psychiatry

Psychiatric diagnoses: does forcing a medical framework onto people problematise informed consent?

Informed consent and clinical psychology

 

Informed consent underpins everything we do as psychologists.  It is an essential ethical principle.  Whether we assess, formulateintervene, evaluate or carry out research. Irrespective of our skills or level of experience ethical dilemmas will arise and, resolving them defensibly, to the best of our abilities, is a central part of our practice.  Regardless of the setting, client population or type of intervention, we are bound to have to make decisions engaging multiple and conflicting ethical principles often, not easily reconcilable.

 

Seeking meaningful consent involves informing potential or actual clients of the basis for our intervention and its rationale. Sharing theoretical and empirical underpinnings and, explaining the anticipated process and possible challengesThough we may not routinely explore challenges to the core assumptions underlying our practice most of us would, hopefully, routinely explain to clients that our model or our way of working is one of many ways of deriving meaning and of supporting people.  

 

As such, we are in a very privileged position.  We are not wedded to any school of thought/therapy or worldview. In theory. This allows us to work with clients using their own explanatory model (s) and attribution style and to some degree, adapt our practice accordingly.  Further, because we (usually) use formulations rather than diagnoses to co-construct the meaning of the experiences that have led people to our doors and to make sense of their distress, we can work from multiple epistemologies. In theory.

 

Outside the therapy room, things are less malleableFor example, if someone is diagnosed with psychosis, it won’t matter much how they formulate or make sense of their distress when they are out in the real world.  In the real world, this diagnosis will be documented onto their medical notes.  Their personal explanatory model (s) or story may matter even less to the people who hold the most social power. Their psychiatric label will likely take precedence over much else.  This is because in the real world, bio-medical explanations are still considered real and are the norms through which human experiences of distress are categorised. Still.

 

Meanwhile in the real world…

 

Thus, it matters very little that one might have been and continues to be oppressed or that one might have been repeatedly abused. This is background or additional information to the core issue that one hasdepression, psychosis, a personality disorder or any other psychiatric diagnosis.  So, when looking for a job, most potential employers will ask ‘have you suffered from/received treatment for any psychiatric illness’ or something along these lines. Such occupational health questions would typically be closed, inviting a ‘yes’ or ‘no’ answer. There may be space to elaborate or to even enclose a formulation done in therapy but, it would not stop many employers considering those who answered  ‘yes’ potential liabilities in terms of sickness absence and think twice about making/confirming an offer of employment (though this may be unlawful).

 

Nothing of course forces anyone to disclose a psychiatric diagnosis but, failure to do so may not only deprive people of potentially valuable support, it may leave vulnerable individuals succeptible to accusations of breach of trust and confidence and/or of dishonesty; should it later emerge that  information related to their psychiatric ‘history’ was withheld.  In addition, of course, the additional stress generated by having to worry about the ‘truth’ coming out needs bearing in mind. I became sorely aware of the limits of informed consent when I was asked to sign a discharge before my son could have surgery.

 

Informed consent and adverse events/consequences

 

The discharge listed the main risks and potential complications from the surgical intervention. It made clear that I was consenting to the possibility of adverse events both short and longer term by signing the discharge and allowing my son to have surgery.  The discharge made no mention of the risks associated with the other options available or of any cost-benefit analysis in relation to the alternative interventions. However, there had been some pre-operative discussions around alternative treatments and the no treatment option upon which the surgical team was relying when presenting me with the information focussing on the intervention at hand. This experience got me thinking.

 

True informed consent can only be given if clients can compare the risks and benefits of each and every course of action available to them and consider them in the short, medium and long term. Typically, when people access our services they have already been diagnosed or are suspected of having some form of mental ‘illness’ (suspicion alone carries consequences, especially if recorded)This is documented onto their medical notes as a matter of course. But does this practice not amount to forcing a medical framework onto people’s experiences? And if so, does it not problematise informed consent; if patients are not made aware of the of the risks and likely adverse consequences associated with having such a diagnosis?

 

Though by the time people get to us their health records have already been amended, they may not necessarily have been made aware of the (medium to long term) impact of being diagnosed with a psychiatric ‘illness’ particularly those seen as more ‘serious’ or ‘enduring’.  They may never have even heard of alternatives to diagnoses or been made aware of their significant empirical and theoretical limitations. How might we argue then that those diagnosed have given their full informed consent?  Isn’t it odd that patients are often given the choice as to whether they want their health records to reflect that they have had a pregnancy termination, sexually transmitted diseases or other stigmatising conditions/interventions but that such consideration is not routinely given to those with mental health problems?

 

On consenting for stigma

 

Given the very real, serious and debilitating consequences of stigma and discrimination, isn’t it ethical to seek fuller consent and as part of that, to give patients a choice as to how they make sense of their distress; including within their own health records? In the mist of our distress we may not have the headspace to consider such questions and of course some people may simply not have the capacity to assimilate this information or to decide.  However, upon recovery, for the majority who did/could, the reality of having been diagnosed with a psychiatric illness may hit home.  People may well find that the psychiatric diagnosis they were given mattersThat it matters enormously.  At which point of course giving informed consent will no longer be an option.

 

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The Elephant in the room: Race Representation, Symbolism and Silenced Wounds.

The first time I sat foot on a psychiatric ward was just under 10 years ago.  I was engaged in doing Community Development and Community Research work within Medium Secure Units (MSU) in London.  This was my first day on a MSU and indeed my first time visiting any kind of psychiatric hospital. Following a brief introduction to the all White psychology team by the clinical lead and consultant forensic clinical psychologist (a White man); I was taken round the ward where a multi-ethnic, but still mainly Black staff base, composed the nursing team who was in turn, overseeing the care of a virtually all Black inpatient/clinical population. Upon entering the ward, I was so overwhelmed by the sea of Black faces staring at me in utter stoicism, that I had to work very hard to contain my urge to cry.

The visit felt surreal and oppressive in an almost suffocating way and; this had nothing to do with the (respectful) way I was being treated by staff. At the time, I was not entirely sure why this sight had provoked such a strong response in me.  I had some knowledge of the extent of race inequalities within mental health services and had also been briefed on the clinical population upon my induction. Yet, something happened in my very first few moments on the ward which took me by complete surprise. Although this ‘Elephant’ remained at the back of my mind as I did further work on the Unit, I became somewhat desensitised to its presence, particularly as the subject was hardly ever discussed with colleagues.  Hence, what I set out to do in the present post is to try and make sense of my experience and to consider some potential clinical implications.

The power of symbolism and representation

As human beings we all make use of symbols to categorize, convey and extract meanings from events and social interactions. From a systems perspective, to start with, the staff composition mirrored traditional power distributions so that at the top of the hierarchy was a White man and at the very bottom of the pyramid of power, were of course the Black staff, followed by Black patients. Thus, at team level, there was a representation of social inequalities in relation to income across staff roles.  Further, the Psychologist role is one of authority that socially occupies the sphere of expertise and; in the context of MDUs; as the role encompasses the assessment of patients’ readiness for release, another layer of power is therefore inherent to the role.

The meaning attributed to the role of the patient (or more accurately patient-offender) and that of the Psychologist cannot be interpreted outside of the racial make-up of the ward.  Connotations and associations whether consciously accessible or not; firmly remain when it comes to race dynamics.  Certain images have the power to tap directly onto this rich symbolic heritage.  Indeed, looking through history, one would not have to search for very long for many constructions of Black people as dependent and as psychologically, socially and intellectually deficient to surface (debates around such constructions are to some degree continuing today). Consequently, and in the context described, the sight of a virtually all Black patient population having been assessed as needing treatment, rehabilitation and indeed control cannot but evoke the historical inferiorization and pathologization of Black people.

Projection and Identification

Returning psychoanalytically to what had happened in my ‘here and now’ experience of the ward, Projective Identification may offer an alternative and viable framework to make sense of the dynamics.  In that line of argument, it may be notable that as the detained Black men appeared to display no feeling and emotion, I experienced an overwhelming sadness and a sense of suffocation. Such feelings appear consistent with experiences which may be triggered by compulsory detention, restraint and freedom deprivation. Thus, it could be envisaged that through my experience, I was acting out the patients’ s disowned and/or unacceptable feelings and wishes which had been projected into me.

There is a long psychoanalytical tradition of viewing racism as a mechanism by which dominant groups project intolerable aspects of themselves into racial minorities.  From an internalised racism perspective, those projected qualities can be said to become accepted as one’s own. The imagery evoked by the racial representation clearly echoes the worst things Black people are all too often socialised to believe about themselves. From a psychoanatytical standpoint, the projections from dominant groups. The Ward context may thus evoke the same images that often give rise to many identity difficulties and other internal conflicts amongst some of us. Thus, whilst working toward ‘Recovery’, Black mental health service users may be exposed to the very painful dynamics that may be be part of their parcel of suffering and that may have contributed to bringing about and/or exarcebating their psychological distress.

Working with the Elephant in the room.

Taking on the role of mental health patient, in the current context, may also means psychically, taking on a role which is consistent with racial stereotypes and which may be experienced as buying into the constructed racial hierarchy which naturally part of the self may resist. From that perspective, it may follow that the role of mental health patient may be an extremely conflictual one for many Black men which may bring to the fore feelings of inferiorisation, marginalisation, exclusion, subjugation, distrust and possibly self-loathing. Although I have not come across many Black mental health patients/service users who have described their experience using symbols, systems representation and psychoanalytical concepts as frames of reference, the sense of suffocation and oppression I experienced has recurrently appeared in my sessions with Black service users as did their experience of being stereotyped on psychiatric wards.

There is ample research evidence suggesting that Black mental health service users have the most conflictual relationships with their clinicians, that they are the most dissatisfied group of all mental health service users and that they continue to report experiences of racism (including racism within services) but; despite these well-established findings; it appears that the Elephant in the room remains too overbearing to acknowledge and to work with for many of us. The dearth of discussion, clinical and empirical attention to the extent of the impact of race dynamics in relation to the psychological functioning and the service use, experiences and outcomes of racialized minorities seems to me to be of particular concern.  Not only because it may be part of the reproduction of existing hierarchical structures that perpetuate the invisibility of race and of White privilege, but also because it prevents opportunities for race related wounds and institutional suffering to be seen and addressed. I believe it may well have been these wounds and suffering I was apprehending and reacting to on my first day on the ward.

Thank you for reading, If you have found this article useful or interesting, please spread the word.

All work published on Race Reflections is the intellectual property of its writers. Please do not reproduce, republish or repost any content from this site without express written permission from Race Reflections.  If you wish to repost this article, please see the contact section for further details.