Sunday, August 1, 2010

Difficult Questions

A few months ago, I saw an Italian movie entitled Vincere. It tells the story of a woman who falls in love with a young Mussolini, marries him, and bears his first child. He then disappears from her life, and while he grows increasingly influential in Italy, she continues to pursue him and demand that he acknowledge and care for his son. Mussolini never responds to her demands and eventually she is thrown into a psychiatric hospital, where she is told that she is delusional and paranoid. Her claims are, in other words, forcefully rendered null and void by the silencing blanket of a psychiatric diagnosis.

The film ultimately never tells you whom to believe. The story is told from the woman’s point of view; the love story is thus as real to you as it is to her – and the psychiatric diagnosis as much of a shock. Then again, the movie reminds you that no documented evidence of the purported marriage, nor of the son’s paternity, has ever been found – and that the woman ultimately had nothing but (irrational?) persistence to fall back on.

The way I see it, this movie brings up an uncomfortable but undeniable issue inherent in the practice of psychiatry: to what extent do psychiatric patients retain the right to a voice, and a claim to truth? Does being mentally ill really mean that one is no longer capable of rationality or logical thought, and does that thereby authorize the rest of us to stop listening to such a person’s voice, and to make decisions on their behalf?

This question has come up a lot for me over the course of my fieldwork at the Clinic – I think of Marwa’s outrageous stories, for example, or Nadia’s and Mr. Abbas’ linguistic (and other) claims to some modicum of status. I think also of other patients who lament that no one at the hospital listens to their complaints, or others who have been abandoned by their families, conveniently left behind and out of sight in the safe confines of a psychiatric clinic. I could write endless stories about the impact of psychiatry on the experience of agency and autonomy among the women I’ve met. And I probably will.

But the reason I bring up this issue now, is that it has recently been thrown into particular relief – in the sense that I seem to have gotten myself quite actively involved in a case where the question of ‘agency’ lies at the very heart of the doctors’ difficulty in devising an adequate “prise en charge.”

A few weeks ago, a European woman was hospitalized at the Clinic’s closed ward. She had been wandering around Morocco for a few days when she was picked up by the police for attempting to trespass on Palace grounds, and brought to the psychiatric emergency department. Because this woman speaks no French and the doctors speak very little English, I was asked to help facilitate the communication by doing a bit of translation. One conversation led to the next, and slowly but surely, I slid right into the middle of it all, becoming a bit of a mediator between doctors, patient, her country’s embassy, and her insurance company.*

The hospitalized woman believes herself to be a medium of sorts. Her supernatural powers have granted her visions, most of which revolve around vast conspiracy theories – some of them involving herself as the target. She is convinced, for example, that the entire global network of her country’s embassies have joined forces with the Moroccan police and the Clinic, all in an effort to silence and imprison her. As you might imagine, this does not exactly leave her willing to listen to anything the doctors (or the embassy) have to say.

The Clinic, understandably uncomfortable with this very foreign patient, would have preferred for the embassy to take her off their hands. They had hoped or assumed that a few phone calls would mobilize this European country’s network of diplomatic and financial resources, and that with a day or two some representative would come to repatriate the delusional wanderer.

The embassy, however, had a very different point of view. The patient had aggressively refused their initial attempts at communication, and to them, this effectively annulled any and all obligations they may have had toward this woman. As they explained to me, the ministry of foreign affairs would not be authorized to do a single thing, unless the woman herself indicated a wish to be assisted.

A group of doctors attempted explanation: a psychiatric patient cannot be taken at her word, they told the embassy’s representatives. This woman’s judgment has been impaired, and her rejection of help should thus in no way be taken seriously. At times like these, decisions have to be made by experts who know what’s best for her. But the embassy stood firm, and politely apologized: the patient was now the responsibility of the hospital and the Moroccan police; they were free to decide as they wished.

This is the stalemate in which we now find ourselves. The hospital feels that it cannot, in good conscience, release this woman back to the streets (not in the least because she herself indicates that she intends to go right back to the Palace and try to gain entry. Which means that most likely she’d just be picked up by the police again, who for all we know might take her to jail next time). However, keeping her at the Clinic clearly is no more of an ideal solution. Without the possibility of actual conversation between patient and doctor, effective treatment becomes nearly impossible, and the stalemate continues.

So what is the answer here? Should the woman’s refusal of help have indeed been ignored, under the presumption that she is in no condition to make decisions on her own behalf? Should the embassy have stepped in? Or were they right in respecting the woman’s voice?

I have to admit that I’m undecided. Theoretically, I would and always will argue that no one should ever be deprived of a voice. Everyone, including someone with a psychiatric diagnosis, has the right to be listened to. Everyone has the right to their own personal version of truth, and behind every delusion lies a subjective lived experience in need of some kind of resonance, even if simply with a sympathetic ear. In addition, dangerous power issues lurk in the shadows of cases like these. There is a dark side to the history of psychiatry; there have been instances in the past (distant and not-so-distant) where it has been used as a convenient way to silence individuals with viewpoints that were dangerous for the stability of the status quo (which is, in fact, exactly what this particular European patient is accusing ‘us’ of doing).

Besides – who are we to decide what’s ‘rational’, ‘true’, or ‘valid’, anyway? What makes a psychiatrist the expert? Aren’t all these concepts ultimately relative?

But this time I’m compelled to think and reflect from a vantage point that is no longer merely theoretical, and it’s led me to think more about the other side of the coin – it’s let me perhaps to better recognize the very real and very thorny complexity of the whole issue. I will always maintain that the above theoretical questions are important to keep in mind, but the very practical scenario that we are dealing with at the moment raises an additional, very different set of concerns; concerns that have not so much to do with the existential right to agency as they do with the real-world consequences of allowing a delusional person to make their own decisions.

Yes, a patient should always be listened to, heard, validated. But if the patient’s only request is to be released from what she sees as inhuman imprisonment, and you know that, were she to be sent back out to the streets she would most likely be picked right back up by the police and brought back to the hospital (or worse, jail), what do you do?

And if a patient refuses to take her medication, claiming that she is not sick – but your medical training tells you that pharmaceuticals are the only quick and effective way to help her find her way out of hallucination, are you justified in forcing it on her?

And finally, where do you draw the line? When Marwa told me about military bases on other planets, I was fairly certain that this truth existed only in her mind. But when a woman claims to have given birth to Mussolini’s oldest son, whom do you believe, and on what basis do you make that choice? How far do you go in finding ‘proof’? Who, in the end, has the right to determine whether or not a mind is ‘rational’ enough to retain its claims to agency?

* This is a new role for me at the hospital. I’ve always been the observer, never the participant. I’m not a psychiatrist, not a psychologist, not even a social worker; I wasn’t qualified or able to really do anything useful. Now, suddenly, I’m being involved, asked for input, even needed perhaps – and I have to admit that it feels really, really good. I love the idea of being able to do something.)

1 comment:

Wael Yassine said...

"Great post. Your blog is still one of the best in Morocco. Have you been nominated for the 2011 Best of Morocco Blog Awards yet?"