Tuesday, January 11, 2011

Concerning power and "therapy"

[Note: In these comments, I have offset some words with quotation marks. I do this to denote that the word, so marked, has meanings that deserve careful questioning. The meanings of these words are sometimes undeserved and frequently driven by the politics of the culture. If the quoting seems excessive, then it only further illustrates how virulent the effects of "professionalized languaging" has infiltrated and influenced the culture.]

Today, I spoke to a "patient", a very nice, bright woman. A year or two ago she was very upset by a variety of events. As she sat in my office, she was clearly very distressed. Because I work in a traditional medicalized system, I did what is expected and required of me in this context. I referred her to a psychiatrist. If I did not make the referral, I could be found guilty of malpractice due to the system of health-care (the context in which I work). Not surprisingly, the psychiatrist arranged for hospitalization and the patient remained in the hospital for over a week. When she was "released", not surprisingly, she had been “diagnosed” with a “mental disorder” and the treating psychiatrist had prescribed several medications. The patient was “released” from the hospital with an entirely inadequate understanding of the “diagnosis” and much less of the medicines prescribed. Because she was a "compliant" patient, she took the medicine as prescribed.

I’m commenting on this because, as I have opined previously, I am troubled by the inherent problems that accompany power discrepancies found in many professions between the “professional” and the “nonprofessional”. Particularly, I think of the medical profession and more so, psychology and psychiatry. The psychological/psychiatric “profession” has appropriated the “authority” to "diagnose" and treat “mental disorders”. It is almost unknown that descriptions of unusual behaviors and experiences that a person may have (other than those in the domain of “health-care professions”) exist. The dominant belief is that only psychiatrists/psychologists/therapists can appropriately "diagnose" and treat these "conditions" or dis-eases.

The Diagnostic and Statistical Manual of Mental Disorders” (DSM-IV) allows only five of its more than 800 pages to acknowledge that there are “culturally-bound syndromes” that are briefly described. The implication is that these culturally-bound syndromes are quaint descriptions originating from less progressive (i.e., less educated) cultures. A patient’s descriptions and explanations of their experience are expected to yield to the more learned (and ostensibly, more accurate) “professional” descriptions. Descriptions that are indigenous to the one experiencing the unusual or troubling feelings/experience often become quickly converted to an alien medicalized idiom. Automatically deferring to the “professionals” is not always a good idea. Monthly, I receive journals that report legal/ethical violations by “professionals”. I am flabbergasted by some of the deplorable behaviors of some in the “profession”.

My concerns are not original and hopefully shared by many others. Perhaps the first to discuss the problems of power discrepancies was the highly controversial French philosopher, Michel Foucault (1926 – 1984). While Foucault probably would have objected to my use of parts-only of his thinking while excluding other portions – I’ll do so anyhow.

A significant portion of Foucault’s work focused on how power is virtually inseparable from knowledge. In fact, in much of his writing he would often speak of a hyphenated power-knowledge, thus acknowledging the reflexive nature of the two, or as some might say, “two sides of the same coin.” I’ll try to briefly sketch the basics of the Foucault’s concept and show its significance in medicine and psychology/psychiatry.

As any type of specialized knowledge develops, so too “experts” emerge. The “experts” develop special (typically unusual) language and concepts that are familiar only to the “experts”. The specialized language, perhaps intended to help “experts” better understand, has the effect of creating a widening disparity between the individual’s experience and the “professional”. (Consider the influence of the Roman Catholic Mass when it was said only in Latin and the separating effects it had on the laity.) Power and control are natural attributes of specialized knowledge. One can easily see how this dynamic lends itself to many professions and disciplines. Let’s look at how this is expressed in today’s culture.
  • In medicine, physicians invest much time to learn and become “expert” in “curing” “illness”. In the process of their education, physicians learn a language that is specialized and unfamiliar to the layman. Physicians are generally held in high esteem. They wear a mantle of god-like authority and power symbolized by their white frocks. Is it only coincidence that these garments share common qualities as the vestments of the clergy? They have the authority to diagnose and prescribe powerful drugs. If the laity (the unordained) question a physician they may well be rebuked, “And what medical school did YOU attend?” If a psychiatrist decides (Remember, there are no tests to diagnose mental illness; no x-rays, no blood tests, no brain imaging.) one is alcoholic and dictates that into a patient’s medical record, it is in the record virtually forever. It is illegal to remove it. It doesn’t matter if the psychiatrist is misinformed. Now, the patient will be labeled and other ordained experts will read that assessment and will almost certainly be influenced by it. If medicines are prescribed and the patient exercises their own prerogative to not take the medicine, they may be labeled as “non-compliant” (a variant of “hostile”) When I see a patient for a first visit, the power dynamic is set in motion long before I ever meet the patient because they assume the posture of one needing help and I in turn posture myself as one who can help. I am ordained by my education, the State of California and the Clinic by which I’m employed. Because my name (with the requisite initials) is on the door, because I have an office, because my chair is different than their chair, because I have a desk, because they must make an appointment with me, because they pay to speak with me and many other reasons, the power dynamic is set. They need help (have less power) and I am expected to provide help (have more power).
  • In a closely aligned profession, the clergy has invested much time becoming experts in the history, liturgy and traditions of their faith. They are “ordained” by governing bodies to be “shepherds of a flock”. They are authorized to perform the rites of sacraments. When members of the congregation are ill, the pastor is called to offer prayers for the afflicted. Priests, rabbis and pastors are also “ordained” by the state to solemnize weddings and bless other events not within the purview of the unordained. The Roman priest can forgive sins, hear the confession of the penitent and is the sole mediator between man and God.
  • Academia is another profession sharing many of the same qualities. The academician invests years of training, studies the works of expert predecessors, writes exhaustively so that other experts might determine if entry may be granted to the rarified air of the ordained. Titles are bestowed: master and doctor and if one is fortunate, they will become an assistant professor and then full professor. Like physicians, no longer are they called by their birth name; now they take the appellation of achievement and expertise – they are referred to as “Doctor” or “Professor”. The professor stands before the class of students and if the students are to become themselves experts, they must learn from the professing expert and pass examinations.

Foucault wrote and spoke about the problems of power, control and knowledge quite a bit. You may find yourself wondering what all this blather has to do with “therapy”. It has quite a lot to do with it. “Therapists” are in the same (dare I say it) game as those mentioned above. My own language shows how much I have been influenced by my heady “profession”. I talk with PEOPLE but often, I will call them “patients”. I am not a doctor but many of my “patients” will call me “doctor”. I correct the misnomer many times. Some tell me they understand I am not a doctor but they feel better calling me doctor. Psychology/psychiatry is not a hard science (yet). Simply reading the “patient” information sheet on a prescription medicine will illustrate the fact. When explaining the pharmacologic mechanism of the drug, the manufacturer typically says, “It is believed …” i.e., it is not KNOWN. Therapists offer beliefs and opinions; frequently with a mantle of undeserved “authority”. Therapists position themselves as relational “experts” (but no one asks how many times the therapist has been divorced), we present ourselves as experts in family matters (but no one is present to see us during family get-togethers).

In large measure, the culture has benignly conspired to rob individuals of their autonomy. Often, those labeled “patient”, have the ability to deal with and understand the meaning of the challenges encountered. As “professionals” we thoughtlessly impose our “clinical” diagnoses and assessments rather than LISTENING to the language and descriptions used by those sitting in the “patient” chair.

It is an act of self-betrayal when any of us abdicate our personal agency and carelessly turn it over to one deemed to be “expert”. When we hire an expert we should always retain ownership of our own personhood, it is after all, sacred.

Addendum: Recently, I spoke with the person referred to in the beginning of this column. I had asked for his/her comments and their comments are an important counterpoint to my comments. They made the point that when one is as "clearly very distressed" as they were, one is not carelessly turning over their personhood - because in that moment, they have lost touch with the sense of personal agency. In that moment, they would like nothing more than to have a sense of ownership of their life.They have sought the help of "professionals" because of the overwhelming distress. 

Again I thank those who help me to understand more clearly the human experience.