Mental Illness and the Body

Beyond Diagnosis

Louise Phillips

• Publisher: Routledge
• Year: 2006
• eBook ISBN: 9781134176854
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

Using real life case studies of people experiencing mental illness, this book identifies how bodily presentation of patients may reflect certain aspects of their 'lived experience'.

With reference to a range of theoretical perspectives including philosophy, psychoanalysis, feminism and sociology, Mental Illness and the Body explores the ways in which understanding 'lived experience' may usefully be applied to mental health practice. Key features include:

• an overview of the history of British psychiatry including treatments
• an analysis of feminism and the way its insights have been applied to understanding women's mental health and illness
• in-depth interviews with four patients diagnosed with mental illness
• an outline of Freudian and post-Freudian perspectives on the body and their relevance to current mental health practice.

Mental Illness and the Body is essential reading for mental health practitioners, allied professionals and anyone with an interest in the body and mental illness.

Chapter 1

Introduction

Some years after leaving Long Grove, I worked in a registered care home for people diagnosed with severe mental illness who had been moved out of other large asylums. I worked closely with one particular patient I will call Marilyn. She was fifty-two and a long-standing patient who had been regularly hospitalised since her twenties. Like the other residents, Marilyn came to live in this particular home because the large institution where she formally lived was closing. Marilyn did not want to leave the institution and was sedated and driven in an ambulance to the registered care home. On arrival she was very distressed. She was verbally aggressive towards staff and other residents, and among numerous examples of disturbed behaviour, Marilyn would regularly lift her clothes to pee on the carpet next to a window in full view of people outside waiting at a bus stop.

Due to the severity of her psychiatric symptoms, Marilyn was prescribed a relatively new anti-psychotic medication called Clozaril and her behaviour became more settled. However, following this intervention, which was considered highly successful by clinicians, other forms of behaviour came to the fore. She consistently refused to wear day clothes or to leave the confines of her home stating that if she did she would be sucked into the sky. Similarly, Marilyn refused to bathe for fear of being sucked down the plughole, resulting in her becoming very unkempt and developing a strong body odour. As she washed infrequently and perspired so much, she developed a painful rash under her breasts and around her groin. She pulled out her hair from the top of her head, leaving a fine downy scalp that was complemented by long and greasy side locks. She carried several bags with her around the house, which appeared to be stuffed full of tissues, clothes and bits of paper. She was very protective of these bags and did not let them out of her sight. Every day, Marilyn sat at the same chair in the dining room in a state of restlessness, smoking nervously and asking staff and other residents how they were getting on. Frequently, following visits by her mother, she giggled to herself, responding to such outbursts by exclaiming ‘naughty girl’ and smacking herself on the arm. Also she picked her nose, lining up her bogies in little balls on the dining room table.

In staff team meetings much emphasis was placed upon Marilyn. Understandably, the staff were concerned about her personal hygiene, physical appearance and domestic cleanliness. The clinicians responsible for her care focused upon Marilyn’s body in terms of citing an imbalance of chemicals in her brain as a causative factor to her mental distress and consequent behaviour. Yet, I was struck by how little emphasis was placed upon Marilyn’s body by both staff and visiting mental health professionals in terms of the possible meanings and significance attached to its very stark expression. No emphasis was placed upon what Marilyn’s body indicated in terms of her lived experience. I wondered what Marilyn’s bodily presentation was about and whether it extended beyond a mere manifestation of her mental illness. I wondered if Marilyn’s body and its surroundings might express in some way aspects of her internal world. Might it be that she was unable to verbalise emotional distress and therefore used her body as a way of expressing it? Or might her body express something about her being a woman in the world? Did her body in some way represent an articulated resistance against societal conventions of femininity? What did her body say about her life? It was possible to look beyond diagnosis.

Bodies are fascinating. They are functional and biological entities, yet at the same time bodies depict aspects of the emotional self. It seems as if a person’s experiences are contained within the physicality of their bodies. I remember as a child being fascinated by the famous escapologist Harry Houdini (1874–1926). I read how he would be contained within chains or submerged under water in locked crates. He would constrict his muscles and then use them to wriggle his way out of the impossible-toescape spaces. He once said that his mind was the most effective key, but rumour has it that he often had a real one. As a teenager, I recall watching the uncoordinated and disconnected limbs of Ian Curtis of Joy Division, frenetically dancing while performing ‘She’s Lost Control’.

The depictions of bodies in art are especially enchanting when they seem to reflect the person being represented as inside out. My personal favourites include the paintings of Francis Bacon (1909–1992). In Triptych (1972) Bacon depicts his partner, George Dyer, who had died suddenly a year before, on the left section. The heart of this figure is not just broken; it has sunken and dropped out of the body and lays splattered on the floor. A big space is left where the heart once was. The nude bodies depicted within the paintings of Lucian Freud who was born in 1922 (I will deal with the work of his grandfather, Sigmund, largely in this book) reveal in the very texture of people’s skin, as he has said, how people happen to be. His paintings are largely autobiographical, consisting of friends, family, lovers and so on.

The body is, of course, something that is essentially biological and functional. This ‘material’ perception of the body can be located within the disciplines of the natural sciences, law and medicine. Consisting of bones, nerves, ligaments, flesh and blood, our bodies enable most of us to function in the world. Our bodies are also vulnerable to the effects of ageing (and, of course, we are constantly encouraged to delay this process), illness and eventual death. There is another consideration of the body, which can be understood as ‘discursive’. In this context, as Jane Ussher asserts, the body also exists as a site of discourse, as the representation of desire and fantasy and of signs and signifiers (1997: 1). Discursive approaches to the body are situated within the academic disciplines of sociology, psychoanalysis, philosophy and feminism.

The body and mental health practice

The body is fundamentally relevant to mental health practice. British psychiatry has historically approached the cause and treatment of mental illness through observation of the body. This tradition continues within current psychiatric and allied mental health practice in the case of mental health assessment. To form a diagnosis, practitioners routinely conduct detailed observations of patients’ appearance, posture, gesture and gait, thereby using the body as a diagnostic index. However, within the biomedical framework of routine mental health practice, there is little scope for considering how the bodily presentation of patients may reflect aspects of their lived experience. This book will suggest that it is useful to consider the meaning behind the gestures, expressions and gait of people experiencing mental illness. These expressions, perhaps, tell us that a person’s experiences are very much present and relevant.

Within professional discourse and practice, there are a number of terms that are used to describe the phenomenon of mental illness. Throughout the book, I will be using the term ‘mental illness’, which, for me personally, is not an accurate term to describe the people I have worked with. It is rather difficult, however, to think of a term that best describes how some people appear to be attempting to relate their experiences and perceptions to others in a way that the rest of us might find bizarre, frightening and strange. The term ‘mental disorder’ is also open to controversy. It implies that there exists a mental order indicating a state of normality. In contrast, a disorder suggests abnormality. ‘Mental distress’ is perhaps not adequate either, as people are often not distressed as a result of their ‘delusional’ (for example) experiences.

As I often tell my students, as a teacher of ‘mental health’ and having worked in the field for nineteen years, I am still unclear as to what mental illness actually is. In terms of psychosis – which is the ‘mental illness’ I will be dealing with mostly in this book – there are certain experiences I have identified in the people I have worked with. People with psychosis (and I prefer to use this term rather than schizophrenia) seem to have some difficulty distinguishing between inside and outside, and seem to feel that parts of them are located within things outside of them. There seems to be a feeling of fragmentation and of being invaded from the outside or of invading objects in the outside world. There is often flatness in mood. I feel that the person experiencing what we call psychosis is perhaps willingly or unwillingly attempting to communicate their experiences in the world. Mainstream mental health practice, however, tends to regard these symptoms as meaningless and solely the result of organic mental illness. There are also a number of terms used to describe a person experiencing mental illness such as ‘client’, ‘patient’, ‘service user’ and so on. In this book, I will be using the term ‘patient’ to describe a person diagnosed with a mental illness.

I have observed in the many patients I have worked with who have a diagnosis of psychosis, that the use of words to express distress is often difficult, or even ineffective. This raises the question of how distress is articulated by language. Perhaps we all express distress through our actions and behaviour. We often use metaphors and clichés to express distress. We moan, cry or wail because we perhaps feel there are no words to communicate intense emotional pain. Perhaps we can say that certain ways of ‘behaving’ are possible indicators or metaphors for distress. Some actions are considered as ‘normal’ and acceptable, while others are deemed as bizarre and strange, as in the case of psychosis. If language is not an effective way of communicating distress, the body itself seems to take on the role of communicator of what that person has experienced or is experiencing.

What this book does not do

In the four case studies I present in Chapter 8, the people all have a diagnosis of psychosis. In addition, they also experience anxiety and depression, and in the case of Alice, alcohol abuse. This book does not cover eating disorders or self-harm. There is already a wealth of information of psychological understandings of these conditions.¹ However, the two women I discuss in the case studies have both experienced difficulties with eating. There are also other psychiatric conditions relating closely to the body. These include Body Dysmorphic Disorder² and psychosomatic disorders. I mention these two conditions in my review of psychiatric texts in Chapter 3, but there has been discussion about the psychological explanations for these forms of distress that I do not cover in this book. Joyce McDougall in Theatres of the Body: A Psychoanalytic Approach to Psychosomatic Illness (1989) for example, provides several case studies of people who present with psychosomatic illness in the form of physical symptoms such as pain, anxiety and insomnia that have no apparent medical cause.

McDougall states that these ‘symptoms’ are a person’s way of coping with life. She demonstrates that symptoms often disappear when the person is able to verbalise their distress. McDougall is, herself, a psychoanalyst and directs her understandings – and her valuable recommendations in terms of clinical practice – to the psychoanalysis profession. However, there have been no books specifically written for mental health practitioners that directly address the body and its presentation³ in the understanding and treatment of mental illness.

Overview of this book

The concept of ‘lived experience’ is firmly located in a philosophical tradition, which I briefly discuss in Chapter 2. I outline the tradition of phenomenology including the work of Merleau-Ponty and his development of the concept of the ‘lived body’. I state Freud’s place in this tradition in his obvious quest throughout his work to explore the correlations between the mind and the body. Along with the phenomenological theorists, Freud’s work seemed to oppose the mind/body split espoused by Descartes in the seventeenth century.

In Chapter 3, I will begin with sociological perspectives on the body, including the work of Michel Foucault. My reason for using aspects of Foucault’s work is to examine, with reference to psychiatric texts, how psychiatric discourse constructs mental illness in terms of its biological and bodily treatment and causation, to the neglect of what the patients’ bodily presentation and appearance might express about their experiences. In this chapter, I provide a brief outline of the history of British psychiatry and the ways in which it has consistently focused upon the body and its observation. Interventions for depression and schizophrenia prevalent in the 1950s and 1960s, such as insulin therapy, epileptic shocks and ECT (electroconvulsive therapy), are all treatments aimed at affecting the body in order to treat the mind.

In Chapter 4, I discuss ways in which the body and mental illness have been approached within feminist theory. I first discuss socialist/Marxist feminist accounts of women’s oppression as a whole. Although they say little about bodily expressions of mental illness, feminists such as Juliet Mitchell do identify how structural factors such as women’s experiences of unemployment, their relation to the capitalist economy and their positions within the family are often influential in their oppression (these perspectives are still relevant today). These ideas have been applied to women’s mental illness by sociologists such as Brown and Harris and Ann Oakley. These writers and others identify social factors as evoking mental illness in women. I state that these theorists say little about the body, but they do focus upon women’s physical labour resulting from their roles as wives, mothers and carers. I proceed to discuss radical feminist thought that identifies patriarchy as responsible for women’s oppression. I discuss how feminist writers, including Elaine Showalter, have identified psychiatry as a patriarchal system that serves to control the female body and sexuality.

In Chapter 5, I turn to psychoanalytic theory and the body in neurosis. I begin by providing a brief history of the construction and treatment of hysteria from the Greeks to Charcot. I then outline the work of Sigmund Freud and Joseph Breuer and their case studies of women patients suffering from hysteria. In a radical shift from previous accounts of hysteria, Freud and Breuer describe the body as communicating repressed psychical conflict and, in their treatment, attend to the language of the body in seeking to understand and treat the distress of their women patients.

I show how Freud’s writings on the body consistently focus, as mentioned above, upon the correlation between psychical and physical processes and how these processes are essential to early development. His writings on infantile sexuality, for example, present the infant’s body as a site of innumerable erotogenic zones through which the infant learns to relate to the outside world. In his writings of 1925 and beyond, Freud represents the needs of the female body as being psychically and physically motivated by a lack of a penis, with women’s mental illness characterised by penis envy. Freud’s admittedly rather sexist claims have provoked angry responses from feminist theorists including Kate Millett. However, in their focus upon Freud’s sexism, feminist writers overall have tended to ignore his writings on the body.⁴

In Chapter 6, I discuss post-Freudian accounts on the body in psychosis. I begin by discussing the work of Paul Schilder who proposes that a person with psychosis lacks a sense of being in, or owning, their body due to a lack of libidinal investment in it. I then discuss the work of Jacques Lacan, whose writings, although challenging, are relevant to an understanding of the role of the body in the experience of psychosis.

Following my discussion of Lacan, I turn to the work of French feminist theorists Luce Irigaray and Julia Kristeva. I outline Irigaray’s argument that the repression of female sexuality and language gives rise to women’s mental illness. According to Irigaray, women’s madness is manifested within their bodies. I also give an account of Kristeva’s concept of the semiotic, which indicates the realm of the maternal body. She describes how women are closely bound with this realm to the extent that they are unable to enter the symbolic, which is referred to as the realm of language. Therefore, according to Kristeva, as Elizabeth Grosz states, women experience ‘a fundamentally unspeakable experience, pleasure, or corporeality’ (1990: 163).

I also focus upon Melanie Klein’s concept that the infant’s experience of complex internal objects through processes of projection and introjection, are valuable in the understanding of body image and psychosis in adults. I then examine the work of Wilfred Bion who discusses how in psychosis, the individual cannot tolerate frustration and will project out their feelings. He suggests that the psychotic person will respond to the world at the level of physical pleasure or pain and have reduced capacity for the tolerance that would enable thinking to bring about relief. I conclude this chapter with a discussion of R.D. Laing who describes how in psychosis, the person perceives a division between their sense of self and their body.

In Chapter 7, I propose that mental health practitioners might usefully pay attention to their own bodies when working with patients. Experiences including fear, tiredness, coldness and so on, may give us an indication of the experiences of the people we are caring for. I discuss the psychoanalytic concepts of transference, countertransference and body countertransference. I discuss the point that Freud’s understandings of transference were mostly in relation to people with neurosis. He stated that people with psychosis are unable to form a transference onto their analyst. However, this view was challenged following the work of Klein, who asserted that people with psychosis do appear to project feelings onto outside objects. I continue to develop Klein’s view by discussing the work of post-Kleinians, including Herbert Rosenfeld and Margaret Little. I also discuss the concept of ‘body countertransference’ as discussed by Susie Orbach. The purpose of this chapter is to suggest that transference and both psychical and physical countertransference feelings may be useful means of understanding interaction with, and the experiences of, people suffering mental illness. I state how I consider these concepts to place value and emphasis upon the lived experiences of people with mental illness.

The reader will no doubt notice that this book contains a significant amount of psychoanalysis. My intention is to demonstrate that psychoanalytic perspectives – although difficult and seemingly irrelevant – provide us with a confirmation that the ‘symptoms’ of people diagnosed with mental illness are meaningful. Freud (whose work is often seen to be irrelevant within large aspects of mental health practice) demonstrates his dedication to this notion in his early case studies on (mostly) female hysterics. As part of his ‘Introductory Lectures on Psychoanalysis’, in a paper entitled, ‘Psycho-analysis and Psychiatry’ (1917), Freud stated his criticism of psychiatry for not paying attention to the form and content of symptoms. In another paper, ‘The sense of symptoms’, he addresses how, in contrast to psychiatry, psychoanalysis asserts that a person’s symptoms are meaningful and relate to their experiences. In other words, as Freud put it, symptoms ‘have a connection with the life of those who produce them’ (1917a: 258).

In Chapter 8, I detail my observations of two male and two female mental health patients. I provide a brief biographical background to each and discuss their diagnosis and treatment. The aim of this chapter is first to describe how these patients demonstrate their lived experience through their bodies and, second, to describe my psychical and physical responses to these expressions. I also outline my interactions with these patients and describe their accounts of their feelings about their bodies and the world around them. From my observations of these patients, their accounts of their experiences of their bodies and my psychical and physical countertransference reactions to them, I offer an alternative ‘reading’ of the meanings apparent in their bodily presentation using the perspectives of embodiment from within sociology, feminism and psychoanalysis.

In Chapter 9, I draw together the issues raised in the book and suggest ways in which mental health practitioners can work with the body as communicator of lived experience within mental health practice. I emphasise that mental health practitioners need to spend time thinking about, and being with, their patients in order to focus on their experiences. It is crucial they are supported in this process. In this chapter, I ask how possible insights into the experiences of patients might improve clinical practice.

This book is intended for mental health nurses, allied professionals and others with an interest in the body and mental illness. It is not intended to replace psychiatric practices but to add to current clinical understandings of the importance of the body in terms of its role in the experience of mental illness. I have carried with me my early fascination with the bodily presentations of people with mental illness. I hope to share this fascination with those who might read this book. I suggest that as mental health practitioners we can make room to think about our patients and what they might be communicating, often through bodily means, about their experiences in the world. This requires us to look beyond diagnosis at the person whose experiences are often very much alive and deserve recognition an...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Acknowledgements
• Preface
• Chapter 1: Introduction
• Chapter 2: Lived Experience
• Chapter 3: Bodily Inscription
• Chapter 4: Women Speaking
• Chapter 5: Unspoken Distress
• Chapter 6: Psychosis
• Chapter 7: The Practitioner’s Body
• Chapter 8: The Patient’s Body
• Chapter 9: Developing Practice
• Notes
• Bibliography