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Chapters reproduced on the web Chapter
Four:
The Ethics of Professionalised Care by
Jim Moorey, BA (joint hons), PhD
1/ Introduction Henry
Kissinger once remarked that we live in the 'age of the expert', and that
'the expert has his constituency - those who have a vested interest in commonly
held opinions; elaborating and defining the consensus at a high level has, after
all, made him an expert'
(quoted in Chomsky,
1982, p.91)
In other words the role
of the expert is to articulate the consensus of people with power. Power can of
course be exercised in both benign and malign ways, but the exercise of power
always requires justification. On examination, however, such justification is
often lacking. While power in a crude form is easy to identify, and in most cases
easily shown to be illegitimate, in its more subtle manifestations the operation
of power may be elusive, even at times invisible. Invisible, that is in its source
and operation, but not in its effects. The writer who has done most to make visible
the operation of power, and in particular to elucidate the crucial relationship
between power and - what can be regarded as the special currency of the expert
- knowledge, is of course, Michel Foucault. Much of what follows in this chapter
is influenced by his perspective, but I hope I have avoided the irony of being
dominated by it. In this chapter I will outline some of
the more notable features of the formation of professions, and highlight some
of the central ethical issues such features raise, especially in the field of
'mental health'. In line with other chapters in this book my goal is not to give
an exhaustive analysis of the issues, but to raise questions and encourage reflection.
2/
The Territory of Professionalised Care
In a figurative
sense 'territory' refers to a sphere, region, or domain, over which some form
of influence or control is claimed or exerted. The Oxford English Dictionary notes
that an implication of the zoological use of the term is that it refers to an
'area held by animal(s) against others of the same species.' The territory of
professionalised care is probably best illustrated by considering examples. The
following brief accounts will help map out the territory, and introduce some of
the questions explored later in the chapter Carlton Carlton
was in his late teens, the youngest of a large family from Moss Side, a working
class area of Manchester, a place with a nationwide reputation for violence. He
was of Afro-Caribbean descent. Like the rest of his family he was unemployed.
Carlton was brought to the psychiatric unit by the police, who thought his loud
and belligerent behaviour was more likely to be signs of madness than criminality
(his mother told me she was glad the police thought he was mad: "At least
the doctors don't break your ribs"). Carlton believed malevolent forces were
trying to control him. Voices gave him orders but he ignored them. He was unkempt
and dirty, he did not like to wash, he did not want to be a "whitewashed
grave". He thought being employed was equivalent to slavery, that cannabis
brought more knowledge than books, and that money was evil. He heard voices, but
preferred them to his mother's nagging. He also thought words were cheap, and
violence natural. He spoke contemptuously of "the white world" that
he believed was trying to control him, resenting what he called "legalised
white violence", and the "chicken-shit goodwill" of "concerned
white liberals". Much of his speech was difficult to follow (although his
mother thought he was rather more articulate than usual). Carlton was very angry,
he swore at the consultant psychiatrist and punched one of the nurses ("for
asking stupid questions"). Carlton was considered to be 'schizophrenic' and
"a danger to himself and others". He showed no gratitude towards staff
for their efforts to confine and medicate him. Carlton
is, of course, like many others who enter the orbit of 'mental health' professionals,
and the outline I have given here will be a familiar picture to many of those
who work in this field. Carlton's behaviour, beliefs, feelings and experiences,
would be regarded by many as in some way the responsibility (the 'territory')
of certain professionals. But many people, including the professionals involved
in Carlton's 'care', strongly objected to him. The gulf between staff and patient
was not simply that between sane and insane. What is it that Carlton provokes
in us, that underlies our desire to intervene? What exactly is it about him that
we want to change? What do we want to control?. When Carlton enters our world
is he expected to learn our language and values - to use our words, verbalising
frustration rather than striking out, for example? Is persuading him to do so
part of the treatment? Or the conditions of treatment? Is it possible to adopt
a framework in which Carlton's violence is seen positively - as it was in his
'subculture'? How do we answer Carlton's mother's question: "He's been surrounded
by violence all his life. What else do you expect him to do?" Must violence
on the part of someone in Carlton's position (i.e., not a soldier, policeman or
someone else with 'appropriate authorisation' [!]), necessarily be either criminal
or pathological? Carlton's aggressiveness and lack of cleanliness provoked much
more upset and debate than his hallucinations, which didn't seem to bother anyone,
least of all Carlton, What are we to make of this? Are 'mental health' professionals
in this situation in the 'business' of cure, care or control? Carlton's beliefs,
his feelings, his experiences and behaviour are all regarded as legitimate areas
for investigation and assessment, and perhaps, control and intervention. Different
professional groups laid claims to various areas of Carlton's life and behaviour.
Psychiatrists, nurses, social workers, psychologists, occupational therapists,
and others, staked their relative claims. On occasions these varying professional
claims came into conflict with each other. But whose interests should be paramount
in this situation? And, we may wonder, in such situations, whose interests usually
do prevail? Clare Clare was
forty when she was referred by her GP to the department of Clinical Psychology.
Her GP described her as "depressed and agoraphobic". Clare had married
when she was thirty one, and given birth to her son, Mark, when she was thirty
six. Within weeks of Mark's birth Clare began to develop what would generally
be regarded as typical symptoms of depression and agoraphobia. Clare's GP prescribed
antidepressants, which alleviated her depression sufficiently for her to continue
to care for Mark, although she would not leave the house unaccompanied. Gradually
she became more withdrawn and unable to enter shops or walk in the street. She
would only leave the house if she could be driven to her destination by her mother
or father, or her husband. Clare's husband, David, had been a research chemist
until shortly after their marriage. In order to increase his income he had changed
his occupation to a managerial post in a pharmaceutical firm. His new job involved
a great deal of evening and weekend work, as well as regular trips abroad. After
about a year in his new job David was obliged to take a post in a different city.
Clare did not want to move, she enjoyed her secretarial job, and wanted to remain
close to friends and relatives. However, she felt obliged to acquiesce: "David's
career obviously had to come first, so we moved". Soon after moving Clare
became pregnant. Her husband and parents were delighted. Clare kept telling herself
how fortunate she was, but her feelings were saying something else. At times,
as she reflected on her past she wept. Being an only child, having everything
she thought she had wanted, being unhappy, her mother's protectiveness, a car
accident when she was ten, being bullied at school, trying to please others. She
wept also when she realised she hated her life. Her own thoughts and feelings
began to terrify her... Again this is a familiar situation
and doubtlessly even with such a brief sketch of Clare's situation, hypotheses
about what is 'wrong' will be suggesting themselves. Of course these hypotheses,
and the presumptions which flow from them, vary enormously depending on the particular
framework that we adopt, or that we have been 'schooled' in. But before this whole
process of explanation and prediction gets going we might pause to ask some general
questions about our perception of Clare. For example: Is there really anything
'wrong' with her? In so far as there is a problem where should it be located?
Is there something wrong with Clare's 'inner world'? Or in her 'object relations'?
Or is it her history of 'conditioning' that is at fault? Does the problem lie
in her 'cognitive schemas'? Perhaps we should locate the problem in her network
of relationships. Or perhaps in her role expectations. Perhaps the problem stems
from issues of gender and power. Or perhaps her 'being - in - the - world' is
essentially inauthentic... Obviously there are various ways of thinking about
'the problem', we can interpret Clare's situation in a multitude of ways. And
of course the way we respond, the help we offer - our 'intervention' - will be
justified in terms of our conceptualisation of the problem(s) and the source of
the problem(s). But the point I want to emphasise here is that the particular
framework we adopt represents a bid for control or influence over aspects of Clare's
life, which may to a large extent be a reflection of professional, rather than
rational or moral commitments. By the time Clare began
therapy she had seen a male GP, a male consultant psychotherapist and a male counsellor.
Now she was seeing a male psychologist. What has already been set in train by
this process? What assumptions have already become attached to Clare, as a recipient
of professionalised care? What can professional health care workers really offer
Clare? Albert Albert described
himself as "a survivor". He was seventy eight. He had been raised in
an orphanage where he had suffered physical and sexual abuse, and had survived
four years as a prisoner of war in Burma and Thailand during the Second World
War. He had witnessed the suicide of his daughter, and his son's death from cancer.
He had worked hard all his life, for many years in various parts of the construction
industry and, later, sweeping streets. At various times in his life Albert had
been a heavy drinker. There had been times when he had beaten his wife, Joan:
Once, so badly the cuts above her eye, and on her nose and ear, needed stitches.
Albert had also sexually abused his daughter, Kate, a "terrible thing",
as he said. But he managed to keep this secret from his wife. Albert
had been told that Joan had Alzheimer's disease when she was sixty eight. Albert
was then seventy. At the time he didn't know what that meant. Over the following
six years the struggle to look after Joan, with minimal support, took its toll.
As Albert put it, "it nearly finished me off". As he watched Joan's
deterioration, there were times when he would become so angry and frustrated that
he would shout at her, and sometimes hit her. Often he would sit for hours and
cry. He felt he had done his best to care for her through those years, but with
no family or friends who could help, it was difficult. He had hoped for more support
from professional and voluntary agencies, and felt very bitter at the meagre help
that was provided. "You work and pay taxes all your life, you go to the other
side of the world to fight when they tell you to, and at the end, when you need
help, they throw you on the scrap heap". When Joan died, Albert seemed to
give up. At first he tried to avoid spending time in his flat because he sensed
Joan's presence there, which frightened him. But the cold outside, and the gangs
of teenagers who taunted him, eventually drove him back to what he called his
"dungeon" (his council flat). The flat was dark and damp. The bedroom
windows needed to be repaired but Albert had lost the will to go through the long
routine of repeatedly badgering the council until they responded. Because the
flat was so cold and damp Albert felt more comfortable in bed. He would stay there
for days, only venturing out to get his pension and buy alcohol, which he preferred
to food. Eventually Albert was seen by a psychiatrist who considered him to be
suffering from "depression associated with unresolved grief after the death
of his wife". Again as we reflect on Albert's experience
how should we regard what has happened to him? Is Albert ill? What is wrong? Who
should help? Who, if anyone, is responsible for Albert's condition? Albert's
problems will be seen as legitimate territory for a whole range of professionals:
His material, physical, psychological and spiritual welfare may all be eyed knowingly
by different groups of experts, eager to diagnose, prescribe and treat. However,
rather than pursue the multiple perspectives that could be advanced in an effort
to explain and offer solutions to Albert's difficulties the reader may reflect
on the following point. The figurative use of the term 'territory' that is used
here, while conveying some aspects of the situation we are considering, is in
other respects very misleading. We are considering the lives of real people -
both professional care providers and those who receive such care. Apart from our
response as professionals - which may be quite rigidly constrained according to
the framework we have been more or less successfully inducted into - we respond
as people. Sympathy or condemnation, fear or contempt, impatience or concern,
boredom or fascination, sorrow or indifference. There is inevitably a personal
response, which we may for the sake of our discussion distinguish from a professional
response. It may arise, indeed it may be quite common, that what we actually feel
conflicts sharply with what we consider we ought to feel, as members of a particular
profession. And it may be just as common for us to attempt to justify what is
actually a personal response by clothing that response in professional garb: this
is easily done when the role is as elastic as that of 'mental health' professionals.
The 'territory' of professional care is unavoidably an interpersonal 'field',
which is shaped (and some might argue constituted) by the beliefs and desires
of the people involved, the persons occupying their respective roles. In particular
this area is one in which various forms of interest emerge and conflict. It is
this question of interest that we will consider in more detail in the following
sections.
3/ Power and Professions A
startling characteristic of advanced industrial societies is the extent to which
the division of labour has led to the creation of professions. Sociologists interested
in this phenomenon have attempted to answer three fundamental questions: What
exactly is a profession? What functions do professions serve? And, how do professions
develop and acquire their status? What are professions is a question of definition
and meaning. What functions do they serve is a question relating to a particular
form of social organisation and its effects, effects that we should be aware of
if we are to be honest about our contribution to society. The question how do
professions develop concerns the acquisition of status and power, and concerns
us particularly in relation to how we gain and use that power as we acquire, as
individuals, our own professional status. We will not dwell on the problem of
defining a profession other than to note suggestions have ranged from providing
lists of the characteristics of professions to the rather more helpful notion
that a profession is a structure for controlling an occupation. The other two
questions, however, concerning the function of professions and the way they develop,
are of direct concern to us, and I shall explore them in the following sections. The
function of professions Concerning the function of
professions there has been a marked difference of opinion. Tawney (1921) and Durkheim
(1957) saw the growth of professions as a positive aspect of industrial societies
because they contributed to 'stability'. They considered the professions to be
a precondition for consensus. The function of professions was seen in terms of
their contribution to social cohesion and resistance to dramatic or radical change.
Similarly Carr-Saunders and Wilson (1933) saw the professions as among 'the most
stable elements in society,' which 'engender modes of life, habits of thought
and standards of judgement which render them centers of resistance to crude forces
which threaten steady and peaceful evolution...'
(p.
497) They are explicit in seeing the function of
professions as employing knowledge in the service of power. Lynn (1963) went so
far as to argue professions are vital, not merely for the stability and survival
of individual industrial societies, but also to 'maintain world order' (p.653),
through their international organisations and identities. A
central feature of the 'stabilising' nature of professions is said to be what
is known as 'professionalism'. This, it is claimed, involves a devotion to the
collective good, and a minimising of self-interest. That is, notions of commitment
to particular standards of work and morality. For example, Halmos (1970) claims
that an 'ethic of personal service' characterises those professions such as medicine
and social work whose 'principle function is to bring about changes in the psychosocial
personality of the client' (quoted by Johnson, 1972 p.13), and that they are 'leaders
in the creation of a new moral uniformity, a natural order influencing all industrial
societies, whatever their political structure.'
(Johnson
1972 p.13)
Professions are seen, from
this perspective, as vanguards of morality as well as stability. The
writers quoted so far in this section all agree that a key function of the professions
is that of engendering social stability by moderating and channelling forces pressing
for change. This function is considered a positive factor in the development of
industrial societies. This sympathetic account of the function of professions
has been criticised in various ways. We can consider two main questions: Are these
accounts accurate - are the professions really stabilising forces? And, if they
are, should they be praised or criticised? Weber's (1964)
analysis accepts the 'stability' function of professions, but is critical because
he considers the professions to be part of the bureaucratisation of society, which
he argues will inevitably lead to individual's becoming subject to increasingly
unaccountable authority. C. Wright-Mills (1956) argued that the expansion of the
professions was not the expansion of learned and humanitarian forces dedicated
to service, stability and democracy, but an explosion of 'experts and technocrats'
who would by virtue of their specialisation be narrow and lacking in vision. Goldthorpe
(1982) takes what may be regarded as a neo-Weberian view that the professions
are a 'conservative element within modern societies', because they have 'a substantial
stake in the status quo' (p.180). Abercrombie and Urry (1983) offer a neo-Marxist
analysis asserting that the 'service class' (i.e. professional and managerial
groups) 'perform the functions of control, reproduction and conceptualisation
- necessary functions for capital in relation to labour' (p.122). Such accounts
agree that the growth of the professions has been a stabilising force, but has
served to influence industrial societies in largely undemocratic ways, ensuring
that whatever change does occur serves the interests of dominant power groups. In
contrast to such critiques, others argue that professions are a positive force
for change, allowing people from relatively unempowered sections of society to
attain a greater share of wealth and privilege through the acquisition of specialised
knowledge and skills. Some have argued the professions (or at least some professions)
are actually the most potent force for change in society. For example Abercrombie
and Urry (1983) argued that during a recession the threats arising from economic
insecurity may serve to radicalise members of the service class. In this respect
the experience of the service class during the 1980's is instructive. Both sectors
of this class (managers and professionals) have expanded dramatically in the last
twenty years. But in the 1980's Conservative governments promoted a managerial
ethic which included a barely concealed contempt for professionals. There is some
evidence (Edgell and Duke 1991), that the professional sectors of the service
class, particularly those working in the areas of health and education, became
more radical in their views following cuts in public spending and the extension
of managerial power that occurred throughout the 1980's. A cynic could be forgiven
for suggesting that professionals only make a fuss and draw attention to the discrimination
and deprivation suffered by users of their service when their own position is
threatened, and are content to remain silent when their privileges are secure.
What we have witnessed (particularly in the health service) is a battle for power
between managers and professions, and between the rival professions themselves,
usually cloaked in rhetoric about the welfare of patients. A critical view may
also suggest that the actual behaviour of professions when under threat reveals
how hollow the talk of ethical professionalism is, and that a profession essentially
exists to promote the self-interest of members, rather than to protect consumers. So
much for our brief exploration of the function of professions and the sort of
contribution we might be making to society by virtue of our roles as professionals.
We must now turn to the way in which professional status and power develops and
how, as individuals, we may participate in this development. In the following
section I may seem to be emphasising the unpalatable aspects of the development
of professional status and power. If so, my intention is not to promote cynicism
or despair. Rather, my goal is to highlight some of the ways our self-interest
might be operating, and in particular to encourage awareness of, and investigation
into, the ethical dilemmas which inevitably arise when 'care' is professionalised. Although
Savage (1992) is surely correct to argue organisational and cultural assets are
inferior to property as sources of class power we should not underestimate just
how valuable are the organisational and cultural assets bestowed on members of
a profession, nor how much power is gained by ownership of these assets. In various
ways our immediate experience is determined, constrained and dominated by the
operation of organisational and cultural power. This is true of our experience
both as professionals and as people forced to rely on professionals for help.
A point which brings us to a key question: What sorts of power do professions
have and how did they get it? The acquisition of professional
power The development of professions can be explored
from various angles, but I want to focus on one particular area, what we might
call the interpersonal strategy of professionalisation. This aspect has been well
documented and described by Johnson (1972). In any society
undergoing industrial development we can observe the growth of occupations with
specialised skills. Such differentiation inevitably results in relationships of
social and economic dependence forming between those who have the required skills
and those who do not. Dependence on the skills of others inevitably results in
a lack of discrimination in consumption. Clearly, the more a 'consumer' can be
made to feel deficient in skills or knowledge in a particular domain the less
confident they will feel in judging the competence of 'producers' ('consumers'
and 'producers' being understood in a very broad sense). The highest levels of
uncertainty will occur when a consumer is unable to specify what exactly is required
of the producer. There are two crucial features of the
interdependence between producers and consumers: social distance and uncertainty.
Clearly when one party in an interaction has knowledge or skills it wishes to
market, and another has needs it wants fulfilled, there is dependence but also
distance. Social distance merely enshrines the fact that the two parties have
different interests, goals, motives, roles and functions in the interaction. There
is a clear distinction between 'producer' and 'consumer'. But this social distance
give rise to uncertainty. What is the nature of the relation? What is expected?
What are the rights and duties of each participant? Who is to specify the terms
of the exchange and the format of the interaction? How are we to assess if responsibilities
have been adequately discharged? What are the relative levels of dependence and
autonomy between the two parties? Such uncertainty is especially acute when the
consumer's lack of discrimination is at its highest - that is when the consumer
does not know how their need can be met. Regarding this uncertainty, inherent
in all producer-consumer relationships, Johnson notes: "Power relationships
will determine whether uncertainty is reduced at the expense of producer or consumer."
(p.41). The operation of power manifests as increased dependency for one party
and a corresponding increased autonomy for the other. In effect power will determine
whose definition of the relationship will prevail, and hence whose interests will
be given priority. Johnson further notes: 'A
significant element in producing variation in the degree of uncertainty and therefore
potential for autonomy is the esoteric character of the knowledge applied by the
specialist.'
(p.42)
'Esoteric'
is the key word here; esoteric means hidden, obscure, veiled, known only to the
initiated. Esoteric knowledge is a very potent way in which the uncertainty inherent
in the producer-consumer interaction can be reduced in favour of the former. This
creates a social distinction characterised by the greater dependency of the consumer
and the greater autonomy of the producer. Hence laying claim to esoteric knowledge
(and the skills which are claimed to follow from this) offers a powerful means
of dominating a producer-consumer exchange, and being able to impose what are
to be the conditions of that exchange. In order to establish
control of a domain, or territory, a profession must persuade potential clients
that members of the profession possess specialised knowledge and skills in three
areas: 1. The capacity to accurately identify a problem.
2.
The capacity to understand the cause of the problem.
3. The capacity to solve
the problem. Knowledge and skills in these three areas
confer the status of 'expert'. With respect to service occupations the assertion
of capability in these three areas, in terms both of knowledge and skills, must
operate through face to face contact between providers and consumers. Johnson
calls this the 'diagnostic relationship'. The diagnostic relationship rests on
the claim that a particular service provider can reliably and accurately identify
a problem, understand its cause, and provide a solution. The three features of
the diagnostic relationship noted here frequently form the basis of an ideological
struggle in which professional groups assert the need for independence and 'professional
status' as a necessary condition for fulfilling obligations to consumers. And
in fact any profession that, within a particular domain, can persuade potential
clients that it alone possesses knowledge in these three areas will be able to
exercise considerable autonomy, be free of pressure from competition, and be able
to rely on continued dependence and compliance from its consumers. It
is easy to see that possession of esoteric knowledge is a very tempting acquisition.
But as Johnson warns, the imbalance in power between practitioner and client provides
opportunities for practitioners to increase social distance, and their own autonomy
and control over practice, 'by engaging in a process of "mystification"'
(p.43). 'Mystification' refers to a process of obscuring,
or shrouding in mystery, of bewildering in order to exploit. Mystification attempts
to render the ideas and practices of the mystifiers unavailable to assessment
and evaluation by outsiders. Mystification serves a number of purposes: it facilitates
control of the assumed area of competence, helps raise effective demand (which
expands the market the professional can exploit) while at the same time preventing
potential clients developing effective discriminating powers (i.e., keep them
needy but ignorant), and helps secure a monopoly in the particular field by dissuading
competitors. Broadly, mystification alms to increase the dependence of the client
and the autonomy of the professional. Important elements of mystification include
the use of technical language, and what might be described as demanding 'rites
of passage', which can strengthen the internal cohesion of the group, and ward
off critical examination and competition from those outside the group. Mystification
may range from what might be regarded as the relatively innocuous use of professional
jargon to various forms of dissimulation, and in some cases to outright. fraud.
But in whatever guise, mystification is essentially a tool of power and self-interest.
As Johnson notes: 'Uncertainty is not, therefore, entirely cognitive in origin
but may be deliberately increased to serve manipulative or managerial ends.' (p.
43). Mystification is closely related to the notion of
ideology, which can be defined as the deployment of ideas that obscure and distort
reality in the interests of a particular group. If a profession can offer not
only merely persuasive grounds for its domination of a domain but also demonstrate
usefulness to wider networks of power, particularly political and economic power,
then its security will be greatly increased. Antonio Gramsci described those who
contribute to a view of the world which effectively serves as justification for
the status quo as 'experts in legitimation'. Any profession that can promote or
protect the interests of those with political and economic power, functioning
as 'experts in legitimation', will have added another layer of protection to their
position. Although this account applies to the professions
in general it is particularly relevant to those working in health and social service
areas. As Johnson notes, these occupations have 'particularly acute problems of
uncertainty', with the judgement of consumers being largely ineffective. In these
situations the seeking of professional help 'necessarily invites intrusion of
others into intimate and vulnerable areas of the consumers self- or group- identity'.
With respect to these professions the greater social distance and greater helplessness
of the client leads to a greater 'exposure to possible exploitation and the need
for social control' (Johnson, 1972, p.43-44).
4/
Colonising distress
What Johnson calls the 'diagnostic
relationship' is at the heart of the function and development of the mental health
professions, especially those who actually control the diagnostic relation. Examining
the operation of the diagnostic relation reveals most clearly the ideological
nature of the mental health industry. As we have noted there are three essential
features of the diagnostic relationship: identifying the problem, understanding
the cause and prescribing the treatment. We will very briefly consider these features
in relation to the specific diagnosis of 'schizophrenia' , one of the foundation
stones of psychiatry. The diagnostic relationship: the
case of 'schizophrenia' Is 'schizophrenia' a disease?
Can 'schizophrenia' be reliably identified? Is the cause, or are the causes, understood?
Can the condition be effectively treated? Clearly the answers to these questions
focus on the credibility of the diagnostic relationship itself, and on the legitimation
of psychiatric power which is based on that relation. However, these matters have
been, and remain, highly controversial. Concerning the first aspect of the diagnostic
relationship, identifying the problem, there are two questions: Can psychiatrists
reliably infer the presence of the construct 'schizophrenia', and is this construct
valid? There have been a number of recent reviews of a large body of evidence
which casts considerable doubt on the reliability, the construct validity, the
predictive validity, and the aetiological specificity of the diagnosis of 'schizophrenia'
(for example Bentall et al, 1988; Bentall, ed., 1990; and Boyle, 1990). The evidence
suggests that the reliability and validity of the construct 'schizophrenia' has
yet to be established, hence its use in both clinical and research settings raises
serious questions. But what about the second aspect of the diagnostic relationship,
concerning cause? (It may be noted that the question, "What is the cause
of schizophrenia?", becomes incoherent if we reject the notion of 'schizophrenia'
as a meaningful scientific construct. But we may ask: "Why do some individuals
manifest the specific forms of behaviour and experience likely to attract a diagnosis
of 'schizophrenia'?"). It is important to consider this second feature of
the diagnostic relationship as it has implications for the fate of those diagnosed
'schizophrenic' and brings into focus the ideological function of the diagnosis There
have been various suggested causes of 'schizophrenia', but most psychiatrists
have focused on biological factors. Despite the efforts expended in the search
for a biological cause, results have been tenuous at best, while the claims have
often been optimistic, and at times bordering on fraudulent (Charlton, 1990; Marshall,
1989). But while the search for the assumed biological origins have continued,
there has been a gradual accumulation of evidence pointing to the importance of
social factors in both the incidence and the course of 'schizophrenia'. In a comprehensive
review of this evidence Richard Warner (1985, 1994) notes that in particular 'political
economy assumes a hitherto underemphasised importance in the production and perpetuation
of schizophrenia.' (1994, p.28). Concerning what may be regarded as typical symptoms
of chronic 'schizophrenia' Warner notes, these are more accurately 'attributed
to the purposeless lifestyle and second class citizenship of the schizophrenic.'(1985,
p.299). And that 'the origins of the schizophrenic's alienation are to be found
in the political and economic structure of society - in the division of labour
and development of wage work.' (1994, p.190). Warner is careful to point out that
he is not arguing 'that material conditions create schizophrenia in any simple,
deterministic way, but rather that they mould the course and outcome of the illness
and influence, along with others factors, its incidence.' The point is that the
significance of social factors has been dramatically underemphasised in favour
of biological theory and research. Given the state of the evidence it is difficult
to see this as other than ideological The third aspect
of the diagnostic relationship will often be regarded as following logically from
the second, although clearly this is not necessarily the case. However, consistent
with a biological approach to causation 'schizophrenia' is usually treated with
medication. But neuroleptic medication may be much less helpful than often assumed.
Crow et al (1986) note that only about 20% of first episode 'schizophrenics' (followed
up for two years) respond to drug treatment. It may be admitted that response
to medication is unpredictable, but what of the claims that, overall, neuroleptics
have dramatically improved outcome? Warner (1994, ch.10) presents evidence demonstrating
that long term outcome of 'schizophrenia' has not significantly improved since
the introduction of antipsychotic drugs in 1954. It also appears to be the case
that despite suppressing symptoms in some patients in the short term, long term
use of neuroleptics may exacerbate what is assumed to be a basic neurochemical
deficit in 'schizophrenia': dopamine receptor supersensitivity (Warner, 1994;
pp.218-221). A number of researchers, for example Swiss psychiatrist Luc Ciompi
(1980, 1984), have argued the polymorphic course of the condition is evidence
against the conception of 'schizophrenia' as a progressive disease process (for
a review of this research see Barham and Haywood, 1990). Recovery from 'schizophrenia'
appears to be crucially related to social and economic factors. After a detailed
review of the research Warner concludes that we know enough about the origin and
perpetuation of 'schizophrenia' to render the condition benign, but 'we may, in
essence, have to restructure Western society' to do so (1985, p.156). It
would appear then that with respect to 'schizophrenia' the diagnostic relationship,
which confers power on psychiatrists, is constructed on some highly contentious
claims, to put it mildly. It is difficult to see the emphasis which is placed
on the concept of 'schizophrenia', and the medically based research and treatment
industry such emphasis has generated, as anything other than ideological. Hence
we may legitimately ask: Whose interests are served by this emphasis? In whose
interests are millions of pounds spent on research into drugs and biochemical
theories of causation? By promoting the view that 'schizophrenia' is a biological
defect we obscure the multifactorial nature of the condition, and in particular
we conceal the fact, argued so forcefully by Warner (1985, 1994), that we are
generating pain and suffering by the way we organise our society. It is in the
interests of all those who do well out of industrial societies to support psychiatrists
and others working in the field of 'mental health' in perpetuating this view of
'schizophrenia'. All this is part of a process of 'mystification' which serves
the interests of power, a means by which those without power are blamed for their
condition and given merely token assistance, through medication or therapy. The
diagnostic relationship: the psychotherapy industry Much
the same questions can be raised with regard to psychotherapy in general. What
are considered to be problems, the way we identify needs, what experience or states
of mind we assume require professional attention, the sorts of explanation we
offer, the language we use, and the processes we consider to be helpful, all reflect
the basic structure of the diagnostic relationship, which invariably operates
primarily in the interests of professionals. It is our definition of the nature
of the interaction which prevails. We find ourselves contributing
to a radical disempowering of people, appropriating their capacity to help and
support each other, by promoting ourselves as experts in the area of 'mental health'.
While, just as with the case of 'schizophrenia' the assumptions of the diagnostic
relationship which we employ are largely bogus. Emotional distress of any sort
is deemed to be the domain of professionals who have esoteric knowledge and expertise
in this field (or 'territory'). The professional will seek to locate the problem
in the person's history of learning, their belief-system, their family relationships,
or internal object relations, or whatever other model is associated with a particular
professional identity. However, the evidence that any of these accounts are true,
or that the specific therapeutic procedures based on them are effective, is almost
non-existent. But as David Smail has noted: 'We find it virtually impossible to
abandon the idea of therapy, to contemplate seriously the possibility that in
fact therapy may really not work.' (1987, p.77). And yet therapy 'is of much less
help then almost any of us can bear to think.' (1987, p.78). Again
one must ask: In whose interests is this situation perpetuated? Who benefits from
this state of affairs? The ideological functions and self-interest of psychiatry,
psychology and psychotherapy may not be seen as such by practitioners, but the
effects are surely obvious. Siphoning off from the community the capacity for
understanding and mutual support serves the interests of professionals who benefit
from a dependent and disempowered group of 'clients' (the implications of the
term do not need spelling out). An important feature of
colonisation is the way it spreads its borders. It is instructive to note the
way new diagnoses are invented to incorporate features of human life and experience
into the framework of 'pathology'. In an unusual reversal of this trend homosexuality
was only removed from DSM in its third edition (1983). While many other aspects
of human variation are drawn into the orbit of 'pathology', colonised by a professional
class eager to extend its borders. R.D. Laing once described this as a "project
of homogenisation": we are all expected to experience and behave in similar
ways, and variations are abnormal (not in the statistical sense, but in the sense
of pathology). This is clearly a process of extending power and control into as
many areas of an individual's life as possible. This process serves the interests
of professionals by giving them an increasingly disempowered and heterogenous
client group, serving to marginalise difference and potential dissent. If we take
this line of enquiry to the point of challenging the ability or the right of any
group to legislate on issues of 'mental health' and normality (i.e., to question
the terms of the diagnostic relationship) we move into dangerous territory. Colonial
powers do not welcome resistance. Damaging professions? Ivan
Illich (1977) has provided a deeply critical account of the effects of professional
health care systems. He outlines three main areas of concern. First, what Illich
calls 'clinical iatrogenesis', refers to damage resulting directly from treatment.
Second, 'social iatrogenesis', meaning the various forms of damage that result
from the 'socio-economic transformations which have been made attractive, possible
or necessary' by the development of the professional and institutional structures
of the health care system (p. 49). For example, social iatrogenesis arises from
the creation of disabling dependence and extravagant expectations, which involves
the expropriation of the capacity of individuals and communities to take care
of and heal themselves (equivalent to creating a 'client' group which has unlimited
effective demand with as little discriminative power as possible). And thirdly,
'cultural iatrogenesis', this refers to the damaging consequences of promoting
a culture in which suffering, sickness, pain, infirmity, old age and death are
enemies against which others (professionals) wage a relentless war on out behalf.
In an advanced stage of such a culture alternatives become virtually inconceivable.
One way in which this is accomplished is through the control of language: 'Language
is taken over by the doctors: the sick person is deprived of meaningful words
for his anguish, which is thus further increased by linguistic mystification.'
(p.175). Overall, Illich argues, a professionalised care system 'cannot but enhance
even as it obscures the political conditions that render society unhealthy', and
will inevitably tend to "mystify and to expropriate the power of the individual
to heal himself and to shape his or her environment' (p.16). Illich
is uncompromising in his claims that the professionalisation of medical and psychological
care has been deeply damaging to individuals and communities. Although I am inclined
to agree with those critics of Illich who argue he has overstated his case, it
does seem to me that the forms of damage which he sought to elucidate are particularly
visible with respect to the mental health industry. It is striking, for example,
to see the way various 'experts' (psychiatrists, psychologists, psychotherapists
and counsellors) are called in whenever someone undergoes a conspicuous trauma
(I noticed recently "trained counsellor's are on hand" to help those
who have a big win in the national lottery!). But we may ask: What has happened
to the capacity of communities to care for those in anguish? And if there really
is more to the counsellor's trade than care and consideration why are these 'skills'
not disseminated to the population at large? The problem
is of course that a population saturated with various forms of social and cultural
iatrogenesis will be convinced that they need the ministrations of professionals,
and indeed to suddenly withdraw those ministrations will leave many without any
help at all (this unfortunately seems to have been the experience of many of those
'liberated' from asylums in Italy through the efforts of the 'Psichiatrica Democratica'
movement). Nonetheless the habit of deferring to professionals in the field of
'mental health' is a deeply damaging one. Caring for people in distress, even
those in psychotic states, is not something that can be appropriated by a professional
class without damage to the community as a whole. It does
not follow from this necessarily that there is no role for specialised care (although
Illich does draw this conclusion). As far as we know in every culture there have
been people whose distress and disability are prolonged and profound. The community
may well decide these people would be most helped by other members of the community
who spend their working lives trying to understand and help those in such difficulties.
Clearly this raises important ethical questions concerning principles of distributive
justice. I believe a very strong case can be made for the primacy of the principle,
to each according to their need. But what we have seen in the 'mental health'
industry is a shift of resources, skills, and concern away from the more chronic
and less glamourous end of the spectrum of difficulties towards the milder forms
of disturbance, that are perhaps easier to work with, and felt to be more rewarding.
In a recent edition of Hospital Update (April 1994), Jeffrey Marks, a consultant
psychiatrist, wrote an editorial entitled: 'The re-emergence of antipsychiatry.
Psychiatry under threat'. The general tone of the article is one of outraged indignation
that the role of psychiatry should by questioned by what he sees as subordinate
groups, in particular nurses and psychologists. One of the criticisms he makes
is relevant to the point under discussion here. He criticises CPNs who have shifted
the focus of their work from severe disturbances to those with relatively mild
difficulties, under the pretext of 'primary prevention'. As Marks notes the evidence
does not support the claims that such work is effective, and it is surely pertinent
to ask whose interests are served by this shift of focus? Issues
of power and domination are of course of much wider scope than we have considered
so far. The writings of Michel Foucault have been instrumental in making visible
some of the intricacies of what he calls the 'strategies of power', which goes
far beyond the familiar Marxist analysis of power resting ultimately with those
who control the economy. Foucault saw modern life as a 'dispersed and indefinite
field of power relations or strategies of domination', with power manifesting
'in a multiplicity of networks' (Kritzman ed., 1988, ch.6). He described what
he considered to be a vast 'normalising' project which has extended over centuries,
in which various forms of difference have been classified, marginalised and controlled
through the proliferation of categories of deviance within the broad domains of
criminality and psychopathology. Foucault tried to demonstrate through the historical
analysis of various institutions, that more subtle methods of domination and control
have largely replaced overt violence. In developed societies various forms of
coercion have been exerted towards the production of regimented, obedient, isolated
and self-policing subjects. It is not difficult to see how key features of the
'mental health' industry contribute to this process. In Foucault's account the
operation of this industry is just one part of a much wider project of domination,
control and exploitation. Hence it would be an error to assume that professionalised
care in the field of mental health is simply a product of professional self-interest:
the 'mental health' industry is shaped by, and serves the purposes of, much wider
and much more powerful interests. To conclude this section
I would like to emphasise a point that has been implicit throughout this section,
and is true of all forms of colonisation: that colonisation is not merely exploitive
it is also formative. The ideas and procedures underlying 'mental health' practice
are constitutive of the reality they purport to describe. That is, our accounts
of psychological disturbance are not simply mirrors, or even models, or reality.
We have noted that the 'mental health' industry in general presents a view of
the world that serves to legitimise abuse and exploitation by advancing theories
of damage and claims of cure that are primarily personal and internal in nature.
However, the application of such views ensures that they are not merely descriptive
or explanatory, but in various ways contribute to the production of the various
forms of behaviour considered to be the professional's legitimate domain. Psychological
theories tend to become instantiated in the phenomena they purport to describe.
This is perhaps the most insidious form of colonisation perpetuated by the 'mental
health' industry.
5/ Democratising distress
In
reviewing the foregoing information it is not my intention to argue that there
is no place for paid workers in the field of 'mental health', but rather to emphasise
some of the ethical issues inherent in any occupation where there are substantial
temptations to mystification. Concerning the general framework of description,
classification and explanation, and current treatment procedures, crucial questions
arise: How legitimate are they? Whose interests do they serve? To what extent
does current understanding and treatment hinder development in other directions? 'Democratisirig
distress' would involve a different way of thinking about and responding to the
various forms of suffering currently regarded as the 'territory' of various professionals.
By way of contrast it is worth reflecting on the communal approach to psychosis
that has often been described by anthropologists in studies of 'traditional' societies.
One example is that of the Navaho healing ceremony in which psychosis is regarded
as a community disturbance and as such the healing ceremony embraces the whole
community. Relatives, friends, and a wider group of participants, all take medicines
and undergo the elaborate purifications and rituals of the ceremony in recognition
of the community's need to be healed, or made whole. The primary value of the
individual's relation to the wider community is thereby re-asserted. In this way
psychosis is not personalised or individualised, hence the person undergoing a
psychotic crisis is not marginalised, stigmatised or pathologised. In tact it
has often been observed that an episode of psychosis may confer an elevated status
in some 'traditional' societies (Kiev, 1964). This way of responding to psychosis
clearly has the advantage of avoiding the secondary symptoms that frequently occur
in those labelled 'schizophrenic' in 'developed' societies as a result of the
marginal and deprived existence they are forced to live. Elements of a tolerant
and communal response to psychosis survive in much of the Third World, and may
well be a significant factor in the superior recovery rates that have been noted
outside of the 'developed' world (Warner, 1994). In contrast
Warner notes: 'We have far to go before the schizophrenic is welcome in Western
society' (Warner, 1985, p.307). With respect to Europe and the United States Breggin
(1993) notes that despite obstacles there have been a number of 'creative alternatives'
to the medically dominated treatment of psychosis that are 'by far the least expensive
and most effective.' (P.479). He describes a number of these alternatives, as
does Warner (1994). Some of these are discussed in other chapters of this book,
hence I will not address these approaches here, but will instead draw attention
to some of the obstacles that are frequently neglected in the search for a more
democratic response to human suffering. I believe Breggin (1993) is right to point
out that 'As long as the psychiatric and medical monopoly controls the delivery
of mental health services creative alternatives will be rare.' (P. 479). But I
would question his exclusive focus on psychiatrists. Psychiatry is not the only
profession in the field of 'mental health' that trades in mystification. All of
us who benefit from the sufferings of others are implicated in this question of
whose interest are served by the operation of the 'mental health' industry. The
question is, of course, not merely a factual one; at its heart it is an ethical
question. And answering ethical questions honestly often involves considerable
cost. David Smail (1987) has rightly pointed out that the 'observance of moral
principle will often operate against individual interest' (p.150). As Sue Holland
(1988) has noted: 'It is only by finding a therapeutic practice which will genuinely
empower the 'patient/client' that we can honestly reject the accusation that we
are 'poverty pimps', enriching ourselves out of the anguish of others.' (P.135) Often
the obstacles preventing the development of 'creative alternatives' are considered
to be the vested interests of psychiatry and the pharmaceutical industry. Breggin's
(1993) book detailing the deficiencies of psychiatric treatments and the psychiatry-pharmaceutical
industry alliance argues this point forcefully. But this is surely only part of
the picture. The operation of power and dominance, and the pursuit of self-interest
is not the prerogative of one or two professional groups. All of those who benefit
from the suffering of others have a vested interest in promoting particular types
of explanation and particular types of treatment. Promoting certain ideas and
practices and attacking others is often only tenuously related to questions of
argument and evidence, and appears more clearly associated with ideological struggle.
Therapeutic enthusiasms, one might even say fashions, may be promoted for many
reasons unrelated to the welfare of the patient. The 'territory' of 'mental health'
has been a region exploited for crude financial gain, but also a means for gaining
status and prestige, for promoting pet theories, for achieving some sense of dominance,
a pretext for revolt, a way of managing personal conflicts, perhaps even a way
of expressing revenge. The challenge of finding democratic alternatives to the
current arrangements, riddled as they are with hierarchy, rivalry, mystification
and self-interest, is a daunting one, not least because our own assumptions, perceptions,
wishful thinking and convictions are likely to be as saturated with self-interest
as those we would criticise. It is not easy for any of us to extricate ourselves
from the intricate web of mystification, dissimulation, wishful thinking, insecurity
and self-interest which both ensnares us, and by which we ensnare others. Not
only is self-interest and wishful thinking deeply engrained, so is the tendency
(when we are not simply indifferent) to either dominate or defer to others. To
talk about 'democratic' alternatives implies both an understanding of democracy,
and a capacity to think and act in a democratic fashion. But how easy is that?
'Representative' democracies like the United Kingdom are of course democratic
in only a very minimal sense. Our lives are shaped by forces which are extremely
antagonistic to democracy, and our capacity to think and act democratically is
very severely constrained. The habit of deferring to 'experts', of needing leaders,
of accepting injustice and coercion, and submitting to sundry authorities are
all very deeply ingrained. We are not permitted to take control of our own lives,
to participate in forming the decisions which will affect us in the workplace
and in our communities. Given the poverty of our experience of democracy it is
bound to be an extremely difficult process to shift the provision of 'mental health'
services in a genuinely democratic direction. The way in
which our responses are informed by assumptions that are often deeply antagonistic
to democratic values may be seen by simply reflecting on how we respond to others.
Concerning the experiences of Carlton, Clare and Albert, outlined in the first
section of this chapter, we may note that various professional groups (doctors,
psychiatrists, social workers, nurses, psychotherapists, psychologists, perhaps
clergy) would diagnose, explain and treat each situation differently. But how
legitimate are the competing claims? It is by no means clear just what would be
the most accurate account of the problem(s) and its cause(s) in each of these
examples. What would be the most helpful approach to these problems? What would
be a good 'outcome' - for the patients, for their families, for the professionals,
for other interested parties? Whose interests will be paramount? Whose version
of the diagnostic relationship will prevail, and why? These questions will usually
be settled by considerations of power and interest. Looking back to the outline
of the three experiences we may give particular attention to our personal responses,
putting aside for a moment the particular form of the diagnostic relationship
that we have been inducted into. What do we want of Carlton, Clare and Albert,
and of the various professionals involved? Do we want to control them? Do we want
to feel powerful, knowledgable or superior? To what extent do our own needs intrude
and shape our perceptions of them? As we reflect on the experiences can we get
a sense of where our interests and judgements lie? Given the brevity of the sketches,
what have we read into the accounts? What do we assume we know? What alliances
and agendas have already taken shape, despite the paucity of information? Have
we already categorised and prescribed, judged exonerated or perhaps condemned?
Are we already caught in a web of power, of accusation and justification? What
happens to Carlton, Clare and Albert, in all of this? It
is important to remember that domination, exploitation and hierarchy are not simply
the product of institutions. We create these relations as reflections of what
we are. I would suggest that the very desire for professional status and expertise
in the field of emotional disturbance is particularly problematic. The struggle
for power inevitable creates distinction and separation. The detrimental consequences
of this raises pressing ethical questions for all those who earn a living in this
field. Alternative approaches may be very difficult to realise. Having lived enmeshed
in networks of abusive power all our lives we may well find ourselves unprepared
and ill-equipped to respond to another's suffering in non-exploitative and genuinely
caring ways.
6/ Conclusion
Nothing
of what I have written is original; the debt to the work of others will be clear
from the references. But I hope I have brought together observations from different
fields that help illuminate some of the ethical problems raised by systems of
professionalised care. Although this brief exploration is doubtlessly deficient
in both depth and range, I hope enough has been covered to raise questions in
the reader's mind about the conflicts of interest implicit in the process of professionalisation
(which are particularly acute in the context of 'mental health' care); the ways
in which perception and practice may be shaped less by reason and evidence and
more by self-interest; the way struggles for dominance and 'territory', and inter-professional
rivalries, may damage service users; the way professional self-interest may block
the development of more effective, and more helpful forms of care; the way in
which the activity of workers in the field of 'mental health' may actually be
contributing to a culture that is toxic to psychological well-being. These and
related issues present us with the inevitability of making multiple ethical choices
with significant consequences both for ourselves and others. But
perhaps the most difficult problems we face are our own capacity for self-deception,
and our own inertia. The pressures involved in surviving in what many experience
as an increasingly hostile work environment can easily lead to an accentuated
sense of personal and professional insecurity, and a blunting of our moral sensibilities.
Returning to the metaphor of colonisation we can note the exploitation involved
does not only have detrimental consequences for the territories colonised: the
colonisers damage themselves. Professional privilege has its costs. Seeing beyond
what we may imagine to be our self-interest, to the wider consequences and implications
of our actions, may require considerable effort and be profoundly unsettling.
We may discover that we are far advanced into a dangerous state of passivity,
acquiescence and moral paralysis. But if, individually and collectively, we are
ever going to be able to dismantle some of what Foucault calls the 'multiple mechanisms
of "incarceration", - which largely define our personal, social and
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