The way in which the Western world has dealt with the phenomenon of suicide has been forever fraught with paradoxes and inconsistencies - it's been declared a criminal act, (akin to attempted murder), valorised and much imitated in the Romantic era by readers of Goethe's The Sorrows of Young Werther, adopted as a form of protest during oppressive political regimes and now apparently medicalised - the near-inevitable outcome of severe melancholic depression. But, hang on. If it's just symptomatic of an advanced state of an illness, why do many psychiatrists and their handmaidens, who usually treat their patients as sick and thus lacking responsibility for their condition, get so flipping mad when their patients try it?
In her penetrating but straightforward book Users and Abusers of Psychiatry, British clinical psychologist Lucy Johnstone describes the case of Linda Hart, whose award-winning memoir Phone at Nine Just to Say You're Alive recounts nine months spent in a psychiatric hospital. Despite an appalling childhood, Linda grew up to lead a full and active life before suffering the first of a series of breakdowns, resulting in numerous hospitalisations. During her last hospitalisation, feeling unable to ever overcome her severe and unrelating distress about her relationship with her father (a violent alcoholic whom she had found dead in the toilet when she was three, and whose voice now hurled abuse at her), Linda tried to hang herself. The response of the nursing staff was predictable, with many telling Linda that she was selfish and that they were angry at her, while others just ignored her completely. This behaviour fed into and exacerbated her feelings about her father, making her hallucinations even more abusive.
As an involuntary patient with an 'illness', Linda was considered to lack responsibility for her condition. Yet, at the very nadir of her 'illness', she was suddenly declared fully responsible for one of its 'symptoms', with her suicide attempt re-conceived as the act of a free agent, and a deliberate, calculating and manipulative one at that. For her trouble, Linda was moved to a locked ward, thus becoming even further entrenched in 'the system'.
It doesn't always work that way, of course. Often, a suicide attempt and the hostility it provokes will actually precipitate a patient's discharge, not only from the hospital or emergency room, but from 'the system' as a whole. Then what? Some would argue that this represents the most gross professional neglect, leaving the patient at risk of further suicide attempts, while others might argue that it's a blessing in disguise, since the patient's condition may well be largely iatrogenic. This is a possibility I'll discuss in a future post.
Saturday, January 27, 2007
Friday, January 26, 2007
The ABC of CBT CAT RET DBT
Not an excerpt from my DNA, but Cognitive Behaviour Therapy and some of its variants - Cognitive Analytic Therapy, Rational Emotive Therapy and Dialectical Behaviour Therapy.
CBT is predicated on the assumption that thoughts cause emotions, and thus negative emotions are the result of negative or irrational thinking or beliefs, which are often long-standing and all-pervasive. CBT and its variations are considered to have several practical merits - that they are benign, evidence-based and time-limited (and hence relatively inexpensive). Assertions of their benignness are reasonable enough - they carry neither the physical risks of medication or the psychological risks of the analytic therapies.
One of the earliest forms of CBT was Rational Emotive Therapy (RET), formulated by irascible Albert Ellis, who's not interested in your childhood (even though he had a less than pleasant one), but nevertheless expects you to do your homework. Influenced by the Stoics, he opined that events and emotional responses are fundamentally causally unrelated, with emotional reactions due not to the events themselves but to our (presumably pathological) beliefs, interpretations, and philosophies of and about those events, particularly those concerning how the world should work. The proposed disjunction between events and emotions is similar to the Saussurian delineation of the relationship between the signifier and the thing signified, i.e that the signified (the animal that moos) bears no meaningful relation to the signifier (the word 'cow').
The RE therapist thus is expected to demonstrate to his or her clients how their absolutist modes of thinking about events lead to their distressing emotional reactions and how to question these modes, with the goal of replacing them with empirically testable modes of thinking that are less likely to make them miserable, a process known as reframing. The process that allegedly underpins depression or anxiety can be summarised as the ABC Technique of Irrational Beliefs:
A - Activating Event - an event that prompts distress,
B - Beliefs - the (negative) beliefs held about the event,
C - Consequence - the negative feelings and/or dysfunctional behaviors that follow.
Non-empirically testable beliefs include, of course, the notion that we have limited control over our emotions and that we cannot help feeling disturbed about certain things. This immediately highlights a significant problem with RET, or perhaps not with RET itself, but with attempts to apply it in certain cases. It is, I believe, a verifiable fact that some of us have less control over our emotions than others; that this is a developmental stage frequently encountered by those suffering from the aftermath of childhood abuse and trauma. This reality, combined with the practice of providing RET in in- or out-patient group settings, guarantees that RET will be offered to people to whom it is not only irrelevant, but potentially damaging. RET establishes a disputatious relationship between patient and therapist, which wouldn't be terribly helpful if the patient has had others constantly invalidating his or her perspective from an early age.
The other problem with RET is that it is ill-suited to those of a philosophical or analytical bent. It abounds with logical cul-de-sacs: " So, I shouldn't say 'shouldn't'? How does that work?", and the distinction between 'it should' and 'I would prefer' may seem a matter of semantics. And needless to say, if the disconnect between event and emotional response is taken to the extreme espoused by Marcus Aurelius... it would be a mighty strange world to live in, that's for sure. Anything goes, anything must go, because how you feel about me killing your children and burning your house down is your problem, babe.
And where do these self-defeating beliefs come from, by the way? Albert Ellis is willing to concede that childhood trauma and other environmental factors may play a part, but that it is secondary to that played by biological factors, which are presumably more salient in those suffering from emotional, social or behavioural problems.
Which takes us to Dialectical Behaviour Therapy (DBT), developed by Marsha Lineham to treat them darn borderlines (TDBs). I DBT I've ever had DBT, so it's hard for me to cast definite DBTs on its usefulness, so all I can do is offer a commentary, based on what are quite possibly DBTful sources, and offer my DBTful conclusions. I have no DBT that someone else could provide a more detailed and penetrating analysis.
DBT utilises many techniques common in CBT, such as self-monitoring, placing emphasis on the here and now, homework and diary-keeping between sessions and a the forging of collaborative relationships (the 'dialectic') between TDBs and their therapists. It is comprised of two essential components:
1. Individual therapy in which the therapist and TDB discuss issues that come up during the week, with particular emphasis on any episodes of self-injury and suicidal behaviour. Then, if the fifty-minute 'boundary' permits, they may also discuss therapy-sabotaging behaviours, and then less important stuff like quality-of-life issues and improving one's lot in general.
2. Group therapy in which TDBs learn to use four specific sets of skills: core mindfulness skills (a cool Zen way of being awake and alert), emotion regulation skills (identifying and managing emotions), interpersonal effectiveness skills (coping with conflict) and distress tolerance skills (for handling crises and accepting things as they are).
DBT posits that TDBs have an underlying biological deficit that inhibits their ability to regulate their emotions, which is then exacerbated by TDBs perceiving others in their environments as invalidating their thoughts and feelings. Note the obvious biogenetic red herring (that Occam's Razor would have little trouble amputating), followed by the insinuation that the sense of being invalidated is often merely a product of TDBs' paranoid little imaginations.
I find that taking as first priority the elimination of self-harm somewhat arbitrary, if not exactly puzzling. If playing noughts and crosses on their thighs with a bit of broken glass is the worst TDBs can do (cf. calling their shrinks at home late at night, I hate you, don't leave me, etc), why are they so unpopular? As unfathomable and distressing to the observer it may be, self-harm is actually a relatively practical and considerate way of self-soothing, in that it is usually a private act, involving little inconvenience to friends/family/enablers/dealers/co-dependents/whatever.
And while the emphasis on the 'here and now' might be a relief for some, but given that TDBs are disproportionately likely to have been sexually, physically or emotionally abused as children, others may experience it as a 'cop-out', 'blaming the victim', or just 'missing the point'. As Australian consumer activist Merinda Epstein put it, "The present clinical fixation on time limited interventions based on changing our ‘behaviour’ suits some but for many of us it can be an insult to both our intelligence and the depth of our pain."*
Finally, there's Cognitive Analytic Therapy (CAT), which is essentially a hybrid of CBT and analytical approaches, particularly object relations theory. It was developed as a short-term (16 session) therapy for use in the UK's National Health Service. Again, the financial advantages of this, particularly from the NHS's point of view, are obvious, and may or may not override any considerations of clinical efficacy.
***********************************
I personally have benefited from a fairly straightforward application of CBT - when I was 11. I was socially isolated, and it made sense for me to try to acquire the skills to change this state of affairs in the year before I started high school, which presented an opportunity for a fresh start. The psychologist taught me, firstly, to identify my 'moods', as well as the various thoughts that apparently precipitated them - "Nobody loves me, everybody hates me", and to consider the impact that they had on my approachability. The treatment was successful - I moved on to high school, where I managed to make a few friends and interact well with most of the others - but a year or so later, I was wondering why nobody seemed to be interested in why I had been socially isolated and subject to mood swings in the first place. (At least at that point, no one seemed to be claiming it was biologically based.) It is almost as if the success of the treatment depended on my inability to put my situation in a political context, thanks to the intellectual limitations imposed by being an eleven year old.
You probably don't have to be a kid to benefit from CBT - certainly, as an adult, there's been occasions when I've thought I don't care why I am like this, I just want it fixed before I drive myself and everyone else nuts. But if you think that your problems are primarily more practical or emotional in nature and cannot be resolved without reference to your past or presence circumstances, the application of CBT and most of its variants may feel superficial, judgemental and impervious to your individuality.
Anyway, here's my A-B-C theory of effective psychotherapy, cognitive, analytic, down-at-the-pub or otherwise:
Adapts to and integrates the patient's understanding of the origin of his or her problems
Builds trust as the therapist creates a space that involves validation of patient's perspective as well as putting forward alternative interpretations of events or emotions
Contextualises the patient's concerns to the degree that is most useful to the patient.
Is this 'evidence-based', i.e. would this work? (At least I think that's what that means.) How do we define the efficacy of a therapeutic approach - by its theoretical coherence? Or its cost-effectiveness? Or merely its compliance rate? But this is another can of worms entirely...
*************
*"Let’s face it! She’s just too f*****d” – the politics of borderline personality disorder. Paper presented at Lock 'Them' Up? Disability and Mental Illness Aren't Crimes Conference, Brisbane, Australia, May 2006.
CBT is predicated on the assumption that thoughts cause emotions, and thus negative emotions are the result of negative or irrational thinking or beliefs, which are often long-standing and all-pervasive. CBT and its variations are considered to have several practical merits - that they are benign, evidence-based and time-limited (and hence relatively inexpensive). Assertions of their benignness are reasonable enough - they carry neither the physical risks of medication or the psychological risks of the analytic therapies.
One of the earliest forms of CBT was Rational Emotive Therapy (RET), formulated by irascible Albert Ellis, who's not interested in your childhood (even though he had a less than pleasant one), but nevertheless expects you to do your homework. Influenced by the Stoics, he opined that events and emotional responses are fundamentally causally unrelated, with emotional reactions due not to the events themselves but to our (presumably pathological) beliefs, interpretations, and philosophies of and about those events, particularly those concerning how the world should work. The proposed disjunction between events and emotions is similar to the Saussurian delineation of the relationship between the signifier and the thing signified, i.e that the signified (the animal that moos) bears no meaningful relation to the signifier (the word 'cow').
The RE therapist thus is expected to demonstrate to his or her clients how their absolutist modes of thinking about events lead to their distressing emotional reactions and how to question these modes, with the goal of replacing them with empirically testable modes of thinking that are less likely to make them miserable, a process known as reframing. The process that allegedly underpins depression or anxiety can be summarised as the ABC Technique of Irrational Beliefs:
A - Activating Event - an event that prompts distress,
B - Beliefs - the (negative) beliefs held about the event,
C - Consequence - the negative feelings and/or dysfunctional behaviors that follow.
Non-empirically testable beliefs include, of course, the notion that we have limited control over our emotions and that we cannot help feeling disturbed about certain things. This immediately highlights a significant problem with RET, or perhaps not with RET itself, but with attempts to apply it in certain cases. It is, I believe, a verifiable fact that some of us have less control over our emotions than others; that this is a developmental stage frequently encountered by those suffering from the aftermath of childhood abuse and trauma. This reality, combined with the practice of providing RET in in- or out-patient group settings, guarantees that RET will be offered to people to whom it is not only irrelevant, but potentially damaging. RET establishes a disputatious relationship between patient and therapist, which wouldn't be terribly helpful if the patient has had others constantly invalidating his or her perspective from an early age.
The other problem with RET is that it is ill-suited to those of a philosophical or analytical bent. It abounds with logical cul-de-sacs: " So, I shouldn't say 'shouldn't'? How does that work?", and the distinction between 'it should' and 'I would prefer' may seem a matter of semantics. And needless to say, if the disconnect between event and emotional response is taken to the extreme espoused by Marcus Aurelius... it would be a mighty strange world to live in, that's for sure. Anything goes, anything must go, because how you feel about me killing your children and burning your house down is your problem, babe.
And where do these self-defeating beliefs come from, by the way? Albert Ellis is willing to concede that childhood trauma and other environmental factors may play a part, but that it is secondary to that played by biological factors, which are presumably more salient in those suffering from emotional, social or behavioural problems.
Which takes us to Dialectical Behaviour Therapy (DBT), developed by Marsha Lineham to treat them darn borderlines (TDBs). I DBT I've ever had DBT, so it's hard for me to cast definite DBTs on its usefulness, so all I can do is offer a commentary, based on what are quite possibly DBTful sources, and offer my DBTful conclusions. I have no DBT that someone else could provide a more detailed and penetrating analysis.
DBT utilises many techniques common in CBT, such as self-monitoring, placing emphasis on the here and now, homework and diary-keeping between sessions and a the forging of collaborative relationships (the 'dialectic') between TDBs and their therapists. It is comprised of two essential components:
1. Individual therapy in which the therapist and TDB discuss issues that come up during the week, with particular emphasis on any episodes of self-injury and suicidal behaviour. Then, if the fifty-minute 'boundary' permits, they may also discuss therapy-sabotaging behaviours, and then less important stuff like quality-of-life issues and improving one's lot in general.
2. Group therapy in which TDBs learn to use four specific sets of skills: core mindfulness skills (a cool Zen way of being awake and alert), emotion regulation skills (identifying and managing emotions), interpersonal effectiveness skills (coping with conflict) and distress tolerance skills (for handling crises and accepting things as they are).
DBT posits that TDBs have an underlying biological deficit that inhibits their ability to regulate their emotions, which is then exacerbated by TDBs perceiving others in their environments as invalidating their thoughts and feelings. Note the obvious biogenetic red herring (that Occam's Razor would have little trouble amputating), followed by the insinuation that the sense of being invalidated is often merely a product of TDBs' paranoid little imaginations.
I find that taking as first priority the elimination of self-harm somewhat arbitrary, if not exactly puzzling. If playing noughts and crosses on their thighs with a bit of broken glass is the worst TDBs can do (cf. calling their shrinks at home late at night, I hate you, don't leave me, etc), why are they so unpopular? As unfathomable and distressing to the observer it may be, self-harm is actually a relatively practical and considerate way of self-soothing, in that it is usually a private act, involving little inconvenience to friends/family/enablers/dealers/co-dependents/whatever.
And while the emphasis on the 'here and now' might be a relief for some, but given that TDBs are disproportionately likely to have been sexually, physically or emotionally abused as children, others may experience it as a 'cop-out', 'blaming the victim', or just 'missing the point'. As Australian consumer activist Merinda Epstein put it, "The present clinical fixation on time limited interventions based on changing our ‘behaviour’ suits some but for many of us it can be an insult to both our intelligence and the depth of our pain."*
Finally, there's Cognitive Analytic Therapy (CAT), which is essentially a hybrid of CBT and analytical approaches, particularly object relations theory. It was developed as a short-term (16 session) therapy for use in the UK's National Health Service. Again, the financial advantages of this, particularly from the NHS's point of view, are obvious, and may or may not override any considerations of clinical efficacy.
***********************************
I personally have benefited from a fairly straightforward application of CBT - when I was 11. I was socially isolated, and it made sense for me to try to acquire the skills to change this state of affairs in the year before I started high school, which presented an opportunity for a fresh start. The psychologist taught me, firstly, to identify my 'moods', as well as the various thoughts that apparently precipitated them - "Nobody loves me, everybody hates me", and to consider the impact that they had on my approachability. The treatment was successful - I moved on to high school, where I managed to make a few friends and interact well with most of the others - but a year or so later, I was wondering why nobody seemed to be interested in why I had been socially isolated and subject to mood swings in the first place. (At least at that point, no one seemed to be claiming it was biologically based.) It is almost as if the success of the treatment depended on my inability to put my situation in a political context, thanks to the intellectual limitations imposed by being an eleven year old.
You probably don't have to be a kid to benefit from CBT - certainly, as an adult, there's been occasions when I've thought I don't care why I am like this, I just want it fixed before I drive myself and everyone else nuts. But if you think that your problems are primarily more practical or emotional in nature and cannot be resolved without reference to your past or presence circumstances, the application of CBT and most of its variants may feel superficial, judgemental and impervious to your individuality.
Anyway, here's my A-B-C theory of effective psychotherapy, cognitive, analytic, down-at-the-pub or otherwise:
Adapts to and integrates the patient's understanding of the origin of his or her problems
Builds trust as the therapist creates a space that involves validation of patient's perspective as well as putting forward alternative interpretations of events or emotions
Contextualises the patient's concerns to the degree that is most useful to the patient.
Is this 'evidence-based', i.e. would this work? (At least I think that's what that means.) How do we define the efficacy of a therapeutic approach - by its theoretical coherence? Or its cost-effectiveness? Or merely its compliance rate? But this is another can of worms entirely...
*************
*"Let’s face it! She’s just too f*****d” – the politics of borderline personality disorder. Paper presented at Lock 'Them' Up? Disability and Mental Illness Aren't Crimes Conference, Brisbane, Australia, May 2006.
Tuesday, January 23, 2007
Big Pharma paraphernalia
I wonder if anyone collects the promotional toys that drug company representatives hand out at meetings and conferences? All I've got is a Solian pillcutter somewhere at home - a nifty little triangular device with a flip top - unless I've loaned it to someone for chopping up the kind of happy pills your doctor can't prescribe you.
I'm imagining a time capsule (green and white, of course) stuffed with Zoloft pens, Zyprexa notepads, Seroquel paperweights (stacks of rocks) and Viagra "stress-diamonds" (a giant rubbery replica of man's new best friend that can presumably be squeezed, bounced, and thrown around the room with impunity). It might make a entertaining medical museum piece a few centuries hence, after Big Pharma collapses under the weight of increased scrutiny and more stringent novelty criteria for obtaining patents, and shrinks start talking to their patients again.
And in doing so, I'm imagining a future where such objects will be regarded as ephemeral, as will the attitudes, beliefs, systems, policies and practices that they symbolise.
I'm imagining a time capsule (green and white, of course) stuffed with Zoloft pens, Zyprexa notepads, Seroquel paperweights (stacks of rocks) and Viagra "stress-diamonds" (a giant rubbery replica of man's new best friend that can presumably be squeezed, bounced, and thrown around the room with impunity). It might make a entertaining medical museum piece a few centuries hence, after Big Pharma collapses under the weight of increased scrutiny and more stringent novelty criteria for obtaining patents, and shrinks start talking to their patients again.
And in doing so, I'm imagining a future where such objects will be regarded as ephemeral, as will the attitudes, beliefs, systems, policies and practices that they symbolise.
Sunday, January 21, 2007
You'll get better, as long as you don't die in the meantime
If you're relatively young, female, and had repeated admissions to psychiatric wards or hospitals, it's quite likely that you've attracted the diagnosis of Borderline Personality Disorder (BPD) at some point. In theory, BPD is diagnosed on the basis of exhibiting at least five out of the following nine symptoms, which form "a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts":
1. frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
2. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
3. identity disturbance: markedly and persistently unstable self-image or sense of self
4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
6. affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
7. chronic feelings of emptiness
8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
9. transient, stress-related paranoid ideation or severe dissociative symptoms.
However, despite the enormous amount of committee-sitting and controversy that surrounds each revision of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM), from which this list has been taken, I doubt that psychiatrists rely too heavily on its decision-making trees, pre-empted diagnoses or even the specific criteria for a particular 'disorder'. Diagnosis in practice tends to be done intuitively, and is subject to the same kind of confirmation bias that affects any other kind of decision-making. Hence, psychiatrists may fixate on the expression of one or two of the above symptoms and extrapolate from there, particularly if the symptoms are considered 'cardinal' with respect to the diagnosis. In the case of BPD, "self-mutilating behaviour" (Criterion 5) would almost certainly lead your average psychiatrist to diagnose BPD, possibly by employing selective attention to any possible manifestations of the other criteria, at the expense of obtaining an overall picture.
The term "borderline" was introduced by psychoanalysts to describe an intermediate state between neurosis and psychosis characterised by the use of "primitive defenses" such as splitting (seeing someone or something as all good or all bad), and by lacking "object constancy" (the capacity to take a longitudinal view of a relationship, as opposed to focusing on the most recent interaction). It is also used in a psychoanalytical context when postulating that a patient has a too-permeable "border" between his/her conscious and unconscious, with primary process thinking "seeping through" in the form of quasi-psychotic phenomena. Psychoanalysts will claim that this rather metaphysical use of the word is merely descriptive and non-judgemental in nature.
However, there is no doubt that in a mainstream psychiatric context, the diagnosis carries a great deal of baggage, with perceptions on the part of staff that the labellee is "difficult", "manipulative", "attention-seeking" and "not really that sick" (as opposed to those carrying a diagnosis of schizophrenia or manic-depression). On the other hand, its recipients often feel that they have been put in a "diagnostic trash can" or that BPD really stands for "Bitch Pissed Doc". (At least one psychiatrist is on the record as stating that his preferred treatment for those labelled with BPD was simply to "refer them.") Samuel Shem's book Mount Misery (about the experiences of a young trainee psychiatrist) offers a hilarious caricature of an erratic, explosive and narcissistic BPD specialist, who bullies his young, female patients (and trainees) into a state that combines "inappropriate, intense anger" (Criteria 8) with all the symptoms of Stockholm Syndrome (Criteria 1 & 2). As he explains to the trainee, after badgering his depressed patient into storming out of ward rounds:
"My friend, you'll get used to it. We all start out oversensitive. These darn borderlines make us oversensitive, make us feel sorry for 'em. Beginners like you always get drawn in - overconcerned, trying to rescue them - these gals are seductive. The things they get us to do for 'em - give 'em meds, find 'em places to live, even loan 'em money! This one - Zoe - she's the kind who'll even show up at your home. You unlisted?... Seduce the pants off us, given half a chance. Incredible talent they have, to somehow pick up on your weakness and go for it - like they have a special radar or something."
A key tactic of the survivor/ex-user/consumer movement is to highlight research that shows that many people who are labelled with BPD have experienced significant physical, emotional or sexual abuse early in life, usually from a primary caregiver. While I believe that the findings of such research are crucial to developing an understanding of the causes of the symptoms associated with BPD, this tactic may meet with some resistance, especially from those who wish to distance themselves from any deterministic account of their problems, whether it be psychosocial or biogenetic in nature. Likewise, those who primarily identify as survivors of childhood abuse (without any specific reference to ensuing psychological difficulties) may resent the perceived promulgation of the idea that child abuse inevitably leads to mental illness as an adult. It may also lead to an implicit 'silencing' of those labelled with BPD whose childhood experiences, although problematic, do not fit neatly into the various categories of child abuse. It is worth remembering that most of the damage we do to each other is not covered by any statutes or prohibitions, and that "that's life".
It also doesn't necessarily follow that mental health professionals would be more enthusiastic about engaging with those labelled with BPD as a result of adopting psychosocial causal beliefs - again, anything that smacks of determinism promotes pessimism with regard to recovery, and their attitude may well be "We're sorry, but you were screwed, and now you're screwed." With few exceptions, the psychiatric system has an appalling track record of acknowledging and dealing with the aftermath of childhood trauma. New Zealand psychologist John Read has extensively researched the nature and prevalence of this inadequacy, particularly with regard to patients diagnosed with psychotic disorders. Others who have written constructively on the subject include psychiatrist Judith Herman, who in her book Trauma and Recovery integrates the symptomatology of BPD with that of dissociative and psychosomatic disorders to propose a new diagnosis, Complex Post-Traumatic Stress Disorder, which is apparently being considered for inclusion in DSM-V, and Canadian researchers Barbara Everett and Ruth Gallop, whose book The Link Between Childhood Trauma and Mental Illness: Effective Interventions for Mental Health Professionals provides more practical advice for practitioners.
I can posit what I consider to be three basic truths about BPD (assuming it has construct validity):
1. In most cases it has developed as a response to some kind of interpersonal trauma;
2. In particular, it may be largely iatrogenic in nature (the trauma being the person's induction into the psychiatric system, particularly at a young age, and being subject to inappropriate and unprofessional behaviour from mental health professionals); and
3. People who meet the criteria for BPD are often bloody difficult to be around, no doubt about it. But with psychiatrists either justifying 'tough love'-style treatments on the grounds that the worse thing you can do is to be nice to them, or declaring them to be 'unengagable', often with respect to unmodified cognitive-behavioural therapies that implicitly blame the patient for his or her emotional states, this shouldn't be surprising. I was once told that there is little you can do for patients diagnosed with BPD in their late teens, but "that are always going to get better, as long as they don't die in the meantime."
So what to do? The disentangling of the models and concepts of causation and all their connotations is an ongoing project, with health professionals, the survivor/ex-user movement and the general public alike only recently beginning to recognise that environment and behaviour influence biology, as well as the other way around, thus rendering the phrase "biological determinism" less redundant than it previously was. In an ideal world "mental health literacy" would have more to do with critical thinking and a rough appreciation of some aspects of philosophy than it would with being able to parrot the prevailing medical model descriptions of causes, symptoms and treatments.
1. frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
2. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
3. identity disturbance: markedly and persistently unstable self-image or sense of self
4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
6. affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
7. chronic feelings of emptiness
8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
9. transient, stress-related paranoid ideation or severe dissociative symptoms.
However, despite the enormous amount of committee-sitting and controversy that surrounds each revision of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM), from which this list has been taken, I doubt that psychiatrists rely too heavily on its decision-making trees, pre-empted diagnoses or even the specific criteria for a particular 'disorder'. Diagnosis in practice tends to be done intuitively, and is subject to the same kind of confirmation bias that affects any other kind of decision-making. Hence, psychiatrists may fixate on the expression of one or two of the above symptoms and extrapolate from there, particularly if the symptoms are considered 'cardinal' with respect to the diagnosis. In the case of BPD, "self-mutilating behaviour" (Criterion 5) would almost certainly lead your average psychiatrist to diagnose BPD, possibly by employing selective attention to any possible manifestations of the other criteria, at the expense of obtaining an overall picture.
The term "borderline" was introduced by psychoanalysts to describe an intermediate state between neurosis and psychosis characterised by the use of "primitive defenses" such as splitting (seeing someone or something as all good or all bad), and by lacking "object constancy" (the capacity to take a longitudinal view of a relationship, as opposed to focusing on the most recent interaction). It is also used in a psychoanalytical context when postulating that a patient has a too-permeable "border" between his/her conscious and unconscious, with primary process thinking "seeping through" in the form of quasi-psychotic phenomena. Psychoanalysts will claim that this rather metaphysical use of the word is merely descriptive and non-judgemental in nature.
However, there is no doubt that in a mainstream psychiatric context, the diagnosis carries a great deal of baggage, with perceptions on the part of staff that the labellee is "difficult", "manipulative", "attention-seeking" and "not really that sick" (as opposed to those carrying a diagnosis of schizophrenia or manic-depression). On the other hand, its recipients often feel that they have been put in a "diagnostic trash can" or that BPD really stands for "Bitch Pissed Doc". (At least one psychiatrist is on the record as stating that his preferred treatment for those labelled with BPD was simply to "refer them.") Samuel Shem's book Mount Misery (about the experiences of a young trainee psychiatrist) offers a hilarious caricature of an erratic, explosive and narcissistic BPD specialist, who bullies his young, female patients (and trainees) into a state that combines "inappropriate, intense anger" (Criteria 8) with all the symptoms of Stockholm Syndrome (Criteria 1 & 2). As he explains to the trainee, after badgering his depressed patient into storming out of ward rounds:
"My friend, you'll get used to it. We all start out oversensitive. These darn borderlines make us oversensitive, make us feel sorry for 'em. Beginners like you always get drawn in - overconcerned, trying to rescue them - these gals are seductive. The things they get us to do for 'em - give 'em meds, find 'em places to live, even loan 'em money! This one - Zoe - she's the kind who'll even show up at your home. You unlisted?... Seduce the pants off us, given half a chance. Incredible talent they have, to somehow pick up on your weakness and go for it - like they have a special radar or something."
A key tactic of the survivor/ex-user/consumer movement is to highlight research that shows that many people who are labelled with BPD have experienced significant physical, emotional or sexual abuse early in life, usually from a primary caregiver. While I believe that the findings of such research are crucial to developing an understanding of the causes of the symptoms associated with BPD, this tactic may meet with some resistance, especially from those who wish to distance themselves from any deterministic account of their problems, whether it be psychosocial or biogenetic in nature. Likewise, those who primarily identify as survivors of childhood abuse (without any specific reference to ensuing psychological difficulties) may resent the perceived promulgation of the idea that child abuse inevitably leads to mental illness as an adult. It may also lead to an implicit 'silencing' of those labelled with BPD whose childhood experiences, although problematic, do not fit neatly into the various categories of child abuse. It is worth remembering that most of the damage we do to each other is not covered by any statutes or prohibitions, and that "that's life".
It also doesn't necessarily follow that mental health professionals would be more enthusiastic about engaging with those labelled with BPD as a result of adopting psychosocial causal beliefs - again, anything that smacks of determinism promotes pessimism with regard to recovery, and their attitude may well be "We're sorry, but you were screwed, and now you're screwed." With few exceptions, the psychiatric system has an appalling track record of acknowledging and dealing with the aftermath of childhood trauma. New Zealand psychologist John Read has extensively researched the nature and prevalence of this inadequacy, particularly with regard to patients diagnosed with psychotic disorders. Others who have written constructively on the subject include psychiatrist Judith Herman, who in her book Trauma and Recovery integrates the symptomatology of BPD with that of dissociative and psychosomatic disorders to propose a new diagnosis, Complex Post-Traumatic Stress Disorder, which is apparently being considered for inclusion in DSM-V, and Canadian researchers Barbara Everett and Ruth Gallop, whose book The Link Between Childhood Trauma and Mental Illness: Effective Interventions for Mental Health Professionals provides more practical advice for practitioners.
I can posit what I consider to be three basic truths about BPD (assuming it has construct validity):
1. In most cases it has developed as a response to some kind of interpersonal trauma;
2. In particular, it may be largely iatrogenic in nature (the trauma being the person's induction into the psychiatric system, particularly at a young age, and being subject to inappropriate and unprofessional behaviour from mental health professionals); and
3. People who meet the criteria for BPD are often bloody difficult to be around, no doubt about it. But with psychiatrists either justifying 'tough love'-style treatments on the grounds that the worse thing you can do is to be nice to them, or declaring them to be 'unengagable', often with respect to unmodified cognitive-behavioural therapies that implicitly blame the patient for his or her emotional states, this shouldn't be surprising. I was once told that there is little you can do for patients diagnosed with BPD in their late teens, but "that are always going to get better, as long as they don't die in the meantime."
So what to do? The disentangling of the models and concepts of causation and all their connotations is an ongoing project, with health professionals, the survivor/ex-user movement and the general public alike only recently beginning to recognise that environment and behaviour influence biology, as well as the other way around, thus rendering the phrase "biological determinism" less redundant than it previously was. In an ideal world "mental health literacy" would have more to do with critical thinking and a rough appreciation of some aspects of philosophy than it would with being able to parrot the prevailing medical model descriptions of causes, symptoms and treatments.
Friday, January 12, 2007
A note on terminology
Clumsy though it appears, I tend to use "ex-user/survivor". "User", because this denotes an element of complicity, at least in the early days of our engagement with system, and "survivor", to moderate this with the knowledge that any control we might have had over the terms of our engagement is short-lived. "Consumer", on the other hand, implies a level of complicity and autonomy way beyond that which is experienced by most people who come into contact with psychiatry, and has a rather Orwellian ring to it. I'll take my hat off (and shake my head in confusion) to anyone who finds referring to themselves this way empowering.
One word I would like see used more in this context is "injury", as opposed to illness, disorder or disability. "Injury" highlights the role of external factors, recognises the need for assistance, and connotes the possibility of healing. You trip on a cobblestone, cut your knee badly, and need to go to the ER for some painkillers and to get it stitched up. No one would infer from this that your condition had a strictly internal cause (at most, you're a bit clumsy, but these footpaths are dangerous) or, because you received an analgesic, that it was caused by a lack of codeine in your body.
Likewise, it takes into account the experiences of those who view the cause of their situation in largely psychosocial terms, yet take anti-depressants or other kinds of psychotropic medications. The pills are equivalent to the bandage or the sutures, or at worst, to the pin in the leg that was crushed by a tractor. If they work, they work - but they don't imply that serotonin re-uptake plays a causal role, merely that it may be a consequence of earlier psychological injury.
One word I would like see used more in this context is "injury", as opposed to illness, disorder or disability. "Injury" highlights the role of external factors, recognises the need for assistance, and connotes the possibility of healing. You trip on a cobblestone, cut your knee badly, and need to go to the ER for some painkillers and to get it stitched up. No one would infer from this that your condition had a strictly internal cause (at most, you're a bit clumsy, but these footpaths are dangerous) or, because you received an analgesic, that it was caused by a lack of codeine in your body.
Likewise, it takes into account the experiences of those who view the cause of their situation in largely psychosocial terms, yet take anti-depressants or other kinds of psychotropic medications. The pills are equivalent to the bandage or the sutures, or at worst, to the pin in the leg that was crushed by a tractor. If they work, they work - but they don't imply that serotonin re-uptake plays a causal role, merely that it may be a consequence of earlier psychological injury.
Saturday, January 6, 2007
Stop the stigma... or whatever
So what exactly causes stigma and what can be done about it? According to the social-psychological concept of attribution theory, if people judge the causes of a mentally ill person’s behaviour to be under the person’s control, then they should be more prejudiced, blaming and unsympathetic. Conversely, if the mentally ill person’s behaviour is attributed to uncontrollable causes, people should be more sympathetic and pitying. So, it would appear to follow that bio-genetic explanations, which attribute mental illness to uncontrollable causes, should encourage less stigmatisation of the mentally ill.
The social policy implications of this reasoning are obvious. However, the evidence linking the promulgation of bio-genetic explanations to a decrease in stigma is mixed and, often enough, bio-genetic explanations seem to be related to greater stigma. Go figure! Let's consider some of the studies done on the subject.
1. STIGMA AND ATTRIBUTION THEORY
In their paper examining whether espousing particular causal models affects the way in which people view and treat those with a mental illness, Mehta and Farina (1997) quote a person with schizophrenia as saying, “Believe me, there is nothing more devastating, discrediting and disabling to an individual recovering from mental illness than stigma.” Dangerous, unpredictable, worthless, dirty, cold, insincere, delicate, slow, tense, foolish, incompetent and unreliable have emerged through many studies as being commonly held beliefs about people suffering from a mental illness (Read and Harré, 2001), prompting the US Surgeon General to note that “people with mental illness suffer not only from their disorders but also from the stigma and discrimination that accompany them” (Phelan, 2002). A National Institute of Mental Health (NIMH) report stated that non-responsibility, unpredictability and dangerousness are the three major attributions underpinning the stigmatisation of the mentally ill (Read and Harré, 2001).
Link and Phelan (2001) have conceptualised stigma as a three-part process in which “a label sets the labelled person apart from others, links them to undesirable characteristics and leads to rejection and discrimination”. The phenomenon of stigma is fertile ground for the application of attribution theory, as developed and elaborated by theorists such as Harald Kelly and Bernard Weiner, and which explores how people explain (‘attribute’) and hence evaluate the behaviour of others. For example, if a person’s disruptive behaviour is judged to be under the person’s control, others are likely to react reproachfully and unsympathetically. In contrast, if the behaviour is assumed to be beyond the person’s control, the expected reaction is sympathy and pity. It has been well established that people with a mental illness are often viewed as being responsible for their conditions, and are to blame for the problems that result. Thus, the phenomenon of stigma appears to accord with the predictions of attribution theory, and it immediately follows that it may be possible to reduce stigma by educating the public that people with a mental illness are not responsible for the conditions, cannot necessarily control their behaviour, and that “mental illness is a brain disease” (Corrigan & Watson, 2004). Indeed, Corrigan and his colleagues have carried out research that supports the attribution theory prediction. After being educated about how mental illness is a biological disorder and not a personal choice, experimental subjects were less likely to sanction blame, anger and social avoidance towards those with a mental illness. However, further research has shown that attributing mental illness to uncontrollable genetic or biological factors has had a complex effect on its stigmatisation, reducing blame and anger on the one hand but exacerbating different kinds of negative attitudes on the other. These mixed results have called into question the adequacy of attribution theory to explain stigma in this context, and inspired the development of alternative models and concepts to help fully explain its genesis and suggest alternatives for its amelioration.
2. WHAT MOST PEOPLE THINK ANYWAY
Before even considering the efficacy of destigmatisation campaigns based on presenting mental illness as a bodily dysfunction, it should be noted that studies have shown that the public, apart from the relatives of people suffering from schizophrenia, does tend to prefer environmental stress as an explanation for mental illness. Even as far back as 1961, the US Joint Commission on Mental Illness lamented that “Psychiatry has tried diligently to make society see the mentally ill [as physically sick] and has railed at the public’s antipathy or indifference”. Psychiatric patients themselves tend to reject ‘medical model’ explanations of their experiences, claiming that they increase stigma, paint a pessimistic picture of the likelihood of recovery, and ignore the multifaceted nature of their situation and experience (Read & Harré, 2001). Ironically, in an era of conceptualising patients as ‘service users’ and ‘consumers’, it does seem that the customer is always right, at least on the first two points, as further studies into the impact of the promulgation of biogenetic explanations for mental illness on stigma have shown.
3. STUDIES LINKING BIOGENETIC CAUSAL MODELS TO INCREASED STIGMA
Research by Read and Harré (2001) found that biogenetic causal beliefs were related to negative attitudes and beliefs, such as people with mental illness are dangerous, anti-social, unpredictable, and undesirable as friends or partners. This accords with the NIMH analysis of stigma cited above. Corrigan and Watson (2004) noted that while biogenetic explanations of mental illness reduce blame and anger, they might also increase other kinds of stigma. They note that Weiner’s theory of attribution accounts only for people’s beliefs about the onset (cause) rather than the offset (consequences) of mental illness, the latter of which may also contribute to stigmatisation. Presenting mental illness as biologically or genetically determined also raises doubts about the likelihood of remission and/or recovery, which in turn encourages patronising and disempowering attitudes. Read and Harré (2001) noted that mental health professionals who prefer biological explanations tend not to allow patient input into the treatment process compared to professionals who take a more psychosocial perspective. Mehta and Farina (1997) examined the assumption that biogenetic explanations for mental illness reduce stigma in a Milgram-esque study that tested both the attitude and behaviour of subjects towards people (actors) with a purported mental illness, where the mental illness was conceptualised in either biogenetic or psychosocial terms. While they were able to replicate some of Corrigan’s results, i.e. that biogenetic explanations reduce blame, they also found that they induced harsher treatment by subjects of the actors, measured via presumed electric shocks. On the other hand, actors whose psychiatric history was described in psychosocial terms did not suffer harsher treatment than actors whose histories were presumed to be normal. Mehta and Farina (1997) speculated that biogenetic explanations lead us to adopt patronising, controlling attitudes to the mentally ill, to perceive them as physically distinct or “another species”, thus invoking callousness, and to fear for our sanity, leading to an increased sense of vulnerability. With respect to this last point, psychosocial explanations enable us to place a person’s mental illness in the context of negative life experiences, which we may not share, while biogenetic explanations imply that anyone may be struck down at any time.
4. THE FASHIONABILITY OF GENETIC ESSENTIALISM
Recent research by Phelan (2002, 2005), Haslam (2005) and Haslam and Levi (2005) has introduced new frameworks through which the stigmatisation of mental illness can be understood, complementing attribution theory and compensating for its inadequacies. Phelan (2002) has argued that the new emphasis on genetics as exemplified by the Human Genome Project has brought about changes in the way in which we view ourselves and our behaviour, modulating concepts such as personal responsibility, the effect of the environment on behaviour, and individuality, to the extent that genetics may become the dominant explanatory mode with respect to these issues and concepts. In contrast to attribution theory, Phelan (2005) describes what earlier researchers have called rise of the genetic essentialist view, in which “genes form the basis of our human and individual identities… and are strongly deterministic of behaviour.” When applied to mental illness, Phelan predicted that genetic essentialism should increase stigma by promoting the beliefs that (i) the mentally ill person is intrinsically different to others (cf. Mehta and Farina, 2005), (ii) mental illness is persistent and serious, and (iii) is likely to affect other members of the mentally ill person’s family. Taken together, all of these beliefs would tend to exacerbate social distance between the mentally ill person and others, and limit their perceived reproductive ‘fitness’, as well as that of other members of his/her family. It is clear that each of these beliefs correspond to the tripartite model of stigma outlined by Link and Phelan (2001) cited above. Setting apart is achieved by viewing biological differences as being more deep-seated and immutable than differences resulting from environmental effects (Phelan, 2001; Mehta & Farina, 2005); linking to undesirable characteristics is exaggerated by the sense that, when genes are involved, mud sticks – “if the problem is in your genes… full and permanent recovery seems less likely” (Phelan, 2001); and rejection and discrimination is exacerbated specifically in the realm of reproductive rights. Phelan tested her predictions using a case study in a nationwide (USA) survey. Like the above researchers, she found little support for attribution theory predictions that biological/genetic explanations for mental illness reduce stigma, except where punishment was concerned. However, she found that, in accordance with genetic essentialist theory, biological/genetic explanations for mental illness increased beliefs about its seriousness, persistence, and the likelihood of it affecting the siblings of a mentally ill person. Interestingly, biological/genetic explanations did not increase social distance from and perceptions of reproductive unfitness of the mentally ill person themselves, but only with respect to their siblings (Phelan, 2005).
It is appropriate at this point to consider whether the public’s genetic essentialist thinking is consistent with the current scientific understanding of how genes influence behaviour. Phelan (2005), following Alper and Beckwith (1993), asserted that “there is no necessary association between the degree of genetic influence on a behaviour and its malleability or persistence.” She also cites studies of people undergoing genetic testing that show that individuals tend to exaggerate the actual risk of developing a disease based on genetic profiles and family histories, and concludes that “public beliefs about the transmissibility of genetic characteristics are likely exaggerated by genetic essentialist thinking”. Her overall conclusion was that “the processes described by attribution theory and genetic essentialism are not mutually exclusive and that [her] findings support the idea that the effects of geneticisation on stigma are complex, ameliorating stigma along some dimensions while exacerbating it along others”. She then noted that conceiving of mental illness as a biogenetic disorder may benefit parents by absolving them of any (environmentally based) causal responsibility, but harm younger relatives of the mentally ill person, such as siblings or children.
5. FRAMEWORKS FOR UNDERSTANDING THE LINK BETWEEN BIOGENETIC CAUSAL MODELS AND STIGMA
Rejecting the notion that laypeople’s ideas about mental illness are merely reflections of professional concepts and allowing for laypeople’s ability to construct their own understanding, Haslam (2005) has developed a model of folk psychiatry, that comprises four dimensions along which the general public seek to understand mental illness. The first of these four dimensions is pathologising, the business of judging a person or his/her behaviour as deviant and abnormal, based on perceptions of infrequency, incomprehensibility, internal attribution, and entitativity, i.e. that those engaged in deviant behaviour form a coherent and ontologically meaningful group. The three other dimensions represent ways of explaining the pathologised behaviour. Moralising involves judging deviant behaviour to be under the actor’s control, and attributing it variously to perversity, sinfulness or criminality. Moralising derives from (the somewhat inaccurate) folk psychology way of explaining human behaviour, in which acts are understood to derive from intentions, which in turn derive from reasons, which are consciously considered beliefs and desires. Moralising assumes that intentionality underlies the deviant behaviour. In contrast, medicalising involves attributing deviance to some kind of physical aberration, a non-intentional causal essence, rendering it “the outward expression of a fixed identity-determining pathological essence” and thus an example of essentialist thinking in which forms of deviance are considered to be natural kinds, i.e. discrete, immutable, non-man-made groups. Psychologising occupies the middle ground, invoking mentalistic but causal and not fully intentional explanations for behaviour (Haslam, 2005). This model was validated in a study by Haslam and Levy (2005).
So what can this folk psychiatry tell us about stigma? The attribution theory approach to stigma clearly relates to the moralising dimension by its linking of the perceived self-controllability of mental illness to blame and anger, and renders sensible efforts to destigmatise mental illness by using biological/causal explanations, akin to the medicalising mode of explanation. The lack of success of such destigmatisation campaigns “reflect components of the essentialist mode of thinking hypothesised to underpin medicalising. Locating the disordered in a bounded category reflects the discreteness component [of natural kind thinking] and pessimism over recovery reflects immutability.” (Haslam, 2005).
The recommendations that researchers have made in the light of their results to reduce stigma vary from the firm line taken by Read and Harré (2001) that destigmatisation programs should primarily involve increasing the interaction between the mentally ill and the larger public, and placing the mentally ill person’s condition in the context of life events rather than biological/genetic factors, to more integrative models favoured by Phelan (2001, 2005) and Corrigan and Watson (2004). These researchers favour continuing to make use of biogenetic explanations in destigmatisation campaigns, given the importance of reducing blame and taking into account political considerations, such as the need to influence resource allocation. However, they believe that biogenetic explanations should be combined with psychosocial factors and information about the effectiveness of treatment and the actual likelihood of violence and other disturbing behaviour (Corrigan and Watson, 2004), and counteracting some of the misperceptions generated by genetic essentialist thinking (Phelan 2001, 2005).
And here's a list of references, so you know I'm not just quoting my imaginary friends:
Corrigan, P. W. and Watson, A. C. (2004). At issue: stop the stigma: call mental illness a brain disease. Schizophrenia Bulletin, 30(3), 477-479
Haslam, N. (2005). Dimensions of folk psychiatry. Review of General Psychology, 9(1), 335-47
Link, B.G. and Phelan, J.C. (2001). Conceptualising stigma. Annual Review of Sociology, 27, 363-385
Levi, M and Haslam, N (2005). Lay explanations of mental disorder: a test of the folk psychiatry model. Basic and Applied Social Psychology, 27(2), 117-125
Mehta, S and Farina, A. (1997). Is being “sick” really better? Effect of the disease view of mental disorder on stigma. Journal of Social and Clinical Psychology, 16(4), 405-419
Phelan, J. C. (2002). Genetic bases of mental illness – a cure for stigma? Trends in Neuroscience, 25(8), 430-431
Phelan, J. C. (2005). Geneticization of deviant behaviour and consequences for stigma: the case of mental illness. Journal of Health and Social Behaviour, 46 (December), 307-322
Read, J and Harré, N. (2001). The role of biological and genetic causal beliefs in the stigmatisation of ‘mental patients’. Journal of Mental Health, 10(2), 223-235
The social policy implications of this reasoning are obvious. However, the evidence linking the promulgation of bio-genetic explanations to a decrease in stigma is mixed and, often enough, bio-genetic explanations seem to be related to greater stigma. Go figure! Let's consider some of the studies done on the subject.
1. STIGMA AND ATTRIBUTION THEORY
In their paper examining whether espousing particular causal models affects the way in which people view and treat those with a mental illness, Mehta and Farina (1997) quote a person with schizophrenia as saying, “Believe me, there is nothing more devastating, discrediting and disabling to an individual recovering from mental illness than stigma.” Dangerous, unpredictable, worthless, dirty, cold, insincere, delicate, slow, tense, foolish, incompetent and unreliable have emerged through many studies as being commonly held beliefs about people suffering from a mental illness (Read and Harré, 2001), prompting the US Surgeon General to note that “people with mental illness suffer not only from their disorders but also from the stigma and discrimination that accompany them” (Phelan, 2002). A National Institute of Mental Health (NIMH) report stated that non-responsibility, unpredictability and dangerousness are the three major attributions underpinning the stigmatisation of the mentally ill (Read and Harré, 2001).
Link and Phelan (2001) have conceptualised stigma as a three-part process in which “a label sets the labelled person apart from others, links them to undesirable characteristics and leads to rejection and discrimination”. The phenomenon of stigma is fertile ground for the application of attribution theory, as developed and elaborated by theorists such as Harald Kelly and Bernard Weiner, and which explores how people explain (‘attribute’) and hence evaluate the behaviour of others. For example, if a person’s disruptive behaviour is judged to be under the person’s control, others are likely to react reproachfully and unsympathetically. In contrast, if the behaviour is assumed to be beyond the person’s control, the expected reaction is sympathy and pity. It has been well established that people with a mental illness are often viewed as being responsible for their conditions, and are to blame for the problems that result. Thus, the phenomenon of stigma appears to accord with the predictions of attribution theory, and it immediately follows that it may be possible to reduce stigma by educating the public that people with a mental illness are not responsible for the conditions, cannot necessarily control their behaviour, and that “mental illness is a brain disease” (Corrigan & Watson, 2004). Indeed, Corrigan and his colleagues have carried out research that supports the attribution theory prediction. After being educated about how mental illness is a biological disorder and not a personal choice, experimental subjects were less likely to sanction blame, anger and social avoidance towards those with a mental illness. However, further research has shown that attributing mental illness to uncontrollable genetic or biological factors has had a complex effect on its stigmatisation, reducing blame and anger on the one hand but exacerbating different kinds of negative attitudes on the other. These mixed results have called into question the adequacy of attribution theory to explain stigma in this context, and inspired the development of alternative models and concepts to help fully explain its genesis and suggest alternatives for its amelioration.
2. WHAT MOST PEOPLE THINK ANYWAY
Before even considering the efficacy of destigmatisation campaigns based on presenting mental illness as a bodily dysfunction, it should be noted that studies have shown that the public, apart from the relatives of people suffering from schizophrenia, does tend to prefer environmental stress as an explanation for mental illness. Even as far back as 1961, the US Joint Commission on Mental Illness lamented that “Psychiatry has tried diligently to make society see the mentally ill [as physically sick] and has railed at the public’s antipathy or indifference”. Psychiatric patients themselves tend to reject ‘medical model’ explanations of their experiences, claiming that they increase stigma, paint a pessimistic picture of the likelihood of recovery, and ignore the multifaceted nature of their situation and experience (Read & Harré, 2001). Ironically, in an era of conceptualising patients as ‘service users’ and ‘consumers’, it does seem that the customer is always right, at least on the first two points, as further studies into the impact of the promulgation of biogenetic explanations for mental illness on stigma have shown.
3. STUDIES LINKING BIOGENETIC CAUSAL MODELS TO INCREASED STIGMA
Research by Read and Harré (2001) found that biogenetic causal beliefs were related to negative attitudes and beliefs, such as people with mental illness are dangerous, anti-social, unpredictable, and undesirable as friends or partners. This accords with the NIMH analysis of stigma cited above. Corrigan and Watson (2004) noted that while biogenetic explanations of mental illness reduce blame and anger, they might also increase other kinds of stigma. They note that Weiner’s theory of attribution accounts only for people’s beliefs about the onset (cause) rather than the offset (consequences) of mental illness, the latter of which may also contribute to stigmatisation. Presenting mental illness as biologically or genetically determined also raises doubts about the likelihood of remission and/or recovery, which in turn encourages patronising and disempowering attitudes. Read and Harré (2001) noted that mental health professionals who prefer biological explanations tend not to allow patient input into the treatment process compared to professionals who take a more psychosocial perspective. Mehta and Farina (1997) examined the assumption that biogenetic explanations for mental illness reduce stigma in a Milgram-esque study that tested both the attitude and behaviour of subjects towards people (actors) with a purported mental illness, where the mental illness was conceptualised in either biogenetic or psychosocial terms. While they were able to replicate some of Corrigan’s results, i.e. that biogenetic explanations reduce blame, they also found that they induced harsher treatment by subjects of the actors, measured via presumed electric shocks. On the other hand, actors whose psychiatric history was described in psychosocial terms did not suffer harsher treatment than actors whose histories were presumed to be normal. Mehta and Farina (1997) speculated that biogenetic explanations lead us to adopt patronising, controlling attitudes to the mentally ill, to perceive them as physically distinct or “another species”, thus invoking callousness, and to fear for our sanity, leading to an increased sense of vulnerability. With respect to this last point, psychosocial explanations enable us to place a person’s mental illness in the context of negative life experiences, which we may not share, while biogenetic explanations imply that anyone may be struck down at any time.
4. THE FASHIONABILITY OF GENETIC ESSENTIALISM
Recent research by Phelan (2002, 2005), Haslam (2005) and Haslam and Levi (2005) has introduced new frameworks through which the stigmatisation of mental illness can be understood, complementing attribution theory and compensating for its inadequacies. Phelan (2002) has argued that the new emphasis on genetics as exemplified by the Human Genome Project has brought about changes in the way in which we view ourselves and our behaviour, modulating concepts such as personal responsibility, the effect of the environment on behaviour, and individuality, to the extent that genetics may become the dominant explanatory mode with respect to these issues and concepts. In contrast to attribution theory, Phelan (2005) describes what earlier researchers have called rise of the genetic essentialist view, in which “genes form the basis of our human and individual identities… and are strongly deterministic of behaviour.” When applied to mental illness, Phelan predicted that genetic essentialism should increase stigma by promoting the beliefs that (i) the mentally ill person is intrinsically different to others (cf. Mehta and Farina, 2005), (ii) mental illness is persistent and serious, and (iii) is likely to affect other members of the mentally ill person’s family. Taken together, all of these beliefs would tend to exacerbate social distance between the mentally ill person and others, and limit their perceived reproductive ‘fitness’, as well as that of other members of his/her family. It is clear that each of these beliefs correspond to the tripartite model of stigma outlined by Link and Phelan (2001) cited above. Setting apart is achieved by viewing biological differences as being more deep-seated and immutable than differences resulting from environmental effects (Phelan, 2001; Mehta & Farina, 2005); linking to undesirable characteristics is exaggerated by the sense that, when genes are involved, mud sticks – “if the problem is in your genes… full and permanent recovery seems less likely” (Phelan, 2001); and rejection and discrimination is exacerbated specifically in the realm of reproductive rights. Phelan tested her predictions using a case study in a nationwide (USA) survey. Like the above researchers, she found little support for attribution theory predictions that biological/genetic explanations for mental illness reduce stigma, except where punishment was concerned. However, she found that, in accordance with genetic essentialist theory, biological/genetic explanations for mental illness increased beliefs about its seriousness, persistence, and the likelihood of it affecting the siblings of a mentally ill person. Interestingly, biological/genetic explanations did not increase social distance from and perceptions of reproductive unfitness of the mentally ill person themselves, but only with respect to their siblings (Phelan, 2005).
It is appropriate at this point to consider whether the public’s genetic essentialist thinking is consistent with the current scientific understanding of how genes influence behaviour. Phelan (2005), following Alper and Beckwith (1993), asserted that “there is no necessary association between the degree of genetic influence on a behaviour and its malleability or persistence.” She also cites studies of people undergoing genetic testing that show that individuals tend to exaggerate the actual risk of developing a disease based on genetic profiles and family histories, and concludes that “public beliefs about the transmissibility of genetic characteristics are likely exaggerated by genetic essentialist thinking”. Her overall conclusion was that “the processes described by attribution theory and genetic essentialism are not mutually exclusive and that [her] findings support the idea that the effects of geneticisation on stigma are complex, ameliorating stigma along some dimensions while exacerbating it along others”. She then noted that conceiving of mental illness as a biogenetic disorder may benefit parents by absolving them of any (environmentally based) causal responsibility, but harm younger relatives of the mentally ill person, such as siblings or children.
5. FRAMEWORKS FOR UNDERSTANDING THE LINK BETWEEN BIOGENETIC CAUSAL MODELS AND STIGMA
Rejecting the notion that laypeople’s ideas about mental illness are merely reflections of professional concepts and allowing for laypeople’s ability to construct their own understanding, Haslam (2005) has developed a model of folk psychiatry, that comprises four dimensions along which the general public seek to understand mental illness. The first of these four dimensions is pathologising, the business of judging a person or his/her behaviour as deviant and abnormal, based on perceptions of infrequency, incomprehensibility, internal attribution, and entitativity, i.e. that those engaged in deviant behaviour form a coherent and ontologically meaningful group. The three other dimensions represent ways of explaining the pathologised behaviour. Moralising involves judging deviant behaviour to be under the actor’s control, and attributing it variously to perversity, sinfulness or criminality. Moralising derives from (the somewhat inaccurate) folk psychology way of explaining human behaviour, in which acts are understood to derive from intentions, which in turn derive from reasons, which are consciously considered beliefs and desires. Moralising assumes that intentionality underlies the deviant behaviour. In contrast, medicalising involves attributing deviance to some kind of physical aberration, a non-intentional causal essence, rendering it “the outward expression of a fixed identity-determining pathological essence” and thus an example of essentialist thinking in which forms of deviance are considered to be natural kinds, i.e. discrete, immutable, non-man-made groups. Psychologising occupies the middle ground, invoking mentalistic but causal and not fully intentional explanations for behaviour (Haslam, 2005). This model was validated in a study by Haslam and Levy (2005).
So what can this folk psychiatry tell us about stigma? The attribution theory approach to stigma clearly relates to the moralising dimension by its linking of the perceived self-controllability of mental illness to blame and anger, and renders sensible efforts to destigmatise mental illness by using biological/causal explanations, akin to the medicalising mode of explanation. The lack of success of such destigmatisation campaigns “reflect components of the essentialist mode of thinking hypothesised to underpin medicalising. Locating the disordered in a bounded category reflects the discreteness component [of natural kind thinking] and pessimism over recovery reflects immutability.” (Haslam, 2005).
The recommendations that researchers have made in the light of their results to reduce stigma vary from the firm line taken by Read and Harré (2001) that destigmatisation programs should primarily involve increasing the interaction between the mentally ill and the larger public, and placing the mentally ill person’s condition in the context of life events rather than biological/genetic factors, to more integrative models favoured by Phelan (2001, 2005) and Corrigan and Watson (2004). These researchers favour continuing to make use of biogenetic explanations in destigmatisation campaigns, given the importance of reducing blame and taking into account political considerations, such as the need to influence resource allocation. However, they believe that biogenetic explanations should be combined with psychosocial factors and information about the effectiveness of treatment and the actual likelihood of violence and other disturbing behaviour (Corrigan and Watson, 2004), and counteracting some of the misperceptions generated by genetic essentialist thinking (Phelan 2001, 2005).
And here's a list of references, so you know I'm not just quoting my imaginary friends:
Corrigan, P. W. and Watson, A. C. (2004). At issue: stop the stigma: call mental illness a brain disease. Schizophrenia Bulletin, 30(3), 477-479
Haslam, N. (2005). Dimensions of folk psychiatry. Review of General Psychology, 9(1), 335-47
Link, B.G. and Phelan, J.C. (2001). Conceptualising stigma. Annual Review of Sociology, 27, 363-385
Levi, M and Haslam, N (2005). Lay explanations of mental disorder: a test of the folk psychiatry model. Basic and Applied Social Psychology, 27(2), 117-125
Mehta, S and Farina, A. (1997). Is being “sick” really better? Effect of the disease view of mental disorder on stigma. Journal of Social and Clinical Psychology, 16(4), 405-419
Phelan, J. C. (2002). Genetic bases of mental illness – a cure for stigma? Trends in Neuroscience, 25(8), 430-431
Phelan, J. C. (2005). Geneticization of deviant behaviour and consequences for stigma: the case of mental illness. Journal of Health and Social Behaviour, 46 (December), 307-322
Read, J and Harré, N. (2001). The role of biological and genetic causal beliefs in the stigmatisation of ‘mental patients’. Journal of Mental Health, 10(2), 223-235
Teen Screen (coming soon to a cinema near you)
BBC Radio's "All in the Mind" recently reported from the U.S.A. on the increasing controversial mental health screening programs for school children. An excerpt of Claudia Hammond interviewing Joanna Moncrieff, MD can be found here. In the interview, Dr Moncrieff highlights the issues of informed consent, misdiagnosis and attendant (self-)stigmatisation, and the inevitability of drug treatment of those identified as 'positive.' She doesn't speculate about financial links between the instigators of Teen Screen and pharmaceutical companies, but plenty of others have done so, as will be apparent from the web link.
So what is Teen Screen screening for, exactly? From a research paper on the official TeenScreen (a.k.a. Columbia Suicide Screen) website:
"Students were identified as screen positive if they endorsed any of the following on the CSS:
(1) suicidal ideation in the past 3 months, or
(2) a prior suicide attempt at any time, or
(3) three of the five emotional items (unhappy, withdrawal, irritability, anxiety, or substance abuse) rated as a bad or very bad problem, or
(4) indication of a youth's desire to speak to a professional about any of five emotional symptom items."
So, here's my screening of Teen Screen:
(1) One wonders how the concept of 'suicidal ideation' was communicated, given that it is a broadly defined term encompassing everything from fleeting fantasies born of temporary frustrations to well-planned, fully intentional but unsuccessful attempts. Not to mention the "To be or not to be" to-and-froing de rigueur in English classes and the cultivation of a quasi-existentialist weltanschuuang - which often persists well into adulthood!
(2) This seems a reasonably straight-to-the-point question to ask, but I'd also want to know how 'suicide attempt' was defined. Would non-suicidal self-injury (e.g. superficial scratches to the wrists) be reported under this category? Would kids be encourage to include incidents of risk-taking behaviour of the boys-will-be-boys variety?
(3) Is 'bad' merely not 'good' or 'neutral'? Will there be some attempt made at establishing why the teenager is unhappy, withdrawn, anxious etc before a prescription is written? Will they take into account the fact that minors live out a somewhat totalitarian existence, and are not as free as adults to change or escape from whatever it is that is contributing to their emotional turmoil?
(4) The study was conducted in New York. (OK, cheap shot.) But people will consult shrinks for plenty of things that fall well within the realm of everyday stresses and strains: relationship problems, career counselling, study techniques... (It seems to me that many psychiatrists in private practice seem to specialise in the Bridget Joneses of this world: "OMG, I'm nearly thirty, still don't know what to do with my life, still haven't met the man of my dreams, how depressing!" etc. And not just in New York!)
It turned out that 84% of positives were false-positives. But if we only save one life... etc... yes, that's a valid point. I'm not so much averse to having kids take the test itself (setting aside for a moment the issues of informed consent and Big Pharma involvement) but to the consequences for the kids who return a positive result, even those in the other 16% . Psychiatry is a mental health hazard to teenagers, conceptualising annoying but temporary and situationally-based adolescent behaviour as ingrained personality disorders, and indoctrinating them into a culture that, to paraphrase Freud, encourages them to make hysterical misery out of common unhappiness. And maybe, just maybe, that's the kind of thing that leads to suicide.
So what is Teen Screen screening for, exactly? From a research paper on the official TeenScreen (a.k.a. Columbia Suicide Screen) website:
"Students were identified as screen positive if they endorsed any of the following on the CSS:
(1) suicidal ideation in the past 3 months, or
(2) a prior suicide attempt at any time, or
(3) three of the five emotional items (unhappy, withdrawal, irritability, anxiety, or substance abuse) rated as a bad or very bad problem, or
(4) indication of a youth's desire to speak to a professional about any of five emotional symptom items."
So, here's my screening of Teen Screen:
(1) One wonders how the concept of 'suicidal ideation' was communicated, given that it is a broadly defined term encompassing everything from fleeting fantasies born of temporary frustrations to well-planned, fully intentional but unsuccessful attempts. Not to mention the "To be or not to be" to-and-froing de rigueur in English classes and the cultivation of a quasi-existentialist weltanschuuang - which often persists well into adulthood!
(2) This seems a reasonably straight-to-the-point question to ask, but I'd also want to know how 'suicide attempt' was defined. Would non-suicidal self-injury (e.g. superficial scratches to the wrists) be reported under this category? Would kids be encourage to include incidents of risk-taking behaviour of the boys-will-be-boys variety?
(3) Is 'bad' merely not 'good' or 'neutral'? Will there be some attempt made at establishing why the teenager is unhappy, withdrawn, anxious etc before a prescription is written? Will they take into account the fact that minors live out a somewhat totalitarian existence, and are not as free as adults to change or escape from whatever it is that is contributing to their emotional turmoil?
(4) The study was conducted in New York. (OK, cheap shot.) But people will consult shrinks for plenty of things that fall well within the realm of everyday stresses and strains: relationship problems, career counselling, study techniques... (It seems to me that many psychiatrists in private practice seem to specialise in the Bridget Joneses of this world: "OMG, I'm nearly thirty, still don't know what to do with my life, still haven't met the man of my dreams, how depressing!" etc. And not just in New York!)
It turned out that 84% of positives were false-positives. But if we only save one life... etc... yes, that's a valid point. I'm not so much averse to having kids take the test itself (setting aside for a moment the issues of informed consent and Big Pharma involvement) but to the consequences for the kids who return a positive result, even those in the other 16% . Psychiatry is a mental health hazard to teenagers, conceptualising annoying but temporary and situationally-based adolescent behaviour as ingrained personality disorders, and indoctrinating them into a culture that, to paraphrase Freud, encourages them to make hysterical misery out of common unhappiness. And maybe, just maybe, that's the kind of thing that leads to suicide.
Thursday, January 4, 2007
Genius and Madness - The Dark Side of the Sun
One of the things that bugs me most about some quarters of the ex-user/survivor movement is their non-too-subtle elision of genius and madness, and the appropriation of those few who are both brilliant and mad as folk heroes. While it might be argued that this is a good way of destigmatising 'mental illness', the self-serving nature of it is all too obvious.
Take the Icarus Project, an online forum for those who identify as suffering from bipolar disorder. Their mission statement includes the following:
"We believe we have a dangerous gift to be cultivated and taken care of, rather than a disease or disorder to be suppressed or eliminated. By joining together as individuals and as a community, the intertwined threads of madness and creativity can inspire hope and transformation in a repressed and damaged world. Our participation in The Icarus Project helps us overcome alienation and tap into the true potential that lies between brilliance and madness."
Much of this, such as the de-emphasis of the medical model and their re-emphasis on their relationship to the world at large, is laudable. But describing extreme mood swings as "dangerous gifts" and referring to "the true potential that lies between brilliance and madness", only serves to cloak the sheer hell of some "extreme states of consciousness" with the allure of the heavenly gift of poesy (together, I suppose, with the heavenly gifts of notoriety, alcoholism, affairs, wild parties and unauthorised biographies).
As Joanne Greenberg, author of the autobiographical novelI Never Promised You A Rose Garden noted in an interview, "Creativity and mental illness are opposites, not complements. It's a confusion of mental illness with creativity... Craziness is the opposite: it is a fort that's a prison... The thing is I want to choose my perceptions.I don't want them to come out of some kind of unconscious soup. I want it to be something I choose to say, not something that says me."*
I was once involved with an advocacy group which liked to speak of "psychiatric (dis)abilities". I never did figure out what a "psychiatric ability" was - tongueing your meds, perhaps? What gets lost in all this palaver about genius and madness is that while some 'mentally ill' people are very talented, they, along with the not-so-talented, are subject to significant and unrelenting emotional and perceptual problems, plus their inevitable mismanagement by mental health services, and this really, really hurts. It's not fun, it's not romantic, and for those who would cultivate their angst and try to short-cut their way to genius via madness, it's not worth it.
Take Harry Crosby, J P Morgan's nephew, Croix de Guerre recipient, founder of the Black Sun Press, but sadly derivative poet of 1920s Paris, who appears to have been an exponent of this manoeuvre:
INVOCATION TO THE MAD QUEEN
I would you were the hollow ship
fashioned to bear the cargo of my love
the unrelenting glove
hurled in defiance at our blackest world
or that great banner mad unfurled
the poet plants upon the hill of time
or else amphora for the gold of life
liquid and naked as a virgin wife.
Yourself the prize
I gird with Fire
The Great White Ruin
Of my Desire.
I burn to gold
fierce and unerring as a conquering sword
I burn to gold
fierce and undaunted as a lion lord
seeking your Bed
and leave to them the
burning of the dead.
Incorporating orgies, affairs, animal sacrifices and a double suicide at 31, Crosby's lifestyle, although perhaps unfairly sensationalised by his biographers at the expense of his good works, amounts to little more than carefully choreographed experimental excess, a life dedicated to chasing the 'black sun' that signified both life and death - but not art, unless life is art - in which case madness and eccentricity seem to be the preferred media.
Instead of presenting your life as art, there is the option of making art out of life experiences - which requires a certain degree of detachment from the self and the capacity to analyse it in its broader socio-political context. Among the unreadable mumbo-jumbo that constitutes Heinz Kohut's Analysis of the Self, lies the insight that one way out of pathological self-absorption is to to engage in useful, creative activities that involve "unsolved intellectual and and aesthetic problems", through which the ego is invested in projects outside of the self.
Bottom line: A lot of people suffer from emotional problems. Some of these people (perhaps a few more than you'd expect going by the general population) possess and utilise creative gifts of the highest order. But most don't, and some of those who don't do try to find meaning and justification for their experiences in fanciful notions of their own 'specialness' - the artist manque, or by assuming dominant, autocratic roles in what are supposed to be democratic ex-user/survivor movements. Ironically, this need to feel or be seen as 'special' may have been part of the problem in the first place.
* Laurice L McAfee, "Interview with Joanne Greenberg", in Ann-Louise Silver, ed., Psychoanalysis and Psychosis (1989) pp.513 - 531.
Take the Icarus Project, an online forum for those who identify as suffering from bipolar disorder. Their mission statement includes the following:
"We believe we have a dangerous gift to be cultivated and taken care of, rather than a disease or disorder to be suppressed or eliminated. By joining together as individuals and as a community, the intertwined threads of madness and creativity can inspire hope and transformation in a repressed and damaged world. Our participation in The Icarus Project helps us overcome alienation and tap into the true potential that lies between brilliance and madness."
Much of this, such as the de-emphasis of the medical model and their re-emphasis on their relationship to the world at large, is laudable. But describing extreme mood swings as "dangerous gifts" and referring to "the true potential that lies between brilliance and madness", only serves to cloak the sheer hell of some "extreme states of consciousness" with the allure of the heavenly gift of poesy (together, I suppose, with the heavenly gifts of notoriety, alcoholism, affairs, wild parties and unauthorised biographies).
As Joanne Greenberg, author of the autobiographical novelI Never Promised You A Rose Garden noted in an interview, "Creativity and mental illness are opposites, not complements. It's a confusion of mental illness with creativity... Craziness is the opposite: it is a fort that's a prison... The thing is I want to choose my perceptions.I don't want them to come out of some kind of unconscious soup. I want it to be something I choose to say, not something that says me."*
I was once involved with an advocacy group which liked to speak of "psychiatric (dis)abilities". I never did figure out what a "psychiatric ability" was - tongueing your meds, perhaps? What gets lost in all this palaver about genius and madness is that while some 'mentally ill' people are very talented, they, along with the not-so-talented, are subject to significant and unrelenting emotional and perceptual problems, plus their inevitable mismanagement by mental health services, and this really, really hurts. It's not fun, it's not romantic, and for those who would cultivate their angst and try to short-cut their way to genius via madness, it's not worth it.
Take Harry Crosby, J P Morgan's nephew, Croix de Guerre recipient, founder of the Black Sun Press, but sadly derivative poet of 1920s Paris, who appears to have been an exponent of this manoeuvre:
INVOCATION TO THE MAD QUEEN
I would you were the hollow ship
fashioned to bear the cargo of my love
the unrelenting glove
hurled in defiance at our blackest world
or that great banner mad unfurled
the poet plants upon the hill of time
or else amphora for the gold of life
liquid and naked as a virgin wife.
Yourself the prize
I gird with Fire
The Great White Ruin
Of my Desire.
I burn to gold
fierce and unerring as a conquering sword
I burn to gold
fierce and undaunted as a lion lord
seeking your Bed
and leave to them the
burning of the dead.
Incorporating orgies, affairs, animal sacrifices and a double suicide at 31, Crosby's lifestyle, although perhaps unfairly sensationalised by his biographers at the expense of his good works, amounts to little more than carefully choreographed experimental excess, a life dedicated to chasing the 'black sun' that signified both life and death - but not art, unless life is art - in which case madness and eccentricity seem to be the preferred media.
Instead of presenting your life as art, there is the option of making art out of life experiences - which requires a certain degree of detachment from the self and the capacity to analyse it in its broader socio-political context. Among the unreadable mumbo-jumbo that constitutes Heinz Kohut's Analysis of the Self, lies the insight that one way out of pathological self-absorption is to to engage in useful, creative activities that involve "unsolved intellectual and and aesthetic problems", through which the ego is invested in projects outside of the self.
Bottom line: A lot of people suffer from emotional problems. Some of these people (perhaps a few more than you'd expect going by the general population) possess and utilise creative gifts of the highest order. But most don't, and some of those who don't do try to find meaning and justification for their experiences in fanciful notions of their own 'specialness' - the artist manque, or by assuming dominant, autocratic roles in what are supposed to be democratic ex-user/survivor movements. Ironically, this need to feel or be seen as 'special' may have been part of the problem in the first place.
* Laurice L McAfee, "Interview with Joanne Greenberg", in Ann-Louise Silver, ed., Psychoanalysis and Psychosis (1989) pp.513 - 531.
Appointments with the Enemy
Let's just say that you haven't lost faith in psychiatry entirely as a helping profession, and you decide to go and see a psychiatrist (or psychologist or whatever) to seek help with dealing with the aftermath of your misdiagnoses/incarceration/over-medication/assault. Naturally, this raises a few delicate issues: how do you know that (a) you're not simply going to cop a second helping of Haldol, (b) that the psychiatrist won't defensively interpret your story as paranoia, and (c) assuming that you choose a psychiatrist from the analytic end of the spectrum (i.e. one that believes in 'talking therapy'), they won't institute their usual flat ban on talking about psychiatry in the abstract?
Talking about psychiatry in the abstract is an obvious way of 'testing the waters', enabling you to see where the psychiatrist stands on various issues before you launch into a potentially distressing re-telling of your story. However, analytic-oriented therapy has a long tradition of instructing patients not to think too hard about the analytic process from a professional point of view and even not to read books on the subject, as this can somehow contaminate the analytic process. Thus, talking about psychiatry in the abstract, even its non-analytic aspects, can easily be construed by the therapist as inappropriate use of the 'therapeutic space.' So what to do?
Talking about psychiatry in the abstract is an obvious way of 'testing the waters', enabling you to see where the psychiatrist stands on various issues before you launch into a potentially distressing re-telling of your story. However, analytic-oriented therapy has a long tradition of instructing patients not to think too hard about the analytic process from a professional point of view and even not to read books on the subject, as this can somehow contaminate the analytic process. Thus, talking about psychiatry in the abstract, even its non-analytic aspects, can easily be construed by the therapist as inappropriate use of the 'therapeutic space.' So what to do?
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