Inscription, Diagnosis, Deception and the Mental Health Industry

How Psy Governs Us All

Craig Newnes

• Publisher: Palgrave Macmillan
• Year: 2016
• ISBN:
  9781137312969
• Topic: Politics & International Relations
• Subtopic: Social Policy
• Index: Politics & International Relations

The Psy complex governs us all by inscribing, diagnosing and interfering in our lives. This volume takes historical, sociological and psychological perspectives in exploring the complicity of patients, professions and governments with Psy and attempts by all three to constrain the industry's activities.

1

Thou Shalt Not Kill

On my desk sit some 30 or so textbooks,¹ two novels,² an autobiography³ and 50 psy journals. The textbooks represent less than 1 per cent of my library, much of which rests in boxes elsewhere. These 30 are worth about US$500, which might be all a commentator needs to know about the psy industry, a global economic endeavour supporting researchers, universities, pharma, clinicians and publishers. The titles before me are revealing; sociological and critical analyses of psy compete with historical accounts. There is an absence of books that might be subsumed under variants of “A Guide to Curing X Using Y: An Evidence-Based Approach”. Contemporary psy practitioners are likely to have shelves more populated by books of the latter type. Whether or not they read them is unknown and, to the publishing industry, unimportant. The barely read volumes on the shelf behind me attest to my own bias.⁴

The date of publication of these volumes has significance dependent on the reader. As noted by Marshall,⁵ there is a tendency among psy practitioners to focus on work of recent origin. Thus the most contemporary book (as it happens, my own)⁶ on my desk might be preferred to The Asylum as Utopia,⁷ first published in 1837, and reprinted with an introduction by Andrew Scull in 1991. Yet The Asylum details many of the arguments still prevalent today between professionals claiming expertise and jurisdiction over the mad. A plea for asylums to embrace moral therapy, it maintains – in a familiar and contradictory fashion – the position that insanity lies within the realm of medicine for understanding and treatment. As now, the position was not without its critics. An editorial in the Quarterly Review from1816 opined: “the strict medical treatment of madness must be regarded … as empirical, and the most extensive experience proves that very little is to be done”.⁸

Within a century, madness had fallen deeper within the embrace of medicine while psychology, via Freud, Watson and others, was laying claim to the territory. A further century on and the psy industry dominates a public discourse of distress, as its language and diagnostic terminology are used by everyone from teachers and concerned relatives to media pundits, including sports and music journalists.

For alienists of the early nineteenth century, the questions of nature versus nurture or character versus environment were as prominent as they are today. Partly due to the influence of phrenology, the brain featured in these disputes: “The brain, as a material organ, was liable to irritation and inflammation, and it was this that produced insanity.”⁹ Despite much claimed “advances” in the mind/brain conundrum, psy is no further forward in crossing the divide between metaphoric constructions such as love, guilt and avarice, and the specific workings of the brain. Concepts such as depression and disorder remain context-bound linguistic devices rather than testable or reliably measurable diseases of the brain. Neville’s conclusion in the first half of the nineteenth century that he could find no “connection of the faculties of the mind with the brain”¹⁰ still obtains. Philosophers have little difficulty with such a conclusion; for those dependent on research funding in the field of neuropsychology, it is an overlooked perspective.¹¹

Contemporary observers would recognize the context in which The Asylum as Utopia appeared. Parliamentary inquiries of 1807, 1815–1816 and 1827–1828 had revealed “medical malfeasance, maltreatment and, even murder” as everyday barbarities within the hospital system.¹²

The psy professions

Professions evolve slowly. Although statements by professional bodies may move with the zeitgeist, the practice of individual members of psy remains invisible to public scrutiny and may not reflect the aspirations of any particular professional body. In an article from 1996, after a brief historical overview of clinical psychology’s alignment with psychiatry and scientism, I suggested:

We need to take both our history and the experiences of our trainees [newcomers yet to be drawn in to the professional rhetoric and aware of “the smell on the ward, the patients’ fear of the effects of medication, the power of the responsible medical officer, the common sense of those deemed mad.”]¹³ more seriously. We need to constantly review our place in maintaining power for some at the expense of others and find ways of helping our profession articulate some of this in ways which ordinary people could understand …

And I concluded: “If we don’t, we are doomed to continue the boring trudge towards professional credibility and political neutrality at the expense of our humanity.”¹⁴ Some might suggest that, as a well-paid, white, professional male in a secure role as psychological therapies director, I was having my cake and eating it. The remarks were heartfelt and formed part of an anti-professional rhetoric traceable to at least the nineteenth century. The appeal for humanity above scientism (they need not be mutually exclusive) could be made again today with little change to the critique of the profession’s public stance.

The British Psychological Society’s (BPS’s) position is a (stereo)typically professional one. The society regularly makes public statements in the fields of psychology and health policy. As in many similar statements by other professional bodies, however, a close analysis reveals contradictions – an inherent difficulty when claiming to respect psy recipients’ dignity and individuality while simultaneously, as human science, categorizing those individuals. This inherent difficulty obtains in the practice and research of psy professionals where their own supposed individuality is disguised by means of appeal to expert status, a status that tends to exclude the presence of psy professional-as-actor within the published discourse. To some extent, this is less the case in psychoanalytic praxis where the examination of countertransference is routine. Here, obscurantism dominates by reference to unconscious processes that only the analyst can divine (through an equally abstruse language and untestable theories).

A further challenge faced by the BPS is that members are people too. They are as likely to be as distressed and oppressed as their patients and research subjects. Claims to expertise in living can be questioned via simple enquiries about a particular psychologist’s experience in, say, parenthood, religion or sexuality.

It has been claimed that some people are so odd, challenging or downright obnoxious to be around that their only chance of human contact is with people paid to attend them. For Wolfensberger, in a moralizing account of the service response, staff–patient or client–carer interactions are likely to add to the distress of service recipients.¹⁵ For all his directness, however, he does not detail the challenges faced by staff and carers. Even John Bailey, in his otherwise brutally honest account of living with the Alzheimic Iris Murdoch, does not dwell on the minutiae of necessary physical procedures.¹⁶ An unflinching account of the indignities and physical unpleasantness of bowel cancer is to be found in Unexpected Lessons in Love. Written by a retired psychoanalyst, the novel is striking in its plainly autobiographical scenes featuring shit and other bodily matters. Like The Iris Trilogy it has the advantage of being transparently honest and should perhaps be required reading for anyone considering a career in nursing.¹⁷

Much publicized scandals in the UK in relation to the hospital care of older people have used terms indicating disgust at a “failure of care” among paid staff, failure that frequently involves assaulting and neglecting patients. Bailey comes closest in describing a possible reaction to the presence of someone who is ill and docile, yet immensely demanding: aggression. He describes with great candour his murderous emotional responses to the woman he had been married to for 47 years.

In exposing the abuse of patients by staff, there seems little room for any discussion of the fact that pace Wolfensberger being paid to care does not remove a professional’s human response. I have discussed elsewhere how little is known about the interactions between trained clinical psychologists and patients in the consulting room.¹⁸ Similarly, little is known about the daily interactions of care and nursing staff with their patients. Patients, however, may be aggressive, repetitively demanding, frustratingly docile and themselves frustrated. This can be the consequence of the ward environment, medication or aspects of the patient’s way of coping that pre-date service involvement. Staff reactions to such conduct can be contextualized in terms of the unrealistic expectations placed on them by professional bodies, their public image (nurses as “saints”), relatives and the patients themselves.

Wolfensberger is loath to concede that facing patients who shout, smear faeces or lash out on a daily basis is too much to ask of paid staff. His position can be seen as contradictory in that he offers frequent examples of elderly parents who have killed their disabled adult children due to concern that the services will not be able to cope when the parents can no longer do so. There are now regular reported incidences of carers who kill in the context of the exhausting demands of their charges. John Knott, for example, was “devoted to his terminally-ill wife Anne” yet shot her and himself. Anne was diagnosed with Alzheimer’s disease.¹⁹ If parents or others who claim to love people placed in care cannot cope to the extent that they have placed them in the hands of strangers, it seems unlikely that those strangers – even when described as caring professionals – will do much better (for a discussionof a psychodynamic understanding of the carer’s predicament, see Chapter 4).

The above discussion focuses on the physical challenges faced by care staff. My intention has not been to reduce the import of other challenges. For example, miserable people, notwithstanding the imprimateur of a depression diagnosis, are miserable to be around – one reason why therapy sessions are only an hour long. Similarly, someone responding to voices telling them to shout at strangers is frightening, with or without a label of schizophrenia. A woman who refuses to eat on a daily basis will irritate and upset nursing staff in a similar way to the effect her conduct has had on relatives or lovers. Self-harm through cutting requires a degree of patience (and tolerance of blood) few people regularly display – staff or members of the public.

John Bailey, for example, has no hesitation in using the tranquillizing neuroleptic promazine to give himself peace from his wife’s restlessness: “Carers … soon become experts at reading the physical symptoms and choosing the remedy from among the sedatives prescribed. When Iris has a wandering fit at two in the morning promazine syrup seems the best bet.”²⁰ Bailey doesn’t require the myth that promazine is an “antipsychotic” chemical agent. Like thousands of care staff concerned to keep their patients as docile as possible, the drug is used as a tranquillizer. Listed as an antipsychotic in the British National Formulary (BNF), promazine is recommended for agitation and restlessness in older people. Due to contact sensitization, staff are warned to handle the tablets with care, yet the drug is taken orally by patients. Almost 50 adverse effects are noted, including agitation. Potential drowsiness, nightmares and insomnia are noted, all effects seen by staff and Bailey himself as features of dementia rather than the results of medication.²¹ Throughout the BNF, adverse effects are listed as “side-effects”, a linguistic device implying that drugs target particular behaviours and symptoms. In fact, medication acts in poorly understood ways on individuals with unique metabolisms who are frequently already affected by other medications, coffee, alcohol and similar psychoactive substances.

It seems too simple to me to place at the door of care staff the responsibility for the indignities and assaults foisted on patients. This recourse to proximal and individualized explanations and accusation may suit organizations, professional bodies and relatives but it is acontextual. Relatives are in a double-bind. Unable or unwilling to take on the task of meeting the daily demands of being a full-time carer, many – it would seem quite reasonably – turn to services. There are regular media accounts of the “sacrifices” made by relatives, though these seem outnumbered by the more newsworthy treatment of hospital or care-home scandals. Similarly, increasing numbers of people describe in the media their adverse reactions to psychotropic medication, promoting instead the benefits of professional counselling. For millions more, the simple experience of being helped by friend or neighbour goes unrecorded. This is, in part, due to the promotional efforts of therapists and counsellors, but also due to the ordinariness of neighbourly conduct and friendship: the media have little interest in discussing the everyday.

For those trusting professional services, who agree to their relatives being labelled, medicated or moved elsewhere, it is a commonplace that their anger at the mistreatment of patients is fuelled by guilt following the act of rejecting their parents or children, or a sense that they should have known what might happen. The hierarchical context of institutional care is such that proximal explanations for mistreatment, along the lines of “The nurse/psychiatrist/paid carer was wicked”, become a focus wherein one factor – the peculiar nature of institutional response – is ignored. Further, the places where people are congregated bear little relation to ordinary homes. The necessary rules around safety make, for example, fire doors ubiquitous, and for many older, more frail people, pushing open a heavy fire door is impossible; they are trapped for the best of intentions. As one ex-patient and carer at Shelton Hospital remarked, “there is nothing normal about these places”.²²

Designed in 1843 to accommodate 60 mad people, Shelton Hospital, then the Salop County Lunatic Asylum, welcomed 120 patients. As in most other similar asylums, overcrowding led to the necessity of calming the residents. Bromides were introduced in 1857 and paraldehyde in 1882. Three years later the po...

Table of contents

• Cover
• Title Page
• Copyright
• Contents
• Acknowledgements
• List of Abbreviations and Acronyms
• Introduction
• 1. Thou Shalt Not Kill
• 2. The “Service Wounds”
• 3. Labelling and Languaging the Other
• 4. Rejection: Exclusion and Incarceration
• 5. Assault as Treatment
• 6. The Oblivion Express: Big Pharma
• 7. A Mouthful of Air: Talking Therapies and the Emperor’s New Clothes
• 8. Governing Professions I: Us and Them
• 9. Governing Professions II: Them and Us
• 10. So It Goes
• Notes
• Bibliography
• Name Index
• Subject Index