In recent years, there has been an annual commemoration of ‘Mental Health Week’, a period in which Australians are subjected to ‘awareness campaigns’ by various media organisations. We tend to receive a familiar style of ‘messaging’, namely, tokenism (‘Are You Ok Day?’), advocacy for more bureaucracy, and censorship of views that do not conform to simplistic biomedical paradigms. It is in this context that the national broadcaster screened ‘Changing Minds’, a series which ‘journeys with mentally ill patients on their road to recovery, from breaking point to breakthrough.’ The setting for the doco is a hospital in Sydney, and patients and staff apparently consented to the footage being made public.
I approach footage such as this with a critical perspective on the psy-disciplines and as a practicing psychoanalyst, two positions emphatically excluded from mental health week. From my perspective, the doco showed numerous moments that were as concerning as they were revealing, in terms of patient treatment. Note, for instance, the moment when a young man is attempting to get himself discharged. The hospital psychiatrist asks him to give an account of his condition, and he says he has a ‘chemical imbalance’ in his brain. This is false, of course, even at the level of general explanation, but this rote-learned utterance suffices for him to win the approval of the medical staff, who assure him he is quite right. Discharge is clearly, albeit subtly, contingent upon discipline.
I will limit my focus here to 29-year old ‘Jason’, a man who has been involuntary committed to the hospital for several weeks. (The exact length of his stay is unclear; you can find his place in the doco around the 23 minute mark onwards). He is diagnosed with schizophrenia, and the voiceover tells us that he initially sought help in a state of intense fear, after receiving death threats and being subject to sinister plots by aliens. By now, these themes of persecution are not prominent (or are omitted from the doco) and he instead has delusions about his body, specifically, that his bones are broken.
Contemporary psychiatry and clinical psychology are not, in the main, very rigorous when it comes to delusions. The voiceover tells us that Jason lacks ‘insight’, which is to say, he disagrees with the views of clinicians. In the mental health system (and in contrast to psychoanalysis, or even classical psychiatry), a delusion is basically just a belief that a clinician finds bizarre. The content rather than the form is at issue. If I present at a hospital with a story that the police/CIA are moving objects around in my house to make me think I’m going crazy, and that I am absolutely certain of this despite a lack of evidence, I will be assessed as delusional. If I attend the same hospital with a story that my spouse/parent/child/housemate is moving objects around in my house for the same purpose, and that I am absolutely certain of this despite a lack of evidence, I will get a very different response, even though formally, the propositions are nearly identical. I will probably be told that my spouse/parent/child/housemate is a ‘narcissist’, and I should get relationship counselling, if not an intervention order.
But let’s return to ‘Jason’. The voiceover indicates that he has been medicated (probably very heavily), and his delusions about bodily disturbances do not appear to provoke the same distress as the ideas of persecution. Nevertheless, his psychiatrist concludes that Jason is ‘a risk to himself’. (This ‘risk’ is not specified). For this reason, he has been sectioned, but the psychiatrist himself hints that, on such flimsy grounds, this arrangement cannot last for long.
Jason is given the opportunity to speak to the camera, and to staff. He outlines the various places where he believes his body to be ‘broken’. He cannot prove it, but ‘it’s real’. ‘I can’t be a fully functional person’ he says.
The psychiatrist follows the standard evidence-based approach of supplementing drugs with cognitive therapy. (In fact, the evidence does not support the use of CBT with psychotic patients, but zealots read evidence their own way). In the cognitive paradigm, Jason holds his beliefs about his body essentially because he is ignorant, a bit stupid even. If only he can be given an education in medical assessment, his views will ‘shift’. Let us not forget, in this homely atmosphere of casual contempt for the patient, that this doco is intended to remove ‘stigma’.
Nonetheless, Jason’s delusions do not ‘shift’. (Indeed, by the end of the doco, Jason still holds to the notion of his body being broken). The psychiatrist berates him: ‘You’re not hearing what we’re telling you’. The same words could be more aptly applied to Dr Psychiatrist and his colleagues, who stubbornly refuse to consider Jason’s words as having any significance other than as an indicator of idiocy. Jason’s discourse could be easily construed as consisting of signifiers. We might ask how he arrived at his beliefs, or what it means to be ‘broken’, and not ‘fully functional’. We might ask whether such delusions have a stabilising function relative to Jason’s mortal terror upon initial presentation. Such questions are not admitted to contemporary clinical practice.
After a failed attempt to correct Jason’s distorted cognitions, the psychiatrist chuckles at the camera. ‘Never a dull moment’, he smiles. One wonders what he might have said had a camera not been present.