Diplomatic psychiatry?

by Arran James

The idea of psychotherapeutic ‘peace settlements’ (see here) seem close to the anarchist idea of arbitration and resemble something that might operate as a counter or autonomous psychotherapy. The problem for me comes if these settlement procedures were applied to orthodox psychotherapy and/or psychiatry where the patient is receiving treatment via legal detention or social coercion. Their proximity to Latourian diplomacy precisely puts them too close to agonistic procedures in which actual antagonism is obscured or naturalised as something to be negotiated.

The power differential, and the way psychiatric sovereignty operates via constantly displacing itself, mean that many patients have to seek advocates (esp. where the therapist or nurses fail in their often claimed advocacy position). The advocate, as in the peace settlement procedures, is a third who is introduced to the two-person adversarial situation of the institutional therapeutic space. Such spaces need not be hospitals, prisons, therapist offices or schools- the mobility of the clinic via community treatment means your the patients home can be a temporary meta-institutional space, wavering between being a clinical and extra-clinical space (and thus ambiguously importing and disturbing the situational norms regulating the behaviour of all parties).

In such cases the advocate is not a third brought in to reach a position of compromise, negotiated peace or other neutrality. The advocate is a partisan third who actively takes the side of the patient against the therapeutic agency. I say “therapeutic agency” because the patient will rarely come into contact with just one person, even at an initial assessment. By the time an advocate is even a possibility the patient will be firmly confirmed in their “patient” role from the perspective of the therapeutic agency, either as a good patient or a bad one.

The idea of a cultural translator might be a good idea in pragmatic terms however, given that we now understand (via transcultural psychiatry), that immigrant populations are often considered psychotic when formulating their (nonpsychotic) experience in terms, metaphors, structures of belief that would be considered perfectly appropriate in the context of their “home” culture.

So when looking at the idea of the peace settlement we have to consider where it is being deployed, and whether it is being deployed on a the basis of a spuriously  neutral pragmatism or one that begins from partisan fidelity to the distressed. Finally, a question that might scramble this in terms of psychotherapy is why the 2-person “consulting room model” (as David Smail calls it) needs to be retained. Except under exceptional circumstances where it was really too traumatic, we could ask why not prefer some form of group-work. And then, if group-work is too traumatic for the distressed person what makes us think they will tolerate even a third? Especially if the third were someone they knew (friends and family are often not really friends), or if they were appointed by the institutions themselves.