Who or what are you? The person or the diagnosis

15Jul10

There is no person-oriented approach as long as the diagnostic-gaze is in operation.

my own (provisional) maxim.

To pick up on my last extensive post on mental health and psychiatric power (the theorist in me really wants to come up with an unnecessary neologism for that) I want to make a brief remark on diagnoses.

I have noticed that without making any conscious effort I have avoided reading any psychiatric files in my placement working with people who have “severe and enduring mental health problems”. Now, I realise that I might assume that this means they are diagnosed schizophrenic or bi-polar but I don’t know anything about their history before I meet them. By this I don’t just mean nothing about their history of presentation but about their existential history. This is pretty much because I regard them as people and I wouldn’t want a summary of the life of everyone I ever met. Beyond that though is the issue of predetermined judgement, jumping the gun. Even the fact that I know most of the people I see will be diagnosed a specific way is more than I’d like to know to begin with. Again, in my own life, things were often at their worst with a woman I was seeing who was diagnosed with bipolar disorder when I began focussing on that diagnosis- either positively or negatively, and this is something I was guilty of from when we first met, constantly asking her if she was alright…it probably played a significant part in the breakdown of that partnership. And this is a generalised lesson… how can you have a partnership with people when they are overshadowed by a diagnosis?

There are already umpteen critiques of the DSM iv and I’m not here intending to reproduce them. I want simply to say that the diagnostic obsession overshadows people’s lives as real, valuable people, existential agents who own their own lives. That’s not a grand theoretic point, to me its axiomatic…I had to learn it the hard way as I’ll always regret losing that partner. In terms of psychiatric power the diagnostic-gaze is also axiomatic, its truth and efficacy do not need to be proved but is everywhere presupposed. If we can talk about the presuppositions of capitalism then here we see an analogous presupposition of psychiatric power in this diagnostic-gaze, which is prior to any particular formulation of power-knowledge. Obviously when had carried and viewed through this gaze I hadn’t intended to…but this speaks to its insidious power to form unconscious schemas that are difficult to uproot. If you spend any time with people who experience mental distress you will find that a number of these people, while stepping outside of the psychiatric attitude in regards to themselves, will often speak about other people- people whom one would assume they had an almost natural solidarity with- as nutters, psychos and so on. Psychiatric power is rather parasitic and is highly adaptable to the conditions it finds itself in.

I am reminded of Merleau-Ponty’s discussion of a certain kind of scientific gaze that breaks things apart into analytic units and then has to reassemble the original object in order to discover it so that in order to know the cup one must break it down into its compositionally primary units and then reassemble them- even though what remains is a cup it is not what it was, it becomes a shadow of its simple components and of the scientist’s language. The diagnostic-gaze performs a similar operation to my mind. The person is broken down into their compositional units- here these are behaviours and thought patterns called symptoms- and each of these units is explored, analysed and then brought together into a…I don’t know, is it an assemblage or just a bundle?- something called a medical diagnosis.

Clinical psychologist Rufus May, who also happens to be have been diagnosed schizophrenic but is in recovery, has said that

If the diagnosis is personality disorder I would expect the person to be manipulative, if schizophrenia I would expect them to be disorganised. A diagnosis of schizophrenia means they are a hopeless case. Its a life sentence…people with manic depression tend to get more benign treatment.

First off, I’d question whether people diagnosed as having bipolar disorder actually do receive ‘more benign’ treatment (more benign by what standard? Chemical constraint? ECT?). So the diagnosis is what forms the professional’s (and the public’s) expectations of someone and this will in turn shape how they interact, respond and treat that person. Certainly in my own extremely limited experience on work placement I have heard people with the schizophrenic diagnosis being talked about as hopeless cases, quite openly, and have heard people who are not at home at the time their CTO stipulates referred to as ‘chaotic’. So they have contravened their CTO and thereby breached the terms of their release from hospital, they are also risking getting a reputation as non-compliant. Why would they risk this? Either they are experiencing distress and therefore compliance isn’t on top of their agenda or they have forgotten (many medications can screw up the memory) or perhaps they are late or got tired of waiting for the cpn to turn up and had other things to do. The idea that these people are ‘chaotic’ has also been applied in my presence to people who do have serious problems with alcohol, drugs and criminality but the problem is that this is put down to the schizophrenia rather than to individual responsibility and so the two different kinds of circumstances are conflated. Whether you were away shooting up or simply decided you wanted to go for a walk in the fresh air on a sunny day, either way you are a chaotic schizophrenic.

A commenter on a previous post of mine read the post ‘Another human variation’ as seeking to find ‘understandable classifications that are both accurate and inoffensive.’ This is undoubtedly the correct orientation but its too limited. What I’d like is for a language to be available that isn’t violent. Ron Coleman and the Hearing Voices Network have strongly advocated that we dispense with terms like schizophrenia and instead use terms such as ‘voice-hearer’ (on this note, why is the person with a severe illness terrifying/evil but the psychic medium really does hear voices/is a bit of fun…it seems we like our voice-hearers to perform in the right context- for our benefit or entertainment). Again someone with a diagnosis of bi-polar disorder might be spoken of as someone who experiences intense feelings. Any other behaviours or thought patterns would be owned by the person in the same way.

The point here is not to just reinforce what truth labelling-theory has. The only reason I refer to the philosopher of experience Merleau-Ponty is to indicate that the diagnostic-gaze penetrates into the individual person, the group, the body, the subject to such an extent that we can speak of it as a kind of ontological violence. It may seem a step too far and obviously in mental health we do require classifications, there is always a need for a language in order to talk about distressing experiences otherwise people really will be left totally isolated, but I’m beginning to think that terms like ‘schizophrenic’ and even ‘psychotic’ are just as bad as ‘crazy’ or ‘nutter’. It may even be that diagnostic terms have become so toxic that they are in the same family as words like ‘nigger’…but, against the implication of an organisation named Mad Pride, they may not be amenable to the same kind of reappropriation. Let me stress that I don’t see this at all as a questionf political-correctness or of simply swapping to nicer sounding words (after all, one can say “afro-caribbean” and still mean “nigger”). This is not a linguistic problem…it is an assault on people’s very existence.

Let me repeat the above, as much for my sake as anyone reading this, in another way. If beings, including human beings, can be said to be composed then what the diagnostic-gaze does is de-compose the person, fragmenting them and isolating units of composition that are occlude all the others, and re-composes that person according to its own explicit schema (which also lurks in everyone else as a kind of implicit schema). Thus the debate on whether something like schizophrenia is real is void. Of course its real; its real because psychiatric power has given birth to it. Whether its reality and the reality of the experience of the person who is recomposed as schizophrenic matches up is what I question, and its a question with necessarily ethical and existential elements as it regards the making of real but denied lives. Again, as I said before in the first post I link to above, there is a question of abjection here, of the psychiatric user as homo sacer. The violence here is properly ontological… and it serves as the basis for all other violences that are carried out later. But let me repeat, I am not talking about rejecting a language of what we now call mental illness and nor am I rejecting the reality of that experience.

Its only now I can get to the real point of this post. All of this has to do with two interrelated phenomena that I have experienced. The first is the NMC code, which as a student nurse relates to me as an object of study and the future ethical document I am to live by, and the person-centred approach, pioneered by humanist psychologist Carl Rogers…(oops, I originally wrote that as Karl…a bit too much Marx floating around my mind perhaps).

The person-centred approach was originally developed by Rogers as a model on which to base the practice of psychotherapy, that kind of therapy in which the crucial thing is that the person experiencing some kind of distress talks through their experience in the hope of finding a way to cope or overcome it. This humanism is in stark contrast to Freud’s own presentation of psychoanalysis as merely transforming pathological misery into everyday unhappiness and I have to admit that I sometimes air closer to Freud’s antihumanism, having studied philosophy with an emphasis on antihumanist approaches, than my very limited clinical experience seems to support. By that last remark I mean to say that while antihumanism is all very well and good in theory the actual practice of caring for a person leans far more towards the kind of attitude that Roger’s indicates. Anyway, moving on from that aside…

Here is a pretty basic definition of person-centred counselling, taken from wikipedia

Rogers affirmed individual personal experience as the basis and standard for living and therapeutic effect. Rogers identified 6 conditions which are needed to produce personality changes in clients: relationship, vulnerability to anxiety (on the part of the client), genuineness (the therapist is truly himself or herself and incorporates some self-disclosure), the client’s perception of the therapist’s genuineness, the therapist’s unconditional positive regard for the client, and accurate empathy. This emphasis contrasts with the dispassionate position which may be intended in other therapies, particularly the more extreme behavioral therapies. Living in the present rather than the past or future, with organismic trust, naturalistic faith in your own thoughts and the accuracy in your feelings, and a responsible acknowledgment of your freedom, with a view toward participating fully in our world, contributing to other peoples’ lives, are hallmarks of Roger’s Person-centred therapy

[emphases added]

As my own field, which I am still fresh inexperienced in, is mental health nursing and this profession has too a large degree adopted just such a person-centred approach. This is clearly reflected in the document produced by the Nursing and Midwifery Council that all registered nurses must adhere to or face the possibility of being suspended or even struck off there register. A handful of examples from the Code will suffice to illustrate the connection.

Make the care of people your first concern, treating them as individuals and respecting their dignity

Treat people as individuals

  • You must treat people as individuals and respect their dignity
  • You must not discriminate in any way against those in your care
  • You must treat people kindly and considerately
  • You must act as an advocate for those in your care, helping them to access relevant health and social care, information and support
  • You must share with people, in a way they can understand, the information they want or need to know about their health
  • Collaborate with those in your care

    • You must listen to the people in your care and respond to their concerns and preferences
    • You must support people in caring for themselves to improve and maintain their health
    • You must recognise and respect the contribution that people make to their own care and wellbeing
  • You must make arrangements to meet people’s language and communication needs
  • To my naive ears all this sounds like a basic statement of being a decent human being and the code continues in this vein. The emphasis on a person-orientation (which I don’t think we can claim is the same as individualism), empathy, mindfulness of the nature and quality of the relationship as well as the vulnerabilities and strengths of those in the registered nurse’s care can clearly be subsumed under the ‘person-centred approach’.

    Yet if these last two posts on psychiatric power hold any water, if there is any truth to them- however partial- then it is clear that the very ethical codes and person-orientation that the nursing profession enshrines and supposedly remains totally committed to are ‘always already’ suspended by the diagnostic-gaze and in practice where services fail to be genuinely emancipatory and only operate as a hub of psychiatric power. The values and principles upheld in the code are worth keeping but if this Code means anything then it means that the mental health system, such as it is, requires a complete overhaul in both the consciousness of its agents and the structure of its agencies…otherwise the Code and clinical person-orientation remain un-kept promises that soothe our consciences and keep service-user groups reassuringly quiescent.

    I readily admit that in criticism the trope of ‘the gaze’ is overused and possibly exhausted…perhaps what I really mean, given that all comes from the perspective of someone who increasingly characterises much of the mental health system as control, what I should really be speaking about is diagnostic-surveillance. The professional can either be someone who engages with the other person, relating to them in a genuine manner, to allow that person to express the experience of their distress and then offer that person whatever help is possible and works for them, and thereby engage in a kind of embedded watchfulness or they can be an agent of mental surveillance, observing, recoding and monitoring the subjectivity of the person in their care from a detached outsider position. The difference is that between sharing and taking, between abundance and superfluity.

    In a very real respect there is a battle between the two kinds of orientation in each nurse, each counsellor, each therapist, carer, member of the public, person experiencing mental distress. I am trying to be the former. I’m not going to pretend that I am yet. There is no perfection, only the constant attempt.

    I suspect that some people, if any, will read this and think its all anti-psychiatric bullshit Marxist-anarchist nonsense idealism dribbled from a student who doesn’t know how the real world of psychiatry works. This isn’t anti-psychiatry at all. This is against a failed and failing psychiatry, against those people and services that act as control portals, as coercion mechanisms, as the agents of the enforcement of a state sanctioned reality-principle and are willing to be abusive, violent and oppressive as possible in order to achieve it. This is a modest step towards the demand (first of all placed on myself) that professionals actually live up to the values, principles and orientation they have signed their names to. And I readily admit that I have barely any real experience and that I am only beginning to see the mental health system in its (broken) totality. Essentially this is pro-psychiatry; this is for an Enlightened psychiatry. Like I say, I place these demands first and foremost on myself. I hope I can live up to and fulfil them. This means that wherever possible, and it is going to be hard without a new and eloquent language, I will endeavour not to begin from the basis of diagnostic-surveillance.

    If I am not helping people to heal themselves, whilst also continuously healing myself of my own failings, then I am merely an instrument of power. I’m not going to pretend that this is going to be easy even on the individual level…if I fail I hope I man enough to hear the voices of the people who tell me so, who are telling those mental health professionals already and have been for a long time.

    I will end this by quoting one of those voices, someone diagnosed with bipolar disorder who also works with the Icarus Project. This is from their book Navigating the space between brilliance and madness; a reader and roadmap of bipolar worlds which is available as a online as a pdf.

    Like many other things, ‘manic depression’ [or any other illness] is just a symbol, a container, a way of organising life so we can communicate. My uncle compared ‘labels’ to a map- gives us a place to start, but we can go wherever we choose. It’s so simple and confusing at once. Sometimes it feels like both I and the other people in my life see me as having this THING, Bipolar Disorder; it feels disconnected, not right…Structures are good as long as we realize the purpose of the structure is to support freedom, not to box ourselves in.

    

    It is not the diagnosis itself which is the problem, as this provides just such a structure, the problem is the agency of the diagnosis.

    UPDATE: Yeh, I know I said “brief remark”… haha!

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    6 Responses to “Who or what are you? The person or the diagnosis”

    1. 1 schizophrenicreality

      Thank God I found someone who isn’t antipsychiatry to the point of wanting to crush them like bugs. Reform in the system. Smashing it would just leave more profoundly sick people untreated. Psychotropics save lives. I don’t like being drugged (these days) but some evils are necessary. Ameliorate at all times. (Also I’m toying with the idea of making my blog into a place for people to check out mental illness completely outside the sytem in an artistic setting. Check it out is you like).
      SZR

    2. 2 dronemodule

      Cheers schizoreality. The main problem for me in regards to antipsychiatry is exactly the complete rejection of the use of medication which can for many people be life saving..although I do share the concern that they are overused, dangerous and often used for social control.

      I think you should have a look at the Icarus Project’s website…they seem also to be looking into way of taking the best of antipsychiatry without repeating the mistakes of the past.

      What is your blog address, as WordPress hasn’t linked to it automatically?

    3. yeh i dont see an addy either :/

    4. 4 dronemodule

      Its a vast and unintelligible conspiracy! Man the life boats! dronemodule overboard!


    1. 1 Mental Disorders 101
    2. 2 Beat Alcoholism 101

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