Mental Health & Social Justice

Trisha Ready
Contact: ready@wolfenet.com
Changing Narratives. This blog will focus on psychoanalytic based reconstructions, creative explorations, and research around mental health social justice issues.

How are mental health narratives impacted and influenced by shifts in such areas as cultural media, global health, economics, and research? How do the discoveries and discourses of academia reach the streets, and how do changing events in the social landscape alter the direction and scope of psychoanalytic  dialogue? Some examples of blog entries would be changing narratives and treatments for psychosis, attachment and medication, psychoanalytic wrangling with the language of neuroscience. Guest blogs in the field and dialogues with guest bloggers will be featured.

Trisha Ready works at an acute psychiatric hospital near Seattle where she directs the partial hospitalization program. She earned a PhD in Clinical Psychology from Pacifica Graduate Institute.  Trisha has conducted psychoanalytic based research focused on the use of self-selected music as a means of emotional containment and expression for people experiencing early stages of psychosis. She has articles published in the American Journal of Hospice and Palliative Medicine, Music and Medicine, and Psychoanalysis, Culture, and Society, as well as a chapter in the forthcoming book: Music and Medicine: Integrative Models in Pain Medicine. Outside of academic venues Trisha has published  social justice and arts based articles, and essays in various magazines and newspapers.

 

For this blog we are inviting people who are actively engaged in the field of critical scholarship on psychiatric difficulties to give updates on their work. Until Trisha Ready is available to manage submissions, please address any submissions to Michael O’Loughlin.

 

3/28/15

 

Michael O’Loughlin, Adelphi University

michaeloloughlinphd@gmail.com

michaeloloughlinphd.com

 

Currently I have two projects underway to address aspects of psychosis. One is a field study, and the other one is a theoretical analysis.

 

  1. 1. Narrating the prose of severe psychic suffering.

My work in this are began with a collaboration with Marilyn Charles at Austen Riggs Center. That work led to a number of publications [see refs. below],  and led to the development of a collaborative project at a residence in New York City for person with chronic psychiatric difficulties. Here is an excerpt form the project, as published in O’Loughlin et al. (2013), with a brief update at the end:

Translating psychic suffering into public experience: Research at some distance

Austen Riggs Center (ARC), nestled in the Berkshire Mountains of Massachusetts, has been providing intensive psychodynamic therapy to what are described as “treatment-resistant” patients for almost a century. It is a haven of last resort for patients who often have chronic and intractable psychiatric difficulties, and it is renowned for its humane and intensive treatment of psychic terror. Michael O’Loughlin began collaborating with Marilyn Charles at ARC in 2008, studying videotape interviews collected by other researchers over a series of years with some ARC patients. While we described some findings from that work in a recent essay (Charles & O’Loughlin, 2012), we are only gradually grasping how to fashion a narrative from the data. This is, after all, research at some distance. The interviews were performed by other clinicians, who were not acquainted with the people they interviewed. As viewers of the archived interviews, we were twice removed. Despite all of this, the arc of human suffering was inescapable. We listened to poignant interviews with patients who had their personal and professional lives inexorably disrupted by the intervention of persecutory and delusional thoughts, by ungovernable anxiety, and by intractable depression. We were witness to young people still struggling with restitution narratives, or seeking bemused refuge in psychiatric diagnoses, while watching life as they knew it slip through their hands like grains of sand. Some had decided that life as they knew it was over and they failed to pick up the narrative threads. We learned to trace the lineage from early traumatic events, and even from intergenerationally inherited trauma, to eventual catastrophic breakdown. Burdened with knowledge from the medical records of the outcome ten years later for each of these patients, we were left with heavy hearts. Could any good come of our turning this private suffering into public experience? We worried about betrayal and exposure. We worried about our own voyeurism and about provoking voyeuristic responses in future readers. We witnessed patients struggle to articulate pain and hope while speaking through a haze produced by massive doses of psychotropic medications, and sometimes through the confusion of the battle between delusional thought and rational thought. We lived with evident dread – the fear of breakdown. Were our attempts to bear witness well intentioned or were we being foolhardy or exploitative?

We came to an understanding of the notion of “wounded storyteller” before we stumbled upon Arthur Frank’s book. The metaphor that came up for us most, in people’s attempts to narrate their experience before the crisis and after, was the notion of impasse. It was evident that each of these patients had a major life rupture and they were now in the throes of seeking to make sense of that rupture and its implications for their capacity to generate a meaningful ongoing life narrative.  For some, impasses resulting from difficulties in negotiating the social sphere had been present since their earliest years. While not all of these patients succeeded in regaining narrative traction, some did, and all were exceptionally fortunate to be in a facility where all of the resources of the institution were directed at assisting them, to the greatest degree possible, in coming to terms with the life rupture, its origins, and its implications for their future lives. The entire thrust of the intensive ARC therapeutic regime is about resuscitation of narrative capacity. Our work at ARC is ongoing but as we continued we began to wonder what might happen if we pursued an inquiry that closed the distance. We also wondered what happened to the overwhelming majority of persons with severe psychic distress – those without the financial and cultural resources to find their way to a place such as ARC.

Closing the distance: A collaborative understanding of psychic suffering

For this new study we set out, following Biehl (2005), to engage in a phenomenologically near inquiry. Medical anthropologist Ellen Corin (1998) borrows the term “contemplative immersion” to describe the research interviewer’s stance and suggests that an ethical interview ought to promote restorative dynamics in participants. Ultimately, this became key.  At first, however, following the logic of the clinical interview process we observed at ARC, we developed a three-part interview (detailed in O’Loughlin & Charles, 2012) that probed into the psychodynamics of the patient’s experience; that inquired into familial, psychosocial, and intergenerationally inherited stressors; and that inquired into the phenomenology of psychosis and particularly the role of diagnostic systems, pharmacology, and the medical model in defining patient identity. While deeply concerned about psychiatric survivors as people, and while committed to progressive principles of qualitative research, we had nevertheless built our inquiry firmly around the clinical dynamic interview pioneered for this kind of work at ARC (cf. Fowler & Perry, 2005). The epistemology of our protocol suggested a much greater concern with ‘what’ than with ‘who’. Furthermore, not having yet identified a site or population, our interview was conceptualized in the abstract. This was closing the distance?

Seeking a community agency that provided residential and rehabilitative services to persons with chronic psychiatric difficulties, we soon ran into resistance. Our plans, we were told, were too clinical and too intrusive.  Non-hospital-affiliated community services often view themselves as providing an antidote to the medical model, and our work at ARC – our calling card – actually put us at a disadvantage. Our intensely clinical interview protocol reinforced those fears. Through a professional connection we finally got an invitation from a facility that follows the clubhouse philosophy of rehabilitation.[i] At our initial meeting with the research committee, we were peppered with questions about methodology. The committee, in this egalitarian community was composed of both client members and professional staff. They were not, as it happened, that concerned about the kind of formal protections that institutional review boards [IRBs] police. Instead, they wanted to know how well we could capture the stories of the members, and how might the information we provided assist them in enhancing the facilitative effect of the therapeutic community they sought to create. We kept the door to negotiation open by affirming our commitment to respect for psychiatric survivors, and our interest in participating in a genuinely collaborative inquiry. The facility has a series of units devoted to various aspects of training and rehabilitation. The leader of one of these units, a person with a graduate degree in anthropology, it turns out, spoke up at one meeting: “If you don’t know the members, they won’t talk to you. And even if they do talk to you, if you don’t know them, you won’t understand what they are telling you.” Heads nodded around the table. Elliott had placed the problem of distance squarely on the table.

Elliott’s comments were a catalyst for two major changes. First, we made a commitment that any person who participated in fieldwork at the facility had to spend 3-6 months volunteering at the facility  in order to build rapport with staff and members. Doctoral students Secil Arac and Montana Queler were welcomed as volunteers in the horticulture unit and were given no special privileges. They were advised to make their own way and to build a space for themselves in the community. They engaged in all aspects of the work of the unit, including plant care, cleaning duties, etc. Michael O’Loughlin will begin a similar immersion shortly as phase 2 of the work gets under way. Second, influenced by the writers discussed above as well as the work of medical/phenomenological anthropologist Arthur Kleinman (1995; 2000; Kleinman, Das & Lock, 1997), we de-emphasized the structured and heavily clinical focus of the inquiry, and instead characterized the work as a series of three-one hour life conversations. While our broad interest remained in understanding the internal psychic life of psychiatric survivors, the social situatedness of suffering, and the influence of the pharmacological-medical model, we now placed a greater emphasis on the narrative quality of the participant’s telling, and particularly our roles as interviewers in the co-construction of the emerging narrative.

From the outset, we had made an intellectual commitment to the research as collaborative but, given the enormous asymmetries in “studying down”, we were unsure how to address the issue. A positive by-product of our slow induction into the community is that community members have gained confidence in us. Participants are eager to participate in the interviews. The clubhouse administrators, seeing the seriousness of our commitment, offered substantial financial support to the graduate students and also provided payments to research participants for contributing their time and expertise to the project.  With the level of trust and shared commitment that has developed, we are confident that we will be able to negotiate setting up a collegial interpretive community.

We are currently launching the second phase of this work, the development of a collaborative interpretive community in which stakeholders form the community join us in interpreting the data and writing up the book that we believe will be developed form this work.

O’Loughlin, M., Charles, M. Crosby, J. Arac, S. & Queler, M. (2014). Field note: Closing the gap: Narrating the prose of severe psychic suffering. Psychoanalysis Culture & Society, 19,  1, 98-106.

O’Loughlin, M. & Charles, M. (2012). Psychiatric survivors, psychiatric treatments, and societal prejudice: An inquiry into the experience of an extremely marginal group. In G. Cannella & S. Steinberg (Eds.), Critical Qualitative Research Reader. New York: Peter Lang Publishing

Charles, M. & O’Loughlin, M. (2012). The complex subject of psychosis. Psychoanalysis Culture & Society, 17, 4, 410-421.

 

The origins of psychosis

Much of the literature on psychosis is silent as to origins, or, where psychoanalysis is invoked, suffers from the limitations of ego psychological and relational perspectives that have taken hold in North America. I am interested in understanding the origins of psychic difficulties and impasses. It is impossible to engage in clinical or therapeutic work without at least an implicit theory of the origins of psychosis. Unfortunately, the emphasis on manualized therapies, “evidence based practices”, and short-term solutions, coupled with an increased emphasis on medication to alleviate symptoms, often leaves the larger questions of origins, context, and life-course unaddressed. Currently, as I noted in the Childhood blog, elsewhere on this blog site, I am particularly interested in developments in Lacanian theory that attempt to explicate the origins of subjectivity, and to explicate the impasses that develop as infants seek to articulate their subjectivities in the crucible of the Other.   Some of the reading that I am currently working on in this area includes:

 

Apollon, W., Bergeron, D. & Cantin, L. (2002). After Lacan: Clinical practice and the subject of the unconscious. Albany: SUNY Press.

Fink, B. (2004). Lacan to the letter: Reading Écrits closely. Minneapolis: University of Minnesota Press.

Fink, B. (2014). Against understanding: Commentary and critique in a Lacanian key [Vol. 1].  New York & London: Routledge.

Fink, B. (2014). Against understanding: Cases and commentary in a Lacanian key [Vol. 2].  New York & London: Routledge.

Gherovici, P. & Steinkoler, M. (Eds.). (2015). Lacan on madness: Madness, yes you can’t. New York & London: Routledge.

Hill, P.F. (2002). Lacanian clinical technique: An introduction. London: Press for the Habilitation  of Psychoanalysis.

.Lacan, J. (2006). Écrits: The first complete edition in English. B. Fink (Trans.). New York: Norton.

Soler, C. (2014). Lacan: The unconscious reinvented. London: Karnac.

Soler, C. (2015). Lacanian affects: The function of affect in Lacanian work. New York & London: Routledge.

Van Haute, P. (2002). Against adaptation: Lacan’s “subversion” of the subject. New York: Other Press.

Vanheule, S. (2013). The subject of psychosis: A Lacanian perspective. London: Palgrave Macmillan.

 

 

 

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