Mental health care is at crossroads. Again. This time trauma-informed care challenges the biomedical model of mental illness. Some see this crossroad as potentially leading to a revolutionary shift in mental healthcare. Others look for ways to join disparate ideas into an amalgamated whole. Yet for anyone who has spent time in the field — as practitioners, service users, or both— the experience of continually returning to crossroads gets exhausting.
What to do? I don’t surely know, but I think it might help to look closely at some of the concepts that carry the most assumptions about human nature. Concepts like responsibility, freedom, subjectivity, individualism, and community. I once had a professor claim these are the kinds of words you could “turn a truck around with.” Yet they rarely get addressed when we’re at the crossroads trying to imagine into a new future. Perhaps they’re the culprit — all those words we think we agree upon, but on closer inspection keep us tied to a past we have no interest in repeating — the ones that have the power to head us back towards the crossroads. Again.
In this blog post, I look at the concept of subjectivity. I reflect on the significance of subjectivity for notions of mental illness, and share why I think we should pay attention to subjectivity, and what we think it means, when determining how well the field is serving both people and society.
Why Subjectivity?
Subjectivity is related to responsibility, and the capacity for making responsible choices — or lack of this capacity — is central to notions of mental illness. Through subjectivity, we witness our minds and internal experiences and make use of them in intentional ways. And through subjectivity, we come to know ourselves as one mind among many other minds.
Subjectivity is essential for success in late-modern/post-modern societies. In the West especially, most psychological notions of success — and thus having a good mind — involve the capacity to leverage current mental states in the pursuit of the imagined self one hopes to become, as well as avoiding the self one doesn’t want to become. Selfhood is a continual project, and subjectivity is the primary tool for staying the course and creating the desired self. Especially in rapidly changing and precarious economies (everywhere?), people are successful when they anticipate changes they need to make to stay relevant, and then are able to implement these changes.
For the mental health field to stay relevant, it too must adapt — and to the very conditions its service users are adapting to. It too must value the need for a fluid sense of self that most people find necessary for living adroitly in uncertain times. Diagnoses are typically not helpful in this regard. Although during crises a diagnosis may seem like a steady mast in stormy waters, it also ties the person to a false sense of security when what is really needed is learning how to adapt to constantly changing seas.
Michel Foucault (1988) once described psychiatry as a discursive practice people use as a technology of the self. By applying psychiatric discourses and practices repeatedly to themselves, people learn if psychiatric knowledge is true of them, and if it contributes to the attainment of the sense of self and life course desired. I think this is the right way to think of mental health services — as technologies of the self to be tried on and tried out, relative truths that are valued for the opportunities and comfort they provide in the moment, as well as for the possibilities they provide for continually becoming in ways that feel true to the selfhood imagined and desired.
The capacity for subjectivity has not always been granted to people experiencing mental illness. In the early nineteenth century, when the mentally ill were locked in madhouses and suffered the most inhumane conditions, they were seen and treated as wild beasts in need of taming (Porter, 2002). The introduction of psychiatry into the squalor of madhouses was a vast improvement, and led to recognizing the capacity for subjectivity in people with mental illnesses.
The Enlightenment’s optimism for reason and science cast a spell on those early psychiatrists, and they began to believe that madness could be cured. Treatments like Philippe Pine’s Moral Treatment worked on the premise that madness was a breakdown of rational function, and in the correct conditions, the mentally ill could become aware of their personal and collective responsibilities. That is, they could begin to exercise subjectivity.
Yet the subjectivity granted was never that of a full member of society, and more like the subjectivity granted to a child. Implicit in the earliest notions of subjectivity was that it was underdeveloped in the mentally ill person, and the role of the psychiatrist was to promote the development of subjectivity. This perceived underdevelopment has justified infantilizing the mentally ill, and still influences how subjectivity is perceived in people diagnosed with mental illnesses.
For instance, in her book, Of Two Minds (2000), anthropologist T. M. Luhrmann described how biomedical psychiatrists in hospital settings listened for signs of underlying brain disorder in their patients’ stories of suffering. How the patient perceived his suffering, as well as what he believed might provide relief, was largely ignored. Instead, the physician listened for symptoms of a brain disorder, identifying sleep patterns and mood states hidden in patient complaints. Furthermore, subjectivity was only granted when the patient willingly accepted the psychiatrist’s biomedical explanation of his suffering:
"When that young man could say that he had been ill and begin to discuss the problem of being ill, his intentions and his reports on his state of mind began to be treated like responsible, reasonable assertions. That part of him moved into the adult category. He became a person with an illness, not an illness and a body. The unfortunate but accurate implication here is that if you wanted to leave the hospital, you were still sick, but if you agreed to stay, you were treated as if you are getting well. . . . The turning point in a patient's stay (as perceived by the unit) was when she understood herself to be and have been very sick." (140)
This account of the practices of biomedical psychiatry shows the patient is assigned the responsibility of abdicating his own subjectivity and the truths he uses to construct his life, and replace them with his physician’s medical model. Yet subjectivity, in its fullest expression, is about freedom of choice, including not only the choice of who one wants to become, but also the methods one uses to create oneself — that is to say, which technologies of the self will be employed. Furthermore, discursive practices are not always selected because they work, like a science experiment run according to cause and effect, but neither are they entirely random. Rather, they are often ethical choices that relate to the person’s beliefs and feelings concerning the best way to live. And in a world of ever-changing memes and scientific data, exercising one’s choice about the discourses used to guide the construction of selfhood may be the greatest expression of freedom.
How do we make subjectivity inalienable?
Until the mental health field consistently respects the subjectivity of service users — no exceptions, not even for psychosis — I think the field will continue to return to the crossroads. To do otherwise is to leave open the possibility of harming the people it has committed to serve. Furthermore, the principle of do no harm that guides medicine may be inadequate for the mental health field and the sensitivity needed to truly avoid harming the very intimate experience of selfhood. Instead, principles of nonviolence that respect the organicity of life are needed. Distinctions between the normal and pathological that play a central role in medicine can impede both the provider’s and the service user’s abilities to witness the value of all aspects of selfhood that contribute to subjectivity.
Wrongly, the mental health field assigned itself the role of developing subjectivity instead of witnessing subjectivity. Shifting to witnessing subjectivity supports people in experiencing their subjectivity with greater awareness. This is a subtle although profound shift, and one that I think most practitioners and service users appreciate. Witnessing subjectivity provides more opportunities to respect all parts of the person seeking help, to create conditions that validate existing strengths and values, and to avoid power dynamics that inevitably hamper progress. Witnessing subjectivity means actively looking for it, and acknowledging shifting mental states changes all aspects of psychic life, including subjectivity. This is true of everyone. We are all at our best when our basic needs for sleep, food, companionship and stimulation are met. Failure to meet these basic needs can reduce anyone’s capacity to act intentionally or responsibly. Just as such reactions would not be perceived as signs of underdevelopment and be treated as such, being mentally ill or traumatized is not sufficient cause for denying a person’s subjectivity or regarding it as underdeveloped.
Of note, I don’t think it is coincidental that psychologists are criticized for their role in torture at Guantanamo Bay during the same time in history when prominent psychiatrists are accused of exchanging scientific principles for profits from pharmaceutical companies. Both situations rely on a two hundred year old understanding of subjectivity as something that can be manipulated. Such an attitude opens the door to the kinds of exploits less scrupulous people will use to justify actions that deny the full humanity of others, whether torture or hiding dangerous side effects of prescription medications. In both cases, the long held belief that people with mental illness are somehow lacking has allowed a sense of urgency and fear to justify unethical solutions, chosen because they might quickly resolve the perceived anomaly (and supposed threat). And I think we keep coming back to the crossroads because the mental health field has yet fully embraced a principle of nonviolence that both respects and protects the rights of the people it purportedly serves.
What Does Inalienable Subjectivity Look Like in Practice?
I think there is fear that respecting the subjectivity of people who are diagnosed with mental illnesses, or suffering chronically from the effects of trauma, is equivalent to giving a gun to a child. Such hysteria is why a nineteenth century conception of subjectivity continues to hold sway even today. Despite all that has been learned about the human psyche and the treatment of mental illness and trauma, there still is a general association of mental illness with the lost capacity for subjectivity, and hence an increased likelihood of violence.
Thinking this way justifies treating people with mental illness as if they have less rights than others, if not savagely, and leads to beliefs that the mentally ill should be feared rather than helped. And by savagely, I mean putting people in physical or chemical constraints, or not taking seriously the isolation and profound sense of loss that occurs with mental illness or after trauma, and thus not providing necessary resources and in a timely fashion. And I think if we start seeing subjectivity as an inalienable experience that is state dependent, and acknowledge the necessity of freedom of choice for ethical living, then we might also start seeing the tragedy that lack of adequate mental health services imposes on people, especially at this particular moment in history when to be human is nearly synonymous with the continual construction of selfhood. I also believe that if we start seeing subjectivity as inalienable, there will be more of an expectation to change the conditions that contribute to mental illness and trauma, which would be great, since changing the conditions would also lessen their likelihood of occurring.
Many providers already adhere to principles of nonviolence and consistently respect their clients’ subjectivity and right to choice of treatment. These practitioners are not looking at service users for evidence that they have failed to develop, or that they suffer from a pathology. Rather, they work with service users to identify the strategies they have developed to survive, given their temperament, their body, the conditions in which they were raised, the traumas they’ve experienced. Whatever modality used, the goal is supporting people in developing new strategies, or relaxing old ones that no longer serve them, so they can grow and adapt to current conditions in their lives.
- These practitioners also increasingly focus on mindfulness, and on supporting service users in gaining greater awareness of present moment experience. With practice, mindfulness increases subjective awareness and the capacity to witness what types of changes lead to desired outcomes. With increased mindfulness, the impact of change can be witnessed not only in thoughts, but also in feelings and body sensations, widening subjective awareness and increasing the ways a person experiences selfhood.
- Even with the application of developmental theories, such as attachment theory, treatment can focus on introducing new strategies rather than improving an underdeveloped mind. The different attachment styles — whether avoidant, disorganized, preoccupied, or secure — represent ways the developing child made use of the attachment figures in her or his life in order to survive. Even if attachment is disorganized, and doesn’t lead to satisfying relationships, adaptation did occur, and there is always the possibility of learning different strategies, and with time and effort, a new way of being in the world can emerge.
- Treatment can also involve using subjectivity differently. For example, Dialectical Behavior Theory supports service users in establishing nonjudgmental self-awareness rather than relying on a critical subjectivity that mimics the language and attitudes that often dominate in emotionally invalidating households.
I hope that I have made the case that how we think about subjectivity is central to the success of the mental health field. The field continues to rely on antiquated notions of subjectivity fashioned at a time when the mentally ill were barely seen as superior to untamed beasts. Fortunately, increasingly “mentally ill” is seen as an experience and not a person, and there’s more respect for the wisdom of the wildest among us — the truly wild animals with which we share Earth. Yet we’ve unwittingly left a loophole through which shoddy, if not unethical treatment can still find its justification. And as long as the mentally ill or traumatized can be pathologized, or perceived as underdeveloped, their rights, and the field, are at risk. However, by establishing and enforcing principles of nonviolence that respect the organicity of life as central tenets, the field will more likely avoid the kinds of setbacks that ignoring fundamental principles of nonviolence has caused.
References
Foucault, Michel. (1988). Technologies of the Self. In H. G. Luther H. Martin, Patrick H. Hutton (Ed.), Technologies of the Self: A Seminar With Michel Foucault. Amherst: University of Massachusetts Press.
Luhrmann, T. M. (2000/2001). Of Two Minds: An Anthropologist Looks at American Psychiatry (2nd ed.). New York: Vintage Books.
Porter, Roy. (2002). Madness: A Brief History. Oxford: Oxford University Press.
© 2015 Laura K Kerr, PhD. All rights reserved (applies to writing and photography).
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