Ideology matters

Lancet Psychiatry has just published a polemic and a response which focused on language. I want to comment on them, because the polemic (with which I tend to agree) and the response miss the point somewhat, although in different ways.

So, the polemicists take issue with the authors when they use phrases such as:

  • patients fail a single antipsychotic trial
  • schizophrenia patients fail to remit to a single antipsychotic

and they write:

As if this situation was not challenging enough, are these people now being told that if their symptoms do not improve with a treatment it is their failing? We would urge the psychiatric community to consider what is being communicated here, whether this language is helpful, and, indeed, whether this statement is even accurate. Is it really the patient’s failure? Or a failure of the treatment?

Before I make my point, I want to say that what the authors of the polemic say makes much sense and I agree with the general sentiment of what they say. The problem is that their argument is (somewhat) outside context.

You see, I don’t think the argument should be directed at, as they say,

world leading psychiatrists, and being put into the public domain by a leading psychiatric journal. In 2018.

Rather, it should be directed at psychiatry, or, really, at medicine in general. The authors of the original article are more than likely to have used such phrases because they are the phrases ‘one uses’. I haven’t done any surveys on the issue, but I suspect that medical discourses have constructed patients as responsible for not ‘responding’ to treatments for a very long time. And so, researchers, having being socialised in such ways of writing and speaking, they write the way ‘one writes’, without giving much thought to the assumptions which are made by what they write. It is very very unlikely that the authors of the original article had sat down and made a conscious decision about constructing the patient as responsible for the treatment’s failure.

Moreover, it’s worth saying that such phrases as ‘treatment resistant’ (I have first come across it in reference to depression) are part and parcel of such discourse. As are, incidentally, fight/violence metaphors in cancer narratives (I have written about them in this post)

My second critical point with regard to the polemic is its very narrow focus – the verb ‘fail’. The problem is that if we are not to use the verb, ‘we’ will try to think about a different one, e.g. ‘respond’. Would the original article be any better if the authors had written about patients not responding to the treatment? In my view, it would not.

This is because it would still construct the patient in a position of doing something to the treatment, rather than the other way round. And I would prefer that it didn’t. And here is, I suggest, a more general issue and, I submit, one which should be considered more usefully. How do ‘we’ want to write about patients and treatment? What’s the most useful way of doing it? I don’t think there are simple answers, although I agree with the polemicists that constructing patients as failing is just about the least useful possible. However, as they write about ‘symptoms not improving’, I am not certain at all this is the way forward. Just saying. Importantly, such questions are not language-related at all, rather, they are political, or ideological, if you like.

Now, let me briefly discuss the response to the polemic. It’s so disappointing. I really hoped the authors would say – yes, you’re right, we shall not use the phrase again. Alas, it was not to be, so, instead, we have a response that misses the point by a country mile or fifteen. First, because having first stated that

no one is to blame when an individual’s symptoms of schizophrenia do not improve with treatment,

the authors actually list all the reasons patients are. But yes, they do it in kid gloves.

Second, because particularly psychiatrists should understand that language is very far from only ‘reflecting’ something. Whatever we say represents as much as it constructs reality. Language use is associated with a ‘structure of faith’ (Menz), often referred to as ideology, which is understood as shared structures of belief and value and their representations in text (often multiple and contradictory).

The ideological potential of discourse applies also to such texts which are culturally expected to be neutral. Academic articles, textbooks, laws, diagnostic manuals, let alone clinical notes (yes, I’m adding it because I am spiteful) are all known to represent reality from a particular ideology-laden point of view and, it’s important to say, this is hardly news and hardly controversial. Their authors make selections as to what they see as criterial aspects of the represented objects and how to represent them.

And I would hope that even psychiatrists would understand that, especially in general discussions, it’s much better not to construct the patient as responsible for treatment not working. I’d go as far as suggesting that even though you can list all those examples of the patient being responsible, it’s better, nicer, and kinder not to put the generic blame onto us. This is because ideology matters.

And you see, I would prefer a (constructed) world in which medicine still has much more to do, rather than the world in which patients fail, don’t respond, or are treatment-resistant. For me, such a world would be nicer to be ill in. And when ‘we all’ start talking like that, we might actually achieve the world in which blaming the patient will be unsayable (it’s likely not to be unthinkable ever, but who cares?). Moreover, when ‘we’ start writing like that in reference to treatment, maybe, just maybe, you’ll stop to think how to write about patients in other contexts (and they are legion).

And so, instead of saying about healing thyself, I’ll say “Medic, take responsibility!”

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