Ellen From the West

 Alt title:  where having your legacy be that of getting written out of existence is a fuck

In my GP placement, I had the pleasure of talking to a patient coming in for repeats for a psychiatric drug.  During our brief chat - it had lasted perhaps 2 minutes - they revealed that they were recently diagnosed with borderline personality disorder.  My reaction was that of disbelief - I did not experience any countertransferance of the sort clinicians typically talk about - and their comorbid psychiatric illness would have caused quite some difficulty in differentiating the two.  But, of course, looking back, that was all utter nonsense, right?  I had all of 2 minutes to talk to them, and I had jumped to the conclusion that the diagnosis was rubbish.  Ah well.

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There's a particular case that apparently all psychs of either the ologist or the iatrist kind know about.  The Case of Ellen West, a young lady who committed suicide after a bout of therapeutic existentialism from her psychiatrist.  In essence, and essentially how this differs from therapeutic nihilism, is that far from being convinced of the futility of treating her illness being the subject of the problem at hand, the psychiatrist in question viewed her suicide as the subject of the problem at hand.  The focus shifts from a numbing despondency towards what appeared to be an unassailable problem to that of an "authentic suicide".

In doing so, the Case of Ellen West is not really about Ellen West - Ellen West, whoever she was, is a non-agent.  She has been inextricably linked to her suicide.  It does not matter who Ellen West was as a person, and to some extent, not even as a symbol of an illness.  Instead all that is left to us is her suicide, and her psychiatrist's framing of her suicide.

Ellen West therefore is not a study of pathology but one of morality.  Ellen West, having been so stripped of her agency, is reduced to a prop with which the actions of her psychiatrist, her family and her society can be critiqued.  And certainly, there is always space for critiques of power structures and dominance.

What is particularly concerning, however, is when this attitude towards Ellen West is repeated amongst other pathologies of the mind, when the person at the heart of the case is forgotten with nothing but moralism to spare.

Let us take Major Depressive Disorder, or melancholia, or whatever term the DSM-nth comes up for it.  Perhaps we should include its sibling, Generalised Anxiety Disorder, in this discussion as well.  In discussions involving these common disorders, you inevitably hear ideas of it overwhelmingly affecting the young, the current youth, and how these disorders did not exist back when we were hunter gatherers struggling to survive (the argument as it goes, is that people were too busy to have depression).

This seems to be a epidemiological problem.  But it's not is it?  No, it's a moral problem.  Far from establishing an actual aetiology to the disorder, it imposes a perception of moral failing on the disorder.  After all, if there was no depression back when people were busy, that just means the society writ large isn't busy enough - it just means that people are slothful.  This is, even if it is not intended to be, a deflection of depression and anxiety away from the actual experiences of anxiety to a moralistic judgement of the patient, and if we're being generous, the society.  This can be further applied to depression and anxiety in younger populations.  One of the hypotheses goes that our perhaps more frivolous use of terms like "depressed", "anxious" etc. contributes to inflated rates of depression and anxiety.  Again, this masks the issue at hand - far from a warranted discussion on the experience of marked, persistent low moods, the problem then shifts to whether or not the kids are faking it.[1]

Let's have one more example.

Anorexia Nervosa, quite possibly, the most notorious of the eating disorders (Heaven forbid pica gets a mention in the news), is a disorder characterised by avoidance or purging of foods[2] and a distorted view of self-image (low BMI is also a criterion from the DSM, but BMI is also a fuck).  You know, the poor little rich girl's disease.  Except of course, the poor little rich girl's disease means fuck all.  The framing of anorexia nervosa as that is again a moralism.  It is meant to decry a personal failing under the assumption that in situation where nothing should go wrong, the patient has found a way to fuck it all up.  What might be generously interpreted as a rather crude form of epidemiology is a mask to pass judgement upon a patient and their experience without involving the patient themselves.  As with Ellen West, the patient becomes a mere object, and the moral judgement of their situation becomes the subject.

So then why do we have to deal with this moralising?  

I have two hypotheses.

Psychiatry deals with disorders of the mind.  The mind, well, it's a whole thing isn't it.  You know, the whole "I think therefore I am" to the fallout of that.  The mind has a privileged place in our thinking - you know, we're meant to be logical, we're meant to be smarter than other animals.  So, what happens when the mind goes wrong?  In this sense, I don't mean a paradox.  Paradoxes have existed since we invented language (and logic and other such things).  What I mean is, what happens when there is a disorder of the mind?  What happens when there is a dysfunction in that thing which supposedly elevates us above other animals?  Then there is a schism.  At once you have this point of privilege, and yet also a fairly fragile construct (see the actual epidemiology of psychiatric conditions).  So if the mind is to stay privileged, then there must be something extraneous that applies to those with psychiatric conditions, but not you.  In short, there must be a moral failing.

Psychiatry lies at the juncture between science and philosophy.  The two tease it in paths that often intersect, but do not follow the same course.  So what happens when you mix up the languages of the two?  What happens when you try to render the subjective into objectivity, and vice versa?  For example, if you are convinced the subjective can be wholly explained objectively, then the language of values becomes fact - moralisms have the same truth value as objective, external reality - and from that, the absurd destruction of the patient as the subject.  Now, the reverse is just as absurd - to approach the objective purely from the perspective of the subjective quickly leads one to incoherence and solipsism, such that the only counter is a swift rock cast at the offender.

Doubtless, there are more reasons.  The way I see it, unless psychiatry deals with the problems of the mind, and of its tension between the philosophical and the scientific, then it cannot do right by either the patient or the practitioner.  

[1]This is particularly egregious as scales for depression are tools meant to guide clinical judgement only, and rely on intertest validity.  There is no real "objective" third party validator in these tests, so the question of "are the kids faking it" quickly boils down to "are you even measuring what you're claiming to measure".

[2]Not to be confused with anorexia bulimia's pattern of binge-purging.