‘Sin your way to heaven and get slaughtered: A byzantine general problem of the self’ (part twenty-five)

Filed under:Sin your Way to Heaven and get Slaughtered — posted by Schizostroller on May 8, 2019 @ 2:46 pm

To investigate problems with the conception of schizophrenia in psychiatry, Blackman talks of the use of what are called Type 2 syndromes in the psychiatric literature. Type 2 in schizophrenia often refers to the negative symptoms observed in schizophrenia. As Blackman points out this distinction is often contested, however she argues it is a “good example of the ways in which psychiatry, despite its heterogeneity, is attempting to provide coherent causal explanations of psychotic experience. Thus the complex constellation of behaviours and thought processes which are problematised within the discursive practice, could be viewed as originating from two distinct disease categories.” (p.25-26). Thus symptoms such as hallucinations are considered indicators of type 1 syndrome. This phase is considered to be acute but responsive to neuroleptics. This is distinguished from a second phase, type 2, which is considered with more chronic with flattened affect and poverty of speech. This phase is thought to be more intractable, with a poor response to neuroleptics and thought to be possibly irreversible and permanent. Blackman continues “within this particular conceptual framework hallucinations appear as temporary markers of pathology which are amenable to ‘cure’, thus offering a trajectory which is used to explain why ‘hearing voices’ appears across the disease classes as a ‘symptom” (p.26). Blackman argues that this conceptual framework imposes a ‘grid’ that orders the symptom of ‘hearing voices’ encountered in practice (but not in theory). What she means by this is that the problems that stem from encountering contradictions in attempting to distinguish between ‘real’ and pseudo-hallucinations can be reorganised within a different rubric providing a theory of disease that takes into account neuro-physiology alongside the context of experience. Again, the categories that were previously used to think through this theory of disease are duration, severity and chronicity (along with insight). Blackman argues that this means psychiatry can no longer be thought of in terms of control, vividness, duration etc. (as do Rosciewicz Jr. and Rosciewicz) that more finely comprehend the complexities of hallucination, even if the medical model still requires that the patho-physiology of the individual be raised as a causal factor.
Thus in this new framework of explanation hearing voices is seen as an indicator of possible psychosis but not necessarily as definitive of schizophrenia, neither the sole diagnosis not the sole marker of a diagnosis. Blackman suggests this is a sign of a shift within psychiatry of the understanding of the phenomenon of hearing voices, but one where psychiatry is still invested in issues of genetics and heredity, but that leaves space for the creation of new perspectives, and from the point of view that I am writing from, new ways for psychiatric survivors to write their own experience into the discursive space opened up.
Blackman points out that there are particular assumptions in the perspective, gaze, which psychiatry turns on the diagnosis of hallucinatory experiences. She argues that what makes a hallucination, outside organic factors or religious experience, is the lack of any other plausible explanation. The symptoms are not to ‘speak of themselves’, instead there is a “conceptual grid used to divide the normal from the pathological within psychiatric discourse, the psychiatric gaze concerns itself with what is ‘absent’ to the immediate gaze of the psychiatrist.” (p.28). “Psychiatric discourse has… produced a taxonomy of natural diseases, of which certain symptoms, such as hearing voices are viewed as first rank signs. The ‘pure’ psychotic states are those where psychotic symptoms are viewed as signs of disease and illness, such as schizophrenia. These are often viewed as degenerative and linked either to structural changes in the brain, or biochemical or neurological deficit or imbalance (the type 2 syndromes).” (p.29). However, on noting this Blackman moves on to another aspect of the psychiatric gaze, the ‘enfeebled personality’. “This is based on a notion that there are certain persons deemed constitutionally lacking in the so-called normal propensities to equip them to deal with the stresses and strains of life.” (p.29). the method by which this enfeebled personality is ‘discovered’ is the psychiatric interview.
Blackman argues that there are two phases of the psychiatric interview; “the first is a description of the present mental state and involves a ‘provisional’ diagnosis. The second phase of history-taking is undertaken to pinpoint any ‘patho-features’ of the person’s biography, which may have made them vulnerable, or in psychiatric terms, ‘at risk’ to a disease process.” (p.30). It is worth noting here that in a sense this is little difference to ‘formulation’ as an alternative to diagnosis that is currently being promoted as a radical new approach to mental poor health and distress. “This ‘social history’ is then used as part of the grid of perception for making sense of the person’s experience. The discursive space opened up to make the distinction between what is deemed normal and what pathological is disparate and heterogeneous. It is a complex assemblage of concepts, which attempt to make it conceptually possible to ‘think’ in terms of disease and pathology. These include the status of the ‘personality’ of the individual, and the context of the experience, which is rendered in relation to the key concepts of source, vividness, control and duration. However, the most general specification, which underpins the dispersal of concepts within psychiatric discourse is the notion of the ‘enfeebled personality’; one who is viewed as unable to maintain particular kinds of relations with themselves and ‘others’. This personality is one whose ‘psychology’ is directly linked to biological inferiority or inadequacy’.” (p.31).
Blackman suggests that there is a split in psychiatric discourse between the natural and the social. “The natural (body) is made intelligible through particular ways of thinking about the body and biology, derived in part from evolutionary theory. Biology is viewed as a static, invariant set of characteristics which predispose persons to particular forms of thought, behaviour and conduct. Biology then sets limits on how a person is able to interact with the social and also the levels to which the social can impact or impinge upon the individual.” (p.31). these assumptions are then overlaid by other dualisms such as “inherited/ environmental, somatic/ psychological, psychotic/ neurotic and even the pseudo-hallucination/ hallucination.” (p.31-32). Blackman reminds us that psychiatry is not simply biologically reductive, but that it combines this ‘hard’ biology with ‘softer’ psychologically oriented science. Psychiatry makes possible its particular way of thinking about ‘hearing voices’ by targeting biology and the social in a way that conceives biology as its originary point. “Biology is opposed to the social, and the social becomes a measure of the individual’s competence in social interactions. Social and psychological life ultimately is explained with reference to biological causes.” (p.32). It is from this position in psychiatry, that I hope to move to the conception of voice hearing in ‘psychology’ before returning to phenomenology of voice haring ,and from thence a return to the dreamwork of Freud as an approach to voicework in hearing voices.

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image: detail of installation by Bronwyn Lace