Recorrido histórico de la formación dual 32 

Foucault’s notion of the battles between the two wills, the perpetuating psychological conflict between staff and patient is also noted in Goffman’s (1961) influential text ‘Asylums: Essays on the Social Situation of Mental Patients and Other Inmates’. Goffman offers an account of how the asylum operates forms of social control via physical and psychological sets of structures; the arrangement of physical structures, the slicing up of time and the staff, to maintain continuous patient conformity, thus creating institutionalisation. Institutionalisation is a progression of becoming formally embodied within a structural set of processes, located away from the wider community. Institutionalisation or indeed, total absorption within these processes is the end result of a series of mediating practices which constitute the life-blood of socially insulated psychiatric hospitals (Cooper, 1970; Goffman, 1961).

Initially, a person is given a diagnostic label usually resulting from the presentation of socially deviant behaviours within the wider community. In turn, this diagnostic label becomes enveloped within the broader labelling of mental health and psychiatric institutions and patients take on the expected behaviours of their particular label (Scheff, 1999). As Cooper (1970, p. 41) notes: “The mental patient, once he has been so labelled, is obliged to take a sick role. Essential to this role is a certain passivity”. This is not to suggest that passivity is prevalent on initial admission but moreover it is the series of confrontations between patient and staff as discussed by Foucault, this ‘wearing down’ and the initiation and continuation of social controls which can enable compliance.

4.6.1 Electroconvulsive therapy as mediator of social control

Electroconvulsive (ECT) or ‘shock therapy’ therapy is arguably still one of the most contentious forms of therapeutic treatment within the psychiatric community (e.g. Smail,

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2007). As such, this treatment has and still remains one of the most ‘feared’ processes which service users can be involved with. Even from a practitioner perspective, this kind of

therapeutic operation is widely positioned as a “cruel” form of treatment (Bentall, 2004, p. 497).

Goffman (1961) provides an exemplar of social control via means of such seemingly

coercive therapeutic interventions by discussing his own ethnographic study conducted within psychiatric institutions in the late 1950’s. Goffman notes how patients who were to be

administered ‘Electroconvulsive Therapy29’ by staff were often assisted by other patients. This assistance consisted of the holding down and the strapping of a patient to the designated bed where the intervention was to take place. As the name of the treatment suggests, the requirement to subdue and stabilise the patient within these situations is to minimise the physical damage such as broken vertebrae caused by the convulsing body of the patient. Nevertheless, the need for physical restraint is possibly more involved with the imagined and experiential horrors that patients have embodied regarding ECT. In terms of social control within the psychiatric institution, this is where the power of such a treatment lies – not as an effective form of treatment but as a visible presentation of the stuff human nightmares are made of.

Of interest here, is that within such scenes other patients become an integral part of the unfolding drama as they become immersed in a duality of roles, one of the enforcer and also one of the condoner of such actions. In this way the social division of staff and patient is temporally blurred as the patient crosses the tangible boundaries of their former role and now takes on a fleeting position imbued with power and control over other patients. It is this brief crossing over which goes on to strengthen this form of social control. For this period of time, the patient undergoing this treatment has no allies, there is no sense of solidarity in the face of the aggressor – there is no mutual uprising to defend this course of action. The offending patient is now, for this period of time at least, isolated from the collective – this newly acquired role is one that is deliberately rooted in social, physical and psychological vulnerability.

Goffman (1961, p. 33) goes on to describe the physical and observable ramifications of such a treatment, the “choking gasps” and “foaming overflow of saliva”. Such scenes were openly visible to other patients as Goffman observed. It is this palpable visibility, again

29

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referring to the nightmarish qualities and effect that such observations can have on the human psyche, which in turn may serve as a timely reminder to those onlookers that deviant

behaviour within the institution might incur the most frightening of punishments30. This sequence of events can work as a warning to patients, it is after all positioned as a well- rehearsed, premeditated exercise in group social control – this is what will happen to you should you step out of line. It is not only the dread of receiving ‘shock therapy’ but perhaps more potently, on the one hand being part of such a highly visible spectacle but also the feeling of being alone, as situated on a side consisting of only ‘one’.

In the following extract, Jane, a 52 year old service user discusses her own feelings of

receiving ECT as a form of therapeutic intervention. It is worth noting at this point that ECT is still used today with some research suggesting that older service users benefit from this intervention (Benbow, 1989; Frazer, Christensen, & Griffiths, 2005; Mulsant, Rosen, & Thornton, 1991). Benbow (1989) points to the ways in which clinical studies indicate that ECT helps to alleviate the re-emergence of depression in the older population with only temporary side effects of anterograde amnesia and only a limited loss of retrograde amnesia of about one or two weeks memory loss prior to this treatment31. Key proponents endorsing the use of ECT as an effective treatment often draw attention to the wider cultural

assumptions that this particular method of intervention suffers from an exaggeration of side- effects and negative portrayals particularly within the media ((Benbow, 1989; Mulsant, et al., 1991). Perhaps for many service users these pervasive and largely negative influences which can be depicted within varying forms of medium act as a platform to instil a feeling of

potential fear before treatment is even undertaken.

Jane has spent periods of time within psychiatric institutions but was discharged into the community to live independently. Although Jane discusses the threat of

compulsory detainment via ‘sectioning’, she was resident within the hospital at the time. This is an interesting point nonetheless as she relates the threat of being

detained, perhaps for a longer period, as a means of getting her to have this particular treatment. It is also worth noting that Jane had twenty four courses of ECT during her stay in this particular institution.

Jane: Yes yeah and then I fell ill and um and (1) I had electric treatment going back about (2) thirty years um and I was forced into it (I=mmm) um (2) they

30 _{It is appreciated however that not all cultures may share the same concerns regarding the use of ECT} 31

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said if I didn’t have they’d section me so they kept pushing and pushing and in the end I just give in (LAS =yeah) and then I tried to run away cos’ I was frightened… I was frightened of it (LAS = mmm I can understand that)… and I had twenty four…um I know you need a lot around you but the fear before it was terrible because when you wake up you don’t know who you are you don’t know where you are (1) and I was so confused I was then than before

(LAS=yeah)

In this extract, Jane initially punctuates her illness as a mediator of receiving treatment “I fell ill”. She then goes on to situate her account of this coercive experience in time “back about thirty years and I was forced into it”. In this way, Jane plants the stakes of time as a mediating factor, as a means of circumscribing this particular memorial event (Reavey & Brown, 2007). A particular period in time when service users did not have a voice or say (e.g. Cooper, 1970) in their treatment but she also indicates her youth which may serve as a way of negating any form of deviance to resist such an intervention due to her immaturity and vulnerability. To summarise, for Jane, at this period in time she was too ill to resist, service users were largely positioned as compliant to psychiatric intervention at this time and, finally she was too young to fight the system with any kind of confidence in her convictions.

Notwithstanding these mitigating factors, Jane talks about she tried to run away. An assumption can be made that this attempt to flee these circumstances was unsuccessful as she does not elaborate on this point further. What is interesting here is the fear factor, “I was frightened…I was frightened of it…you know the fear before it was terrible”. This particular narrative illustrates quite clearly the real fear and dread that ECT holds within the human psyche, that complex mixture of stuff that nightmares are made of. Perhaps, these kinds of anticipated feelings of terror may be exacerbated by the monstrous associations with electric shock therapy, by this I mean the ways as children we associate electric shocks when placed near the brain as having links with fantastical creatures such as the creation of Mary Shelley’s fictional character of ‘Frankenstein’. These kinds of images can resonate within our conscious minds as we picture the man-made object which is shocked to life, via electricity, this monster which ultimately becomes a destructive force.

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Perhaps for Jane as with many Westernised communities, this imagery is one that pushes the boundaries of what it is to be essentially human and what it is to be a manufactured creature. This may be represented as a step too far in changing one’s sense of self identity and changing one’s biological structure in that neurological structures are altered. Thus, equating not only to a neurological invasion but also an invasion of the soul, the essence of what makes us human but above all, a sequence of unwanted, personally invasive events.

These types of changing representations of self are reinforced when Jane states “when you wake up you don’t know who you are you don’t know where you are”. Here she emphasises a great loss, the loss of self-identity and the loss of location. Not only had this treatment distorted her sense of who she had been and who she now was but her spatial footings had been uprooted too. Subsequently, this therapeutic intervention had essentially displaced her in all ways possible. Jane then wraps the entirety of this period of her life as one of confusion, both psychologically, physically and space – she has no fight left in her and temporally, no stake in a place to mark her own territory. Perhaps she felt left in a kind of spatial limbo.

These are important elements to bear in mind when discussing ECT as a therapeutic intervention which go some way to explain the contentious arguments that still ensue around giving this particular form of treatment. It is a narrative of an epiphany, an irrevocable moment of change of Jane (Denzin, 2001), as her body was now violated by human touch and moreover, by the force fields of electricity. Or as Denzin (2001) would suggest; it is a narrative testimonial relating to the intersection between the personal and the wider, historical institutional and cultural aspects of her own life story.

Using clinical interventions such as ECT, the notions of the institution mobilsing itself as a spatial entity primarily concerned with producing compliance and conformity have become acknowledged as a well-rehearsed argument. Drawing from the

discourses and visual imageries borne out of the uprising of critical psychiatry during the 1960’s and 1970’s, such debates have created a mixture of political, cultural and social strands seeking to explore the conception, function, method and outcomes relating to the mechanisms of the asylum.

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For example, the release of the film, ‘One Flew Over the Cuckoo’s Nest’ in 1975 was and still is a highly influential and critical portrayal of institutional life (e.g. Anderson, 2003; De Carlo, 2007; Hyler, Gabbard, & Schneider, 1991). In essence, this particular film plays out the scenes of power, confrontation and patient surrender, the

Foucauldian concept of psychologically ‘wearing down’ the patient. In addition, as the drama unfolds one is aware that punctuated throughout the film the use of certain therapeutic apparatus plays an essential part as a means to exert social control as per Goffman’s writings.