Who am I? In some ways a psychiatric facility is the ideal place to encounter this question, but I personally haven’t broken step with sanity – a statement which you’ll have to take at my word. I maintain that the question is lucid and indeed I asked it long before I was admitted here. Perhaps it is fair to say that it is my protracted inability to answer the question which has delivered me this latest opportunity to again consider my identity. Though this time I’m in a place where identity and culture exist principally as pathology – sources for interpretation, rather than celebrations of individuality.
I am supposed to be sick. I can understand this much from having been admitted to hospital and, before that, through being diagnosed and medicated. But is this who I am? I don’t feel sick, apart from the side effects of medications. Sick, then, to mean somehow disordered, or dysfunctional. What does that look like? Is it supposed to look like anything? If not, then why – how, even – should I ‘be’ that (or myself, if the two are different)?
In here, reality unites all of us who for whatever reason can’t hold our issues at arm’s length to see their place in a bigger picture.
Such surmising is considered unhealthy here. I’ve been told it is not the content of ‘normal‘ thought — that it suggests disorder. I did ask what I should be thinking, but clearly that wasn’t it either, because my query was met with a blank stare and written in my notes. Obviously there are norms here to deviate from. I wonder, then, if the norm is my identity from which my behaviour deviates, or if there are social norms which my identity is deviating from. Perhaps it is both. Or neither.
As confusing as this seems, there is substance to my so-called disordered wondering. Much of the confusion in my experience occurs around the concept of identity. An identity is something which is so close to most of us that we can’t see it until it’s brought into relief. As we move through life we take on parts of the world which we experience, reject other parts and often replace previously accepted elements with new material. This is the process most broadly known as growing up. The process effectively ends when we die, but at some point we become more or less aware of an identity. That is, a collection of life attributes that we identify with. We base our ego on this identity, our ego being simply our sense of ourselves as distinctive human beings. Ego is often used in a critical way, but everyone needs an ego in order to recognise their existence. Subsequently, on our ego is built our self-esteem and personality. It is possible to lose this identity temporarily or permanently, but it is also possible to deviate from it – to repress it, or live in spite of it. It is this deviation which interests me most.
We may not realise it, but our first encounter with identity occurs very early in our existence. When we are born – even before we are born – we are identified as boys or girls. This confuses sex with gender, and for some individuals results in tremendous disparity and suffering when they come to realise their identity does not straightforwardly align with their physical structures. This is a case where behaviour which deviates from that identity would almost certainly result in personal distress, even if the individual walked in perfect step with every social norm expected of their deviated identity.
The idea that being true to yourself, or to your identity, is now so embedded in society that it is widely considered right to “be yourself” and “to hell with the expectations” of any social norm. For example, if the same individual with a deviating gender identity were to decide to embrace their identity and whatever physical difference that entailed, they would have a more faithful identity, but one which would potentially deviate from many social norms. Especially if the resulting physical differences were deep and far reaching (of course they need not always be – gender identity is a far more nuanced subject than sex organs and choice of wardrobe allude to). The distress would be different, but certainly still present. This is the type of distress which psychiatry and psychology attempts to address. It is now (scarily, a quite recent development) unpopular to attempt to directly ‘correct’ identity issues themselves. Consider, as an example, those who consider themselves specialists in ‘curing’ homosexuality with counseling.
Of course there are various social norms that exist whether we conform to them or not – though they are not at all absolute, even if they seem it at times. Known broadly as culture, they are frameworks to which we belong, if not always through willing subscription. The idea that any deviation from these cultural paradigms be considered disorder, dysfunction or sickness is surely as old as society itself. But where the frameworks of societies were once determined by their rulers or powerful institutions, individuals in more recent history have managed to engineer a liberation from this traditional authority, generally through co-operation and innovative technologies. Among other differences this change has facilitated, a levelling of sorts has occurred which permits conflicting frameworks to co-exist – or, more accurately, makes it impossible to eradicate frameworks which don’t conveniently align with majority ideas. Ostensibly this is a positive social progression, but it is not without its casualties.
The struggle for influence between popular majorities and ‘protected’ minorities (protected by anti-discrimination legislation, for example) is a major issue facing psychiatry and its involved population. A cohesive society is in many ways the antithesis of individual identity and in its noble moments psychiatry aspires to find, and sometimes attempts to be, the reconciliation of the human condition. What psychiatry diagnoses (outside of the relatively small number of severe psychiatric illnesses) could be described in terms expressed above as individual inabilities to balance the deviations of individual identities from themselves and their encompassing (and perhaps conflicting) social cultures. Through this lens the diffuse boundaries between the intersection of individual and social function and dysfunction can be brought into useable focus, if not pristine clarity.
All of this boils down to the reality that identity is the only factor which treatment can be based on. It is the only point of reference which psychiatry can work from. In reality, the twenty-first century poster child discipline of neuroscience offers psychiatry little of practical use at this stage, though its future potential is expected to be immense. Some might say the potential is imagined and perhaps it is – but it is imagined with a sense of desperate expectation in the present environment of therapy which is often both ineffective and excruciatingly condescending and medical treatment which feels like having a choice of alternative hells.
Admittedly this is a dim view of the situation. But psychiatric medication, while hardly alchemy, is horrendously reliant on trial and error. The cases of severe psychiatric illness seem to respond quite well to appropriate medication, but in the much broader pool of psychological disorders which include depressive and anxiety, medications frequently seem patently useless. When I questioned my doctor about this he said there are clinical trials which suggest that the efficacy of many of these medications scarcely beats a placebo for many patients. Importantly, this doesn’t mean that most people might as well take placebos – it should be read that all too often the medication simply doesn’t alleviate the suffering. And in the cases where it did a placebo would have done nearly as good a job as the prescribed medicine more often than any drug company would enjoy admitting. Of course these medications work for some people. We call them lucky. There aren’t too many of them in here though.
Medication is handed out in this hospital seemingly like candy, but in spite of that the attitudes of the doctors suggest a conservative practice. There is a contingent of patients who like to ‘shop’ for doctors more willing to prescribe certain medications, but none of the doctors I’ve encountered appear to be covert representatives of drug companies. Some of the most common medications administered here are antipsychotics which are used as sedatives by a lot of patients. In a very real sense, these medications serve to mask distress experienced by an individual where therapy and other medications have failed. The incidence of actual psychosis here is far less than the medication prescribed would suggest. Medication isn’t candy. But the suffering is no less real because of this fact. Doctors do what they can to balance treatment of conditions with mere alleviation of symptoms with hopelessly limited options and in my experience they take this grossly inequitable responsibility seriously.
Thankfully there are no lobotomies performed here, but electroconvulsive therapy (ECT) is administered on a large scale. Public opinion of this therapy is typically negative, and certainly there is justifiable confusion and concern for what seems to be (and at times has been) a tortuous and inhumane pseudo-treatment. As a last chance antidepressant reserved for use when all other treatment has failed, it works with enviable efficacy. Yet despite the many cases in which it returns remarkable results, very little is actually known about what exactly it does, or why it works. The doctors who administer electric shocks to the heads of patients have little by way of confirmed knowledge to rely on. They gauge a ‘good’ shock by looking at the induced seizure on an electroencephalogram without any objectively meaningful guide. It is merely their own and others’ shared experiences which they call upon to judge a ‘good‘ seizure, though this is in no way to imply guesswork or flippancy. And the alternative isn’t a ‘bad‘ seizure, by the way. It’s just not an ideal one based on the doctors knowledge of how that particular patient responds to the treatment.
ECT is administered to patients here typically three times a week, often for five weeks, but more or less depending on how successful the treatment is. It’s administered under short-acting general anaesthetic and muscle relaxants, and is by all accounts painless. It takes away the most ghastly psychiatric zombies and returns them as functional, engaged human beings with what seems like (and actually is) the flick of a switch. Despite the treatment seeming to present a hideous and unworthy risk to life, it is administered here in ways which are known (true, this knowledge came at human expense) to minimise the odds of mishap. Patients often temporarily lose their recent memory, but worse side effects are rarely experienced here. It is a confronting treatment and while it is unquestionably amazing, it seems unlikely that it will ever shake the image of being a dark and risky art.
Less invasive treatments are also not entirely free from reliance on imperfect understandings of identity. Psychology particularly does its best to quantify behaviour and cognition with mostly incomplete or imprecise biological qualification. The efficacy of therapy is measured by statistics derived primarily from observation and personal report. Psychology can understand behaviours in increasingly more useful terms and frames, and, slowly, various imaging and scanning technologies are being refined and recruited in a biologically-framed pursuit of what being human is (many would call this an impossible goal). But even so, psychology is still reliant on working with an individuals identity so they can prevail over the results of deviance from social norms. Psychology can express concern for social frameworks in various ways, but direct intervention in cultural psychology is fraught with peril and unintended consequence.
Here in hospital, deviance from social norms is a very prominent cause of distress. Of course it is not diagnosed as such, but the various symptoms are diagnosed by relevant category and statistic and therapy – typically both pharmaceutical and psychological – is undertaken to restore and reinforce the identity of the patient. It is certainly true that these patients are the greater in population here, but there are others who have lost their identities or are suffering the pains of repressed identity.
The patients who ‘lose’ their identity can be remarkable to witness. For example, a few days ago I noticed a woman in the courtyard. I noticed her because she was dressed in a smart business suit and was working on her laptop with her briefcase beside her. I thought perhaps she was a lawyer visiting a patient. The next day I noticed her again. This time in the dining room, working at a table with an iPhone beside her. I didn’t think much of it. But then yesterday I saw her husband arrive with flowers for her. She is a patient. A lawyer with a very intact membership to her social norms. It is her identity which has vacated her. She is lost in some place and some time which is not here and not now. There exists the visibly functional shell of culture, but the narrative of her identity is, as far as psychiatry can tell, absent. I hear that she has been admitted to undergo ECT.
Similarly misplaced is the elderly lady whose dementia has haphazardly deviated her identity to a distant past time in her memory. At night meals she often sits with one patient who in her mind is her daughter. Thankfully the patient she has attached to is congenial. There are other patients here who are rather less inclined to humour a demented elderly lady.
And then there is one symptom of deviated identity I’ve encountered here which particularly interests me. It presents in three young adult female patients. These patients are often talking about dissociation. Specifically, how they dissociate, and how the other two don’t.
One of these patients is a qualified nurse. She has a soft temperament (at least toward me) and is one of my favourite patients to spend time with. She also has a beautiful singing voice. Last night when I came downstairs to have a cup of Milo for supper she performed a pitch-perfect rendition of Sarah McLachlan’s Angel. It is a moving song even when casually encountered, but in the large, high-ceilinged and usually noisy dining room, her voice was the only sound, and few eyes remained dry. What felt peculiar about the experience to me though, was that there was no applause when she finished singing. Of course this is understandable – especially knowing of the years of abuse she suffered throughout her childhood and adolescence, and seeing the hundreds of scars on her arms where she has in moments of blind distress cut herself to shreds – but it still caught me off guard.
Dissociation, as these patients explain it to me, is doing something without being conscious of doing it. They relate it as being experienced in times of duress – when the consciousness isn’t able to cope with the reality presented to it, it simply blanks out. I’m led to believe the sufferer can still function. That is, it’s not blanking out like a coma, there’s just no recall of the event in the person’s mind.
From their description, this phenomenon would appear to resemble a deviation from their identity. What’s interesting about this is that the situations which trigger these deviations are themselves deviations from social norms. So which comes first, or which is more influential? These patients have conscious identities until they dissociate. They all struggle with other symptoms which are the result of their deviations from social norms, but their identity is present and their symptoms respond well to it being bolstered.
What’s even more interesting than this peculiar phenomenon is that each patient holds the opinion that the other patients ‘put on’ their dissociations. Each speaks from a position of experience and self-denoted authority, so what is left but for me to agree with each of them? I do question the broader implication of this very common behaviour though. The behaviour, of course, being the dynamic of discerning ‘real’ issues from ‘fake’ issues. There are rules here strictly forbidding this practice, but symptoms and diagnoses are naturally some of the most discussed topics among the patient population.
All of this raises interesting questions which are widely debated, not only here, but in the mental health community and any affected population. What is a mental illness? At what point should a difference be considered a dysfunction, and when does it further become a disability? Are simple variations in human behaviour becoming too readily considered diagnosable, and is it better to risk over-diagnosis, or under-diagnosis? What place does self-report and suffering have in diagnosis?
The various debates are at fever pitch currently because a new version of the manual predominantly referred to in diagnosis is in the pipeline. There are proposed changes in this new version which, some pundits allege, will increase diagnosable conditions substantially and with unpredictable consequences. There is concern about the alleged increase of medicalising human diversity, particularly as it pertains to children and their development.
These are worthwhile topics to debate, certainly. But here around me I see real suffering, regardless of diagnoses being rightly or wrongly placed. In here, reality unites all of us who for whatever reason can’t hold our issues at arm’s length to see their place in a bigger picture. In the foreseeable future then, it seems that while yet there is conflict arising through deviations from identities and social norms, psychiatry will continue to work on strengthening identities and mitigating resulting distress with whatever psychological and pharmaceutical tools it can.
And as for me? I still don’t really know who I am. It seems such a benign idea that I should have an inescapable concept of self. It’s not unfair to insist that I do have a self-concept, even if I’m not aware of it. And perhaps that’s true – but what difference does it make? I understand that I am not another. To that extent at least I have a self concept, or ego. But who am I supposed to be in this place? Or anywhere, for that matter. “Be yourself,” is as patently unhelpful to me now as it’s ever been. What does it mean to be myself? My doctor, therapists and all the nurses are intent on uncovering my identity so they can help me reinforce it. And who am I to deny them? I am being observed, and my identity has diverted to what I can ascertain to be the social norms here. Am I dysfunctional? I am certainly diagnosed. But you can be sure that this time I won’t make the mistake of mentioning these thoughts to my doctor when he comes to see me in the morning. ◾