Wednesday 17 April 2013

Hegemony and madness: I rage!

[I wrote this in 2002, occasioned by the incarceration in mental hospital of a friend; I haven't published it before, but now I feel it may be useful to several people whom I know are presently going through periods of difficulty]

All of us are biased. All of us have our own demons, our history, our prejudices, our own understanding of the world; it is impossible for anyone, no matter how concerned, no matter how caring, no matter how professional, to truly act as advocate for another. Only the individual can speak for him or herself. And yet when an person is vulnerable, when their confidence is undermined, when they are going through difficult and unpleasant experiences, that person is not in the best condition to fight their own corner, to argue their own case. When a person is vulnerable, they may need an advocate, however imperfect, to argue their case. And when a person is vulnerable, they are most vulnerable to exploitation by would-be advocates who wish to argue another case.

So the best anyone can do when trying to present a case for another is to make their own biases, their own history, explicit: to make visible to everyone concerned where the advocate is coming from.

I have my own experience of mental hospitals and of mental health professionals. As individuals, those I have dealt with have been without exception admirable people, concerned, dedicated, caring, and professional. I had a very disturbed childhood which culminated in an fifteen month incarceration in a psychiatric hospital; during my adult life I've had two serious episodes of disturbed and difficult behaviour which led me to accept out-patient psychiatric treatment. I have had a very fair opportunity to observe and assess psychiatry at close quarters.

And I have learned a very profound antipathy to its methods, its practice, and its ethics.

On the nature of psychiatric illness

Everyone, all the time, has some degree of stress, anxiety, fear and emotional turmoil. This is normal. It's normal for these things to fluctuate throughout one's life; it's normal to have bad times in one's life when they increase. As these things increase, of course, there comes a point where it is difficult for the individual to carry on the basic activities of normal life; as these things increase there comes a point where the individual's behaviour begins to disturb others. But there is no qualitative difference, no step-change, no break point along this continuum. There's no objective point at which one can say, by reference to an objective measurement, that this person is ill (although there may - will - come a point at which one says 'I can no longer cope with this person's behaviour').

Contrast this with those things we normally call illnesses. When I have a cold, I cough and sneeze and everyone can see this. When I have flu, my temperature fluctuates, and this can be measured using a thermometer. If I had anaemia, the proportion of red cells in my blood would fall, and they could be counted. If I had diabetes, the proportion of sugar in my urine would increase, and this could be demonstrated by chemical analysis. If I had cancer, there would be a hard lump of demonstrably abnormal tissue somewhere in my body, and it would be growing.

This isn't to deny, of course, that medical doctors use observation and judgement in their diagnoses, but nevertheless their discipline is primarily technical and objective. Contrast mental health professionals: they use no thermometers, no pressure cuffs, no stethoscopes; and it's natural that they do not, because they have no objective symptoms to measure.

Whereas the medical doctor is in some sense a scientist, or at least recognisably a technician, the psychiatric doctor is a priest, a magi, or a judge; his tools are observation, comparison, judgement and hegemony.

If I accept the judgement of a medical doctor that I have flu, it does not in any way affect the objective fact of whether or no there are actually active influenza virii in my body, and it does not in any way affect my cure. By contrast, if I accept the judgement of a psychiatric doctor that I am schizophrenic, then I am schizophrenic, and my chances of recovery are immediately and drastically diminished. Before, I was going through a bad time, and I knew I was going through a bad time, and I knew what I had to do was get my act together, sort my life out and get on with it. Now I am mad. My recovery is no longer within my own hands, no longer my own responsibility. I have an illness, which can only be cured by taking toxic drugs - tranquillisers which will damage my will, make me more docile, make me less able to assert myself and get my life back onto an even keel; and anti-psychotics which will gradually eat away at my brain's ability to function, and give me the shakes which will mark me out in the street as a madman. With every day that passes, full recovery to the person I was before becomes less and less possible, because the mental equipment to enable that recovery is being gradually eroded. Gradually I learn to be a sick person, a docile person, a grateful recipient of the essential medicines of the wise doctors. Gradually I learn no longer to have the ambition to be a full member of society, no longer to seek to take my part in its civic life.

The human brain is a curious organ, curiously self referential and recursive; if you can persuade it that it is sick, it is sick. Of course, persuading it that it is not ill is not sufficient to make it healthy, to reduce those levels of stress, anxiety, fear and emotional turmoil back to levels which are tolerable to the individual and to those around the individual: but it hands the responsibility of behaving normally back to the individual where it belongs. It returns autonomy.

Axiom: in a free society, the autonomy of a person is inalienable

In a free society, an underlying assumption - an axiom - is that individual members of the society are moral beings with responsibilities, duties, and rights, which they exercise autonomously as independent agents. That is what a 'free' society means, and is what distinguishes it from a tyranny.

So if human rights have any meaning in a free society, the most precious right - the most inalienable right - must be the right to autonomy. To live one's own life, make one's own decisions, make one's own mistakes, and live with the consequences.

Thesis: suicide is not the worst thing that can happen to a person

There's an unexamined assumption which underlies the medicalisation of society that the worst thing that can happen to a person is that they can die. Thus anyone who attempts suicide is necessarily acting irrationally. This assumption does not bear examination. No-one now believes in (or admits to believing in) an arbitrary, harsh or vengeful deity; society is divided between those who believe in a life after death supervised by a good, just and loving deity, and those who believe there is no deity and no life after death.

Lemma the first: supposing there is a deity

If someone finds life to be intolerable, and commits suicide deliberately, is it credible that a loving deity will condemn that person to further punishment? Such behaviour would clearly be unjust and unkind. So a loving deity (if there were one) could not do it. Suppose someone who does not on the whole find life intolerable commits suicide in a brief moment of despair, is it credible that a loving deity would impose eternal punishment for the unconsidered action of a moment? Such behaviour would - again - clearly be unjust and unkind. So a loving deity (if there were one) could not do it. So there can be no religious grounds for viewing suicide, in itself, as leading to further suffering.

Lemma the second: supposing there is no deity

If someone finds life intolerable, and commits suicide, then their experience ends. It ends completely, as though a light were switched off. They can experience no more suffering.

Thus by dilemma, the worst consequence for the individual of suicide is an end to suffering. For the people who surround the individual, of course, there is loss, grief, and possibly guilt, so suicide is not without consequence; but there are worse things. After all, for some people (Diane Pretty died today), life is intolerable.

What is all this about?

Two months ago, a friend of mine tried to kill herself. It was a spur of the moment action, but followed a period of several months during which she'd been getting progressively more anxious and less confident of her own ability to cope with her life. She's been incarcerated in a mental hospital ever since. She's a very important friend to me, because she's the person who principally helped me through my own most recent very difficult period, about eight years ago. It would be wrong to say we were close friends, but we are, I think, good friends.

One can never tell how close someone else's experience is to one's own. It's very easy to see analogies between what one understands of someone else's life and what one knows of one's own. I perceive that my friend's experience of the bad times in life are similar to my own, I feel that this was what enabled her to be so supportive to me, and I feel empathy for her; but I cannot tell whether she feels that my experience is similar to hers, and in her present vulnerable state that doesn't feel like something I can ask.

But I look at her condition, and how she is being treated - how her dignity is being assaulted, her autonomy denied, her will suppressed - and I rage. I rage. I rage inwardly, of course, because my rage is my problem and doesn't help her, because until she can present a meek, placid, docile face - until she can at least pretend to have clipped wings - she will not be let free. But inside, I rage.

'You can't leave until you accept you're ill'

From the point of view of the medical professional, this statement makes some sense. If you believe a person is chronically ill, and needs drug therapy to stabilise their condition, then clearly you believe that they should keep taking their drugs for their own good, and they won't do this unless they believe there is a valid reason to do this, because the drugs are toxic and have unpleasant 'side' effects. So that, unless they come within your mind set, accept your hegemony over their condition, they aren't safe to leave.

But compare this with two other forms of statement:

'You can't have parole unless you confess you're guilty'

This, of course, is a form of statement still used in the British penal system: in order to qualify for parole, prisoners must confess to the crime for which they've been imprisoned. Innocent people who maintain their innocence can't have parole.

'We won't stop torturing you until you confess your heresy and recant'

The famous inquisition standard. Very tough if you're not a heretic.

What these statements have in common is that the institution  requires the individual to accept the belief state of the institution, before the individual can be relieved of the treatment which is appropriate to that belief state. Why is this?

Because in each case, the treatment of the individual by the institution is unconscionable - impossible to reconcile with conscience - unless it is justified. To deprive a free individual of their autonomy, to hold them captive, to forcibly or coercively feed them toxic substances - all these things are utterly unacceptable behaviours unless you are in some sense doing it for their own good.

However, while is is arguably a matter of objective fact whether or not someone has committed a crime (even though the process of detection and justice may be flawed), it is not a matter of objective fact whether or not someone is mentally ill. It's a matter of subjective judgement; a matter, ultimately, of tyranny.

And this tyranny is very clear in the treatment of my friend. We go, together, to find the nurse who is 'in charge' of her 'care'. May she, she asks, come out for the afternoon with me a week hence? 'Perhaps' is the answer. 'If you're well enough'.

What does 'well enough' mean in this context? Does it mean 'if your temperature has fallen back to normal'? Does it mean 'if the bleeding has stopped'? Does it mean 'if your blood-sugar level has fallen to this value'?


There are no objective measurements of 'madness'.

It means 'if we say so'. It is arbitrary tyranny at it's most naked and blatant. It can too easily mean 'if you're docile enough'; too easily mean 'if you accept our hegemony'.

But this tyranny is not merely evil in its own right. It's also, in the case of people who are going through difficult periods in their lives, desperately counter-productive. For many people - as for my friend - a major part of the stress which made her vulnerable in the first place was anxiety about being able to retain her independence, anxiety about being able to continue to earn a living. To recover, to become (from the viewpoint of the mental health professionals) 'well', she needs to recover her sense of mastery over her life, her sense of being in control of her destiny. In a simple word, her autonomy.

Yet imposing hegemony on her, denying her her freedom, denying her her autonomy over her own body serves to undermine, to erode these very things. To reduce her from a free, creative, capable member of society into a docile, pill-popping dependent. And the tragedy is that in the eyes of the mental health professionals, this is a positive outcome. It's a positive outcome because the individual, reduced to this dependent, tranquillised,  medicalised state, will stay alive. Set free, restored to her autonomy, allowed to take her own decisions, to take her own risks and make her own mistakes, she might yet freely choose to die.

Well, so she might. That's her inalienable right. To die is not the worst thing that can happen to a person. To be diminished, to be caged, to live with clipped wings, to be drugged into docility: these are worse things.

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