‘Chronic’ identities in mental illness

Abstract

The term ‘chronicity’ is still widely used in psychiatric discourse and practice. A category employed in political, administrative and therapeutic contexts, it guides practitioners’ beliefs and actions. This paper attempts a review of the attitudes and procedures that result as a consequence of identifying ‘chronically’ disturbed identities in clinical practice. An essentially social, relational and materialist understanding of mental illness is used to highlight the kind of thinking underlying the notion of ‘chronic’ identities in day-to-day psychiatric routines. Problematising the notions of singularity and expressiveness, as well as mind/body- and self/other-distinctions, it claims the category itself is responsible for creating a ‘chronic’ kind of being. A spatial metaphor is presented in the conclusion, illustrating a mental strategy by which we can re-shape our thinking about ‘chronic’ identities. It attempts to describe how the shift from an epistemological to a praxeographic approach could build a more complete understanding of mental illness.

Keywords:

• cultural psychiatry
• stigma
• psychiatry
• identity
• chronic

Acknowledgements

The author is grateful to the patient giving informed consent for the analysis and publication of the described situation. She perceived herself as a model, such that anthropologists and psychiatric scholars might learn about how change in mental illness might be generated. Her identity has been anonymised. Funding source: none. Conflict of interest: none.

Notes

1. As Weiner states, one should be careful when adding the prefix ‘inter-’ to the noun stem ‘subjectivity’, making it appear as though the latter were a derivative from the former – that subjectivity comes first and inter-subjectivity is dependent upon it. Nevertheless, there seems to be a lack of vocabulary for referring to relational phenomena without implying entities that connect them. This indicates the urgent need for a new language, describing the multitudes of interrelations and correlations, constituting ‘chronic’ identities.

2. In this sense, system-oriented approaches try to focus on pathologising environments to explain and contest ‘chronicity’ (Böker and Brenner 1989; Ciompi 1980; Schweitzer 1995; Simon 1993). The causal locus for persisting symptoms and ‘chronic’ behaviour is demonstrated to be exterior to the patient, being located in his or her material and social environment. ‘Chronicity’, however, is seen as a mere construction in these approaches, a product of the environment rather than an embodied and therefore ‘real’ phenomenon.

3. Johnson explains this tendency to engage in bipolarities as deriving from our monotheistic tradition. He describes the doctrine of one normal human being and ‘consequently the belief in one normal God, beside whom there are only false, spurious Gods’, and contrasts this with the ‘polytheistic man's free and many-sided thinking’ (Johnson 1985, 116). This binary logic has been reinforced in anthropological traditions by structuralist approaches. As stated by Johnson, the reason Levi-Strauss's approach appeals to many as an explanatory device for studying culture is because it so perfectly reflects the thinking of those persons, which are interested in becoming anthropologists.

4. Certainly there have been considerable efforts to describe the self as a relational construct within psychiatric/psychotherapeutic discourses and practices. Symbolic interactionism in particular has come to the fore as a means of perceiving the subject through its encounters, as both have (been) widely influenced (by) psychoanalytic theory. Freud's concept of introjection, which maps exogenous agency within the subject and the fact that the analytical practice itself is a social situation – one where ‘truth’ is constructed in interaction – played an equal role in inspiring these arguments (Buchholz 1999). Similarly, Lacan's subject is constituted from the same acts of speech and perception as all other objects and relations, taking its place in the space created between them rather than prior to them (Lacan 1966). It therefore emerges in processes of successive identification and assimilation with the other, and it is only by doing so that a sense of selfhood becomes possible. Lacan's Imaginary refers to the image of one's body as it emerges from the subject's visual confrontation with an encountered other, leading to a relational, corporeal materialism. For Freud and his scholars, the processes of incorporating the other are mostly pathologised (dissociation, traumatising introjects, split identities, ambivalences, etc), while Lacan's ideas have so far remained theoretical and have not been translated into concrete, operationalised psychiatric practice.

5. The term ‘praxeographic’ refers to Anemarie Mol's (2006) work, which argues that objects (as for example any identity) have to be examined in relation to specific sites and situations in order to evaluate their ontological substance.

6. In a subfield known as psychogeography, we find an approach concerned with unravelling the way inner space is mapped on the outside, thereby investigating how people experience themselves as indistinguishable from where they are (Gregory-Guider 2004). In a different way, spatial representations are involved in the concept of mind maps, serving to organise ideas and cognitions (Luutz 2007). While the former remains related to the distinction between in- and outside reality, the latter neglects concerns such as the unconscious, emotions and embodied materiality.