The Need for Relational Authenticity Strategies in Psychiatry

Psychiatric disorders involve changes in how you feel, think, perceive, and/or act—and the same goes for psychotropic medication. How then do you know whether certain thoughts or feelings are genuine expressions of yourself, or whether they are colored by your psychiatric illness, or by the medication you take? Or, as Karp (2006) nicely sums up the problem: “if I experience X, is it because of the illness, the medication, or is it “just me’?” Such “self-illness ambiguity” (Sadler, 2007) seems to be quite an ubiquitous problem in psychiatry (Estroff, 1989; Hope, Tan, Stewart, & Fitzpatrick, 2011; Inder et al., 2008; Karp, 2006; Singh, 2014). It is a very unsettling problem, moreover, and not easy to resolve.

In their article “Self-management in psychiatry as reducing self-illness ambiguity,” Dings and Glas (2020) carefully discuss the many sides of self-illness ambiguity. They point to the likely effects of how one conceptualizes one’s disorder on this ambiguity, and to the epistemological difficulties it opens up. When you cannot fully trust yourself, it makes sense to rely more on the people around you, in particular on loved ones, and clinicians. This makes dealing with self-illness ambiguity a social endeavor, which moreover takes place in a specific societal setting (with its stigma’s and identity issues) that affects these social processes.

Yet the solution Dings and Glas suggest does not do justice to the social dimension they describe. Like many theories, they eventually rely on individual reflection for achieving authenticity. To resolve self-ambiguities, including self-illness ambiguities, they argue, one should “reflect on one’s self-concept or deliberate on one’s self-narrative” and make it coherent (2020, p. 336). With a coherent self-narrative in place, we can decide whether experiences are internally motivated and thus authentic or not. Their solution thus relies on reflection, on changing one’s self-narrative, and on a conception of authentic actions as internally motivated, and of inauthentic actions as externally motivated. However, all of these are problematic, especially in the case of self-illness and self-medication ambiguities.

First of all, relying on reflection is problematic, because this reflection itself may be affected by one’s psychiatric disorder. Being depressed, for instance, not only affects your current experiences, but also colors your reflection on these experiences. Outside the psychiatric context too, reflection might not be the best resource for establishing authenticity. For the question who we are and what suits us typically comes up in emotionally charged times when we are precisely not the kind of rational, stable persons who can calmly reflect and deliberate. Dings and Glas do mention that we should not overemphasize the importance of reflection, but it is still the only route to the authenticity they recommend.

Similarly, self-narratives too may be part of the problem rather than the solution. Dings and Glas follow Schechtman (2007) in proposing that we should change our self-narratives to incorporate (unsettling) life-events. Although it sounds logical that we need to make sense of what is happening to us and that our self-narrative helps us to bring order to the chaos of our experiences, self-narratives do not actually help. A helpful self-narrative is the outcome of rather than the means to achieving authenticity. For the ambiguities in our experiences just as much concern our self-narratives too: there are competing self-narratives that are all compatible with the current situation, yet offer contradictory explanations of what is going on. Is it me, or is it my disorder? Is it me, or is it (the side-effects of) my medication? Can I enjoy my high spirits or should I be worried that I’m sliding into a manic phase again? Is it because I’m depressed that I don’t feel love for my partner anymore, or is our relationship not working? The problem in self-illness ambiguity is precisely that we do not know how to choose between such competing accounts of what we experience. And our self-narratives as such do not offer such grounds for choosing...