Deconstructing Paranoia: An Analysis of the Discourses Associated with the Concept of Paranoid Delusion
David J. Harper PhD Thesis June 1999
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Implications for political interventions in mental health
By revealing the constructed nature of psychological phenomena, we create a space for making available alternatives to what 'is'. Thus, it could be expected that discourse analysts have something to say about how things could be done differently. For example if discourses of psychopathology and their associated practices and institutions disempower users of mental health services, then how can this be changed? Are there ways of talking about emotional distress which are preferable? And how can such alternative constructions and practices be promoted?
Willig (1998, pp.94-95)
8.1 IMPLICATIONS AND APPLICABILITY: THE VERY IDEA
In the previous chapter I explored some of the interests involved in the construction of this piece of research. In doing so I also noted some of the ways the research had influenced me. I want to continue this thread in this chapter by looking not only at how the research has influenced me (and my practice) but at how it could potentially influence other forms of practice. In other words, this chapter will be standing back from the research and asking questions like 'so what?' and 'what now?'. But it will attempt to do this whilst aiming to remain analytic and reflexive. There is a danger in sticking too closely to one's research and when researchers do they often too readily use clichés like 'further research on this is needed'. As a result I will focus not only on the minutiae of 'findings' about paranoia specifically but also at some of the consequences of the broader themes in the thesis. Many of the implications are general and not focused specifically on 'paranoia'. This is because I did not want these suggestions to be framed by a concept which is constructed within a dominant psychiatric discourse. The idea of suggesting implications which cut across such categories is, of course, an intervention in itself. There are potential criticisms: that one could suggest such implications without having done the research, that is, that there is no link between the study and the implications. There are two responses to this. Firstly that I myself am a link and that the research has influenced my ideas and practice and ideas about practice and I attempted to describe this process in the previous chapter. Secondly, as I will argue later in more detail, interventions do not necessarily have their origin in academic research. My aim here then is to note of all the possible interventions one could make, which are the better ones in the light of this study?
It has become customary for many theses to have a section focussing on the implications of research. However, what is often not made explicit is what it is that the implications flow from and who are they aimed at. Moreover the notion of objectified 'research findings', abstracted from a particular context and 'applied' elsewhere is problematic. In this chapter I will briefly review some of the dilemmas involved in the notions of implication and applicability, arguing instead for a notion of usefulness and the generation of new ideas about intervening (including consideration of how to judge the radical potential of new developments) in order to help change the situation of current users of mental health services. As I argued at the end of chapter 7, my aim is not to talk of true but of better stories and the same goes for implications. I will suggest the need for a concerted but diverse range of targets: academic researchers in psychiatry and allied fields like nursing, social work and clinical psychology; practitioners in those fields; the wider group of practitioners involved in providing psychotherapy and counselling; users of mental health services and their relatives and friends; and the broader political arena. The what of implication will be both general and specific ideas emerging from this current study linked with allied developments in each of the target areas.
8.1.1 Problematising 'applicability': the case of clinical psychology
The notion of applying research has often been problematic for many disciplines. Within psychology, the profession of clinical psychology -- with its notion of the scientist-practitioner as a model to which all aspire -- perhaps exemplifies some of these tensions and difficulties. Because of this and because also of my professional location as a clinical psychologist, I will use this profession to highlight some of the important issues here.
One common criticism in clinical psychology is that much research is not applicable. Watts (1984) for example, has argued for a distinction between two kinds of research activity: applied (ie oriented to a core area of psychology) and applicable (ie oriented to solving a problem). In this paper Watts raised concern about whether the status of clinical psychologists as scientist-practitioners was merited by claiming that 'the majority of clinical psychologists in the NHS do not do any research at all' (p.41). The debate about clinical psychologists and research has gone on for some years with Head & Harmon (1990) continuing to raise concern about the relative lack of research activity from a discipline so wedded to it as an identity. Milne et al. (1990) claim the situation is better if the definition of research is widened. However the most common finding in such surveys is that few psychologists do research or consume it as it is ordinarily understood. Thus Norcross et al. (1992) reported that the modal number of publications by British clinical psychologists was zero and that 8% produced approximately half of the published work although 76% had published at least once in their careers. Only 20% of Milne et al.'s (1990) sample read an academic journal each week (although 45% did monthly) whilst only 14% attended national scientific conferences more than once a year (although 66% attended annually). They also reported that only 16% thought published research had 'a lot' of influence on their work.
Pilgrim & Treacher (1992) devote two of their seven chapters to the scientist-practitioner issue, clearly seeing it as of central importance to British clinical psychology(1). Surveying this debate, they concur with other commentators in concluding that clinical psychologists' practice is more influenced by discussions with colleagues and experience than by published research and that few psychologists do research or see it as anything other than a rhetoric of professional legitimation.
Thus although the notion of applicability has strong rhetorical power (especially in terms of legitimating professional groups) it seems to happen less in practice than might be supposed. Potter (1982) argues that the work of psychology practitioners is not directly influenced by research for the simple reason that theory and practice are seen as separate and are often separated institutionally (eg holding separate conferences etc). We have seen in chapter 6 how theory often seems to follow developments in treatment as a post hoc justification (Gabbay, 1982). Potter (1982, p.46) concurs, noting that 'it is not hard to conceive of theories being used as a gloss on application which has been undertaken for quite different reasons' .
However, both the arguments for and against applicability rest on what Hoshmand & Polkinghorne (1992) see as modernist and positivist assumptions. McNamee & Gergen (1992b) note how the modernist scientist-therapist model has come under sustained attack from: critical therapists; family therapists; community psychologists; feminist scholars; phenomenologists; constructivists; hermeneuticists; and ex-service users. Hoshmand & Polkinghorne (1992) argue instead for a 'constructivist' paradigm which emphasises 'the mutuality of science and practice' (1992, p.55). John (1997) similarly sees evidence both of positivist and postmodern discursive repertoires regarding theory and practice. I will consider these views in more detail later, but there are other problems with applicability to consider first.
8.1.2 Further problems with 'applicability': ethics and politics
Willig (in press) takes up these points and develops them further specifically in relation to DA. She distinguishes between different types of DA (eg a focus on discursive practices à la Potter & Wetherell, 1987, versus a focus on discursive resources à la Burman & Parker, 1993). She notes the traditional 'scientific' criticisms of the dangers of political bias in applying psychology and picks up three critiques of applicability: Potter's ideology of application critique (which we briefly described above); the view that application is open to abuse; and the critique that applying DA findings might risk reification.
Elsewhere, she has noted problems with relativist critiques of political intervention (Willig, 1998) and cites Eagleton (1990) who has suggested there be more political rather than merely philosophical debate. Willig comments that applied relativism allows dominant discourses to go unchallenged. Her view is that applying DA research is a necessity and her critical realism is a:
result of the recognition that we as human agents find ourselves within a context in which things are always already going on or being done. Within this context it is impossible to abstain from involvement since inaction is always a form of action. Thus, we can only ever argue for or against, support or subvert particular practices or causes but we can never disengage ourselves from them.
I would agree with Willig that applying research is desirable but it would be a mistake to assume that DA research is straightforwardly applicable. There are a number of problems: for instance what constitutes 'research' and what constitutes 'research findings'? Moreover what counts as an 'intervention'? These questions seem particularly pertinent at the end of a discourse analysis. There are no summary statistics of 'findings' here and attempts to give a broad sweep of this analysis might lead to excessively vague generalisations. Rather than start at the level of this thesis and see what might be 'applied' I have found it helpful to focus on particular target groups and ask what might be of interest or of use to them as well as to ask which might be the most influential medium of communication for each group. I am persuaded by Pilgrim & Treacher's (1992) findings about how to influence the practice of clinical psychologists, doing this by focusing less on publications and more on influencing networks of psychologists by word of mouth, small training workshops or newsletter-type publications which more professionals read. By contrast, one might seek to influence academics through the published literature. Indeed, Willig's (in press) criticism of most recent attempts to apply DA related to the media of application: predominantly academic texts and thus focusing both on a minority of those one might wish to influence and on the already-converted. My ability to apply ideas from this research is obviously limited within the constraints of this dissertation since it is likely that it will only be read by a small number of people. However, it can stand as some kind of intervention if it is also augmented by communication through other media (eg articles for user magazines and newsletters, professional journals and conferences etc).
8.1.3 Even more problems with 'applicability': definitions and oppositions
There is relatively little work on understanding what counts as an intervention, what counts as a 'good' intervention and on understanding how effective interventions come about. Traditional conceptions of applying research, as we have seen, do not help us here, constrained as they are by the implication of an unhelpful opposition between theory/practice. This has led to the mechanistic use of interventions described in the literature, to researchers showing political naïveté -- for example, being surprised that effective pilot projects do not receive continued funding even when they appear to be successful (cf Cook & Shadish, 1986). Rather than draw on positivist notions which assume a mechanistic, linear and naïve notion of theory and practice, I prefer the notion of usefulness. Gergen has discussed this concept elsewhere (Misra, 1993). By usefulness here I mean to refer to whether a particular idea or intervention leads to richer understanding and to just and socially responsible outcomes. Of course there are still difficulties here. For example the concept does not tell us who it is who judges whether something is useful and there is the danger, as Danziger (1997) points out, of the old wine, new bottles syndrome where, for example, the therapy establishment assimilates useful ideas into conventional practices. This links in with Willig's (in press) criticism that workers seeking to 'empower' others fail to offer criteria for differentiating between differing definitions of empowerment. Thus McLean (1995) notes that within the psychiatric ex-patient/consumer movement the term empowerment has assumed 'diverse and even contradictory meanings' (p.1055) since it may refer to:
an increase in mental health treatment options and in opportunities for consumers to voice their preferences to help determine future options. It may refer to a process, a goal to be achieved, or a combination of these. It may also refer to processes occuring in relation to the individual, the organization or the larger social structure, or to interrelations among these levels. Finally it may be used to refer to a service approach
McLean (1995, pp.1055-1056)
Bhavnani (1988, 1990), Burton & Kagan (1996) and Smail (1995) all warn against simplistic individualised and psychologised notions of empowerment.
In chapter 3 I warned that deconstruction was not about simplistic humanistic empowerment but was about challenging the oppositions implied within clinical categories: individual/social; reason/unreason; pathology/normality; form/content; pure categories/messiness; and professional/popular. I have suggested elsewhere (Harper, 1996b) that the value of interventions (eg therapies in mental health) could be judged by the extent to which they challenge these oppositions and that all need to be challenged. Frosh (1992) argues that such challenges require not necessarily choosing one term over another but by challenging the basis of the opposition, the conceptual policing that keeps the terms apart. I would agree that what I would consider 'better' interventions would be involved in the deconstruction of these oppositions as well as tracing the influence of power and the production of gender, race, age, class and sexuality. But we risk a utopianism here and it may be that a short-term politically-effective intervention might be one which champions a currently subjugated term over its dominant rival. Burman & Parker (1993) note that 'discourse analysts now can champion the cause of a particular discourse by elaborating the contrasting consequences of each discursive framework, and can promote an existing (perhaps subordinate) discourse' (p.170). As Parker et al (1995) remind us, there are no perfect interventions and all involve some problematic assumptions. But some are less worse than others and thus we may choose to use them to 'trouble mainstream approaches' (p.102) as 'deconstructive spanners in the clinical truth machine' (p.102). Such work involves tactical thinking rather than a reliance on notions of fixed truth. However, Willig (in press) has warned that a focus only on tactics is misconceived since 'tactics must flow from a position which itself cannot be the result of tactical choices'. So when we are engaged in alternative practices we have to remain vigilant that the new practices do not simply re-assert the old problems in new guises.
As I have argued elsewhere (Harper, 1995c), however, interventions do not flow directly from research, rather the use of these ideas is a matter of practical engagement through one's political standpoint. Even if forms of DA and deconstruction are not used explicitly they may still inform interventions. Theory/practice, then, needs to be seen as less linear and separate but instead as dialectical, recursive and reflexive since reflection on practice is theorising and since theorising is itself a practice. Thus, following Kolb et al. (1974) and Andersen (1992):
practice reflection/theorising practice reflection/theorising
Such a view has much in common with John's (1997) postmodern repertoire of theory and practice and Hoshmand & Polkinghorne's constructivist/postmodern view of 'the science-practice relationship' (1992, p.55)(2). Drawing on a systemic model, they argue that this:
places generative theorizing and theory-testing within the context of practice. It is only through this type of interdependent relationship and mutual feedback that researchers and practitioners can benefit from each other ... the productive interaction of theory and practice in a primarily practice-based approach to inquiry can contribute to what we regard as the knowledge of practice.
Hoshmand & Polkinghorne (1992, p.60)
Of course, there need to be ethical and political principles and criteria to orient us to what counts as better theories and/or practices, as I have outlined above.
As we move towards research which focuses on intervention, can we not find ideas from research already conducted of use? Willig (in press) suggests it is possible to find DA research that is of use in developing interventions and she lists a number of different strategies of or types of intervention: exposing how dominant discourses operate; providing a space for alternative constructions; therapeutic interventions; education/consciousness-raising; campaigning; and lobbying . There are difficulties with some of these. Thus, in relation to the exposing of dominant discourses, Danziger (1997), noting how constructionism has most obviously functioned as a form of critique, comments on the danger of reifying the object of the critique and thus becoming dependent on it through the use of traditional categories (like 'paranoia') such that new theorisation looks little different from current concepts. In relation to providing space for alternative constructions, writers like Bhavnani (1988, 1990) have problematised notions of providing spaces for alternative constructions, questioning whether simply giving a voice to marginalised groups is empowering. Burman et al (1996), commenting on McLaughlin's (1996) emancipatory discourse analysis, note his concern that 'the 'voice' given to previously silenced people does not necessarily speak for them' since 'the whole notion of giving a voice runs the risk of reproducing those power relations the research was intended to transform, by reintroducing a relationship of patronage' (p.178). In relation to therapeutic interventions, Danziger (1997), commenting on McNamee & Gergen's (1992a) Therapy as Social Construction, has noted how new 'deconstructive' therapies seem much like old therapy, with relatively few explicit links to social constructionism or deconstruction -- Luepnitz (1992) and Hak (1994) have made similar criticisms. Finally, Willig's list of attempts at interventions (from the pages of the journal Discourse & Society) seem to be more studies of lobbying or studies of campaigning rather than lobbying and campaigning using discourse analytic or deconstructionist ideas.
How can research activity be helpful to political intervention? First, it can be directly linked to intervention (eg action research) especially where the research agenda is driven by users of mental health services. Second, it can be helpful as an ally, for example where research findings support the views of service users (Rogers et al., 1993, is a good example of this) or where it deconstructs professional views I would see as harmful (Bentall's, 1990, work is a good example of this). The current research falls into this latter category and so the issue here is less about particular findings leading directly to political intervention but rather that future intervention might be informed by ideas like these. There is, of course, no guarantee that research will not be misused -- thus Walkup (1994) has noted how reactionaries can be constructionists too -- or not be reified. One must seek simply to seek to abstract enough to be useful but not so much that reification sets in.
In the rest of this chapter I will focus on seven target audiences for whom there are some different general and specific implications from this research. Although some of these audiences will not necessarily be used to academic styles of language the sections are written in academic language. This is because this thesis is an academic text, written for an academic audience. I have noted what I think would be relevant to say to different audiences and highlighted particular aspects of the research which I have considered relevant to that audience (I have not sought to incorporate material from all the chapters in every section). As I have said elsewhere I would need to do something additional to this thesis were I to try to reach these audiences. Some of the interventions are really resources (eg further reading) which give further detail on the points I want to make. I have not tried to list every possible intervention and resource (and interested readers may find further resources in Parker et al., 1995).
We begin with comments addressed to those working within current statutory mental health/psychiatric services. Many of these interventions come from other traditions of critique or innovative practice, rather than discourse analysis or deconstructionist or social constructionist work. But, as Burman & Parker (1993) note, you don't have to be a discourse analysis to see the political context of issues, in this case of mental health practice surrounding notions like paranoia.
8.3 PRACTICAL IMPLICATIONS FOR DIFFERENT INTEREST GROUPS
8.3.1 Implications for the organisation and delivery of mental health services: from power to partnership?
In their recent review of analyses of the social organisation of psychiatry, Pilgrim & Rogers (1994) remind us that despite a postmodern enthusiasm for analyses of psychiatry moving beyond the realms of the hospital, the reality of psychiatric intervention remains much as it was some years ago. They see elements both of a postmodern trend in, for example, the development of Community Mental Health Centres (see Griffiths, 1997, for an interesting analysis of professional negotiation with psychiatry) and of a continuing modernist trend in the predominance of biological views (witness the enthusiasm for new wonder-drugs and the continued use of ECT), the continued high expenditure on hospitals (85% of the British mental health budget is bound up with hospital-based services -- Sayce, 1991) and the use of coercion both in the use of the Mental Health Act and practices like 'seclusion'. It is clear too that some hospital institutions are abusive in the way they treat patients (see, for example, Potier, 1993). Commentators like Samson (1995) have detected signs of the fracturing of medical dominance through the operation of National Health Service reforms and through the pushing of other professional groups (like clinical psychology) into traditionally medical terrain. Psychiatry has responded by trying to be eclectic, maintaining dominance through the continued use of medication and by taking on aspects of the consumer culture. Moreover, as community care has begun to lose some of its glow, Samson sees psychiatry's role as an authority on risk as useful in maintaining dominance and legitimacy (see Rose, 1996, on this).
Much of this analysis is accepted by more progressive psychiatrists. Thus Thomas et al. (1996) state that 'community care has failed because the policy has effected nothing more than a geographical shift in the locus of care' (p.401). They argue that psychiatry needs to take poverty, employment, housing and other environmental influences seriously rather than place a greater emphasis on biology. These links are long-established (see Cohen, 1993; Goldberg & Huxley, 1992). Bracken & Thomas (1997) have tried to push this debate even further by claiming that 'psychiatry has failed to live up to its promises, promises which were misguided from the outset' (p.18). Thomas (1997) argues that the recent history of psychiatry has been a dialectical one, characterised by pro and anti-psychiatry positions. He suggests that each side of the dialectic is needed in order to understand the needs of mental health service users and argues strongly both for a new ethical position for doctors which draws out the dilemmas of the Hippocratic oath (eg autonomy versus beneficence) and for working with users to change services so that they provide what they want and need. Some of these views are finding a resonance in psychiatric publications (eg Cohen, 1998). Thomas concurs with those arguing for a research focus on 'symptoms' rather than categories like 'schizophrenia'. Barrett (1996) agrees with this, suggesting the need for 'biological investigations on groups of people categorized in other ways that are less steeped in our cultural history' (p.305). He also suggests actively involving users of services in writing their case records in order to enhance therapeutically beneficial processes of 'objectification' (ie a distancing from their symptoms). Barrett suggests processes of 'reintegration' from hospital ward to community could be enhanced by making this agenda explicit and encouraging users to bring family and friends to team meetings. Noting the importance of moral evaluations by staff members of users, Barrett suggests that these judgements be made explicit through the development of 'a new clinical language' (p.306). He also suggests vigilance since these processes may also have harmful side-effects.
Others have been less cautious about the need for new languages for mental health workers. Thus Gergen (1990) has described how, despite humane intentions, mental health professionals draw on discourses of deficit. He asks 'what are the effects on human relationships of the prevailing vocabularies of the mind?' (p.357) and he notes how concepts of 'healthy functioning' are suffused with moral and cultural assumptions. Empirical studies of psychiatric case discussions (eg Soyland, 1994b) and case records (eg Mohr & Noone, 1997; Swartz, 1996; Terre Blanche, 1997) suggest that many of the terms used to describe service users are objectifying and imply pessimism and negativity. Gergen has developed his critique of such terms, and of the notion of diagnosis in general, elsewhere (Newman & Gergen, 1995; Gergen, Hoffman & Anderson, 1996) whilst others have mounted deconstructionist critiques (Parker, in press b). Suffice it to say that professionals need to develop new languages, practices and concepts for the way they assess people and plan services.
I have described some of the current issues for those working in mental health services but before going on to make some further practical suggestions, the next box will summarise, with an eye on this particular target audience, salient themes and issues from this research.
|Abstract box 184.108.40.206. General
and specific implications for workers in mental health
This research has investigated how the concept of paranoia is constructed in psychiatric and popular culture. In doing so it has described some of the dominant discourses and institutional practices which, as it were, fix paranoia in place. These discourses prescribe particular positions for service users and professionals and, as I have noted, many of these positions are limiting for users. Moreover, the way users and professionals talk about aspects of paranoia and its 'treatment' is not straightforward but, rather appears to serve a range of political interests. Thus, for example, discussions of the failure of medication are cast so as absolve professionals and medication of responsibility. For the most part, however, interests are hidden by the use of, for example, professional scientific language which obscures the occasioned and variable nature of discourse. We see this again in the way apparent 'failures' of medication are discussed. Professionals and users do not talk in the way they are predicted by text-books and dominant cultural conceptions. For example, psychiatric text-books convey certain constructions linking beliefs and distress and beliefs and action but the interview material reveals a wider variety of constructions of paranoia.
|Moreover, notions of plausibility have been demonstrated to rest on a number of unarticulated cultural assumptions. This thesis has attempted to tease out such assumptions (for example, the implied oppositions in discussions about paranoia) and to detail the consequences they have for users and professionals. By focusing on the way users and professionals talk, this research has highlighted the importance of language in constructing paranoia and in defining certain kinds of objects (eg paranoia, delusions etc) and subjects (eg the paranoid) and that language is an active constitutive agent rather than a passive transparent medium.|
In this apparently post-modern world of ours the old overarching grand narratives have broken down and it is possible for the practitioner to either feel so paralysed by competing ideas that they cannot move forward or feel the only way to do anything is to ignore many critical voices and instead simply engage with the individual client. The harder choice is to enter that ambiguous terrain where we act strategically to do what is possible in our individual positions whilst continuing to question dominant ideas and practices. Michael White notes:
Rarely do the institutions of our culture succeed in establishing states of pure domination. Because of this, in most institutions, spaces or gaps can be found through which workers can express their moral agency. And, in stepping into these gaps, we can all play a role in the transformation of the institutions that we work for.
Stewart (1995, p.152)
In the following box I try to summarise what actions could be taken that flow from this research either specifically, or from its general political position.
|Interventive Box 220.127.116.11
Suggestions for action by workers in mental health
1. Adopt a bill of rights for users of services. The following is an adapted version of Newnes' (1993) editorial, drawing on the list produced by the Walk-In Counselling Centre in Minneapolis:
As a client you have the right to:
2. Within the mental health system, it is the user movement which looks likely to be the most progressive political force. Symbolised by groups like Survivors Speak Out and the National Hearing Voices Network, these groups need all the help they can get to democratise the mental health system, particularly in terms of their rights in relation to physical treatments and the choice of alternative services. Professionals should seek to create opportunities for more user power (Brunning et al., 1994; Nelson & Walsh-Bowers, 1994; Williams & Lindley, 1996). One example might be to have joint training involving users, carers and workers (Brunning et al., 1994). Dulwich Centre (1995) describes an imaginative way that professionals could consult with users. Perkins and her colleagues (Perkins & Dilks, 1992; Perkins & Repper, 1996) have outlined an approach to mental health practice which focuses on working alongside people with mental health problems.
3. Much of psychiatric treatment revolves around hospitals, medication and ECT. There is a need to offer users more choice and information about these treatments. Moreover professionals should help develop alternative community and self-help services (eg crisis houses) -- Lindow (1994) gives some examples.
|Users also request easier access to
counselling and psychotherapy (Rogers et al.,
1993) as well as complementary therapies (Brindle, 1997).
Professionals should seek to develop services which
respond to this need. Even though medication is still a
first choice treatment by many GPs and psychiatrists for
mental health problems, the empirical evidence on outcome
is variable (Kriegman, 1996; Warner, 1985) and the
side-effects, especially for anti-psychotic medication,
are very harmful. It is unhelpful to take a simplistic
pro or anti stance on medication since some users find it
helpful some of the time whereas others do not (see
Brigitte et al., 1996). Professionals involved
in prescribing and administering medications should
explore with clients the pros and cons of medication,
looking in detail at the consequences for them and the
way they and others view themselves (cf Simblett, 1997).
White (in Stewart, 1995) suggests workers need to ask the
following questions about how one might go about
assisting service users to:
Stewart (1995, p.117)
This approach is distinct from that of 'compliance therapy' (Kemp et al., 1998) where motivational interviewing is used to encourage users to comply with their medication regime. If medication is used, much research suggests it works best at low dosages and at times when problems seem worst (Carpenter, 1996; Carpenter et al., 1987; Healy, 1997). Professionals should be more honest about the essentially pragmatic nature of treatments and should give users more control over them as well as developing audits of medication levels. Professionals can also be of help in assisting users to be more assertive in case reviews and reviews of medication (Day & Bentall, 1996; Harper, 1998, in press). Hospital care also could be improved with more of a focus on talking to users rather than on administrative, ancillary and medically-focused duties. Diana Rose (1998b) has made some suggestions in this regard as have Blaska et al., (1995), Carson & Sharma (1994) and Savage & McKeown (1997). Primary Health Care also needs further development to be more sensitive to the needs of people with mental health difficulties.
|4. Professionals need to engage in much
more public debate about their decisions and to be more
honest about the limitations of their models and help and
the constraints placed upon them. The notion of mental
health workers protecting the public needs to be firmly
critiqued as the notion of risk becomes central in
British mental health care (Bracken & Thomas, 1997).
Pfohl (1978) has suggested decisions on dangerousness
should be made in a public (and not solely professional)
5. There is a need for mental health workers not only to challenge dominant models of mental health but also to challenge services as they actually operate (since many do not even follow the models they espouse). There is a need for professionals to build alliances with user groups (eg ECT Anonyomous).
6. Nelson and Walsh-Bowers (1994) list a number of activities for radical workers wishing to share power and resources with users: acting as resource persons (eg providing education within an active learning model) to survivor-controlled self-help organisations; conducting participatory action research with survivor groups; work in partnership with survivors in helping develop meaningful survivor participation in mental health services; working with survivors and other citizens to advocate for supported housing, for the reallocation of funds to survivor-controlled organisations and businesses and for other social policy changes which would improve survivors' quality of life; finally, they can take a lead in eradicating stigma and discrimination (eg challenging media misrepresentation of mental health difficulties).
7. Workers need to link their work much more with anti-poverty, housing and employment projects rather than simply focus on psychological factors. Parker et al (1995) suggest other resources, some of which may be helpful for professionals.
8. Workers need to find a language and concepts that do not individualise mental health problems, do not separate people with such difficulties off from 'normal' people, by pathologising them and seeing them as deficient. One suggestion could be to focus assessment and care planning on what service users say they want and need rather than what professionals think they need. Newnes (1993) comments 'it might be an interesting exercise to imagine a service based on the assumption that the desires of clients would be met no matter what the cost' (p.2). Professionals need to find respectful means of communicating with users. Pilkington & Fraser (1992) have discussed some of these issues in relation to psychiatric files. The issue of language will be further discussed in the section aimed at therapists.
9. Workers need to develop ways of creating change that can be sustained and working within systems without colluding with them -- Johnstone (1989), for example, describes how innovations can be assimilated by oppressive systems. Praill & Baldwin (1988) arguing against a 'hero-innovator' model of institutional change, make a number of concrete suggestions for enabling and maintaining change in organisational systems as do Williams & Lindley (1996). Workers need to support each other when whistleblowing (Potier, 1993).
|10. Practitioners in particular disciplines may find the following resources of use given some signs of autonomy despite continued dominance by psychiatry. Mental health nurses (Campbell & Lindow, 1997; Hopton, 1995, 1997); pharmacists -- eg providing non-biased information about drugs and auditing medication levels and research (Day & Bentall, 1996; Donoghue, 1993); social work (Humphries, 1997). Clinical psychologists, community psychiatric nurses and some psychiatrists have adopted a cognitive-behavioural approach which is described more below in the section addressed to therapists.|
8.3.2 Users of mental health services
The organised psychiatric service user movement dates back to the 1970s and Chamberlin (1990) gives a useful description of the beginnings of the movement and its prospects in the 1990s and beyond. She sees its two main goals as 'developing self-help alternatives to medically-based psychiatric treatment and securing full citizenship rights for people labelled 'mentally ill' ' (p.323). There are a number of tensions and dilemmas in the movement. Thus McLean (1995) describes tensions arising as a result of contradictions in the notion of empowerment, tensions between the notions of advocacy and self-help, problems of hierarchies in organisations as well as other funding and organisational difficulties meaning that sometimes practice does not follow ideology. Rogers & Pilgrim (1991) have given an account of the development of the British service users' movement. They, too, note internal tensions and contradictions in the movement regarding ideology, for example about the nature of relationships with relatives, professionals and other agencies. They also note how one of the vulnerabilities of the user movement is its definition in relation to the services it has had contact with and the diagnostic labels considered stigmatising.
In chapter 3 we briefly discussed the ability of marginalised groups, like service users, to define their own identities, drawing on the work of Sampson (1993). As Blanch et al. (1995) have observed, users experience a denial of voice at a fundamental level since they are considered to lack the capacity to define reality. Using Sampson's distinction between 'accomodative voice' (in which the participation of oppressed groups is simply added to the discussion defined by those in power) and 'transformative voice' (where oppressed people speak in their own voice and are heard in a manner that allows the nature of the discourse to be transformed) they argue that often service users find that their participation is accepted 'only if they learn to speak in the language of those in power' (Blanch et al., 1995, p.50) and that users' suggestions that are not framed within standard bureaucratic or clinical frameworks are frequently dismissed as impractical' (p.50). They suggest user groups maintain contacts with external consumer/survivor political organisations and begin dialogues between groups of users and groups of professionals. I noted in the previous section how the Dulwich Centre (1995) has described a similar project. Sampson (1993) has argued for a dialogical view of the relationship between 'experts' and their clients. For this to be more than mere talk, however, there is a need for a powerful psychiatric service users -- or system survivors -- movement and it is likely that any progressive mental health service will either be provided by or, at least, be heavily involved with that movement. As Sampson (1993) has pointed out, the distortion of people's identities is not something that can be corrected by finding a true picture, the problem comes from the domination of one group's version. It is in diversity, both of power and of ideas, therefore, that a way forward is likely to lie. Indeed, the title of the British Hearing Voices Network's 1993 conference was 'the importance of a diversity of explanations' where biological accounts lay alongside parapsychological, spiritual and cognitive accounts (Baker, 1993).
Drawing on the work around the hearing voices movement it would seem that the best diversity occurs if service-users themselves are largely responsible for, or at least involved in, the planning and delivery of services. Thus the Hearing Voices Network (a voluntary group largely run by users and ex-users of mental health services) supports or is in contact with a wide variety of hearing voices groups (Baker, 1993). There have been successful partnerships here between users and researchers. Thus McLaughlin (1996) has described an action research project which resulted in the production of a video (McLaughlin, undated) for use by voice hearers and others. An increasing area of research and writing comes from those users and ex-users who either write about their own experiences biographically, or who theorise user experiences or who do both.
Autobiographical accounts of paranoia, since they give legitimacy to the author's beliefs, usually removed by other kinds of research, accord with a social constructionist approach. Steiner (1971) has declared that paranoia is 'a state of heightened awareness. Most people are persecuted beyond their wildest delusions' (1971, p.282) and we have noted the views of Blaska (1992) in chapter 3. Examples like these allow those considered to be paranoid to engage in a debate with those who attribute pathology to them. Such engagement lends credence to the view that there is a diversity of explanations for paranoia although as we have noted earlier, simply giving space to these views does not mean they will achieve any dominance.
Some users and ex-users have tried to theorise their and others experiences. Thus Coleman (1994) has declared he is 'psychotic and proud' and has written (Coleman, 1995) about how his experiences have shaped his views of psychiatry and madness. Davey (1996) has attempted to develop theories about the relationship between upbringing and psychosis. Probably the most thoroughgoing exploration of theories of paranoia from both a personal and a technical point of view are to be found in the writings of Peter Chadwick. In Chadwick (1992) he published the results of his doctoral research testing out various hypotheses about mystical and paranoid experiences. In Chadwick (1993) he developed a phenomenological account of his own 'schizoaffective psychotic crisis' which included some interesting observations on mental health theory and practice. He noted how professionals could learn a lot from users and noted that 'it was not at all therapeutic for me to regard myself either as in some sense categorically different from standard-minded people ... or as 'basically OK really' and merely labelled as ill for political reasons' (Chadwick, 1995a, p.31). He developed these ideas further later (Chadwick, 1997b) and has also published a comprehensive review of research and treatment on paranoia in a format accessible to professionals, users and their relatives (Chadwick, 1995b). In Chadwick (1996) he developed his theory of the relationship between spirituality and paranoia and has also given detailed descriptions of users's accounts, including a bravely honest account of his own experiences, arguing that although frightening, such experiences also made positive contributions (Chadwick, 1997a).
Of course, given such diversity we should not expect users of mental health services to have a homogeneous view since they also will have their own values, ideologies and political interests. Not all users will appeal to a liberatory discourse to explain their experiences. Bowden (1993), for example, adopts a straightforwardly medical interpretation of his experiences: 'I'm a paranoid schizophrenic. Many psychologists and psychiatrists have told me this over the years, but I am just coming to the point where I actually believe it' (1993, p.165).
|Abstract box 18.104.22.168 General and
specific implications for users and ex-users of mental
This research has described how users and their views tend to be excluded both in histories of paranoia and in contemporary professional literature. Moreover, professional discussions tend not to connect psychopathological theories with the construction of paranoia as a social category in culture. In making such a connection, this analysis has examined how the position of 'paranoid' may, on the one hand, be ascribed by others, for example, as a way of undermining one's legitimacy, whilst, on the other hand, it may be adopted by the self to fulfil a wide range of other functions. However, we have seen how the category of paranoia draws on a range of unarticulated assumptions which then construct those so positioned as individually pathological, irrational and so on rather than as adopting a conspiratorial position in order to serve particular interests. There is a relative lack of alternative concepts available in the professional literature and in popular culture by which we might understand such interests socially and individually without again indulging in pathologisation. Moreover, there is some fluidity in the positions that users and professionals adopt in discourse about paranoia and 'empowering' users through airing their views or by attacking a particular discourse may be unsuccessful if interests are not challenged and the languages and concepts available for people to define themselves through are not transformed.
|Interventive Box 22.214.171.124
Suggestions for action by users and ex-users of mental
1. There is a need to challenge dominant oppositions like normal/pathological and professional/user. If users realise that their experiences are normal this can reduce their anxiety. If professionals realise there is no separation between them and users this can lead to a more sensitive appreciation of the power imbalances between professionals and users. Thus, for example, Thomas (1997) calls for users to be more involved in the training of professionals and there are a number of training videos available which have heavy user involvement (eg Blackman, undated; McLaughlin, undated).
|However, there are dangers in
challenging these oppositions. Thus as McLean (1995) has
noted, when users become professionals new imbalances of
power may emerge. Moreover as users build alliances with
workers there is a danger of loss of independence and as
users become more involved in service-planning there is a
danger of tokenism.
2. There is a need for the development of user-controlled alternatives to statutory services (eg crisis houses and drop-in centres) but it is important to see that these do not simply become new mini-establishments. McLean (1995) has noted the importance of maintaining diversity in organisations although it is equally important not to be so diverse that there is political fragmentation.
3. Users need to demand rights in treatments (see 126.96.36.199) including the right to refuse treatments which may be harmful (including medication, ECT and even counselling).
4. This research has shown how complex some discursive frameworks can be thus there is a need to train users in how to deal with discourse, for example, about their treatment (eg Harper, 1998, in press).
5. There is a need for users to do more user-focused research although funding is a difficulty. One way around this might be to build alliances with radical workers adopting a collaborative or action research orientation (cf Rogers et al., 1993; McLaughlin, 1996).
6. Users' continued challenging of workers' limited views is essential. Thus, as McLaughlin (1996) notes: 'In 1995, the [Manchester Metropolitan University] Discourse Unit brought together, in the psychology department, to an audience of nearly 200 people, 29 voice hearers and professionals to present papers on hearing voices; the voice hearers outnumbered the professionals; this, we understood as opening up a practical discourse analysis. This in a small way posed the possibility of subverting boundaries' (p.242-243, emphasis in original).
7. Users often find material written by, or at least drawing on the experience of, users helpful. The Hearing Voices Network has produced an excellent booklet by Baker (1995) whilst Ron Coleman and Mike Smith have developed this work further through the publication of a detailed workbook (Coleman & Smith, 1997). Pembroke (1994) and Spandler (1996) have described users' perspectives on self-harm whilst Shelley (1997) has produced a similar book on anorexia. I have already mentioned the work of Peter Chadwick in this regard. The Hearing Voices Network also publishes a regular magazine, Voices, which also enables users and professional allies to network. Asylum magazine is another useful publication.
8. Users considered paranoid or deluded might wish to set up groups with others with similar difficulties in order to support each other, find useful explanations and helpful ways of coping similar to Hearing Voices Groups. Users might also contact
|currently operating interest groups with others having similar ideas so they are no longer in contexts where others think their views are odd -- there are a wide variety of religious, paranormal and UFO groups with people who have beliefs others might regard as odd.|
8.3.3 Relatives, friends and carers of users
In much of the critical writing about schizophrenia, relatives often get grouped with an array of powerful interests which seek to individualise and pathologise those attracting a diagnosis of schizophrenia. The National Schizophrenia Fellowship and Schizophrenia: A National Emergency (SANE), both charitable and campaigning groups, are largely run by relatives of users and seen as inherently conservative. There are relatively few, if any, progressive groups which involve relatives. Moreover, relatives are often placed in a position where pathologising their relative is the only way to secure support from services -- Birch (1991) has described how services may reinforce such unhelpful patterns. There is then a need to develop a wider variety of positions for relatives to adopt and which enable them to support their relative in a non-pathologising manner -- this is possible (see, for example, Powell, 1998).
|Abstract box 188.8.131.52 General and
specific implications for relatives, friends and carers
This research did not specifically research the views of relatives, friends and carers and so the implications noted here will, necessarily, be speculative and limited. It is possible that, as with much critical work, this study, in attempting to deconstruct the concept of paranoia will be seen as negative and destructive (in fact the word deconstruct is often confused with destruct). However, as others including Ussher (1989) have noted, to deconstruct something is not to deny distress. I have described some of the ways in which users become positioned by others -- it is possible that relatives, for example, might be caught up in such positioning and may even feel that this is the only way to get help for their relative. In the same way, such discursive work also positions relatives and it is interesting to note how so often the words carer and relative become synonymous. One wonders if Sampson's (1993) point about identity is apposite here -- in that relatives' identites may become dominated by a discourse of caring.
|Interventive Box 184.108.40.206
Suggestions for action by relatives, friends and carers
1. It is important for those close to a service user to understand the difficulties they may be going through. Self-help books and accounts can be useful in this respect. Chadwick (1995) also gives some useful advice as do Perkins & Dilks (1992) albeit in a more general fashion.
2. It is important for relatives to see 'paranoia' as an exaggeration of an essentially normal process: users of services are not categorically different from the rest of us. Labelling and pathologising a relative are not the only way to get help and there is an onus on services here too to ensure that services are not made inaccessible. Moreover, there is a need for relatives to try to ensure their identities do not become dominated by the caring role.
3. There is a need to develop more progressive relatives' organisations which more clearly support users' choices and which do not put complete reliance in a solely biological approach to mental health problems.
8.3.4 Psychotherapy and counselling practitioners
The message that emerges most powerfully is that people want to be heard and taken account of as valued individuals, rather than as vessels of diseased or badly programmed brains.
Rogers et al. (1993, p.157)
Rogers et al., (1993) note that 60% of their sample of psychiatric service users reported receiving some form of talking treatment although the definition of this seemed wide with the sample reporting having received it from more than one type of practitioner including psychiatrists, GPs, Occupational therapists, CPNs, clinical psychologists, GP surgery counsellors, private therapists and voluntary sector counsellors. Moreover, length of therapy varied with 22.3% of those reporting having received talking treatments having had five or fewer sessions with 45% getting twenty or more. These results suggest it is, perhaps, misleading to talk about 'therapy' and 'therapists' as if these were homogeneous groupings. However, for the purpose of targetting I will be using this as an umbrella term. Before going further, however, it is necessary to set therapy in context as an intervention.
220.127.116.11 The notion of therapy
One obvious radical implication of deconstruction would be to argue for the dismantling of the systems and practices of therapy since otherwise we risk reproducing some of the modernist assumptions and oppositions identified in this research. I have argued for an increasing role for service-users in the planning and delivery of services and, will later be arguing for broader political change that will attempt to address the dividing and exclusionary practices that lead us to offer therapy and to have 'services' for people. There is a dilemma here since having services itself leads to division and exclusion. However given that such radical change is likely to be a long-term strategy there is a need to explore shorter term strategies, including therapeutic alternatives which are available for mental health practitioners. Willig (in press) notes that therapy is one arena for the application of DA ideas.
Critics of therapy have generally seen it as a valid though severely limited approach, though some are resolutely opposed (Masson, 1988). Pilgrim (1997), in his review, concludes that a 'fainthearted defence' can be mounted for psychotherapy as an 'ameliorative industry' (p.152). Smail (1990, 1993) has argued for an environmentalist psychology in which therapy plays a secondary part to socio-political change and ordinary relationships. More recently Smail (1996a) has argued more strongly for self-help and political reform -- however, he has come under attack from those wishing to defend therapy (eg Rowan, 1997). Of course, suggesting therapy has a place does not mean denying the importance of political change. As Ussher (1989) has argued in the case of women:
Suggesting therapy does not imply that women are ill, that they need to be treated. It does imply that there are many difficulties and contradictions inherent in being a woman in our society and that women may need support and understanding on an individual level. Yet in the advocation of therapy, we must be careful not to fall into the trap of maintaining women's oppression.
Ussher (1989, p.141)
Moreover, Banton et al. (1985) note, in their advocacy of a politically-informed psychoanalytically-derived therapy that 'the development of radical therapy must arise out of a wider political awareness and practice, just as it will inform it' (p.162).
There is a dual danger of claiming that therapy can either do more or less than it can without a clear analysis of the context and resources that are necessary for change (eg see Smail, 1990). It has been argued elsewhere that a postmodern critical position concludes that rather than 'anything goes', it is a case of 'nothing goes' (Harper, 1996b; Parker, et al, 1995; Stenner & Eccleston, 1994) -- in other words, therapy, like all other potential interventions has intrinsic possibilities and dangers. Parker et al., (1995) reviewed a number of therapeutic approaches (psychoanalysis, anti-psychiatry, family therapy and cognitive approaches). I will not repeat such a review here but will instead briefly appraise some different approaches to therapy -- with the first two representing those most likely to be considered for service users -- to weigh up potential possibilities and dangers.
18.104.22.168 Cognitive-behaviour therapy
Recent years have seen an explosion of interest in applying cognitive-behavioural ideas to working with people with severe and enduring mental health problems (see, for example, Birchwood & Tarrier, 1994; Chadwick, et al., 1996; Fowler, et al., 1995; Haddock & Slade, 1996; Kingdon & Turkington, 1994). Much of this work has been conducted by clinical psychologists -- although some psychiatrists (eg Kingdon & Turkington, 1994) were early advocates -- and Hughes & Budd (1996) see a crucial role for clinical psychologists in this area. Boyle (1996) argues that, whilst valuable, these approaches fail to challenge traditional assumptions about madness and psychotic experiences. First, they continue, for the most part, to use psychiatric terms and concepts -- again it is a professional view which is dominant (power is as much a part of the psychotherapeutic encounter as it is in psychiatry). Second, they continue to locate pathology within the individual -- with either individual clients being seen for treatment or, with family education models, with the family being seen but with the problem still seen as located in the diagnosed individual. Third, researchers continue to focus on psychiatric rather than general populations despite evidence that psychotic experiences are normally distributed --pathologization is still privileged although rather than categorical models, conitinuum models are used instead (although if you are at the end of the continuum you are probably regarded as pathological). Fourth, they privilege reason over emotion -- whilst some approaches seek to understand how paranoia might be a rational response to circumstances it is more often seen as a sign of irrationality or a cognitive distortion, error or bias. Fifth, they continue to construe intervention as a means of getting rid of symptoms rather than as finding ways of understanding their meaning and function for those who experience them -- there is varying acknowledgement of content but outcome is often measured in terms of form: asking whether the delusion has 'gone' or 'lessened'.
Boyle is not completely pessimistic, however, and sees that these approaches have some power to challenge traditional assumptions: they often focus on particular experiences (like hearing voices) rather than supposed syndromes; they focus on the content of these experiences; and, finally they apply principles of 'normal' psychology to populations considered 'abnormal' previously. Parker et al (1995) have noted other criticisms of cognitive-behavioural approaches, especially their tendency to locate pathology in the individual. One offshoot of cognitive-behaviour therapy with those considered psychotic is work with the family.
22.214.171.124 Family-management/psycho-educational approaches
This tradition has its roots in some early work looking at the families of psychiatric patients (eg Brown et al., 1958; Brown et al., 1972; Vaughn & Leff, 1976). These studies suggested that families considered to have high levels of 'expressed emotion' (eg hostile and critical comments, emotional over-involvement and a relative lack of warmth or positive remarks) were likely to experience more and earlier relapses by the family members with a psychiatric diagnosis. Since that time a number of approaches to this have been adopted, many following a broadly cognitive-behavioural approach including educating family members about schizophrenia and helping them to adopt alternative ways of coping with their problems (Tarrier, 1996). These principles are being widely disseminated, especially to CPNs (eg Brooker et al., 1994) and are even being used in some hospital wards (Savage & McKeown, 1997).
Johnstone (1993a, 1993b) has mounted a thorough-going critique of family management models. She argues that there are a number of methodological flaws in research studies and that these are compounded by two conceptual problems: firstly that they unproblematically assume the validity of the schizophrenia construct; and, secondly, that they hold contradictory assumptions about blame and responsibility. To expand on this latter point, families are told (in education sessions) that schizophrenia has a biological and environmental cause and that they are not to blame -- this, in order to distance Family Management (FM) from the work of Gregory Bateson, R.D. Laing and others which is considered to have left many relatives being blamed and stigmatised (Johnstone, 1993b). However, they are then told that they can reduce relapse by changing the way they communicate. As Johnstone (1993a) notes, this leads relatives to ask 'if we're all doing well and it's not our fault, why do we have to learn all these new ways of doing things?' (p.443). Birch (1991) similarly notes this and other contradictions as well as arguing that current psychiatric practice sets up 'dis-abling cycles' (eg of victimhood, of fatalism etc). Johnstone argues that a close reading of the research shows that family relationship styles do play a causal role in 'initial breakdowns' as well as 'relapses'. However, to accept this would mean challenging traditional psychiatric assumptions which locate pathology within the individual schizophrenic. Johnstone also comments that the heavy reliance of FM models on traditional psychiatric notions (eg the use of neuroleptic medication as a prophylactic measure) obscures the fact that probably a majority of those diagnosed with schizophrenia could be treated drug-free. Johnstone's charges have been responded to vociferously (Leff & Vaughn, 1994). Although these approaches are often termed family therapy, Johnstone notes that FM workers are not family therapists in the usual sense since their role is:
not to uncover and find ways of expressing and exploring emotional tensions and conflicts, which is indeed a highly skilled job, but primarily to apply the sticking-plaster of behavioural and problem-solving techniques while avoiding or blocking the emergence of more difficult or deep-rooted tensions.
Johnstone (1993a, p.444)
Reviews of family intervention services reveal that a wide variety of models are drawn on (Burbach, 1995) although those training in the CPN courses noted above adopt a cognitive-behavioural orientation (Brooker, et al., 1994; Tarrier, 1996). One area which has attracted more interest recently is that of psychodynamic therapy.
126.96.36.199 Psychodynamic/counselling approaches
Recently, there have been attempts to use psychodynamic principles in work with people considered to be psychotic. Thus Mace & Margison's (1997) volume reviews current work in this area. Hingley (1992, 1997a, 1997b) has attempted to integrate psychodynamic and cognitive-behavioural approaches in developing a stress-vulnerability model of psychosis. Psychodynamic work with those considered psychotic has waxed and waned over the years and increasing interest is a positive contribution in that it challenges, to some extent, cognitive psychology's 'worship of rationality' (Boyle, 1996, p.39). Although rationality is not privileged, however, it continues to individualise and pathologise the experience of psychosis. There have been attempts in psychoanalytic thought to address some of these criticisms, including in the realm of psychosis (Georgaca, 1996; Parker et al., 1995). Feminist critiques and therapeutic models have had some impact here (eg Seu & Heenan, 1998).
188.8.131.52 Feminist approaches
I have already noted Rachel Perkins' work in this area (Perkins & Dilks, 1992; Perkins & Repper, 1996). Her analyses derive from a standpoint informed by lesbian feminism. In Kitzinger & Perkins (1993) this approach sees madness largely as a product of heteropatriarchal oppression. However, they note that 'it is difficult to see all distrurbances of thought and feeling as exclusively products of oppression' (emphasis in original) and they argue that:
it is hard to see how all learning disabilities (mental handicap), senile dementia, brain injury, and the major disturbances of thought and feeling called 'schizophrenia' or 'manic depressive illness' will be eliminated along with heteropatriarchy. These problems are, of course, exacerbated by oppression, but are more than simply products or inventions of it.
Kitzinger & Perkins (1993, p.165)
Although they draw on biological assumptions here, linking 'schizophrenia' and 'manic depressive illness' unproblematically with less controversially biologically-related categories like brain injury and senile dementia, they argue for a conception of madness as social disability which includes both a consideration of individual difficulties and also marginalisation and exclusion by wider 'able-minded' society (including the lesbian community). They conclude that:
socially disabled lesbians do not need a psychiatry or a lesbian feminist therapy, that individualises and privatises their problems and attempts to enable them to 'fit-in' to an able-minded world. We need a politics of social disability...
Kitzinger & Perkins (1993, p.184)
Instead of therapy, Kitzinger & Perkins argue for the need to challenge able-minded assumptions, to enable access into lesbian communities by socially disabled people and I will discuss this further in the section aimed at political activists. They also suggest the need for friends and allies, asylum, practical help and psychiatric medication. Perkins (1994) has also argued for the right to choose ECT. It seems strange that medication and ECT are seen as having some benefits whilst therapy is seen as having none and that drugs are not seen as individualising or pathologising women (as well as harming them) in a similar manner to the way that therapy can although I would agree with their call for communities to be more accessible. But whilst attempting to avoid individualising and pathologising people through therapy, they risk doing so through a commitment to physical treatments.
Ussher (1989, 1991) by contrast, sees a place for individual psychological help for women in the context of other political interventions and there are examples of feminist therapy, drawing on different models, which offer ways forward, connecting with social reality and taking the power-imbalance in therapy seriously (Chaplin, 1988; Seu & Holland, 1998). Similar criticisms could be levelled at these attempts as will argue later in relation to social constructionist approaches. However, some approaches have attempted to address the individual/social divide more vigorously than merely by developing new therapies, instead blurring the distinction between therapy and community and political action.
184.108.40.206 Therapy and community action
Holland (1991, 1992) has described a model of social action psychotherapy which acknowledges the need for individual psychotherapeutic help for women but quickly broadening this out, in a stage model, to talking in groups and then on to community action. Models such as this do not deny individual needs but try to transform these into social needs. This has much in common with advocates of community psychology and preventative programmes (Newton, 1992) -- Albee (1986), one of the main proponents of such approaches, has argued strongly that psychotherapy is futile (Albee, 1990). Another attempt to blur the distinction between therapy and political action is the Institute for Social Therapy in New York. However, there are political and ethical difficulties caused through such blurring (Parker, 1995) -- for example the temptation to see one political party as the agent of change. Such criticisms are rejected by the Institute (Holzman, 1995). Community psychology approaches have been criticised for psychologizing political issues and continuing trends of individualisation and pathologisation (Smail, 1994).
220.127.116.11 Therapies in response to postmodernism and social constructionism
Some of the work noted above is unashamedly modernist if not positivist whilst other therapies have been informed by post-structuralist feminist and other political analyses. However, increasingly, theorists in different therapeutic traditions have taken post-modernist critiques on board and attempted to develop theoretical responses. Woolfolk (1992) has discussed how psychotherapy and behaviour therapy can address the implications of hermeneutics and social constructionism. Here I will focus on therapeutic traditions which have been linked to systemic family therapy, in particular approaches explicitly linked to discourse analysis, Narrative therapy, Just Therapy, Solution-focused brief therapy, as well as the work of Tom Andersen, Harlene Anderson and Harold Goolishian. I wish to use these traditions as exemplars of therapists' responses to social constructionist, deconstructionist and postmodernist concerns since I am acquainted with them. I will review some of the work in this area first before discussing it more critically, finally reviewing some other therapeutic alternatives.
Discourse analysis has been used to investigate psychotherapy as a socially constructed activity (see, for example, Burman, 1992; Madill & Barkham, 1997; Soal & Kottler, 1996), as a means for understanding processes in therapy (eg Kogan & Gale, 1997; Frosh et al., 1996) and even as a means of investigating discourse analysts' accounts of psychotherapy (see Stancombe & White's 1997 account of Frosh et al.,'s 1996 analysis). Some work explicitly draws on discourse analytic studies. Thus Heenan (1998) has used a 'reflexive discourse analysis' as 'a possible framework for broadening out the focus of clinical supervision beyond content and process, to contextualising therapeutic discourse'. Foreman and Dallos (1992) used Hollway's (1989) and others' discourses of sexuality in their intervention in a case of 'sexual problems'. Hare-Mustin (1994) draws on a similar example to examine 'the discourses that circulate in the therapy room' (p.19) and to argue that therapists need to be reflexively aware of the limited and dominant nature of some discourses so that they can 'challenge the assumptions of dominant discourses rather than merely going along with them' (p.33). The notion of dominant and subjugated discourses is also a prominent feature of what has become termed Narrative Therapy.
18.104.22.168.1 Narrative therapy
Narrative Therapy (White & Epston, 1990), draws on the work of Foucault and aims at working in a non or anti-pathologizing manner. In this approach, client and therapist are seen as united in a struggle against a problem which is deliberately viewed as external to the person since it is 'the problem that is the problem' not the person or their intra-psychic state. Clients, including those diagnosed as 'schizophrenic' are invited to consider not only the dominance of the problem in their lives but also the history of their resistance to it and to examine 'unique outcomes', in other words, times when their resistance has worked. White (1987) discusses this particular style of therapy with families where a member is diagnosed as schizophrenic -- a diagnosis which, he comments, leads to an 'in-the-corner' lifestyle. He attempts to help the family undermine the dominant story of schizophrenia to find subjugated stories of personal autonomy and identity by 'externalising' schizophrenia. Allen (1994) quotes an example from White about how he might approach a client diagnosed as 'paranoid':
If a person is totalized as 'paranoid', I might ask them a series of questions like: How did you get recruited into the sense that you are under surveillance? In response to this question, persons speak of their experience more politically.
Narrative Therapy (NT) has now been described in a wide range of specialised texts (eg Epston & White, 1992; Monk et al., 1997; White, 1995a) as well as edited collections (eg Gilligan & Price, 1993; McNamee & Gergen, 1992a). There is even a how-to-do-it guide (Freedman & Combs, 1996) as well as a user's perspective (Sand, 1993).
Of most relevance here is some of the work done relating to people diagnosed with schizophrenia. Dulwich Centre (1991b) summarises some of this and includes a use of NT in a group setting, the 'Worthy of Discussion' group (Tapping, 1991). In a further description of this group the facilitators comment:
In talking about their experiences with others for whom the effects of mental illness has also been significant, the men's stories became validated. This validation encouraged further unravelling of the stories and provided us with the opportunity to externalise the problems and their effects. Through the process of externalisation, the men started to separate themselves from their problems. Restraints were reduced, they became empowered and were able to access other self knowledge. This gave them information of alternative life styles that could exist for them.
O'Neill & Stockell (1991, p.205)
As well as developing therapeutic techniques, White has developed a whole range of practices which avoid theorising either on the aetiology of problems, or diagnosing pathology, instead subverting institutional practices like the ward round, seeing hospital admission as a 'rite of passage' (similar to Barrett's, 1996, ideas on re-integration) as well as describing novel approaches to working with those who hear voices similar to the work of Romme & Escher (1993, see Stewart, 1995). He has also facilitated a group for those who hear voices, the 'Power to Our Journeys' group (Brigitte et al., 1996). Simblett (1997), influenced by similar ideas, has even developed a NT approach within psychiatry.
Narrative therapists aim to have effects outside the therapy room through the use of letters (Epston, 1994; White & Epston, 1990) and other documents, for example documents of 'solidarity' (Brigitte et al., 1996), of 'identity' (Stewart, 1995) and others (White, 1995c; White & Epston, 1990) as well as recruiting 'audiences' (eg family members and friends) to the therapy process, who can then witness therapeutic change, via meetings or letters (O'Hanlon, 1994).
This desire to broaden therapy beyond the therapy room extends to developing self-help campaigns like the Anti-Anorexia/Anti-Bulimia Leagues (which Stephen Madigan estimated as having over 300 members in 1994) and letter-writing campaigns where users write to support and advise each other (Madigan, 1994; Madigan & Epston, 1995). Madigan (1994) notes how the League's media watch committee publicly denounces media representations of women (eg the recent vogue for 'waif' models) and writes to company presidents, newspaper and magazine editors and gives media interviews. Grieves (1997) has described the history of these Leagues and other of their activities including running training workshops and producing the magazine ReVive. Such approaches, as O'Hanlon (1994) has observed, blur the distinction between therapy and politics (and thus trouble the individual/social opposition).
There are, as we will see below, some criticisms of this approach and some accuse White of developing a guru-worshipping movement where criticism is discouraged (Bruggen & Byng-Hall, 1996). There are also, of course, links between NT and other therapies. McLeod (1997) has attempted to broaden the notion of NT by describing all therapies as essentially narrative therapies whilst White (1995b) has adapted Andersen's (1991) reflecting team approach. However, possibly the closest similarities are between NT and Solution-focused brief therapy.
22.214.171.124.2 Solution-focused brief therapy
Solution-focused brief therapy (de Shazer, 1988; George et al., 1990) similarly aims at a non-pathologising model of therapy in that the focus is on helping clients find solutions to their difficulties by focusing on 'exceptions', times when the problem does not seem as bad. This need not involve much, if any, discussion of causes which is where other therapies tend to dwell, producing a pathology-saturated interaction.
de Shazer (1988), in developing his ideas about Solution-focused brief therapy (SFBT), has also offered insights consistent with social constructionist thought. He uses an approach termed deconstruction (used here as a technical term for a therapeutic intervention rather than in the Derridean sense). These ideas have been used with those considered to be psychotic thus, de Shazer describes the case of an ex-CIA operative who became convinced his previous employers were trying to kill him and began leaving loaded weapons around the house in case of attack. The therapist worked with the man, not to convince him his beliefs were untrue but, rather, that given he was trying to protect his family, should he not be more cautious about leaving weapons lying around? Furthermore, the therapist asked about apparent inconsistencies in the client's account such as why the CIA had not killed him yet -- would the CIA send incompetent killers? Such a strategy appeared to work in this case and is illustrative of the fact that in the case of delusions, it may not be necessary to see the 'delusion' per se as the problem.
There are similarities and differences between solution-focused and NT approaches (Chang & Phillips, 1993) and although the concepts of 'exceptions' (SFBT) and 'unique outcomes' (NT) seem similar (White, 1993) de Shazer argues they are very different (de Shazer, 1993). One difference has been the extent to which the political context is noted in therapy -- narrative work aims to do this explicitly although some Solution-Focused workers have discussed the influence of gender, for example, on their work (Lethem, 1996). One of their similarities however is that the therapist is an active questioner and shaper of the interview -- a co-constructor as the literature would have it. However, another thread of systemic responses to post-modernism puts more emphasis on listening and reflecting.
126.96.36.199.3 Andersen and Anderson & Goolishian: From questioning to listening and reflecting
The work of Tom Andersen is in stark contrast to SFBT -- here the therapist is a reflective listener rather than an active questioner in the style of NT and SFBT. Andersen moved away from the traditional idea of a family therapy team where a therapist's colleagues would observe an interview with a family through a one-way screen and would then hold discussions with the therapist during the interview to which the family were not privy. He originated the idea of a reflecting team whose discussion with the therapist would occur in the presence of the family in order to give them some ideas, allow a more reflective conversation which might open up competing possibilities, and restrain a tendency for disrespectful and pathologising discussions about clients. This work has been presented in a variety of contexts (Andersen, 1991; 1992) and there have been practical (eg Doan & Bullard, 1994; Lax, 1995) and theoretical (Perlesz et al., 1994) comments on this approach as well as attempts to engage users in reflections on the use of these techniques (Janowsky et al., 1995). White has adapted the use of reflecting teams to include user consultants, family and friends and to enable users to comment on the therapy interview itself and the questions the therapist asked (White, 1995b).
Narrative and solution-focused brief therapies place importance on language as a medium of therapeutic change, prompted by questions. Andersen's work develops this with an emphasis on listening and conversation. However, one approach that puts language at the centre of therapy is the work of Harlene Anderson and Harold Goolishian. In Anderson & Goolishian (1988) they argue, building on a metaphor of human systems as linguistic rather than structural systems, that therapy is a 'linguistic event' and that the role of the therapist is that of a 'conversational artist' (p.372). In Anderson & Goolishian (1992) they have developed a 'not-knowing' approach to therapy, seeing the client rather than the therapist as the expert. In some ways the work of Anderson & Goolishian (and to a lesser extent the work of Andersen) has been seen as the most constructionist of systemic therapies although Larner (1995) suggests that it is deconstructive in practice rather than theory.
Narrative therapy has been linked to other traditions too, notably through the Dulwich Centre Newsletter published from Michael White's Dulwich Centre. For example two issues of the newsletter have focused on the work of the New Zealand Just Therapy group (Dulwich Centre 1990, 1994).
188.8.131.52.4 Just therapy and the notion of accountability
Just Therapy is an approach that 'takes into account the gender, cultural, social and economic context of the persons seeking help' and attempts to address 'some of the injustices that occur in a society' (Waldegrave, 1990, p.5). In pursuing these objectives, the Just Therapy group have established accountability structures including gender and culture caucuses. For example, the women's caucus calls the men's caucus to a meeting when 'an issue of injustice is felt in staff relationships, models or practice' (Tamasese & Waldegrave, 1994, p.59). There is also an attempt to connect to identified wider communities. Such structures provide an accountable context within which therapy can occur. As a result of such work, some therapists, for example, White (1994), have sought to establish similar structures of accountability rather than the somewhat individualised ones they had previously. But do innovations like these actually transform therapy fundamentally? Or is therapy inevitably an individualising, pathologising modernist conception?
184.108.40.206 Social constructionist/postmodernist therapies: A contradiction in terms?
Some have argued that therapies which say they draw on social constructionist therapies only do so at a superficial level -- we have already noted Danziger's complaint that social constructionist therapy (SCT) seems to have relatively little in common with social constructionist theories. Moreover, given the dominance of individualistic cognitive constructivist models in therapy culture it would be relatively easy for seriously intentioned radical approaches to be assimilated. There have been suggestions that despite their stated aims of avoiding the individualising assumptions of other traditions, social constructionist approaches have similar assumptions. Thus, despite claims by White (in Stewart, 1995) that NT does not imply a notion of a normal or ideal self, McCafferty (1996) has argued that social constructionist therapies, like NT, imply notions of internal processes borrowed from psychodynamic theories to supplement gaps in theorists' descriptive schema of systems. Moreover, comments at workshops I have attended by therapists like Andersen and Epston indicate that many see more similarities between these approaches and other traditions, especially cognitive therapy.
Hak (1994), in his review of Therapy as Social Construction, largely concurs with Efran & Clarfield's (1992) chapter, noting that much of what passes for SCT is vague and abstract. However, Hak appears to be judging the book from a modernist perspective when he asks for the evaluation of 'treatment outcomes in a systematic manner' (1994, p.154). Luepnitz (1992), in a commentary on the work of Michael White has argued that, far from advocating new kinds of therapy, Foucault would wish to turn the focus on investigating therapies themselves. Comments like these have led some of these therapists to clarify their drawing on post-structuralist and social constructionist writers. Thus, White explicitly states that it is not his intention to perform a 'deconstruction of the knowledges and the practices of specific and established models of therapy' (1991, p.21). However, it could be argued that this is exactly what a truly deconstructive and social constructionist approach to therapy might entail.
Birch (1995) comments ironically on some of the difficulties here -- for example that the 'narrative approach [to therapy] deconstructs itself' (p.224) although he argues that it still has value. In particular he argues that holding onto the provisionality of stories (perhaps through the use of Andersen's, 1991, reflecting teams) about distress might be one way around the dilemma of dealing with 'schizophrenia' where there is often covert and overt sniping between different camps of professional helpers, all seeking to position the Other as the 'Bad Guys'.
There is clearly concern about the extent to which therapies drawing on social constructionist theories are social constructionist and this is complicated by the differing definitions of social constructionism appealed to. One way of examining this, as we have noted, is to look at how these approaches address some of the oppositions noted earlier. Here, for convenience, I will again be using an exemplar, Narrative Therapy, to illustrate this, drawing on other approaches when necessary.
Interestingly, given their emergence from family therapy, many of these therapists work with individual clients. Although, within NT and JT there is evidence of some group work (eg the Power to our Journeys and the Worthy of Discussion groups), family work and even work with wider communities (like the Just Therapy team, the Dulwich Centre's Community Mental Health Project and the Anti-Anorexia/Anti-Bulimia Leagues) this individualising trend still appears dominant in SFBT and the work of Anderson & Goolishian. Tom Andersen's use of a reflecting team perhaps lessens this to some extent but again, here, much focus is on individual clients.
Perhaps more than any of the other oppositions, all these therapies attempt to address the pathologisation of service users. They do this in different ways: focusing on solutions; externalising the problem and so on. However, these therapies are often located in institutional and agency settings which have long dwelt on assumptions of pathology and examples of these therapies in such settings illustrate that this does not result in the removal of notions of pathology. Other institutional constraints, about which little is mentioned in the literature include referral systems, the writing of reports on clients, the need (in the US at least) to give a DSM-IV diagnosis for third-party (health insurance) payments, the need for services to be paid for -- all these factors may well continue to reinforce individualisation and pathologisation regardless of what goes on in the therapy.
Again, few of these therapies privilege rationality or reason in the way, for example, that cognitive therapy does although techniques like SFBT's 'deconstruction' has much in common with the Socratic styles of questioning found in cognitive therapy. They are more pragmatic and, to some extent, humanistic, . However, they are clearly internally coherent and consistent and so do not privilege unreason either.
Although these therapies ascribe more importance to the content and meaning of people's experiences, they vary in how they respond to this issue. Andersen and Anderson & Goolishian would be more interested in the content and meanings people ascribe to their experiences whereas narrative and solution-focused therapists would be more interested in creating new kinds of forms (externalised problems or exceptions) which incorporate meaning.
None of these approaches uses the notion of diagnosis, indeed they could be said to be anti-diagnostic and deconstructive of the diagnostic process (Parker, in press b). Moreover, there is a great attempt to encourage therapists to situate themselves and their ideas (see, for example, Madigan, 1993) and to be open about the dilemmas they find themselves in (Anderson, 1995; White, 1998; White & Hales, 1997). Although they embrace the messiness of real life by not trying to squeeze it into diagnostic categories and by acknowledging the influence of personal history and context, there is some ambivalence about how to accommodate other aspects of therapy. For example, O'Hanlon (1994) has suggested that a NT approach requires a therapist to be a 'psychotic optimist' (p.22) and there is a tendency in much of this kind of writing to be positive and optimistic to the point of banality -- White (1995b) himself has commented on this in respect of some members of reflecting teams.
These therapies, perhaps more than any others, attempt to privilege lay and user knowledge by focusing on them as 'experts' (Anderson & Goolishian, 1992) and as repositories of 'alternative knowledges' (O'Neill & Stockell, 1991). However, although lay and user knowledge is gathered and disseminated (see, for example, Brigitte et al., 1996) it is often in a context controlled by professionals (White, for example, is described as a facilitator and scribe in the Power to our Journeys group -- Brigitte et al., 1996). Some attempts to address the issue of the therapist's power and the status of expert knowledge can ring a little hollow. Thus Hak (1994) notes Karl Tomm's wish to share authorship of his chapter with his clients (Tomm, 1992) although only he is listed in the 'notes on the contributors' section (and only he is listed as having copyright). Moreover, it is unclear who wrote the text for the Power to our Journeys article (Brigitte et al., 1996) -- if White was the scribe in this instance, why not credit himself? Attempts to use clients as consultants in their own and others' therapy seem more authentic if still a little individualistic (Epston & White, 1992). However, larger scale consultations, between users and professionals where workers listen to users' concerns and attempt to develop ways forward, seem more hopeful (Dulwich Centre, 1995). An example of this is the newsletter Currents produced jointly by the Dulwich Centre's Community Mental Health Project and the Power to Our Journeys Group. Such initiatives attempt to address not only the user/professional opposition but also the individual/social one too.
Some commentators have warned of the dangers of postmodernist approaches to therapy. Sass (1992) discusses the possible consequences of challenging realist assumptions in psychoanalytic interpretations. He notes that the idea of 'discovery' is an important belief for clients and that without it they might not want to create endless narratives, a practice which, he feels, might be seen as futile and self-indulgent since, for example, 'the brute undeniable reality of certain memories may make them less attracted to the idea of merely making up stories' (1992, p.173).
Pocock (1995), however, argues that modernist and postmodernist approaches need to be seen as in a dialectical relationship with one another with each restraining the excesses of the other. For him stories are not seen as merely stories and therapy is not about creating a truer story but is, rather, about creating a better story for clients.
But is a social constructionist/postmodern therapy possible within the constraints of what we understand as 'therapy'? The obvious answer is 'no' since it is likely that such a thing would be self-contradictory. McNamee associates the rise of the profession of psychotherapy with a continued concern for the self-contained individual. Thus 'the social construction of psychotherapy as we know it is strong testimony to the prominence of modernist discourse' (1996) although she later appears to imply that a 'relational' psychotherapy would free itself from these assumptions. Frosh (1995) is clear on this point:
I am suggesting that so-called 'postmodernist therapies' are not really post-modernist at all, but are, rather, modernist, with a heightened awareness of the slippery nature of 'truth' and of the dangers of abusive uses of power in the service of, for example, sexism and racism. This awareness is taken from postmodernism, but that does not make the approach itself postmodernist.
Frosh (1995, p.189)
In other words if the therapy looks like therapy then it is likely to be located within a modernist discourse. However, if one is going to 'practice' or be a client in therapy there are going to be some better and some worse practices to adopt. I have attempted to delineate some of these here, focusing especially on therapies which have attempted to respond to a range of concerns, especially those under the umbrella of social constructionism and postmodernism.
|Abstract box 220.127.116.11 General and
specific implications for therapists
I have already noted how a key element in this study has been the description of unarticulated cultural assumptions which shape the language and concepts of mental health (including of course, the concept of mental health itself). I have noted how there are dilemmatic oppositions at work in these assumptions and that certain poles are privileged which leads to certain consequences. I have attempted to draw on popular culture to show that paranoia is a dominant cultural category and not solely an individual psychopathological one and that similar patterns of discursive positioning may occur both for individuals and larger groups adopting or being placed in a paranoid position. I have suggested some of the discursive functions that may be served by such positioning and it is likely that similar functions are served at an individual level by both those positioned and those doing the positioning. To a small extent, therapy itself has been focused on in this research. In the chapter on medication talk we saw how medication is seen as primary by professionals whereas some users feel therapy would be helpful. Moreover, some professional speakers adopted an either/or (either medication or therapy) as opposed to a both/and position.
|Interventive Box 18.104.22.168
Suggestions for action by therapists
1. Follow relevant suggestions in Interventive box 22.214.171.124.
2. Therapists need to act with others in distress -- as they and others define it -- by working within current dominant conceptions (of what constitutes psychological distress and what is appropriate conduct for a mental health professional) which are historically and culturally contingent whilst simultaneously trying to challenge them. White (in Allen, 1994) has identified a number of ways in which mental health practitioners can make such challenges. First, he argues that critical accounts of mental health practice, particularly of their history and real effects, should be pursued. Second, he suggests practitioners might take up positions 'at the margins of culture' and explore alternatives to dominant practices. Third, he proposes soliciting 'critical' feedback from persons of other cultures, races and classes. Fourth, he argues for clinicians to openly acknowledge day-to-day political dilemmas at work. Finally, he calls for an imaginative use of language, especially metaphor, to 'stretch culture'.
3. Therapies informed by social constructionism and postmodernism need not seek to make assumptions about someone's difficulties. If a person with an apparently strange or unwarranted belief is content with it there is no need for intervention. If those close to the person disagree, then it may be worthwhile focusing intervention around that network rather than the one person. If however, someone comes in a state of distress requesting therapy then it should not be denied although the therapist again may choose not to concentrate on the delusion but, rather, on the cause of the distress which may be related to others' reactions or to other past and present predicaments in their lives (Smail, 1996a).
4. There is a need for much more questioning of the notion of 'bizarre' or 'paranoid' beliefs since, as we have seen, professionals and others draw on a number of unarticulated cultural assumptions about plausibility and normality in making such judgements. At the very least, such assumptions should be made explicit in professional discussions, correspondence and file notes. Moreover, therapists should continue to develop much more curiosity about what the beliefs are, their history and context. This should especially be the case given one finding in this research that GPs and other professional referrers are more likely to ascribe a diagnosis of paranoia after talking to a relative. There needs to be much more thoughtful and respectful interviewing of relatives about the context of such belief-talk and behaviour -- especially given the often ambiguous linking of belief and actions. Moreover, given that they may have coped with their relative for some time, therapists need to understand why help is being sought now. What do the relatives and the potential service-user actually want from professionals? Is it possible to negotiate a contract of work with commonly agreed (and non-pathologising) goals. Obviously if people are in a state of considerable emotional distress such negotiation may need time and skill and may even have to be postponed whilst the user is in a place of safety. There is a need for more creative responses to
|such situations which build on what
service-users themselves say is helpful at these times.
However, often 'emergency' and 'crisis' responses mean
little more than admission to an acute psychiatric ward
where the user hardly talks to anyone about the reason
for their admission and is left powerless and confused.
5. Therapists need to acknowledge that emotional distress or the notion of a 'strange' belief may arise from people's comparison with a norm which is historically contingent. It is worthwhile remembering that such norms change according to the politics of the time, witness the APA's decision in 1973 to remove homosexuality as a diagnostic category (Wilson, 1993). Therapists can work with their clients to understand with them the operation of power in their life (M. White, 1991) and seek to de-mystify and stress the limitations of therapy (Hagan & Smail, 1997a, 1997b; Smail, 1990, 1996a).
6. There is a need for therapists to judge their work not simply by its accordance with some abstract therapy procedures or even codes of conduct but more broad ethical and political criteria: for example, to what extent does the therapy challenge the oppositions I have described? To what extent does it address the effects of inequalities of gender, race, sexuality, age and class? (The use of accountability structures like caucuses could be helpful here: Tamasese & Waldegrave, 1994; White, 1994).
7. Given that those positioned as 'paranoid' may be living a text of fear to serve a variety of (not necessarily intentional) purposes for themselves or others (see chapter 2 and Boyle, 1992), what alternative ways can therapists and users find to serve such purposes in ways that are not so harmful to the user? Moreover, what variety of explanations could therapists and clients find for such experiences that are not simply pathologising?
8. There is a need for therapists and professionals to be more honest about the essentially arbitrary and contingent nature of their language, concepts and even treatments. Medication may 'work' or 'fail' in some cases for reasons we do not understand. If it does 'work' such effects are not specific to certain problems. There is a need to be more openly pragmatic with users rather than pretending there is some secret expert knowledge. Rather therapists need to be clear about the situated nature of the limited knowledge they have.
9. Therapists need to work to challenge the user/professional opposition. As Griffith & Griffith (1992) note, when therapists acknowledge there is no essential difference between themselves and their clients, the power imbalance in therapy need not become an abusive imbalance.
8.3.5 Training and supervision of mental health professionals
We can intervene directly in clarifying consequences of discursive frameworks with speakers (as in training or action research, for example), as well as commenting on the discursive-political consequences of discursive clashes and frameworks.
Burman & Parker (1993, p.170)
There has been a large amount of work published on training therapists in traditions influenced by social constructionist and postmodernist thought. Thus Anderson & Swim (1993) explicitly avoid the notion of teaching trainees a form of expert knowledge, placing an emphasis on learning instead whilst Griffith & Griffith (1992) focus less on 'technique' and more on the therapist's 'emotional posture' of respect and curiosity. White (1992; 1997b) is more interested by what training participants originate in their attempts to copy other therapists: in other words, what is uniquely theirs. One technique he uses is to interview professionals about their counselling careers to identify 'unique outcomes' in their work. Other practitioners have been more interested in stressing a recursive link between theory and practice (Burnham, 1992; Burnham et al., 1994). Such approaches have been discussed in relation to Narrative Therapy supervision (Parry & Doan, 1994; White, 1997a) and the explicit use of stories and narratives in place of the more abstract and technical case studies many professional training courses use (Green, 1989).
Although such approaches would place an emphasis on the constructed nature of knowledge there is a limit to the extent both to which trainers and supervisors explicitly use discourse analytic theories and methods in their work and to which they locate therapy itself in a sociopolitical context. Social constructionist work demonstrates to mental health workers that their talk constructs notions of mental illness and positions their clients in particular ways, thus influencing processes of 'referral', 'assessment' and 'intervention'. Marks (1993) has suggested that discourse analytic exercises could be used in training. However, she notes:
for discourse analysis to have any critical value in drawing attention to the way in which meanings and subsequent outcomes are constructed in and through language, the analysis must be taken out of its context and examined in a non-threatening setting.
Marks (1993, p.151)
Such an approach might enhance trainees' curiosity about the conflicting demands made upon them; the different positions they can adopt, be forced into and place others in; and the personal and social functions served by different discourses and positions. There are examples of such work, thus McKenzie & Monk (1997) describe how they get trainee therapists to practice identifying discourses and positions adopted by themselves and their clients in therapy. Heenan (1998) has described using reflexive discourse analysis as a framework for broadening out the focus of clinical supervision beyond simply a concern with therapeutic content and process to a contextualisation of therapeutic discourse itself paying attention to, for example, the ways in which gender influences therapeutic work.
A final issue which has increasingly been taken up in the training of therapists and other professionals is the challenging of the user/professional opposition and the exclusion of users' views about what forms of help are actually helpful. Thus Crepaz-Keay (an active ex-service-user) has collaborated with mental health professionals to produce a booklet focusing on involving survivors in training and continuing professional development (Crepaz-Keay et al., 1997). We have already noted that Thomas (an active psychiatrist) has made a similar call for the involvement of service users in the training of psychiatrists (Thomas, 1997).
|Abstract box 126.96.36.199 General and
specific implications for trainers and supervisors
Central to this study is the notion that language does not simply express or reflect reality but that it is constructive and constitutive. Such a view has implications both for the content and process of professional training courses. The review of the professional literature and interviews with professionals and users has revealed a wider diversity of views than one might expect having read textbooks or attended professional training courses. I have used this fact to challenge dominant models (eg of fear, or of the 'link' between beliefs and actions). Moreover the research has demonstrated the variety of assumptions implicit in much professional theorising and the consequences of such theorising, particularly for the way in which professionals and users are positioned in discourse.
|Interventive Box 188.8.131.52
Suggestions for action by trainers and supervisors
1. Given that language is an active and constructive medium there is a need for trainers to look much more at how their trainees actively construct their practice and to use this fact to lead to better training. Thus the process of training needs to be reflexive, with an emphasis not on copying or being taught but on learning from experience with feedback on one's own practice (Andersen, 1992; Hoshmand & Polkinghorne, 1992; Kolb et al., 1974; White, 1992, 1997b). Such a process might do away with the experience of many trainees of a gap between practice and text-book theory (Bostock, 1990; Spellman & Harper, 1996).
2. Such training needs to challenge the oppositions noted earlier, especially the user/professional binary which leads to so many professionals positioning the user as Other (cf Thomas, 1997). One way of challenging this is to link professional's own personal lives with their practice but not in the way that much training often does, by seeking to diagnose and pathologise professionals. Rather there is a need for a celebration of life as it is really lived by professionals (Anderson, 1995; White, 1997c; White & Hales, 1997).
3. Another way of challenging this binary is through more involvement of users both in feeding back about therapy and in training courses. Seeking the views of users should become a central aspect of therapy, rather than tagged on after. Users can be seen as consultants on themselves (Epston & White, 1992) and on the difficulties they have faced (Grieves, 1997) and can be allied with in the therapy process. Users need to become centrally involved in training otherwise how are professionals to know what is really helpful to users? There are a number of suggestions about how to take such ideas forward (eg Brunning et al., 1994; Campbell & Lindow, 1997; Coleman, 1995; Crepaz-Keay et al., 1997; Thomas, 1997; Williams & Lindley, 1996).
4. Discourse analysis itself can be used as a training and supervisory tool (Heenan, 1998; Marks, 1993; McKenzie & Monk, 1997) in order to examine subject positions and discourses in therapy but also to set therapy in its wider context.
5. Trainers looking for suggestions about how to develop training experiences which are explicitly critical might find Newnes & MacLachlan (1996) and Newnes (1997) of use. Williams (1996), Williams & Watson (1991a, 1991b, 1994) suggest ways in which teaching on social inequalities can be introduced into clinical training programmes and clinical supervision.
8.3.6 Implications for academic researchers in psychiatry and allied disciplines
Rather than outsider-based empiricism it is my belief that research that transcends the clinician-patient divide and that marries narrative with fact and at a process level to produce a 'person' rather than 'symptom' oriented approach will produce theories and rehabilitative efforts that should command greater confidence with the people we treat.
Chadwick (1997b, p.586)
Academic research on topics relating to psychopathological diagnoses tends to fall into two camps: either of critiquing current practice but offering no practical alternatives; or of focusing solely on practice but failing to critique the institutional context of psychiatry. Bentall (1990) was ground-breaking in critiquing the diagnostic category of svhizophrenia and recommending a focus on symptoms. In Harper (1992) I queried whether research on symptoms would be so straightforward yet increasingly such radical work has become assimilated into what I have termed a cognitive-psychiatric paradigm. Boyle (1996) has expressed ambivalent feelings about such research. On the one hand she sees such study as welcome since it valorises work with this group of people and is offering something of an alternative to psychiatry(3), yet on the other hand it continues psychiatry's individualising and pathologising tendency. There needs to be more critical work in this area which examines the interests and consequences of dominant discourses but which also offers practical alternatives in terms of theory and practice. Moreover, there is a need for research to be driven much more by the agenda of users rather than professionals. It is likely that cognitive approaches have been blunted by their need to meet editorial standards for psychiatric journals and dependence on funding from drug companies, both direct (eg sponsoring conferences) and indirect (eg drug company adverts achieve a good deal of revenue for many psychiatric journals). Critical researchers then, need to keep a distance from such barriers.
Social constructionist qualitative research adopting a similar political standpoint can be immensely useful in developing a non-traditional research strategy. It can help to trace the history of clinical categories, detailing the interests served by their creation (Harper, 1994a; Hepworth & Griffin, 1990). It can also focus on the use of those categories, examining the positions that are available in such discourses for diagnoser and diagnosed (Harper, 1994b; 1995c; Hepworth, 1994). Secondly, it can contribute to a celebration of theoretical diversity. Rather than relying on mono-explanatory (and mono-method) accounts, we could turn to a notion of competing and co-existing theories, of 'sympatricity' (Curt, 1994). Harper (1996a), Parker et al. (1995) and Parker (in press a, in press b) have argued that discursive and 'practically deconstructive' approaches can be beneficial in such an enterprise in undermining dominant categories and by transforming the oppositions implicit in them, for example between the individual and social, the normal and the pathological and so on. They have suggested that unless such oppositions are challenged 'new' theories and practices run the risk of maintaining 'old' practices of division and exclusion.
Our explanations need to embrace diversity rather than aim to be normative and restrictive. Thus Romme & Escher's (1993) work on 'hearing voices' -- the term itself acting as a political intervention against the traditional psychiatric conception of 'auditory hallucinations' -- argues that such voices need not imply pathology (many spiritualists, for example, derive great meaning from such experiences) and that explanations need to include alternative perspectives from traditional psychological or psychiatric ones. Such an approach is useful in that users are given more of a choice in how to understand their experiences. Other useful work has emerged from the efforts of Romme, Escher and colleagues (Romme & Escher, 1989, 1991, 1993, 1996; Romme et al., 1992). They have noted that the hearing of voices (having 'auditory hallucinations') is not just a rare occurence and that there are many people who either cope well with their voices without the aid of psychiatric intervention or who find their voices of positive value -- as in the case of spiritualist mediums. Romme (1997) and Romme & Escher (1996) have argued that traditional psychiatric diagnostic criteria do not discriminate between voice-hearers diagnosed as dissociative, schizophrenic or normal. They have suggested that it is not the occurrence of voice-hearing per se which leads to diagnosis but the experience of negative voices with which the person finds it hard to cope. Such a conclusion suggests we should not research on particular symptoms per se but rather on aspects which lead people to not cope or to come into contact with psychiatric services.
Given the conceptual and empirical difficulties I outlined earlier, I would argue that attempts to find a 'correct' definition and a 'correct' theory of paranoia are flawed. Instead, as I have suggested elsewhere (Harper, 1992), researchers and clinicians should seek to be extremely cautious in the use of the term 'paranoia', to be curious about the processes that lead professionals and others to construct such diagnoses and to seek to understand what legitimate reasons a person might have for their wariness. For example, this study has indicated patterns of positioning which occur around 'paranoia'. Moreover, as in this study, investigation of categories like paranoia can serve as a way of examining the micro-political dilemmas (or at least local realisation of macro-political dilemmas) in everyday mental health talk.
There should be an exploration of other metaphors in understanding how people come to be diagnosed as paranoid including viewing paranoid discourse as: a type of story told by people or a form of rhetoric; interpersonal communications; alternative realities; as adaptive and meaningful 'illusions'; or as a response to traumatic life experiences (eg victimisation, sexual abuse, racism and so on). Such ideas could lead to alternative forms of practice.
|Abstract box 184.108.40.206 General and
specific implications for academics and researchers
This study has attempted to show that studies of popular culture can be helpful in examining the context of paranoia and its use, for example, in delegitimising the Other. In examining the professional literature, a number of oppositions have been found implicit in the concept of paranoia and the influence of age, race and gender has been described in relation to the plausibility of fear. Notions of plausibility and credibility have been deconstructed here and the employment of certain rhetorical devices which establish im/plausibility has been described. Thus the notion of paranoia says as much about 'us' as it does about the Other. This study has shown that views and accounts are complex and are not served by being categorised as simply pro- or anti- a particular
|position. Explanations are fluid and dynamic and different positions may be taken up by different groups at different times and may position users and professionals in unintended ways. This thesis has been about the questioning of assumptions, theories and models and the challenging of pathology and exclusion through revealing the interests and consequences of different discursive frameworks. 'Paranoia' has not always been, and therefore need not always be with us.|
|Interventive Box 220.127.116.11
Suggestions for action by academics and researchers
1. There is an onus on academics to think what alternative worlds would look like which would not require a concept like paranoia. There is a need also to focus on that which is subjugated, as we have seen many silences in the professional histories of, and literature surrounding, paranoia.
2. There is a need to draw on diverse theoretical and methodological frameworks (eg cultural studies) and to move towards both inter-disciplinary and trans-disciplinary research (Romm, 1998).
3. There is also a need to continue to examine the consequences of implicit assumptions and to explore how the negative effects of the dominance of some of these assumptions can be challenged and the binaries transformed.
4. Given that this research has established that it may often not be 'the delusion' itself which brings people into contact with services but the concerns of others, there is a need for further ethnographic studies of how people come into contact with mental health services, how professional judgements are made and also how people avoid such services (cf Romme, 1997). There is also a need for research on the variety of 'odd beliefs' that 'normal' people have and that do not come to the attention of mental health services. For example the 1995 Manchester Metropolitan University Discourse Unit conference mentioned earlier gathered together spiritualists, parapsychologists, shamans and so on, many of whose beliefs might be regarded as odd but who lived perfectly ordinary lives. Moreover, researchers need to draw on wider frames of understanding (including telepathy and so on) rather than judging some varieties of meaning (eg positivist and scientistic) as correct.
5. One way of broadening the narrow aim of this study might be to develop a Q-methodological project focusing on the definition, models of cause and of treatment of paranoia.
6. In order to further augment the aims of the present study, there is a need to develop new languages and new concepts, not merely to find another way of talking about
|'paranoia' but, rather a way of
transforming the concepts and assumptions that bring
paranoia into being. Academic work needs to take a lead
here since it so often sets the theoretical scene for
7. Academic inquiry should not be a study of either therapeutic applications and techniques or of the political interests and consequences of theories but needs to be of both simultaneously. Theory needs to be located in actual use (cf Hoshmand & Polkinghorne, 1992).
8. It can also be helpful for researchers to focus (as this research has done) on professionals. For example Cape et al., (1994) demonstrate that far from there being a monolithic psychiatric view about schizophrenia there is a diversity of views about causation and treatment.
9. Researchers could focus on issues of the quality of psychiatric care, using consumerist notions of choice, autonomy and information-giving.
10. As in this research, researchers need to locate the interests that may have shaped their own research and need to refuse funding by drug companies (cf Johnstone, 1989).
11. Whilst pragmatically it may be helpful to focus on particular symptoms of psychosis (cf Bentall, 1990; McLaughlin, 1996; Thomas, 1997) researchers need to take care that their research is not conducted and published in a manner which aids assimilation into mainstream psychiatry.
12. There is a need to make clearer links with groups of users in order to influence research agendas rather than have them determined solely by professionals.
8.3.7 General political action
In the section aimed at therapists I noted the progressive potential of therapeutic activities which blurred the distinction between therapy and political action. Of course, this does not remove the necessity for political action in its own right. However, I, as a mental health professional, must be cautious in recommending particular courses of political action since, as Pilgrim (1997) notes, there are no particular grounds for privileging the political views of therapists. In what follows I will not be claiming a special role for mental health professionals. Smail (1994) has commented that 'political action, by its very nature, is not a matter for a professional elite, but for the citizenry itself' (p.6). The call to politics is a call to all those who might identify with the different groups above (and, of course, people might already belong to more than one of those groups). But what political objectives are we to have? I have already implied that it is pointless to eliminate therapy without changing society. Societal change requires political, not professional, action in order to remove the need for therapy, replacing it with an environment where we do not see users of mental health services as:
manipulable deviants from unassailable norms ... [but as] characters in search of public structures which are generous enough to accommodate them, appreciative enough to profit from their talents without exploiting them, caring enough to maximise their opportunities and minimize their handicaps, honest enough to acknowledge their private pain and take account of the lesson it teaches.
Smail (1990, p.10)
In focusing on the notion of deviance here, Smail brings out a point made elsewhere in this thesis: that users of services are seen as Other to the unitary rational Western subject and in positioning that other as mad, we simultaneously position ourselves as sane. Thomas (1997) sees such othering practices as behind the tendency to think in terms of polar opposites and sides. If activists were to focus their campaigning on the issues of exclusion, 'othering' and accomodating difference and diversity there might be points of connection with other movements of resistance and identity (cf Sampson, 1993).
In some ways political activity in mental health has lagged behind the political actions of other marginalized groups. The gay and lesbian rights movement, for example, took devalued terms like 'gay' and 'queer' and gave them new and affirmative meanings. Mental health activists could learn from this and, with Coleman (1994) proclaim 'I'm psychotic and proud'. Other strategies might include finding new languages and concepts. However, one must be careful here since, as Sinason (1989) has found, there can be a tendency to find new words which simply obscure old practices of exclusion. New languages and concepts must, then explicitly aim to be anti-exclusionary -- as Danforth & Rhodes (1997) put it, there needs to be 'strategic disruption of patterns of spoken and written communication that continue the usual hierarchy of ability and disability' (p.364).
Mental health activists could build on the tradition of the disability movement. First there could be less of a focus on individual pathology and more emphasis on how 'disability' is imposed by society's 'able-bodied' and 'able-minded' assumptions demonstrated through social interaction, the design of the built environment and so on (Kitzinger & Perkins, 1993; Marks, 1997; Perkins & Repper, 1996). Second, there needs to be a focus on rights for users and access to advocacy services. Third there needs to be a focus on the issue of access to communities (Kitzinger & Perkins, 1993; Perkins & Repper, 1996). Fourth, mental health politics has often been a concern of the 'great and good' but more radical change can be seen to have come most often through more direct action by users and their allies. Groups like SANE have been extremely clever in their use of the media with blunt exclamations of a crisis in mental health care. More progressive activists need to be equally media-wise and could learn from other groups like single-issue environmental protests. The Disability Action Network uses direct action as a political strategy which puts disability issues on the front page of newspapers. Mental health activists could learn from this -- there could be more direct actions focused on, for example physical treatments like ECT(4) or medication (eg picketing pharmaceutical conferences).
Of course, in conducting such action, there is a risk of essentialising mental health problems -- a strategy that some (eg Kitzinger & Perkins, 1993) adopt. Is this the only alternative? Activists could learn from some emerging traditions in feminist and gay and lesbian writing. I will briefly note two such traditions which have not been drawn on much in mental health theorising to date.
The first such tradition is that of Queer Theory (Minton, 1997) -- premised upon the non-essentializing of sexual identies (indeed such approaches see marginal identities as produced by the effects of hegemonic normativity such as patriarchy and racism). Thus identities are seen as non-essential and, as produced in response to attempts to enforce 'normality'.
A second tradition is that of the new kinds of political strategies emerging from within feminism. Thus Haraway (1990) uses a cyborg metaphor to argue for a kind of politics that could 'embrace partial, contradictory, permanently unclosed constructions of personal and collective selves and still be faithful, effective -- and, ironically, socialist feminist' (p.199). She prefers a networking and weaving image of activism, with activists existing on boundaries and learning new coalitions. Such coalitions, then, are likely to be fluid and we might find, as Segal (1987) has noted, 'one's closest allies in one area being one's most immediate, and therefore most irritating, opponents in another' (p.246). However, there is a need for diversity not to be overtaken by the kind of fragmentation that can lead to political paralysis (Willig, in press).
|Abstract box 18.104.22.168 General and
specific implications for political activists
The political context of mental health practice has been a central theme in this research. I have endeavoured to trace political interests in the history of the concept of paranoia and its use in popular and professional cultures. I have described the macro-political contexts in which paranoia is used to position one's own or other groups. I have also described some of the micro-political contexts of paranoia. Thus I have shown how the im/plausibility and in/credibility of user's accounts is constructed. I have also shown how professional judgements (eg about fear, risk and so on) are shot through with cultural assumptions (eg about gender, race and class) which have political consequences for those considered paranoid. I have also attempted to demonstrate in the concrete area of medication, how the interests of the 'psychopharmaceutical complex' are served by the maintenance of different views about medication and by the existence of a repertoire of reasons accounting for medication failure. Discourses about paranoia have further political consequences in that they create certain kinds of object and subject: in particular they construct the suspicious and wary subject as pathological and the trusting subject as normal.
|Interventive Box 22.214.171.124
Suggestions for action by political activists
1. There is a need for political activists to organise around the themes of exclusion/inclusion and 'otherness' and to campaign against public policies and practices which serve to continue to exclude users of mental health services. Such campaigns are timely as the UK Labour government claims to place special emphasis on combating social exclusion. Links need to be made in the public mind between social inequalities like sexism, racism and classism and mental health problems (Johnstone, 1989; Williams, 1996).
|2. Mental health activists need to learn
from other campaigns, especially about use of the media.
There need to be more high profile protests around issues
of concern -- like for example, the lack of proper audit
of ECT procedures (Salford Community Health Council,1998)
and of medication (Rogers et al., 1993).
Campaigners could use Direct Action techniques borrowed
from environmental protests and the Disability Action
Network. They need to combine such protests with
well-argued material for policy-makers and legislators.
3. There needs to be further action to extend users rights (eg to a right to refuse ECT, for example).
4. More use needs to be made of the Law, for example in suing NHS Trusts who allow doctors to prescribe over British National Formulary limits (see Bradley, 1997). John Gunnell's recent 10 minute rule bill attempting to legislate for good practice in the use of ECT is another example.
5. There needs to be firmer regulation of the pharmaceutical industry: in reducing the costs of medication and in minimising the influence they have on doctors.
6. Activists need to question their own and others 'able-minded' assumptions which might serve to exclude users from areas of social life. For example, there is a need to question the cultural assumption which sees suspicion and wariness as abnormal rather than legitimate.
7. There is a need for much more public debate about the remit and aims of mental health policy, especially as it moves into the roles of policing 'risk' (Bracken & Thomas, 1997).
In this chapter I have attempted to reflect on the implications of the work in the previous seven chapters for interventions, political, therapeutic and otherwise in mental health practice. This reflects my concern that the historical, cultural, conceptual, empirical and reflexive analyses here are not to be seen as narrowly 'academic' but as sites where interventions which seek to unravel and undo dominant individualizing and pathologizing discourses of psychopathology, in particular those constructing the concept of paranoia, can be made. I have highlighted aspects of the research relevant to different target audiences and tried to link these with concrete suggestions for action and further resources. Change in the politics of what we know as 'mental health' is possible if we continue to develop vibrant ideas and practices which would function as critical alternatives to the dominant mainstream.
The philosophers have only interpreted the world, in various ways; the point however, is to change it.
Epitaph on the grave of Karl Marx (1818-1883), Highgate cemetery, London.
1. Since writing this I have found Long & Hollin (1997) which provides a useful review of the scientist-practitioner model.
2. Unfortunately, whilst briefly mentioning the model of the reflective practitioner, Long & Hollin (1997) do not offer an appraisal of it.
3. These approaches are likely to be a good deal less physically harmful than biochemical interventions and it is worth remembering that biolological approaches are still being made to the study of this area (Kirkpatrick & Amador, 1995).
4. Indeed, early 1998 saw an anti-ECT picket of the Royal College of Psychiatry's London offices.
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