Institutionalising Personhood: Biomedicine, Illness Narratives and the Negotiation of Meaning

Institutionalising Personhood: Biomedicine, Illness Narratives and the Negotiation

of Meaning

AbstractIn their current forms, biomedical and medical anthropological approaches to understanding the mental illness experience are outdated and insufficient for their aims. "rough modelling themselves on traditional “hard-science” approaches, the reliance upon objectivity that is supposed to afford each a degree of methodological credibility serves to deepen con$icts between individual and institutional negotiations of meaning in the mental illness experience. "e innate subjectivity of humans cannot be reduced to objective components and continued insistence upon the use of such an approach culminates in a struggle for power in which the authenticity of both institutional and individual narratives is called into question. Meanwhile, the original intention of understanding mental illness is pushed into the periphery as individual and insititution each attempt to navigate the mental health experience, negotiate meaning and establish their own narrative as dominant. Biomedicine must revise its determinist approach and %nd a way to marry soft and hard scienti%c approaches so as to remain as malleable as mental illness understanding demands, lest it remain un%t for purpose and condemned to failure.

Keywords: biomedicine; illness narratives; institutionalisation; mental illness; personhood; poststructuralism

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IntroductionUnderstanding the mental illness experience is a relatively modern pursuit within biomedical practices today, with afflictions of the mind having historically been either sidelined or created as a means to serve political ends (Foucault 2003). Female ‘hysteria’ , for instance, was as much a tool to constrain the female body to the demands of traditional ideas about femininity as it was an attempt to understand how physical processes such as hormonal changes may affect temperament and emotion ( Jutel 2010). Medical narratives are malleable across space and time and as such, illness categories must be assessed in their own context. Here, though, the cultural dimensions of medicine are not discussed and instead I direct you to the rich studies of Gaines and Davis-Floyd (2004); Fadiman (1997); and Kukla (2005). Rather, this paper argues that biomedicine creates categories to explain phenomena at odds with existing knowledge and thus constructs a $awed discourse, professing to explain away gaps in biomedical knowledge as the result of individual rather than institiutional $aws. Biomedicine models its own approach to understanding the complexities of the human body upon the “hard” science approach of observing objective realities through an analysis of physical matter. "is analysis at the material level is adequate for the assessment, diagnosis and treatment of physical afflictions but insufficient when applied to the mental illness experience. By forgoing the innate subjectivities of human feeling which lie at the core of the mental illness experience, biomedicine creates a super%cial understanding of afflictions of the mind and thus condemns itself to failure when looking to adminster treatment considered suitable based on this premise. Medical anthropology, with its grounding in the soft-science approach, has the potential to school biomedicine on remedying these shortcomings by way of recognising the value of these rife subjectivies as a means to better understand the mental illness experience. In practice, however, medical anthropology has sought to establish itself as a more legitimate and scienti%c approach than it was once considered and in the process, has partially aligned itself with the biomedical, hard-science approach that is grounded in assigning the objective as authentic and the subjective as folly. In pandering to claims that the soft-science approach exists in opposition to legitimate science, medical anthropology has compromised one of its most valuable methods for understanding the mental illness experience. Here, then, I argue that a marriage of the two which reestablishes the objective and subjective as equally important in understanding the mental illness experience could better serve instititions and individuals alike. Of course, where medical anthropology works to the context of whichever biomedical institution it is implicated within, it is biomedicine that must take the %rst steps towards this new

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approach. "is could be problematic for two reasons. First, biomedicine is not unaware of its shortcomings and as such, has located its weak points and created a language and discourse which obscures them. At the same time, through exclusive semantics, individuals are considered bewildered through their ignorance of medical terminology, reproducing a discourse of power and authority of knowledge which seeks to establish biomedical and thus institutional understandings of the mental illness experience as superior to individual understandings of the same as each looks to negotiate meaning. Second, clinical practitioners as agents of institution are considered more credible than individuals. "is individual ‘ignorance’ is blamed for the failings of institutions and a biomedical approach ill-equipped to deal with the mental illness experience. Ultimately, where biomedicine looks to establish its own concepton of mental illness as dominant and does so in the name of ‘cure’, in reality the causes and symptoms of the mental illness experience itself have not been readdressed but merely reimagined. Of course, biomedicine is not beyond salvation. However, it is only through an intelligent and informed marriage of biomedical and medical anthropological approaches that the divisive binaries between objectivity and subjectivity can be reconciled. Forging an inclusive discourse that operates along the fault lines of biomedical capability and the individual/institutional negotiation of meanings in the mental illness experience is imperative to handling mental illness in a way that is bene%cial for both patients and practitioners alike.

De!nitionsMental illness as discussed here is de%ned according to the World Health Organisation (WHO) framework as used by social scientists and medical practitioners worldwide (Larsen 2004). ‘Mental illness’ and ‘mental health’ serve as umbrella terms for a diverse group of health complaints pertaining to the mind as part of a larger conception of overall health that collapses mind-body dualism, reiterates the importance of mutually informing states of physical and mental health, and de%nes each as crucial to ‘a state of complete physical, mental and social well-being, and not merely the absence of disease’ (World Health Organisation 2015). While existing mental illness categories are later deconstructed as being culturally and contextually variable and thus demonstrative of their innate subjectivity, it is necessary to begin such a critique by presenting these mental illness categories as they currently exist. In doing so, the contemporary institutional reality of clinical conceptions of mental illness are brought to the fore,

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before subsequently introducing alternative approaches necessary to improving the biomedical handling of mental illness and individual realities.

Later, a discussion pertaining to the “hard sciences” refers to traditional scienti%c approaches grounded in the observation of phenomena as evidence. "at is, the analysis of observable, immovable and de%nite processes concerning chemicals or matter such as is found in physics, chemistry or biology. Seen to hold more academic rigour, these approaches hold something of an unrequited opposition to the ‘soft’ social sciences (Wilson 2012), which in their concern for inherently volatile and subjective human processes cannot work on the same premise. Here, I argue that the ‘soft’ and ‘hard’ sciences hold equal value but their effectiveness in different contexts render them incomparable. Where biomedicine aligns itself with the ‘hard’ sciences’, an approach appropriate only for the objectivity of physical afflictions (and one that obscures the fact that medicine is no more culturally impermeable than anything else (Gaines and Davis-Floyd 2004)) there must be a call for greater incorporation of ‘soft’ scienti%c approaches in dealing with mental illness; a biomedical category which in reality is largely subjective and interpretative.

Finally, clinical medicine and biomedicine are terms used interchangeably to denote that which relates to biology and medicine in the traditional clinical setting - for instance, GP services, hospitals and institutions where patients are treated by physicians (Bittar and Bittar 1997).

Background"ough written from the perspective of someone who has been implicated within the English biomedical healthcare system as a patient following a diagnosis of rapid cycling bipolar disorder as a teenager, this paper does not draw from this experience as either observational or anecdotal evidence of any argument presented here. Instead, in the spirit of full disclosure, this paper argues from a relatively ‘niche’ angle that goes some way to reaffirming the need to bridge the divide between observation and experience. While the approaches offered by medical anthropology have an invaluable contribution to make in the arguments for reforming biomedical approaches to mental illness as presented here, many of the problems surrounding biomedical conceptions of mental illness are present in the approaches used by medical anthropologists also. Ethnographic data collection is particularly problematic in the realm of mental illness in that distinguishing between what people say and what they do is ampli%ed. Or rather, the division between what individuals say they do and what anthropologists say they do

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is ampli%ed. Unlike physical afflictions, mental illness cannot be observed at its root and it may be that mental illness behaviours have a cultural habitus just as much as any other element of life (see Mauss 1973; Bourdieu 1990; Mudge 2007). Certainly mental illness has a language just as any other medical category, and in trying to formulate an alternative representation of mental illness narratives that incorporates individual meanings alongside the institutional (as opposed to viewing the two as oppositional), medical anthropology still operates within a pre-established medical discourse which excludes the untrained individual from participation. What biomedicine and academia alike deem colloqiualisms in need of revision and translation into formal language are in actuality the rawest, most untampered representation of the realities of individuals concerned. Medical anthropological approaches may be just as guilty as biomedicine in reproducing feelings of inferiority that accompany being reduced to a passive recepient of medical knowledge designed to replace one’s own. "is paper argues for the reformation of biomedical and medical anthropological approaches to the handling of mental illness, neither of which in their current state can serve the individuals they claim to work for.

Medical Anthropology and BiomedicineSince the 1970s, medical anthropology has undergone radical changes so as to be accepted as a legitimate branch of the anthropological discipline and as a self-supporting discipline in its own right (Gaines and Davis-Floyd 2004). As a social science - a ‘soft’ science - anthropology does not coexist easily with the self-labelled ‘hard’ science approach of biomedicine. As such, medical anthropology has grappled with the dilemma of legitimating itself through the adoption of traditional scienti%c approaches grounded in ‘observable objectivity’ whilst retaining the recognition of human subjectivity that necessitated the direction of an anthropological gaze towards biomedicine in the %rst place. "ese methodological changes have spurred the increasingly critical lens through which medical practices are viewed and as such, medical anthropology has not been cautious to highlight perceived shortcomings of clinical medicine in particular (ibid). From Farmer’s idea that it is frequently a relabelling of poverty from which individuals suffer rather than any ‘true’ sickness (2001), to Scheper-Hughes assertion which, in much the same vein as Farmer, suggests that the medicalisation of socio-political issues de$ects from state failings (2007), medical anthropology seeks to locate and separate the complex interplay of remedy and hegemony within clinical medicine. Here, I turn this critical lens inwards. Indeed, what

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are the obstacles to credible ethnography? How can representations of individual illness narratives preserve the agency of these individuals any more than the at times oppositional institutional narratives of clinical medicine? "e issues discussed throughout this paper may often be applied to ethnographic research more generally of course, but for the purposes here are discussed within the sphere of medical anthropology speci%cally. It would be undeniably hypocritical of the medical anthropologist to claim their approach as superior, particularly when one considers that the issues facing ethnographic representation share a great deal with those of the heavily criticised biomedical domain. After all, where complete and universal representation of every observed or recorded event, discussion, movement (or anything else) is impossible, practicality alone demands emittance in some form, lest encyclopaedia-style volumes are to be published on every research endeavour. Of course, certain patterns or meanings may be extracted based precisely upon these omissions (LeCompte and Schensul 2013), and it is here that the anthropological and cultural lens becomes apparent. "e anthropologist is tasked with distinction; with choosing between what they consider signi%cant enough to warrant inclusion and as such, an alternative representation of reality is constructed on behalf of the individuals such work looks to represent. Biomedicine, though for different reasons, shares this problem and as such, Foucauldian conceptions of clinical medicine serve as a springboard here. While Foucault made no pledge of allegiance to medical anthropology - or indeed, to anthropology in general - his disdain for biomedical approaches has regardless been hugely in$uential in the %eld. Clinical thinking demands compliance with a particular mode of analysis: conveyance through the use of medical language rather than colloquialisms and the reduction of the human being into a human body are the most notable. For Foucault, clinical thinking is characterised by its integration of picture into structure (2003). "at is, physical afflictions of the body as viewed under the clinical gaze, made sense of through a combination of established illness categories and semantics, and articulated through ‘the essential language of disease’ (p. 138). Under the medical gaze, physical afflictions form a picture of sickness as it is conceptualised and shaped in material terms and through this reconstitutes the body into a site of sickness. "e objective physical affliction may be mapped upon the body as it is reduced to a site of physical illness, but for the relatively hidden conceptualisation of mental illness which is experienced, somatised and manifested subjectively, this approach as evident in the hard science approach of biomedicine is insufficient. Unfortunately, a refusal to recognise individuals as agents rather than merely as passive receptacles of the medical gaze serves to place Foucault in the same category of superiority he seeks to challenge and thus is a central

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%gure in the discussions presented here. It is precisely this stubborn objectivism and reduction of ‘the sick person’ into ‘the sick body’ that further compounds the problematic components of the mental illness experience. If biomedicine is to handle and understand the mental illness experience completely, this approach must be revised. It is here that biomedicine may do well to adopt certain faucets of the medical anthropological approach to conceptualising the mental illness. Certainly, the biomedical focus must shift from how it is perceived to how it perceives.

"e Biomedical versus Medical Anthropological ApproachWhere institutional narratives frequently trump those of the individual through their legitimacy and authority of knowledge, medical anthropology seeks to provide the necessary bridge between individual and institution alike, affording each an equal opportunity to present their account of the re$exive relationship that exists between them.1 Although any contest over meaning between individual and institution will swing unfavourably from the former, it is not that individuals are passive when placed in mental health categories but rather that they are untrained in how to navigate them. It is possible to adopt the language of medicine so that it may be subverted into a weapon of empowerment, and it is precisely this that should be the task of the medical anthropologist. On the one hand, medical anthropology seeks to view situations holistically, assigning proportionate attention to all individuals concerned, and attaching meaning afterwards. In this regard, biomedical approaches can learn much from the human-centred approach of medical anthropology. "ough clinical medical narratives and individual narratives often constrain their absorption of external meaning to that which %ts with their own conceptions of mental illness, as patients negotiate meaning in the realm of clinical medicine rather than the other way around it is biomedicine that must make allowances for digression and take the %rst steps towards a reconciliation of individual and institutional narratives. Likewise, where medical anthropology studies biomedicine analytically, it must work within existing structures pertaining to clinical medicine. As such, medical anthropology will follow the biomedical lead and thus any revised approach must, again, %rst begin with biomedicine.

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1 "e Foucauldian concept of the authority of knowledge regards the term power/knowledge and relates to the reproduction of power through the production of forms knowledge considered dominant, held to be correct, and thus able to exert authority over other forms of knowledge (1988). Likewise, individuals who possess such knowledge are able to assert power and dominance through the same. For instance, medical practitioners have the authority of knowledge in the clinical setting in comparison to the patient and thus are able to establish their own conceptions of sickness as dominant over those of the patient.

Mental Illness and the Biomedical ApproachIn their current form, neither biomedical nor medical anthropological approaches are effective in understanding mental illness; likewise, these shortcomings hinder biomedical capabilities for treatment of the same. Biomedicine - indeed, all medicine - establishes whether an individual is sick based upon universally de%ned illness categories as the primary referent. Once sickness is located and de%ned, biomedical approaches turn their full attention to treatment with a %nal look to remedy. For physical ailments, this consultation-cure trajectory is the swiftest path to absolution: locate the problem, monitor its condition and treat it accordingly. With observable symptoms acting as evidence to quantify both the severity of sickness and progress made towards healing, biomedicine generally serves those with non-terminal physical afflictions well. Good (1994) describes this process as medicine creating a formula of both disease and the physical self: the body is mapped, and sickness is formulated in the clinical setting in materialist terms. Of course, illness of the mental self works differently. Biomedical preoccupations with creating salient categories (Gaines and Davis-Floyd 2004) do not readily translate into conceptions of mental illness; a sickness located within the mind and as volatile, subjective and immeasurable as the very site it exists within. Mental illness, if viewed as a sickness located within the mind, is volatile and immeasurable. Much diagnosis comes from approximations and interpretations based upon external displays believed to be related to an internal illness which follows the hard science approach of using observable phenomena as a means to place symptoms - and individuals themselves - into an objective and precise illness category. To best summarise the biomedical approach: it works by establishing itself upon a foundation of traditional hard-scienti%c approaches where conclusions and diagnoses are drawn from observations, and remedies are geared towards the alteration or expulsion of immovable or predictable matter considered $awed, problematic or unruly. In the name of clinical accuracy the body is reduced to its component parts, and studied at the smallest and most basic anatomical level. Components of the physical body may be extracted and studied at the microscopic level such as in histopathology, or analysed whilst still attached to the body (for instance, through MRI scans or examinations by a GP). Reduction of this kind may provide a degree of analytical predictability in afflictions of the physical body that pertain to changes in bodily tissue or chemical balance, such as fractures de%ned always by physical bone damage or cancer as the rapid division of abnormal cells. Certainly, components of the physical body may also demonstrate universal inevitabilities as can be found in traditional hard sciences, such as combustion when mixing oxygen and hydrogen. Mental afflictions are different, however, and herein

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lies the problem with traditional biomedical approaches to the diagnosis and treatment of mental illness.

Sickness as a Categorical De!citIn biomedical practice, the diagnosis of mental illness works only because of the widespread assumption that there is a ‘correct’ way of being; a correct way of internalising environments; a correct mode of processing events; a correct emotional response. "is is a partial truth, particularly at the societal level. Medicine – and particularly the sick body – are not socially or culturally impermeable (Gaines and Hahn 1982) and as such, there are certain modes of performing sickness. Rather than discussing the cultural dimensions of medicine (instead, I direct you towards the work of (Petryna 2004), (Salonsalmi et al. 2009) and (Scheper-Hughes 2007)), mental illness behaviours used to help diagnose mental illness are in reality the display of a social ill in that they prevent individuals functioning in wider social life as opposed to necessarily inhibiting their function at the personal, anatomical level.

Physical manifestations of mental illness generally appear after the illness has already taken hold and are a representation of the illness as it exists elsewhere, unlike directly observable sicknesses of the physical body such as broken limbs or tumours. As a result, physical symptoms of mental processes may be more easily misinterpreted and misunderstood than physical symptoms of physical processes. Where physical afflictions may be treated using the observe-diagnose approach, addressing mental illness using the same method carries great risk. Human beings cannot be reduced to any single component. Existence alone is dependent on thousands of simultaneous reactions and processes that cannot exist exclusively of one another. Physical illness may be located and assigned to a particular ‘$aw’ in ones physiology; mental illness comprises a multitude of mutually enforcing factors that cannot be viewed in isolation. "at is, behaviours themselves are not the illness and herein lies the problem with biomedical approaches that centre around observable phenomena. Where the human mind cannot be deconstructed and stripped down to component parts in the same way as the physical body, biomedical approaches alone are not sufficient for either diagnosis, treatment or understanding of mental illness. Indeed, the complexity of mental illness surpasses any known medical approaches and this is precisely due to the complexity of human beings themselves. Mental illness may manifest partially through the physical body but this is frequently what I shall refer to as a response-symptom: the physical body becomes a vessel for the performance and embodiment of mental illness. "ere may be no impairment to

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function at the physical level, but rather at the level of what constitutes social acceptability. Individuals in the middle of a psychotic episode may be, in purely anatomical terms, in perfect health. "is is not to say that the mind and body exist separately, but rather that the mechanics of human function and motility are not necessarily affected by mental illness. "e behaviours that result from, for instance, psychosis - to speak metaphorically, through the power the mind has over the physical body - are rather a social impairment in that they frequently veer into the realm of social unacceptability and noncompliance. "e operative word here is, of course, noncompliance: in the contest over what it is to ‘be’ mentally ill, the mere adoption of institutional narratives and conceptions of mental illness may be the ‘cure’ biomedicine claims to possess.

Foucault’s concept of Panopticism holds some stock here. In the clinical setting, biomedicine subjects individuals to the medical gaze and assigns them a condition of health. Outside of the clinical setting, reminders about what it is to be healthy or unhealthy are present on television, street billboards and school syllabuses. "us, biomedicine becomes omnipresent, with the intention that individuals will internalise a desire for ‘good’ health by self-monitoring and complying with clinical guidelines as a means to achieve this optimum standard of health (1995). Although biomedicine certainly does reproduce and disperse its knowledge through clinical institutions, such claims by Foucault reduce individuals to the sum of their body and does a disservice to the agency of patients and clinical practitioners alike. Further, in reducing individuals to merely a body without agency or capacity for constructing their own realities in the face of contest coercing them to do otherwise, his claims once again reproduce the techniques of the biomedical realm he is so keen to criticise. Let us revisit Foucault’s authority of knowledge here. Where biomedicine cannot fully grasp mental illness based upon its current methodological approach, medical discourse and language go some way to obscuring its shortcomings. "rough this, a failure to communicate through the medical mouthpiece unfamiliar to those struggling to make sense of their mental illness experience as outsiders may be considered a failure of the individual and thus detract from shortcomings of institutional understandings of mental illness. In turn, individuals subject to biomedical pressures to adopt the institutional conceptions of mental illness in place of their own may somatise, and come to embody, the medical discourse applied to them during the vulnerable period in which they simultaneously seek an autonomous route to understanding undesirable mental processes whilst relying on biomedical knowledge to provide relief from symptoms they perceive as unpleasant, threatening or interfering. "is poststructural critique may serve

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as a metaphor for the often opposing but not necessarily antagonistic approaches of clinical medicine and medical anthropology.

Poststructuralism as MetaphorBy aligning itself with the hard-science reliance on objectivity and observation (and thus on physical explanations of physical and mental afflictions alike), biomedicine shares much in common with the structuralist approach as it is found in anthropology. Indeed, Blackburn summarises structuralism as a belief that surface phenomena are the result of constant, rigid laws regardless of how abstract they may initially appear (2008). "is is not dissimilar to observing symptoms (or signi%ers) as they manifest upon the physical body as indicative of certain illness categories (or the signi%ed). Biomedical semantics interpret this language of the body into a medical langue, translate it into medical parole as used by clinical practitioners when addressing their patients and thus create a precise medical discourse as related to the authority of knowledge discussed previously. De Saussure’s structuralist explanation of language as central to the world we inhabit and the essential instrument through which we constitute and articulate our world (Harris 1988; De Saussure 1995) is, again, an apt metaphor for a biomedical approach that reproduces its power partially through this exclusive discourse. While something of an insistence by biomedicine to establish its own narrative as dominant through this technique is critiqued by medical anthropologists (Fadiman 1997), they themselves are well versed in working to a particular semantic framework and may provide the missing link with which to reconcile individual and institutional negotiations of meaning in the mental illness experience. "e medical anthropological approach to understanding the mental illness experience is more closely aligned with the poststructural tradition. "at is, the innate subjectivity of human beings cannot be measured through existing analytical structures but where individuals are implicated within these same structures, no separation is possible (Poster 1989). Instead, medical anthropology must navigate the narrow corridor between the institutional meaning and individual meaning of mental illness experience. "e same metaphor could be applied to physical (structural) and mental (poststructural) illness and thus it is clear that rather than orbiting one another, each approach should merge and apply as necessary their respective diagnostic and understanding procedures. Further, where each approach can be found within the anthropological discipline, it is clear that its sub-branch of medical anthropology may provide the malleability and mediation that any useful approach to understanding the mental illness experience demands.

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Institutional Compliance"ough individuals experiencing mental illness are not merely passive vessels thrown to the mercy of biomedical institutions - indeed, patients and clinical practitioners alike share a mutually active and re$exive role in understanding the mental illness experience - understandings of illness vary across space and time, and in relation to particular dimensions of mental illness being discussed (Larsen 2004). Aside from the contest between individual and institutional quests for meaning in the mental illness experience, biomedical treatments of mental illness may lead to the compromise of personhood for individuals implicated within the medical system as patients and clinical practitioners alike. Any approach that may undermine or manipulate individual ideas about the self demands a critical analysis such as I undertake now. It is important to reiterate that neither individuals nor agents of institutions are passive recipients of medical doctrine, nor that either are immune to institutional in$uence. Rather, individuals may actively resist their diagnosis just as clinical practitioners may look for ways to circumvent medical convention in order to better serve individual patients for whom blanket medical conceptions do not suffice. "e relationship between individual patients and their doctors is as complex as it is re$exive; a $uid journey of autonomy and the negotiation of meaning evident in Larsen’s two year study of young Danish adults recently diagnosed as being on the schizophrenic spectrum following their %rst psychotic episode (ibid).2

At a hospital in Copenhagen, the Danish biomedical healthcare system pioneered an early intervention program called OPUS, designed to treat young people recently diagnosed as being on the schizophrenic spectrum following a %rst-episode of psychosis (ibid). Treatment is tailored to individuals, prescribing the lowest possible drug dosages

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2 Schizophrenia is a psychotic disorder, categorised as a severe mental illness. Individuals experiencing psychosis generally struggle to understand reality (Mueser and McGurk 2004) or at least, individuals experiencing psychosis struggle to attach or articulate meaning to their reality in a way that is comprehensible to others. While hallucinations and delusions are a common part of the mental illness experience for individuals with schizophrenia related psychosis (Longden et al. 2012), the concept of ‘delusion’ is one this paper struggles to support. To experience anything is to con%rm it as a reality as authentic as any other, and it is within biomedical conceptions of the mental illness experience that the failings of an objective approach become apparent. Visions may not be of the physical, material world and yet biomedicine attempts to assess them based on the same premise as exactly that: physicål afflictions of the material world. Of course, the experiences categorised as delusions or hallucinations are not be observable to anyone else and as such, are dismissed by biomedicine as being ‘not really there’. "at individuals do see, hear or experience particular sensations thus con%rming they are real means little: these individual narratives fail to comply with institutional understandings of the mental illness experience and as such are translated into the language of biomedicine, reimagined and translated back to the individual in an attempt to recon%gure their own understanding of their own %rst-hand, mental illness experience.

coupled with therapy and counselling. "erapy largely initially takes place within the hospital setting but, once individuals make noticeable progress towards restoring their mental health, therapy may take place in more neutral or informal settings such as cafes or parks. Initially, individuals appeared to seek empowerment and found ways to incorporate their illness diagnosis into their personality so as to reaffirm their autonomy and stake a claim to their own personhood. At least in the beginning of their treatment, no patients considered themselves de%ned by their illness but rather as individuals who happen to have psychosis as an additional, rather than fundamental, faucet to their sense of self. One young patient, Claus, found that the biomedical concept of “racing thoughts” (tankemylder) served as an accurate description of the sensations he experienced during his psychosis. "at this sensation was not exclusive him but common enough to warrant its own semantic component in medical linguistics was a source of comfort for Claus, who stated that “you can put your thoughts and emotions into words. You can categorise them and say ‘this is this, and this is this’” (ibid: 459). For Claus, the objective biomedical approach of categorisation provided stability during a turbulent stage of his life, thus providing feelings of relief and security often denied to individuals by their experiences of psychosis. Self-labelling processes are an important element of negotiating meaning during mental illness experience ("oits 1985) and where biomedical approaches may alone lack the ability to make sense of these experiences in a subjective and $uid way in-keeping with the human experience, it is clear that the current hard science approach of biomedicine can be bene%cial when considered supplementary, rather than central, to the quest for meaning. Over the course of their in-patient period, and for numerous reasons, a determination to self-label and de%ne psychosis as something situated within an individual context rather than on rigid biomedical terms faded for many individuals enrolled on the OPUS programme. However, for almost half of the program participants, a year after leaving the environment their role in self-labelling was strengthened once more (Larsen 2004). "is begs the question: does the institution consider a patients adoption of the institutional narrative over the individual an important element of the ‘curing’ process? Further, does diagnosis and treatment create an environment in which individuals come to embody their proscribed illness through constant reiteration of diagnostic validity?

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Frank was twenty years old when he was %rst hospitalised and diagnosed with paranoid schizophrenic psychosis. "ough not resistant to this diagnosis, Frank was convinced that the onset of his illness was related to heavy drug use, with his symptoms growing in frequency until present even when no drugs were in his system. Alternating between feelings of grandeur and intense paranoia, Frank occasionally found these experiences enjoyable but generally unsettling. Indeed, some time into his treatment, Frank disclosed his desire not to recount events relating to his psychosis due to the feelings of depression they invoked within him. Just over one year into the OPUS program, however, this changed. As a side-effect of the medication he was taking, Frank gained weight and grew more apathetic to the extent that discussing his period(s) of psychosis no longer invoked depressive feelings. Or rather, if they did, Frank no longer considered this severe enough to warrant his refrain from discussion (ibid). Several issues arise from analysis of these exchanges. First, that Frank initially recognised his experience of a psychotic episode as a negative one is telling in that it implies the ‘healthy’ mind and the ‘sick’ mind do exist in the same space and do not operate exclusively of one another. Frank was still receiving treatment and as such was not ‘cured’: his schizophrenia and psychosis were still seen to pose a threat to his own wellbeing as well as that of other people, and yet his lingering illness did not cloud what would generally be considered the ‘rational’ judgment of a healthy mind. Frank located his illness, recognised its negative consequences and largely aligned his own conceptualisation of it with the biomedical perspective of schizophrenia. In other words, Frank essentially complied his way into embodying the model patient. At the same time, Frank embodied the model citizen as best he could whilst also seeking to embody himself as an independent individual. Post-diagnosis, Frank continued to pursue his own interests and work part-time whilst receiving state welfare (kontanthjœlp). "e biomedical approach further intervened anyway.

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During treatment, illness narratives vary across space, over time and depending on the dimension being discussed. "is owes itself partially to innate human volatility, partially to the altered chemical processes brought about by drug and therapy treatment programs, and partially to the insecurity of being removed from ones environment and subject to daily monitoring. Indeed, the very nature of biomedical treatments, particularly when administered to in-patients within the institutional setting, transforms lifeworlds into the same standardised and routine experience that is typical of

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biomedicine more generally. While perhaps an attempt to offer stability to individuals undergoing the transition from ‘sick’ to ‘well’ (and possibly repeating the process several times), the uniformity of this goes against human tendencies for subjectivity, volatility and inconsistency and in doing so infringes not just upon the path of human instinct but upon personhood and opportunities to control one’s own life. "at is, the ‘outside’ world is more chaotic and unpredictable than the hospital environment where individuals receiving treatment for mental illness recover. In-patients became ill ‘outside’ the institution and thus the transition from ‘sick’ to ‘well’ as mentioned above could in itself threaten individual wellbeing further. Where Claus found the stability of biomedical objectivity comforting in that it illustrated the medical - and therefore ‘curable’ - nature of experiences he considered unpleasant, when viewed in isolation the bene%ts of biomedical approaches based upon Claus’ experience could be misleading. Illness narratives as they come to be understood in the clinical setting, as a result of both environment and their historical trajectory at the individual level, may become a self-ful%lling prophecy. On the one hand, anything that provides solace to individuals experiencing discomfort as a result of mental illness may be commended, such as where Claus considered the OPUS intervention into his period of psychosis a blessing rather than a curse. On the other, medical terminology lent some authority to medical conceptions of Claus’ experiences as ‘delusions’ rather than experiences considered real insofar as that they were experienced, and as such conceal a biomedical desire to establish its own narrative of the mental illness experience as dominant. Carr (1988) argues that when individuals experience delusions and psychosis-related sensations, these are not illnesses in themselves but coping mechanisms set in motion by the mind to help themselves regain control and autonomy when in a subjective state they cannot understand. First, this suggests that mental ‘illness’ and mental ‘health’ cannot be separated but in fact exist in the same place, further complicating its treatment and reaffirming the idea that biomedicine alone is not sufficient for treating mental illness. Due to a clinical need to isolate components, hone in on the problem and begin treatment at the smallest possible level (Fordham 2015), biomedicine lacks the capacity for subjectiveness that is a necessary accompaniment to the objectivity of biomedical approaches. Second, one means for individuals to regain feelings of control and thus reassert their personhood in periods of mental volatility is to attach meaning to the experience (Carr 1988). Biomedical intervention that dismisses individual meanings in an attempt to coerce patients into adopting institutional conceptions of mental illness experience may further complicate individual understandings of the self and compound the emotional

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volatility that led to the disturbing phenomena experienced by patients. To move between the routine security of the clinical setting and the relative chaos of the larger world may eventually lead to feelings of insecurity in both environments, further compounding the volatile nature of mental illness experience as a daily reality. Illusory patterns are more likely to be perceived by individuals who feel as though they lack control over themselves, their environment and their lifeworld (Whitson and Galinsky 2008). Hallucinations characteristic of psychosis are a ‘window into the mind’ in that they generally feel uncontrollable and spontaneous (Luhrmann 2011). "ough there is little consensus on why hallucinations occur, the biomedical community widely agrees on what hallucinations are: the experience of internal sensory stimulus as if physically material and perceived as an external source of experience. As Luhrmann asserts, hallucinations are not necessarily the result of some cognitive $aw but rather the interpretation of mental experience as a physical experience (2011). Considering this could serve as a metaphor for biomedical understandings of the mental illness experience, why does biomedicine insist on calling such experiences ‘delusions’ or ‘unreal’? While the source of experience may be misplaced, the experience itself is as real as if the source was physically material. As such, to tell an individual that their perceptions are incorrect or unreal surely cannot serve to improve their feelings of mental wellbeing. Indeed, for Frank, a contest between individual and institutional meanings of mental illness experience followed this exact trajectory. While it could be assumed that Frank would change his outlook following his treatment - after all, the treatment was itself designed to alter his mental processes to some degree - the biomedical intervention that took place in reality was a subversion of Frank’s willingness to cooperate with clinical conceptions of his own illness. Considering Frank’s conviction that his use of street drugs was what led to his development of schizophrenia induced psychosis, alongside the OPUS programs alleged commitment to prescribing only the necessary levels of clinical drugs, the situation Frank found himself in just over one year into the course of his treatment is curious. Markedly more apathetic than when %rst diagnosed, Frank’s general indifference led to a willingness to discuss his psychotic episode that he once avoided due to the depressive feelings such recall would instill within him. Although treatment may have encouraged Frank to accept his illness as an unavoidable reality and therefore spur discussion of it rather than avoid the subject entirely, a desire to forget traumatic or undesirable experiences is a reaction that biomedicine recognises elsewhere as being healthy, natural and expected (Leibman 1941).

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Humans generally possess an instinctive desire to maximise pleasure and avoid pain (Louch 1969; Bailey 2013) and thus where Frank negotiated his own meanings of psychosis as he experienced them %rst-hand, recognised psychosis as problematic and thus sought to distance himself from it whilst still undergoing treatment, it is clear that his ‘healthy’ mind and ‘unhealthy’ mind cannot be separated and thus exist in the same space. It is perhaps the very idea of ‘curing’ mental illness that lies at the very core of a biomedical inadequacy to serve individuals diagnosed with the same. Instilling within an individual the hope that one will be able to return to their former self may worsen insecurities and emotional volatility to a greater degree in that when symptoms do persist, the meaning negotiated by individuals as a response to the institutional conceptions of the mental illness projected upon them may be rendered meaningless. To reiterate "oits, the negotiation of meaning during mental illness experience is an important mode of reclaiming personhood for individuals going through the mental illness experience %rst hand. "e ability to make sense of these subjective experiences is unavailable to biomedicine in its current deterministic approach and as such, biomedical and medical anthropological approaches must be reconciled. It is only through the mutual application of each approach that individual and institutional narratives are recognised for their respective value in particular contexts; an application that is imperative to serving individuals and institutions alike as they navigate through the unpredictable terrain of mental illness experience.

ConclusionWhere the hard science approach of biomedicine is designed to treat the biological self, the innate human subjectivities only recognised by soft sciences are forgone and instead replaced with the medicalisation of emotion and a medical discourse in which ‘emotion’ is nulli%ed and translated into a ‘symptom’. "is is not to say that biomedicine is completely inadequate when it comes to understanding and treating the mental illness experience; indeed, mental illness is still so relatively mystical that claims both for and against the suitability of biomedical approaches are somewhat fastidious. Instead, I suggest that biomedicine somewhat medicalises human emotion and in doing so further muddies the relationship between external and internal factors in the degradation of mental health, whilst at the same time sabotaging itself by seeking to understand this relationship using an approach doomed to fail by its own rigid objectivity. From the issues discussed here, it is clear that biomedicine must take some lead from medical anthropology in humanising its approach and recognising the need to incorporate subjectiveness into its conception of the mental illness experience.

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If the approaches of biomedicine and medical anthropology are to be reconciled, there is much promise for a greater mutual understanding of institutional and individual understandings of the mental illness experience and the meanings negotiated as a result. For this to take place, short of banishing it altogether, the authority of knowledge must shift from its position in any one camp. Any diagnosis and understanding must be context dependent and must take into account the multiple and variable factors that lead to, and later constitute, the mental illness experience. Finally, and perhaps most importantly, it must be reiterated that current biomedical approaches in their current essentialist form must be revised where the human mind is perhaps the best metaphor for an embodiment of relativism. Fortunately, it is no great task to marry the biomedical and medical anthropological approaches towards understanding the mental illness experience with a look to understanding afflictions of the mind in a way that serves institutions and individuals equally.

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