This month’s (August’s) edition of the British Journal of Psychiatry features an editorial entitled, “Antipsychotics: is it time to introduce patient choice?”.  The authors (Anthony P Morrison, Paul Hutton, David Shiers and Douglas Turkington) make an important and provocative argument (given the journal in which their editorial appears – which is not best known for heterodoxy within psychiatry), which is grounded upon an interrogation of “whether everyone who meets the criteria for a schizophrenia spectrum diagnosis requires antipsychotics in order to recover.”

There have, to date, been nine letters published by the BJP responding to this article. One of them is mine (“Long-standing arguments from the service user movement reprised in the BJPsych”). Notably, none is by a self-identified psychiatrist – a fact certainly worthy of reflection.

What narrative options are afforded to letter writers to scientific/medical journals? “N”, the author of the blog Ruminations on Madness, is the author of a letter responding to the editorial that the BJP has, to date, not published. N has posted that unpublished letter online ­– thereby entering it into what I fantasize can become part of a dispersed and virtual archive of ‘not-published-letters’ that future historians of psychiatry will be able to use as a rich source.  N has also written a fascinating analysis of the 9 letters that have to date been published, arguing that:

there are two, fairly clear categories: letters from established academics (none of whom, whether they are or aren’t, explicitly describe themselves as user/survivors) and … two accounts from “unambiguous” service users.  The former are predictably ‘academic”—i.e. any obvious (non-empirically grounded) descriptions of experience and sociopolitics inevitably involve others, not the letter writer—whereas the latter revolve around (and to a large extent rhetorically depend on) rich personal self-description.

N concludes by arguing that the editorial decisions by the BJP on this occasion contributes to the “relentless fortification and re-fortification of the ‘first person account’ and/vs the properly academic commentary”.

N’s post made me think in much greater detail about how I imagined my own narrative options as a letter writer. My letter would belong to the group that N categorises as “letters from established academics (none of whom, whether they are or aren’t, explicitly describe themselves as user/survivors).” I know that I redrafted my letter a number of times prior to submitting it. In the process, I shifted its register, the implied reader, and, not least, the narrative voice.  In its earlier iterations, the letter was grounded within – and took as its well-spring – the service user movement (to use a complex abstraction, if ever there were one). For a number of complex reasons, I positioned myself in later iterations of the letter (including in the version that was published) as in some ways to one side of the service user movement. While one of my (honorary) affiliations is listed as the Service User Research Enterprise, a unit in which the vast majority of staff use, or have used, mental health services, the published letter’s narrative voice appears to usher – I think – more obviously from the medical humanities, as well as from human rights advocacy. (I list, alongside my position in Durham’s Centre for Medical Humanities, another affiliation – the international human rights organization, the Mental Disability Advocacy Center.) The letter thereby comes to ‘represent’ the arguments of the service user movement without necessarily being part of it.  Thus the published letter sits much more obviously on the ‘academic’ side of N’s divide between the ‘academic’ and the ‘personal’, whereas it had, in its origins, perhaps tried to scuff the dividing line.

My exchanges with N on such matters have also made me see anew the challenges I face as a historian of psychiatry who reads letters in psychiatry (and related) journals from the twentieth century. How, in short, do I read, and interpret, and frame, those letters – and those letter writers? How ought I try to think through the generic constraints, as well as the range of possible narrative voices, that shaped (in not entirely conscious ways) the letters of those who wrote, for example, to the editors of US psychiatric journals in the 1960s? How do I try to understand what drove some (male) doctors in the fin-de-siècle to write letters to journals such as the British Medical Journal or the Lancet, in which they publicly claimed for themselves the new nosological category of agoraphobia? How do I attempt to infer the kinds of editorial decisions that determined, at different moments, which letters were published or not? I know of a few examples of famous/notorious cases within psychiatry of letters being ‘sat on’ by editors (because of the controversies surrounding the research to which the letters were responding), or of the full list of letter authors transmogrifying upon publication into a lonely sole author. But a fuller history of the “letter to the editor” remains – at least to me – obscure.

Is there a body of work out there by medical humanities scholars and historians of medicine/science that carefully analyses the generic constraints of “letters to the editor” of medical and scientific journals? Are there case studies that explore particular historical moments at which that genre was cemented or transformed? And are there – and this is perhaps what I am most gripped by – analyses that have pieced together fugitive archives of that lonely artifact, the unpublished letter to the editor?


_N_ · August 16, 2012 at 11:53 am

Great questions.

This is somewhat tangential but it did occur to me to wonder what the fate of a letter to the editors of the BJP like Belmaker & Wald’s 1977 “Haloperidol in normals” (in which the writers (both researchers) describe the first-person subjective effects of antipsychotics) would be today and/or how a letter such as theirs might ‘trouble’ my own typology… (Curiously, for instance, Belmaker & Wald refer to themselves both in the first-person and, in the same paragraph, as “subjects,” which totally confused my own editor when I included a longish quote of theirs in a published commentary… But perhaps this was simply standard practice at the time?

Stan Papoulias · August 20, 2012 at 3:59 pm

While this entry raises questions about a fertile area of research, I find it rather fascinating that – at the same time – it positions these questions as an evasion of the very issue it is ostensibly addressing: namely the self and institutional policing which undergirds not just any letters to the editor as a genre, but this particular set of letters to the BJP specifically. So, on the one hand, the blog entry brings up immediately the non-disclosure of Felicity’s service user status, and how such a gesture fortifies a dichotomy between academics and those speaking from personal experience as service users. However, at the same time, the blog post immediately turns away from discussing the specifics of that non-disclosure and instead presents us with a very polished and eloquent set of academic questions about the history of letters to the editor and their legitimating frameworks. What is quite stunning here is that Felicity appears to highlight N.’s concern only to perform again further down, the very fortification she is at pains to problematise. In other words, this blog post seems to repeat the gesture of evasion initially performed in the BJP letter at the very moment that the writer comes out as a service user.

I think in this context it is not enough to say that the reasons for the changing the narrative voice during the drafting of the initial letter are ‘complex’. One issue that is hinted here for example is that of representation: is it just service users who can speak on behalf of service users? However, in the context of this policing of categories highlighted by N. I would think that this is not the central issue here. Rather the question is: what is the cost of coming out as a service user academic and, in particular, of doing so while addressing a psychiatry journal? Would such an act preclude the publication of such a letter? If so, then are we saying that in order to safeguard our academic voice it would be more strategic to silence a service user history (at least in certain instances)? Or at the very least that we imagine this to be the case?

So, while I too would love to see research on the framing practices that have historically constituted letters to the editor, in the present of this exchange between letter and blog entries, I wish to ask the following: what are the real/imagined/phantasised stakes around occupying both the service user and the academic position at the same time? Does one delegitimize the other? Can this occlusion of the one in favour of the other be seen as opportunistic? Or would a co-occupation of both positions be opportunistic in certain cases?

_N_ · August 21, 2012 at 1:11 pm

One is, of course, most interested to hear Felicity’s thoughts on these provocative observations and questions…

In response to Stan, I would add some additional questions: is it, for example, really a matter of “coming out” (in Felicity’s original letter, for instance, is it really so difficult to connect the dots?) or rather of the way in which one does or does not, explicitly, draw on one’s own experience or status in a particular text? Is it, that is, a question of occupation or co-occupation or rather the rhetorical and substantive *ways* in which certain spaces are (co-)occupied?

Then my question becomes: how can one rhetorically & substantively occupy both positions in a single text? Is it even possible outside some kind of (literally) heterotopic production? Is subjective experience, save as an illustrative example of a point argued through more traditional means, not fundamentally incompatible with the “post-positivism” that dominates the field of psychiatry? Given, that is, that the very force of the properly empirical argument (arguably) constitutively excludes the “first person” save as aggregating computational ‘processor’…? (*I have no good answers.*)

As a kind of afterthought, I might also draw attention to the even more complete exclusion of anything like “real” madness from academic discourse. Even the most confessional academic narratives, that is, are invariably written from the perspective of logos, reason, and so forth (even when, arguably, “badly” argued). Diana Rose, who sometime ago wrote a commentary on service user research entitled “Madness Strikes Back” could not, at least in a certain sense, have been more wrong.

Perhaps then, at least for me, the source of a deep tension: no matter how “personal” and confessional my more autophenomenological writings are, they invariably (re)perform precisely the exclusion that I/they superficially profess to circumvent. Discourse on user/survivor academics is thus arguably even more plagued by certain aporias than similar debates involving women, LGBTQ theorists, and racial/ethnic minorities…

Felicity Callard · August 30, 2012 at 9:57 am

Stan and N both raise important and difficult questions. And Stan is right that my blog post does itself ‘perform … the very fortification [that N is, and I am] at pains to problematise’. There are many psychoanalytic interpretations that could made here. I have no doubt that my own passage through the Service User Research Enterprise (SURE) (and hence through the Institute of Psychiatry (IOP)) – and my own changing feelings and interpretations vis-à-vis how I was being viewed while there by ‘conventional’ academics – have played a part in the evasion of my blog post. While at SURE/IOP, I undoubtedly relied on an ability – and, no doubt, an intense desire – to perform and inhabit logos: I think I felt intensely the threat of being positioned on the other side of it. This opens up many interesting sociological and ethnographic questions: no doubt other academics hired as ‘service user researchers’ might well have responded to the challenges of such a context in very different ways.

N and Stan have also have made me think of the rich literature on ‘passing’ in writings on ‘race’/ethnicity and in relation to gender/sexuality – and the extent to which a history and/or present of psychiatric service use (and/or the inhabiting of a ‘mad’ identity) can be usefully analysed through a lens of passing. I have, like, N, for a long while felt an unrelieved conceptual ‘itch’: the sense – deeply felt, though not on my part adequately analysed – that writings on service user/survivor identity face challenges different from those besetting work on other so-called axes of identity.

The question of how to think through the multiple ways in which ‘madness’ might appear in and through the written text requires a much lengthier post than I am able to provide here. A couple of very schematic questions that populate my daydreams at the moment: To what extent does the hovering master trope of ‘the psychotic and/or schizophrenic text’ occlude consideration of other ways in which texts can be ‘mad’? (When I read some of my writings – both for academic and non-academic audiences – that I at times managed to squeeze out when in periods of severe and non-psychotic psychic pain, I feel that I can read in them a kind of madness, but I would be very hard-pressed to provide criteria that I have used to make such a judgement.) What would it mean for a service user who claims the identity position of being eating-disordered or obsessive-compulsive somehow to ‘perform’ that identity through his or her writing? When, in a written text, does an extreme manifestation of, and/or commitment to, reason itself become ‘mad’? And how, moreover, does the very category of ‘the service user/survivor’ itself privilege phantasies of certain kinds of identities and performances of madness? (I would be intrigued to know how this is different in different geographical and cultural contexts.)

_N_ · August 30, 2012 at 3:07 pm

Really glad you’ve raised these issues, Felicity. The politics behind what sort of “mad” experiences are seen as legitimate or authentic in particular contexts, as well as the internally policed “madness” hierarchy, are themes that often surface in informal conversations, but virtually never (to my knowledge) in public fora. Not to mention the consequences of the (historically recent) “artifactual” divisions between classic “mental illnesses” and so-called “neurological,” “neuropsychiatric” and/or “neurodevelopmental” disabilities such as Autism or temporal lobe epilepsy…

I was just re-watching 12 Monkeys a few nights ago, and these same issues occurred to me with respect to the presentation of the film’s various “mental patients”–none of them, that is, are clearly categorizeable as “schizophrenic” or “depressed” or so on, but for precisely this reason tell us something much more revealing about how “generic” madness figures in the collective cultural imagination…

And then, even within the more narrow world of “schizophrenia” research and scholarship, there is a clear prioritization (romanticization, cathection, fetishization?) of so-called positive symptoms (delusions, hallucinations, etc.) over affective, cognitive, and motivational changes, even though all of these are empirically far more important in “predicting” outcomes… [Critical aside: Hearing the Voice arguably falls into this same trajectory, perhaps something worth considering as the project moves forward…]

[Second aside: clearly someone really needs to edit a special issue of a journal or organize a conference specifically designed to encourage serious critical exploration of these tensions and themes… ! 🙂 ]

Last but not least, the issue of the problematic academic positioning of user/survivors reminds me of the many critical texts written by members of the first wave of gender and ethnic minority scholars in the States. Who, after all, wants to be “given” an academic position because of a certain unasked-for identity (or set of experiences) rather than the rigor or quality of their research or scholarship? Particularly given that other scholars will, almost inevitably, find “subtle” ways of reminding them of this fact, and thus legitimizing certain claims they might make even while de-legitimizing others?

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