Metaphors in Our Mouths: The Silencing of the Psychiatric Patient

When she had reached the top of the stairs and had opened the door to her room and walked in, she could no longer pretend; she shrugged away the commonplace Yes No I see I understand, she cried, No, No, No, I’m a migratory bird.

—Janet FrameTowards Another Summer

A patient who turns up on a psychiatric ward on the more vulnerable side of the health care relationship often exhibits more distress than she might in less intimidating circumstances, and psychiatrists have learned to pay attention to how the health care situation affects their patients. But they have been slow to turn a reflexive gaze on their descriptive practices—particularly on their habit of judging their own descriptions of their patients’ experiences to be more accurate than their patients’. Psychiatrists have developed a powerful vocabulary to render their patients’ experiences medically intelligible and to carry out treatment, and its prevalence in psychiatric clinics is to be expected. But when those who speak this language assert its epistemic supremacy, much of its healing power is lost in a wake of alienation, disempowerment, and silencing. The patient loses her ability to speak with authority except to the extent that her language conforms to the standard medical discourse.

Such was my experience over the course of an involuntary detention at two institutions. I wanted very badly to get out, but I understood the grounds for my detainment and had no real argument against the decision to commit me. What I found distressing—what threatened to erode any composure I could manage in hospital—was not the involuntary commitment, but rather the distinct feeling of being unheard. Everything I said or did was taken to be a product of my illness and categorized accordingly. I had questions and worries and thoughts and even a good deal of imagination, but I was cut off from all meaningful conversation by the veil of my diagnosis, through which my speech and behaviors passed before doctors and nurses heard, saw, and interpreted them. There was a clear and distinct vocabulary being used to talk about my experience, and that vocabulary was not mine. But by adopting it, I began to regain some standing as a speaker worth listening to; I was then judged to exhibit that peculiarly esteemed quality psychiatrists call insight. This meant, in effect, learning to see and speak about myself and my condition as my doctors and nurses saw and spoke about them, forsaking the uniqueness of my own perspective, understanding, and expression.

I denied suicidal ideation, talked about creating support systems outside the hospital, swallowed SSRIs, discussed setting and meeting goals and making progress in therapy, assured authorities I would comply with my treatment. All the while, a gulf widened between the self I was able to be outside the hospital and the self I had to present inside. I spoke as I knew I had to in order to be heard, aware of the dishonesty that saturated every obeisance and distressed that I was losing a sense of wholeness, splitting apart the young woman whose religious and existential crises had precipitated a desperate self-assault and the young woman who pretended that group therapy was interesting and helpful in order to move a notch further toward her discharge.

The philosopher Naomi Scheman writes that “those in subordinated, marginalized, or closeted social locations” learn that, in order to be taken seriously, they must adopt “the privileged ‘view from nowhere,’” speaking as if they were outside themselves.¹ This silencing effect should worry us both because it contributes to the marginalization of unique voices and because a person’s recovery from mental illness depends so critically on an ability to reestablish a functioning self, engaged authoritatively with the aspects of the person’s life that are most meaningful. In compelling psychiatric patients to adopt a “view from nowhere,” practitioners pressure them to become alien to themselves and may end by creating minds more fragmented in perceiving and speaking than those that first turned up for help.

Provisional Truths

As a picture of a patient’s experience, a psychiatric diagnosis and...