Mental health: The World of Order meets the World of Chaos
The Self and the Body
This essay is about the self and the body and therefore it is – consequently – about identity. As Brubaker & Cooper (2000) outline the term identity has been overloaded with meanings in social science which led to a certain confusion and ambiguity of the term. Looking at the self and the body as two inseparable entities, there are only two alternative terms, as proposed by Brubaker & Cooper (2000), which fit into this context: self-understanding and social location, as well as identification and categorization. The first, also described by the authors (2000:17) as “situated subjectivity”, refers to “one’s sense of who one is, of one’s social location and of how (given the first two) one is prepared to act”. Even though the authors do not explicitly refer to the body as location of subjectivity, it is evident that because we are born in this world with a body, we experience everything through our bodily senses and it is through the body that action is exerted, one can only sense who he or she is by means of his or her body. Of course, this does not imply that the body necessarily determines who one is (e. g. considering a self-understanding as transgender).
Categorization in medical systems
Mol & Law (2004) distinguish between the body we have, the body we are and the body we do. In contrast to the body we have and the body we are Mol and Law suggest: “the body-we-do is not a whole (…) keeping ourselves together is one of the tasks of life (…) this has implications for what one might ask or expect of medicine” (2004:57). In that sense healing is also an actor-centered activity. Mol and Law advocate for an approach in medicine where “patients come in again: aware, not just self-aware, but equally able to tell stories about medicine and the effects of its interventions” (2004:59). Before looking closer to the self and the body within medicine, I would like to touch up on the second alternative term Brubaker & Cooper (2000) present and which I deem of importance in the context of medical anthropology: identification and categorization. This is the process of identifying others and oneself and as this is a process it calls for an agent. When this agent is represented as an authority it gets institutionalized (cf. Brubaker & Cooper, 2000). In this context the Foucauldian concepts of ‘biopolitics’ and ‘governmentality’ gain major importance. And more precisely the question of what is a healthy body or mind, what is a sick body or mind? The categorization of medical systems in societies ultimately turn a person into a patient. Nowhere else is this a more controversial categorization than in the context of mental health, one in which the building of order turns into a systematic production of waste, human waste (cf. Baumann, 2004).
Order and Chaos
As Baumann (2004:19) outlines “it is human design that conjures up disorder together with the vision of order, dirt together with the project of purity (…) the thought trims the image of the world first, so that the world itself can be trimmed right after”. If society is designed up on a certain order, one that prevents chaos and immorality, then those who do not serve and function within this order become a ‘matter out of place’ (cf. Baumann, 2004). These people do not perform their proper function and are thus considered a danger to society and its order. Van Dongen (2004) describes how the psychotic world is denied because it is endangering the world of others. This happens under the phenomenon of countertransference. In brief, countertransference in psychotherapy is understood as the process in which the totality of emotional reactions of caregivers and therapists triggered by patients, influences their interpretations and actions (cf. Van Dongen, 2004). Concluding, the psychotic world in psychiatry is being denied, because it is regarded as part of the pathology (cf. Van Dongen, 2004; Berkhout et al., 2019). In that sense the psychotic world is not only receiving little attention by therapist and psychiatrist, but it is further turned into a taboo (cf. Van Dongen, 2004). As Van Dongen (2004:56) explains “taboo is a moral prohibition, founded on the assumption that chaos leads to immorality”. Therefore, and since the psychotic world is regarded as disordered, the psychotic world is threatening the world of others (cf. Van Dongen, 2004). Thus, the narratives of patients are forbidden as they are viewed as “‘sick’ part consisting of such expressions of psychotic reality as aggression, chaos, lack of insight, wildness and ‘wild’ associations of thought and speech” (Van Dongen, 2004:224). What occurs is that the psychotic person is categorized by the medical institution into a ‘sick’ and a ‘healthy’ part (cf. Van Dongen, 2004). The passive structure in the previous sentence highlights that this is not a division that the patient takes up on himself, but one that is imposed on him through the authority of the psychiatric institution.
Dichotomies in medicine
This duality of a sick part and a healthy part is reflected through the patient’s moving back and forth between the psychotic world and the ‘normal’ world, which is considered a symptom of psychotic disorder (cf. Van Dongen, 2004). However, this duality results in another duality experienced by the psychotic person, namely one that is divided into subject and object. As Van Dongen (2004:57) outlines in order to prevent the transition between the psychotic world and the normal world “the biographical experience of the psychotic patient is constantly objectified (…) the patient becomes a subject only if he first becomes an object for himself, and this is achieved by adopting the mental health worker’s perspective”. Similarly, to Van Dongen (2004) Berkhout et al. (2019) critically reflect on the psychoanalytical categorization of “normal or healthy” and “pathological or sick” self-experience and address asymmetric power structures in the health care system. The authors contrast their findings with the current psychological literature around self-disorder, taking a feministic, postcolonial stance towards the self with respect to the work on a critical anthropology of selfhood by anthropologist Rebecca Lester. This includes an understanding of the self and selfhood as “embodied, enacted and constituted through interpersonal as well as institutional practices” (ibid.:447) and rejects the dualism between body and mind often prevalent in medical epistemology.
The body in the 21st century
What is a body in the conditions of possibility at the beginning of the 21st century? That is a question the article of Mol and Law (2004) poses in the context of medical anthropology. They discuss the bodily object and subject distinction in medicine and touch up on the privilege given to knowledge within the domain of medicine. By looking not at the body we have or the body we are, the authors shift their focus to the body we do and ask “what are the consequences if action is privileged over knowledge?” (2004:46). The authors address the question by looking at the case of people living with hypoglycaemia. One point they make is to state that medicine should regard patients as having the ability to act and thus appreciate and promote self-awareness, as it is done in hypoglycaemia. Further, they argue knowledge of the body involves all senses, in- and outside. Therefore, the bodily boundaries are semi-permeable. Another point the authors make is the one of tensions within the body and within its life as enacting body: some measure and steps we take might benefit certain parts of our bodies on the dispense of others, so might certain lifestyles interfere with our health. An interesting reflection the authors make is the one of unpredictability. “But what happens to individuals is unpredictable” (2004:56) no matter what knowledge and data about the patients are collected there is no certainty in prognoses or illness trajectories.
In this essay I have been trying to demonstrate the connection between who we are, as the self, and the tool we have at hand to enact ourselves, experience ourselves and the world around us, the body. Moreover, I outlined how the person and his or her body in the context of Western medicine is turned into the object of interest, one that falls under clear categorizations of what is sick and healthy or bad and good, rather than being regarded as a subject. This power of identification that lies within medical and especially psychiatric institutions reinforces our social order and thus sets apart humans who do not function properly – they become dehumanized and ultimately human waste. Medical categorizations are based on society’s regimes of truths. The new approaches towards the self and the body, as having multiple characteristic and states (cf. Mol & Law, 2004), being for example semi-permeable encourages science to look in different directions. Those in which we acknowledge a causality between the self and the body and the broader society, one in which civilization informs madness and vice versa (cf. Foucault, 1989). Duyvendak & Scholten (2011) look critically at research and policy dialogues when dealing with introducing societal order, their findings can be likewise applied to research and medical dialogues.
“In other words, the interaction between fields tends to reinforce the co-production of truth or knowledge claims. For instance, the type of knowledge claims that are developed by researchers will also depend on the sorts of capital that can be obtained with these claims, in terms of economic capital (e.g., research funding), but also social capital (e.g., networks) and cultural capital (e.g., authority, influence).”
(Duyvendak & Scholten, 2011:336).
As researchers we have to take up responsibilities to maintain “critical distance required for ‘critical frame reflection’” (Duyvendak & Scholten, 2011:336), whenever humans are being identified and categorized as sick, as waste, as a matter out of place or as danger.
Bauman, Z. (2004). Wasted Lives. Modernity and its Outcasts Cambridge: Polity Press.
Berkhout, S. G., Zaheer, J., Remingto, G. (2019). Identity, Subjectivity, and Disorders of Self in Psychosis. Cult Med Psychiatry, 43, pp. 442–467. doi: 10.1007/s11013-019-09631-y
Brubaker, R. & Cooper (2000). Beyond Identity. Theory and Society, 29: 1-47.
Duyvendak, J.W. & P. Scholten (2011). Beyond the Dutch multicultural model. International Migration and Integration, 12:331-348.
Mol, A. & Law, J. (2004) Embodied Action, Enacted Bodies: The Example of Hypoglycaemia. Body & Society, 10(2-3), 43-62.
Van Dongen, E. (2004). Worlds of Psychotic People. London and New York: Routledge. doi: 10.4324/9780203506257.