Den psykiatriske pasient: En begrepshistorisk studie
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The psychiatric patient – a conceptual and historical study Throughout history, a variety of ways have been used to describe the psychiatric hospital patient and I want to examine the relationship between the new and the old concepts. This study is about how have these patients been conceptualized historically and politically. The hospital chosen for the empirical study is Opdøl Asylum - a 100-year old psychiatric hospital which was established in 1913 and quickly gained over 100 patients. Since that time some major changes in several areas have taken place. To mention just a few of them: 1) The hospital had some 470 beds in the 1970s - today there are about 20 patients. 2) The word “insane” – once in common use - is today virtually never used. 3) It appears that topics such as what constitutes treatment and patients’ rights have acquired a new significance. The theoretical perspective is the German historical semantics. Reinhard Koselleck (1923-2006) was one of the founders and editors of the Geschichtliche Grundbegriffe. The lexical work was written in the period 1967-1992. That was at path-breaking encyclopedia. Koselleck argues that certain concepts can be regarded as basic. By this, he means that concepts become political and ideological issues. The book Futures Past. On the Semantics of Historical Time (Koselleck 2004) is about constructing conceptual pairs. The attention is on the role language plays in reflecting and constructing concepts in society. It would appear that today’s concept of the psychiatric hospital patient is a basic concept according to Koselleck’s sense of the phrase. It is also part of a conceptual pair in contrast to the somatic patient. Conceptual history and social history complements each other but can hardly be reduced to one another in either direction (Junge 2011:18). Michael Foucault defines psychiatry as a policy area in which different ideologies prevail (2009). Ideologies are capable of reflecting ideas, attitudes, values, aims or solutions and may be expressed as language. Based on an assumption that linguistic change may therefore indicate ideological change, I subscribe to Kosellecks historical approach to verbal concepts: If a verbal concept can have more than one meaning and apply to different situations then it follows that it can also 1) express different perceptions of reality, 2) lead to different problem understanding and 3) indicate different treatments. This study examines the terminology which has traditionally been used to describe psychiatric hospital patients and looks at how our concepts about this group have changed fundamentally. It is not a history of the concepts themselves, but of shifting descriptions and different historical phases. My purpose is to examine movement in our conceptualization of psychiatric patients and to place these in historical context – and to look at changes in linguistic practice and consider what implications these have had to justify for example treatment. Foucault questioned how and why it could be that very different things in the world were collated, characterized, analyzed and treated under the same heading of ‘mental illness’ (Veyne 2010:171). My intention in this study is to analyze terminologies working together. The various terminologies describing the psychiatric hospital patient are like the many threads of a cloth. When we place a ‘net’ over these we call it discourse. Discourse helps establish analytical distinctions. My goal is to identify discourses which shape our ideas about the patient in different ways and my strategy for identifying discourses is to look at both everyday routines and language. Reading of texts can help identify discourses. In these texts we can find traces which indicate who is speaking, what is being spoken about and what action has been taken. I have read various texts, such as hospital annual reports and budget comments, patient’s case notes, and letters from patients, doctors and others, in addition to official documents such as legal statutes and government white papers. I have also used fictional literature. The hospital has a museum with historical objects and pictures. There are also recordings of interview with people who worked in the hospital for about 50 years. Asylum can in itself be seen as a form of treatment. The institute of asylum was first established after the Insanity Act of 1849. The law demanded, among other things, that the asylum director must be a doctor. There was to be a strict departmental structure taking into account factors such as gender and patient behavior. In addition, practice relating to staff rules, doctor’s rounds, and the recording of case notes and protocols was established. How have psychiatric hospital patients been conceptualized and talked about in connection with various forms of treatment? What kind of discourse might lie behind these conceptions? How have specific interpretations of what constitutes the psychiatric patient become commonplace and how have they been expressed in language. Insane’ is woven into the tapestry of terminology which surrounds the psychiatric patient. The word appears to occupy a central place both as a medical and a legal term. It is used in Norway’s first Insanity Act in 1849. It seems that for more than 120 years the word ‘insane’ was extremely important, and yet it has gradually ceased to be used. (The national daily) Aftenposten claims that the word has been absorbed into everyday language and, as such, is no longer used in psychiatry (03.02.2011). What does this really indicate? What was ‘insane’ supposed to tell us and what alterations of meaning has it undergone? Have other expressions replaced ‘insane’? To what degree is this about changing our concept of the phenomenon as a problem, and what political and ideological processes are involved? It is here that Foucault’s discourse theories come in: Veyne argues that discourses can be seen as “glasses” (“spectacles”) through which people understand phenomena and which have themselves shaped thoughts, actions and language (2010:28). In what ways do discourses represent different usage of language thereby contributing to different questions being asked? Starting with the concept of ’the psychiatric patient’ I have explored related concepts and their metamorphosis over time. The expression ‘insane’ was of central importance for more than 100 years when it was replaced by ‘the psychiatric patient’ and in still more recent years by ‘customer’, ‘user’ and ‘citizen’. These linguistic changes reflects historical and social processes like human rights, struggle for freedom, to be accepted as citizens, equality and self-determination. These conceptual transformations relating to the psychiatric patient has been conductive in turning concepts like necessary and active in to contested concepts. Necessary and active can in the context of the psychiatric patient be seen like historical concepts. In a historical perspective what was necessary or active has not been questioned. These to small words has been used in psychiatry as something self- evidently right. That can be seen like the light of power. The concept of the psychiatric patient has been a good case in studying conceptual changes, and how psychiatric power and conceptualization is working together. Like many other social and political concepts, it can be traced back to the revolutionary and enlightenment transformations in the period around 1800. The concept of the psychiatric patient has been part of accelerated conceptual changes related to modernization. Today the concept is part of conceptual struggles. One of them is how to name “the mental patient”. Naming “the mental patient” is part of a structural asymmetry. It labels persons, patients of a particular kind. Historically the structural asymmetry has been transformed in to the new concepts.