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Rebecca J. Lester “Brokering Authenticity”

April 24, 2013 Leave a comment

Lester, Rebecca J. 2009. Brokering Authenticity: Borderline Personality Disorder and the Ethics of Care in an American Eating Disorder Clinic. Current Antrhopology 50(3): 281-302.

Managed care is first and foremost an economic model; a system of organizing and rationing health care services within a capitalist system where market forces determine both the cost and value of those services. Built on a rational-choice model of human action with profitability as the ultimate good, managed care is predicated on the stan-dardization of a product (health care) across domains, a reg-ulation of the provision of that product, and a rationing of the supply of the product in order to maximize economic profit and minimize loss (Baily 2003; Goldman 1995; Peterson 1998). To do this, managed care organizations (MCOs), such as Blue Cross, Aetna, United Healthcare, and so forth, con-tract with hospitals and providers to offer services to sub-scribers at reduced costs—what Donald (2001) calls “the Wal-Marting of American psychiatry.” (282)

How, then, do clinicians navigate this minefield of managed care and still feel ethical about what they do? (282)

It is clear, then, that the vast majority of clinicians view managed care as the enemy and perhaps almost as harmful to the client’s health as the eating disorder itself (see also Robins 2001; Ware et al. 2000). How then do eating disorder clinicians function within such a system? (284)

Borderline talk at Cedar Grove is a mode of everyday dis-course among clinicians that invokes BPD to shorthand clus-ters of behavioral and interpersonal concerns. It takes a number of forms. It can be explanatory, accounting for a client’s behavior (“She’s really borderline. She can’t handle that kind of feedback from her peers without going into crisis”). It can be cautionary, as a way of preparing another clinician for an encounter (“Watch out! She’s in full borderline mode to-day!”). It can also become a way for therapists to communicate to each other their personal struggles or even burn out (like the Dementors comment). (285)

The standard managed care view is very different from Cedar Grove’s. In synergy with biomedical psychiatry and cognitive-behavioral approaches (which enable controlled outcomes research and, therefore, lend themselves to cost-benefit analyses in ways psychodynamic approaches do not), managed care tends to figure these illnesses as episodic

cognitive-behavioral dysfunctions that are essentially resolved once the symptoms abate (Wiseman et al 2001). From this perspective, unlearning an eating disorder rests primarily on interventions targeting the specific behaviors involved (food rituals, caloric restriction, purging). The underlying causes and ongoing functions of an eating disorder are not a focus of concern, and issues such as “voice” or “sense of self” are deemed irrelevant. Managed care rests on a rational choice model that presumes people act out of a desire for self-preservation. (286)

“Psychodynamic” is a somewhat generic term that can include a number of different schools of thought, but we can rea-sonably characterize as “psychodynamic” those approaches that entail the following core set of assumptions about human behavior, human motivation, and psychiatric distress: (1) Hu-man behavior is meaningful. This is thought to be true even when the meaning of the behavior is not readily apparent to the individual, the clinician, or others; (2) The meanings of human behavior derive from an interaction between an in-dividual’s life experiences and current social context; (3) The meanings of behavior are closely entangled with an individ-ual’s cognitive and emotional processes, which tend to or-ganize themselves in functional response to an individual’s social and interpersonal environments over time; (4) Indi-viduals themselves may not be aware of the meanings of their behaviors or the substrates of emotion and cognition that motivate them and can even be perplexed or distressed by them; and (5) Therapists and other mental health profes-sionals are specially trained to help individuals uncover the meanings of their behaviors (why they do what they do) or the origins of distress (why they think what they think, or why they feel what they feel). (288)

[…] the idea that mental health is characterized by the development and solidification of the “self” as a seat of largely independent thought, motivation, and action is central to all such models. Specifically, the notion that a healthy self is a “true” self forms the core of the psychodynamic approach. Authenticity, in its epistemic sense, then, is viewed as necessary for the achievement of healthy autonomy. (288-289)

The managed care approach to health care rests on propositions that sit uneasily with those central to the psychody-namic approach. Specifically, the managed care model is built on a notion of autonomy as entailing procedural, versus ep-istemic, authenticity. In this view, authenticity involves the development of capacities to act in accordance with the values and ideals one endorses. Here, authenticity refers more to a consistency of action within a moral system rather than an expression of intrinsic, essential self. Authenticity in this sense involves bringing a subject’s actions in line with the ideolog-ical commitments she espouses. To act authentically means to behave in a way that is consistent with these values. (289)

Contrary to managed care’s rational choice assumption that an individual’s prime directive is self-preservation, the psychodynamic perspective recognizes that mental illness often entails self-destructive intention (e.g., su-icidal gestures, poor self-care, social isolation), the causes of which are frequently outside an individual’s conscious awareness. (289)

Unlike the psychodynamic view, the managed care perspective understands psychiatric distress as episodic rather than endemic, as a “state” the per-son is in versus a “trait” that endures. Using a somewhat different theoretical lexicon, we might say that the managed care model construes authenticity as a technology of action, whereas the psychodynamic model con-strues authenticity as a technology of self (Foucault et al 1988). (290)

Specifically, borderline talk engages the conflicts between procedural and epistemic authenticity in a singular, if dis-turbing, way—by rendering epistemic authenticity itself impossible. (292)

If, to paraphrase Rhodes’s prison guard, Caroline’s behavior is construed as manipulative in large part precisely because she is a manipulator, then it becomes difficult for the clinical team to ever perceive her as acting authentically, regardless of her motivations. In a context where authenticity (procedural, epistemic, or both) is un-derstood as foundational to autonomy and psychological health, this rendering of Caroline as incapable of epistemic authenticity—because she has no authentic self from which to act—configures her as largely outside the purview of rea-sonable clinical intervention. It therefore upholds an evaluation of her treatment based on her outward actions alone. Under such circumstances, it becomes not only acceptable but ethical to discharge her from treatment until and unless she is prepared to invest in her own care, with the burden for demonstrating this readiness resting squarely with her. (293)

We can see how, in cases like Caroline’s, invoking borderline talk enables a provisional resolution of the authenticity problem by rendering any reliable subjectivity at all unattainable for a given client. This, of course, requires clinicians to negate the very thing they claim necessitates their existence as trained professionals—the “self” as an entity deserving of care. At the same time, this practice affirms and supports the ends of the managed care organizations. (293)

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Robert Castel, Francoise Castel, Anne Lovell “The Psychiatric Society”

February 3, 2013 Leave a comment

Castel, Robert; Francoise Castel; Anne Lovell 1982. The Psychiatric Society. New York: Columbia University Press.

 

Part Three: Psychamerica

With the advent of mental medicine, the lunatic came to be seen as a patient suffereing from a malady. For the first time, a distinction was made between the mentally ill individual and others belonging to such miscellanous categories as social deviants, delinquents, vagabonds, vagrants, debauchees, wastrels, idiots, criminals, and others guilty of violating social and sexual norms. (171)

The nosographic classifications of mental illness have always been dubious, however. They are based on the assumption that there is a clear divdiding line between people who are „ill“ and therefore within the purview of psychiatry, on the one hand, and people who are „normal“ – though they may come under the jurisdiction of some other repressive agency, such as the courts – on the other hand. (171)

The people who seek these new services exhibit symptoms that are signs not so much of a specific pathology as of a malaise in daily life: exaggerating somewhat, one might say that what must be cured is normality. Now that we have reached the point of „therapy for the normal“, virtually all of social space has been opened up to the new techniques of psychological manipulation. (172)

 

Chapter 6: The Psychiatrization of Difference

In many police departments social workers are on call around the clock. There are „roving medical teams“ which include a psychologist and an intern who work for the police. This gives mental health personnel access through the police to people who would never have thought of seeking psychiatric help on their own, particularly in the ghettos and other poor areas. (177)

American courts confront a basic contradiction. Unable to mete out the prison sentences provided for by law, they discharge their responsibilities by sending lawbreakers to community treatment programs, most of which the judges know to be shams. What makes this deceit credible is that the concept of „treatment“ is invoked – in other words, the contention is that techniques based on medicine will be used to rehabilitate delinquents. Were it not for this safety valve, perhaps the fiction that justice is being done by the courts would have been exploded long ago, and people might then have been willing to look more closely at the foundations of a legal system (and a society) so conceived that nearly a third of the nation’s young people violate its laws. Rather than raise basic questions about the system, people have cast about for dubious alternative to what are ostensibly the most brutal forms of punishment. What is paradoxical about all but a few of these „alternatives“ is that they have done nothing to empty the prisons while augmenting the number of people mixed up with the courts. (183)

[…] the legal criterion for accepting or rejecting experimentation of this sort turned on the degree to which the technique in question was genuinely „medical“. (188)

According to some estimates, however, the number of addicts was most likely higher in the early twenties than it is today, perhaps nearly as high as one million. But addiction was not yet recognized as a social scourge. What has happened lately is not so much a drug „epidemic“ – a term suggestuve of the medicalization of the problem – as a stepping up of coordinated efforts to control certain social groups. (190)

In retrospect, the nineteenth and realy twentiet centuiries have been called a „drug addicts’ paradise“: morphine and heroin were widely used both for medical purposes (in the treatment of alcoholicm, as sedatives, and for „women’s troubles“) and simply for pleasure. The definition of a substance as a drug is a social act and goes hand in hand with efforts to restrict its use. (191)

[…] methadone has two decisive advantages in connection with drug control policy: there is no withdrawal, so users are less likely to be drive to violent crime in search of drugs or money to satisfy their craving, and users become dependent on methadone and are thereby forced to submit to daily scrutiny by the medical personnel who dispence the drug. Official documents recognize the fact that methadone users are in a dependent state and hold that this is one key to its effectiveness. One stated that many addicts have difficulty forming close relationships, and if they were not dependent on metadone, they would find it difficult if not impossible to go to the dispensary every day and establish a long-term relationship with the staff. Thus the dependence created by methadone is crucial to establishing a potentially therapeutic and rehabilitatice relationship with the addict. (197)

The new techniques have made it possible to tighten surveillance and control and extend their range. If prisons are beginning to look like hospitals, this means that their claim to provide therapy is not incompatible with their repressive function. (202)

For children even more than adults, psychiatric labels are often thin disguises for difficulties in adjusting to specific social, family, or scholastic situations rather than descriptions of clear-cut pathologies. (202)

The present goal is not merely to segregate abnormal individuals but also to detect potentially troublesome cases early on. One element of the new stategy is to examine everyone belonging to certain specific social groups or age categories. (204)

Schools are increasingly being used to separate the wheat from the chaff, the normal from the pathological, and growing numbers of specialists are being trained to assist, cousel, and treat what might be calles „abnormal pupils.“ (206)

Thus it seems clear that the real target of the treatment is the child’s disruptive behavior per se. The therapeutic excuse for the use of these drugs has been abandoned, and they are now openly accepted as instruments of control. As one pediatrician has put it, the object of medication is to improve the functioning of the brain so that the child becomes more normal in his thinking and responses. (209)

[…] childhood in general has become the prime target of an indiscriminate hunt for anomalous behavior. (210)

William Ryan has used the phrase blaming the victim to describe the ideologies and practices that have been used in the United States against deprived groups and individuals suspected of menacing law and order. This is how it works: „First, identify a social proble,. Secon, study those affected by the problem and discover in what ways they are different from the rest of us as a consequence of deprivation and injustice. Third, define the differences as the cause of the problem itself. Finally, of course, assign a government bureaucrat to invent a humanitarian action program to correct the difference.“ (210-211)

If we are right in thinking that we are now witnessing a transition to a new and more effective level of technological manipulation of marginal social groups, hten criticism of social control policies must also shift its ground to focus on the manipulative uses of the „scientific“ approach. (213)

 

Chapter 8: Psy Services and Their New Consumers

One comes away with an impression that everyday life is utterly suffused with interpretations stemming from medical psychology; the methods are now so flexible that nothing further stands in the way of their unlimited proliferation. The political implications of this colonization of social life by psychology are enormous. (257)

The same society that welcomed Freud as the messiah continues to celebrate his lesser epigones. Why? Because the role that psychoanalysis played in the United States was not limited to dominating, as it once did, the narrow field of mental medicine. Psychonanalysis was the main instrument for the reduction of social issues in general to questions of psychology. (261-262)

With the arrival of the post-psychoanalytic era it has become possible to speak of „therapy for the normal“ on a much wider scale. This is an important change, for it implies that anyone and everyone now falls within the purview of one of the new types of therapy. (264)

[…] behavior modification has been used as a way of imposing scientifically designed controls on the daily routine of many people; it therefore lends itself to a virtually unlimited range of applications. With some exaggeration, perhaps, it might be said that behavior modification turns all of life into an educational and disciplinary institution. (266)

„Therapy for the normal“, then, uses an array of mental and, particularly, physical tehcniques to maximize the „human yield“ of each individual; it is not aimed at healing, as standard therapies presumably are. The goal is not to get well, but to become healthier (that is to experience more pleasure, to „get in touch with one’s feelings“, to become aware of one’s body, etc.). Medical healing gives way to personality growth: Encounter groups are designed for people who are functioning normally but who wish to impove their relationships with others. (282)

To earn the right to treatent (as psychoanalysis had suspected), the normal individual must exhibit neurotic symptoms. But what is a symptom? „A psychic symptom today is no longer a symptom but a sign that life lacks joy.“ Normal life – social life – is sick, it requires therapy, therapy for nomrality, and techniques to develop human potential and foster autonomy and enhance pleasure in a sad and alienated world. Adjustment, then, has been supplanted by a normative notion of normality – normality seen, in this new light, as the product of „working on“ one’s own personality. (282-283)

If a man’s social status is merely a product of the way he lives his life, then it is possible to use technical means to manipulate the factors that enter into his choices. With regard to relations between social groups, this outlook has led unions, for wxample, to take a particular line, namely, to make demands aimed at enabling the category of worker they represent to „play the game“ successfully within the system, i.e., to compete successfully in the struggle for advancement. With regard to the lowest strata in the society, it has led to a welfare policy that seeks to minister to individual shortcomings without touching the structural conditions that may be responsible for them (293)

What is being worked out, in short, is a completely rational concept of man, a concept perfectly attuned to the dominant notion of what is rational. The problem then ceases to be one of healing the sick, reeducating the guilty, ot controlling deviant behavior (these goals remain, of course, but as objectives allied with new techniques). Instead, „normal“ man has come to the fore as the center of attention in a society whose only passion is to produce earnestly and efficiently. To heal is good, to precent is better, but to maximize output by adjusting each individual to his social role and by calibrating change to the social dynamic as required by the necessity to reproduce the social order is surely the ideal of policy without politics. (295)

 

Conclusion

Underlying the boldest attempts to standardize behavior is a conception of a sort of „scientific“ utopia: to achieve happiness for both the individual and the community by means of rational planning carried out by technical experts. (316)

If the study of recent changes in psychiatry proves anything, it is how much the present expansion of psychiatry’s sphere of influence owes to those who have come one after another to work on the fringes of the profession, pushing back its boundaries by „moving beyond“the old models, which they descrube as archaic, coercive, prescriptive, and so forth. (319-320)

Psychiactric sociaty: No longer a society in which psychiatry takes care of a few patients, whether really ill or merely purported to be, in any case defined bu a starky contrast between the normal and the pathological; but rather an organization of everyday life in which manipulative techniques, more often than not developed and popularized mental medicine, become coextensive with all aspects of social life. No longer the manifestation of naked power exerted directly to repress social and political differences; but rather diffuse pressures of many kinds, which invalidate such differences by interpreting them as so many symptoms to be treated. Not the country of gray dawns in which state commissars drag dissidents out of bed at the crow of the cock; but rather a padded world watched over night and day by squads of skilled specialists, many of them well-meaning. Skilled at what? At manipulating people to accept the constraints of society. (320)

Nikolas Rose “Neurochemical Selves”

Rose, Nikolas 2003. Neurochemical Selves. Society 41(1): 46-59

We could term these “psychopharmacological” societies. They are societies where the modification of thought, mood and conduct by pharmacological means has become more or less routine. In such societies, in many different contexts, in different ways, in relation to a variety of problems, by doctors, psychiatrists, parents and by ourselves, human subjective capacities have come to be routinely re-shaped by psychiatric drugs. (46)

This is a point that should be born in mind: the increasing worldwide dependence of health services on commercial pharmaceuticals is not restricted to psychiatric drugs and much of the growth in this sector is in line with that in drugs used for other conditions. (48)

But despite the law suits, anti-psychotic drugs had become central to the rationale of deinstitutionalization in the United States by the midsixties and to the management of the decarcerated or never incarcerated-population. The gradual acceptance of the reality of tardive dyskinesia, of its prevalence, and of its causation by drug treatment could not reverse the policy or the use of the drugs. A dual strategy took shape. On the one hand, the pharmaceutical industry met with FDA to discuss how to label the propensity of their compounds to cause tardive dyskinesia. On the other hand, the search began for alternative drugs that would not produce such damaging side effects. This track would eventually lead to the marketing of the socalled “atypical neuroleptics.” But it also underpinned other attempts to engineer so-called “smart drugs” which could be said to directly target the neurochemical bases of the illness, or at least the symptoms, with the minimum of collateral damage. (50)

In this context, drug treatment outside hospital becomes the treatment of choice, although short-term, focused, behavioral or cognitive therapy may also be funded, designed to ensure that the patient has the insight to recognize that he or she is suffering from an illness, and hence to increase the likelihood of compliance with medication. (51)

The epidemic of prescribing for ADHD in the United States seems a pretty clear example of a “culture bound syndrome.” (52)

But other factors also need to be addressed. First, no doubt, these developments are related to the increasing salience of health to the aspirations and ethics of the wealthy West, the readiness of those who live in such cultures to define their problems and their solutions in terms of health and illness, and the tendency for contemporary understandings of health and illness to be posed largely in terms of treatable bodily malfunctions. Second, they are undoubtedly linked to a more profound transformation in personhood. The sense of ourselves as “psychological” individuals that developed across the twentieth century-beings inhabited by a deep internal space shaped by biography and experience, the source of our individuality and the locus of our discontents-is being supplemented or displaced by what I have termed “somatic individuality.” By somatic individuality, I mean the tendency to define key aspects of one’s individuality in bodily terms, that is to say to think of oneself as „embodied,” and to understand that body in the language of contemporary biomedicine. To be a “somatic” individual, in this sense, is to code one’s hopes and fears in terms of this biomedical body, and to try to reform, cure or improve oneself by acting on that body. At one end of the spectrum this involved reshaping the visible body, through diet, exercise, and tattooing. At the other end, it involves understanding troubles and desires in terms of the interior “organic” functioning of the body, and seeking to reshape that – usually by pharmacological interventions. While discontents might previously have been mapped onto a psychological space-the space of neurosis, repression, psychological trauma-they are now mapped upon the body itself, or one particular organ of the body-the brain. (54)

In this way of thinking, all explanations of mental pathology must “pass through” the brain and its neurochemistry – neurones, synapses, membranes, receptors, ion channels, neurotransmitters, enzymes, etc. Diagnosis is now thought to be most accurate when it can link symptoms to anomalies in one or more of these elements. And the fabrication and action of psychiatric drugs is conceived in these terms. Not that biographical effects are ruled out, but biography-family stress, sexual abuse-has effects through its impact on this brain. Environment plays its part, but unemployment, poverty and the like have their effects only through their impact upon this brain. And experiences play their part substance abuse or trauma for example-but once again, through their impact on this neurochemical brain. A few decades ago, such claims would have seemed extraordinarily bold-for many medicopsychiatric researchers and practitioners, they now seem “only common sense.” (57)

Where Foucault analyzed biopolitics, we now must analyze bioeconomics and bioethics, for human capital is now to be understood in a rather literal sense-in terms of the new linkages between the politics,  economics and ethics of life itself. (58)

We have seen that, in certain key respects, the most widely prescribed of the new generation of psychiatric drugs treat conditions whose borders are fuzzy, whose coherence and very existence as illness or disorders are matters of dispute, and which are not so much intended to “cure”-to produce a specific transformation from a pathological to a normal state-as to modify the ways in which vicissitudes in the life of the recipient are experienced, lived and understood. (58)

So the capitalisation of the power to treat intensifies the redefinition of that which is amenable to correction or modification. This is not simply blurring the borders between normality and pathology, or widening the net of pathology. We are seeing an enhancement in our capacities to adjust and readjust our somatic existence according to the exigencies of the life to which we aspire. (58)

The new neurochemical self is flexible and can be reconfigured in a way that blurs the boundaries between cure, normalization, and the enhancement of capacities. And these pharmaceuticals offer the promise of the calculated modification and augmentation of specific aspects of self-hood through acts of choice. (59)

An ethics is engineered into the molecular make up of these drugs, and the drugs themselves embody and incite particular forms of life in which the “real me” is both “natural” and to be produced. (59)

Edward J. Comstock “The End of Drugging Children”

Comstock, Edward J. 2011. The End of Drugging Children: Toward the Genealogy of the ADHD Subject. Journal of the History of the Behavioral Sciences 47(1): 44-69.

[…] over the course of the century, through new relations between knowledge, the body, and techniques and technolo-gies such as the drug test and brain scanning, ADHD emerged at the intersection of an ethi-cal knowledge and practice that reflects an emerging psychiatric power, but that cannot be reduced to the terms of social control. (45)

[…] the nosography through which the deviant subject was diagnosed relative to external moral/juridical values or standards is replaced over the course of the century within a shifting discourse on the body built around behavioral norms, where abnormal behaviors of any kind become a potential sign of ADHD. (45)

[…] the valuation of behavior is given a new basis in the “deepest” levels of the individual—where the individual represents the self as a subject of knowledge and rational investment, and where drugs work to establish our true identity. (46)

To begin with, the person with an attention deficit or hyperactivity did not occupy a positive identity as a “human kind” (e.g., Hacking, 1991; Hacking in Wasserman & Wachbroit, 2001); rather, these individuals were understood to have (heterogeneous) underlying psychological conflicts that resulted in antisocial behaviors that the drugs, alongside other therapeutic techniques, were meant to eradicate (deviancy in gen-eral). The focus was on behaviors, conformity, and institutional roles. (52)

The key word here is “adjustment”; Bradley was not anticipating a return to some more inherently normal or ideal self for his subjects, but rather a return to more socially normal (adjusted) behaviors and roles. Ultimately, the drug is used to treat behavior—in the first instance to eliminate socially unacceptable behaviors— providing the conditions under which one can do better in school. But drugs only work in this regard by temporarily eliminating unwanted behaviors, not by addressing an underlying disorder. (53)

Indeed, it was not until the 1950s, and the invention and diffusion of chlorpromazine in psychiatric institutions, that some psychiatrists would begin to claim drugs as something like a cure (or at least a medical treatment) for mental disorders. (53)

But for the purposes of the genealogy of ADHD and the medicating of behavior disorders, the major significance of Bradley’s work is in shifting the nature of the problem from behaviors as a sign of an organic or metaphysical deficiency, to behaviors as the problems themselves. To wit, shortly following Bradley, hyperactivity becomes not a sign of minimal brain dysfunction or organic pathology, but a “disorder” of its own: hyperkinesis. And for the first time drugs are used in processes meant to produce behaviors and identities, rather than solely to eradicate immoral behaviors owing to moral concern.13 As institutionalized practices of power created new possibilities for managing and producing behaviors, the subject of knowledge shifts accordingly. (55)

[…] while Bradley and the experimental psychologists understood stimulant medication to work precisely through the emotional effect of the “drugging” of the child and the “sense of stimulation, well-being, and confidence” that the drug imparts (Bradley & Bowen, 1941, p. 101), now it is understood that the drugs “stabi-lize the brain” and normalize biological “function,” making the most inner and essential mental processes of the child “more normal” (Oettinger, 1971, p. 163). What an incredible reversal! (56)

In part, no doubt, we see here a shift in theoretical models—the passing from behaviorism to cognitivism as the en vogue theory of child development in education and psychology. However, at a more fundamental level, this shift can be attributed to the emergence of a new body—a new human nature made intelligible in part by positing a universal functioning of the individual as naturally self-interested and entrepreneurial. (56)

The difference is that by the time of the Johns Hopkins studies in the early 1960s, “usefulness” and “improvement” are not simply articulated relative to external social norms—norms derived from ethical and institutional custom and law—but instead these developmental concepts are elaborated in relation to norms of behavior itself at the level of the individual. (57)

By establishing the brain as the material cause and principle of intelligibility of behaviors in this way, there is a direct relationship between the brain—which “functions” in knowable ways according to a transcendental human program—and behaviors, rather than anbimplied and generic relationship between a physiological abnormality and behavioral abnormality. In this new configuration, behaviors lose their absolute value and are now only intel-ligible by relating them back to the individual (who is reducible to a brain) and the transcendental economical/rational brain program that caused them. In other words, within this circular and self-confirming system of knowledge, behaviors, given this organic basis, can now be viewed and codified in terms of their functionality at the level of the individual rather than in terms of their institutional/moral quality. (58)

[…] in many “official” versions of knowledge, these technologies would help give ADHD the status of a differentially diagnosed neurological disorder, and thus the hard-science status of pathological anatomy and true illness. (59)

The norm, in this regard, is no longer simply mapped on top of the sovereign and juridical as it applies to a universal trajectory of human development (the social norm). By the mid-century, as the culmination of a discourse on deviancy and the body that had emerged years before, the tech-nique of “the norm” becomes freely applied to any and all human behavior by way of anal-ogy to normal and abnormal physical “functions.” As a result, for example, deficiency in attention can become in and of itself a disorder. (59)

So it was through analogy that the deviant was linked to the pathological, as norms of behavior were assumed to reflect norms of the body and by proxy the inherited code of the species—morality and law were inscribed in the disciplinary body through the inherited human nature (which, of course, the deviant deviated from). (60)

At this point, to be medically abnormal, one had to first be socially abnormal, and the power of moral law and custom always preceded medical power. (60) -> No longer referring to social deviancy  per se, these mental technicians were able link identity to the “normal” or expected response to the drugs themselves, thus making the analogy itself—the major issue psychiatric power had to overcome to insinuate itself in the institutions—invisible. (60)

But perhaps most importantly, because psychotropic drugs replace institutional moral and juridical norms as the test for this behavior disorder, the new disorder could be found in anybody and in any behaviors based no longer on these norms but on the reaction to the drug in relation to a synthetic ideal of behavior. The fact that the drugs “work” in making the individual function better is often enough. And in this process, by bridging the gap between behaviors and the body, psychotropic drugs establish an ostensible  causative relation to appear between brain and behavior, where before (at least in cases where no physical pathology was evident) there was only an analogical relation between behavior and body. (61)

Once it was understood that brain function was at issue with ADHD, the use of medications was given its final justification as the best way to reach the disorder itself. The seeming “paradox” of drug effects on the ADHD-type could be reconciled—without resorting to an explanation that referenced the euphoric dimensions of the drug—by recognizing that stimulants allowed the brain to function more normally, more naturally. (62)

Now, for example, instead of referring to the abstract con-cepts of happiness or discontent, one could reduce these things to the “pleasure center” in the brain and speak of the quality and character of mental representations, and then use EEG technologies as empirical evidence. Hyperactivity, rather than belonging to an organic defect, becomes reducible to the firing of synapses—and therefore can become in and of itself an abnormality. (62)

[…]I believe that normality itself finds its basis in a “pure” discourse (and a tech-nology) that has the effect of opening up all behaviors to normalization techniques. (63)

Drugs become a test of the pathology in question. They work not only through the eradication of behaviors, but in the production of entirely new identities that extend from these tests. We see here a kind of inversion of the relationship between the norm, drugs, and identity compared to the relationship we saw with Bradley. (63) As the basis of the norm shifts from social external standards to the “deep” spaces of individuality, the individual him/herself replaces a universal social reality as the principle of a knowledge of behaviors. (63)

behaviors are now only given value in relation to the complex interplay of the volitional self, environmental context, and the particular biological/developmental needs and limitations of the individual. And whereas before only illegal and immoral behaviors were viewed as symptoms of a developmental disorder, where behaviors themselves were the sign and  the symptom of the disorder, by the late mid-twentieth century all behaviors become potential symptoms of the malfunctioning organism. (64)

Whereas before one was normal with respect to an ontological discourse based on the absolute construct of morality and the universally applicable social contract, now, freed from this discourse, science bases its new mode of seeing and knowing on nothing but a discourse on human behavior itself. I believe that this was the final transformation or rupture in the intelligibility of the human body during the twentieth century. In the shifts within the discourse on the ADHD-type, we can see a compelling example of an entirely new, nonreciprocal, intelligibility or dispotif of the body that emerged over the course of the century around the enterprising and self-interested individual, Homo economicus. (66)

The goal is no longer to identify deviant individuals or to control deviant behaviors—both of which extend from an intelligibility that ascribes absolute (moral) value to behaviors—but to produce new possibilities of behavior and identity bychanging the ethical relationship Man has with him/herself. (67)

Robert Castel “From Dangerousness to Risk”

April 18, 2012 Leave a comment

Castel, Robert 1991. From Dangerousness to Risk. – Burchell, Graham; Gordon, Colin; Miller, Peter (eds). The Foucault Effect: Studies in Governmentality. Chicago: The University of Chicago Press: 281-298.

The new strategies dissolve the notion of a subject or a concrete individual, and put  in  its  place  a  combinatory  of factors,  the  factors  of risk. […] The essential component of intervention no longer takes  the  form  of the  direct face-to-face  relationship  between  the  carer and the cared, the helper and the helped, the professional and the client. It comes instead  to  reside in the  establishing  of flows  of population  based on the collation of a  range  of abstract factors deemed liable to  produce risk in general. (281)

The examination of the  patient  tends  to  become  the examination of the  patient’s  records  as  compiled  in  varying  situations  by  diverse professionals and specialists interconnected solely through the circulation of individual  dossiers. (281-282)

For classical  psychiatry,  ‘risk’  meant essentially  the  danger  embodied  in the  mentally  ill  person  capable  of  violent  and  unpredictable  action. Dangerousness  is  a  rather  mysterious  and  deeply  paradoxical  notion, since  it  implies  at  once  the  affirmation  of a  quality  immanent  to  the subject  (he  or  she  is  dangerous),  and  a  mere  probability,  a  quantum  of uncertainty, given that the proof of the danger can only be  provided after the  fact,  should  the  threatened  action  actually  occur. (283)

Hence the  special unpredictability  attributed to the  pathological  act:  all  insane  persons,  even  those  who  appear  calm, carry~a threat, but one whose realization still remains a matter of chance. (283)

Such  a  shift  becomes  possible  as  soon  as  the  notion  of  risk  is  made autonomous  from  that  of danger.  A  risk  does  not  arise  from  the  presence  of particular precise danger embodied in a concrete individual or group. It is the  effect of a  combination of abstract factors  which render more  or less probable  the occurrence  of undesirable  modes  of behaviour. (287)

One  does  not  start  from  a  conflictual  situation  observable  in experience,  rather one  deduces  it from  a  general  definition of the  dangers one  wishes  to  prevent. (288)

These preventive policies thus promote a new mode of surveillance:  that of systematic  predetection.  This  is  a  form  of surveillance,  in  the  sense  that the  intended  objective  is  that  of  anticipating  and  preventing  the emergence  of  some  undesirable  event:  illness,  abnormality,  deviant behaviour,  etc.  But  this  surveillance  dispenses  with  actual  presence, contract,  the  reciprocal  relationship  of watcher  and  watched,  guardian and  ward,  carer  and  cared. (288)

What the  new  preventive policies  primarily  address  is  no  longer individuals  but  factors,  statistical correlations  of heterogeneous  elements. […] Their primary aim is  not  to  confront a concrete  dangerous situation,  but  to  anticipate  all  the  possible  forms  of irruption of danger. (288)

1)      The separation of diagnosis and treatment, and the transformation of the caring function into an activity of expertise;

2)      The total subordination of technicians to managers. (290-291)

Instead of segregating and eliminating  undesirable  elements  from  the  social  body,  or  reintegrating them  more  or  less  forcibly  through  corrective  or  therapeutic  inter-ventions,  the  emerging tendency is  to  assign  different  social  destinies  to individuals  in  line  with  their  varying  capacity  to  live  up  to  the requirements  of competitiveness  and profitability.

But  one  has  to  ask  whether,  in  the  future,  it  may  not  become technologically feasible  to programme populations themselves,  on the basis of an  assessment  of  their  performances  and,  especially,  of  their  possible deficiencies.

[…] it would be possible thus  to objectivize absolutely any type  of difference, establishing on the basis of such a factorial definition a differential  population  profile. (294)

The  profiling  flows  of population  from  a  combination  of characteristics  whose collection depends on  an epidemiological method suggests  a rather  different  image  of  the  social:  that  of  a  homogenized  space composed of circuits laid out in advance, which individuals are invited or encouraged  to  tackle,  depending  on  their  abilities.  (In  this  way,  marginality itself, instead of remaining an  unexplored or rebellious  territory, can  become  an  organized  zone  within  the  social,  towards  which  those persons  will  be  directed  who  are  incapable  of  following  more  com-petitive  pathways.) (295)

Victoria Margree “Normal and Abnormal”

April 17, 2012 Leave a comment

Margree, Victoria 2002. Normal and Abnormal: Georges Canguilhem and the Question of Mental Pathology. Philosophy, Pshychiatry and Psychology 9(4): 299-312.

In the sphere of mental health, positivism is that which understands mental disorder on the model of physical illness (the „medical model“). […] This position is to be contrasted with anti-psychiatric positions […] which posit mental disturbances as originating in meaningful relations between people. (300)

If science is characterized by the periodic reinvention of its own norms, this is because science is something that living beings do, and life itself, at its most irreducible, is normative activity. (300)

Canguilhem defined life between vitalism and reductionism, as polarized activity. Life is fundamentally that which is not indifferent to its environment. […] As such, life is that which regulates its relationship to its environment through the adoption of norms of living, that is, patterns of behavior that express an evaluative relation to an environment, that judge a phenomenon to be good or bad for the organism’s survival. (301)

Health as such is a creative, propulsive, and dynamic state. It is fundamentally opposed to the adoption of a way of being that is fixed or static. […] For Canguilhem, tha state of health is of a necessarily indeterminate nature, being inherently uncontainable within fixed parameters. (301-302)

If sickness had no distinct being of its own but was merely a quantitative deviation from a set of constants, it was possible to convert the pathological back into the normal through knowledgeable human intervention. In this way the notion of the pathological itself began almost to disappear. To the extent that pathology existed at all, it was as a statistically abnormal state of affairs. (302)

As Canguilhem says, „The state of health is a state of unawareness where the subject and his body are one. Conversely, the awareness of the body consists in a feeling of limits, threats, obstacles to health“ (1991, 91).

„Wherever there is life there are norms. Life is polarized activity, a dynamic polarity, and that in itself is enough to establish norms“ (Canguilhem 2000, 351).

„Disease is a positive, innovative experience in the living being and not just a fact of decrease or increase“ (1991, 186). (303)

As such, whilst the pathological state is still normal in the sense that it prescribes and regulates ways of being according to a spontaneous valorization, it is not normative, in the fullest sense that refers to the capacity for continual revision and self-transcendence. Pathological norms are characterized by their conservatism and intolerance of change. If health is variability and flexibility – normativity – then pathology is defined as the reduction of these. (303)

This then is the radical import of Canguilhem’s thesis: the constancy and fixity that for the positivist tradition defined health, now define pathology. (304)

The immediate consequence of refusing the assimilation of pathology to biological abnormalities (in the statistical sense) is that the ascertaining of any particular phenomenon as pathological is never an objetive undertaking, in the sense of something that can be determined by measurement alone. […] The criterion for qualifying any biological fact as pathological is not then its deviation from the normal, but its reduction of the individual’s possibilities for interactions with its environment, which is felt as the experience og suffering and limit. (304)

First, if the same biological features can prove pathological under some conditions and healthy under others, then pathology is not located simply within the organisms, but in its reciprocal relationships with its environment. […] if no biological feature is inherently pathological, then the literal reference of even bodily illness is never, strictly speaking, the body. […] this is the same reference that makes physical pathology a concept of meaning and value. (305)

Second, we may say that in the human sphere, even the distinction between physical and mental illness is problematic once health and pathology are defined in terms of relationships to an environment. […] Therefore, both this environment and the human body itself are to some extent the product of social an psychological norms. (305)

For Canguilhem […] the pathological state is still normal in that it remains a regulation of behavior in response to vital values. […] The pathological norm is necessarily intolerant of infractions of its functioning. It buys the organism its continued existence but at the cost of its normativity. […] pathological mental phenomena such as psychoses can express an order, and […] this order is created by an attempt to make sense of an altered relation to the world.

First, this means that unusual or distressing mental states are, strictly speaking, never disorders. (306)

For Canguilhem, the antonym of pathological is not normal but normative. […] he establishes ilnness on the grounds of reduced capacity rather than social deviancy. (307)

[…] even when deviant or anomalous behaviors correspond to distinct biological abnormalities, these still are not sufficient to establish such behaviors as illnesses. […] Such a demonstration needs to establish that this feature impacts negatively upon the individual’s normativity, not merely that it is excessive or deficient with respect to a statistical norm and/or influences a behavior felt to be antisocial. […] all states are normal that enable the individual to exist creatively and flexibly within her environment, and this includes those structures or processes that are statistically anomalous. (308)

[…] for the human being, the pathological value of even a biological feature is never just biological. (308)

The concept schizophrenia could never fall simply within the domain of a biological science. This does not mean that it is not a medical concept; it means […] we have had to expand the definition of the medical to signify an evaluative activity attentive to human cultural and political norms.

I say political because norms of life are unintelligible except as the relation of an organism to its environment. […] An individual who is only able to act in accordance with societal norms is only apparently healthy because he has renounced that capacity to institute other norms that is inscribed in full normativity as the openness to being transcended. (310)

As such, any therapeutic intervention into the pathological norms of psychiatric symptoms is a political act, because it is one that refers an individual’s norms of life to the norms of a society. (310)

Psychiatrists and their patients have to make choices about the relative health gais of different forms of social actions, and no account of the organic, genetic etiology of psychiatric illness can remove this political dimension. (310)

Psychiatric concepts are healthy, not when they strive to be definitive, but when they are open to their own usurpation by new norms. (310)

Foucault “Teadmine, võim, subjekt”

Foucault, Michel 2011. Teadmine, võim, subjekt. Valik räägitust ja kirjutatust. Tallinn: Varrak

 

Mis on valgustus? 366-390

[…] kui Kanti järgi on küsimus selles, et teada, millistest piiridest peab tunnetus nende ületamise nimel lahti ütlema, siis tänapäeva kriitika küsimus peab minu arvates naasma positiivse küsimuseasetuse juurde: milline on ainulaadse, sattumusliku, meelevaldsetest piirangutest sündinu osa kõiges selles, mis on meile antud universaalse, paratamatu ja kohustuslikuna. […] kriitikat ei rakendata enam formaalsete, universaalset väärtust omavate struktuuride otsimiseks, vaid ajaloolise uurimusena sündmustest, mis on viinud meie kujunemisele, võimaldanud meil ennast ära tunda oma tegude, mõtete, sõnade subjektina. (384-385)

[…] see on eesmärgilt genealoogiline ja meetodilt arheoloogiline. Arheoloogiline […] selles mõttes, et see ei taotle mitte kõigi teadmiste või kogu võimaliku moraalse tegevuse universaalsete struktuuride eritlemist, vaid nende diskursuste käsitlemist, mis liigendavad meie mõtteid, sõnu ja tegusid kui ajaloolisi sündmusi. Ja genealoogiline on see kriitika selles mõttes, et ei tuleta mitte meie praeguse olemise võrmist seda, mida meil on võimatu teha või teada, vaid loob sattumuslikkusest, mis on teinud meist need, kes me oleme, esile võimaluse mitte enam olla, teha või mõelda seda, mida me oleme, teeme või mõtleme. (385)

Meie endi kriitilisele ontoloogiale omast filosoofilist ethos’t iseloomustaksin ma seega kui ületatavate piiride ajaloolis-praktilist proovilepanekut, niisiis kui meie endi tööd iseenda kallal niivõrd, kuivõrd me oleme vabad. (386)

Homogeenseks referentsiväljaks ei tule võtta mitte pildid, mida inimesed endast ise annavad, ega ka tingimused, mis neid nende endi teadmata määratlevad. Vaid see, mida nad teevad ja kuidas nad seda teevad. See tähendab, need ratsionaalsuse vormid, mis organiseerivad tegemise viise (see, mida võiks nimetada nende tehniliseks aspektiks), ja vabadus, millega nad neis praktilistes süsteemides tegutsevad, reageerides teiste tegevusele ja teatud piires mängureegleid modifitseerides (see, mida võiks nimetada nende toimingute strateegiliseks küljeks). (388)

Eetika genealoogiast: poolelioleva töö ülevaade. 310-354

Mina tahan näidata, et kreeka põhiprobleem ei olnud enese techne, vaid elu techne. See oli techne tou biou – kuidas elada. (321)

Idee bios’est kui esteetilise kunstiteose materjalist on midagi, mis mind kütkestab. Samuti idee, et eetika võib olla väga tugev eksistentsistruktuur, ilma et tal oleks mingit seost juriidilisega per se, autoritaarse süsteemi ega distsiplinaarse struktuuriga. (321-322)

Arvan, et meil oleks vaja vabaneda ideest, nagu oleks eetika ja muude sotsiaalsete, majanduslike või poliitiliste struktuuride vahel analüütiline või paratamatu seos. (323)

Ideest, et meie ise ei ole meile ette antud, tuleneb minu meelest ainult üks praktiline järeldus: meil tuleb luua iseennast nagu kunstiteost. (325)

Klassikalises enesehooles oli teadmistel teistsugune roll. Teadusliku teadmise ja epimeleia heautou vahel on väga huvitavaid asju, mida analüüsida. See, kes pidas enda eest hoolt, pidi kõigi nende asjade seast, mida teaduslik teadmine võimaldab tundma õppida, valima üksnes neid, mis olid temaga seotud ja elu jaoks olulised. (337)

Taheti muuta oma elu teatavat laadi teadmise objektiks, teha sellest techne – kunst. Meie ühiskonnas pole peaaegu mitte midagi järel ideest, et peamine kunstitöö, mille eest meil tuleb hoolitseda, see tähtsaim ala, kus esteetilisi väärtusi rakendada, on meie ise, meie elu, meie eksistents. (339-340)

Niisiis, kui soovite, on hypomnemata ja enesekultuuri tähelepanuväärseks kokkujooksmispunktiks just see punkt, kus enesekultuur seab endale eesmärgiks täiusliku enesevalitsemise – teatava püsiva poliitlise suhte ise ja enese vahel. (342)

Tähtis pole mitte jälitada kirjeldamatut, paljastada varjatut ega öelda ütlematajäänut, vaid vastupidi, koguda juba öeldut, korjata kokku see, mida kuuldi või loeti, ja kõike seda eesmärgil, mis pole midagi vähemat kui iseenese moodustamine. (344)

Niisiis pole küllalt sellest, kui öelda, et subjekt moodustub sümboolses süsteemis. Subjekt ei moodustu mitte lihtsalt sümbolite mängus. Ta moodustub reaalsetes praktikates – ajalooliselt analüüsitavates praktikates. On olemas enesemoodustuse tehnoloogia, mis kasutab sümboolsed süsteemid ära ja läheb neist risti üle. (349)

Alates hetkest, mil kristlus enesekultuuri üle võttis, pandi see teataval viisil tööle pastoraalse võimu teostamiseks, nõnda et epimeleia heautou’st sai tegelikult epimeleia ton allon – teistehool –, mis oli pastori töö. Kuivõrd aga individuaalne lunastus – vähemasti teataval määral – pidi käima läbi pastoraalse institutsiooni, mille objektiks on hingede hooldamine, kadus endises mõttes ka klassikaline enesehool, see tähendab, ta integreeriti ja kaotas suure osa oma autonoomiast. (350-351)

Suhe enesega ei pea enam olema askeetlik, selleks et jõuda suhteni tõega. Tõe taipamiseks piisab sellest, kui suhe enesega paljastab mulle ilmse tõe selle kohta, mida ma enese jaoks näen. Võin seega olla ebamoraalne ja tunnetada tõde. […] Enne Descartes’i polnud võimalik olla ebapuhas ja ebamoraalne ning tunnetada tõde. Alates Descartes’ist on otsene silmanähtavus piisav. Pärast Descartes’i on meil mitteaskeetlik tunnetuse subjekt. See muutus teeb võimalikuks tänapäeva teaduse institutsionaliseerumise. (353)

Tõde ja võim. 228-262

Seda tahangi ma nimetada genealoogiaks, see tähendab niisuguseks ajaloo uurimise vormiks, mis suudab seletada teadmiste, diskursuste, objektivaldkondade jne. ülesehitamist, ilma et ta seejuures peaks viitama subjektile, mis on sündmuste välja suhtes kas transtsendentne või siis kulgeb tühja samasusena läbi terve ajaloo käigu. (239)

See, mis võimu tugevaks teeb, mis ta vastuvõetavaks muudab, on lihtne tõsiasi, et ta kunagi ei rõhu peale paljalt ei-ütleva jõuna, vaid et ta tegelikult on kõikeläbiv, et ta loob asju, tekitab naudingut, vormib teadmist, toodab diskursust; teda peab hoopis rohkem võtma produktiivse võrgustikuna, mis läheb läbi terve sotsiaalse kehami, kui negatiivse instantsina, mille funktsiooniks on ärakeelamine. (242)

Sellistes ühiskondades nagu meie oma iseloomustavad tõe poliitilist ökonoomiat viis ajalooliselt olulist tunnusjoont: tõde on keskendatud teadusliku diskursuse vormi ja nende institutsioonide ümber, mis seda toodavad; ta on allutatud pidevale majanduslikule ja poliitilisele takkakihutamisele (tõde vajab ni majanduslik tootmine kui poliitiline võim); ta on, erisugustes vormides, tohutu levitamistöö ja tarbimise objektiks  […]; teda toodetakse ja antakse edasi mõnede suurte poliitliste või majanduslike aparaatide mitte küll väljasulgeva, aga domineeriva kontrolli all (ülikool, armee, kirjutus, teabevahendid); ja lõpuks, ta on peapanus kõigis poliitilistes väitlustes ja kõigis sotsiaalsetes kokkupõrgetes (ideoloogilised võitlused). (260)

[…] tõde minu jaoks ei tähenda mitte kogumit tõeseid asju, mis tuleb avastada või omaks võtta, vaid kogumit reegleid, mille järgi tõene lahutatakse väärast ja liidetakse tõesele võimu spetsiifilised avaldused […] (260)

[…] poliitliseks peaküsimuseks pole mitte viga, illusioon, võõrandunud või ideoloogiline teadvus; selleks on tõde ise. (262)

Intellektuaalid ja võim. 170-184

Võitlus võimu vastu, võitlus võimu tuvastamiseks ja paljastamiseks seal, kus ta on kõige nähtamatum ja salakavalam. Võitlus mitte „südametunnistuse äratamiseks” […] vaid võimu õõnestamiseks ja ülevõtmiseks, üheskoos kõigi nendega, kes võimu eest võitlevad, mitte üksinda taamal, et võitlejaid valgustada. „Teooria” on selle võitluse regionaalne süsteem. (Foucault, 173)

Teooria ei totaliseeri, teooria paljuneb ja paljundab. Võimu loomuses on totaliseerida ja te ütlete väga õigesti, et teooria on loomult võimuvastane. […] Tõepoolest, see süsteem, milles me elame, ei suuda taluda kõige vähematki: see tingibki tema hapruse igas punktis, nagu ka vajaduse igakülgse repressiooni järele. Minu arvates te tegite meile esimesena […] selgeks ühe väga olulise asja: teiste eest kõnelemise väärituse. […] teooria lähtekohast peaksid lõppeks ainult otseselt asjasse segatud inimesed rääkima praktilisel moel iseenda eest. (Deleuze, 174-175)

Vangla on ainus paik, kus võim saab ennast ilmutada alastu kujul oma kõige äärmuslikumates vormides ja õigustada ennast sealjuures kõlbelise jõuna. (Foucault, 176)

[…] kui inimesed hakkavad tegutsema ja rääkima iseenda nimel, ei vastanda nad ühte esindamist (olgu see või pea peale pööratud) teisele, nad ei vastanda uut esindamist võimu väärale esindamisele. Näiteks meenub mulle, kuidas te ütlesite, et pole olemas rahvakohut, mis vastanduks tavalisele kohtule; see toimub hoopis teisel tasandil. (Deleuze, 177)

Võitlusdiskursus ei vastandu teadvustamatule: ta vastandub varjatule. […] Terve rida arusaamatusi on seotud mõistetega, nagu „peidetud”, „tõrjutud” ja „mitteöeldu”, mis lubavad odavalt „psühhoanalüüsida” seda, mis peaks olema võitluse objekt. Varjatut on tõenäoliselt keerulisem esile tuua kui teadvustamatut. (Foucault, 181)

Seega ei taga võitluste üleüldist iseloomu kindlasti mitte see totaliseerumisvorm, milles te äsja kõnelesite, see teoreetiline totaliseerimine „tõe” kujul. Võitluse üldise olemuse tagab võimu enda süsteem, kõik võimu teostamise ja rakendamise vormid. (Foucault, 184)