Power & Control

Today’s interviewing class on the psychiatry ward felt very thematic, much more so than before. Perhaps my own particular research bias makes me see power issues everywhere, but today I got a very strong sense that the topic on the table was control. The class was led by what I eventually realized was a psychologist, not a psychiatrist, who spent the first half of the class talking mostly about the doctor-nurse relationship on the ward. The issue was how to help nurses deal with difficult patients. The psychologist saw an educational and managerial role for the doctor here: they were to explain to nurses how to cope with patients they disliked, and to manipulate the nursing schedule so that difficult patients were distributed evenly among the nurses. Interestingly, a slight disconnect occurred here: the residents unanimously expressed their disagreement with the psychologist’s view of the doctor’s role. They expressed a shared sense that in reality, they had no such power on the ward at all, and felt they had little influence on nursing practices. To this the psychologist responded by reclaiming that power: “you”, the residents, were the “supreme beings” on the ward and should claim authority over the day-to-day care of your patients.
I was even more struck by the psychologist’s stance once I realized she herself was not a doctor. She fully endorsed and pushed for a model of caretaking in which the doctor was the ultimate authority, and portrayed nurses as either uninvolved and ignorant (she suggested that nurses work on automatic pilot with little to no knowledge of a patient’s personal history or current pathology) or pathologically overinvolved (suggesting that nurses have a ‘baseline’, an MO of caring for others before caring for oneself, a tendency that can turn pathological and lead to ‘burnout’ and ‘compassion fatigue’. Doctors have that same tendency, she admitted, but in a different way. As in, not pathological?) caretakers. At first, assuming her to be a physician, I was unsurprised by her viewpoint, and the resident’s contestation of this sense of power actually struck me more. Most literature on psychiatric anthropology describes (and critiques) this sense of and claim to power by doctors on the ward. When I realized she had a PhD rather than an MD, the discrepancy felt even greater. But now that I am writing all this down, it seems to make more sense. The literature does actually describe the daily struggles for power that often go on among caretakers on a ward. The residents, as MDs, stand at the forefront of this conflict every day, which would explain – and make very understandable – their expressed sense that they feel a lot less powerful than the psychologist made them out to be. The psychologist, on the other hand, looks upon the medical profession from the outside and attributes to them the power that a medical degree confers in the popular imagination. She herself might be looking for that sense of power or authority on the wards, perhaps feeling like she has more to prove than a psychiatrist?

The purported topic of the day was Erikson’s developmental stages. Judged by the way in which the psychologist talked about developmental theories, and the way in which the residents then brought up Freud, I got the sense that none of the residents in the room knew very much about these psychoanalytic and psychodynamic theories, which surprised me. I wondered, then, on what they base their treatment. Because it does seem as though they engage in a lot of interpretive work with their patients; there is more involved in treatment at this hospital than pharmaceutical therapy, and there seems to be a lot of attention for patients’ background, goals, and social network.

In any case, the issue here was how to use these developmental stages in therapy. Erikson identifies the various developmental stages as a series of fundamental struggles or conflicts that have to be resolved before one can move on to the next stage. The first stage, for instance, constitutes the conflict between trust and mistrust: the developmental lesson here is to adopt a basic trust in others (one’s caretakers). If this goes awry, the result is either a ‘malignancy’ – that is, a failure to acquire trust, which leads to behavior of withdrawal – or an overcompensation; a pathological way of compensating for the failure to acquire basic trust, which results in delusional, or spoilt behavior. These developmental stages can be a tool in therapy by providing a framework to interpret the conflicts that underlie a patient’s behavior and/or pathology. The point of today’s class was to bring in a patient whose behavior could be attributed to a failure to resolve one of these conflicts, and to use one’s knowledge of this underlying struggle to help the patient move beyond it. One of the residents brought in one of his PTSD patients, who had come in with homicidal and suicidal ideations and uncontrolled episodes of rage. We had agreed beforehand that he most likely had failed to resolve the conflict between autonomy and shame/doubt, in which a toddler acquires a basic sense of self-control, and self-esteem as he acquires better motor coordination and learns to control his bodily urges. A failure to resolve this conflict can either lead to a self-limiting compulsion and lack of self-esteem, or an overcompensating impulsivity and recklessness – which could explain this man’s rage. We decided that control was probably an important issue for him, and so the psychologist explained that rather than interpreting his problems for him, she would try to guide him into a kind of self-realization, and ask permission before she herself provided any insight.

In my opinion she gave the man a lot less control than she had promised. She talked a lot, constantly reiterated what he said (which I understand is useful and may not necessarily be a form of claiming control, but putting myself in the man’s shoes I wondered if it would make me feel stifled), and did actually do a lot of interpreting. A resident later suggested all this, but stayed away from any notion of critique. In any case, it became clear that control and self-esteem were in fact a very big part of the problem for this man. His rage seemed like a way of compensating for an extreme sense of not having control (over others, and the effect of others on his own life), but simultaneously contributed to an extreme lack of self-esteem. In the way he talked about his wife, he portrayed himself as an utterly bad individual; the sense of having no control seemed to extend also to a failure to keep himself and his anger in check. His anger seemed like an externalized, projected form of anger toward the self. As the psychologist suggested, helping the man explore his internal response to feelings of betrayal and powerlessness would probably turn his homicidal ideation into suicidal ideation.

One of the residents brought up a good point here: anger is, essentially, what men are ‘supposed’ to feel when they feel conflicts of control. We (as in, our society, and many others) socialize men to deal with lack of control and insecurity by acting out, by being angry. What do we do with that, then? How do you help someone calm his rage without threatening his sense of masculinity? The resident brought up a good strategy: explore the man’s own ideals of masculinity, and try in some way to clarify the issue of degrees. Anger in itself is not always bad, but it should not be taken to extremes. As is the case with anything, of course. Questions of cross-cultural treatment come up here, I think – in the sense that different societies put forth different ideals of masculinity. A psychiatrist needs that awareness when treating someone like this, and I think the resident’s strategy of exploring the man’s own ideals is a good idea here. That way nothing is imposed, you allow the patient to establish the value framework within which his experience makes sense, and you can tweak your therapy and interpretation to match that framework, to make it make sense as well.

Paranoia and Survival of the Fittest?

An article in Medical News Today (“Extent of Public Paranoia Revealed by Virtual Reality Underground Ride”) reported findings of a study on paranoia. The study sent a number of subjects on a virtual tour around the London Underground, examined their judgment of people around them, and concluded that paranoia is by no means limited to the severely mentally ill. The article quotes one of the investigators: “About one-third of the general population regularly experience persecutory thoughts. This shouldn't be surprising. At the heart of all social interactions is a vital judgment whether to trust or mistrust, but it is a judgment that is error-prone. We are more likely to make paranoid errors if we are anxious, ruminate and have had bad experiences from others in the past."

Naturally, given the current climate of global politics, the researchers link the presence of paranoia among subway users to general fears of terrorism. And in that way, the issue of inter-cultural or inter-ethnic conflict – and stereotypes – enter into this issue of social judgments. Perhaps in an effort to strike a positive note on these issues of conflict and mistrust, the researchers suggest that the existence of paranoid thoughts (and the social judgments to which it is linked) may be the only thing we all have in common as human beings.

I wrote an article, years ago, about the universality of the human need to define oneself in contrast with an ‘other’ (this, of course, being a big concept in anthropology. It is, for better or worse, our subject matter). I argued in this article that individuals and groups always need a contrast to paint themselves against; we do not know who we are if we cannot point to someone who is everything we are not. In that article I didn’t go into the possible evolutionary or biological reasons for this need – and I think it’s a murky subject, as anything related to evolutionary psychology is. But it seems to me that this need to contrast oneself to an ‘other’ is linked, conceptually, to these judgments, and to the paranoia engendered by those we judge untrustworthy. And it seems plausible that all that might be linked to some basic mechanisms for survival. I can imagine that in a world dominated by survival of the fittest, in which human beings need the help of others but also compete with them, snap judgments are sometimes necessary. Is this person going to help me survive, or will he threaten my right to live? And perhaps paranoia (or conflict, or prejudice – which I think can reasonably be linked to paranoia) is a mental mechanism that induces the individual to keep his distance from those deemed threatening.

But despite this potential universality, I’d be interested also in the cultural and gender variation in these judgments. Because there must be variation in these judgments: a woman will react differently to a particular man than another man will, and in the same way a Westerner ignorant of Middle Eastern cultures will react differently to an encounter with a man wearing a turban than a person from Calcutta will. And that’s interesting, because that suggests that universal, neurological mechanisms are shaped by culture and thus manifest themselves differently in people from different backgrounds. I wonder if this study looked into such variations at all.