The Making of Illness
A Study of New Psychiatric Practices in the Netherlands and their Implications
Léonie A. J. Mol 5884780 MA Thesis Philosophy
University of Amsterdam - Department of Philosophy Supervisor: dr. Federica Russo
Second reader: Prof. dr. Huub O. Dijstelbloem June 17, 2016
2 Summary Thesis MA Thesis: The Making of Illness. A Study of New Psychiatric Practices in the Netherlands and their Implications
In this thesis, I aim to analyze how the modern psychiatric patient is portrayed and how this framing is related to the reorganization of psychiatric institutions. My analysis is based upon different types of data: I combine data gathered during a four-month fieldwork project in an open clinic in the Netherlands. I combine these ethnographic findings with a thorough discourse analysis of policy documents in which the restructuring of Dutch public mental health care is being reorganized. I draw from anthropological, philosophical, and medical literature to highlight the contemporary changes, with special attention to two concepts: “shared decision-making” and “ambulantorization”. The first refers to a theory aiming to make psychiatric treatment a negotiation taking place between doctor and practitioner. The second refers to the tendency to increase the number of patients receiving ambulatory care, meaning that they are treated at home instead of a clinical setting.
In the first chapter, I introduce the clinic as a case study and sketch the latest
developments in Dutch mental health care. In the second chapter, I discuss the changing role of the doctor as medical expert. In the third chapter I focus on the psychiatric patients, their responsibilities and changing role in today’s psychiatric treatment.
3 Table of Contents
Introduction: Why Studying Contemporary Psychiatry? Some Reflections about Modern
Psychiatric Practices in the Netherlands ... 4
Changing Practices in Public Mental Health Care ... 6
Psychiatry and Philosophy ... 8
Methodology... 10
Empirical Philosophy and Philosophy of the Social Sciences ... 10
Organization of the Thesis ... 12
Chapter One: Closing Down the Clinic: Ambulatory Care and Shared Decision-Making in the Netherlands ... 16
1.1 Public Mental Health Care in the Netherlands: an Introduction ... 4
1.2 Introducing the Case Study: the Open Psychiatric Clinic ... 19
1.3 Contemporary Psychiatric Practices and their Implications ... 21
Ambulantorization ... 21
Shared decision-making ... 22
1.4 “Betwixt and Between”: Clinical Treatment as Liminal Experience ... 23
Chapter Two: Medical Expertise and the New Role of the Psychiatrist. From the Power to Judge to the Negotiation of Illness... 27
2.1 From Medical Perception to Mutual Consent: Classical Analyses of the Medical Expert ... 28
2.2 Medical Expertise in the 21st Century... 29
2.3 Shared Decision-Making and “Activating” Patients ... 32
2.4 Medical Expertise: from Diagnosis to a Coherent Narrative ... 33
2.5 Managing Uncertain Futures: the Emphasis on Prevention ... 37
Chapter Three: The Emancipated Patient. New Responsibilities and Expectations about Patients42 3.1 Diagnosis and the Making of a Patient ... 44
3.2 Shared Decision-Making and Patient Knowledge: Conceptualizing the Patient’s Contribution ... 47
3.3 “The Patient’s Best Interests”: What Happens in the Case of Conflicting Views ... 49
3.4 Directing your own Recovery Process: New Responsibilities for Patients ... 52
3.5 Relocating Responsibilities: Changing Roles and Responsibilities ... 54
Conclusion: The Making of Autonomy and the Future of Clinical Treatment ... 58
Shared Decision-Making: How are Patients’ Views Implemented? ... 60
Ambulatory Care and the Interaction between “Patient” and “Society” ... 61
Financial Aspects of New Psychiatric Practices ... 64
From Ill “Minds” to Ill Behavior ... 65
Bibliography ... 70
4 Introduction: Why Studying Contemporary Psychiatry? Some Reflections about Modern Psychiatric Practices in the Netherlands
“The annual report 2014 of mental health care gives no reasons for optimism”, the Dutch organization for public mental health care in the Netherlands states on its website.1 Reasons for
this reluctant claim are the high financial pressure the organization experiences. Furthermore, there seem to be around 100.000 psychiatric patients less than a year before, which makes the organization question whether these people are actually receiving the “care they need”. Or did around this number of patients miraculously recover, and are there some thousands of patients less than a year before?
The Dutch government is highly concerned with the reorganization of public mental health care. The high financial impact of the large number of psychiatric patients has been framed as a major concern to the Dutch government (GGZ 2012:1, Weehuizen 2008). This concern has, more recently, been used as an argument to reorganize public mental health care. The Dutch umbrella organization regrouping all institutions concerned public with mental health care, the Geestelijke Gezondheidszorg (GGZ - in English: Dutch Association for Mental Health and Addiction Care) is therefore being thoroughly restructured.
For example, since 2015 the Dutch municipalities are partly responsible for psychiatric services for youth, elderly people and long-time care.2 Psychiatric treatment within mental
institutions is also changing. Contemporary psychiatric practices increasingly focus on the integration of the patient’s viewpoint and perspectives with regard to the design of his own treatment. The implementation of “shared decision-making”, which refers to a (psychiatric) treatment as the outcome of a negotiation taking place between patient and practitioner, is an example of this (GGZ Nederland 2012:8-9). This development goes hand in hand with the target of significantly reducing residential care, which is called the “ambulantorization” of psychiatric mental health care. “Ambulantorization” is a translation of the Dutch ambulantisering, which refers to the aim to organize (psychiatric) care “at home”, in the patient’s “normal” environment instead of in a clinical setting (GGZ Nederland 2013: 20, 22; 2012:2). The question whether being treated in a clinic is the best option for patients, is a topic being thoroughly discussed (GGZ 2013:2).
1 http://www.ggznederland.nl/actueel/ggz-nederland--jaarverslagenanalyse-ggz-2014-is-geen-reden-voor-optimisme
(accessed May 29, 2016)
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The Dutch government and GGZ aim to limit the number of patients receiving residential care by 30% in 2020 (GGZ 2012:8).3 The GGZ portrays this target both as a
“decentralization” of its services, as well as a tool to reduce costs. This “decentralization” is explained as organizing mental health care within society, instead of in closed off institutions.4
Thus, decentralization is also related to ideas about where a patient’s recovery should and can take place. The diagnostic criteria in use and listed in the Diagnostic and Statistical Manual for Mental
Disorders (DSM-5) are also up for debate. The DSM is a manual that contains all recognized
psychiatric disorders and illnesses, republished every few years by the American Psychiatric Association and used by clinicians worldwide (APA 2014). The main topics currently under debate are the classification of diseases in the DSM, and how patients can be “activated” to participate in shared decision-making (Van Aalst 2014; Van Os 2015).
In this thesis, I aim to highlight recent changes in contemporary psychiatric practices in the Netherlands. Where, by whom, and in what kind of setting will psychiatric patients be treated in the future? How will they be expected to take care of their mental illness, and what role should and can they play in their own treatment? New psychiatric techniques and the current reorganization of public mental health care have hardly been studied in practice. Yet, they have profound impact on how psychiatric care is portrayed, carried out and experienced by health care workers and patients. I want to disentangle the current discourses and narratives emerging around and about psychiatric practices, which I want to link to broader narratives on health and illness.
What does it mean to suffer from a mental disorder today? How are psychiatric patients portrayed? In what kind of setting are they expected to recover? These topics are related to the conceptualization of medical expertise, the role of the patient, and the role of clinics and mental hospitals. They are also related to ideas about how patients are expected to take care of their own mental illness, and what kind of place they have in society. Studying these discourses and hegemonic narratives is important in order to understand which cultural concepts are “at work” today, and how they shape and polish ideas about health and illness (Gramsci 2000; Holland and Quinn 1987; Ochs & Capps 2002; Said 1979).
3By the time of writing, the Dutch government is constituted by a coalition formed by the VVD, the liberal party,
and the PvdA, the Labor Party. One of the concerns of this current government is to keep (mental) health care affordable (see https://www.rijksoverheid.nl/onderwerpen/themas/gezondheid-en-zorg (accessed May 13, 2016). Since this government has been installed in 2012, the GGZ has emphasized on ambulatory care and a strong reduction of patients receiving treatment in a clinical setting. “Clinical treatment should always be the last possible option”, the official website of the Dutch government states (See https://www.rijksoverheid.nl/onderwerpen/geestelijke-gezondheidszorg (accessed May 13, 2016)
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In the first section of this introduction, I will first explain why studying psychiatry with philosophical methods is important. Then I will introduce the different perspectives of studying psychiatry within philosophy and give a brief introduction on the clinic and how it has been theorized within philosophy and the social sciences. In the third section, I discuss my methodology and the data I have used for this analysis. Finally, in the fourth section, I present the contents of the thesis.
Changing Practices in Public Mental Health Care
Traditionally, psychiatry as a discipline is concerned with demarcating the “normal” and the “pathological”. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) I mentioned before contains all disorders and symptoms which are considered to be part of a syndrome. The DSM is the manual psychiatrists and psychologists use worldwide, to define from which mental disorder a patient is suffering and how it can best be treated (APA 2014). The syndromes as listed in the DSM are, in turn, drawn from the ICD-9 or ICD-10, which stands for the
International Classification of Diseases, containing all official illnesses and issued by the World Health
Organization (WHO).5
The first edition of the DSM was published by the America Psychiatric Association around 1921, when the organization itself was established.6 The newest version of the DSM (5)
was published in 2013 and is currently being implemented. It defines a mental disorder as following:
A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.7
It is worth noting that this quote explicitly distinguishes “social deviant behavior” from “mental disorders”. Yet, the difference between disorders or syndromes coming “from the patient” as opposed to what society labels as “deviant” is not always so easy to make, as will become clear
5 See http://www.who.int/classifications/icd/en/ (accessed June 9, 2016).
6 See https://www.psychiatry.org/psychiatrists/practice/dsm/history-of-the-dsm (accessed June 9, 2016).
7 See http://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425596.UseofDSM5 (accessed May 29,
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throughout the thesis. Important concepts in this quote are the distress related to mental disorders and disability. Patients suffering from these symptoms experience difficulties and need to be helped, cured or treated.
The cited DSM-5 contains all officially recognized “disorders”, which are organized within sub-groups, such as “Depressive Disorders” or “Personality Disorders”. Each disorder, for example “Bipolar Personality Disorder” is described as a particular list of symptoms. In the case of bipolar personality disorder, examples of symptoms are “…a pattern of unstable and intense interpersonal relationships” and “identity disturbance.”8 People who display a certain
amount of symptoms for a certain period of time could in turn be labeled as suffering from a borderline personality disorder. This way of classifying and organizing diseases is based on a certain nosology. Nosology, from the Greek “nosos” and “logos”, refers to the modern classification of diseases.9 In the DSM, a syndrome (such as, for example, bipolar personality
disorder) is divided into several symptoms. Historically, this can be traced back to Kraepelin and his classification of diseases (DSM 2014; Veith 1957).
The origins of psychiatry are related to the identification of certain symptoms and syndromes. The role of psychiatrists is to decide about what is the most suitable treatment. What kind of behavior and symptoms are viewed as treatable therefore contain important information about what is perceived as a mental illness, which, in turn, is related to what is considered to be “sound” or “normal” behavior, as opposed to “ill” or “pathological”. What those patterns of behavior are, is in the case of psychiatry sometimes difficult to grasp. Most psychiatric syndromes concern a specific way of thinking or behavior; symptoms are not “tangible” in the same way as in somatic medicine. The perception of psychiatric symptoms is done differently than a diagnosis, which concerns physical symptoms or diseases.
Psychiatry and its practice do not take place in a vacuum. I therefore contextualize my analysis by discussing the changes in psychiatry within a specific example: an “open” psychiatric clinic where I conducted fieldwork for four months during the summer of 2015. This open psychiatric clinic was located next to large hospital in a small town in the north of the Netherlands. It is specialized in short-term mental health care and has room for seventeen patients, who live there on a full-time basis.10 During my fieldwork, I had the opportunity to
interview several times ten members of staff and four patients. I also observed the patients
8 See http://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425596.dsm18#BCFFGIBG (accessed
May 29, 2016).
9 In Greek: “νοσος” ”λογος”.
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during their stay and their meetings with their psychiatrist.11 In chapter one in section 1 and 2 I
will introduce this clinic more in depth.
I use the data I gathered during my fieldwork to make a philosophical argument. This way of conducting philosophical analysis has been theorized as “empirical philosophy” by anthropologist and philosopher Annemarie Mol. She argues that to understand the meaning of changing concepts and theories, it is necessary to look at the practice. Concepts acquire meaning because they are being implemented, and vice versa (Mol 2002; 2006). This turn to the study of disciplines such as psychiatry and science in practice has also happened in philosophy of science (Chang 1999). I argue that the data I gathered have given me valuable material and insight into how the medical staff viewed their work, and how they put newly introduced psychiatric theories and concepts into practice. My observations and interviews provided me with information about how contemporary policies from the GGZ were implemented from by the responsible medical personnel. It also gave me a lot of information about how doctors and nurses themselves reflected on these changes in psychiatric practices. The fieldwork thus gave me a unique insight in how Dutch psychiatric health care is changing today, and how those who have to carry out these changes place them into perspective.
Psychiatry and Philosophy
The philosophy of psychiatry is, in philosophy, divided in to three separate domains. The first approach concerns the analysis of psychiatry “as a science”, addressing psychiatric concepts and methods. The second domain is centered on the conceptualization of what a mental illness is. The third discussion combines psychopathological research with philosophy of mind (Murphy 2015).12 I position myself in the debate concerned with the first two families of this discussion. I
analyze new psychiatric practices such as shared decision-making and their philosophical implications, but I also pay attention to wider narratives on mental illnesses and how these are viewed and dealt with in society. I use medical, philosophical and anthropological literature to highlight these topics in my analysis. I will start with a philosophical and anthropological discussion of the clinic, and then introduce other theorists to discuss today’s psychiatric residential care.
In philosophical, historical and sociological analysis, “the clinic” or “the asylum” has been theorized in famous contributions. French philosopher and historian Michel Foucault’s (1926-1984) iconic La Naissance de la Clinique (first published in 1983 and translated as The Birth of
11 See also Mol (2016:6-7).
12 For more background information about these debates, thee the entry of psychiatry and philosophy of the
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the Clinic) and Histoire de la folie à l’âge classique (first published in 1964, translated as The History of Madness) sketch a fascinating image of how psychiatry operates. Foucault has extensively
published about power mechanisms and governmental politics. The birth of disciplinary power and how people are governed are important themes in his works. His early works focus on psychiatric power as normalizing force, meaning that psychiatry is rooted within societal rules and norms. He interprets psychiatry as a normalizing and disciplining force, aiming to produce docile bodies and obedient patients. Power and knowledge are closely related and produce psychiatric identities or subjectivities. By “subjectivity”, I mean what kind of person or subject that these techniques aim to create. The patient’s “subjectivity” is thus a term to designate the framing of psychiatric patients and how they are expected to behave.
Thus, psychiatry is closely linked to the production of knowledge, and this knowledge is closely related to how “we” or “society” thinks Man “is” or “should be”. Medical practices are also linked to how we think we can study human behavior and “know” what is going on inside people’s minds. The birth of psychiatry meant the production and conceptualization of a particular body of knowledge concerned with these issues. This means that psychiatric practice, in this context, should be understood as a repressive and productive force. It incites patients to behave in a certain way, but also contributes to the creation of a certain subjectivity (cf. Foucault 2003; 2004). Therapy and psychiatric treatment are actively “molding” experiences (Biehl & Moran-Thomas 2009).
This complex relationship between psychiatry, knowledge and power has been extensively written about by Foucault. At the end of the lecture series Le pouvoir psychiatrique (Psychiatric power), Foucault asks rhetorically: “Est-ce possible que la production de la vérité et de la folie puisse s’effectuer dans des formes qui ne sont pas celles du rapport de connaissance ?” (351). If the redistribution of psychiatric practices does not go hand in hand with a certain way of conceptualizing and knowing human nature, how does this influence our view of the psychiatric patient? These questions will be elaborated in the chapters to come, to highlight the relation between psychiatric practices, knowledge and power, and how these can be characterized today.
In sociology, the unequal power relation between practitioner and patient has long been up for debate, as in psychiatry itself in the 1960s and 1970s (Freidson 1971, Szasz 1961). Sociologist Erving Goffman (1968) theorizes the clinic as a “total institution”, were a fundamental barrier divides mental patients from medical staff. A total institution carefully “protects” its inhabitants (patients) from the outside world. According to Goffman, as a result the clinic does not isolate patients only in a physical way, the stigma of a mental illness does so too. I interpret “stigma” as “an attribute that is deeply discrediting” (Goffman 1974:3). Goffman
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emphasizes the relational aspect of “stigma”; while one person might be stigmatized by an attribute, this attribute can be useful for someone else (1974:3). How and why someone is stigmatized, is therefore always related to the social context.
The analyses I have mentioned until here focus upon unequal power relations existing between patients (“inmates” in Goffman’s vocabulary) and the medical staff. It is true that the becoming of a mental patient, which officially happens through being diagnosed as such by a medical expert (most often a psychiatrist), is a mechanism that needs to be discussed. The affirmation and performing of medical expertise is conducted among other things through these diagnoses of patients with a psychiatric syndrome as listed in the Diagnostic and Statistical Manual of
Mental Disorders (DSM). Every hospitalized patient is diagnosed with a diagnosis from the
DSM-IV or 5.
Methodology
In this thesis I use ethnographic data to introduce a case study (the clinic), and use these findings as underpinnings for my analysis. I combine ethnographic data and a study of psychiatric practices with philosophical analysis. I use anthropological, sociological and philosophical material available about psychiatry and clinical care. The methodology I used during the fieldwork consists of what Julie Livingston has coined as “hospital-based ethnography” (Livingston 2012:7). Ethnographic research methods rely on observations, interviewing and taking notes within the medical setting they which to research. I combine these ethnographic data with a thorough discourse analysis of medical, anthropological, philosophical literature and policy documents, to get a grip on the current narratives within the domain of psychiatry. By “discourse analysis” I refer to the analysis of discursive events as explained by Michel Foucault in Les mots et
les choses (1966: 46). A “discourse” can be characterized, in Foucauldian terms, as a compilation of
texts and utterances which make a claim to knowledge and truth and simultaneously defines the conditions for this truth (Foucault 1972).13 By “narrative” I refer to Gérard Genette’s analysis of
literary texts as autonomous structures (Bertens, 2008:71). This means that texts have a logic on their own, which needs to be disentangled in order to understand the underlying principles of the text. I take “narrative” to be the organizational principle of the a story or text.
Empirical Philosophy and Philosophy of the Social Sciences
I locate this work within a specific domain of philosophy which has been coined as “empirical philosophy” (Mol 2002:4). This approach combines ethnographic and theoretical data
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and relies on analyzing how (philosophical) concepts emerge from enactments happening “in practice”, a turn that recently happened in philosophy of science too (Chang 1999; Schickore 2011). “Empirical philosophy” or “philosophy of science in practice” have actively tried to engage the study of science and its application in practice with philosophical analysis. Philosophers of science Rachel Ankeny and Hasok Chang have argued that philosophers of science need to study how science is conducted in practice. To understand the outcomes and results of science, the actual process of doing science needs to be studied (Ankeny et al. 2011; Chang 1999). Philosopher Jutta Schickore argues that philosophical analysis of practice improves philosophical understanding (Schickore 2011:359). Yet, what philosophers can “do” by studying science in practice is more important than just achieve a better understanding of scientific practices. Philosopher Hasok Chang argues that due to specialization most sciences do not scrutinize their underpinnings because this might interfere with the practice of actually doing science (Chang 1999). Philosophers therefore need to scrutinize questions that are ignored by scientists themselves. Drawing from philosophers Phyllis Illari and Federica Russo, I argue that the ethnographic part, or the “case study” of this research can therefore not be reduced to a mere example but is a means to enrich the theoretical debate (Illari and Russo 2014). Illari and Russo’s text makes the case for the study of causality, but the methodology and meta-philosophical stances thereby presented are exportable outside the causality debate.
This philosophical approach offers a wide range of possibilities. In the first place, it gives me the possibility of having a look at how principles and ideas about “care”, for example, work out in practice. What “is” a psychiatric patient? And who is the doctor treating them? How is a “good” plan for treatment set up? These were questions that came to my mind when I had the chance to have a close look at how those patients and doctors you study actually work, watching how concepts such as psychiatric treatment, patient and expertise acquire meaning “in the making”.
This ethnographic approach of the object I study – the clinic – also comes with certain challenges. Psychiatric settings are difficult to enter when you do not fit into one of the categories of “health care worker” or “patient”. At the beginning of my research, my presence gave rise to suspicion. What was I doing in the clinic, if I was not a patient neither a doctor? It was also quite difficult to obtain access to the clinical environment in the first place. Researchers need an official permission granted by the responsible director, the research committee (commissie
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approach psychiatric patients in the Netherlands.14 This procedure often astonished the medical
personnel working in the clinic. “This is an open setting, so why don’t you just ask them if they want to talk to you?”, nurses would ask me. This does not mean that they did not think about how to protect their patients; quite the opposite. However, the many rules that need to be taken into account when approaching psychiatric patients shows that, at least as some level, the medical setting is quite difficult to enter. The ethical procedures to follow required me to be patient and perseverant. They also show that, for people falling outside of the categories of “patient” or “health care worker”, the clinic might not be as open as it present itself. But, as sociologist Erving Goffman famously put it: through the “porous membranes” of the closed institution there are ways to enter them (Goffman 1968:15).
I draw from various sources and types of literature in my thesis. Since psychiatric practices take for a large part place through language, I work with Michel Foucault’s analysis of language as performative and psychiatry and psychiatric language as a specific kind of discourse. In line with many social scientists, I view language as a political tool that actively shapes social conditions and cultural ideologies (Bourdieu 1975; Duranti 1988; Maynard & Heritage 2005; Silverstein 1976). Language does not mirror blankly inner thoughts or states of mind, but it is also a socializing and molding force (Carr 2011; Holland & Quinn 1987; Wilce 2009). In linguistic theory, this has been developed by Austin with his concept of “performative” language (Austin 1962). In other words, what someone can “say”, is closely linked to what one can “do”. Bourdieu (1975) theorized this a authorized” language, meaning that what language one speaks is related to one’s social function. What we say is also something we “do”: Austin calls this language as action a “speech act”. A successful speech act meets the conditions of felicity, i.e. corresponds to the speaker’s social status, the context and situation in which it is uttered. Since psychiatric analysis still is based for a large part on talkative practices, this shaping of a modern subject and how it is discussed is an important issue to address. The fact that patients used to be treated in closed settings, retreated from society in specialized “spaces” (the psychiatric clinic) still seems to contribute to this idea.
Organization of the Thesis
I have organized this thesis in three separate chapters:
14 For more information about the procedures that need to be followed see:
https://www.vumc.nl/afdelingen/METc/wmo-oordeel/ (accessed May 31, 2016). The rules and regulations concerning research with psychiatric patients falls under the law “Wet wetenschappelijk onderzoek met mensen”.
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In the first chapter, I introduce the clinic where I conducted research as a case study. I also pay attention to the main concepts I will use and explain what “ambulantorization” and “shared decision-making” mean and entail, and where those concepts come from. I draw from philosopher and historian Michel Foucault and sociologist Erving Goffman’s to give some relevant background information about clinical care and it theorization. Since I explain shared decision-making and “ambulantorization” as being implemented today, I also use policy documents to explain and illustrate what those concepts mean, and how they are being used in today’s documents and rules and regulations within public mental health care
In the second chapter, I pay attention to the changing role of the doctor and medical expertise. I first introduce the conceptualization of the psychiatrist as medical “expert”, drawing from Michel Foucault’s La Naissance de la Clinique (1983) and sociologist Eliot Freidson’s (1971) work on professionalism. I also pay attention to how medical expertise is conceptualized in medical training, and how a shift in focus on the treatment of existing symptoms to the emphasis on prevention changes medical expertise. I introduce Eliot Freidson’s concept of professionalism and analyze the practitioner as expert. I then work with Kleinman’s concept of explanatory models and Cheryl Mattingly’s analysis of clinical plots as challenging medical expertise, with a special focus on narrative within the clinical practice. I will conclude with political scientist Louise Amoore’s (2013) analysis of risk management.
In the third chapter, I analyze what kind of patient the implementation of new psychiatric practices and changing role of psychiatric institutions presuppose and entail. I combine it with the analysis of anthropologist E. Summerson Carr (2013), who focuses on the metalinguistic aspects of therapeutic language. I will also draw from anthropologist and medical practitioner Arthur Kleinman’s concept of Explanatory Models (EM). I use philosopher and anthropologist Annemarie Mol’s analysis of the logic of choice as opposed to the logic of care. To highlight the new responsibilities for patients the new developments entail, I use philosophers Nicholas Rose and Carlos Novas’ (2005) work on biological citizenship.
Studying the underpinnings and assumptions of psychiatry is important for a double reason: in the first place, because psychiatry is an “applied” science with a high level of specialization, not questioning every of its underpinnings. Secondly, because of this specialization and application, novel psychiatric practices have a large impact on medical practice and the lives of patients, the practice of medical expertise and what is conceived to be a “mental illness”. Studying psychiatry means also studying who fits into society and who does not. Philosophy of science with an eye
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for the practice can thus inform us about these underpinnings of psychiatry, reflecting on current changes and taking stance with regard to what is happening today.
Changing contemporary psychiatric practices do not only have influence on the therapeutic encounter, a patient’s treatment or the conceptualization of medical expertise. New psychiatric practices therefore mean changing narratives about what normality “is”. They also mean a changing treatment for patients who do not fit into this scheme of normality, if we keep Foucault’s analysis in mind. Psychiatry shapes a certain image of a patient, meaning that it contributes to what is seen as ill or healthy behavior. Psychiatric practices therefore need our attention and careful analysis. In this thesis, I aim to critically analyze and review the new practices and policies to highlight on what premises they are both based. I also want to point out the necessity of studying these changes, now and in the future, and to point out what is lacking in the policy documents. In line with the work of Hasok Chang (1999) I cited, I argue that philosophers of science in practice have an important task. Since the specialized and applied sciences cannot question every presupposition or premise on which their practices rely, the need for philosophical analysis of current psychiatric practices becomes all the more urgent. The changes occurring in psychiatry today have impact on patients’ treatment, the conceptualization of medical expertise and the role of the clinic within someone’s recovery trajectory. Since psychiatric treatment is concerned with treatment and alleviation of pathological symptoms, studying psychiatry means also studying the shaping of “the normal” or “healthy”. How are patients expected to deal with, or do something about their illnesses? And what does this say about how we conceive a mental illness today? These are crucial questions to address. The changes happening today will have a large impact on these questions. In this thesis, I aim to disentangle the contemporary narratives at work in Dutch society about psychiatric patients and the responsibilities that come with being ill. Through the chapters to come, I will lay out what the changes in the debate are, and how they can be related to new ways of treating patients. These new ways of treating patients also change the label of a mental illness. For the philosopher, highlighting these forgotten and implicit concepts psychiatry works with, is not only an important but also a fascinating task.
16 Chapter One: Closing Down the Clinic: Ambulatory Care and Shared Decision-Making in the Netherlands
The building is a large block of grey cement, located next to a busy crossroad were cars drive way faster than the speed limit allows. A small orange container serves as a shed for the bicycles. Next to that, two parking spaces that should remain free at all times for coming in ambulances.
Small windows with offices in them along the walls. Behind the windows, people spend their days typing, writing, and printing. The automatic doors open softly when I have arrived before the entrance. I enter a light, warm space: the high ceiling is made of glass, there are wooden bench to sit on, and the place is filled with trees that can best be described as giant bonsais. To the right is the entrance to the secretariat. To the left, we enter the clinic. I continue. The PAAZ (psychiatric and somatic department) is directly to the right. The walls are painted in green pastel colors. The closed unit is at the end of the hallway; one cannot enter it without a special badge. The open clinic is to my left. Behind a desk, two nurses are typing and drinking coffee. A man in his early thirties approaches me, with short blond hair and very blue eyes. “Can I help you? Are you new here?” It is only when I see the badge he carries discreetly in his left pocket that I notice he must be a nurse, too. (Notes, June 24 (A))
This is an excerpt from my very first field notes. I will start every chapter with a short observation or comment related to the topic of the chapter, to give the reader an impression of how it was like to conduct research in the clinic, and to introduce the main issues of the chapter.
In the introduction, I characterized the clinic as historical setting where psychiatric patients are treated. In this chapter, I concentrate upon Dutch clinical care as carried out today. In section 1.1, I will mention the most relevant developments and changes in psychiatric organizations in the Netherlands today (GGZ 2010; 2015). In section 1.2, I will introduce the psychiatric clinic where I conducted fieldwork and give information about how patients are being hospitalized there and how treatment is carried out. In section 1.3, I will introduce two important concepts for my analysis: “ambulantorization” and “shared decision-making”. I will introduce “ambulantorization” and shared decision-making as psychiatric techniques, both linked to institutional and governmental practices, as well as to new ways of treatment design and interpretation of “best practices” (GGZ 2010; 2012; 2015). “Ambulantorization” is a term much used in Dutch policy documents nowadays, which refers to carrying out psychiatric care at patients’ homes instead of in a clinical setting such as a mental hospital (GGZ 2013:8). “Shared decision-making” is a theory and practice developed within medical science which presents the patient as active participant in his own recovery process (Elwyn et al. 2012, Dy & Purnell 2012;
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GGZ 2010; 2015, Godolphin 2009; Schofield 2013). Finally, in section 1,4, I will argue that clinical treatment has become a “liminal” experience, which means that it takes place in a setting which can be defined as an “in-between” experience. Anthropologist Victor Turner (1920-1982) has theorized “liminality” as a situation in which a person moves from one state to another, temporarily being in a period of crisis (Turner 1966:94).
1.1 Public Mental Health Care in the Netherlands: an Introduction
The large number of psychiatric patients seeking treatment has been portrayed as major concern to the Dutch government and an argument in the discussion about reforming the mental health care sector (Aleman & Denys 2014; GGZ 2010:8; 2015:16; Weehuizen 2008). In the Netherlands, public mental health care is organized within the umbrella organization “GGZ”, which stands for geestelijke gezondheidszorg, in English: Dutch Association for Mental Health and Addiction Care.15 The organizations which are part of the GGZ are accredited and financed by
the government. For Dutch citizens, health insurance is compulsory, and covers also psychiatric or psychological assistance when offered by an officially accredited institution. Most often, a referral from the person’s GP or psychologist is required in order to partly cover the costs of psychological treatment.16 In a recent policy document, titled “Care works” (Zorg werkt) the GGZ
characterizes its own function as following:
The GGZ is an important pillar of the Dutch mental capital. Mental health is an economic factor of great significance. Improving mental health directly pays itself back in other domains of society. (GGZ 2012:1)17
This quote shows how mental health care is seen as a domain that expands itself into various domains. “Good mental health” is important, in other words, not only for the mental condition of people and patients, but also because of the cost-effectiveness of “good” psychiatric treatment. The need to improve mental health is underscored. The importance of “investing” in mental health care is in other policy documents described as investing in “mental capital” (GGZ 2012:1). The concept of “mental capital” as used in GGZ policy documents refers both to the psychological well-being of the Dutch population as well as to the economic benefit which is the result of psychological well-being (ibid.). “Mental health is an economic factor of great
15 The literal translation is simply “mental health care”. On their website, the organization has translated is own
name as mentioned above: http://www.ggznederland.nl/pagina/english (accessed May 18, 2016).
16 http://www.ggznederland.nl/pagina/english (accessed May 18, 2016).
17 “De ggz vormt een belangrijke pijler onder het mentale kapitaal van Nederland. Geestelijke gezondheid is een
economische factor van betekenis. Het bevorderen daarvan verdient zich direct terug op andere maatschappelijke terreinen” (GGZ 2012:1). The title of the document, Zorg werkt, has a double meaning. The Dutch verb “werken” (to work) means both “to function” and “to work”, i.e. to put effort into something.
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significance”, as the GGZ puts it (2012:2).18 The mental health care section therefore needs to be
reorganized to both deal with the increasing economic costs of psychiatric health care, as well as to offer a “good” or satisfying level of “mental capital” in Dutch society.
In 2015, the Dutch Ministry of Health, Well-being and Sports (Ministerie van
Volksgezondheid, Welzijn en Sport) published a report in 2014 which announced important cutbacks
within the sector. Therefore, a thorough reorganization of the sector was needed (Rijksoverheid 2015c). Important changes, next to the general aim to reduce costs, was the new distinction made between “basic” and “specialized” GGZ services, referring to the severity of someone’s symptoms and the costs of treatment needed.19 A year later, in 2015, some GGZ-services such as
psychiatric care for elderly people and children under 18 were transferred to the Dutch municipalities.20 The government aim to, in their own words, “decentralize” mental health care
(ibid.). The term “decentralization” refers to the carrying out of mental health care elsewhere than in the traditional institutions (mental hospital or psychiatric clinic) as well as to giving the patient more influence with regard to his treatment. According to this line of thought, “decentralized” psychiatric practices do not take place strictly within a medical setting, therefore giving patients a say in their treatment since it happens in and around patients’ homes (GGZ 2013:8).
This decentralization happens, among other things, through another important change in the organization of public mental health care, which is called “ambulantorization”. This refers to the aim to decrease the number of patients receiving patients in a clinical setting, such as a mental hospital or clinic and treating them at home instead (GGZ 2012:2). This type of care is called “ambulatory care”. Next to reducing costs, ambulatory care should also contribute to a greater patient’s autonomy. The emphasis on an active and autonomous patient is also mentioned by the GGZ when introducing the concept of shared decision-making (GGZ 2013:8). As I mentioned above, shared decision-making is a concept which conceptualizes psychiatric treatment as a negotiation between patient and practitioner (Elwyn et al. 2012; Godolphin 2009). The GGZ frames shared decision-making as a response to modern patients’ needs and wants. “Patients are becoming more and more the directors of their own recovery trajectory,” the GGZ writes in their long-term policy document.21
18 “Geestelijke gezondheid is een economische factor van betekenis” (GGZ 2012:2). All the translations made from
Dutch to English in this thesis are mine.
19See
https://www.rijksoverheid.nl/onderwerpen/geestelijke-gezondheidszorg/inhoud/basis-ggz-en-gespecialiseerde-ggz (accessed May 29, 2016).
20 See https://www.google.nl/webhp?sourceid=chrome-instant&ion=1&espv=2&ie=UTF-8#q=ggz%20gemeente
(accessed May 29, 2016).
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Next to ambulatory care and shared decision-making, a third important theme mentioned is “prevention”: signaling symptoms as early as possible reduces costs on the long term. Ambulatory care and prevention are therefore closely related: not only are they both linked to financial cutbacks and the reducing of (future) costs related to mental health care, they also influence the future treatment of psychiatric disorders. This theme will be developed further in section 2.5.
1.2 Introducing the Case Study: the Open Psychiatric Clinic
I contextualize my analysis of contemporary psychiatry with ethnographic data gathered during a four-month fieldwork project which I conducted this fieldwork for my Master’s thesis in Anthropology. This project took place in an open “open” psychiatric clinic offering psychiatric mental health care. This clinic was part of “specialized” GGZ services, which means that patients need a referral from their GP and have been diagnosed by a psychiatrist.22 According to
the GGZ, “specialized” psychiatric care is designed for patients suffering from “complex and very severe” symptoms.23
In the open clinic, patients are not tied to a fixed daily program and can, under certain conditions and restrictions, leave the clinic and choose how they fill in their days. They need to ask permission before they can leave and have to report unexpected absences to the nurses. This is called the negotiation of “freedoms”: patients can ask to leave two hours per day as they wish, for example. Although treatment nor participating in daily activities cannot be formally imposed, this is greatly encouraged. For example, every day starts with an opening (dagopening) during which the activities, varying from specific therapy sessions to cooking lessons or short trips to the seaside, are announced. Patients are encouraged to be present during this start of the stay (at 9:30 AM) and other activities, because, as one of the doctors phrased it, this helps to structure the patients’ days.24
Patients who neglect their “freedoms” and go out and come in as they please without evaluating and discussing this with their medical supervisors will be “punished”; one’s freedoms will probably be restricted more tightly.25 Before letting someone go and leave as they pleased,
the medical personnel had already made a risk analysis of the patient.26 Also, if patients are
considered too violent or dangerous for this clinic and in need of a certain type of antipsychotic,
22 See http://invoeringbasisggz.nl/onderwerp/wat-is-gespecialiseerde-ggz (accessed December 8, 2015).
23See
https://www.rijksoverheid.nl/onderwerpen/geestelijke-gezondheidszorg/inhoud/basis-ggz-en-gespecialiseerde-ggz (accessed May 31, 2016).
24 TR 24 June 74-76, TR 29 July (1) 512 – 515, TR 29 July (3) 47-51. 25 TR FG 441-444.
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they are sometimes referred to the closed clinic. This closed clinic and the PAAZ are entirely different settings than the one I describe here: there are many patients who have been brought in by the police after having been arrested. These patients have legal restrictions and often receive forced medication. The closed clinic also disposes of an isolation cell. Both clinics are located within a large hospital, next to a psychiatric department (PAAZ) and closed psychiatric unit. The “closed” unit is for patients suffering from “more severe” symptoms and exhibit “dangerous behavior”. The PAAZ treats people who suffer from severe psychiatric symptoms and need somatic treatment.27 The PAAZ is often the institution wherein patients with the “most” severe
symptoms are treated, then follows the closed unit, and the “open” unit is the institution with the least restrictions of the two institutions. The open clinic is often the “last” stage before patients are being discharged. Of course, there are also patients who have only been hospitalized in the open clinic.
The clinic has a living room, dining room and small kitchen. The walls are painted in pastel, joyful colors. The medical personnel portrayed this as an “opening up” of the space. “We do not hide in ourselves in our offices anymore”, a nurse told me. Indeed, the atmosphere in the clinic is quite relaxed. Nurses are drinking coffee with their patients, joking with them and loosely discussing possible activities they could undertake during the day. When I asked the medical personal about this way of organizing clinical care, they said they indeed wanted to “neutralize” their working space, and not make it look like a “sterile” clinic.28 The fact that
patients are being hospitalized because of severe symptoms was downplayed. One of the nurses told me she thought the whole setting and contact with patients had become “more humane”, compared to a few years ago.29 The fact that the medical personnel intended not to distinguish
themselves from patients too much (by not wearing the white coat, for example) was something they viewed as an important feature of their work.30 The creation of a “relaxed” atmosphere was
and had been an important topic.31 This “making the space relaxed” is an important aspect of
clinical treatment. As I aim to make clear throughout the thesis, this neutralization of space was not only framed in positive terms, as I will discuss in section 1.4.
The patients hospitalized suffer from various symptoms and diagnoses vary a lot. In order to be hospitalized in one of these clinics, patients need an official referral from a doctor or psychiatrist. This means that people stay in the clinic on a “voluntary basis”, as the clinic
27 See https://www.ggzingeest.nl/hulp-nodig/aanbod/haarlem/klg-hlm/ (accessed May 28, 2016). “PAAZ” stands
for psychiatrische afdeling algemeen ziekenhuis. In the thesis, I will make some comparisons between the open and closed unit. Due to lack of time and space I do not have time to discuss the setting of the PAAZ in the chapters to follow.
28 Notes 13 March, 22 June, 30 June. 29 TR 29 July (2) 114-117.
30 TR 30 June 344-347.
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describes, but medical experts need to provide “indications” that clinical treatment is the best thing to do.32 Since the clinic is part of specialized GGZ services, this referral is a condition for
people to be hospitalized. When receiving a residential treatment, patients live in a clinic on a full-time basis. Yet, this clinical stay should last as short as possible. As a result, clinical care is seen as a temporary process in someone’s recovery trajectory.33 In other words, the focus lies on
“reintegrating” patients and making clinical treatment as short as possible. The emphasis is put on organizing psychiatric care at home and ambulatory care instead of residential treatment. Also, the clinic focuses on both more “tailor-made” treatments to which the patients should actively contribute as well.34
1.3 Contemporary Psychiatric Practices and their Implications
In the introduction of this chapter I mentioned two important concepts that play an important role in the reorganization of public mental health care in the Netherlands: “ambulantorization” and shared decision-making. In this section, I introduce these concepts more in depth.
Ambulantorization
“Ambulantorization” (a translation of the Dutch ambulantisering) refers to the new efforts and techniques used to center psychiatric care around the patient’s home (GGZ Nederland 2013: 20, 22; 2012:2). In GGZ policy documents, “ambulantorization” is partly justified as a tool meaning to increase the patient’s autonomy. The goal of ambulatory health care is therefore linked to the creation of a specific subjectivity of the psychiatric patient: someone who is taken care of by a variety of social services (the community, police, housing corporations) instead of a clinical medical team (GGZ Nederland 2012:2). Ambulatory psychiatric care is therefore implemented along several levels of organization. The GGZ links this focus on ambulatory care and decreasing the number of patients receiving treatment in a clinical setting to a general focus on “decentralization”. As I mentioned, “decentralizing” psychiatric care is both linked to carrying out treatment somewhere else than in a clinic or hospital, as well as to reducing the costs of psychiatric care.35 Yet, through decentralizing psychiatric care the GGZ also aims to make more
32 See https://www.ggzingeest.nl/verwijzers/bereikbaarheid-verwijzen/verwijsprocedures/amstelland/ (accessed
April 1, 2016).
33 The latest report states an average treatment lasts 17,5 months. Since 2013, the emphasis is put on shortening
clinical and ambulatory treatments (GGZ Nederland 2015:8). In 2014, there were around 100.000 patients less receiving specialized GGZ care (http://www.ggznederland.nl/actueel/ggz-nederland--jaarverslagenanalyse-ggz-2014-is-geen-reden-voor-optimisme, accessed April 1, 2016). In 2013, around 9% of all patients received clinical care (2015:7). This amount is around 9% less than in 2011 (ibid.:22).
34 See GGZ 2012:2 and https://www.ggzingeest.nl/hulp-nodig/aanbod/haarlem/kl-hlm/, (accessed March 31,
2016).
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psychiatric patients participate in society.36 “People suffering from a mental disorder should also
be able to participate fully in our society”, the GGZ writes about this participation law.37 This
participation of patients has to be realized partly by reducing drastically the number of patients being treated in clinical settings: residential care and treating patients within a clinical setting should be reduced with at least 30% (GGZ Nederland 2012:2). “Ambulantorization” of mental health care is an important aim in the next years to come. Therefore, it has far reaching consequences for not only the (technical) organization of how psychiatric care is structured, organized an carried out, but also for our understanding of what a psychiatric patient is, and therefore is also related to how mental illness is defined. Secondly, by doing so, it also contributes to new discourses and broader narratives about how the “mentally ill” are expected to behave. And third, it completely changes the organization and meaning of the clinic as space to cure patient. “The clinic” becomes an institution that is not only a costly business, but also harms patients and slows down their treatment.
Shared decision-making
Shared decision-making is a concept coined by medical scientists, which refers to both a theory and a practice how to achieve the “best” treatment. In medical science, shared decision-making is explained by how patient and practitioner try to achieve a common understanding of treatment and a path for action (Broersen 2011; Elwyn et al. 2012; Godolphin 2009). Elwyn and Godolphin, both medical scientists, argue this model of cooperation between practitioner and patient can be put into practice by asking three questions:
- Introducing choice (“What are the options?”)
- Describing choice (“What do the several options entail?”)
- Helping patients explore their preferences (“What is best for me?”)
Shared decision-making implies a joint narrative and understanding of the disease and illness. In this model, the doctor is introducing, describing and helping the patient to decide what is best for them (cf. Elwyn et al. 2012; Godolphin 2009; Schofield et al. 2003 and Van Aalst 2014). In opposition to this shared decision, I want to briefly mention what practitioners call “lack of insight”, meaning the patient failing to acknowledge or recognize his own disease, feeling ill or
36 This development is parallel to the new “Participation law” (Participatiewet) which passed on January 1, 2015. This
law is designed to make “disabled” people participate in the labor market (see https://www.rijksoverheid.nl/onderwerpen/participatiewet, accessed May 31, 2016).
37 “Mensen met een psychische stoornis moeten volwaardig kunnen deelnemen aan de maatschappij” (see
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not wanting to cooperate (see Cuesta and Peralta 1994, 1998 and Miller, Shayne and Lynam 2011).
The aim of shared decision-making is to create a treatment created and supported by the patient, the outcome of this model includes two types of knowledge: medical expertise from the doctor’s side, and experiential knowledge from the patient. The focus lies upon the creation of a shared explanation and narrative about the patient’s disease. I therefore interpret shared decision-making as a technique to enhance treatment as well as a tool to help make the patient aware of the role they are expected to play in their own recovery process. By invoking the patient’s responsibilities, it is also a crucial element embedded in the treatment trajectory meant to prepare patients to function in society more quickly (GGZ Nederland 2012:8-9). Patients should not just “sit and wait” for the doctor, telling them what to do. On the one hand, this opens up the possibilities for the patient to speak up and have a say in their treatment. On the other hand, emancipating or “empowering” the patient, as shared decision-making is often explained, has consequences for what is considered to be “good” or “responsible” patient behavior. I will come back to this more in depth in Chapter Three, especially in section 4 and 5.
Just like “ambulantorization”, shared decision-making changes the role the doctor and patient are expected to play during a patient’s treatment. Shared decision-making challenges, at least on a theoretical level, the power that the doctor, as medical expert, traditionally has over their patient. Shared decision-making presupposes that the best possible treatment is achieved when clinician and patient negotiate together, and the outcome of this negotiation is taken as a starting point. Shared decision-making presupposes a patient who actively negotiates their own treatment, and whose knowledge should be taken into account. The perspective of the patient is, next to medical expertise, something that should be taken into account.
1.4 “Betwixt and Between”: Clinical Treatment as Liminal Experience
In section two of this chapter, I mentioned how the clinic was “neutralized” by the medical staff: nurses and doctors do not wear white coats and they put a lot of effort in making the clinic a “relaxed” and nice environment. Yet, this way of creating a nice ambiance for patients was framed in different ways.
First of all, there was the effort to make the clinic not seem too much like a clinic. This was perceived as a positive element by both health care workers and patients. But it had also other effects. Patients who became too “attached” to this nice environment and who were not eager enough to leave quickly, for example, were considered to be a problem. The clinic is explicitly described as a place where patients are treated on a temporary basis. “Temporary” here
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does not refer to a clearly defined period of time; yet, theoretically, all patients should be discharged “as soon as possible”. See for example how the clinic presents itself on its website:
Together we look for a shared explanatory model that will be used as the guiding principle for a successful plan for treatment and recovery. We aim at keeping our treatment as short as possible, in order to let someone recover in their everyday surroundings.38
The clinic is explicitly described as a place where the first and most acute symptoms should be treated. Treating patients in a clinical setting is designed to make people recover more quickly. Yet, if people are too much at ease, clinical treatment results in the opposite: patients want to stress treatment instead of go home. Medical personnel frames this as “hospitalization” (hospitaliseren) of patients In medical jargon, “hospitalization” means getting too accustomed to the medical setting.. They become, in the eyes of the medical personnel, too much used to the intensive care and setting, and become attached to the clinical environment. The “lay” meaning of the world means simply being treated in a hospital. When referring to the first meaning, I will put the word between brackets. When I refer to treatment taking place in a hospital or psychiatric unit, I use the word without brackets.
“Hospitalization” is, in the eyes of the medical personnel, a dangerous development. If people become too used and accustomed to the clinical setting, they might not want to leave quickly again. This is at odds with what they think to be the goal of clinical care (quick discharge). Doctors also view “hospitalization” as harmful because, according to them, if patients have become too attached to the clinical environment, they will have more difficulties to function outside of this clinical setting again, without the constant attention and presence of nurses and doctors. The clinical episode of someone’s treatment is meant to help patients manage the first “crises” of their mental disease, but specifically not meant to stay for longer than that. The medical staff is highly concerned with patients who stay in the clinic for “too long”. Recovering “at home” is always portrayed as a better option, because it helps make people more autonomous (GGZ 2013:8; GGZ 2012:1). Patients who do not want to leave the clinic are not only portrayed as lacking insight with regard to their own “best interests”, they are also portrayed as patients who do not take responsibility.39 Health care workers portray this group of
38 “Samen zoeken we naar een gedeeld verklaringsmodel, dat als leidraad dient voor een succesvol herstel- en
behandelplan. We streven ernaar onze behandeling zo kort mogelijk te houden, zodat iemand zo snel als mogelijk in zijn of haar eigen leefomgeving verder kan herstellen.” (See http://www.ggzingeest.nl/hulp-nodig/aanbod/haarlem/kl-hlm/, accessed October 19, 2015).
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patients as “too dependent” and “too much contained within their patient role.”40 This focus to
treat patients at home can of course be linked to the GGZ’s target to reduce clinical care over the next years; yet, it is also related to ideas about how and where people recover best. The medical personnel expressed their concern that people staying in the clinic too long would be affected with regard to their “sound” or “healthy” parts. The focus on ambulatory care is, thus, also related to a supposed interaction that should take place between patient and society.41 The
contact between patient and society is supposed to have a “good” influence on patients’ recovery trajectory.
The open clinic presents itself as a space where the first steps toward recovery can be taken. It can therefore be interpreted as a kind of “borderland”. Patients are expected to behave responsibly, but not fully. The progress they make is partly evaluated through how they deal with their “freedoms”. If patients are allowed to leave the clinic three subsequent hours per day, but come back after six, this is interpreted as “irresponsible” behavior. “Then you simply can’t deal with your freedoms”, nurses say.42 So the initial restrictions, for example not being allowed to
leave, is punished with “real” consequences when the freedom is not respected. Yet, the fact that not being restricted to a certain number of hours with regard to how much time patients are allowed to spend outside of the clinic would in fact be more freedom, and that patients who stay away longer “take” this freedom, is not taken into account. Patients are held responsible and expected to behave responsibly; but in a way, these responsibilities are already taking place within a restricted domain.
I therefore interpret the clinic as a “liminal” environment. The clinic is “in between” the real world and the hospital. I invoke Victor Turner’s concept of liminality here. In this context, a “liminal” experience refers to a situation in which the patient finds themselves “in between”. Turner, an anthropologist who conducted fieldwork in the 1950s and 60s in Zambia, studied the meaning and carrying out of rituals in depth. Turner interprets rituals as processes of transformations, in which a person is “betwixt and between the positions assigned”, meaning that the societal role someone should fulfill is unclear (Turner 1969:95). A liminal situation is uncertain, during which people are in a temporary borderland between statuses (ibid.:99). The focus put upon making people ready for society and neutralizing the clinical environment can be interpreted as attempts to make psychiatric patients’ stay in this “borderland” as short as possible, since they might forget their societal roles altogether. The reorganization of public mental
40 See http://www.ggzingeest.nl/hulp-nodig/aanbod/haarlem/kl-hlm/ (accessed March 1, 2016) and TR FG
175-176, 254-256, TR FG 174-177.
41 See also www.ggznederland.nl/themas/decentralisatie (accessed May 28, 2016). 42 TR FG 442.
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health care services creates new discourses about patients’ responsibilities and presents the patient as an emancipated and enlightened consumer who should be looking for the optimal strategy to manage his illness (Mol 2006; Rose and Novas 2003).43 In the chapters to come, I will
discuss how this changing role of the clinic is related to the position of the doctor as medical expert and how the patient is expected to perform his patient-role. In philosophical terms, the clinical experience can thus be interpreted as a “liminal” experience. Patients are not forced to take medication, nor do they receive cold showers to “confess” their madness. However, the clinic still is kind of borderland. Patients are treated in order to re-enter society again, but the risk the clinic might make it more complicated for them to actually learn to behave themselves within society is constantly mentioned.
In this chapter, I have described the current situation of psychiatric institutions in the Netherlands. I have sketched the developments in public mental health care in the Netherlands today, and focused in particular on the practices of “ambulantorization” and shared decision-making, which are important to understand in which direction psychiatric care is heading today, and what this means for the future of psychiatric institutions and people suffering from a mental illness. Practices such as “ambulantorization” and shared decision-making conceptualize the role of the patient in a different manner. Participating in society is seen as having salutatory aspects “on its own”. In this respect, there is a major shift going on in how medical expertise is defined, as well as healing aspects of clinical care. If the clinic is seen as temporary space where the first crisis (or crises) needs to be taken care of, this also has consequences for how clinical care is viewed in the temporality of someone’s disease and treatment. Policy documents and health care workers emphasize the differences between the clinic and “the world outside”. The fact that the clinic is so different from society in which patients ideally fit, interrogates the role of the clinic. Is it still beneficial for patients to treat them within a clinical setting? And what are the consequences of organizing psychiatric care within a setting so different from society? These are questions the GGZ and Dutch government struggle with at this very moment.
43 There is no proper translation of the word “ambulantorization”, in the sense that it catches both the focus on
ambulatory care as well as the transition to an outpatient centered psychiatric treatment. English similar concepts are “short treatment care” or “outpatient care”, but since the Dutch suffix –isering refers to a process in transition, I decided to use the Dutch word. In this thesis I will use the word “ambulantorization” between brackets.
