'Making sense of patients:
An analysis of practical reasoning by psychiatric nursingstudents
Peter W. Nolan
'Making sense of patients:
An analysis of practical reasoning by psychiatric nursing students'
This study examines thirty psychiatric nursing students' constructions of narratives about clients, based on their responses to a series of hypothetical case studies. They were asked to detail the diagnosis, plan of care and prognosis they would expect. To make sense of these situations and events nurses appeared to draw on wider cultural frames of reference, which enabled them to reformulate the information. Their reports appear to draw upon professional and lay theories about race and family problems, and demonstrate the kinds of reasoning used to make apparently bizarre behaviour intelligible. This therefore illuminates the kinds of complaints which previous writers have made about the treatment of black people in the mental health system. In conclusion we highlight the importance of looking at professionals' constructions of clients as organised accounts in their own right and discuss how the power imbalances in the process of keeping records can be addressed.
'Making sense of patients:
An analysis of practical reasoning by psychiatric nursing students'
Is psychiatric evaluation based on the characteristics of the 'patient', or is it a construction of meaning originating in the patient-practitioner relationship? To address this question a class group of psychiatric nursing students was invited to respond to a set of hypothetical 'patients'. A narrative analysis of their written responses was undertaken to detect the role of assumptions or 'taken-for-granteds' contained within cultural narratives, and how these might affect the construction of meaning, reality, diagnoses, and prognoses within clinical practice. Commencing with a discussion of psychiatry's role, its medical model approach to mental illness, and some current thinking about practitioners' literary constructions of patient narratives, it is hoped that a clearer understanding of patient-practitioner interaction will be achieved.
The Power of Psychiatry
Psychiatry is a potent agency of social control (Zola, 1963). Some have argued that it is similar to the judicial system. Legitimised by, and sheltering under the auspices of the state, both wield the ultimate in power - the right to remove the freedom of those who stray from the agreed norms of society (Littlewood & Lipsedge, 1982; Cochrane & Sashidharan, 1995). In much the same way as there has been growing public recognition of injustices, inequalities and prejudice in the law, psychiatry also has been accused of similar biases against various sub-sections of the wider population, as evidenced by the over representation of, for example, ethnic minorities in institutions for the 'mentally ill' and inconsistencies in the processes of care and treatments prescribed (Burke, 1984; Montsho, 1995).
However, the analogy between the judicial system and psychiatry is highly controversial. Those who oppose this view argue that these systems differ markedly in ideology and intention. Whilst the former is a punitive, the latter - psychiatry - purports to be a scientific province within the realm of the caring professions. Like other medical specialisms, psychiatry aims to treat the sick, to cure, to safeguard and promote the interests and well-being of patients or clients irrespective of patients' ethnic origin, religious beliefs, age, class, gender or any other characteristics (UKCC Code of Professional Conduct, 1992) Yet, despite this 'declaration of fairness' statistical evidence on admissions, diagnoses and prognoses, suggests that professional adherence to these directives is questionable. The whole of western psychiatry is argued by some to be 'shot through with a Eurocentric bias' and also to alienate and victimise groups which it purports to help (Cochrane & Sashidharan 1995, p. 3). From this point of view, psychiatry is heavily laden with cultural values and granted a powerful legitimacy, and thus is able to distort and override the patients' own account of their experiences.
To understand how a self-consciously scientific discipline can be subject to this kind of suspicion it is important first to look at the history of European and North American explanations for human distress.
Medical Science versus Social Construction
For centuries problems of the mind have been discussed and theorised in terms of 'sickness' inherent in the sufferer. For example, with regard to schizophrenia, various toxins or chemicals secreted by the body were implicated as far back as the nineteenth century by Emile Kraepelin (1883) and others who postulated a biological basis for problems of the mind - as yet, cultural differences in the expression of emotional states had been only crudely addressed. Through the twentieth century the 'medical model' monopolised the phenomenon of the mind in distress, conceptualising problems of the mind like problems of the body. This led to formulations such as 'disease', 'sickness', 'aetiology', and 'deficits' being scientifically constructed and defined for those whose behaviour cannot be understood.
Modern understanding of psychiatric practice is that it is 'scientific'. It has inherited the stages of medical evaluation, employing the method of examination leading to the identification and interpretation of symptoms which in turn determine the diagnosis and resulting treatment (often pharmaceutical). The very concept of science opens up a conceptual lexicon of systematic investigation, measurability, reliability and the application of basic rules, principles and general laws (Shotter, 1994). Consequently, the naive layperson in need of its services might perceive the standards of this controversial discipline to be universal, objective, consistent and factual, uninfluenced by the attributes of the practitioner and able to discern in some sense the true problems of the patient.
Furthermore, the ideology of scientific knowledge is reinforced and ratified by the symbolisms of the 'medical culture' which are clearly visible upon entry into a psychiatric hospital (Goffman 1961). The training, skills and legally sanctioned professional registration required to operate as a practitioner in such an environment are confined to a small group who are highly regarded in the negotiated order of the hospital environment. Foucault (1980) makes clear the inseparable bond between knowledge and power.
Yet, despite all the symbolic trappings and ideological rhetoric, when compared to other scientific disciplines, there is a fundamental ingredient missing from this systematic approach to evaluation. Many of the classic critiques of psychiatric practice (e.g. Szasz, 1961) have highlighted the absence of any rigorous physical test which can confirm or refute a psychiatric diagnosis. Even though this clear separation between psychiatric and physical phenomena has itself been criticised (e.g. Clare, 1975), the 'metaphorical' aspect of physical illness highlighted (Sontag, 1979), and forecasts made about immanent discoveries in the neuropharmacology of mental illness (Gershon and Reider, 1992), this critique highlights psychiatry's reliance upon the interpretations of practitioners. However, these interpretations themselves often resist modality - they preclude any statement of limitation. As Saleebey, (1994, p. 358) puts it:
'The global truth claims of the proponents of "objective reality" - the dominative truth in the western world - subjugates other knowledges and other systems of meaning.'
Social Construction: Culture Driven Narratives
The concept of psychological ill health is often counterposed to a definition for mental health. Hinsie & Campbell (1970) defined mental health as:
'Psychological well being or adequate adjustment particularly as such adjustment conforms to the community accepted standard of what human relations should be. Some of the characteristics of mental health are; reasonable independence, self-reliance, self direction, ability to do a job, reliability, persistence, ability to work under authority, rules and difficulties, ability to show friendliness and love, tolerance of others and of frustrations and a sense of humour...' (Hinsie and Campbell, 1970, p. 338)
This definition implies that mental well-being is an ability to adjust one's behaviour in keeping with the standards of the majority culture of a given community. This highlights the extent to which good mental health is relative and in a state of flux. Such social constructs as reasonable, friendliness, independence, and tolerance cannot be universal, as their implicit meaning and outward manifestations vary between individuals and cultures (Rack, 1982).
From a social constructionist perspective we could argue that human beings, in their attempt to make sense of any situation or event, do so by accessing frames of reference that are based not only on their own generalised past experiences but also drawn from a 'multiplicity of interconnecting social and cultural narratives' (Shotter, 1993). This has become an increasingly popular approach in the analysis of psychiatry as an organised sense making process. Hosking and Morley (1991, p. 95) state:
'Part of this process (sense-making) involves learning various narratives, stories, sagas, or scripts about social life. Whatever the language used, the general point is the same. Narratives, stories, sagas, and scripts make explicit the meanings inherent in the social dramas which they portray.'
Saleebey (1994, p. 351) suggests that human beings build themselves into the world by creating meaning, by symbolically fashioning a sense of what the world is about. Moreover, culture gives meaning to action by situating it in an interpretive system or repertoire (Potter and Wetherell, 1987). This is evident in psychiatry, where mental illness involves an inability to behave in ways that can be understood. We create meaning out of patients' behaviour by attempting to provide explanations and reasons, and in doing so we may omit or add pieces of information in a way which recollects cultural norms, values and expectations. It is our aim to try to detect whether Saleebey's view is supported in accounts from future health professionals in training. These accounts may be informed by (i) wider Eurocentric cultural values and norms and by (ii) medical culture (Hak, 1992; Strauss, 1963). Combined, these cultures assist in the creation of meaning. As Saleebey (1994, p. 351) states: 'there is a link between individual constructions and the larger environment of social institutions and culture.'
Many authors have claimed that Western society uses cultural narratives about people from other races which are the very opposite of 'good mental health' as defined by Hinsie & Campbell (1970) and by wider society and psychiatry. For example, Western society's narrative of the black young male includes anti-social, dangerous, aggressive, law breaker, lazy and so forth (Rack, 1982) - which accords with the social narrative of mental illness and is at odds with Hinsie and Campbell's definition of mental health. Thus, it follows that he is therefore in need of 'treatment'. This process of sense making seeks congruence - information which contradicts the social construction is likely to be omitted, discounted, misinterpreted, or ascribed to some other reason so that the cultural narrative of the majority is upheld and reinforced.
In psychiatric care the implications of this are particularly important when we consider the kinds of people who disproportionately come into contact with psychiatric services, namely ethnic minorities, women, and those perceived to be of lower socio-economic class or status. They represent the patients who are most likely to acquire the highly stigmatised and contentious diagnostic labels of psychiatry, most likely to be forcibly incarcerated under the Mental Health Acts in the UK, more likely to be the recipients of electro-convulsive therapy and prescribed medication of high strength and dosage (Cochrane & Sashidharan, 1995).
This viewpoint is supported by the findings of Lewis et al (1990) who found the prevalence of negative racial and gender stereotypes to be significant among British psychiatrists. Respondents were more likely to judge African-Caribbean cases to be more violent, with a greater degree of criminality. These perceptions involved 'race thinking', characterised by an almost 'common-sense' air (Husband, 1982). The approach of analysing cultural narratives may lead us part-way to understanding the disproportionate representation of ethnic minorities (in particular Afro-Caribbeans) in the consumer population of psychiatry. Professionals, working within the social or cultural narrative construction of these patients, are likely to unwittingly produce interpretations which complement society's taken-for-granteds, but override patients' own realities (Crawford, Nolan and Brown, 1995).
Nurses: Co-authors of the patient's narrative
Nursing students were the target group in this study because nurses hold a critical position in the hospital's 'sphere of influence' (Leininger, 1984) which has consistently slipped through the net of academic researchers who seek to investigate inconsistencies in wider psychiatric practice. Most attention has been focused on psychiatrists as traditionally they were formally qualified to diagnose and recommend a course of treatment. Hence, in many classical critiques of psychiatry, psychiatrists rather than nurses have been perceived as the ones with the most power. More recently however, the importance of nurses in the construction of narratives about patients has been highlighted (Crawford, Nolan and Brown, 1995; Saleebey, 1994).
Psychiatric patients' records constitute a source of information whose authority and objectivity often goes unquestioned. Authored by individuals such as social workers, perhaps even police officers, doctors, nursing staff, and possibly family members who seek to conceptualise the patient's life experiences at given points in time, patients' records become a conglomerate of interdependent stories or narratives. These medico-nursing records may become progressively more distant from the patients themselves and their lived reality. Indeed, 'Since mental patients have more biographers than the most famous of Hollywood stars, we should be even more rigorously sceptical than we are with scandal stories.' (Crawford, Nolan & Brown, 1995, p. 1147).
On a daily basis nurses spend more time with patients compared to the briefer and more infrequent contact with psychiatrists. Patients' behaviour may in turn be reported to other members of staff, and may achieve relative permanence in the form of written records. This information might then influence decisions made by psychiatrists about the clinical management of patients. Each account provides a foundation upon which subsequent authors apply their literary skills, thus adding new chapters, new dimensions, and more importantly new interpretations of the patients life, which may be so far from what the patient knows as to be 'fictional biographies, which will ultimately entrap or linguistically incarcerate many individuals.' (Crawford, Nolan and Brown, 1995, p. 1144). Written records, often lurid with contentious interpretations, have a long 'shelf-life' which can influence the patient's psychiatric career even in the absence of the author (Ekdawi & Conning, 1984; Cochrane, personal communication) or any independent validation.
Taking the case history is the primary step in the authoring of any new narrative about a patient, and indeed the very act of inquiry is a prominent feature in 'medicalising' a patient. The case history marks the introduction of the patient to the world of institutional care, denoting fact finding, thoroughness in the search for 'truth and knowledge', and a caring interest in the good of the patient. Compiling case histories is fraught with difficulty however. Even when we adopt the stance of most textbook writers - that case histories are about the facts which precede the present consultation - there are obvious problems. Compiling a patient's history depends, to a large degree, upon the recollection of the interviewee (Ekdawi & Conning, 1994, p. 39). The picture becomes even more problematic once we include the arguments we have rehearsed earlier:- that the nature of these 'facts' themselves may be contested, as a consequence of culture bound views of the world and inequalities which are inherent in health care in Europe and North America.
Moreover, the typically highly structured nature of assessment interviews restricts the information the patient can provide, thereby repackaging the patient's own narrative. Yet the practitioner may also unwittingly engage in sense-making and interpretation in order to (i) 'fill' in the gaps where the patient's recollection has failed and (ii) appease conflicting pieces of information introduced into the patient's records by other authors.
Language, professional practice and elitism
Several authors (e.g. Ng and Bradac, 1992) have recently highlighted some of the functions of the technical and esoteric vocabulary employed by health care professionals. It serves not only to consolidate and exemplify their power over their patients, but also provides a linguistic bond and professional recognition among colleagues. Medical language is noticeably richer, more diverse and shrouded in jargon and acronyms, and is usually different from the understanding of those whom it concerns - the patients. It has been incorporated into the structured format regulating admission, examination, diagnosis, treatment and eventual discharge procedures - in short, it encompasses the patient's 'psychiatric life' (Bradac and Wisegarver, 1984; Cooper, 1970). Such proficiency in 'medico-terminology' is quickly acquired by nurses. It deviates sufficiently from the vocabulary used by the lay-person to place the patient at a disadvantage - unable to challenge, question or even comprehend the clinical assumptions communicated in this dialect or 'elite discourse' (van Dijk, 1993).
The combination of these trappings and symbols bolsters scientific legitimacy and provides a foundation upon which the current frames of reference are constructed and reconstructed. They are part of the implicit assumptions and taken-for-granteds which characterise practitioners' constructions of the 'patient' as one who is sick, unable to provide an explanation for their own behaviour, or whose actions lack meaning. Thus practitioners compensate for this perceived deficit, attempting to create reason and logic with their inevitable cultural overtones.
Although much of the previous research has been useful in highlighting inconsistencies in psychiatric practice which suggest that racial prejudice and stereotypes are prevalent among practitioners, and may actually be inherent in the system, they provide little information concerning the 'literary catalysts' of such manifestations. They tell us what is done, but not how it is done. We need to ask what processes nurses engage in when they construct narratives about patients. Therefore the present study sought to characterise how future psychiatric nurses make sense of some hypothetical patients, presented in the form of short scenarios. It was hoped that this would be a useful form of 'voyeurism', allowing us to generate some examples of the reasoning, inference and understanding which emerges. It might allow a thoroughgoing examination of how the information people are given at the outset is elaborated by them into a narrative which makes sense in relation to widely held cultural beliefs. Perhaps this also has implications for patient-practitioner interaction, which is vital if we are to gain a more holistic understanding of the over-representation of ethnic minorities in psychiatric care.
The study was a structured observation employing the case vignette method (Shaughnessy and Zechmeister, 1994; Miles & Huberman, 1994) in which the researcher creates a set of case studies or stimulus narratives containing characters or actors. Similar to the case-vignette method used by Lewis and Appleby (1988), eight short stories were written for the present study each of which described a fictitious scenario of a patient which comprised a photograph and a brief outline of the patients history. In the task participants were randomly allocated two of the possible eight scenarios. Each scenario bore a common structure of 5 main features, as follows:
1) The racial origin of the patient
namely Black African-Caribbean; Asian-Pakistani; Anglo-Irish; English; Scottish.
2) The gender of the patient
namely male or female
3) The age of the patient
4) The type of behaviour that brought the patient to the attention of the Psychiatric services.
(a) Bizarre: This refers to any behaviour that would be considered unusual, odd or
eccentric i.e. talking to ones self in a public place, continuous washing and so forth.
(b) Misdemeanour: This refers to any behaviour which could be considered socially
disruptive, to the extent that it warrants the attention of the police, but does not
necessarily result in a prosecution.
(c) Criminal: This refers to any behaviour that clearly violates the law, inviting
5) How the patient was admitted to the hospital.
(a) Voluntarily: referred by their General Practitioner
(b) Forcibly: against their will via the police station
These features may be viewed as variables, although they were not manipulated in the manner of a controlled experiment. As this study was not designed to test a particular hypothesis - being more at the theory generating end of the continuum - it was felt that random variation presented a better simulation of the real cases that staff would often encounter in a clinical setting. Furthermore, if only one variable was manipulated whilst all others were held constant, it would have not only limited the diversity of the cases, but would have called for a far greater number of participants than the scope of this study would allow.
However, two case scenarios are identical. The case history of (a) Mr Gordon Dixon and (b) Mr Walter James Peterson were duplicated - the only feature that was altered was the ethnicity of the patient. Whilst Mr Dixon was originally from Jamaica and is photographed as a black man, Mr Peterson was originally from Scotland and bears the photograph of a white man. Thus, the effect of ethnicity on the construction of narratives about patients could be closely observed.
Thirty participants (PNs) were recruited from the second year intake of the degree course in psychiatric nursing at a Midlands (UK) university. All participants were female, aged between 19 and 22 years. None of them had worked in a mental health setting for a duration of 1 year or more. Of the 30 PNs, 29 indicated their racial origin as 'White European' and one as 'Asian'. No other racial group was represented.
Each participant was presented with two case scenarios, two A4 sized response sheets and a 'task outline'. They were told not to consult with each other during the task, and advised to read the scenarios carefully before referring to the directions of the 'task outline' which informed participants that they were part of a psychiatric team and were to prepare for a forthcoming team meeting a written evaluation of the patient covering the following information:
1) Indicate the diagnostic label they would expect to be attached to the patient.
2) Recommend some kind of care plan for the patient.
3) State how they thought the patient would respond to the hospital environment.
4) Give some indication of the type of support system (family and friends) that would be available to the patient.
5) Judge the overall long-term prognosis of the patient in terms of a successful return to the community.
No time limit was placed on the task and participants were encouraged to elaborate and express opinions.
Finally, after gathering all the responses, the aim and purpose of the observation was disclosed and discussed with participants.
Analysis of data
In this section we shall consider the relationship between wider cultural and social narratives and the attempts of the nursing students to create meanings about the fictional patients. We are particularly interested in how people in clinical practice interpret and re-inflect information about patients.
Categorising the observations made in this study was a complex task because the richness and diversity of qualitative data allows no standardised format for developing categories for discourse analysis (Dey, 1993). Inevitably the kinds of categories created depend on the type of data being analysed, the aims, inclinations, knowledge, interpretations and theoretical sophistication of the researcher (Dey, 1993). It is a method of analysis that may be criticised as being more or less subjective, but without it much linguistically and interpersonally mediated experience would remain inaccessible, making any discipline purporting to study mental life incomplete (Miles and Huberman, 1994). The data was categorised using a method consistent with the work of Rennie (1994) and Lewis and Appleby (1988) which emphasised theory generative phrases and themes. Fragments of participants' texts were initially identified as suggestive, and the texts were then examined more systematically for additional evidence for common implicit assumptions and themes. As a result the following categories or typologies of concerns were generated which we shall use in an attempt to make sense of the statements made by the nursing students.
1) Acts of Omission and Commission.
2) Attribution of Reasons.
3) Enlisting the family as co-therapists.
It is important to note that these categories often overlap because phrases or sentences used by the nurses are often a combination of sense-making tools. Hence, discussion of the results is a more complex task This is a common problem of category generation, but Dey (1993) suggests that it may allow for an appreciation of the multiple meanings and practices which qualitative data involves.
Results and discussion
Overview of the results
The results gathered here indicate that clinical evaluations of the nursing students are more influenced by the race of the patient than the manner in which the patient was admitted or the type of behaviour manifested. Participants appeared to access the wider social and cultural narratives about the ethnic group to which the patient belongs in their attempt to interpret and to make sense of a given situation, and in discussing patients they reproduce race thinking, 'common sense' (Gramsci, 1971), taken for granteds and cultural assumptions as though they were facts gleaned from the case scenarios themselves.
It would be impossible to include here every statement that falls within a particular category. Instead we shall provide examples which demonstrate the tools of sense making at work in narrative construction.
1) Acts of omission and commission
Participants omitted or added information to the scenario, and worked it into their narrative about the patient so that it fitted prevailing stereotypes and expectations, thereby facilitating order and continuity both within patients' stories and between these and existing stereotypes and values. These were of four types, namely i) 'confirming the diagnoses', ii) 'pathologising the black family', iii) 'violence, aggression and harm to others' and iv) 'social order and control'.
i) Confirming the diagnosis
For example, in the report produced by participant 1 (PN1) an act of commission is apparent: When discussing the patient Andrew Porter she writes:
"This man would appear to be a manic depressive, as he's always changing moods."
In the scenario of Andrew Porter it is clear that the statement "as he's always changing moods" is not supported by information presented in the case history. But this clause has a distinct function - it acts as a 'trailing definition' of the opening remark. The diagnosis she has evoked calls for justification and so an evidencery statement follows. Thus, the opening clause 'makes sense' as the last clause of the sentence provides a convenient reason for the diagnosis of manic depression. Maybe it is indicative of the academic knowledge she has gained through training and her immersion in the medical culture. Just from reading this statement the lay person is able to deduce that one of the characteristics of manic depression is "changing moods" and this is consistent with the symptoms detailed in DSM IV (APA, 1994; Davison and Neale, 1994, ps. 227-228). There has been growing recognition and concern about the power of diagnoses to orient the source of explanations to something within the patient (Antaki, 1994; Mehan, 1990). According to the manifest position of medicine we would expect behavioural indicators to lead to the diagnostic label but many researchers argue that in numerous cases the opposite is true - behaviour is interpreted so that it fits the diagnosis.
In some of the other texts we can see how the acts of omission and commission can be combined to underline racial stereotypes.
ii) 'Pathologising' the black family
In the case of 'Delroy Williams', a young black man, the patient scenario states "Staff soon contacted his family who eagerly provided a detailed case history", with the term eagerly perhaps suggesting a desire to help. Yet PN8 omits this piece of information and produces a response which ignores his parents' efforts:-
" ...his parents don't want to know."
This perception of Delroy's family was common. Of the 8 participants who were assigned the case, all but one said his family would not support him: For example:
PN17 "I don't think he'll get much support from his family"
PN1 "His parents don't seem to be supportive of him"
PN18 "Possibly friends but NOT family support either in or out of hospital"
PN22 "I don't believe his support system of friends or family will be good"
Even PN13, who was ambiguous about family support in this case, feared that the presence of his family might hinder his recovery:
PN13 "But if his parents are heavily involved in his return to the community... it is likely to make him more rebellious and agitated which will hamper his progress and lead to further breakdowns."
In the absence of any information in the case scenario to validate these statements, participants seem to be accessing wider social perceptions of the black family as dysfunctional or pathological. Howitt & Owusu-Bempah (1994) argue that race-thinking has promoted the notion of the 'defective black family' which is supposedly characterised by a matriarchal structure, punitive and irresponsible child rearing patterns and weak emotional ties. Though these characteristics may also be common to many white families, such views dominated the research literature on 'West Indian' family life in the 1970s. For example Lobo (1978, p. 34) states:
"West Indian childbearing patterns are known to be able to cripple a child's development in the curiously cold and unmotherly relationship between West Indian mothers and their children."
Lobo presents the stereotype with an air of common sense or factuality and evokes the idea that the black family can be blamed for children who may not be considered socially well adjusted.
The statement made by PN13 is curiously similar to the quote from Lobo and the kinds of logic which dominated research and theory on black families in the 70s (Lawrence, 1983). She is unsure that his family will be supportive and says it is likely that any family involvement would hinder his progress. In a clinical situation where staff believe the family would be counterproductive to a patient's progress, family involvement might be surreptitiously discouraged. This vilifying of the black family serves a wider purpose in that it supports oppressive social narrative constructions of black men, and identifies the very fabric of West Indian culture - the family - as the 'problem' (Howitt and Owusu-Bempah, 1994).
None of the participants alluded to racism as a possible cause for the distress of either Delroy or any other Black or Asian patient. This occurred despite widespread scholarly acknowledgement of the importance of racism in understanding black people's distress (e.g. Cox, 1986; Rack, 1982; Fanon, 1991; Hemsi, 1967; Hickling, 1992 and Wetherell & Potter, 1992).
iii) Violence, aggression and harm to others.
'Violence' and a 'danger to others' was a recurring theme in the responses concerning Delroy. It was written about almost as if it was a fact stated in the case scenario even though no such statement was made. For example:
PN8 "Protect the people around him"
PN12 "Delroy is a danger to himself and the public"
PN13 "He's obviously physically violent"
PN17 "Going to need his behaviour restrained to protect others"
PN16 "Delroy will need strong medication to reduce his violence"
PN26 "He is violent."
Participants have worked the issue of 'violence against others' into the narrative construction of Delroy. It becomes an important feature of his character which justifies high doses of medication.
Perhaps some elements in the case scenario implied that Delroy was violent. He was "involved in a disturbance in the street" (though this could refer to almost any incident), he was "verbally abusive", he "resisted sedation" and had "bruising to his face and body". However this only implies that he could possibly be violent. None of the participants suggest that he could have been a victim, or seek to explore why and how he came to be so severely bruised. Delroy's perceived violence is discussed as a 'reality' rather than as a possibility. Emphasis is placed on warning staff and preventing further violence by Delroy.
Let us compare Delroy's scenario to that of Jonathan Spencer-Summers, a young white male student of comparable age, also involved in a 'strange' religion. In addition the latter had committed arson, but none of the participants who discussed Jonathan's case mentioned that he presents a danger to the public, or discussed his actions in terms of violence. Instead, this act of arson is attributed to the pressures of student life and evokes recommendations of out-patient treatment which must include counselling to discover the reasoning behind his actions.
PN8: "I don't think Jonathan will appreciate being in hospital, it might make him worse."
PN13: "The arson offence is an indication of the frustration or fear that he feels about his studies."
PN21: "Jonathan might have to be given medication to control his illness but hopefully drugs will be a last resort."
PN22: "Jonathan's care plan needs to focus on counselling"
The majority of the PNs stressed the importance of discovering how Jonathan feels, how he thinks, why he did what he did. He is accredited with a mind, in the sense of suffering from frustration and fear, he is autonomous and it seems to the participants to be desirable that he gets the opportunity to tell his own story. In stark contrast, the consensus on treatment for Delroy was long term admission, physical restraint, seclusion, and high doses of medication. This relates to the well-documented finding that patients of African-Caribbean origin are more likely to be recommended stronger doses of medication than their white counterparts even when their symptoms and diagnoses are the same (Littlewood and Lipsedge, 1982; 1988; Littlewood and Cross, 1980; McGovern and Cope, 1987). None of the participants who discussed Delroy suggested reasons for his supposedly violent behaviour besides his illness. He is not granted a 'mind' in the same way as his white counterpart, which parallels the way that Sanders (1993) writes about the 'granting of limited mindedness' to non-human species. It is as if Delroy is somehow not quite as human as Jonathan. The possibility of Delroy expressing himself, or having wants is avoided or problematised:
PN18: "May want to continue to smoke cannabis on the ward. May complain about the amount of bruising to his body."
It is almost as though his complaints about bruising would be problematic in the same way as smoking cannabis on the ward.
The acts of omission and commission employed by the participants when discussing these cases effectively maintain the social narratives that construct both these individuals and the racial groups to which they belong. This illuminates some of the concerns mentioned by Cochrane and Sashidharan (1995, p. 5): "What are we, and more significantly the community concerned, to make of the fact that black young men are twice or three times more likely to be brought to a mental hospital by the police and doctors and detained there compulsorily than are white men? The very same group are more likely to be detained in prison."
Western society, and in particular the practical common-sense of psychiatry, constructs a narrative of the black male involving aggressive and anti-social behaviour (Littlewood and Lipsedge, 1982) The participants' responses to Delroy are complemented by the findings of Lewis et al (1990) who found that psychiatrists were more likely to judge African-Caribbean cases as more violent, and Lewis & Appleby (1980) who found that young black males in particular were more readily perceived as a danger to others and were therefore recommended for more stringent methods of control.
These contrasts may be illustrated further by examining participants' responses to the case of Christine Marsh, a white middle-aged woman who abducted a child. She was not perceived as a danger to the public. Again this is supported by the findings of Lewis et al (1990) who found that females were perceived by psychiatrists as less violent and less criminal, even when their case histories had indicated criminal behaviour. Christine Marsh, being both white and female, in Western cultural narratives would be considered relatively harmless.
iv) Social Order and Control
The ability to abide by rules and work under authority were two aspects of mental well being as outlined and discussed by Hinsie and Campbell (1970). As an agent of social control psychiatry appears to define as 'ill' those who are either unable or unwilling to comply with the agreed rules of society. In addition the perceived lack of compliance to a rule or norm may vary according to the racial origin of the individual whose behaviour we scrutinise (Littlewood and Lipsedge, 1982). This was frequently employed by participants in their responses to Delroy Williams. For example:
PN18: "Delroy is suffering from depression and boredom... May want to smoke cannabis on the ward... He will deteriorate unless he finds a job".
This statement was an indication of the type of diagnosis PN18 would expect to see attached to this patient. Though the diagnosis of depression suggests that the patient is ill in some way it is followed by the term boredom which suggests that his illness is partly of his own making. The issue of 'finding a job' as indicative or essential to mental stability was never raised in responses to other unemployed patients' scenarios. Suggestions were made that he may not be able to abide by the law or the rules of the hospital:
PN13: "His frequent conflict with the police shows that he finds it difficult to appreciate rules and this will present problems for staff".
This participant has interpreted Delroy's problems in terms of his not being able to understand and obey rules or respect authority, and this is something that staff must be prepared for. Delroy is commonly construed as a problematic patient. This contrasts with Andrew Porter where, despite being brought in by the police and being a frequent drug and alcohol abuser who was also unemployed, participants typically predict that he will respond well to staff:
PN1: "He will respond to the hospital,... I think Andrew will talk to staff and other patients a lot".
No participants perceived his drug or alcohol use to be a problem that staff need to be warned about. This contrast is consistent with the wider social stereotyping of black people as lazy, idle and unwilling to work (Billig, 1978).
In the cases of Gordon Dixon and Walter Peterson which vary only in the ethnicity of the patient, Mr Dixon (the black man) is perceived as unsociable, and to have difficulty in communicating:
PN4: " He seems quite an unsociable man... I also think that he may have problems in communicating with others."
This occurs despite the case history clearly stating that he is articulate and amiable gentleman. But when participants discuss Walter Peterson, they often describe him as communicative:
PN16: "I think he will respond well to the hospital environment, he seems to communicate happily with others... community groups could be helpful as he appears to want to communicate with others in the community."
PN26: "I think he will respond well to the hospital environment in terms of his interaction with others."
These statements reconstruct the characteristics of the client in a way which appears to fit the wider social narrative about people of the corresponding ethnic group, as documented above.
2) The Attribution of Reasons
In attempting to make sense of situations, people formulate reasons and explanations. It is a pervasive strategy which consolidates the observer's preferred interpretation of events. This process is even more readily enabled when the observer is working within the legitimate authority of psychiatry. Explanations are often rooted in common-sense plots and stories, and are richly context-dependent. The attribution of reasons discloses a great deal about the aims, expectations, frames of reference and cultural narratives accessible to the observer, and also the legitimate opportunity granted to the observer to 'slot' their explanation into the dialogue of understanding (Antaki, 1993). Furthermore, the process of explaining things works in two directions. Billig (1992) speaks of the kaleidoscope of 'explanans' and 'explanandum' - a phrase coined to emphasise the circularity and interconnectedness of explanations, for the very event that we seek to explain is utilised as an explanation for other events.
When employed in clinical practice this strategy of sense-making is able to prevail over the patient's own reasoning about his or her actions. As psychiatric patients are deemed disordered in mind, their own reasons lack credibility, and they are likely to be perceived as unable to think clearly, unreasonable, irrational and illogical. Thus, professionally attributed meanings given to the actions of the mentally ill provide reasons for what is seemingly bizarre. In so doing professionals are likely to reaffirm their own stereotypes and prejudices. In providing a reason for the illness they seem to use the illness also to explain behaviours. In the case of Christine Marsh for example several participants felt that she was ill because her marriage had failed, and she abducted a child because she is ill. Thus meaning and continuity are established in the narrative about this patient, which is compatible with an ordered, rational 'medical model' approach to mental illness. There is a reason for the illness in the form of the loss of a marriage and the illness has symptoms and sequelae in the form of the abduction of a child. To highlight two of the common features of reasoning in this context we shall examine reasons in terms of how participants sought to establish cause and effect, and how this fits in with broader patterns of common-sense.
i) Establishing cause and effect.
The interplay of cause and effect can also be seen in the case of Delroy, where all participants suggest he is ill because of frequent cannabis usage, and his illness and cultural background provide the reasons behind his obsession with religious beliefs or delusions. For example:
PN26: "I've read that some ethnic minorities with schizophrenia characterise their behaviour by religious behaviour which seems to fit in with Delroy's activities."
Here, the participant formulates a version of the cultural implications of behaviour and psychiatric diagnosis which is so inclusive it could encompass many whose beliefs, practices, and values differ to that of the prevailing western culture. In demonstrating this tentative multiculturalism, she is at the same time profoundly complicit with the 'race thinking' which many authors have identified in psychiatry and psychology (Howitt and Owusu-Bempah, 1994). Moreover, Rack (1982) warns that even though delusions might be a false belief it does not necessarily indicate mental illness, unless it is out of keeping with the individual's normal beliefs and the group to which the individual belongs. Delroy's beliefs might well be appropriate in the cultural group to which he belongs (Williams, 1981). Thus, this kind of understanding of cultural diversities consolidates over-zealous diagnoses rather than facilitating the appreciation of other peoples' belief systems in their own right.
On the other hand, with the religious obsessions of Jonathan Spencer-Summers, a young white man, many participants emphasised the importance of finding out why he believes what he does. For example:
PN29: "Discuss with him how he came to his beliefs in the occult."
PN3: "A care plan for this patient should focus on talking through Jonathan's beliefs and how he came to believe in them."
Yet no-one sought to discuss Delroy's religious beliefs with him. Thus, as well as the strangeness of a belief, the person who holds that belief is an important factor. In particular, Jonathan Spencer-Summers is being credentialed such that he can explain himself whereas Delroy Williams is not.
As mentioned above, Delroy's 'illness' was often seen as having another kind of cause:
PN13: "Delroy is no doubt suffering from schizophrenia brought on by constant use of cannabis."
Delroy's seemingly bizarre behaviour is now not so bizarre. It has a reason - cannabis. Even in light of little formal evidence to support the belief that cannabis induces psychosis, 'ganja psychosis' has become an increasingly popular way of explaining the behaviour of young black men (Howitt & Owusu-Bempah, 1994; Littlewood and Lipsedge, 1988). Thomas et al (1993) report that existing studies detect no significant difference in the proportion of African-Caribbeans and Europeans who smoked cannabis in the week prior to admission and this finding is supported by the work of Harvey et al (1990) who detected more cannabis use among whites than blacks. Still, diagnoses of 'ganja psychosis' are often made without blood tests being carried out and without even asking the patient whether he or she uses cannabis (Howitt and Owusu-Bempah, 1994). In not asking patients such questions, their own stories are systematically excluded from the process of diagnosis. The expression 'no doubt' was commonly used by participants when quoting a widely held belief which has debatable academic support suggests that their training has not problematised these beliefs and indicates how indelibly these stereotypes have been ingrained. These statements about the frequent and pathologically linked use of cannabis among black males is a part of the social construction of black men as criminals (Littlewood and Lipsedge, 1982). The word 'cannabis' in the patient scenario has opened up for PN16 a narrative of crime and criminal associates:
PN16: "He (Delroy) is involved in drugs and crime - these people do not change overnight... he is involved with drug dealers and criminals."
This participant is implicitly working the boundary between some class of people - 'these people' - perhaps black people or 'mental patients' - and the rest of us. Radical reformulations of psychiatry, beginning with Laing and Szasz in the 1960s have repeatedly called into question the way the discipline creates this boundary between those it presumes sane and those it identifies as having some sort of illness, problem or deficit. This kind of boundary thinking is even evident in much of the formal and informal construction of patienthood. For instance, also in relation to Delroy, we have:
PN8: "He's a little different".
However when Andrew Porter, a young white male, is described in the case scenario as a frequent drug and alcohol abuser, this piece of information was often omitted by participants who instead indicated other precursors such as poverty or a lack of family attention as the cause of his distress. Drugs and alcohol, where participants mentioned them, were incidental - not something that is 'no doubt' the cause of the illness. For example:
PN6: "I think he will benefit from basic attention and support as being one of six [children] he will have missed out on the basic needs in his youth.... I don't believe that drugs are necessary such as the anti-abuse drugs available, unless this is perceived to be a problem by Andrew.... He should try to cut down on his alcohol consumption."
In this way the patient is almost exonerated from any culpability in causing his illness, as it is attributed to social or domestic circumstances. The treatments mentioned takes into account how the patient perceives his situation. Drugs are discussed in a way that allows the patient some autonomy - although she may perceive it to be a problem, Andrew may not. Through self-expression Andrew Porter may be given the opportunity to contribute to his own narrative.
ii) The common-sense nature of reasons.
The reasons attributed for the patients mental distress are presented almost as a matter of common sense. However, as Shotter (1993, p. 173) points out "what one person knows is taken to be, more or less, the same as the other...[but]...common sense is far from unitary"
This disunity of common sense makes it particularly difficult to get to grips with. Perhaps, as suggested by Billig et al (1988) everyday thinking is shot through with dilemmatic aspects. Whereas in Delroy's case there were aspects of the reasoning which were redolent of a naive pharmacological determinism, a more psychologistic repertoire was developed for another patient, Hassan Ali:
PN2: " He needs to accept the loss of his job and the breakdown of his marriage has caused his depression"
PN7: "Hassan became depressed due to being made redundant and his marriage break-up"
PN20: "The loss of his family seems to be causing him much grief"
No participant mentioned asking Mr Ali if he feels his divorce has been the major cause of his depression. Instead participants provide elaborate arguments about getting Mr Ali to come to terms with his present situation. Other possibilities such as his mental illness leading to the break-up of his marriage or that the mental illness was caused by the marriage itself not the divorce, are not addressed.
It is important to note that Hassan Ali and Delroy Williams are not credited with the ability to tell their own stories in an intelligible way. This might be indicative of some broader inferential structure in which psychiatric patients are too ill to think for themselves, and to give their own reasons. However this contrasts with the interest shown in the person's own reasoning, storying, talking and communicating around Jonathan Spencer Summers and Andrew Porter. The implication is that privilege of telling one's own story might be extended most readily to white men. The selective interest shown in people's own explanations recollects Antaki's (1994) insistence that the reasons we attribute are powerful influences over the solutions we then recommend.
In the case of Hassan Ali, the attributed reasons lead to the recommendations for counselling to get him to accept his circumstances, and participants spoke negatively of his family as the cause of his distress. It is one aspect of the processes that are used to create reason, and by creating reason we construct the patient. A complex causal chain is elaborated for Hassan Ali, in that his domestic situation is the reason for his depression and now his depression is the reason for his aggressive behaviour.
3) Enlisting the family as co-therapists
The need for the family to be a part of the recovery process was a central feature in respondents' accounts, and this fits closely with professional interest in care in the community. Enlisting the family in therapy too also has roots in the popularisation of psychotherapy in the 1950s (Parry and Doan, 1994). As an adjunct to formal therapy it is often considered by clinicians to be a vital ingredient in the process of recovery, as if it were intrinsically beneficial and almost infallible. The family also has a more explanatory role, in that it is used by professionals to help make sense of a patient's behaviour.
In line with this, many participants mentioned increasing family awareness of the individuals 'illness'. Families are almost expected to become experts in the distress of the patient. Participants rarely alluded to the possibility that some families may be unable to provide ongoing support, or be unwilling to assume the responsibility - and there is no space available for the family to express such opinions. Instead, participants discuss family support as though it were an obvious function of any family.
Secondly, the family is often a source of information in the patient's case history. They may provide information informed by the narrative that the family has constructed over a number of years, and this may differ from the patients own account (Stone, 1988). Families may have a vested interest in how the patient is portrayed. Families may bring about increasingly sophisticated effects with repeated performance of their narratives, such that the perceived dysfunction is presented as a delusion in the mind of the patient, and not in the family unit. Challenges to the preferred story which the patient might make may well be considered a sign of paranoia on the patient's part, further supporting the diagnosis. Instead of being co-therapists we could argue that the family may become co-conspirators in the adulteration and subjugation of the patient's own narrative.
In addition, by introducing the family as co-therapists there is the danger that the patients confidentiality may be compromised (Zimmerman & Dickerson, 1994). We can see these issues emerging in the following examples drawn from the participants. Again, in the case of the first one, there are intimations of wider social perceptions of race.
With reference to Hassan Ali PN7 states:
" I think his family will be supportive as Muslim families tend to stick together more."
With reference to Jonathan Spencer-Summers PN3 states:
"In order for Jonathan to become well his parents need to be informed so that they can understand his illness."
And with reference to Andrew Porter PN11 states:
"The family needs to be talked to so they can understand his condition...with family support he will be able to return to the community."
However, whilst the family was generally perceived as intrinsic to recovery and a successful return to the community, this was not the case for Delroy Williams, whose family involvement was considered to be a hindrance to any progress he might make. Again this is consistent with the social construction of the black family as dysfunctional.
The aim of this study was to investigate the influence and purpose of wider social and cultural narratives in the textual construction of a patient by professional carers. The analysis of the texts produced by the student nurses who took part in this study revealed some properties which correspond to the depiction of black people in some academic, medical and popular thinking. This supports the findings of Lewis, Croft-Jefferys & David (1990), Lewis & Appleby (1988) and many others, and also seems to provide a wider picture of the dynamics of social sense-making that professional carers may engage in. This in turn relates to the everyday prejudices and account building which finds its way into the written productions and reproductions of stories about patients. Many of the previous studies on racism in psychiatry appear to work with a model of prejudice which emphasises intentionality. Our position is rather different. We believe that humans can only make sense of situations by employing various sense making tools and those tools reflect the society in which psychiatry practices (Hak, 1992). Unfortunately, the scope of this paper can only highlight some of the implicit references that practitioners draw upon in the everyday act of narrative production and reproduction.
The kinds of interpretations evident in the texts have enormous implications for those who depend on the services of psychiatry. In the participants' reformulations of patient scenarios we can see how they utilise a variety of stereotypes and implicit assumptions in attempting to make sense of an event or situation, and in so doing they have permeated and moulded the original story about the patient in keeping with norms, values, and definitions which are consonant with the western social consensus. It could be argued, moreover, that these kinds of norms and values are implicated in, for example, the disproportionately high rate of compulsory admission and drug treatment which black people are subject to in the UK mental health system as a whole.
We are not suggesting that professionals are intentionally engaging in racial biases. Indeed, the evidence in this study suggests that participants were attempting to express their knowledge and awareness of the cultural implications in psychiatric care, but even in doing so, they produce statements which are imbued with generalisations about the particular racial group to which the patient belongs - statements which are bound up with a selective rendering of some academic theories. The data were collected by the first author (KR) who is black herself. Perhaps the presence of a black researcher would have in some way reduced the obviousness of negative racial stereotypes. The intrusion of these forms of reasoning into the participants' accounts suggests that they are so pervasive and part of the 'common sense' of psychiatric situations that they were not undermined by the researcher. An extension of this research would be to examine the effects of changing the ethnic group of the researcher, to detect whether this variable mediated the kinds of responses which participants make.
Therefore, we must conclude by echoing the point made elsewhere (Crawford, Nolan and Brown, 1995), that rather than being representations of 'facts' or 'reality', the written records on patients in clinical settings are in an important sense 'works of fiction' bearing, at best, slight resemblance to the 'true nature of things' (Capera, 1983). Not only are case notes 'masterpieces of compression' which are able to transform pieces of information, but they are punctuated by the writers' own expectations, aims and interpretations, all of which are informed by and deeply rooted in wider social and cultural narratives (Saleebey 1994). It could be argued that the aim and purpose of keeping records on a patient, in what purports to be a scientific and objective caring profession, is to some extent defeated by the human quirks of sense-making. We must ask what use such records are if they reveal more about the author than the patient. Psychiatric writings about patients, in the form of reports and records, are powerful tools in powerful institutions, and because written transcripts are relatively permanent when compared with the spoken word - able to affect an individual's life for many years - they warrant closer investigation and scrutiny. An examination of the implicit assumptions contained within the patient-practitioner interaction is important to gaining an understanding of the over-representation of ethnic minorities in institutions. This paper has highlighted the need for further study in this field, and explored the vital role of social constuctionism as a perspective for analysing psychiatry at work.
Crawford, Nolan and Brown (1995) suggest there must be organisational recognition of the culture-laden narratives which must involve radical changes in the training that nurses receive concerning record keeping. While this may inform those in power over the patient, it does not address the inequality of power in the creation of records and narratives about the patient. We should explore ways of removing the secrecy and esoteric vocabulary that so often obscures narratives about patients from the people who matter most - the patients themselves. With knowledge of their own records patients can more effectively challenge and contribute to what is written about them. With the current emphasis in psychiatry being "the empowerment of the user", users must be able to disrupt, and hence validate those stories in which they are the central character. By increasing users' access to medical notes and inclusion of their points of view in records, racism may be reduced in narratives based in the culture of psychiatry. The past, present and future of racial stereotyping may be challenged.
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