Cheryl Mattingly’s The Paradox of Hope

The Paradox of Hope:
Journeys through a Clinical Borderland

By Cheryl Mattingly
University of California Press, 2010, 288 pp.

Offered as a philosophical anthropology, The Paradox of Hope: Journeys through a Clinical Borderland is intended as a meditation on hope in “in all its vagaries, vulnerabilities, and paradoxes” (233).  As a book grounded as much in ethnographic particulars as it is devoted to exploring ideas, Mattingly offers vignettes tracing key events through an intimate cast of participants’ lives. In the first chapter Mattingly transports readers into the bustling lobby of an urban hospital where we are introduced to Andrena. After nearly a year of countless emergency room visits and no answers, Andrena describes the nightmarish visit in which she learned her young daughter had a brain tumor; her anguish is palpable and her steadfast resolve to hope is followed throughout the book. Mattingly avoids theorizing hope as blind optimism as she shows us, through characters like Andrena, that hope is not simply an emotional state, but a socially embedded practice which holds a unique role in urban clinics.

For this book, Mattingly draws upon thirteen years of ethnographic research and analyzes how African American families cultivate hope when faced with the chronic illness or disability of a child. “Hope,” Mattingly argues, “most centrally involves the practice of creating, or trying to create, lives worth living even in the midst of suffering, even with no happy ending in sight” (6). Hope is paradoxical because it requires actively constructing positive potentialities for the future while its practice is simultaneously a constant reminder of present day suffering and poor prognoses. Circumstances are particularly challenging for many of the families Mattingly follows because they live in centers of the urban poor in Chicago and Los Angeles. Underfunded clinics and the current state of health disparities in American health care provide the backdrop for the stories and practices Mattingly describes. However, the politics of clinical disparity largely remain as a backdrop (but never hidden or ignored) as Mattingly focuses on the particularities of individual experience. She follows the families to emergency rooms, doctor’s visits, physical therapy appointments, and their own homes all the while describing how parents and children consistently cross the sociocultural borders of better resourced hospitals primarily staffed by white practitioners. These “clinical borderlands” of urban hospitals are sites of challenging interactions as both families and practitioners work to overcome cross-cultural misunderstandings (77-114). Analyzed as a practice, Mattingly shows how hope is uniquely essential to encounters in borderland clinics because through practices of hope, Mattingly argues, clinicians and families can circumvent “othering” practices and find common frames for fostering “communities of care” (6).

Theoretically, this book builds on Mattingly’s previous work in occupational therapy, healing dramas, and emplotment. However, it offers her most comprehensive theoretical statement to date with her proposed “narrative phenomenology of practice” (37-76). In dialogue with discussions on the limits of practice theories, Mattingly asserts that a theoretical focus on the reproduction of social structures cannot fully expose spaces of possibility (39). Influenced by hermeneutic phenomenologists such as Heidegger and Ricouer, she offers narrative phenomenology as a conceptual and methodological framework that enables her to recognize macro structures while “foreground[ing] the personal, intimate, singular, and eventful qualities of life” (p. 7). Thus her research methods focus on intimate moments in participants’ lives and microanalysis of important events (many of which are recorded for fine-grained analysis).

In Mattingly’s framework, narrative is a central concept that draws attention to the dramatic, discursive, and temporal aspects of experience. Mattingly believes, “as everyday actors, we locate ourselves in unfolding stories that inform our commitments about what is possible and desirable, our narrative anticipations and judgments about how things should and will unfold, and an understanding of the motives and actions of our interlocutors” (43). She skillfully analyzes this complex process through three main narrative acts: narrative mind reading, narrative emplotment, and storytelling (48). The framework allows Mattingly to illuminate how, even in the most difficult conditions, people interact to project possibilities for an indeterminate future. On the discursive level of interaction between clinicians and patients, she identifies four canonical genres of healing storytelling: healing as a science detective story, healing as a battle, healing as machine repair, and healing as a transformative journey (55-76). Showing that these dominant genres provide “authorized action framework[s],” linking the discursive to action, Mattingly argues that the genre of healing as a transformational journey most fully allows for cross-cultural community-building through the cultivation of hope. In such narratives, the conviction to act in the face of potential tragedy allows for common frames clinicians and families can draw upon, but also brings the paradox of hope to the fore. Through Mattingly’s experience-near lens, we see that narrative dramas are always muddled in “life’s moral and practical complexities, confusions, mysteries, and obstacles” (233).

Mattingly’s writing is fluid and accessible, while the cases and moments she chooses to include are emotionally poignant. Medical anthropologists interested in the morality of care, cultural anthropologists interested in the anthropology of experience, and clinicians interested in narrative approaches to treatment will all find the book engaging. It should also interest many linguistic anthropologists as Mattingly teases apart interaction in a complex and nuanced way.

In the end, Mattingly presents her final case against structurally determining theories of practice. Readers learn that a little girl who once begged for her own life to end, seemingly the utter victim of structural disparity – stuck not only in a hospital bed, but under the adults struggling with the border-crossing necessary for her care – has become a competent border-crosser who now manages her own care and is taking college courses with the hope of become a doctor. With this final vignette, Mattingly suggests that through our narratives, we construct possibilities for a future that is never fully clear and never blindly optimistic, but is a space of change and potentiality upon which we should focus our ethnographic gaze.

Abby Forster is a PhD student at the University of Wisconsin-Milwaukee. She draws from both medical and linguistic anthropology. Her dissertation research interests focus on the politics of therapeutic discourse and mental health institutions. Abby approaches this topic through study of narrative and treatment practices for eating disorders in the United States. She considers how the treatment of eating disorders is embedded in larger American ideas of selfhood, bodily self-regard, health, and language.