however, in this study as well as others ( Jenkins 1991 1996 b 2013; Je nkins and Valiente 1994 ) is the profound bodily and psychic vertigo commonly experience d when one's sense of reality is ruptured (often recurrently) by traumatic events of penetrating assault, betrayal, and shock. In the immediate aftermath and subseque ntly as a distant kind of ghostly refrain seems the sense (and often the actual words) that "I just can't believe. I just can't imagine. I n ever thought it's not real. Reality is defined by the profound sense of unreality in the realm of what is ( un) imaginable. The unbelievability, the unreality, the simultaneity of utter doubt and certainty surrounding what really did or possibly could have happened, marks the shady boundaries of what is felt and not felt as reality. The phenomenological sense of being in the world that deep bodily and psychic trauma can wield can be summarized as unfathomability as an enduring lived reality. The array of anguish for which the diagnosis of post traumatic stress disorder might be applied is vast (Breslau 2004; Henry 2006; James 2010 ; Jenkins 1996a ; Kienzler 2008). Questions arise as to whether a vast range of nosological and therapeutic application is called for in light of the reality of the broad range of all too common human suffering or if the diagnosis simply m isses or is inadequate to the task of defining and healing. Reasonable arguments can be mounted for both sides of this epistemological quandary. In an account of the range of situational application and the geographic circulation of the term, Fassin and co lleagues (2009) offer an historical analysis of trauma as empire instituted through uncontested claims of the veracity and moral worthiness of PTSD. The problem of contestation and the logic of care meriting treatment and compensation can be less straigh tforward elsewhere ( Hoge et al. 2006 ; Young 1997 ). Adolescents in particular are not trying to "get stuff" (i.e., services, statuses, diagnoses). The diagnosis may be experienced as much as an imposition, as was the case when Alisa said that mental health professionals "threw the PTSD at me." I am less concerned with the ontological, historical, or political status of PTSD and more interested in the lives of adolescents struggling with raw existence of trauma. My preference for the term trauma over that o f PTSD is based on cultural and existential considerations and my identification of several complex and distinctive factors that define the social and psychological experience. First is the structure of the experience of psychic trauma as circumscribing on e's being in the wo rld. U nder enduring and inescapable conditions of psychic trauma, habitual self processes of protection may occur through absorption or dissociation Absorption occurs as preoccupation and dissociation as disconnection and detachment of self and traumatic world. Whether through absorption or dissociation (or both), the taking up of the trauma into psychic structure can provide enshrinement or respite. Although adaptation following exposure to warfare is intricate, we know far less about t he process of defense and adaptation of children who are repetitivel y exposed to traumatic events as the everyday condition of their lives.

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! "$ Not included in Diagnostic and Statistical Manual ( DSM ) criteria but crucial to understanding is the cultural meani ng of the injury as within or beyond the bounds of human making. When injury is perpetrated by interpersonal force of violence, there may be a personal degradation of psychological and moral moorings of trust, security, and safety. When perpetrated by inti mates of households and neighborhoods, the affront goes to the core of psychological conditions for social re lations ruptured by betrayal. T he rupture of trust by betrayal can surprisingly, be reported as the "worst" of all that has occurred ( Hollifield e t al. 2005 ). The particularity of response to traumatic events based on rigorous methodological attention to cultural validity provide s empirical support for a theoretical model of culture, psyche, and social world as inextricable. Concluding Remarks In t his article I have discussed the reciprocal shaping of subjective experience and social institutions particularly in relation to the provision of care through state run healthcare facilities and the family sector. When understood as separate levels of analysis, institution and experience both appear abstract and without substance, whereas in lived experience they are vitally intertwined in the fabric and the "rhythm of life" ( Jenkins 1997 ) Based on my analysis of ethnographic materials from this study, I have argue d that : ( 1) cultural and psychological analysis of trauma requires an understanding at both the personal and the collective level to apprehend the depth and durability of the problem. The foundation for this analysis compels us toward a philos ophical anthropology and a historical psychology; and (2) there is an identifiable pattern of conditions of abandonment and neglect that make possible the events of trauma as an etiological structure for violations of the psychic dignity and bodily integri ty of children. The danger is doubly so for girls. As a matter of oppression, it comes as no surprise that the systematicity of such arrangements is common among the economically and socially disenfranchised These conditions provide the etiological ground s for traumatic violation, often routine and repetitive, in the lived experience of the young. Resources that could counter such maltreatment within the health care and educational sectors are either unavailable or inadequate to the task of transforming ad verse conditions and events that foreclose the horizons of possibility for youths. These conditions present profound challenges for young and developing persons who must navigate conditions that threaten their existential grounding of moral sensibility an d sufficiency as "life affirming" in the sense outlined by Nietzsche (1967). The problem posed by the need to create cultural meaning was described by Geertz (1973:100) in relation to the notion of chaos with his assertion that bafflement, suffering, and a sense of intractable ethical paradox are all, if they become intense enough or are sustained long enough, radical challenges to the proposition that life is comprehensible and that we can, by taking thought, orient ourselves effectively within it" (1973 :100). For children and adolescents, the breaking point brought on by the uninterpretability may threaten their very existence. This article is but a first step in the examination of ruptures of cultural meaning, inadequacies of social institutions, and in terpretations that can fully address the phenomenological and historical aspects of psychic trauma among youths. The analysis is also limited insofar as these are youths who actually had psychiatric treatment and cannot be empirically compared with sociode mographically similar children who have not received any care or have not experienced trauma. 7 A strength of the work (i.e., anthropological work with a

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! "% relatively large number of carefully diagnosed teens whose lives can give us a broader appreciation for the types of problems from which they suffer ) is also a limitation in that this is not an intensive study of one neighborhood or village. While ethnopsychological, cultural, and social acc ounts of trauma among persons are critical, they are insufficient insofar as they fail to incorporate an understanding of the intergenerational, collective reach of trauma. The notion of a collective reach of trauma that I have in mind is rooted in an appraisal of interrelated social psychological processes and conditio ns of adversity: (1) the mental health effects of structural vio lence and vulnerability ( Biehl 2005; Bourgois and Schonberg 2009; Fa r mer 200 4 ; Good et al. 2006; Henry 2006; James 2010 ; Quesada et al 2011; Lovell 1997; Scheper Hughes 1993 ); (2) the role of the state in constructing a political ethos that produces insecurity and conditions for the possibility of oxymoronic recurrent extraordinarily damaging events ( Jenkins 1991 ; Lovell 2012) ; (3) the reproduction and transmission of state produced warfare an d political violence as domestic abuse within family settings ( Mart’n Bar— 1988 ); and (4) intergenerational inheritance of loss and longing in a context of ache and disconnection (Garcia 2010). Across these levels of analysis, I see institutional oppressio n and neglect of citizens by the state as tragically reproduced and enacted within domestic settings ( Jenkins 1991). These interwoven processes twist the experiential field of families and individuals to form enduring social psychic webs of subjugation, un ambiguous ferocity for survival, or an alternatingly vexed and enervated being in the world. Notes 1. It is common in anthropology and other social scien c es to understand the contemporary term "adolescent" as a historically and culturally fluid determinatio n of the last century (e.g., Mead 1928) 2. Research for this article was supported by the National Institute for Mental Health Research Grant 1 R01 MH071781, Thomas J. Csordas and Janis H. Jenkins, Co PIs. We are grateful to Dr. David Mullen and the de dicated clinical staff of the Children's Psychiatric Hospital of the University of New Mexico Medical School, and all the participants in the "Southwest Youth Experience of Psychiatric Treatment" (SWYEPT) Project who took the time to speak with us on sever al occasions about their experience. Special thanks are due to members of our research team including Bridget Haas, Whitney Duncan, Heather Spector Hallman, Allen Tran, Jessica Novak, Nofit Itzhak, Celeste Padilla, Richelle Bettencourt, Michael Storck, El isa Dimas, and Mary Bancroft. 3. Not all adolescents and parents were interviewed beyond an initial set of visits. Some were lost to follow up due to geographic moves out of state for which we did not have logistic capability or we could not locate them. We did make repeat visits to Texas, Colorado, and California. For New Mexico, our research team scoured the entire state and carr ied out ethnographic interviews. 4. Upon entering the state, roadside signs and license plates alike are emblazoned in vivid yellow and red colors that hail New Mexico as the "Land of Enchantment." For the past six years, I have given presentations (conferences and invited lectures), in which I have used powerpoint slides that ironically refer to the Land of Enchantment; however I wish to note that I recently came across an excellent account by Trujillo (2009 ) that also uses this term specifically for transformation in n orthern New Mexico. In this respect, the present work

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! "& contributes to more recent anthropological scholarship o f New Mexico that troubles an idyllic narrative of New Mexico (Garcia 2010; Trujillo 2009; Willging and Semansky 2010). 5 Lovell (2012) provides a nuanced application of the notion of ontological "precarity" rooted in etymological origin in supplication as a mode of subjectivity 6. T hanks to one of the reviewers for noting this point precisely. 7. Not presented here are forthcoming comparative analyses from the SWYEPT study of adolescents who, according to research diagnostic criteria, have no psychiatri c disorders nor have they received any treatment. References Cited Adams, V T van Hattum, and D English 2009 Chronic Disaster Syndrome: Displacement, Disaster Capitalism, and the Eviction of the Poor from New Orleans. American Ethnologist 36:615 63 6. Anderson, W., D. Jenson, and R. Keller, eds. 2011 Unconscious Dominions: Psychoanalysis, Colonial Trauma, and Global Sovereignties. Durham: Duke University Press. Anderson Fye, E. P., and J. Lin 2009 Belief and Behavior Aspe cts of the EAT 26: T he C ase of S choolgirls in Belize. Culture, Medicine, and Psychiatry 33 :623 638. Bateson, G., D. D. Jackson, J. Hal ey, and J. Weakland 1956 Toward a Theory of Schizophrenia. Behavioral Science 1 :251 254 Biehl, J. 2005 Vita: Life in a Zone of Soc ial Abandonment. Berkeley: University California Press. Bourgois, P., and J. Schonberg 2009 Righteous Dopefiend. Berkeley: University of California Press. Breslau, J. 2004 Cultures of Trauma: Anthropological Views of Posttraumatic Stress Disorder in I I nternational Health. Culture, Medicine and Psychiatry 28:113 126 Capra, D. 2000 Writing History, Writing Trauma. Baltimore: Johns Hopkins University Press. Carpenter Song, E. 2009a Children's Sense of Self in Relation to Clinical Processes. Ethos 3 7:257 281. 2009b Caught in the Psychiatric Net: Meanings and Experiences of ADHD, Pediatric Bipolar Disorder, and Mental Health Treatment in the U.S. Culture, Medicine, and Psychiatry 33:61 85. Chavez, T E. 2006 New Mexico: Past and Future. Albuquerque: University of New Mexico Press. Csordas, T J. 2013 Inferring Immediacy in Adolescent Accounts of Depression. Journal of Consciousness Studies 20:239 2 53. Das, V. 1995 Critical Events: An Anthropological Perspective on Contemporary India. Oxford: Oxf ord Press. Desjarlais, R. L. Eisenberg B. Good and A. Kleinman eds.

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! "' 1996 World Ment al Health: Problems and Priorities in Low Income Countries. Oxford: Oxford University Press. Farmer, P. 2004 An Anthropology of Structural Violence. Current Anthr opol o gy 45 :305 325. Fassin, D., R. Rechtmann, and R. Gomme 2009 The Empire of Trauma : An In quiry into the Condition of Victimhood. Princeton: Princeton University Press Foucault, M 1980 Power/Knowledge: Selected Interviews and Other Writings, 1972 1977. C Gordon ed New York : Pantheon. Garcia, A. 2010 The Pastoral Clinic: Addiction and Dis possession along the Rio Grande. Berkeley : University California Press. Geertz, C. 1973 The Interpretation of Cultures. New York: Basic Books. Good, B. J. 199 2 Culture and Psychopathology: Directions for Psychiatric Anthropology. In New Directions in Ps ychological Anthropology. T. Schwarz, G. White, and C. Lutz, eds. Pp. 181 205. Cambridge: Cambridge University Press. Good, B J., M J DelVecchio Good, J Grayman, and M Lakoma 2006 Psychosocial Needs Assessment of Communities Affected by the Conflic ts in the Districts of Pidie, Biereuen, and Aceh Utara. Jarkarta: Institute of Medicine. Good, M. J. Delvecchio Good, S. Willen, S. Hannah, K. Vickery, and L. Park, eds. 2011 Shattering Culture: American Medicine Responds to Cultural Diversity. New Yor k: Russell Sage Foundation. Gupta, A., and J. Ferguson 1997 Culture, Power, and Place: Explorations in Critical Anthropology. Durham: Duke University Press. Hendren, R., and I. Berlin 1991 Psychiatric Inpatient Care of Children and Adolescents: A Multic ultural Approach. New York: John Wiley and Sons. Henry, D. 2006 Violence and the Body: Somatic Expressions of Trauma and Vulnerability during War. Medical Anthropology Quarterly 20:379 398. Hinton, D. E., A. Hinton, Y. Chhang, K. T. Eng, and S. Coung 2012 PTSD and Key Somatic Complaints and Cultural Syndromes among Rural Cambodians: The Results of a Needs Assessment Survey. Medical Anthropology Quarterly 26:383 407. Hoagwood, K., and S. Olin 2002 The NIH Blueprint for Change: Research Priorities in C hild and Adolescent Mental Health. Journal of American Academy of Child and Adolescent Psychiatry 41: 760 767. Hoge, C. W., J. L. Auchterlonie, and C. S. Milliken 2006 Mental Health Problems, Use of Mental Health Services, and Attrition from Military Serv ice after Returning from Deployment to Iraq or Afghanistan. JAMA 295: 1023 1032. Hollifield, M. H., V. Eckert, T. Warner, J. H. Jenkins, B. Krakow, J. Ruiz, and J. Westermeyer 2005 Development of an Inventory for Measuring War r elated Events in Refugees. C omprehensive Psychiatry 46:67 80.

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! "( James, E. C. 2010 Democratic Insecurities: Violence, Trauma, and Intervention in Haiti. Berkeley: University of California Press. Jenkins, J H. 1991 The State Construction of Affect: Political Ethos and Mental Health among Salvadoran Refugees. Culture, Medicine, and Psychiatry 15:139 165. 1996a Culture, Emotion, and Post Traumatic Stress Disorder. In Ethnocultural Aspects of Post t raumatic Stress Disorder. A. Marsella and N. Freedman, e ds. Pp. 165 182. Washington DC: American Psychological Association Press. 1996b The Impress of Extremity: Women s Experience of Trauma and Political Violence. In Gender and Health: An International Perspective. Upper Saddle River, NJ: Prentice Hall 1997 Subjective E xperience of P ersistent S chizophrenia and D epression among U.S. Latinos and Euro Americans. British Journal of Psychiatry 1:20 25. 2013 Palpable Insecurity and Sen's Comparative View of Justice: Anthropological Considerations. Critical Review of Social and Politica l Philosophy 16:266 283. Jenkins J. H., and M. Valiente 1994 Bodily Transactions of the Passions: El Calor (The Heat) among Salvadoran Women. In Embodiment and Experience: The Existential Ground of Culture and Self. T. Csordas, e d. Pp. 163 182. Cambridg e: Cambridge University Press. Kano, M., C. Willging, and B. Rylko Bauer 2009 Community Participation in New Mexico's Behavioral Health Care Reform. Medical Anthropology Quarterly 23:277 297. Kienzler, H. 2008 Debating War trauma and Post traumati c Stress Disorder (PTSD) in an Interdisciplinary Arena. Social Science & Medicine 67:218 227. Kleinman, A. 1988 Rethinking Psychiatry: From Cultural Category to Personal Experience. New York: The Free Press. Korsgaard, C. M. 1996 The Sources of Normativ ity. Cambridge, MA: Harvard University Press. Lovell, A M. 1997 "The City Is My Mother : Narratives of Schizophrenia and Homelessness. American Anthropologist 99:355 368 2012 Tending to the Unseen in Extraordinary Circumstances: Severe Mental Illness and Moral Experience during Hurricane Katrina. Invited s ession, "Embodied Morals, Demoralized Minds (Society for Medical Anthropology), 111th Annual Meeting, American Anthropological Association. San Francisco, CA November 14 18 Macartney S. 2011 Chil d Poverty in the United States 2009 2010: Selected Race Groups and Hispanic Origin. Washington, DC: U.S. Census Bureau. Mart’n Bar—, I 1988 La violencia politica y la guerra como causas del trauma psicosocial en E1 Salvador. Revista de Psicologia de E 1 Salvador 7: 123 141. Mead, M. 1928 Coming of Age in Samoa: A Psychological Study of Primitive Youth for Western Civilization. New York: William Morrow & Co.

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! ") Merikangas, K. R., J. P He, M. Burstein, S. Swanson, S. Avenevoli, L. Cui, C. Benjet, K. Georgi ades, and J. Swendsen 2010 Lifetime Prevalence of Mental Disorders in U.S. Adolescents: Results from the National Comorbidity Study Adolescent Supplement. Journal of American Academy of Child Adolescent Psychiatry 49 :980 989. National Institute of Mental Health (NIMH) 2012 The Numbers Count: Mental Disorders in America. http://www.nimh.nih.gov/health/publications/the numbers count mental disorders in america/index.shtml (accessed October 12, 2012 ). New Mexico Department of Health 2011 Indic ator Report Drug Ind uced Deaths. http://ibis.health.state.nm.us/indicator/view/DrugIndDth.Cnty.Race.html ( accessed December 12, 2012 ). Nietzsche, F. 1967 The Will to Power. New York: Rando m House. Patel, V., A. J. Flisher, S. Hetrick, and P. McGorry 2007 Mental Health of Young People: A Global Public health Challenge. The Lancet 369:1302 1313. Quesada, J L K Hart, and P Bourgois 2011 Structural Vulnerability and Health: Latino Migra nt Laborers in the United States. Medical Anthropology 31 :339 362. Sanchez, G. 1996 Forgotten People: A Study of New Mexicans. 1st ed., 1940. Albuquerque: University of New Mexico Press. Scheper Hughes, N. 1993 Death without Weeping: The Violence of Ev eryday Life in Brazil. Berkeley: University of California Press. Trujillo, M L. 2009 Land of Disenchantment Latina/o Identities and Transformations in Northern New Mexico. Albuquerque: University of New Mexico Press. U.S. Department of Health & Human Serv ices 2011 Office of Adolescent Health. New Mexico Adolescent Substance Abuse Facts. -../0112223--43567184-168-1896:;4<;=. > -;8:.> .6/?<414@A4.8=<; > 8A@4;14.8.; 41=B3-.B: (accessed December 16, 2012 ). Ward, S. 2003 On Shifting Ground: Changing Formulations of Place in Anthropology. Australian Journal of Anthropology 14:80 96. Watson. M., C. Bonham, C. Willging, and R. Hough 2011 "An Old Way to Solve and Old Pro blem": Provider Perspectives on Recovery o riented Services and Consumer Capabilities in New Mexico. Human Organization 70: 107 117. Willging, C., and R. Semansky 2010 It's Never Too Late to Do It Right: Lessons from Behavioral Health Reform in Ne w Mexico. Psychiatric Services 61:646 648. Willging, C., H. Waitzkind, and L. Lamphere

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! "* 2009 Transforming Administrative and Clinical Practice in a Public Behavioral Health System: An Ethnographic Assessment of the Context of Change. Journal of Heal th Care for the Poor and Underserved 20: 866 883. World Health Organization 2005 Child and Adolescent Mental Health Policies and Plans. Geneva: World Health Organization. Young, A. 1997 Harmony of Illusions: Inventing Post traumatic Stress Disorder. Prin ceton: Princeton University Press. !!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !