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UBC Theses and Dissertations

Making sense of a diagnostic category : a study of the relationship between theory and practice Maidstone, Peter 1981

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MAKING SENSE OF A DIAGNOSTIC CATEGORY: A STUDY OF THE RELATIONSHIP BETWEEN THEORY AND PRACTICE by PETER MAIDSTONE B.A., The University of Br i t ish Columbia, 1969 M.A., The University of Toronto, 1971 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE STUDIES (Department of Anthropology and Sociology) We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA September 1981 © P e t e r Maidstone, 1981 In p r e s e n t i n g t h i s t h e s i s in p a r t i a l f u l f i l m e n t o f the requirements fo r an advanced degree at the U n i v e r s i t y of B r i t i s h Columbia, I agree that the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e fo r reference and study. I f u r t h e r agree tha t permiss ion for e x t e n s i v e copying o f t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the Head of my Department or by h i s r e p r e s e n t a t i v e s . It i s understood that copying or p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l ga in s h a l l not be a l lowed without my w r i t t e n p e r m i s s i o n . Department The U n i v e r s i t y of B r i t i s h Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 i i ABSTRACT Members of sc ient i f i c discipl ines and lay persons alike commonly hold the view that the practical work carried out by those very same members is theory governed. The problem undertaken by this study was to observe, in a psychiatric hospital , the practical work of psycho-therapists, with the intent of characterizing the role played by theory in their work. An ethnographic approach was employed, and the research was focused on psychotherapy with patients diagnosed to be members of a single diagnostic category. The researcher began his fieldwork with the assumption that his knowledge of psychiatric theory would allow him to make sense of his observations. Contrary to his expectations, he was unable to discern the theoretical significance of the act iv i t ies that he observed. This led the researcher to conclude that there was a "gap" between his knowledge and his observations. The researcher devel-oped a number of plausible explanations for the "gap," none of which proved to be adequate. The "gap," in i t s e l f , raises a hitherto unacknowledged issue of the relationship between theory and practice. It is argued that the "gap" exists not only for the researcher, but also for any persons who would study a body of sc ient i f i c theoretical knowledge, and then observe what purports to be the practical applica-tion of that knowledge. . The "gap" seems to be integral to any theory-guided d isc ip l ine . The study explicates, i t is argued, a characteristic of sc ient i f i c work. The lack of an adequate explanation for the "gap" is not a fa i l ing of the study, but rather points to the lack of a i i i standard which specifies what "theory governed" means. Although the study presents us with a puzzle, i t does not put into question the efficacy of theorizing with respect to the accomplishment of practical work in the c l in ica l or any other d isc ip l ines. i v TABLE OF CONTENTS ABSTRACT i i ACKNOWLEDGEMENTS vi Chapter 1 INTRODUCTION 1 The Perspective 1 The Development of the Perspective 11 The Choice of a Diagnostic Category 18 The Research Setting 25 Access to the Research Setting 28 Methodology 34 The Data and Their Collection 35 Footnotes 53 2 DEVELOPING CONSTRUCTS: THE RESEARCHER STUDIES THE LITERATURE 58 The "Map": The Evolution of the Researcher's Perspective 58 The "Map" Becomes More Detailed 67 Paranoia Gets on the "Map": The Researcher Develops a Focus 70 Consolidating the Perspective 84 Footnotes 95 3 FIELDWORK BEGINS: THE RESEARCHER ENTERS THE RESEARCH SETTING 101 The Format of the "Story": Use of the Narrative Style 101 First Impressions 104 V Chapter Becoming Oriented to the Setting I l l Further Puzzles Emerge: The Problems of Making Sense 126 The Puzzles Are Compounded 138 Footnotes 153 4 THE PUZZLES ARE NOT RESOLVED: THE RESEARCHER OBSERVES PSYCHOTHERAPY 158 The "Paranoid's" Uncharacteristic Talk: The Patient's Talk Does Not Make Sense as Expected 158 The Therapist's Uncharacteristic Talk: The Therapist's Talk Does Not Make Sense as Expected 169 The Researcher's Talk 176 Attempting to Account for the Puzzles 17/9 Footnotes J 183 5 THE "GAP" BECOMES MORE EVIDENT: THE RESEARCHER IS UNABLE TO MAKE SENSE OF HIS OBSERVATIONS 186 Footnotes 210 6 CONCLUSION 212 The First Explanation 214 The Second Explanation 219 An Evaluation of the Explanations 234 Conclusions 241 Footnotes 259 BIBLIOGRAPHY 266 vi ACKNOWLEDGEMENTS I have been influenced by many social scientists in my studies and work in various academic inst i tut ions. I am unable to acknowledge individual ly , my debt to a l l of them. My Advisor, Roy Turner, stands out, however, as one who has had the most signif icant impact upon my thinking, and who has made an immeasurable contribution to the comple-tion of this work. I wish also to acknowledge the thoughtful crit icisms and suggestions of Adrian Marriage and Ken Stoddart who helped to shape this work by enabling me to c lar i fy my ideas. The staff and patients of "University Hospital" provided me with the means to carry out my research; to them I am indebted. I owe thanks to The Canada Council and other institutions that granted me financial assistance. My typist , Eleanor Lowther, fac i l i ta ted , in many ways in addition to her excellent typing, the production df this document. To her, I also owe thanks. F inal ly , I am deeply indebted to my family and most importantly my wife, Sheila Joy, who inspired me, advised me, and sustained me. To them, this work is dedicated. CHAPTER 1 INTRODUCTION The Perspective Hans Strupp, in his introductory ar t ic le to a major psychotherapy text, notes that psychotherapists are " . . . mental health professionals whose technical concepts (e .g . , ego strength, impulse control) . . . are ostensibly s c i e n t i f i c , objective, and value free."^ Later in his a r t i c l e , Strupp points out that: Techniques are of course the core and raison d'etre of modern psychotherapy and . . . are usually anchored in a theory of psychopathology or maladaptive learning. Psychoanalysis has stressed the interpretation of resistances and transference phenomena as the principal curative factor, contrasting these operations with the "suggestions" of ear l ier hypnotists. Behavior therapy, to cite another example, has developed i ts own armamentarium of techniques, such as systematic desensitization, modeling, . . . aversive and operant conditioning, . . . training in self - regulation and se l f - cont ro l . . . . In general, the pro-ponents of a l l systems of psychotherapy credit their successes to more or less specific operations which are usually claimed to be uniquely effect ive. A corollary of this proposition is that a therapist is a professional who must receive systematic training in the application of the recommended techniques. The above quotations i l lus t rate a perspective which is shared al ike by the psychotherapist, the social sc ient is t , and the lay person. Members of a l l three groups commonly hold the view that psychotherapy is a theory-governed act iv i ty . By this, we mean an act iv i ty which is deter-mined in a fundamental way by a body of sc ient i f i c knowledge. Therefore, in the case of psychotherapy, i t is .aillegeclJ to be an act iv i ty which can be explained and understood by appealing to the sc ient i f i c knowledge 2 known as psychiatric theory. Together these groups have in common the bel ief that the work done by the psychotherapist is governed by the canons of psychiatric theory. This perspective asserts that i t is these canons which provide the "rules" by which the psychotherapist carries out his/her work, and i t is therefore to these canons that the therapist appeals when deciding what he/she should or should not do in 4 the course of his/her work. Thus, we find that three different categories of people al l share a common conception with respect to the nature of the work done by psychotherapists. Using the ethnographic method, this thesis wi l l c r i t i c a l l y examine the view that psychotherapy is a theory-governed act iv i ty . Contrary to the beliefs of the lay person and the social sc ient is t , and the claims of the psychotherapist, the researcher dis -covered that psychotherapy did not seem to be an enterprise that was governed by the canons of psychiatric theory. It appeared to the researcher, that psychotherapy was a practical and pragmatic enterprise which could be understood not by making reference to psychiatric or social sc ient i f i c theory, which the researcher had studied, but rather by drawing upon the common sense cultural knowledge which the researcher shared with the other members of his culture. The task of the researcher wil l be to demonstrate the researcher's discovery, and to analyse why he was unable to make sense of psychotherapy in terms of psychiatric or sociological theoretical constructs bui l t upon the taken-for-granted notion cited above. The research "will show that the researcher was unable to bring these constructs into the research sett ing, the wards of a psychiatric hospital , and use them to make sense of, explain, or 3 evaluate what he observed. It seemed to the researcher that one could not view psychotherapy in terms of, nor as a product of such constructs, but instead, had to view i t as an act iv i ty conducted in terms of what 5 he chose to cal l the intuit ion of the therapist, as the constructs did not seem to be applicable to the work that took place within the set-t ing.^ The research was focused, for reasons that wi l l be discussed below, on psychotherapy with patients who had been diagnosed as "paranoid." 7 The thesis, therefore, is an ethnographic study of psychotherapy with "paranoid" patients in a psychiatric hospital . Its task wil l be to demonstrate the existence of a "gap" between the researcher's con-structs, and his observations in the fieldwork sett ing, which raised the question of a "gap" between the theoretical knowledge on paranoia cited in the psychiatric and social sc ient i f i c l i terature , and actual o instances and the treatment of the disorder. The evidence of the research points, i t wi l l be argued, toward the conclusion that, contrary to our taken-for-granted notion, psychiatric theory does not determine even in a rudimentary way the nature of psychotherapists' work with "paranoids"; exclusive of their accounts of their work. We shall analyse this conclusion, and two other plausible conclusions that contradict i t , with the aim of arriving at an adequate explanation of the "gap." We shall show, however, that none of the conclusions provide an adequate explanation of the "gap." This f inding, together with the discovery of the "gap," are, we assert, the major research findings of the thesis. Our findings, in turn, introduce, we claim, a larger issue 4 with respect to the character of the r e l a t i o n s h i p between any body of theory and r e l a t e d p r a c t i c e i n any s c i e n t i f i c d i s c i p l i n e . Thus our f i n d i n g s , d erived from our study of psychotherapy, are, we *shall argue, of relevance to the understanding of other s c i e n t i f i c d i s c i p l i n e s , as they r a i s e unanswered questions t h a t are common to a l l of them. The a n a l y t i c a l framework of the t h e s i s i s derived from the ethno-9 methodological p e r s p e c t i v e . I t was t h i s perspective that both prompted me to pursue an ethnographic approach i n my research, and adopt a narra-t i v e format, which I s h a l l now begin to employ. I t a l s o u l t i m a t e l y provided me w i t h the means t o c r i t i c a l l y examine my observations gained from my f i e l d w o r k . I do not c l a i m , however, that the t h e s i s stands as an example of ethnomethodology. I view i t , r a t h e r , as a work f a l l i n g w i t h i n the broader i n t e r a c t i o n i s t paradigm that derives from phenomen-o l o g i c a l philosophy, and encompasses a v a r i e t y of perspectives i n a d d i t i o n to the ethnomethodological, such as symbolic i n t e r a c t i o n i s m , l a b e l l i n g theory, and that of Erving Goffman. The perspective of the t h e s i s draws, i n p a r t i c u l a r , upon works by Roy Turner, David Sudnow, and J e f f C o u l t e r . ^ Turner's "Occupational Routines" paper and Sudnow's book Passing On helped to convince me, p r i o r to doing my fieldwork research, t h a t an ethnographic approach to the study of psychotherapy w i t h "paranoids" would provide me with a more fundamental understanding of the nature of the d i s o r d e r and i t s t r e a t -ment, than the adoption of a l t e r n a t e p o s i t i v i s t research s t r a t e g i e s that u t i l i z e d , f o r example, a survey research approach. As I had a back-ground i n anthropology, I was, to some extent, predisposed to the accep-tance of t h i s type of research design. Furthermore, adopting t h e i r 5 approach f i t t e d w i t h my t h e o r e t i c a l o r i e n t a t i o n w i t h i n s o c i o l o g y . I had been exposed to a v a r i e t y of i n t e r a c t i o n i s t . p e r s p e c t i v e s i n both my undergraduate and graduate work i n the d i s c i p l i n e , t h e r e f o r e was able to make sense, a l b e i t at a s u p e r f i c i a l l e v e l , ^ o f the ethnomethodo-l o g i c a l p erspective advocated by Sudnow and Turner. In h i s paper, Turner s t a t e s t h a t : . . . ethnographic studies of sc i e n c e , medicine, e t c , w i l l have as t h e i r pay-off not c r i t i q u e s and remedies, but some more funda-mental understanding o f how these a c t i v i t i e s are c o n s t i t u t e d i n the f i r s t place. My t h e o r e t i c a l i n t e r e s t , i n advocating such s t u d i e s , i s to d i s c l o s e , not "the s o c i a l i n f l u e n c e s upon," but "the s o c i a l s t r u c t u r e of" the c e n t r a l events and a c t i v i t i e s of the professions and occupations. Like David Sudnow, I am advo-c a t i n g a concern with "the procedural basis of events," and "the concrete o r g a n i z a t i o n a l foundations" of a c t i v i t i e s . 1 2 I t was to t h i s task that I addressed myself, aiming to discover the "procedural basis of events" that made up the d i s o r d e r and i t s treatment. P r i o r t o , and concurrent with the adoption of t h e i r perspec-t i v e , I had evolved my own t h e o r e t i c a l perspective on the d i s o r d e r , that emerged from my study of the c r i t i c a l l i t e r a t u r e on p s y c h i a t r y and paranoia. Thus, I began w i t h , and c a r r i e d through the course of my f i e l d w o r k , two mutually e x c l u s i v e o r i e n t a t i o n s ; one (the a n t i - p s y c h i a t r y perspective) that was c r i t i c a l o f , but nevertheless formulated i n terms of t r a d i t i o n a l p s y c h i a t r i c and s o c i o l o g i c a l theory, and the other (the perspective o f Sudnow and Turner), which stood as an ethnomethodological c r i t i q u e of a l l other theory including the a n t i - p s y c h i a t r y v a r i e t y . Unbeknownst to me, I u t i l i z e d throughout the course of my fieldwork a set o f constructs formulated i n terms of the same t h e o r e t i c a l o r i e n t a -t i o n t h a t Sudnow and Turner, from t h e i r ethnomethodological p e r s p e c t i v e , r e j e c t e d . 6 One may l e g i t i m a t e l y question my n a i v e t e , with respect to the c o n t r a d i c t i o n w i t h i n my approach, which I s h a l l not attempt to e x p l a i n at t h i s p o i n t , as the chronology o f my changing perspectives on the di s o r d e r c o n s t i t u t e s the body o f the t h e s i s . S u f f i c e i t to say, at t h i s p o i n t , t h a t i t was not u n t i l a f t e r I had f i n i s h e d my fieldwor k that I came to a more fundamental understanding of the depth of the ethno-methodological p e r s p e c t i v e , and the inadequacy o f my preconceived c o n s t r u c t s . I t was at that p o i n t that I went back to Turner's and Sudnow's work and the work of. other ethnomethodologists, and began to u t i l i z e t h e i r perspective i n an e f f o r t to make new sense of my research observations. Thus, I drew upon t h e i r work at two d i f f e r e n t points i n time, and at two d i f f e r e n t l e v e l s of understanding. I am, t h e r e f o r e , unable to present i n the i n t r o d u c t i o n to the t h e s i s a concise o u t l i n e of i t s p e r s p e c t i v e , as my perspective changed over the course of the research, and the changes i n my t h i n k i n g which are documented i n the t h e s i s , became the substance of i t . Thus, to gain an understanding of the a n a l y t i c a l framework of the t h e s i s , one must keep i n mind t h a t i t i s a framework which evolved i n the course o f , and as a consequence o f , pursuing my f i e l d w o r k , and was not formulated u n t i l a f t e r the fie l d w o r k had been completed. The three other sources c i t e d above, Turner's a r t i c l e s , "Utterance P o s i t i o n i n g as an I n t e r a c t i o n a l Resource," and "Some Formal P r o p e r t i e s of Therapy Talk," and Coulter's book, Approaches to Insanity, a l s o c o n t r i b u t e d to the development of t h i s framework. I encountered them a f t e r f i n i s h i n g my f i e l d w o r k , and they helped me to analyse my data, and formulate a p l a u s i b l e conclusion with respect to the data. 7 From C o u l t e r , I was able to derive some assis t a n c e i n r e l a t i n g the perspective advocated by Turner i n h i s paper, "Occupational Routines: Some Demand C h a r a c t e r i s t i c s of P o l i c e Work," and u t i l i z e d by Sudnow i n his book, to my own p a r t i c u l a r area of i n t e r e s t ; psychotherapy with "paranoids." He helped me to reconsider the r e l a t i o n s h i p between p s y c h i a t r i c theory and p r a c t i c e , which allowed me to a r r i v e at one answer f o r the many problems that I encountered i n attempting to make sense of my research observations i n terms of my o r i g i n a l c o n s t r u c t s , derived from the a n t i - p s y c h i a t r y p e r s p e c t i v e , which I brought i n t o the research s e t t i n g . C o u l t e r defines h i s understanding of the r e l a t i o n s h i p between p s y c h i a t r i c theory and p r a c t i c e t h i s way: I have drawn a p e r s i s t e n t d i s t i n c t i o n between p s y c h i a t r y , understood as an irremediably p r a c t i c a l and pragmatic a f f a i r , and psychopathology, understood as a t h e o r e t i c a l e n t e r p r i s e that aims to r a t i o n a l i z e the experiences w i t h insane members of a community i n s c i e n t i f i c terms J 3 I t was t h i s a n a l y s i s , developed by Counter i n h i s book, which helped to give me the means to r e t h i n k my research experiences and observations. Rather than r e l y i n g upon my o r i g i n a l c o n s t r u c t s ; i . e . , t h e o r e t i c a l explanations of paranoia and psychotherapy formulated i n terms of common sense b e l i e f s , I began by u t i l i z i n g h i s perspective to conceptualize the d i s o r d e r and i t s treatment i n terms of an a l t e r n a t e understanding as to the nature of these "phenomena." Coulte r argues f o r c e f u l l y i n his book that the p r a c t i c a l work of t h e r a p i s t s which we 14 know of as psychotherapy, i s not guided by the tenets o f p s y c h i a t r i c theory, but r a t h e r i s organized i n terms o f the t h e r a p i s t s ' s o c i a l stock of knowledge (common sense knowledge, f o l k wisdom, e t c . ) . 8 Coulter's a n a l y s i s provided me with the means to focus the perspective advocated by Turner and Sudnow upon my area of research i n t e r e s t . By drawing upon h i s work, I was able to evolve a perspective which seemed to allow me to make sense of my research f i n d i n g s , and account f o r the "gap" that I had discovered between my constructs derived from the t h e o r e t i c a l l i t e r a t u r e and my research observations. He r a i s e d f o r me the question of r e c o n c e p t u a l i z i n g one's understanding of the r e l a t i o n s h i p between p s y c h i a t r i c theory and p r a c t i c e , which l e d me to reconsider my i n s i g h t s as to the "procedural basis of events" t h a t made up p s y c h i a t r i c p r a c t i c e . C o u l t e r expresses the perspective t h a t I drew upon t h i s way: . . . the idea of a p s y c h i a t r y without c u l t u r a l reference i s l i k e the idea of conceptual thought without l a n g u a g e — i n both cases, the l a t t e r i s p a r t i a l l y c o n s t i t u t i v e of the former, and could i n no sense be considered a f e t t e r upon i t . We should not be so r e a d i l y tempted i n t o harbouring a common view t h a t sees ordinary c u l t u r a l knowledge as always d e f e c t i v e ; commonsense c u l t u r a l knowledge and standards are not a l l of a p i e c e , but are accom-modated to p a r t i c u l a r s o r t s of work, and enable us to do that work (the tasks of p s y c h o l o g i c a l assessments amongst others) adequately and r o u t i n e l y . 1 5 I encountered Roy Turner's other works ("Some Formal P r o p e r t i e s of Therapy Talk," and "Utterance P o s i t i o n i n g as an I n t e r a c t i o n a l Resource") subsequent to my study of Coulter's book. From his a r t i c l e s , I drew a conclusion t h a t I had begun to consider i n i t i a l l y as a consequence of my research experience, and subsequently as a r e s u l t of my study of C o u l t e r . Psychotherapy w i t h "paranoids" might not, I began to see, be a theory-guided a c t i v i t y , as i t may derive i t s d i r e c t i o n from the t h e r a p i s t ' s common sense rather than h i s / h e r p s y c h i a t r i c t h e o r e t i c a l knowledge. This new view was a r a d i c a l departure from my previous views 9 which had been formulated (according to the commonly held view t h a t psychotherapy i s a theory-governed a c t i v i t y ) i n terms of my constructs that I had derived from my study of the p s y c h i a t r i c and s o c i a l s c i e n -t i f i c t h e o r e t i c a l l i t e r a t u r e on paranoia. The perspective from Turner's work t h a t I drew upon i s best summed up i n h i s own words: Thus, i t may w e l l be the case t h a t a component of p s y c h i a t r i c competence i s the a b i l i t y to "discover" r e t r o s p e c t i v e l y i n routine utterances the t h e r a p e u t i c motivations taken to govern t h e i r production; but nonetheless i t i s n e c e s s a r i l y a l s o the case t h a t i n the course of conducting the p s y c h i a t r i c i n t e r v i e w the thera-p i s t e x e r c i s e s those conversational s k i l l s he possesses as a member of the c u l t u r e , competent to t a l k to other members and be understood. I t does not matter, of course, that the t h e r a p i s t may have p r i n c i p l e d grounds f o r breaching conversational r u l e s : the r e c o g n i t i o n and production of breaches are dependent upon the very same competence which provides f o r the r e c o g n i t i o n and -|g production of t a l k which observes those ru l e s i n the f i r s t place. I was i n f l u e n c e d l a t e r by the work of other researchers which l e d me to r e j e c t my conclusion discussed above, and subsequently r a i s e and r e j e c t two other p l a u s i b l e c o n c l u s i o n s . I , i n f a c t , came to see that there i s a b a s i s , i n the quotation c i t e d immediately above, f o r arguing t h a t psychotherapy i s a theory-guided a c t i v i t y . By now, i t may be apparent t h a t the perspective of the t h e s i s evolved w i t h the passage of my doctoral work, and i t i s the e v o l u t i o n of the perspective that c o n s t i -tutes the body of the t h e s i s . I am, t h e r e f o r e , p r e s e n t l y unable to o f f e r f u r t h e r d e t a i l s as to the nature of the perspective of the t h e s i s beyond the b r i e f comments noted above, as i t s substance, to r e i t e r a t e , derives from a documentation of my changing views as to the nature of paranoia and the character of i t s treatment; the culmination of which i s the t h e s i s p e r s p e c t i v e . 10 Two f u r t h e r p o i n t s , however, need to be c l a r i f i e d at t h i s time. F i r s t of a l l , the t h e s i s i s not meant to stand alone, as an autobio-graphical account of one i n d i v i d u a l ' s study of paranoia. I b e l i e v e that the experiences and observations that I w r i t e about, as they p e r t a i n to my changing perspectives on the d i s o r d e r , have a wider relevance. I am arguing t h a t they have broader import, as I a s s e r t t h a t anyone who s t u d i e d the l i t e r a t u r e on paranoia and then conducted an ethnographic study of i t s treatment i n a p s y c h i a t r i c s e t t i n g would a r r i v e at the same conclusions as I d i d . I make the assumption that the t h e s i s stands not as a mere piece of r e f l e c t i v e s e l f - e x p l o r a t i o n . Rather, I see i t as a s o c i o l o g i c a l work formulated i n terms o f , and grounded i n , a body of s o c i o l o g i c a l knowledge. Thus, I am a s s e r t i n g t h a t i t f u r t h e r s our s o c i a l s c i e n t i f i c knowledge of the l a r g e r i s s u e s , s p e c i f i c a l l y the question of the r e l a t i o n s h i p between p s y c h i a t r i c theory and p r a c t i c e , and the question of the r e l a t i o n s h i p between any body of s c i e n t i f i c theory and r e l a t e d p r a c t i c e , t h a t were confronted i n the course of documenting my own personal research experiences. F i n a l l y , i t i s important to note that the t h e s i s i s not intended to stand as a c r i t i q u e of p s y c h i a t r y . Contrary to the purpose of some research i n t h i s area, which i s o r i e n t e d toward f i n d i n g examples of the misuse of therapy or "poor" therapy, the t h e s i s w i l l not t r y to develop such common sense normative p e r s p e c t i v e s . I argue that what i s of s o c i o l o g i c a l i n t e r e s t i s the a n a l y t i c a l d e p i c t i o n of the a c t i v i t y which we know of as psychotherapy with "paranoids," rather than common sense judgements of i t . 11 The Development of the Perspective The perspective of t h i s t h e s i s evolved from a process of r e t h i n k -ing my understanding of the f i e l d of mental d i s o r d e r and p s y c h i a t r y . My i n t e r e s t i n t h i s area had i t s roots w i t h i n my f a m i l y . A r e l a t i v e of mine was a p s y c h i a t r i s t , and I had frequent o p p o r t u n i t i e s to discuss w i t h him and h i s f r i e n d s who were al s o p s y c h i a t r i s t s , t o p i c s that I s t u d i e d i n my undergraduate work i n s o c i o l o g y . I found that I often had a d i f f e r i n g i n t e r p r e t a t i o n of human behaviour from t h a t held by these p s y c h i a t r i s t s , and I became aware of the s i g n i f i c a n t d i s t i n c t i o n between a s o c i o l o g i c a l and a p s y c h i a t r i c a n a l y s i s of phenomena. In the d i s c u s s i o n s t h a t I had with the p s y c h i a t r i s t s , I f e l t at a disadvantage as I had not s t u d i e d the p s y c h i a t r i c l i t e r a t u r e , nor had I f i r s t - h a n d knowledge of what psychotherapy a c t u a l l y was. I r e a l i z e d that the p s y c h i a t r i s t s themselves were not w e l l versed i n s o c i o l o g i c a l knowledge, but to them t h i s d i d not seem to be too important, as they f e l t t hat u l t i m a t e l y a l l human behaviour had to be accounted f o r i n terms of the p s y c h i a t r i c viewpoint. Thus, i t seemed that t h i s view asserted not only an a l t e r n a t e explanation of human phenomena, but a l s o an explanation that d i d not r e a l l y accept a s o c i o l o g i c a l l e v e l of a n a l y s i s . The experience t h a t I had of being exposed to t h i s viewpoint made me decide to gain more knowledge of the f i e l d of mental d i s o r d e r and p s y c h i a t r y . In my f i r s t year of graduate work, I d i d a reading course i n the s o c i o l o g y of knowledge which focused on the works of Sigmund Freud and t h e o r i s t s i n f l u e n c e d by h i m J 7 I was i n t e r e s t e d i n e x p l o r i n g the p s y c h i a t r i c l i t e r a t u r e which gave r e c o g n i t i o n to concepts such as c u l t u r e and s o c i e t y , as I wanted to f i n d the common ground between a 12 p s y c h i a t r i c and a s o c i o l o g i c a l p e r s p e c t i v e . I t seemed to me tha t the two perspectives could p o s s i b l y o f f e r complementary i n t e r p r e t a t i o n s of human behaviour. As I became more f a m i l i a r with the l i t e r a t u r e , I began to develop an i n t e r e s t not only i n the common ground between s o c i o l o g i -cal and p s y c h i a t r i c t h i n k i n g , but als o i n the s o c i o l o g i c a l study of p s y c h i a t r i c theory and p r a c t i c e . I became i n t e r e s t e d i n analysing p s y c h i a t r y as a phenomenon i n our s o c i e t y composed o f both a body of t h e o r e t i c a l knowledge and a p r a c t i c a l a c t i v i t y ; psychotherapy. Thus, rather than l o o k i n g f o r elements i n p s y c h i a t r i c t h i n k i n g that provided a l i n k w i t h s o c i o l o g i c a l p e r s p e c t i v e s , I now began to focus on a so c i o -l o g i c a l a n a l y s i s of p s y c h i a t r y . My new i n t e r e s t stemmed from my o r i g i n a l need to know what p s y c h i a t r y " r e a l l y was a l l about," but also I o was i n f l uenced by the: .advent o f the a n t i - p s y c h i a t r y l i t e r a t u r e . There was a current i n t e r e s t i n ana l y s i n g the f i e l d of p s y c h i a t r y , and the p s y c h i a t r i c p r o f e s s i o n was coming under i n c r e a s i n g attack by c r i t i c s who claimed that i t was a mechanism of s o c i a l c o n t r o l . Some of t h i s l i t e r -ature made sense to me, as i t appeared to provide an a n a l y s i s o f ps y c h i a t r y which exposed the nature of p s y c h i a t r i c theory and p r a c t i c e , and seemed to reveal the i n f l u e n c e upon s o c i e t y of the p r a c t i c e of psychotherapy. Thus, I explored a body of l i t e r a t u r e which provided a new viewpoint on p s y c h i a t r y , and I began to decide that I would undertake to study the f i e l d of p s y c h i a t r y f o r my doctoral research. P r i o r to e n t e r i n g a doctoral program, I a p p l i e d to the Canada Council f o r a f e l l o w s h i p , and an examination of my a p p l i c a t i o n form may provide a useful means of documenting my p a r t i c u l a r research i n t e r e s t s and t h e o r e t i c a l perspectives at t h i s p o i n t i n time. On my a p p l i c a t i o n 13 form, I o u t l i n e d my program of study and research. I proposed to study ". . . the r e l a t i o n s h i p between psychoanalytic theory and the i n f l u e n c e 19 upon s o c i e t y of the p r a c t i c e of p s y c h i a t r y . " I wanted to combine my previous i n t e r e s t i n the sociology of knowledge with respect to the p s y c h i a t r i c t h e o r e t i c a l perspective ( i . e . the p s y c h i a t r i c v i e w p o i n t ) , w i t h my more recent i n t e r e s t s i n p s y c h i a t r y as a p r a c t i c a l a c t i v i t y , and as a p r o f e s s i o n which a l l e g e d l y was i n v o l v e d i n s e r v i n g a p o l i t i c a l purpose as a mechanism of s o c i a l c o n t r o l . Thus, on my a p p l i c a t i o n form I wrote: I am i n t e r e s t e d i n r e l a t i n g the p o l i t i c a l c r i t i q u e of p s y c h i a t r y to psychoanalytic theory. Psychoanalytic theory w i l l be analysed both as a world view which has p o s s i b l y o r i e n t e d the d i r e c t i o n o f p s y c h i a t r i c p r a c t i c e toward s o c i a l c o n t r o l , and as an ideology which p o s s i b l y has served as a j u s t i f i c a t i o n f o r the p r a c t i c e o f s o c i a l c o n t r o l . The aim of the research w i l l be to e s t a b l i s h whether there are elements of psychoanalytic theory which are r e l a t e d to the p r a c t i c e of p s y c h i a t r i c therapy as a mechanism of s o c i a l c o n t r o l , and to i d e n t i f y these elements.20 I proposed to examine the elements t h a t made up psychoanalytic theory, as I wished to s p e c i f y how i t s i n t r a p s y c h i c and b i o l o g i c a l l y based concepts such as the model of i n s t i n c t s and repression denied the pos-s i b i l i t y o f e x p l a i n i n g mental d i s o r d e r i n terms of the e f f e c t s of the environment upon the i n d i v i d u a l , as no r e c o g n i t i o n appeared to be given to the i n f l u e n c e of socio-economic v a r i a b l e s . Thus, i t seemed to me t h a t psychoanalytic theory o r i e n t e d psychotherapy toward a r o l e of s o c i a l c o n t r o l as i t provided f o r the p r a c t i c e of a d j u s t i n g a d i s t u r b e d i n d i v i d u a l to h i s / h e r s o c i a l world regardless of whether t h a t s o c i a l world was the source of h i s / h e r disturbance. Therefore, at t h i s point i n time, I b e l i e v e d that one could understand the nature of p s y c h i a t r i c 21 p r a c t i c e i f one had an understanding of p s y c h i a t r i c theory. I t seemed 14 to me that psychotherapy was a theory-governed a c t i v i t y , and t h e r e f o r e t h a t the body of t h e o r e t i c a l knowledge known as p s y c h i a t r i c theory i n a fundamental way determined what a t h e r a p i s t d i d or did not do when he/she p r a c t i s e d psychotherapy. This idea was b a s i c to my perspective on p s y c h i a t r y , and from i t I was able to develop my a n a l y s i s of the p o l i t i c a l c r i t i q u e o f p s y c h i a t r y . I f psychotherapy was a theory-governed a c t i v i t y , then one must look f o r explanations of the a l l e g e d p r a c t i c e of s o c i a l c o n t r o l i n the nature of the p s y c h i a t r i c theory, not i n the p r a c t i c a l a c t i v i t y of psychotherapy, as t h i s a c t i v i t y merely r e f l e c t e d the tenets of the theory. In my doctoral research I planned ther e f o r e to do a c r i t i q u e of p s y c h i a t r y , documenting how one could account f o r p s y c h i a t r i c p r a c t i c e i n terms of p s y c h i a t r i c theory. Having developed what seemed to be a sound t h e o r e t i c a l p e r s p e c t i v e , I pursued my doctoral studies using t h i s perspective as a focus f o r i n t e r p r e t i n g the material that I s t u d i e d . As I gained more knowledge of mental d i s o r d e r and p s y c h i a t r y , I r e f i n e d some of my ideas and decided to concentrate my work on the d i a g n o s t i c category paranoid s t a t e , as t h i s d i a g n o s t i c category seemed to lend i t s e l f to s o c i o l o g i c a l analy-s i s . I d i d not, however, f i n d reason to change my view that psycho-therapy was a theory-governed a c t i v i t y , and thus I s t i l l sought t o do a c r i t i q u e of p s y c h i a t r y , analysing p s y c h i a t r i c p r a c t i c e i n terms of p s y c h i a t r i c theory. My subsequent a p p l i c a t i o n s to the Canada Council f o r renewal of my f e l l o w s h i p continued t h e r e f o r e to s t r e s s t h i s approach, and I maintained i t w i t h i n my Ph.D. t h e s i s proposal. In my proposal I wrote, f o r example, with respect to the s i g n i f i c a n c e of my doctoral research t h a t : 15 The proposed study should make a c o n t r i b u t i o n to our knowledge of how p s y c h i a t r i s t s " b r i n g o f f " t h e i r p s y c h i a t r i c encounter with the "paranoid," and how t h i s accomplishment i s r e l a t e d to . . •. t h e i r p s y c h i a t r i c understanding of "paranoia" and mental i l l n e s s . This knowledge would i n turn enable us to develop f u r t h e r i n s i g h t i n t o the r e l a t i o n between the p r a c t i c e of p s y c h i a t r i c therapy and the e x e r c i s e of s o c i a l control.22 I t was not u n t i l I began to do research i n the f i e l d , that my t h e o r e t i c a l perspective began to lose i t s relevance to me. I t i s my purpose at t h i s p o i n t i n the t h e s i s to note b r i e f l y why t h i s process took p l a c e , and to o u t l i n e b r i e f l y how a new t h e o r e t i c a l perspective evolved. The data which documents the actual process of t r a n s i t i o n i n my t h i n k i n g and other t o p i c s touched on at t h i s time, w i l l be d e a l t with i n the main body of the t h e s i s . The material that i s being discussed i n t h i s s e c t i o n of the t h e s i s has been presented i n order to e s t a b l i s h the background t o , and th e r e f o r e give a f i r m e r understanding of the evolu-t i o n of the t h e o r e t i c a l perspective of the t h e s i s . My fi e l d w o r k was conducted i n a p s y c h i a t r i c h o s p i t a l i n which I adopted the r o l e of a no n - p a r t i c i p a n t observer. I spent time i n the h o s p i t a l observing the i n t e r a c t i o n between the s t a f f and the p a t i e n t s , and i n p a r t i c u l a r spent time observing therapy sessions i n which p a t i e n t s who had been given the d i a g n o s t i c l a b e l "paranoid" took part. At l a s t , I was able to have the opportunity of witnessing at f i r s t hand the p r a c t i c a l a c t i v i t i e s of p s y c h i a t r y . I f e l t t h a t now I would be able to understand what psychotherapy " r e a l l y was a l l about," as I would be able to use the knowledge that I had gained from the p s y c h i a t r i c l i t e r -ature to make sense of what went on i n the wards and i n the therapy s e s s i o n s . My understanding of the events and a c t i v i t i e s that I exper-ienced and observed i n the h o s p i t a l however, d i d not turn out to be what 16 my t h e o r e t i c a l perspective had l e d me to expect. A f t e r being i n the s e t t i n g f o r some time and t r y i n g to make sense of my o b s e r v a t i o n s , I began to r e a l i z e two t h i n g s . F i r s t of a l l , I became aware th a t the work done by t h e r a p i s t s d i d not seem to be s t r u c t u r e d i n terms of p s y c h i a t r i c theory. The second t h i n g that I came to r e a l i z e was t h a t I d i d not seem to need to make reference to p s y c h i a t r i c theory i n order to make sense o f what t h e r a p i s t s or p a t i e n t s s a i d . I t h e r e f o r e began to go through a process of r e - e v a l u a t i n g my o r i g i n a l p e r s p e c t i v e , and by the time that I had f i n i s h e d my f i e l d w o r k , I questioned whether t h i s perspective could be used to e x p l a i n the data that I had c o l l e c t e d . In the months that followed I mulled over my data, and I slowly began to see that the material t h a t I had c o l l e c t e d might be explained i n terms of a perspec-t i v e which c o n t r a d i c t e d my o r i g i n a l viewpoint. I became aware that p s y c h i a t r i c p r a c t i c e might not be a theory-governed a c t i v i t y . Thus, my t h i n k i n g was transformed, as I r e a l i z e d that one might not be able to analyse p s y c h i a t r i c p r a c t i c e and draw conclusions about i t s i n f l u e n c e i n s o c i e t y by making reference to p s y c h i a t r i c theory. Instead, I came to accept the premise t h a t one had to view p s y c h i a t r i c p r a c t i c e i n terms of common sense c u l t u r a l knowledge, r a t h e r than seeing i t as a product determined by a body of t h e o r e t i c a l knowledge. I concluded, f o r example, that one could not argue t h a t a t h e r a p i s t ' s understanding of and i n t e r -a c t i o n w i t h a "paranoid" p a t i e n t was determined by the t h e r a p i s t ' s knowledge of p s y c h i a t r i c theory. I e v e n t u a l l y r e j e c t e d t h i s p o s i t i o n , and then adopted and subsequently r e j e c t e d two other explanations of my research f i n d i n g s . Thus, the perspective of the t h e s i s evolved through a process of r e t h i n k i n g my views. 17 I t i s also necessary to discuss the r o l e played by my research methodology i n f a c i l i t a t i n g the transformation i n my t h i n k i n g . The ethnographic method was employed i n the f i e l d , and at the outset of my fieldwork I assumed t h a t I would be able to u t i l i z e t h i s approach to gather data which would document how p s y c h i a t r i c theory governs psychi-a t r i c p r a c t i c e . Thus, I entered the research s e t t i n g with my p r e v i o u s l y discussed preconceptions, and I assumed that the observational data that I gathered would serve to confirm my ideas. As i t turned out, however, my t h i n k i n g underwent a t r a n s f o r m a t i o n , and i t was the ethnographic method which enabled me to make t h i s t ransformation. Had I adopted a d i f f e r e n t methodology such as a survey.research approach, i t would have been d i f f i c u l t to overcome my preconceived ideas, as these ideas would have been formulated w i t h i n the methodology i n such a way that the methodology would have produced data that I myself had generated out of the s e t t i n g . Using such an approach, I might have developed question-n a i r e s , i n t e r v i e w schedules, r a t i n g and a t t i t u d e s c a l e s , e t c . , which would have provided me with a means of g e t t i n g data from the s e t t i n g which made sense i n terms of my theoretical perspective or preconceived construct of what was going on i n the s e t t i n g that I was studying. This approach would not, however, have provided me with a p i c t u r e of what a c t u a l l y t r a n s p i r e d on an everyday basis f o r members i n the s e t t i n g . I would have made a b a s i c e r r o r which has been noted by J e f f C o u l t e r t h i s way: One must avoid t r e a t i n g a c t i o n - i n - a c c o r d - w i t h - a - r u l e as action-governed-by-a-rule, s i n c e one can e a s i l y b r i n g some course of observed a c t i v i t y under the auspices of a r u l e l i k e formula-t i o n without such a formulation expressing the s t a t e of know-ledge of the member doing the a c t i v i t y . 2 3 18 Roy Turner has a p t l y described t h i s process i n terms of a metaphor. He argues that " . . . such studies proceed by the assembly of 'snapshots' 24 of the s o c i a l world." As these "snapshots" provide only s e l e c t e d glimpses of what i s happening i n the research s e t t i n g , one may, he argues, r e a d i l y assemble "snapshots" to i l l u s t r a t e one's p a r t i c u l a r preconceived c o n s t r u c t s . What I wish to point out i s that the unstruc-tured approach of the ethnographic method did not provide me with the means of engaging i n t h i s p r a c t i c e . In c o n t r a s t to other approaches, t h i s method allows f o r what Turner, again using h i s metaphor, c a l l s 25 ". . . a continuous and un-edited videotape of s o c i a l phenomena." Thus, any and all a c t i v i t i e s t h a t I observed i n the s e t t i n g c o n s t i t u t e d my data. This denied the p o s s i b i l i t y of assembling "snapshots," which would serve to confirm my preconceptions. I was, t h e r e f o r e , able to view p s y c h i a t r i c p r a c t i c e as a continuing a c t i v i t y which gave me the opportunity to discover that my o r i g i n a l constructs could not e x p l a i n the data that I was c o l l e c t i n g . The constructs that I u l t i m a t e l y d i d adopt as a r e s u l t of t h i s experience form the t h e o r e t i c a l perspective of the t h e s i s . The Choice of a Diagnostic Category P r i o r to doing my f i e l d w o r k I developed, as was p r e v i o u s l y noted, 26 an i n t e r e s t i n the d i a g n o s t i c category paranoid s t a t e (DSM-11-297). In p a r t i c u l a r , I became concerned with "paranoids" who had persecutory d e l u s i o n s . This i n t e r e s t stemmed from my reading of the p s y c h i a t r i c l i t e r a t u r e i n which I found that t h i s d i a g n o s t i c category was d i s t i n -guished from other categories such as schizophrenia by a number of 19 important f e a t u r e s . I t was pointed out, f o r example, that there i s 27 l i t t l e evidence of a p h y s i o l o g i c a l basis f o r the d i s o r d e r . Nor i s the "paranoid," u n l i k e the "schizophrenic," seen to be d e s o c i a l i z e d . Norman Cameron claims that the "paranoid" has o r g a n i z a t i o n and contact with r e a l i t y , d e s c r i b i n g t h e i r c o n d i t i o n t h i s way: " . . . both i n perception and i n a c t i o n the p a t i e n t i s not nearly as d e s o c i a l i z e d as 28 are other psychotic persons." The Diagnostic and S t a t i s t i c a l Manual of Mental Disorders notes that the core of the "paranoid's" disturbance i s not a mood or thought d i s o r d e r , but rat h e r a delusion which may be 29 composed of both complex and l o g i c a l t h i n k i n g . Persons diagnosed to be "paranoid" are seen to share the c h a r a c t e r i s t i c of a s s e r t i n g coherent versions of s o c i a l r e a l i t y which c o n t r a d i c t the commonly held "normal" v e r s i o n s . They are seen to have a sustained r e l a t i o n s h i p with the s o c i a l world which i s c h a r a c t e r i z e d by a disagreement with other members of the c u l t u r e , as to the nature of th a t world. One p s y c h i a t r i s t describes the d i s o r d e r t h i s way: "thus the main s i n g l e f a c t o r that i s emphasized i n the existence of a b e l i e f or b e l i e f s held to be f a l s e by 30 the examiner or evalu a t o r . " The l i t e r a t u r e acknowledged that there was a s o c i a l component common to the behaviour of the "paranoid" which i s not always present i n the behaviour of others seen to be mentally i l l . Thus, i t seemed to me th a t t h i s d i a g n o s t i c category was p a r t i c u l a r l y s u i t e d to s o c i o l o g i c a l research. A f t e r reviewing the l i t e r a t u r e on paranoia, I concluded that i t not only was a d i s o r d e r s u i t e d to s o c i o l o g i c a l research, but al s o t h a t i t was p a r t i c u l a r l y s u i t e d to an a n a l y s i s i n terms of my t h e o r e t i c a l 31 p e r s p e c t i v e . I t seemed to me that psychotherapy with "paranoids" 20 i l l u s t r a t e d most c l e a r l y the r e l a t i o n s h i p between p s y c h i a t r i c theory and p r a c t i c e , and how t h i s r e l a t i o n s h i p could be understood i n terms of the concept of s o c i a l c o n t r o l . My reasoning proceeded as f o l l o w s . P s y c h i a t r i c theory accounts f o r paranoia i n a number of ways such as a f a u l t y i n t r a p s y c h i c s t r u c t u r e , or a disturbance of i n t e r p e r s o n a l r e l a t i o n s h i p s , and excessive use of p r o j e c t i o n . These t h e o r e t i c a l explanations of the d i s o r d e r have i n common t h e i r denial of the p o s s i -b i l i t y t h a t the delusion of the "paranoid" may i n f a c t be a " l o g i c a l " response to the present or past l i f e s i t u a t i o n of the i n d i v i d u a l . They do not allow f o r the chance t h a t the "paranoid" i n d i v i d u a l a c t u a l l y i s responding to real persecution. Instead, these views assume th a t the b e l i e f s of the i n d i v i d u a l have no basis i n r e a l i t y , and that the roots of the i n d i v i d u a l ' s disordered thought and behaviour are to be found w i t h i n the i n d i v i d u a l . Thus, i t seemed to me t h a t p s y c h i a t r i c theory, which I b e l i e v e d governed p s y c h i a t r i c p r a c t i c e , would d i r e c t the thera-p i s t to search f o r defects i n the i n d i v i d u a l who was diagnosed as "paranoid," r a t h e r than l o o k i n g f o r experiences i n the l i f e of that i n d i v i d u a l which would account f o r f e e l i n g s of persecution. I t seemed c l e a r that,as the theory d i d not allow f o r an a l t e r n a t e explanation of the "paranoid's" f e e l i n g s , t h e v t h e r a p i s t whose work I assumed was governed by t h i s body of t h e o r e t i c a l knowledge would not have grounds f o r accepting the "paranoid's" claims of persecution. I t h e r e f o r e b e l i e v e d t h a t therapy sessions w i t h p a t i e n t s diagnosed "paranoid" would f o l l o w a p a r t i c u l a r form. I thought t h a t the i n t e r a c t i o n between the t h e r a p i s t and the "paranoid" would be an encounter i n which two con-t r a s t i n g versions of r e a l i t y would be asserted. I b e l i e v e d that the 21 session would be dominated by a r e a l i t y d i s j u n c t u r e ; the "paranoid" expressing h i s / h e r d e l u s i o n , and the t h e r a p i s t o f f e r i n g a competing explanation o f the pa t i e n t ' s b e l i e f s . I took i t that the t h e r a p i s t made sense o f the "paranoid's" behaviour i n terms of hi s / h e r t h e o r e t i c a l understanding of paranoia, and there f o r e would not honour the p a t i e n t ' s account, as t h i s account would be seen as having no basis i n r e a l i t y . I assumed that the t h e r a p i s t would i n t e r p r e t the pa t i e n t ' s account as stemming from some f a u l t i n the psyche of the p a t i e n t , and would there-fore s et about to convince the "paranoid" that h i s / h e r b e l i e f s were mistaken. Thus, I b e l i e v e d t h a t therapy sessions with "paranoid" p a t i e n t s focused on a w e l l - d e f i n e d d i s j u n c t u r e between competing ver-sions of s o c i a l r e a l i t y , and proceeded along a course i n which the t h e r a p i s t negated the "paranoid's" version and imposed h i s / h e r own upon the p a t i e n t . This pre-fieldwork a n a l y s i s of the d i a g n o s t i c category, paranoid s t a t e , which I developed, f i t t e d w e l l with my perspective on the r e l a -t i o n s h i p between psychotherapy and s o c i a l c o n t r o l . I f e l t t hat therapy with "paranoids" h i g h l i g h t e d how p s y c h i a t r i c theory determined psychi-a t r i c p r a c t i c e i n such a way tha t the p r a c t i c e could be viewed as a form o f s o c i a l c o n t r o l . Since the theory made no p r o v i s i o n f o r accept-i n g the account of the p a t i e n t as t r u e , the t h e r a p i s t , r e l y i n g on t h i s theory, would simply i n v a l i d a t e the "paranoid's" account. One version of s o c i a l r e a l i t y would be imposed at the expense of another. I t was the act of i n v a l i d a t i o n , which I assumed took pl a c e , t h a t I saw to be of importance. The theory-based negation of the "paranoid's" account served, I b e l i e v e d , the f u n c t i o n of s o c i a l c o n t r o l as the therapy would 22 adjust the d i s t u r b e d i n d i v i d u a l to h i s / h e r s o c i a l world despite the f a c t that t h i s s o c i a l world might be the source of the disturbance. Thus, I b e l i e v e d that psychotherapy might be s e r v i n g the f u n c t i o n of s o c i a l c o n t r o l rather than l i b e r a t i o n , and I thought that my research would e x p l a i n and document t h i s process. Having developed my a n a l y s i s of paranoia w i t h i n the framework of my t h e o r e t i c a l p e r s p e c t i v e , I then i n t e g r a t e d i t i n t o my research design. Using the ethnographic method, I planned to gather data which would i l l u s t r a t e how psychotherapy with "paranoid" p a t i e n t s was l i n k e d to p s y c h i a t r i c theory, and could be viewed as a form of s o c i a l c o n t r o l . U t i l i z i n g my a n a l y s i s of t h i s d i s o r d e r , I decided to compile data from four cases which had been diagnosed to most c l o s e l y approach the diag-n o s t i c sub-category "true paranoia" (DSM-11-297.0). This d e c i s i o n was based on my assumptions about what happened i n therapy sessions with "paranoid" p a t i e n t s . I assumed that the diagnosis of "true paranoia" was reserved f o r cases i n which i t i s perceived by the t h e r a p i s t that there i s a more c l e a r l y defined r e a l i t y d i s j u n c t u r e between the thera-p i s t and the p a t i e n t , than f o r example i n cases given the d i a g n o s t i c l a b e l paranoid s c h i z o p h r e n i c . By observing t h i s type of case, I b e l i e v e d t h a t i t would be e a s i e r f o r me to i d e n t i f y such a d i s j u n c t u r e . I t followed t h e r e f o r e t h a t i t was i n these cases of '.'true paranoia" t h a t the i n v a l i d a t i o n of the "paranoid's" version of r e a l i t y would a l s o be most apparent. Thus, my a n a l y s i s l e d me to b e l i e v e t h a t the obser-vation of psychotherapy with "true paranoids" would most r e a d i l y reveal data which supported my preconceived c o n s t r u c t s . 23 Upon e n t e r i n g the research s e t t i n g , I found, as has already been b r i e f l y noted, that my constructs d i d not f i t w i t h what I was e x p e r i -encing and observing. F i r s t of a l l , I discovered through discussions w i t h some of the c l i n i c a l supervisors of the wards i n the h o s p i t a l t h a t only one p a t i e n t i n the previous two years had been diagnosed as a "true paranoid." This d i d not deter me, however, as I f e l t that even i f I did not get the opportunity to observe psychotherapy with such a p a t i e n t , I would s t i l l be able to lo c a t e the same processes happening ( a l b e i t i n a l e s s c l e a r form) with p a t i e n t s who had been diagnosed as s u f f e r i n g from some other form o f "paranoid" d i s o r d e r . As i t turned out, I only was able to l o c a t e one p a t i e n t whose diagnosis f i t t e d i n t o the Diagnostic and S t a t i s t i c a l Manual category number 297, paranoid 32 s t a t e s . I t i s necessary at t h i s time to point out th a t there i s considerable disagreement w i t h i n the p s y c h i a t r i c l i t e r a t u r e as to the c o r r e c t diagnosis to make i n cases of "paranoid" d i s o r d e r s . We f i n d , f o r example, one p s y c h i a t r i s t n o ting t h a t : " u n t i l the various paranoid c o n d i t i o n s can be d i f f e r e n t i a t e d by c h a r a c t e r i s t i c s other than c l i n i c a l f e a t u r e s , the primary value of designations such as paranoid p e r s o n a l i t y , 33 paranoid s t a t e . . . i s to f a c i l i t a t e communication." What, however, was important to me was t h a t i f a p a t i e n t ' s diagnosis included a reference to some form of "paranoid" c o n d i t i o n , then t h i s was a p a t i e n t who the t h e r a p i s t perceived to possess a c e r t a i n set of c h a r a c t e r i s t i c s , and according to my p e r s p e c t i v e , the t h e r a p i s t would set about t r e a t i n g them i n terms of t h e i r t h e o r e t i c a l understanding of the c o n d i t i o n . I came to d i s c o v e r , however, that the a c t i v i t y which ensued i n therapy sessions and on the wards with "paranoid" p a t i e n t s d i d not make 24 sense i n terms of my co n s t r u c t s . The analyses and theo r i e s of paranoia discussed i n the p s y c h i a t r i c l i t e r a t u r e seemed to have l i t t l e to do with how t h e r a p i s t s a c t u a l l y understood and what they a c t u a l l y d i d with "paranoid" p a t i e n t s . My data, which i l l u s t r a t e t h i s f i n d i n g , w i l l be presented l a t e r i n the t h e s i s , but s u f f i c e i t to say th a t my constructs d i d not agree with the data t h a t I was c o l l e c t i n g . -To put i t b r i e f l y , the t h e r a p i s t s d i d not seem to r e l y upon p s y c h i a t r i c theory i n t h e i r work with "paranoid" p a t i e n t s , and I d i d not have to make reference to my knowledge of the theory i n order to make sense of t h e i r work. Thus, I could not l o c a t e examples of the processes such as i n v a l i d a t i o n and r e a l i t y d i s j u n c t u r e s , which I assumed I would f i n d , t a k i n g place. I d i d not r e j e c t , however, my choice of d i a g n o s t i c category. In the period that followed my fieldwor k as I was developing new perspec-t i v e s , I r e a l i z e d t h a t the focus on paranoia, which I had developed because o f my o r i g i n a l p e r s p e c t i v e , could s t i l l be of use. I became aware t h a t the data which I gathered on the work done with these p a t i e n t s , h i g h l i g h t e d my new perspectives on psychotherapy. Although I a l s o i n t e r p r e t e d work done with non-"paranoid" p a t i e n t s i n terms of my new p e r s p e c t i v e s , i t was the work done with "paranoids" which most c l e a r l y revealed what seemed to be a "gap" between the t h e o r e t i c a l knowledge on p s y c h i a t r i c disorders c i t e d i n the p s y c h i a t r i c and s o c i a l s c i e n t i f i c l i t e r a t u r e , and actual instances and the treatment o f these di sorders. 25 The Research Setting The p s y c h i a t r i c h o s p i t a l i n which I conducted my f i e l d w o r k i s a voluntary admission p s y c h i a t r i c i n s t i t u t i o n which i s l o c a t e d on a u n i v e r s i t y campus. The h o s p i t a l i s owned by the u n i v e r s i t y i n which i t i s l o c a t e d , and i s administered by the u n i v e r s i t y ' s department of p s y c h i a t r y . The h o s p i t a l i s l o c a t e d i n a modern s t r u c t u r e b u i l t during the l a t e 1960s, which also houses the f a c u l t y o f f i c e s and teaching f a c i l i t i e s o f the department of p s y c h i a t r y , two day-care programs, a c h i l d and f a m i l y c l i n i c , a psychology c l i n i c , and a basic science research wing. There are three i n - p a t i e n t wards i n the h o s p i t a l , each of which has twenty beds, and there i s a l s o an o u t - p a t i e n t c l i n i c . Two of the wards are designated as longer-stay wards, while the other ward and the o u t - p a t i e n t c l i n i c are i n t e g r a t e d ". . . t o form a combined e v a l u a t i o n and assessment u n i t with c r i s i s - i n t e r v e n t i o n and short stay i n t e n s i v e care. This assessment u n i t has back-up s e r v i c e s from a l l the 34 other programs i n c l u d i n g the longer-stay wards." The most recent s t a t i s t i c s a v a i l a b l e (at the time of my re s e a r c h ) , which were given to me by the h o s p i t a l a d m i n i s t r a t i o n , i n d i c a t e t h a t i n 1974 there were 922 admissions to the f a c i l i t y , and that the average length of stay was 24.16 days. The p a t i e n t population does not r e f l e c t the l o c a t i o n i n which the h o s p i t a l i s s i t u a t e d , as the .hospital does' : not ca t e r to the health care needs of the u n i v e r s i t y community, which are met by a separate f a c i l i t y . Rather, the p a t i e n t population i s d i v e r s e , and r e f l e c t s the make-up' of the general population of the c i t y i n which the h o s p i t a l i s l o c a t e d . P a t i e n t s are g e n e r a l l y admitted upon r e f e r r a l by t h e i r p h y s i c i a n , although some pa t i e n t s seek admission by 26 themselves. The h o s p i t a l information booklet notes t h a t : Admission to U n i v e r s i t y H o s p i t a l i s u s u a l l y done by having an "assessment i n t e r v i e w " i n our Outpatient C l i n i c where the person i s seen and then e i t h e r sent to one of the three i n p a t i e n t wards or put on a w a i t i n g l i s t . Sometimes he i s r e f e r r e d to an a l t e r n a t i v e resource w i t h i n the community o r , perhaps, one of our Day Care programmes.35 An a d m i n i s t r a t o r of the h o s p i t a l pointed out to me that the type of p a t i e n t admitted to the h o s p i t a l i n recent years had changed, owing to the advent of community mental health c l i n i c s . She noted that l e s s problematic cases,which p r e v i o u s l y were admitted to the h o s p i t a l , were now being seen i n these c l i n i c s . This l e d , she e x p l a i n e d , to a higher percentage of problematic cases being admitted to the h o s p i t a l . A p a t i e n t information pamphlet which i s given to p a t i e n t s and t h e i r f a m i l i e s , describes the h o s p i t a l t h i s way: The purposes of the H o s p i t a l i n c l u d e teaching and research as w e l l as p a t i e n t care. There are three i n - p a t i e n t wards of the H o s p i t a l . Each ward func t i o n s independently of the other wards and as an i n d i v i d u a l community. The community i s made up of the twenty p a t i e n t s on the ward and the team of doctors, nurses, p s y c h o l o g i s t s , s o c i a l workers and occupational t h e r a p i s t s . I t i s the b e l i e f of the s t a f f of the H o s p i t a l t h a t each person who comes to the H o s p i t a l seeking help has i n d i v i d u a l needs and problems. Although one method of p r o v i d i n g such help i s through c o n s u l t a t i o n with a doctor, there i s also much to be gained through working on problems i n a group s e t t i n g . In order to f a c i l i t a t e t h i s process, group meetings are held on each of the wards. At times the e n t i r e community meets together and at times small groups of p a t i e n t s meet with s t a f f . 3 6 The d e s c r i p t i o n notes a number of c h a r a c t e r i s t i c features of U n i v e r s i t y H o s p i t a l . As i t i s a h o s p i t a l attached to a department of p s y c h i a t r y of a u n i v e r s i t y , i t i s o r i e n t e d not only toward the treatment of p a t i e n t s , but a l s o toward research and the t r a i n i n g of students. The h o s p i t a l a l s o maintains what may be termed a "progressive" as opposed t o a " t r a d i t i o n a l " treatment program f o r p a t i e n t s . Wards i n the h o s p i t a l 27 are c a l l e d t h e r a p e u t i c communities, and the personnel working w i t h i n them are c a l l e d treatment teams. Although p a t i e n t s are assigned a primary t h e r a p i s t and a primary nurse, the treatment program of the h o s p i t a l emphasizes the involvement of p a t i e n t s i n the a c t i v i t i e s of the ward community and with the other members of the treatment team. U n i v e r s i t y H o s p i t a l i s a t y p i c a l of other p s y c h i a t r i c i n s t i t u t i o n s i n i t s area, because of i t s research and t r a i n i n g o r i e n t a t i o n , and i t s team treatment and ward community approach to p a t i e n t care. I t also i s c h a r a c t e r i z e d by i t s modern and u n - h o s p i t a l - 1 i k e appearance. On a number of occasions I heard i n d i v i d u a l s who l i v e i n the c i t y i n which the h o s p i t a l i s l o c a t e d , r e f e r to i t as the " p s y c h i a t r i c H i l t o n . " The f i r s t time t h a t I v i s i t e d U n i v e r s i t y H o s p i t a l I d i d experience the f e e l i n g of being i n a h o t e l . I d i d not have the impression of being i n a h o s p i t a l or a p s y c h i a t r i c f a c i l i t y , as the f l o o r s were carpeted, the f u r n i t u r e was modern and s t y l i s h , the w a l l s were wood p a n e l l e d , the l i g h t i n g was not harsh, background music was p l a y i n g , and none of the s t a f f wore uniforms. Thus, u n l i k e my experience i n v i s i t i n g other p s y c h i a t r i c f a c i l i t i e s , I d i d not have an immediate sense of being i n a medical s e t t i n g . During the course of my f i e l d w o r k my impression of the h o s p i t a l changed, and I l o s t a l l sense of the s e t t i n g being of a non-medical nature. I a l s o found that c h a r a c t e r i s t i c s which supposedly defined the h o s p i t a l d i d not become obvious to me. I d i d not, f o r example, through-out the period of my f i e l d w o r k , encounter anyone who was doing research i n the h o s p i t a l o f e i t h e r a medical or a s o c i a l s c i e n t i f i c nature. I assume that work of t h i s type was going on, but on no occasion was I 28 aware of i t . I was, however, w e l l aware of the student t r a i n i n g programs i n the h o s p i t a l , as I had contact with p s y c h i a t r i c r e s i d e n t s , f o u r t h year medical students, student nurses, and s o c i a l work students. I t h e r e f o r e concluded that the work done on the wards was o r i e n t e d much more toward student t r a i n i n g and p a t i e n t care than toward research. I also found that I d i d not become aware of the concept of a ward community to be of major s i g n i f i c a n c e on the wards, although my impression may stem from a lack of data on t h i s t o p i c . By c o n t r a s t , however, the team treatment approach was r e a d i l y d i s c e r n i b l e on the wards. I discovered that I was able to gather verbal and w r i t t e n information about p a t i e n t s whom I was i n t e r e s t e d i n not only from t h e i r primary t h e r a p i s t and nurse, but a l s o from other h o s p i t a l s t a f f , as these i n d i v i d u a l s a l s o had ongoing contact as team members with the p a t i e n t . Access to the Research Setting Before I could carry out my fieldwork i n the h o s p i t a l , I had to gain the permission of two committees; the Faculty of Medicine Committee on Research I n v o l v i n g Human Subjects which was a committee from my u n i v e r s i t y , and the Research Committee of the h o s p i t a l i n which I plan-ned to do the research. I s h a l l discuss the procedures that were invo l v e d i n o b t a i n i n g permission to do my research, as such a d i s c u s s i o n i s i n f o r m a t i v e of the response of a p s y c h i a t r i c i n s t i t u t i o n to a request t h a t i t allow i t s e l f to be s t u d i e d , and also may serve to h i g h l i g h t the d i f f e r e n c e s between the o f f i c i a l p o l i c i e s with respect to l e g a l matters and to the w e l f a r e , r i g h t s , and privacy of the subjects s t u d i e d , and the actual ongoing p r a c t i c e s that may a f f e c t these f a c t o r s w i t h i n the 29 h o s p i t a l . My experience was that I had to p a r t i c i p a t e i n an extensive screening procedure and commit myself to a s e r i e s of r u l e s before I was allowed to do my research, y e t when I got w i t h i n the research s e t t i n g , I found t h a t the work that was done there was not always organized s t r i c t l y i n terms of these o f f i c i a l p o l i c i e s . I t i s my purpose at t h i s point to describe the procedures that I had to f o l l o w i n order to gain permission. The f i r s t step t h a t I took to gain entry to the h o s p i t a l was to contact the Head o f the h o s p i t a l , and to e x p l a i n my i n t e r e s t i n doing research there. This procedure was f a c i l i t a t e d by my personal acquain-tance with the Head through my r e l a t i v e who was a p s y c h i a t r i s t . Thus, I had a h e l p f u l means of i n i t i a l l y e s t a b l i s h i n g contact with the i n s t i -t u t i o n . The Head gave h i s t e n t a t i v e approval to the study, subject to i t s approval by the two committees, and appointed one of the h o s p i t a l p s y c h i a t r i s t s to a s s i s t me i n working out the d e t a i l s of my research plans. At that p o i n t , my r e l a t i o n s h i p with the h o s p i t a l as a prospec-t i v e researcher changed, as the Head l e f t the c i t y f o r the duration o f my ne g o t i a t i o n s with the committees, and I thereby l o s t the advantage of t h i s personal input to the proceedings. My next task was to w r i t e a research proposal f o r each committee, and I consulted w i t h the p s y c h i a t r i s t who had been appointed by the Head on how to go about doing t h i s . He was h e l p f u l i n g i v i n g sugges-t i o n s as to the content of the proposals, and i t seemed that there would be no d i f f i c u l t y i n gaining approval f o r my proposed work. I prepared the proposal f o r the committee from my u n i v e r s i t y according to a standard format defined by the u n i v e r s i t y . This proposal which was 30 c a l l e d a "statement of p r o t o c o l " was an o u t l i n e of the procedures that I would f o l l o w i n order to ensure the w e l f a r e , p r i v a c y , and r i g h t s of the subjects s t u d i e d . I d i d not have a format to f o l l o w f o r the other proposal, but the p s y c h i a t r i s t had informed me that i t was necessary to include an o u t l i n e of not only the steps that I would take to ensure t h a t my research procedures were e t h i c a l , but also an i n d i c a t i o n that they would not i n t e r f e r e with the normal f u n c t i o n i n g of the h o s p i t a l . I then submitted the statement of protocol to the research a d m i n i s t r a t o r of the u n i v e r s i t y committee, t h i n k i n g that i t was l o g i c a l to get the u n i v e r s i t y ' s permission f i r s t to proceed with my work, and then to gain the approval of the h o s p i t a l . The a d m i n i s t r a t o r informed me that the protocol required a l e t t e r of permission from the h o s p i t a l Head and the signature of the p s y c h i a t r i s t who was my appointed advi s o r . I contacted the p s y c h i a t r i s t about t h i s , and he was not prepared to sign f o r me as the Head was out of town. He suggested that I contact the A c t i n g Head of the h o s p i t a l , which I d i d , and I found that I was i n the p o s i t i o n of being an unknown o u t s i d e r . The A c t i n g Head had not been p r e v i o u s l y informed o f my i d e n t i t y and my plans, and to him, I was j u s t anyone o f f the s t r e e t who abruptly was asking f o r a l e t t e r of permission to do research i n the h o s p i t a l . I t was h i s opinion that I should get the h o s p i t a l ' s approval, which he defined as h i s own and the c l i n i c a l s u p e r v i s o r s ' approval, f i r s t before I submitted my statement of protocol to the u n i v e r s i t y committee. I got i n touch with the p s y c h i a t r i s t to discuss my problem, and found that he now f e l t t hat my attempt to gain access to the h o s p i t a l had to be put o f f u n t i l the Head's r e t u r n , and al s o t h a t he 31 f e l t that h i s r e s p o n s i b i l i t y f o r and involvement with my work was minimal. Thus, i t seemed to me that my p o s i t i o n i n r e l a t i o n to the h o s p i t a l had been transformed. Lacking the personal contact with the Head, I no longer had the means to e a s i l y e f f e c t an entry to the s e t -t i n g . I decided to check w i t h the Head of the u n i v e r s i t y committee i n order to e s t a b l i s h the exact nature of the l e t t e r t h a t was r e q u i r e d , as i t was not c l e a r i f i t committed the person who signed i t to accept r e s p o n s i b i l i t y f o r my work. This i n d i v i d u a l informed me that the signature was not an acceptance of r e s p o n s i b i l i t y , but r a t h e r r e l i e v e d the h o s p i t a l of l i a b i l i t y f o r my work. He suggested that I again con-t a c t the A c t i n g Head, and e x p l a i n the meaning of the l e t t e r , and added that he would a l s o speak to him. Thus, I contacted the A c t i n g Head once more. A f t e r some d i s c u s s i o n , he agreed to read my research propo-s a l , and suggested t h a t I make copies of i t f o r the c l i n i c a l s u p e r v i s o r s . The next day the Head of the h o s p i t a l committee informed me that a meeting had been set up f o r me to get together with the committee the f o l l o w i n g week. The A c t i n g Head al s o contacted me, and l e t me know th a t he would discuss my proposal w i t h the s e n i o r s t a f f of the h o s p i t a l , and t h a t i f the H o s p i t a l Research Committee found my work to be acceptable, then I would not have to a n t i c i p a t e any problems i n gaining approval from the u n i v e r s i t y committee. At t h i s p o i n t , I again sensed a change of my s t a t u s , t h i s time from that of " o u t s i d e r " to one who has some le g i t i m a c y i n requesting access to the h o s p i t a l . I b e l i e v e t h a t my i d e n t i t y and the background of my request had become known to the A c t i n g Head and the other s e n i o r s t a f f , and t h i s , I assume, accounted f o r the change i n my s t a t u s . 32 One month a f t e r I began the process to negotiate my entry to the h o s p i t a l , I met with the Research Committee of the h o s p i t a l at a meeting that had been e s p e c i a l l y c a l l e d to discuss my proposal to do research. Present at the meeting were the chairman of the committee, the Ac t i n g Head and c l i n i c a l s upervisors o f the h o s p i t a l , the p s y c h i a t r i s t who had been appointed to a s s i s t me, and three other a d m i n i s t r a t i v e s t a f f of the h o s p i t a l . I a r r i v e d at the appointed time, and found that the meeting was already i n progress; the committee members having met e a r l i e r to discuss my proposal. I was introduced to the members, and the chairman then asked me to "take the hot seat." The way he phrased h i s request f i t t e d the way.that I f e l t at that moment. I t i s an unusual experience to attend a meeting i n which the ma j o r i t y of the p a r t i c i p a n t s are p s y c h i a t r i s t s , and i n which the d i s c u s s i o n focuses on onese l f . I was asked f i r s t by the chairman how I a r r i v e d at my t o p i c . I was then asked by other members how I planned to gather data, and what was my understanding of the paranoid form of di s o r d e r . A d i s c u s s i o n then evolved on the d i f f e r e n c e between a p s y c h i a t r i c and a s o c i o l o g i c a l p erspective on mental d i s o r d e r . The c l i n i c a l s upervisors seemed to be i n t e r e s t e d i n f i n d i n g out what ideas I had, coming from a s o c i o l o g i c a l background, on the nature of psychotherapy and paranoia. The chairman and the A c t i n g Head focused t h e i r remarks on o u t l i n i n g the procedures 37 t h a t I would be required to f o l l o w i n c a r r y i n g out my research. The c l i n i c a l s upervisors expanded the d i s c u s s i o n beyond the t e c h n i c a l i t i e s o f these procedures, and questioned me as to how I planned to put i n t o p r a c t i c e these r e g u l a t i o n s . Thus, I was asked how I would manage to gain the consent o f the p a t i e n t s and al s o the t h e r a p i s t s . 33 By the end of the meeting, I f e l t somewhat burdened by the extensive l i s t o f r e g u l a t i o n s to which I was committed. Not only was my work to be governed by the rul e s of the u n i v e r s i t y committee, but a l s o by those of the h o s p i t a l committee. In a d d i t i o n to the rul e s of e t h i c s p e r t a i n i n g to the t h e r a p i s t s ' and the p a t i e n t s ' w e l f a r e , r i g h t s , and p r i v a c y , which I was bound to f o l l o w , I also was committed to f o l l o w r e g u l a t i o n s w i t h respect to l e g a l matters, and to non-interference with the f u n c t i o n i n g of the h o s p i t a l . I f e l t the r e s p o n s i b i l i t y of making sure t h a t my work would not breach any of these r u l e s and r e g u l a t i o n s , and I a l s o f e l t a demand to simply not do anything which would break protocol i n the h o s p i t a l . The l a t t e r f e e l i n g was responsive not to any s p e c i f i c r u l e or r e g u l a t i o n , but derived from my month long experience of n e g o t i a t i n g my entry. The g r a v i t y of the response to my request to do research had created w i t h i n me a tension about proceeding with my work i n the research s e t t i n g . At the end of the meeting, I was t o l d that the A c t i n g Head would inform me of the committee's d e c i s i o n i n three days. Upon contacting him, I was n o t i f i e d that both the h o s p i t a l committee and the u n i v e r s i t y committee had granted me permission to carry out my research. I t i s important to note t h a t I do not harbour any negative f e e l -ings about my month long experience, despite the f a c t that I found upon e n t e r i n g the research s e t t i n g that the r u l e s and r e g u l a t i o n s s t i p u l a t e d by the committees are not always s t r i c t l y observed i n the course of ongoing work t h a t gets done i n the h o s p i t a l . I t was the task of the two committees, and i n p a r t i c u l a r the h o s p i t a l committee, to screen " o u t s i d e r s " who wish to do work i n the h o s p i t a l , i n order to make sure 34 t h a t o f f i c i a l p o l i c i e s and r e g u l a t i o n s are not abused. I t i s the task of the s t a f f working w i t h i n the h o s p i t a l to t r e a t p a t i e n t s , and these two tasks are not n e c e s s a r i l y compatible, as they are s t r u c t u r e d according to d i f f e r e n t demands. Methodology The methodology of the t h e s i s has already been b r i e f l y discussed. I s h a l l again take up t h i s t o p i c , and s h a l l o f f e r a f u r t h e r d e s c r i p t i o n and defence of i t . I have argued t h a t the ethnographic method which was employed to gather data allowed me to discover that my preconceived constructs,' which I brought with me i n t o the research s e t t i n g , d i d not make sense i n terms of what I observed and experienced i n the s e t t i n g . As the ethnographic approach d i d not provide f o r the use of instruments such as i n t e r v i e w schedules and a t t i t u d e s s c a l e s , I was not able to gather data which would simply serve to support my c o n s t r u c t s . I was unable to ga i n , to use Turner's metaphor, "snapshots" of a c t i v i t i e s such as t h e r a p i s t s i n v a l i d a t i n g "paranoid" p a t i e n t s ' versions of the world. Instead, I entered the s e t t i n g and began n o n - p a r t i c i p a n t observation without the baggage of t h i s type of methodological instrument. I did have my preconceived perspective which I had worked out i n d e t a i l , but I d i d not have the means to o p e r a t i o n a l i z e i t . Thus, I am arguing that the ethnographic method enabled me to make sense of the s e t t i n g i n terms of what I a c t u a l l y observed and experienced, r a t h e r than r e l y i n g upon my preconceived ideas of what was t a k i n g place. The c o n s t r u c t s , which I l a t e r d i d develop, evolved from my fieldwo r k experience, rather than my fiel d w o r k experience being determined by my co n s t r u c t s . I th e r e f o r e d i d 35 not engage i n a process which David Sudnow describes as ". . . perform-38 i n g transformations on the obje c t . " I d i d not impose my schema on the s e t t i n g , and provide myself with "snapshots" of what was happening t h a t had l i t t l e to do with the actu a l ongoing a c t i v i t i e s of the s e t t i n g . I concur with J e f f Coulter's a s s e r t i o n that "the m o r a l i t y of s o c i a l o r g a n i z a t i o n i s s u r e l y not a t o p i c f o r a r b i t r a r y r e d e f i n i t i o n by 39 s o c i o l o g i s t s o f a l l people," and I am arguing that the ethnographic method allowed me to avoid t h i s p r a c t i c e . The Data and Their •Collection I conducted my fieldwork over a period of seven months. During t h i s time, I v i s i t e d the h o s p i t a l p a r t i a l l y on a scheduled b a s i s ; every second week I attended the therapy session of a "paranoid" o u t - p a t i e n t . The r e s t of the time that I spent i n the h o s p i t a l was not r e g u l a r l y scheduled. One week I would spend part of every day at the h o s p i t a l , while the next I might only be there f o r two days. I d i d not v i s i t the h o s p i t a l on a regular d a i l y basis because of my p a r t i c u l a r research i n t e r e s t . Sometimes there were no pa t i e n t s on the wards who had been diagnosed as "paranoid." Since I was i n t e r e s t e d p r i m a r i l y i n p a t i e n t s with t h i s type of d i a g n o s i s , I spent more time i n the h o s p i t a l when such p a t i e n t s were present. I had arranged with one t h e r a p i s t from each ward to n o t i f y me when a p a t i e n t whose admitting diagnosis made reference to 40 a paranoid type of d i s o r d e r , was admitted. I ther e f o r e was able to keep track of the flow of "paranoid" p a t i e n t s i n t o the h o s p i t a l . My observational work i n the h o s p i t a l was organized i n terms of these p a t i e n t s , and thus the frequency of my v i s i t s to some degree depended 36 upon the number of "paranoids" who were i n the h o s p i t a l , or were coming to the o u t - p a t i e n t department. I gathered three types of data while i n the research s e t t i n g . I made tape recordings of therapy sessions i n which a t h e r a p i s t and a "paranoid" p a t i e n t p a r t i c i p a t e d . ^ I examined and made notes on the c l i n i c a l records of these "paranoid" p a t i e n t s that were made by t h e i r primary t h e r a p i s t s and other members of the h o s p i t a l s t a f f , and I made f i e l d n o t e s of my observations of the therapy sessions and other a c t i v i -t i e s t h a t I experienced and observed while i n the h o s p i t a l . In a d d i t i o n to these data, I developed a f o u r t h type of data which c o n s i s t e d of a jo u r n a l which I wrote at home, and i n which I kept a l o g of my r e f l e c -t i o n s upon what I had observed each time that I was i n the h o s p i t a l . Together, these four types of data provided me with a number o f perspec-t i v e s on the work that was done with "paranoid" p a t i e n t s ; my own, the t h e r a p i s t s ' , and al s o the o b j e c t i v e record of therapy sessions which the t r a n s c r i p t s o f tape recordings provided. My data were not, however, simply l i m i t e d to the a c t i v i t i e s which ensued with "paranoid" p a t i e n t s . In the course of c o l l e c t i n g the data on "paranoids," I al s o gathered data on the other a c t i v i t i e s which were going on around me i n the h o s p i t a l . Thus, my f i e l d n o t e s , j o u r n a l , t r a n s c r i p t s , and notes on the c l i n i c a l records d i d not f i l t e r out references to a c t i v i t i e s t hat I experienced and observed which were not d i r e c t l y r e l a t e d to p a t i e n t s who had been diagnosed as "paranoid." When I attended, f o r example, rounds because a p a r t i c u l a r "paranoid" p a t i e n t whom I was i n t e r e s t e d i n was being discussed, I al s o observed the d i s c u s s i o n of other p a t i e n t s by the t h e r a p i s t s , and I kept a record of these observations. Another 37 example w i l l i l l u s t r a t e t h i s p o i n t . One day I was i n the nursing s t a t i o n o f a ward t a l k i n g to a fourth year medical student about a "paranoid" p a t i e n t whom I wished to meet when a p s y c h i a t r i c r e s i d e n t came up to us and i n v i t e d us to watch a videotape of a therapy session wit h a woman who had been diagnosed as sch i z o p h r e n i c . I went to a room i n another part of the h o s p i t a l with the medical student and the r e s i -dent, and spent the next hour watching the videotape with them, the p a t i e n t , and four other medical students. During the next two hours I sat i n the room while the p a t i e n t discussed how she f e l t about seeing h e r s e l f on the videotape, and I a l s o was present w h i l e the re s i d e n t and the students discussed the p a t i e n t a f t e r she had l e f t the room. This was the pattern of how I spent my time i n the h o s p i t a l . I organized my work around gathering data on "paranoid" p a t i e n t s , but often I ended up observing and recording a c t i v i t i e s t h a t were not r e l a t e d to p a t i e n t s who had t h i s p a r t i c u l a r d iagnosis. Thus, I was able to gather data and develop i n s i g h t s on psychotherapy with not only "paranoid" p a t i e n t s , but al s o p a t i e n t s w i t h other diagnoses. This allowed me to put the work done with "paranoids" i n t o perspective i n terms of how i t compared to the work that was done with other p a t i e n t s . Once I gained permission from the Research Committee of the ho s p i t a l to do my research t h e r e , I was not able to simply proceed, and walk i n t o the h o s p i t a l and begin my f i e l d w o r k . I did not have an iden-t i t y or a r o l e i n the h o s p i t a l , and I there f o r e could not walk o f f the s t r e e t and i n t o the s e t t i n g . As I d i d not have a s t r u c t u r e d r o l e i n the h o s p i t a l which would provide me with a "cover" f o r being there ( i . e . a job such as an aide or a c l e a n e r ) , i t was necessary f o r me to make 38 contact w i t h the h o s p i t a l s t a f f and e s t a b l i s h my i d e n t i t y as a researcher, and e x p l a i n to them the purpose of my work i n the h o s p i t a l . In my meeting with the Research Committee of the h o s p i t a l , I had met the A c t i n g Head of the h o s p i t a l , some of the c l i n i c a l s upervisors of the wards, and a number of other s e n i o r s t a f f members. I had p r e v i o u s l y met the Head of the h o s p i t a l and a s t a f f p s y c h i a t r i s t who had been appointed by the Head to discuss w i t h me my i n t e r e s t i n doing research i n the h o s p i t a l . I d i d not know, however, anyone e l s e on the h o s p i t a l s t a f f , and the s e n i o r s t a f f t h a t I had met u s u a l l y were not present when I came on a ward. I t h e r e f o r e had throughout the course of my f i e l d w o r k to account f o r my presence i n the h o s p i t a l , and e s t a b l i s h my i d e n t i t y with the s t a f f as a researcher. Although I came to know a number of s t a f f on every ward, I always met new ones, and t h e r e f o r e i t was necessary f o r me to go through t h i s process of e x p l a i n i n g who I was, and what I was doing on t h e i r ward. I even had, f o r example, problems e s t a b l i s h i n g my i d e n t i t y with s t a f f whom I had p r e v i o u s l y met. At the beginning of my f i e l d w o r k , I phoned one of the c l i n i c a l supervisors i n order to f i n d out i f there were any "paranoid" p a t i e n t s on h i s ward. He d i d not at f i r s t remember who I was, and gave the phone to h i s s e c r e t a r y , apparently with the i n t e n t of " g e t t i n g r i d of me." The s e c r e t a r y proceeded to t e l l me that I could not simply come i n t o the h o s p i t a l and do research. She t o l d me that I had to speak to other people i n order to do research t h e r e , and t h a t I had to f o l l o w a s t r i c t procedure i n order to gain permission. While I t r i e d to e x p l a i n to her t h a t I already had been granted permission, she went on and warned me that "there have been problems w i t h people doing studies i n the h o s p i t a l . " R e a l i z i n g that 39 the c l i n i c a l s u p e r v i s o r had forg o t t e n who I was, I d i d not give up, and I repeated my explanation of who I was, and why I wished to speak to him. By t h i s time, he had remembered who I was and again got on the phone, and began to discuss w i t h me the pa t i e n t s on his ward. On another oc c a s i o n , I went to the Medical Records O f f i c e of the h o s p i t a l i n order to look at the c l i n i c a l records of a p a t i e n t who I was i n t e r -ested i n . The head o f the o f f i c e (a medical l i b r a r i a n ) was out, and the woman to whom I spoke s a i d I had to see the l i b r a r i a n before I could look at the p a t i e n t ' s c h a r t , although I had explained to the o f f i c e worker who I was and what I was doing i n the h o s p i t a l . Two hours l a t e r the l i b r a r i a n returned, and I introduced myself, and explained what I wished to do. The l i b r a r i a n responded by saying that she didn't know who I was, and tha t she i s always informed f i r s t i f anyone i s doing research i n the h o s p i t a l . Thus, I was faced with a challenge of my i d e n t i t y , and the l e g i t i m a c y of the work that I wished to do. I hap-pened to have w i t h me' a two-page l i s t of re g u l a t i o n s concerning my research, which the Research Committee had given me, and I presented i t to her as proof o f my i d e n t i t y . The l i b r a r i a n looked over t h i s l i s t and l e c t u r e d me on each of the r u l e s on i t , although I informed her that I had already gone through t h i s procedure with the Research Committee. F i n a l l y , she s a i d t h a t she remembered g e t t i n g a memo about me and my work, and thus acknowledged t h a t I was "okay." I d i d not always have as d i f f i c u l t a time i n e s t a b l i s h i n g my i d e n t i t y , but i t was necessary f o r me to e x p l a i n who I was, and what I wished to do every time t h a t I made contact with a s t a f f member whom I had not met before. Sometimes I was able to make my task e a s i e r by 40 d i s t r i b u t i n g a copy of the statement of protocol which I had prepared f o r the Faculty of Medicine Committee on Research I n v o l v i n g Human Subjects. This protocol o u t l i n e d the nature o f my research p r o j e c t , and the steps t h a t I planned to take i n order to ensure that the r i g h t s of the i n d i v i d u a l s whom I st u d i e d would not be abused. When I was able t o , I would send a copy of the protocol to s t a f f members before I met 42 them. I found that t h i s procedure worked w e l l , as i t gave the s t a f f members the opportunity to get to know who I was through a more gradual process. A f t e r the members of the s t a f f had had a chance to read the p r o t o c o l , I would arrange to meet them, and I found that these encoun-t e r s went much more smoothly than when I met s t a f f members who had no p r i o r knowledge of who I was. In a d d i t i o n to the problems t h a t I had i n e s t a b l i s h i n g my i d e n t i t y i n the h o s p i t a l , I was al s o faced with the task o f n e g o t i a t i n g my entry onto the wards and i n t o therapy se s s i o n s . Simply e s t a b l i s h i n g who I was, and that I had o f f i c i a l permission to carry out my research, d i d not guarantee me the opportunity to carry out my work. In order to observe therapy s e s s i o n s , make tape recordings, attend rounds, e t c . , I required both the w r i t t e n permission and the co-operation of the s t a f f who were in v o l v e d . I t th e r e f o r e was necessary f o r me, a f t e r I had e s t a b l i s h e d my i d e n t i t y on a ward, to develop a f r i e n d l y working r e l a t i o n s h i p with the s t a f f of that ward. To some degree, the volume and kind of data t h a t I gathered were a f f e c t e d by the strength of the r e l a t i o n s h i p s that I worked out with s t a f f members. On the wards where I had c l o s e r r e l a t i o n s h i p s w i t h the s t a f f , f o r example, I al s o was kept b e t t e r informed o f the admittance of "paranoid" p a t i e n t s , i n v i t e d more often 41 to observe therapy sessions and attend rounds, provided with more information about a c t i v i t i e s on the ward and i n the h o s p i t a l , and i n general allowed more free access to the ward. The r e l a t i o n s h i p that I developed with the c l i n i c a l s u p e r v i s o r of a ward seemed to a f f e c t the q u a l i t y of the r e l a t i o n s h i p s which I worked out with the other s t a f f of the ward. On one ward, f o r example, the c l i n i c a l s u p e r v i s o r was i n t e r -ested i n my work and gave me encouragement, and i t was from t h i s ward t h a t I received the most co-operation from the s t a f f . On another ward, my f i r s t meeting with the c l i n i c a l s u p e r v i s o r d i d not go w e l l , as the a s s i s t a n t c l i n i c a l s u p e r v i s o r from the ward, whom I had met before and who attended t h i s meeting, expressed doubts about the value of my work. He s t a t e d that my "hypothesis" was unclear, and t h a t I would not be able to f i n d p a t i e n t s w i t h the diagnosis that i n t e r e s t e d me. The c l i n i c a l s u p e r v i s o r seemed to be i n f l u e n c e d by him, and began to express d i s -i n t e r e s t i n and s k e p t i c a l remarks about my work. I subsequently found t h a t i t was on t h i s ward that I had the hardest time i n making contact with the s t a f f and i n c a r r y i n g out my work. I s h a l l now o u t l i n e i n more d e t a i l how I a c t u a l l y went about gathering data. The f i r s t phase of my work in v o l v e d making contact with the s t a f f on the wards which i n v o l v e d , as has been discussed above, making phone c a l l s , sending copies of my statement of p r o t o c o l , and arranging to make my i n i t i a l v i s i t s to the wards. I kept track of these encounters and a l l subsequent experiences t h a t I had i n the course of my f i e l d w o r k i n my j o u r n a l . Every evening I set aside time to record my observations and experiences from the day i n the h o s p i t a l . At f i r s t I found t h i s to be a d i f f i c u l t t a s k , as I was not used to consciously 42 remembering and analysing i n a d i s c i p l i n e d fashion what had happened to me during the day. I found i t a s t r a i n every evening, to b r i n g up again i n my mind material t h a t I had already d e a l t with before. A f t e r the f i r s t few weeks, however, I adjusted to t h i s new pattern i n my l i f e , and no longer found i t so t r y i n g to ret h i n k the events o f the day. The jou r n a l proved to be a useful source of data, as I was a b l e , i n the calmness o f my home away from the immediacy of the research s e t t i n g , to analyse and develop i n s i g h t i n t o what had happened that day. I was able to make use of my f i e l d n o t e s to help me remember what had gone on, and then I was able to r e f l e c t and b u i l d upon t h i s m a t e r i a l . I found that there was a s k i l l i n v o l v e d i n t h i s process, and th a t my a b i l i t y to ca r r y i t out improved over time. My f i r s t v i s i t s to the wards were s t r e s s f u l to me. Although I had v i s i t e d mental h o s p i t a l s before, I had never done so i n the capacity of a researcher. My head was f i l l e d with the r u l e s of research conduct t h a t I had agreed with the h o s p i t a l Research Committee and the Faculty of Medicine Committee on Research to abide by. I was als o very aware of the commitments t h a t I had made to the h o s p i t a l Research Committee with respect to making sure t h a t my presence and work would not i n t e r -fere with the f u n c t i o n i n g of the h o s p i t a l . Thus, I f e l t on edge, worried t h a t I might i n a d v e r t e n t l y do or say something wrong. I had already been "coached" by one of the h o s p i t a l p s y c h i a t r i s t s on how to look and behave. He had advised me th a t I should dress l i k e him; ". . . dress l i k e a doctor," i n a sweater, t i e and s l a c k s . By adopting his s t y l e of dress, I was able to look l i k e one of the s t a f f , as none of them wore uniforms. He had als o given me advice on how to t a l k to 43 p a t i e n t s , and i n p a r t i c u l a r how to t a l k to "paranoid" p a t i e n t s . Thus I entered the research s e t t i n g g i n g e r l y , and during one of my e a r l y v i s i t s I arranged with a t h e r a p i s t (who had been introduced to me by the c l i n i c a l s u p e r v i s o r o f a ward, because the t h e r a p i s t was t r e a t i n g a "paranoid" p a t i e n t ) to observe and tape record a therapy s e s s i o n . I s h a l l discuss the steps t h a t were in v o l v e d i n the observation and tape recording of t h i s therapy s e s s i o n , and the o u t l i n e may serve as a guide to how I t y p i c a l l y went about gathering t h i s type of data. In my f i r s t meeting with the primary t h e r a p i s t , I had ( a f t e r e x p l a i n i n g what I wanted to do) to gain the t h e r a p i s t ' s informal approval, to proceed. I was not always successful i n gaining the approval of the t h e r a p i s t . One r e s i d e n t , having been encouraged by her c l i n i c a l super-v i s o r to work with me as she was t r e a t i n g a "paranoid" p a t i e n t , d e c l i n e d , saying t h a t she f e l t t hat the p a t i e n t (who was an o u t - p a t i e n t ) might terminate therapy i f I became i n v o l v e d . A f t e r I got the t h e r a p i s t ' s approval, I arranged the date and time at which I would be able to observe a therapy s e s s i o n . This i n part depended upon when the obser-v a t i o n room on the ward was a v a i l a b l e . This was a room from which one could see (through a one-way m i r r o r ) and hear what took place i n the adjacent room. During the therapy session I would s i t i n t h i s room and observe the s e s s i o n , w r i t i n g down my observations i n my f i e l d n o t e s . Beside my I would have my tape recorder which was connected to an audio pick-up l o c a t e d i n the other room. Thus, I was able to c l e a r l y see and hear what took place i n the other room without r a d i c a l l y changing, because I was not present, the nature of the i n t e r a c t i o n between the primary t h e r a p i s t and the p a t i e n t . Although they were both aware t h a t 44 I was observing them, one can assume, as i t seemed to me a f t e r watching a number of s e s s i o n s , t h a t my presence i n the other room did not have a s i g n i f i c a n t e f f e c t upon how the therapy session evolved. The p a r t i c u l a r therapy session which I am addressing myself t o , the f i r s t one t h a t I observed, d i d not take place i n a room connected to an observation room. This happened because the p a t i e n t refused to be observed i n t h a t s e t t i n g The p a t i e n t d i d agree, however, to have me s i t i n on the s e s s i o n , which I d i d ; s i t t i n g o f f to the side of the p a t i e n t and the t h e r a p i s t , making notes and operating my tape recorder. I t was through t h i s experience t h a t I was able to see how my immediate presence could a l t e r a s e s s i o n . When I sat i n on the s e s s i o n , the p a t i e n t made reference to me i n h i s dialogue with the t h e r a p i s t , and at times turned and addressed me. Although my presence a l t e r e d the nature of the s e s s i o n , I found that s i t t i n g i n on a session provided me w i t h new i n s i g h t s as I became more d i r e c t l y i n v o l v e d with the p a t i e n t and the t h e r a p i s t . The p a t i e n t ' s r e f u s a l to be observed from behind a one-way m i r r o r occurred when I asked him f o r h i s w r i t t e n consent to record and observe the s e s s i o n . Before I taped a s e s s i o n , I was required by the h o s p i t a l Research Committee to f o l l o w a s t r i c t procedure with respect to o b t a i n -in g permission. The r u l e s that I had to adhere to were set down by the committee as f o l l o w s : (a) Each of the p a t i e n t s would sign a v a l i d consent form permit-t i n g the recording and observation. (b) Each of the primary t h e r a p i s t s would a l s o sign a v a l i d consent form on each occasion t h a t a session was recorded and/or observed. (c) For each p a t i e n t , Mr. Maidstone would obtain the approval of the c l i n i c a l s u p e r v i s o r and of the head nurse before proceeding to record and/or observe the s e s s i o n s . (d) For each taping s e s s i o n , the primary t h e r a p i s t would record 45 his c l i n i c a l opinion that the p a t i e n t understood the nature of the consent he had given. This statement by the primary thera-p i s t together with the primary t h e r a p i s t ' s own w r i t t e n consent would be entered i n the p a t i e n t ' s chart at the time of the taping.43 I took these r u l e s s e r i o u s l y and, on every occasion that I attended a s e s s i o n , I attempted to f o l l o w them e x a c t l y . To my s u r p r i s e , some of the s t a f f that I met d i d not seem to take the rul e s s e r i o u s l y and, i n f a c t , at times disregarded and were c r i t i c a l of them. This phenomenon w i l l be discussed l a t e r i n the t h e s i s . A f t e r I had observed and taped a s e s s i o n , which u s u a l l y l a s t e d about f o r t y to s i x t y minutes, I thanked the p a t i e n t , and sometimes had the opportunity to t a l k to the p a t i e n t by myself f o r a short time. During these conversations, the p a t i e n t s f r e q u e n t l y asked me such questions as: what I hoped to f i n d out by observing them, what was my job i n the h o s p i t a l , or what was I studying at u n i v e r s i t y . I u s u a l l y t a l k e d to the t h e r a p i s t a f t e r the s e s s i o n , and I found that the thera-p i s t s were often anxious to hear my opinions on what had evolved during the s e s s i o n , and what I thought about the p a t i e n t . A c l o s e r r e l a t i o n -ship seemed to develop between the t h e r a p i s t s and myself a f t e r I had shared the experience of a therapy session with them. I think that they f e l t t h a t we now had more i n common, and i n these t a l k s a f t e r the ses-sions I received many data. The t h e r a p i s t s would t a l k not only about the p a t i e n t they were t r e a t i n g , but al s o about a range of t o p i c s such as t h e i r understanding the "paranoid" d i s o r d e r , t h e i r r e l a t i o n s h i p s with the other s t a f f , t h e i r f e e l i n g s about t h e i r job or r o l e i n the h o s p i t a l , t h e i r views on the nature of t h e i r ward and the h o s p i t a l , e t c . I found, a f t e r taping s e s s i o n s , t h a t I became more accepted by both the 46 t h e r a p i s t with whom I had worked, and the other s t a f f on the ward. I t seemed t h a t the r e s t of the s t a f f a l s o f e l t more i n common with me, and my involvement i n the therapy sessions served to provide me with more of a r o l e on the wards to which the s t a f f could r e l a t e . I now became not only the graduate student doing research, but als o the person who observed and had a s p e c i a l i n t e r e s t i n the "paranoid" p a t i e n t or pa t i e n t s on the ward. Thus, the c l i n i c a l supervisors a l s o would some-times discuss w i t h me a "paranoid" p a t i e n t whose sessions I had observed. One day, f o r example, a f t e r I had taped and observed a s e s s i o n , I met the c l i n c i a l s u p e r v i s o r i n the nursing s t a t i o n , and he asked me with i n t e r e s t what I thought of the ideas o f the p a t i e n t whom I had observed, and i f I thought t h a t the p a t i e n t had f i x e d d e l u s i o n s . A f t e r I expressed my op i n i o n s , he then gave me h i s a n a l y s i s of the p a t i e n t . My r o l e i n the h o s p i t a l , t h e r e f o r e , at times s h i f t e d from that of non-p a r t i c i p a n t observer to p a r t i c i p a n t observer. One t h e r a p i s t i n p a r t i c -u l a r made a poin t of c o n s u l t i n g a f t e r every session with me, on my views o f how her p a t i e n t was progressing i n therapy. I never sought out the opportunity to adopt t h i s r o l e , and p a r t i c i p a t e i n these types of d i s c u s s i o n s , but rat h e r found t h a t the s t a f f brought me i n t o the r o l e of a p a r t i c i p a n t . On another oc c a s i o n , I was i n v i t e d by a p s y c h i a t r i c r e s i d e n t to present my views of a "paranoid" p a t i e n t i n rounds, because I had p r e v i o u s l y observed a number of sessions w i t h t h i s newly admitted p a t i e n t on another ward. Thus, my involvement i n , t a p i n g and observing therapy sessions provided me not only with data on the s e s s i o n s , but al s o helped to create the opportunity f o r me to gather data i n other s e t t i n g s . 47 My other two methods of data c o l l e c t i o n were my f i e l d n o t e s , and my notes on the c l i n i c a l records. I kept my f i e l d n o t e book with me at a l l times when I was i n the research s e t t i n g , and i n i t I kept my immediate observations of what was happening around me. Sometimes t h i s took the form of an account and b r i e f a n a l y s i s of an a c t i v i t y t h a t I was w i t n e s s i n g , such as a therapy s e s s i o n , while at other times I would include an o u t l i n e and quotations of a conversation t h a t I was having or had had; or t h a t I was hearing or overhearing. When i t was p o s s i b l e , such as when I was i n the observation room or when a person gave me t h e i r informal permission to make notes, I would w r i t e the f i e l d n o t e s at the same time as the a c t i v i t y that I was in v o l v e d i n took place. At other times, I had to wai t f o r the f i r s t opportunity that I got to get away from an a c t i v i t y i n order to w r i t e my notes. I made a point o f doing t h i s as q u i c k l y as p o s s i b l e a f t e r something happened that I wanted to get down, so t h a t I was able to preserve my o r i g i n a l sense of the conversation or a c t i v i t y . On one ward there was a room provided f o r s o c i a l work students to use as a study, and I often went to t h i s room to w r i t e up notes. I a l s o used the o f f i c e s of medical students, and sometimes went to the h o s p i t a l c a f e t e r i a to make notes. At times, i f I f e l t t h a t I needed pr i v a c y i n order to w r i t e something up, I would go and w r i t e i n my van, which was parked beside the h o s p i t a l . The fou r t h type of data that I gathered was taken from the c l i n i c a l records of the p a t i e n t s whose therapy sessions I had observed and taped. I c o l l e c t e d t h i s type of data, as I was i n t e r e s t e d i n gain-in g an i n s i g h t i n t o the perspectives which the t h e r a p i s t s had on the "paranoid" p a t i e n t s who they were t r e a t i n g . U n t i l a p a t i e n t was 48 discharged from the h o s p i t a l , h i s / h e r records were kept i n the nursing s t a t i o n of the ward. I had noted i n my research proposal to the Research Committee of the h o s p i t a l t h a t I would not examine p a t i e n t s ' records while they were kept i n a nursing s t a t i o n i n order to avoid i n t e r f e r i n g w i t h the work c a r r i e d on i n the s t a t i o n . I had made t h i s p oint i n my proposal on the advice of the s t a f f p s y c h i a t r i s t who had been appointed to discuss my research i n t e r e s t s w i t h me. He f e l t t hat the Research Committee would look favourably upon a suggestion by me t h a t I would t r y to avoid i n t e r f e r i n g w i t h h o s p i t a l work. As i t turned out, on a number of occasions I was i n v i t e d by t h e r a p i s t s to examine p a t i e n t s ' records before they had been discharged. At these times I would mention my commitment i n the p r o p o s a l , but i f they s t i l l extended the i n v i t a t i o n , then I would take i t up. I would l o c a t e , w i t h t h e i r h elp, a place to work such as the back of the nursing s t a t i o n , and begin to peruse the records. I was able to gather two types o f data at these times; not only d i d I gain data from the p a t i e n t s ' c h a r t s , but a l s o the s e t t i n g i n which I worked was an e x c e l l e n t source of data f o r my f i e l d -notes. Located i n the corner of the nursing s t a t i o n w i t h a p a t i e n t ' s chart s e r v i n g as an i d e n t i f i a b l e explanation f o r my extended presence t h e r e , I was able to gather much useful data on the a c t i v i t i e s which ensued i n the nursing s t a t i o n . I examined charts of discharged p a t i e n t s i n an o f f i c e that was used f o r t r a n s c r i p t i o n s e r v i c e s , and was l o c a t e d across the h a l l from the Medical Records O f f i c e of the h o s p i t a l . The l i b r a r i a n (whom I men-tio n e d above i n my d e s c r i p t i o n of the problems I had i n e s t a b l i s h i n g my i d e n t i t y ) o f the o f f i c e i n s i s t e d t h a t I had to get her personal 49 permission every time that I wanted to see a chart. She warned me that she would be checking on the charts of the p a t i e n t s whose therapy ses-sions I had observed and taped, i n order to e s t a b l i s h whether a l l the consent procedures had been properly recorded i n the c h a r t s . ^ This produced anxiety i n me, as my experience had been that not a l l thera-p i s t s took these r u l e s s e r i o u s l y , and I worried that some had not followed the procedures c o r r e c t l y . The l i b r a r i a n saw the charts i n terms of her task which was to p r o t e c t the h o s p i t a l from l e g a l s u i t s and to p r o t e c t the p a t i e n t s ' r i g h t s and p r i v a c y , while the s t a f f d i d not seem to share t h i s concern to the same degree. When I examined the records, I found that they c o n s i s t e d of reports on and analyses of the p a t i e n t made by h i s / h e r primary t h e r a p i s t and other members of the s t a f f who saw the p a t i e n t . U s u a l l y , there would be several e n t r i e s made by d i f f e r e n t s t a f f members f o r each day that the p a t i e n t stayed i n the h o s p i t a l . The records also contained an admitting d i a g n o s i s , h i s t o r y , and problem l i s t , plus any previous p s y c h i a t r i c or r e l e v a n t medical records, a discharge summary, and a record o f medications that were p r e s c r i b e d . From t h i s m aterial I would copy verbatim, e n t r i e s t h a t I thought revealed the s t a f f ' s perceptions of the p a t i e n t , s i m i l a r information from previous p s y c h i a t r i c admissions, and the o f f i c i a l diagnoses that were made upon admittance and discharge. What f o l l o w s i s a t y p i c a l e n t r y , of the s o r t that I copied, made by a s t a f f member. 45 #9 Paranoid #10 I n t r o v e r s i o n S. "I walked around-- "No-- I saw no one I knew "No-- I know I'm to get a job and I ' l l s t a r t on i t Monday" "I have an idea" "No I won't t e l l you i n f r o n t of everyone" "No I won't go to 50 my room-- Why should I t e l l you? I t ' s simply that I won't stay here a day longer than I have t o - - won't leach o f f your system any longer. 0: very angry tone. A: -- remains paranoid re: exchanging information i n f r o n t of pa t i e n t s on t o p i c s even as general as "Did you shop?" -- remains defensive re: problem sharing with t h e r a p i s t s . . . . Orders: Remains suspicious of s t a f f i n t e n t i o n s . -- Use f r i e n d l y greetings i n h a l l , day room, e t c . to increase h i s sense of "OK" v i a s t a f f . . . . A number o f f a c t o r s which made my fieldwor k d i f f i c u l t and hindered my data c o l l e c t i o n need to be mentioned. Some of them have been pointed out a l r e a d y , and others w i l l be discussed more f u l l y l a t e r i n the t h e s i s . I am b r i n g i n g these points up because i t i s necessary to make i t c l e a r t h a t I was not able to gather data e a s i l y , simply because I had been given permission to conduct my research i n the h o s p i t a l , and i t , i s r e l e v a n t to account f o r t h i s , as my d i f f i c u l t i e s , I t h i n k , r e f l e c t the i n f l u e n c e upon my fieldwor k of features of the s e t t i n g w i t h i n which I worked. F i r s t of a l l , I had to conduct my work w i t h i n the bounds l a i d down by my u n i v e r s i t y ' s Faculty of Medicine Committee on Research I n v o l v i n g Human Subjects and the Research Committee of the h o s p i t a l i n which I conducted my fi e l d w o r k . These ru l e s complicated my work, and at times denied me the p o s s i b i l i t y of gaining data, as a p a t i e n t would refuse to give h i s / h e r formal w r i t t e n consent to be taped and observed during a therapy s e s s i o n . The rul e s also created problems f o r me, as I found t h a t the s t a f f d i d not always f o l l o w them, and I had to spend time making sure that t h e i r omissions were co r r e c t e d . The seriousness with which the two committees t r e a t e d the research r u l e s a l s o created 51 tension f o r me, as I f e l t pressure to meet these o b l i g a t i o n s ; a task which, as noted, was not always easy. This tension at times i n h i b i t e d me i n my e x p l o r a t i o n of the h o s p i t a l , as I sometimes f e l t t hat I had to "watch my step" i n order to avoid breaking the p r o t o c o l . I have already discussed my problems i n e s t a b l i s h i n g my i d e n t i t y and i n f i n d i n g a r o l e f o r myself i n the s e t t i n g . Part of these problems can be traced to what might be termed " h o s p i t a l s e c u r i t y . " As the h o s p i t a l was a p s y c h i a t r i c h o s p i t a l , the s t a f f seemed to share an awareness of the need to keep c l o s e t r a c k o f the p a t i e n t s , and to fend o f f i n t e r f e r e n c e with the pa t i e n t s from the outside world. There e x i s t e d a c l e a r d i s t i n c t i o n of being an " o u t s i d e r " i f one was n e i t h e r a p a t i e n t nor a s t a f f member, and "o u t s i d e r s " were t r e a t e d with s u s p i c i o n , and denied information about h o s p i t a l a c t i v i t i e s . Even a f t e r I had e s t a b l i s h e d my i d e n t i t y as a researcher, found that a r o l e had evolved f o r me, and made f r i e n d s w i t h some of the s t a f f , I s t i l l sensed that t h i s b a r r i e r e x i s t e d . This hampered me, as i t denied me the opportunity to simply "hang out" i n the s e t t i n g f o r longer periods of time. I found as an " o u t s i d e r " that I always needed a reason to be i n the s e t t i n g such as seeing a thera-p i s t and p a t i e n t , or l o o k i n g at a c h a r t , e t c . I could not, f o r example, simply s i t down i n the nursing s t a t i o n f o r two hours and record what I observed. I found t h a t I needed to be inv o l v e d i n a task i n order to account f o r my presence i n the s e t t i n g . Being an " o u t s i d e r " I t h i n k , a l s o accounted f o r the lack of i n t e r e s t , co-operation, and at times s u s p i c i o n t h a t some of the s t a f f d i s p l a y e d toward me and my work. I t seemed t h a t some of them f e l t uncomfortable being observed by an i n d i -46 v i d u a l who came from the "outside." I would venture to guess t h a t , 52 undertaking the same research p r o j e c t , I would have received more co-operation and t r u s t from these i n d i v i d u a l s i f I had been a medical student or a r e s i d e n t . Another f a c t o r to consider i s t h a t some of these i n d i v i d u a l s were themselves medical students and p s y c h i a t r i c r e s i d e n t s , and therefore may have f e l t somewhat insecure i n t h e i r work i f they were being observed. F i n a l l y , i t i s necessary to note that the p a t i e n t s , given a diagnosis that made reference to a "paranoid" c o n d i t i o n , a l s o tended to be p a t i e n t s who e x h i b i t e d the c h a r a c t e r i s t i c of being mis-t r u s t f u l . T h e i r m i s t r u s t made i t more d i f f i c u l t f o r me to gain t h e i r co-operation and consent i n c a r r y i n g out my work. 53 Footnotes ^Hans H. Strupp, "Psychotherapy Research and P r a c t i c e : An Over-view," i n Handbook of Psychotherapy and Behavior Change: An Empirical Analysis, eds. Sol L. G a r f i e l d and A l l e n E. Bergin (New York: John Wiley and Sons, 1978), p. 8. 2 1 b i d . , p. 11. 3 A d i s t i n c t i o n must be made between the b e l i e f of the psycho-t h e r a p i s t , and the b e l i e f s o f the s o c i a l s c i e n t i s t and the l a y person. While the psychotherapist may espouse the same b e l i e f as the o t h e r s , we s h a l l see that h i s / h e r b e l i e f must be understood i n a d i f f e r e n t context, as the t h e r a p i s t , u n l i k e the s o c i a l s c i e n t i s t or l a y person, i s a l s o the person who a c t u a l l y p r a c t i s e s therapy. ^The argument claims t h a t p s y c h i a t r i c theory (which I define as the range of t h e o r i e s p e r t a i n i n g to mental i l l n e s s and psychotherapy derived from the work of both ps y c h o l o g i s t s and p s y c h i a t r i s t s ) provides " r u l e s " or g u i d e l i n e s f o r the t h e r a p i s t with respect to the diverse matters with which he/she must deal w h i l e working with p a t i e n t s ; such as the c o r r e c t way of c o n c e p t u a l i z i n g a p a t i e n t ' s remarks, the appro-p r i a t e manner of speech to use when addressing a p a r t i c u l a r type of p a t i e n t , the proper time to be d i r e c t i v e with a p a t i e n t , e t c . See, f o r example, Strupp's remarks with respect to the r o l e of p s y c h i a t r i c theory, noted above. 5 The researcher defined i n t u i t i o n as a sense derived from one's common sense knowledge, acquired through s o c i a l i z a t i o n , and shared with w i t h the other members of one's c u l t u r e . g What was being r e j e c t e d here was the t r a d i t i o n a l s o c i o l o g i c a l approach to p s y c h i a t r y which t h e o r i z e s about t h i s e n t e r p r i s e i n terms of our common sense notions with respect to i t . The data from the researcher's f i e l d w o r k w i l l show th a t he came to r e a l i z e that he could not proceed i n t h i s way, u t i l i z i n g these common sense notions as a resource to accomplish h i s work. Rather, he came to see that what was re q u i r e d was a more fundamental understanding of the e n t e r p r i s e , which could only be accomplished by t r e a t i n g our common sense knowledge of i t , as a t o p i c . For a f u r t h e r d i s c u s s i o n of t h i s approach, see: D. Zimmer-man and M. P o l l n e r , "The Everyday World as a Phenomenon," i n Under-standing Everyday Life, ed. J . Douglas (London: Routledge and Kegan P a u l , 1971). See a l s o : A. Blum, "The Sociology of Mental I l l n e s s , " i n Deviance and Respectability, ed. J . Douglas (New York: Basic Books, 1970). 'We use the term "paranoid" i n quotation marks throughout the t h e s i s , as the researcher i s unable, despite a b a s i c s h i f t i n h i s 54 understanding of paranoia as a consequence of his fieldwork, to sub-scribe to the psychiatric diagnostic system of nomenclature. A further discussion of this point is taken up in footnote 26 of this chapter. o The term "gap" is used in quotation marks in order to signify that we are unable to prove whether the "gap" is merely a construct of the researcher, who, due to his inabi l i ty to make use of psychiatric theory, arrived at a superficial evaluation, based on appearances of what he observed, or whether i t i s , in fact , an integral feature of the practice of psychotherapy. g The following sources are representative of the ethnomethodo-logical perspective: Harold Garfinkel, Studies in Ethnomethodology (Englewood C l i f f s , N.J . : Prent ice-Hal l , 1967); David Sudnow (ed.) , Studies in Social Interaction (New York: The Free Press, 1972); and Roy Turner (ed.) , Ethnomethodology (Harmondsworth, England: Penguin, 1974). ^ 1 am referring to the following sources: Jeff Coulter, Approaches to Insanity (New York: John Wiley and Sons, 1973); David Sudnow, Passing On (Englewood C l i f f s , N.J . : Prent ice-Hal l , 1967); and Roy Turner, "Occupational Routines: Some Demand Characteristics of Police Work," paper presented to the CSAA, Toronto, June 1969; "Some Formal Properties of Therapy Talk," in Studies in Social Interaction, ed. David Sudnow (New York: The Free Press, 1972); "Utterance Positioning as an Inter-actional Resource," Semiotica, 17:3 (1976), 233-254. ^ 1 make reference here to my level of understanding (of their perspective) which I shall discuss shortly. 12 Roy Turner, "Occupational Routines," pp. 17-18. 13 • . Jeff Coulter, Approaches to Insanity, p. v i i i . 14 He is referring to the co l lect iv i ty of act iv i t ies such as com-municating with patients, making sense of patients' behaviour, etc. 15 Jeff Coulter, Approaches to Insanity, p. 150. 1 c Roy Turner, "Utterance Positioning," p. 236. ^7In addition to Freud, some of the authors studied were Wilhelm Reich, Erich Fromm, Phil ip Rieff , and Erik Erikson. I Q Representative of this l i terature are such works as: J . Agel (ed.) , The Radical Therapist (New York: Ballantine Books, 1971); 55 R.D. La i n g , The Politics of Experience and the Bird of Paradise (Middlesex, England: Penguin, 1968); and T.S. Szasz, Ideology and Insanity: Essays on the Psychiatric Dehumanization of Man (New York: Doubleday-Anchor, 1970). 19 Peter Maidstone, Canada Council Doctoral Fellowship A p p l i c a t i o n , Vancouver, B.C., 1971, p. 1. 2 0 I b i d . , p. 1. 21 I t i s important to note t h a t I was p a r t i c u l a r l y i n t e r e s t e d i n psychoanalytic theory but that I f e l t that t h i s a n a l y s i s was a p p l i c a b l e to other schools o f p s y c h i a t r i c theory; i . e . , I f e l t t h a t these other p s y c h i a t r i c t h e o r i e s a l s o r e s p e c t i v e l y determined the nature of psyc h i -a t r i c p r a c t i c e . 22 Peter Maidstone, Ph.D. D i s s e r t a t i o n P r o p o s a l , Vancouver, B.C., November 1974, pp. 5-6. 23 J e f f C o u l t e r , Approaches to Insanity, p. 142. 24 Roy Turner, "Occupational Routines," p. 3. " i b i d . , p. 3. 26 This term i s taken from the "Diagnostic and S t a t i s t i c a l Manual of Mental Disorders" (Washington, D.C: American P s y c h i a t r i c A s s o c i a t i o n , 1968), p. 38. I do not subscribe to the cl a i m that i n d i v i d u a l s given such a d i a g n o s t i c l a b e l n e c e s s a r i l y possess a s p e c i f i c s et of character-i s t i c s . Paranoia, a f t e r a l l , as Morton Schatzman has pointed out i n h i s book Soul Murder (London: Penguin Press, 1973), i s an a t t r i b u t i o n , not an experience. Rather, the terms paranoia and paranoid s t a t e w i l l be used i n order to denote behaviour seen by t h e r a p i s t s to be representa-t i v e of t h i s type of d i s o r d e r , or to i n d i c a t e t h a t an i n d i v i d u a l has been given t h i s d i a g n o s t i c l a b e l . Thus, my use of these terms and other d i a g n o s t i c l a b e l s such as paranoid p e r s o n a l i t y or paranoid s c h i z o p h r e n i c does not imply a commitment on my part to the p s y c h i a t r i c d i a g n o s t i c system of nomenclature. 27 D. Swanson, et a l . , The Paranoid (Boston: L i t t l e , Brown, 1970), p. 249. 28 Norman Cameron, Personality Development and Psychopathology (Boston: Houghton M i f f l i n , 1963), p. 508. 56 29 "Diagnostic and S t a t i s t i c a l Manual of Mental Disorders," pp. 37-38. 30 Kenneth Munden, "Consideration o f the Paranoid Problem i n P s y c h i a t r i c P r a c t i c e , " The Journal of the Tennessee Medical Association, 60:9 (1967), 939. 31 I am speaking here of my o r i g i n a l perspective t h a t psychotherapy i s a theory-governed a c t i v i t y . 32 Of the other three p a t i e n t s whose cases I followed i n d e t a i l , two were diagnosed as paranoid s c h i z o p h r e n i c s , and the other was seen to be s u f f e r i n g from an acute paranoid r e a c t i o n . 33 David Swanson, et a l . , The Paranoid, p. 34. See a l s o the work of A. Lewis, "Paranoia and Paranoid: A H i s t o r i c a l P e r s p e c t i v e , " Psycho-logical Medicine, 1 (Nov. 1970), 2-12; and G. S i s l e r , "The Concept: 'Paranoid'," Canadian Psychiatric Association Journal, 12:2 (1967), 183-187, who als o argue t h a t there i s considerable d i f f i c u l t y i n assign-ing the c o r r e c t d i a g n o s t i c l a b e l s to behaviour that i s seen to be of the "paranoid" type. 34 "Residency Brochure," Department of P s y c h i a t r y , U n i v e r s i t y H o s p i t a l , 1973. 35 "Hospital Information Booklet," U n i v e r s i t y H o s p i t a l , 1976, p. 1. 36 " P a t i e n t Information," Department df P s y c h i a t r y , U n i v e r s i t y H o s p i t a l , 1971, p. 1. 37 These procedures are noted i n the s e c t i o n on data c o l l e c t i o n . In a d d i t i o n to those o u t l i n e d t h e r e , the f o l l o w i n g two r u l e s were s t i p u l a t e d by the committee, and are quoted from the minutes of the meeting: In response to a s p e c i f i c question from the chairman, Mr. Maidstone undertook that the tapes would be t r a n s c r i b e d only by himsel f or h i s w i f e , t h a t they would be erased immediately a f t e r t r a n s c r i p t i o n and th a t no one other than he or h i s w i f e would have access to the tapes. Neither p a t i e n t nor primary t h e r a p i s t would be i d e n t i f i e d by name i n the t r a n s c r i p t or i n any record made from the t r a n s c r i p t o r , i n p a r t i c u l a r , i n Mr. Maidstone's Ph.D. t h e s i s . Mr. Maidstone would a l s o require access to the charts of the f o u r p a t i e n t s whom he was i n v e s t i g a t i n g . I t was agreed by the committee that t h i s was reasonable subject to the usual safeguards. 57 38 David Sudnow, Passing On, p. 9. 39 J e f f C o u l t e r , Approaches to Insanity, p. 63. I conducted my fieldwork i n three wards of the h o s p i t a l ; the out - p a t i e n t ward and two r e g u l a r i n - p a t i e n t wards. The Research Commit-tee of the h o s p i t a l recommended that I not do observational work i n the fou r t h ward of the h o s p i t a l , as the primary t h e r a p i s t s (the p a t i e n t ' s main t h e r a p i s t ) on t h i s ward were medical students who had had l e s s experience i n p r a c t i s i n g psychotherapy than t h e r a p i s t s on other wards. I t turned out, however, that I d i d encounter primary t h e r a p i s t s on the other wards who were medical students. I tape recorded therapy sessions of four d i f f e r e n t "paranoid" p a t i e n t s . 42 T h i s , of course, was not always p o s s i b l e , as I often encountered s t a f f members f o r the f i r s t time on the wards. These rul e s were set down i n the minutes of the meeting of the h o s p i t a l Research Committee i n which my proposal to do research i n the h o s p i t a l was discussed. A copy of the minutes of the meeting was sent to me by the chairman of the committee. 44 I t i s important to note t h a t I f e l t no animosity toward her because of her behaviour. I j u s t saw her s t r i c t n e s s i n l i g h t of the job which she was faced w i t h . 45 Each d a i l y entry was preceded by one or more d i a g n o s t i c terms which were numbered, and which were seen by the t h e r a p i s t who made the entry to describe the p a t i e n t ' s current c o n d i t i o n . The e n t r i e s were als o organized i n terms of a p a r t i c u l a r format. "S" stood f o r the word s u b j e c t i v e and under t h i s term were included quotes t h a t were seen to express the p a t i e n t ' s current s t a t e . "0" stood f o r o b j e c t i v e , and was the s t a f f member's d e s c r i p t i o n o f what the p a t i e n t l o o k e d l i k e , and what they were doing when the quoted material was expressed. "A" stood f o r assessment, and was the s t a f f member's a n a l y s i s of the p a t i e n t ' s current c o n d i t i o n . "Orders" i n d i c a t e d the s t a f f member's proposed str a t e g y as to how the p a t i e n t ' s therapy should proceed. 46 In the previous year another researcher from the "outside" had conducted fieldw o r k i n the same h o s p i t a l , and had by the end of h i s fiel d w o r k become inv o l v e d i n a feud with one of the s t a f f p s y c h i a t r i s t s over the way he had conducted himself i n the h o s p i t a l . P o s s i b l y , t h i s controversy was i n part the source of the negative f e e l i n g s that I got from some of the s t a f f . 58 CHAPTER 2 DEVELOPING CONSTRUCTS: THE RESEARCHER STUDIES THE LITERATURE The "Map": The Evolution of the Researcher's Perspective I t i s my purpose at t h i s point i n the t h e s i s to set out, i n some d e t a i l , the constructs or preconceptions which I held w i t h respect to paranoia p r i o r to e n t e r i n g the research s e t t i n g . These thoughts formed, i n a sense, a map i n my mind which would, I assumed, serve as a r e f e r -ence guide while i n the research s e t t i n g . In other words, I made the assumption that my study of the l i t e r a t u r e on paranoia would provide me with the means to understand my observations and experiences i n the p s y c h i a t r i c h o s p i t a l . Thus, I prepared myself as i f I were an anthro-p o l o g i s t about to enter the f i e l d . J u s t as they attempt to become, through the l i t e r a t u r e , f a m i l i a r with the c u l t u r e t h a t they intend to enter, so too d i d I attempt to glean as much as p o s s i b l e from the l i t e r -ature on paranoia which would enable me, I assumed, to make sense of my encounters with paranoia i n the s e t t i n g . Thus to me, the p s y c h i a t r i c h o s p i t a l represented to some degree a f o r e i g n c u l t u r e which I planned to enter i n order to f u r t h e r my know-ledge of one aspect of the " c u l t u r e " ; paranoia. In some ways, i t ' f e T t l i k e my f i r s t opportunity to do a n t h r o p o l o g i c a l f i e l d w o r k , having done my undergraduate degree i n anthropology. I , t h e r e f o r e , s t u d i e d the l i t e r a t u r e on paranoia as i f I were studying ethnographies of a f o r e i g n c u l t u r e which I would l a t e r do f i e l d w o r k i n . 59 P r i o r to en t e r i n g the s e t t i n g , I formulated from the p s y c h i a t r i c , s o c i o l o g i c a l , p s y c h o l o g i c a l , and popular l i t e r a t u r e some d e f i n i t e ideas as to the c h a r a c t e r i s t i c s of paranoia and the "paranoid."^ These ideas or constructs derived from the l i t e r a t u r e , were the basis of my expec-t a t i o n s as to what I would f i n d i n the research s e t t i n g . They provided me with my "map" which would serve, I thought, as a guide to making sense of the " f o r e i g n c u l t u r e " that I was to enter. As has been p r e v i -ously pointed out, my map d i d not serve i t s purpose. What I was l e d to expect, and what I a c t u a l l y found i n the research s e t t i n g were not synonymous. I intend at t h i s point i n the t h e s i s to o u t l i n e c h ronologi-c a l l y how I put t h i s map together, and to discuss i t s contents. Later i n the t h e s i s , I s h a l l document by means of my research data, what I a c t u a l l y experienced and observed i n the s e t t i n g . As was pointed out p r e v i o u s l y i n the t h e s i s , I developed an i n t e r e s t i n p s y c h i a t r y and mental i l l n e s s p r i o r to the emergence of my i n t e r e s t i n paranoia. I t i s re l e v a n t to discuss these i n i t i a l concerns, as i t was from t h i s p e r i o d i n my stu d i e s and research that I evolved my understanding of p s y c h i a t r i c theory and p r a c t i c e . I then u t i l i z e d t h i s understanding to explore the l i t e r a t u r e on paranoia. Thus, to f u l l y grasp, to use the popular parlance, "where I was coming from" when I began my research i n the p s y c h i a t r i c h o s p i t a l , i t i s necessary to d i s -cuss my• initn;a\l(analyses o f p s y c h i a t r y and mental i l l n e s s . My i n t e r e s t i n t h i s area grew out of a de s i r e to broaden my under-standing of human behaviour. In my undergraduate work i n s o c i o l o g y , I developed a s p e c i f i c concern with the s o c i o l o g y of knowledge. This i n t e r e s t stemmed from my b e l i e f that an understanding of human behaviour, 60 required one to understand the ideas or th e o r i e s that shaped human consciousness. Having s t u d i e d the s o c i o l o g i c a l l i t e r a t u r e i n t h i s area, i t seemed reasonable to explore the p s y c h o l o g i c a l l y o r i e n t e d m a t e r i a l which addressed i t s e l f to t h i s question. In p a r t i c u l a r , I was i n t e r -ested i n the l i t e r a t u r e t h a t attempted to bridge the gap between so c i o l o g y and p s y c h i a t r y , as I wished to b e t t e r understand the l i n k between i n d i v i d u a l and c o l l e c t i v e consciousness. Part of my motivation to pursue t h i s work stemmed from numerous dis c u s s i o n s t h a t I had with a r e l a t i v e who was a p s y c h i a t r i s t , and with other p s y c h i a t r i s t s who were his f r i e n d s . As was pointed out e a r l i e r , I discovered that t h e i r per-s p e c t i v e s d i f f e r e d considerably from mine, p a r t i c u l a r l y because they seemed to ignore the s o c i o l o g i c a l point of view. In my f i r s t year o f graduate work, I had the opportunity to explore the common ground between so c i o l o g y and p s y c h i a t r y i n terms of a so c i o l o g y of knowledge per s p e c t i v e . I focused my studies on t h e o r i s t s who had attempted to i n t e g r a t e s o c i o l o g i c a l and p s y c h i a t r i c explanations 2 of human behaviour. In p a r t i c u l a r , I focused on the w r i t i n g s of what 3 has been termed the Freudian L e f t ; those authors who had attempted to synthesize the work of Marx and Freud. T h e i r endeavours were of impor-tance to me, as they, the Freudian L e f t , drew upon both sociology and ps y c h i a t r y and sought to e x p l a i n human behaviour from what seemed to be an i n t e g r a t e d p e r s p e c t i v e . Thus, from t h i s work, I hoped to f i n d the means to resolve some of the d i f f e r e n c e s that emerged i n my dis c u s s i o n s w i t h p s y c h i a t r i s t s . I thought t h a t I might discover p s y c h i a t r i c t h e o r i e s t h a t a l s o could account f o r s o c i a l phenomena, and that would e x p l a i n the l i n k between the consciousness of the i n d i v i d u a l and the c o l l e c t i v e . 61 Thus, I was l o o k i n g f o r p s y c h i a t r i c t h e o r i e s t h a t contained a s o c i o l o g -i c a l component, and acknowledged i t s importance. As I worked my way through the l i t e r a t u r e , I came to the r e a l i z -a t i o n that the t h e o r i s t s of the Freudian L e f t had to transform a funda-mental tenet of Freud's perspective i n order to synthesize h i s work with Marx's s o c i o l o g i c a l l y o r i e n t e d p e r s p e c t i v e . They were forced to r e j e c t Freud's view t h a t there e x i s t e d an i n e v i t a b l e c o n f l i c t between human 4 i n s t i n c t u a l needs and the needs of s o c i e t y . To accept Freud's view, meant the acceptance of the n e c e s s i t y of r e p r e s s i o n , the i n e v i t a b i l i t y of i l l u s i o n s , and the i m p e r f e c t a b i l i t y of humans. Most importantly from a s o c i o l o g i c a l point of view, i t meant t h a t a l l s o c i o l o g i c a l a n a l y s i s was i n a sense redundant, as the core of human behaviour was to be found i n b i o l o g y , not i n the nature of a s o c i e t y or a h i s t o r i c a l epoch. Thus, I discovered i n the work of Wilhelm Reich and Herbert Marcuse an empha-s i s upon the need f o r the l i b e r a t i o n by s o c i e t y of human i n s t i n c t s 5 r a t h e r than t h e i r necessary r e p r e s s i o n , as s t a t e d by Freud. Contrary to Freud's view of i n e v i t a b l e r e p r e s s i o n , Reich argues, f o r example, with respect to r e p r e s s i v e c i v i l i z a t i o n , that ". . . t h i s s t r u c t u r e i s not n a t i v e to man but was i n c u l c a t e d by s o c i a l c o nditions . . . ," and g t h e r e f o r e may be subject to what he terms " r e s t r u c t u r i z a t i o n . " E r i c h Fromm took h i s a n a l y s i s even f u r t h e r , dropping completely the r e l i a n c e on b i o l o g y , and p l a c i n g emphasis in s t e a d upon the r o l e played by a s p e c i f i c s o c i e t y i n shaping the behaviour of i t s members. Thus, Fromm i n a d i s c u s s i o n of "the s i c k i n d i v i d u a l and the s i c k s o c i e t y " 7 argues t h a t : 62 Freud sees man as p r i m a r i l y formed by his experience i n the family group; he appreciates l i t t l e t hat the family i s only the r e p r e s e n t a t i v e and agent of s o c i e t y , and he looks at various s o c i e t i e s mainly i n terms of the qu a n t i t y of repression they demand, r a t h e r than the q u a l i t y of t h e i r o r g a n i z a t i o n and of the impact of t h i s s o c i a l q u a l i t y on the q u a l i t y of the t h i n k i n g and f e e l i n g of the members of a given s o c i e t y . 8 My study of the l i t e r a t u r e of the Freudian L e f t , confirmed the conclusion t h a t I had reached as a consequence o f my dis c u s s i o n s w i t h p s y c h i a t r i s t s . P s y c h i a t r i s t s , or at l e a s t the ones th a t I had met, d i d not acknowledge the v a l i d i t y of a s o c i o l o g i c a l p e r s p e c t i v e . Now, I f e l t , I knew why. The i r o r i e n t a t i o n was e x p l i c a b l e to me. As t h e i r point of view was derived from Freudian theory, there was no place i n t h e i r thought f o r a s o c i e t a l explanation of human behaviour. I knew, from the l i t e r a t u r e , that one had to r e j e c t or transform major elements of Freud's pers p e c t i v e i n order to i n t e g r a t e the s o c i e t a l p o i n t o f view. Thus, I f e l t t h a t I was able to e x p l a i n the p s y c h i a t r i s t s ' perspectives i n terms o f the o r i e n t a t i o n of Freudian theory. This was an important observation f o r me, as i t marked a s i g n i f i -cant p o i n t i n the development of my t h i n k i n g . P s y c h i a t r i c thought, I now r e a l i z e d , was shaped by a body o f theory that could be seen as g e s s e n t i a l l y i d e o l o g i c a l . As i t r e j e c t e d the p o s s i b i l i t y of fundamental s o c i a l change, Freudian theory, I came to r e a l i z e , was a conservative d o c t r i n e . Thus, those who adopted t h i s d o c t r i n e would understand human behaviour i d e o l o g i c a l l y . This had, I f e l t , important s o c i a l and p o l i -t i c a l i m p l i c a t i o n s . I f t h i s was the o r i e n t a t i o n of p s y c h i a t r i c t h i n k i n g , what was the o r i e n t a t i o n of p s y c h i a t r i c p r a c t i c e ? I f the thought was con s e r v a t i v e , would the p r a c t i c e of p s y c h i a t r y a l s o be o r i e n t e d t h i s way? These questions began to i n f l u e n c e my t h i n k i n g , and l e d me to 63 refocus the d i r e c t i o n of my work. I became i n t e r e s t e d not only i n the nature of p s y c h i a t r i c theory, but als o i n the nature of p s y c h i a t r i c p r a c t i c e , and i n p a r t i c u l a r , i n the r e l a t i o n s h i p between t h i s p r a c t i c e and the o r i e n t a t i o n o f the theory. The s h i f t i n the d i r e c t i o n of my work developed d i r e c t l y out of my study of the l i t e r a t u r e of the Freudian L e f t , as was discussed above. In a d d i t i o n , the authors noted i n the second footnote of t h i s chapter a l s o helped to shape my new d i r e c t i o n . I had o r i g i n a l l y read t h e i r work searching f o r the common ground between p s y c h i a t r y and s o c i o l o g y . I discovered, however, t h a t the prevalent theme i n t h e i r work was a c r i t i q u e of p s y c h i a t r y . Rather than e x p l o r i n g the i n t e r r e l a t i o n s h i p between s o c i o l o g i c a l and psycho l o g i c a l p e r s p e c t i v e s , the authors often used a s o c i o l o g i c a l perspective to discuss c r i t i c a l l y p s y c h i a t r i c theory and p r a c t i c e . I read these works and made t h i s discovery subsequent to the development of my new i n s i g h t s w i t h respect to the i d e o l o g i c a l nature of p s y c h i a t r i c theory. The conclusions of these authors, there-f o r e , complemented my own a n a l y s i s that I had derived from my study of the Freudian L e f t . They provided me with more evidence to support the premise t h a t the c o n s e r v a t i v e , " a n t i - s o c i o l o g i c a l " o r i e n t a t i o n of Freudian theory had s i g n i f i c a n t s o c i a l and p o l i t i c a l i m p l i c a t i o n s , p a r t i c u l a r l y w i t h respect to the p r a c t i c e of p s y c h i a t r y . I had f i r s t encountered a s p e c i f i c reference to the s o c i a l and p o l i t i c a l consider-a t i o n s t h a t may be r a i s e d with respect to psychotherapy, i n the work of Herbert Marcuse, who, quoting from Freud, noted the f o l l o w i n g i n a d i s c u s s i o n of Freud's work: 64 . . . therapy i s a course i n r e s i g n a t i o n : a great deal w i l l be gained i f we succeed i n "transforming your h y s t e r i c a l misery i n t o everyday unhappiness" ( J . Breuer and S. Freud, "Studies i n H y s t e r i a , " Nervous and Mental Disease Monograph No. 61, New York, 1936, p. 232) which i s the usual l o t of mankind. . . . the a n a l y s t , as a p h y s i c i a n , must accept the s o c i a l frame-work of f a c t s i n which the p a t i e n t has to l i v e and which he can-not a l t e r (S. Freud, New Introductory Lectures, New York, W.W. Norton, 1933, p. 206). This i r r e d u c i b l e core of conformity i s f u r t h e r strengthened by Freud's c o n v i c t i o n t h a t the re p r e s s i v e basis of c i v i l i z a t i o n cannot be changed anyway--not even on the s u p r a i n d i v i d u a l , s o c i e t a l scale.10 These new authors f r e q u e n t l y made reference to t h i s i s s u e , often l i n k i n g t h e i r analyses o f the p r a c t i c e of p s y c h i a t r y , psychotherapy, back to t h e i r analyses o f p s y c h i a t r i c t h e o r y . ^ Thus, I found support f o r my new point of view, and no longer wished to simply analyse p s y c h i a t r i c theory, independent o f the p r a c t i c a l a c t i v i t y of p s y c h i a t r y , psycho-therapy. I t was at t h i s point i n time that I encountered a new body of l i t e r a t u r e t h a t had r e c e n t l y emerged; the a n t i - p s y c h i a t r y l i t e r a t u r e . The l i t e r a t u r e t h a t may be termed a n t i - p s y c h i a t r y d i f f e r e d from e a r l i e r c r i t i q u e s of p s y c h i a t r y , such as those p r e v i o u s l y c i t e d , as i t represented a new d i r e c t i o n i n the c r i t i c a l l i t e r a t u r e . Much of i t was published i n the l a t e s i x t i e s and e a r l y s e v e n t i e s , and was d i r e c t l y l i n k e d to the s o c i a l and p o l i t i c a l movements of that time. Unlike e a r l i e r c r i t i q u e s such as those of Thomas Szasz and R.D. Laing, the new l i t e r a t u r e attempted to not only c r i t i c a l l y analyse p s y c h i a t r y , but al s o to r e l a t e t h i s a n a l y s i s to p o l i t i c a l and socio-economic i s s u e s . In some ways, i t represented the "New L e f t ' s " and the "Counter C u l t u r e ' s " p o s i -12 t i o n on the issue of psychotherapy and mental i l l n e s s . A quotation from the Manifesto of The Radical Therapist, a c r i t i c a l j o u r n a l of the 65 time, may i l l u s t r a t e the new p e r s p e c t i v e : In the midst of a s o c i e t y tormented by war, racism, and s o c i a l t u r m o i l , therapy goes on with business as usual. In f a c t , t h e r a p i s t s often look s u s p i c i o u s l y at s o c i a l change and l a b e l as " d i s t u r b e d " those who press toward i t . Concerned with maintain-ing and j u s t i f y i n g current p r a c t i c e s , therapy avoids moving toward making l i f e more meaningful f o r a l l p e o p l e J 3 The Manifesto goes on to s t a t e t h a t : The t h e r a p i s t i n t h i s s o c i e t y i s safe: he l i v e s near the top of the heap, pursuing moneyed comforts, i n f l u e n c e , and pres-t i g e , w h i l e the r e s t of s o c i e t y i s racked by v i o l e n c e and war. . . . Often he even seems unaware of the bias he perpetuates or of the oppression he enacts i n the name of " l i b e r a t i o n . " Expert as he may be at a n a l y z i n g i n t r a p e r s o n a l f o r c e s , he i s often ignorant about forces c o n t r o l l i n g the l a r g e r s o c i e t y i n which he l i v e s . . . . Therapy today has become a commodity, a means of s o c i a l c o n t r o l . We r e j e c t such an approach to people's d i s -t r e s s . ^ I found no d i f f i c u l t y , at t h a t time, a s s i m i l a t i n g t h i s perspective i n t o my own a n a l y s i s . As i t b u i l t upon e a r l i e r works such as Szasz, Laing, Foucault, e t c . which I had already i n t e g r a t e d i n t o my understand-ing of p s y c h i a t r y , and as i t d i d not c o n t r a d i c t the perspective which I had evolved from my study of the Freudian L e f t , i t seemed to be the l o g i c a l a p p l i c a t i o n of these more general works to the s p e c i f i c issues of the day. Furthermore, I was myself a c t i v e l y i n v o l v e d i n the move-ments of t h a t p e r i o d , and found t h a t the new l i t e r a t u r e provided me with the means to r e l a t e my own p o l i t i c a l views to the more general under-standing of p s y c h i a t r y which I had already e s t a b l i s h e d . Thus, I was r e c e p t i v e to the l i t e r a t u r e , as i t f u r t h e r c l a r i f i e d my point of view. In p a r t i c u l a r , the new l i t e r a t u r e r a i s e d f o r the f i r s t time i n a systematic way, the theme of s o c i a l c o n t r o l . Psychotherapy, i t claimed, should be viewed as a p o l i t i c a l act whose i n t e n t may be to p a c i f y and defuse d i s s e n t , and thereby s t i f l e s o c i a l change. Seymour H a l l e c k , i n 66 his book The Politics of Therapy, put i t t h i s way: A p s y c h i a t r i s t u s u a l l y focuses on h i s p a t i e n t ' s i n t e r n a l problems, presupposing t h a t the p a t i e n t ' s environment i s ade-quate and not c o n t r i b u t i n g to h i s misery. But the p a t i e n t i s part of a s o c i a l system. Treatment that doesn't encourage the p a t i e n t to examine or confront h i s environment strengthens the s t a t u s quo. Treatment that emphasizes the oppressiveness of the p a t i e n t ' s external environment or shows the p a t i e n t how to change i t may help a l t e r the status quo. The p s y c h i a t r i s t e i t h e r encourages the p a t i e n t to accept e x i s t i n g d i s t r i b u t i o n s of power or encourages the p a t i e n t to change them. Every encoun-t e r with any psychotherapist, t h e r e f o r e , has p o l i t i c a l i m p l i c a -t i o n s . ^ Although t h i s theme had been i m p l i c i t i n my own a n a l y s i s , and e x p l i c i t at times i n the work of others t h a t I had s t u d i e d , i t was not u n t i l t h i s p o i n t , t h a t i t became the core of my a n a l y s i s , around which I subsequently f i t t e d my previous ideas. Now, I f e l t t h a t I had a f i r m grasp of p s y c h i a t r i c theory and p r a c t i c e . The theory guided the p r a c t i c e . Being conservative i n o r i e n -t a t i o n , i t d i r e c t e d p s y c h i a t r i c p r a c t i c e , psychotherapy, away from 1 g l i b e r a t i o n and toward s o c i a l c o n t r o l . Thus, to understand p s y c h i a t r y one must, I b e l i e v e d , understand p s y c h i a t r i c theory. A f i r m understand-ing o f the theory would, I thought, allow one to make sense of the p r a c t i c e . Having evolved a defined p e r s p e c t i v e , I f e l t ready to pursue my doctoral s t u d i e s . I planned to focus on the then current p o l i t i c a l c r i t i q u e of p s y c h i a t r y . My i n t e n t was to v a l i d a t e the c r i t i q u e . I hoped to show that the e x e r c i s e of s o c i a l c o n t r o l t h a t I saw as b a s i c to psychotherapy, had i t s source i n the conservative element t h a t I perceived to be fundamental to p s y c h i a t r i c theory. 67 The "Map" Becomes More Detailed Upon beginning my doctoral s t u d i e s , I d i d not immediately pursue the o b j e c t i v e o u t l i n e d above. In my f i r s t semester, I had the oppor-t u n i t y to p a r t i c i p a t e i n graduate seminars which r e l a t e d to my i n t e r e s t s i n the s o c i o l o g y of knowledge. I a l s o took part i n a s o c i a l psychology course which was d i r e c t e d toward the e x p l o r a t i o n of in t e r p e r s o n a l r e l a t i o n s through c o u n s e l l i n g , both at the e x p e r i e n t i a l and conceptual l e v e l s . I had not, however, l o s t i n t e r e s t i n an a l y s i n g p s y c h i a t r y . I p a r t i c i p a t e d i n the graduate seminars because I f e l t t h a t they would complement my broader t h e o r e t i c a l concerns with consciousness, and I took part i n the s o c i a l psychology course because I thought t h a t i t would o f f e r me some f i r s t hand experience i n psychotherapy. I s h a l l b r i e f l y o u t l i n e my experiences i n these courses, as the knowledge t h a t I gained from them a l s o forms part o f the "map" discussed e a r l i e r . One of the graduate seminars was devoted to an attempt to fuse Marx i s t theory with ethnomethodology. The aim of the synth e s i s was to develop the means of p u t t i n g i n t o p r a c t i c e a r a d i c a l s o c i o l o g y . By combining the methodology of ethnomethodology with the theory of Marxism, the members of the seminar hoped to evolve an approach through which c r i t i c a l thought could be p r a c t i c a l l y a p p l i e d to the understanding of the s o c i a l world. The focus of the attempt was d i r e c t e d toward an a n a l y s i s o f the r o l e of id e a s , the production of ideo l o g y , and the development of f a l s e consciousness. This focus complemented my own research i n t e r e s t , as I saw the p o s s i b i l i t y of u t i l i z i n g ethnomethod-ology, i n the ways discussed i n the seminar. I thought t h a t i t might provide me w i t h the means to unmask the p r a c t i c e of s o c i a l c o n t r o l t h a t 68 I assumed ensued i n psychotherapy, as a consequence of the o r i e n t a t i o n o f p s y c h i a t r i c theory. Therapy, I b e l i e v e d , adjusted the i n d i v i d u a l to an unjust world, and the process of adjustment, I came to see, could be understood as the production of f a l s e consciousness. Although the seminar i t s e l f d i d not touch upon the area o f mental i l l n e s s and p s y c h i a t r y , I was able to draw upon the a n a l y s i s developed w i t h i n i t to f u r t h e r my own understanding o f p s y c h i a t r y . At the end of the seminar, each student was required to w r i t e a short paper on what he/she had gained from the course. I s h a l l quote b r i e f l y from my paper, as i t may i l l u s t r a t e the impact which the seminar had upon my perspec-t i v e : The seminar has d i r e c t l y i n f l u e n c e d my t h i n k i n g w i t h respect to my research i n t e r e s t . The focus of my research w i l l be an a n a l y s i s of the r e l a t i o n s h i p between p s y c h i a t r i c theory and the in f l u e n c e upon s o c i e t y of the p r a c t i c e of p s y c h i a t r y . I have come to r e a l i z e t h a t I could u t i l i z e the ethnomethodological approach to penetrate the i d e o l o g i c a l cover of p s y c h i a t r i c p r a c t i c e , and get at the p r a c t i c a l operations of p s y c h i a t r i s t s . An example o f t h i s type of research would be an a n a l y s i s of how p s y c h i a t r i s t s who are inv o l v e d i n the penal, w e l f a r e , or the m i l i t a r y systems "get through the day."17 The other graduate seminar that I p a r t i c i p a t e d i n was devoted to an a n a l y s i s of the attempt to formulate a Marxist theory of conscious-ness. The work of Lukacs, Habermas, the Frankfurt School, and the Freudian L e f t was examined with the aim of formulating a more thorough understanding of c l a s s consciousness and f a l s e consciousness. Dealing as i t d i d with the Freudian L e f t , and focusing on the question of con-sciousness, the seminar proved u s e f u l . Although i t d i d not provide me wi t h a f i r m e r grasp o f how I might a c t u a l l y do my research (as was r a i s e d i n the other seminar), i t d i d enable me to develop a b e t t e r 69 understanding of c r i t i c a l theory. Again, I found t h a t my research i n t e r e s t seemed v i a b l e i n l i g h t of the course m a t e r i a l . The c o n t r o l of consciousness, the c e n t r a l concern of the course, was a f t e r a l l , i n my view, the primary task of the psychotherapist. Thus, I was able to r e l a t e the a n a l y s i s i n the course, centred as i t was on the c o n t r o l of consciousness at the s o c i e t a l l e v e l , to what I f e l t was a s i m i l a r pro-cess o c c u r r i n g at the i n t e r p e r s o n a l l e v e l of psychotherapy. The thera-p i s t was, I b e l i e v e d , engaged i n shaping consciousness to f i t the demands of the s o c i a l system, and t h e r e f o r e could be seen as simply another agent of s o c i a l c o n t r o l , engaged i n the e x e r c i s e of another means of s o c i a l c o n t r o l . The t h i r d course that I took, i n t e r p e r s o n a l r e l a t i o n s , d i d not, i n my view at t h a t time, f u r t h e r my understanding of p s y c h i a t r y , and as a consequence, I withdrew from i t . I had e n r o l l e d i n the course with the aim of developing a b e t t e r understanding of the t h e r a p e u t i c process, as I f e l t t h a t I needed to become more f a m i l i a r with the actual subject matter of my proposed research. The course was designed to be p r i m a r i l y e x p e r i e n t i a l i n o r i e n t a t i o n , and I assumed that i t would take the form of group therapy conducted by a t h e r a p i s t . Thus, I thought that I would gain some i n i t i a l exposure to what psychotherapy was r e a l l y l i k e . The course d i d not, however, f o l l o w the form that I thought i t would. Rather than group therapy, each student counselled another student, and I was t h e r e f o r e unable to witness the a c t i v i t i e s that i n t e r e s t e d me. I d i d not have the opportunity of observing a t h e r a p i s t a d j u s t i n g a student to the s o c i a l w o rld, as each student simply became both the c l i e n t and " t h e r a p i s t " of another student. As the students were not t r a i n e d t h e r a p i s t s , and had no substantive knowledge of psychi-a t r i c theory, I f e l t t h a t the processes which I was loo k i n g f o r would not be found i n t h i s s e t t i n g . Thus, I gave up the course i n order to devote more time to the study of the relevant l i t e r a t u r e . Paranoia Gets on the "Map": The Researcher Develops a Focus I t was i n my second semester o f doctoral s t u d i e s , that I encoun-t e r e d , f o r the f i r s t time, an extensive a n a l y s i s of paranoia. I was ta k i n g a course which was devoted to a s o c i o l o g i c a l e x p l o r a t i o n of the r o l e played by emotions i n human behaviour. The b a s i c t e x t i n the 1 g course was a two-volume work e n t i t l e d Affect—Imagery—Consciousness. The author o f the t e x t argued t h a t emotions, not i n s t i n c t s or d r i v e s , were the fundamental determinants of human a c t i v i t y . He presented a c r i t i q u e of t r a d i t i o n a l explanations of both normal and abnormal behaviour. Focusing i n p a r t i c u l a r on Freud, he argued that one's p e r s o n a l i t y was shaped by one's emotional experiences and regulated by one's a f f e c t system r a t h e r than by one's s e x u a l i t y . Each student i n the c l a s s was expected to lead a seminar on a chapter of the t e x t , and I s e l e c t e d a chapter which was e n t i t l e d , " C o n t i n u i t i e s and D i s c o n t i n u i t i e s i n the Impact of H u m i l i a t i o n : Some S p e c i f i c Examples o f the Paranoid Posture." I had chosen the chapter as i t d e a l t with m a t e r i a l which seemed to make sense i n terms of my e x i s t i n g perspective on i n s a n i t y and p s y c h i a t r y . I t was the author's contention t h a t i n d i v i d u a l s who were seen to s u f f e r from paranoia were v i c t i m s of e x t e r n a l l y induced negative emotional experiences, i n par-t i c u l a r , h u m i l i a t i o n and t e r r o r . This a n a l y s i s caught my a t t e n t i o n , as 71 i t argued that the source of paranoia l a y not i n i n t r a p s y c h i c sexual problems, as Freud had argued, but r a t h e r was derived from the external environment. As proof of h i s t h e s i s , the author s t a t e d that paranoia may be induced on a c o l l e c t i v e basis amongst persecuted m i n o r i t y groups, through the same processes of t e r r o r and h u m i l i a t i o n as are r e s p o n s i b l e f o r the d i s o r d e r i n the i n d i v i d u a l . The author, S i l v a n Tomkins, put h i s argument t h i s way: The paranoid has been hu m i l i a t e d and t e r r o r i z e d at once, by a parent who combined shaming with attempts to dominate and c o n t r o l , and who was quick to threaten punishment f o r r e s i s -tance. 19 Tomkins l i n k s t h i s a n a l y s i s to what he sees as a c o l l e c t i v e phenomenon: . . . there are m i n o r i t y groups who have been subjected by s o c i e t y at large to the same pressures to which the paranoid s c h i z o p h r e n i c has been subjected by h i s parents i n the process of s o c i a l i z a t i o n . 2 0 Tomkins notes t h a t diagnosed paranoids, when compared with normal sub-j e c t s , using a p i c t u r e arrangement t e s t , showed a marked denial of p h y s i c a l aggression. He s t a t e s , i n t u r n , t h a t a study by Karon of normal b l a c k s , using the same p i c t u r e arrangement t e s t , i n d i c a t e d t h a t the greater the chance t h a t the i n d i v i d u a l might be exposed to v i o l e n c e , f o r example, a Southern r u r a l b l a c k , then the greater the p r o b a b i l i t y t h a t the i n d i v i d u a l s u f f e r e d from a complex of t e r r o r and h u m i l i a t i o n , f e e l i n g s of p e r s e c u t i o n , which was i n d i c a t e d on the t e s t by a marked 21 denial of p h y s i c a l aggression. Tomkins a l s o c i t e s a study which he conducted with paranoid schizophrenics i n s t a t e mental h o s p i t a l s . He found t h a t the black paranoid schizophrenics had a tendency to show a more marked denial of p h y s i c a l aggression on p i c t u r e t e s t s than d i d the 22 w h i t e s , thus i n d i c a t i n g the e f f e c t s of more massive persecution. 72 Tomkins 1 a n a l y s i s and evidence drew my a t t e n t i o n to the d i s o r d e r of paranoia. P r i o r to t h a t time, I had only encountered passing r e f e r -ences to i t i n the l i t e r a t u r e . From h i s work, I came to r e a l i z e t h a t i t was a d i s o r d e r t h a t l e n t i t s e l f to a n a l y s i s i n terms of my p e r s p e c t i v e . Tomkins pointed out that the commonly accepted Freudian view of the d i s o r d e r denied the p o s s i b i l i t y t h a t the "paranoid" i n d i v i d u a l ' s f e e l i n g s might have any basis i n r e a l i t y , p l a c i n g t h e i r source i n a s e x u a l l y based i n t r a p s y c h i c disturbance. Freud's view t h a t Tomkins discussed was, I r e a l i z e d , an example of Freud's a p p l i c a t i o n to a s p e c i f i c d i s o r d e r of his more general theory of human behaviour t h a t I had already c r i t i c a l l y analysed. Tomkins' perspective presented an a l t e r n a t i v e i n t e r p r e t a t i o n which f i t t e d with my own view t h a t p s y c h i a t r i c problems could be caused by, and t h e r e f o r e explained i n terms o f , forces i n the external environ-ment of the i n d i v i d u a l . Thus, I was able to i n t e g r a t e h i s views i n t o my a n a l y s i s , but more importantly he made me aware of a s p e c i f i c d i s o r d e r which h i g h l i g h t e d the c o n t r a s t between the Freudian based explanation of human behaviour, and a l t e r n a t e o r i e n t a t i o n s , t h a t s t r e s s e d explanations i n terms of s o c i a l f o r c e s . The paranoid d i s o r d e r centred on f e e l i n g s of persecution which were s a i d to be d e l u s i o n a l i n nature. The important i s s u e that emerged f o r me out of studying Tomkins' work was: are these f e e l i n g s , i n f a c t , d e l u s i o n a l ? I f t h e i r source l a y , as he argued, i n the external environment of the i n d i v i d u a l , then psychotherapy which ignored the s o c i a l basis of the d i s o r d e r ( l a b e l l i n g the f e e l i n g s as d e l u s i o n a l ) , could be seen as an act of s o c i a l c o n t r o l . Paranoia, t h e r e f o r e , seemed to be the i d e a l d i s o r d e r f o r me to examine, as the c o n t r a s t between the 73 i n t r a p s y c h i c and s o c i e t a l t h e o r e t i c a l explanations of paranoia appeared to become e x p l i c i t i n the p s y c h i a t r i c p r a c t i c e t h a t I b e l i e v e d derived from the r e s p e c t i v e t h e o r i e s . The Freudian perspective would by d e f i n -i t i o n o r i e n t the t h e r a p i s t toward r e j e c t i n g the "paranoid's" version of his w o rld, which might, i n f a c t , be the accurate r a t h e r than d e l u s i o n a l explanation o f what was, or had been, happening to the i n d i v i d u a l . Thus, I came to see that paranoia was an i d e a l d i s o r d e r f o r me to examine i n order to v a l i d a t e the p o l i t i c a l c r i t i q u e of p s y c h i a t r y . The r e j e c t i o n of the "paranoid's" f e e l i n g s as d e l u s i o n a l , epitomized f o r me the act of adjustment that I saw as b a s i c to psychotherapy. Drawing as i t d i d upon the i n t r a p s y c h i c perspective of Freud, psychotherapy would i n e v i t a b l y deny the v a l i d i t y of the i n d i v i d u a l ' s claims of p e r s e c u t i o n , as i t would search i n s t e a d f o r defects w i t h i n the i n d i v i d u a l which would account f o r h i s f e e l i n g s . By focusing on the paranoid d i s o r d e r , I f e l t t h a t I would be a b l e , t h e r e f o r e , to c l e a r l y i l l u s t r a t e the t h e o r e t i c a l l y based e x e r c i s e of s o c i a l c o n t r o l that was fundamental to psychotherapy. Having i d e n t i f i e d a d i s o r d e r t h a t seemed to lend i t s e l f to analy-s i s i n terms of my p e r s p e c t i v e , I set out to f a m i l i a r i z e myself with the l i t e r a t u r e t h a t focused on i t . Tomkins' work helped me to f i x my d i r e c t i o n , and I now began to b u i l d upon t h i s i n i t i a l knowledge of paranoia. Thus, I added more material to my "map." By now, however, I was beginning to narrow the scope of my work, and I was able to be more s e l e c t i v e as to the appropriateness of the material t h a t I added to i t . By t h i s stage, I was a c t i v e l y engaged i n developing from the l i t e r a t u r e the b a s i c constructs t h a t formed my understanding of paranoia at the time t h a t I entered the research s e t t i n g . 74 I turned my a t t e n t i o n next to Freud's work on paranoia, t h i s time 23 using primary sources. As h i s perspective represented the essence of the p o i n t of view which I had set out to c r i t i c a l l y review, I f e l t t h a t i t was necessary f o r me to deal d i r e c t l y with h i s work on the paranoid d i s o r d e r . Having already read Tomkins' c r i t i q u e of Freud's p e r s p e c t i v e , I was f a m i l i a r with the b a s i c elements of his argument. Reading his w o r k f i r s t - h a n d simply confirmed f o r me my more general understanding of Freud's explanation of human behaviour. Once again, I encountered the view t h a t a l l i n d i v i d u a l s were faced with an i n t r a p s y c h i c b a t t l e between t h e i r i n s t i n c t u a l needs, and the needs of s o c i e t y , represented i n the superego. The paranoid d i s o r d e r , f o r Freud, seemed to be another ver-s i o n of t h i s phenomenon that had i t s own s p e c i a l elements such as l a t e n t homosexuality and excessive use of p r o j e c t i o n , but that was, i n essence, simply another example of a d i s o r d e r t h a t stemmed from the same inherent human c o n d i t i o n . I discovered that the p a r t i c u l a r dynamic of the d i s o r d e r i n Freud's view was homosexual c o n f l i c t . He argued that a person who i s unable to repress unconscious homosexual impulses develops strong g u i l t f e e l i n g s which he/she p r o j e c t s , and t h e r e f o r e experiences as persecution from the e x t e r n a l environment. Freud put h i s argument t h i s way: . . . we are i n point of f a c t driven by experience to a t t r i b u t e to the homosexual wish-phantasy an i n t i m a t e (perhaps an i n v a r i -able) r e l a t i o n to t h i s p a r t i c u l a r form of disease. D i s t r u s t i n g my own experience on the s u b j e c t , I have during the l a s t few years j o i n e d w i t h my f r i e n d s C.G. Jung of Zurich and S. Ferenczi of Budapest i n i n v e s t i g a t i n g upon t h i s s i n g l e point a number of cases of paranoid d i s o r d e r which have come under observation. The p a t i e n t s whose h i s t o r i e s provided the material f o r t h i s i n q u i r y i ncluded both men and women, and v a r i e d i n race, occu-p a t i o n , and s o c i a l standing. Yet we were astonished to f i n d t hat i n a l l of these cases a defence against a homosexual wish 75 was c l e a r l y recognizable at the very centre of the c o n f l i c t which underlay the disease, and that i t was i n an attempt to master an unconsciously r e i n f o r c e d current of homosexuality that they had a l l o f them come to g r i e f . 2 4 Freud's view of paranoia stood i n o p p o s i t i o n to that of Tomkins. As the source of the problem, f o r Freud, l a y i n the psyche of d i s t u r b e d i n d i v i d u a l s , t h e i r f e e l i n g s of persecution were, by d e f i n i t i o n , delu-s i o n a l . Once again I f e l t t h a t I faced the crux of the i n s t i n c t u a l l y based explanation of behaviour. As no s i g n i f i c a n t r e c o g n i t i o n was granted by Freudian theory to the external world of the i n d i v i d u a l , the p o s s i b i l i t y t h a t t h e i r f e e l i n g s were v a l i d , and that they were, i n f a c t , the v i c t i m s of persecution was not an i s s u e . Thus, Freud's conceptual-i z a t i o n of the d i s o r d e r took as given the premise that the s o c i a l world i n which the d i s t u r b e d i n d i v i d u a l l i v e d was not a h o s t i l e world that v i c t i m i z e d the d i s t u r b e d i n d i v i d u a l . Tomkins' a n a l y s i s and evidence had r a i s e d i n my mind the p o s s i -b i l i t y t h a t "paranoids" were, i n f a c t , v i c t i m s of p e r s e c u t i o n , as he was able to demonstrate that the d i s o r d e r could be induced by external as opposed to i n t r a p s y c h i c f o r c e s . I f t h i s was the case, then psychother-apy that derived from an i n t r a p s y c h i c p e r s p e c t i v e , and l a b e l l e d the "paranoid's" thought and f e e l i n g s as d e l u s i o n a l , would be r e s p o n s i b l e f o r a d j u s t i n g the i n d i v i d u a l to a s o c i a l world that was, i n f a c t , the source of h i s / h e r disturbance. The i n d i v i d u a l would, t h e r e f o r e , be denied the p o s s i b i l i t y of i d e n t i f y i n g and a l l e v i a t i n g the source of p e r s e c u t i o n , as the t h e r a p i s t , working i n terms of an i n t r a p s y c h i c model of the d i s o r d e r , would deny i t s e x i s t e n c e . These ideas drew me back to my o r i g i n a l perspective on the r e l a t i o n s h i p between p s y c h i a t r i c theory 76 and p r a c t i c e , and brought forward once more i n my mind the i s s u e of s o c i a l c o n t r o l that had been r a i s e d by Seymour Halleck and others. One could a f t e r a l l , I r e a l i z e d , analyse the r e l a t i o n between homosexuality and paranoia without r e l y i n g on any i n t r a p s y c h i c arguments. I f one considers the persecution t h a t i s brought to bear upon a homo-sexual i n our s o c i e t y , then i t does not seem i l l o g i c a l f o r a l a t e n t homosexual to have f e e l i n g s of paranoia. Tomkins, i n a c r i t i q u e of Freud's view, put i t t h i s way: When one fears d e t e c t i o n of an immorality . . . i t i s a l t o g e t h e r p o s s i b l e that what he c a l l s g u i l t would more properly have been l a b e l l e d t e r r o r l e s t I be h u r t , exposed and degraded f o r sexual behavior.25 I concluded that I could account f o r Freud's explanation i n terms of my e s t a b l i s h e d p e r s p e c t i v e . I d i d not need to a l t e r my point of view i n order to come to gr i p s w i t h h i s understanding of the d i s o r d e r . Further-more, my reading of Freud's views on paranoia confirmed f o r me the value of examining t h i s p a r t i c u l a r d i s o r d e r . I t seemed th a t one could i l l u s -t r a t e the s o c i a l c o n t r o l argument c l e a r l y from a c r i t i c a l a n a l y s i s of the i n t r a p s y c h i c explanation of the d i s o r d e r . I set out, t h e r e f o r e , to review more of the l i t e r a t u r e that d e a l t w i t h i t . I chose next to examine the work of an author who had w r i t t e n 26 e x t e n s i v e l y on paranoia, Norman Cameron. Cameron had both a Freudian and a symbolic i n t e r a c t i o n i s t p e r s p e c t i v e . I became aware of h i s work, as I was t a k i n g a graduate course e n t i t l e d " S o c i a l C o n t r o l , " which was devoted to an a n a l y s i s of symbolic i n t e r a c t i o n i s m , and i t s o r i g i n s i n the work of John Dewey and George Herbert Mead. In p a r t i c u l a r , the course focused on t h e i r theory of s e l f - c o n t r o l , and made reference to 77 Cameron's work, as i t represented a more recent formulation of t h e i r p e r s p e c t i v e s . From my f i r s t reading of Cameron, I uncovered two points t h a t I f e l t strengthened the explanation of the paranoid d i s o r d e r , that I had begun to c o n s t r u c t . Cameron noted t h a t paranoia i s d i s t i n g u i s h e d from s c h i z o p h r e n i a , as "paranoids" are seen to have good o r g a n i z a t i o n , and to have contact with r e a l i t y . He argued, f o r example, that " . . . both i n perception and i n a c t i o n the p a t i e n t i s not nearly as d e s o c i a l i z e d as 27 are other psychotic persons. Furthermore, he s t a t e d that the t h i n k i n g of normal i n d i v i d u a l s could at times resemble the d e l u s i o n a l thought of "paranoids." He put h i s argument t h i s way: A l l of t h i s leads up to the question of d i s t i n g u i s h i n g between d e l u s i o n a l and nondelusional t h i n k i n g . The way we a l l have of a c t i n g on the basis of fragmentary i n f o r m a t i o n , of i n t e r -p r e t i n g signs and s i g n a l s , of depending h e a v i l y upon hidden meanings and i n t u i t i o n s , of r e c o n s t r u c t i n g what we " r e c a l l " and of being always subject to s h i f t i n g emotional i n f l u e n c e s , makes a c l e a r d i s t i n c t i o n exceedingly d i f f i c u l t to formulate.28 Cameron goes on .to add t h a t : I t would not be d i f f i c u l t to make a case f o r the presence of delusions even among normal people. The f u l l acceptance of a b e l i e f , and i t s i n d e f i n i t e p e r s i s t e n c e , even though i t contra-d i c t s a l l the o b j e c t i v e evidence, i s not uncommon i n ordinary l i f e . 2 9 The two points t h a t he made, again, i n my mind, r a i s e d doubt as to the v a l i d i t y of the i n t r a p s y c h i c explanation of the d i s o r d e r . I f those l a b e l l e d "paranoid" were u n l i k e other p s y c h o t i c s , and resembled "normals" i n t h e i r t h i n k i n g , and i f "normal" people thought i n ways that were i d e n t i c a l to those of "paranoids," then one had, I thought, to question the premise that""paranoids "' f e e l i n g s of persecution were n e c e s s a r i l y d e l u s i o n a l . This aspect of Cameron's a n a l y s i s seemed to i n d i c a t e that 78 "paranoids" had a sustained r e l a t i o n s h i p with t h e i r s o c i a l w orld, which r a i s e d the p o s s i b i l i t y , f o r me, once more, that the source of t h e i r t h i n k i n g had i t s basis i n r e a l l i f e experiences of the i n d i v i d u a l . I f t h i s were the case, then one could argue that not only d i d "paranoids" and "normals" think a l i k e , as Cameron had s t a t e d , but a l s o t h a t "para-noids'" thought was not d e l u s i o n a l . - I t c o u l d , I b e l i e v e d , be seen as thought t h a t a c c u r a t e l y r e f l e c t e d the experiences of the "paranoid," but t h a t had come to be seen as having no basis i n r e a l i t y . I f t h i s were the case, then "paranoids" d i d not s u f f e r from d e l u s i o n s , but r a t h e r from the f a i l u r e of those around them to acknowledge the v a l i d i t y of t h e i r f e e l i n g s and thought. The conclusions that I had drawn from Norman Cameron's a n a l y s i s d i d not f i t , however, w i t h his p e r s p e c t i v e . Cameron was Freudian i n o r i e n t a t i o n , and to him, t h e r e f o r e , the "paranoid's" thoughts were d e l u s i o n a l , not r e a l . T h e i r source la y not i n the s o c i a l world of the i n d i v i d u a l , but r a t h e r w i t h i n the i n d i v i d u a l , stemming from what he terms " i d e r u p t i o n s , " or " p r i m i t i v e f a n t a s i e s and c o n f l i c t s " which the "paranoid" then p r o j e c t s and experiences as persecution from the external 30 world. Although Cameron acknowledged that the "paranoid's" t h i n k i n g resembled normal thought, and t h a t the "paranoid" was not d e s o c i a l i z e d , the "paranoid" to Cameron, was a p s y c h o t i c i n d i v i d u a l who experienced delusions which were a consequence of being ". . . swamped by c r u e l , 31 s a d i s t i c , homoerotic and murderous f a n t a s i e s . " Cameron i n t e g r a t e d a symbolic i n t e r a c t i o n i s t p e r s p e c t i v e i n t o h i s a n a l y s i s which w i l l be discussed below, but f o r him the s o c i a l components of t h i s d i s o r d e r were d i r e c t l y t i e d to an a n a l y s i s t h a t was fundamentally Freudian i n o r i e n -79 t a t i o n . This may, perhaps, be revealed most c l e a r l y i n his a n a l y s i s of the development of paranoid l o g i c : The force of t h i s i r r e s i s t a b l e forward movement comes from i d impulses. Delusional reasoning i s d r i v e organized. I t i s p r o p e l l e d forward by l i b i d i n a l and aggressive pressures. I t s d i r e c t i o n s are determined by p r e v i o u s l y unconscious motivation which has come to take charge of thinking.32 Although he accounted f o r the source of paranoia i n terms of a Freudian a n a l y s i s , Cameron d i d adopt an i n t e r p e r s o n a l o r i e n t a t i o n , sym-b o l i c i n t e r a c t i o n i s m , to e x p l a i n the s t r u c t u r e of paranoid thought. He, i n f a c t , l a b e l l e d as s t a t i c , i n t e r p r e t a t i o n s of the d i s o r d e r that f a i l e d 33 to acknowledge an i n t e r p e r s o n a l component. As I became more f a m i l i a r with the symbolic i n t e r a c t i o n i s t perspective through the course t h a t I was t a k i n g , I r e a l i z e d that my r e j e c t i o n of the Freudian part of Cameron's a n a l y s i s d i d not r u l e out the p o s s i b i l i t y of drawing upon the symbolic i n t e r a c t i o n i s t element w i t h i n his work. One aspect b a s i c to symbolic i n t e r a c t i o n i s m , i n p a r t i c u l a r , made sense to me i n terms of the understanding of paranoia that I was devel-34 oping; the concept of shared s o c i a l meanings. George Herbert Mead argued t h a t members of a s o c i e t y share in-common a set of s o c i a l mean-ings which they have i n t e r n a l i z e d , and which form the basis of t h e i r consciousness. This set of meanings, which he termed the "generalized other," allowed f o r s e l f - c o n t r o l and t h e r e f o r e s o c i a l i n t e r a c t i o n , as the i n d i v i d u a l adjusts h i s / h e r behaviour i n terms of the expectations of o t h e r s , by means of adopting the standpoint of the " g e n e r a l i z e d other" p r i o r to a c t u a l l y engaging i n a s p e c i f i c behaviour. I n d i v i d u a l s are, t h e r e f o r e , able to see themselves the way t h a t others see them, which may serve as a basis of a c t i o n . 80 Norman Cameron made use of t h i s a n a l y s i s to e x p l a i n the nature of paranoid t h i n k i n g . He argued t h a t "paranoids" lack b a s i c s o c i a l s k i l l s such that they are unable to adopt the standpoint of the "generalized other," and are ther e f o r e unable to see themselves as others see them. This leaves them, he f e e l s , i n a vacuum devoid of means to measure the v a l i d i t y of t h e i r perceptions of the s o c i a l world. At the same time, he argues, they experience the " i d e r u p t i o n s " discussed p r e v i o u s l y . Unable to i d e n t i f y and deal with t h i s negative unconscious m a t e r i a l , "paranoids" p r o j e c t i t and experience i t as emanating from r e a l and imagined persons i n t h e i r s o c i a l environment. Cameron argues that "paranoids" see these i n d i v i d u a l s to be l i n k e d together i n a conspiracy against them, and has 35 l a b e l l e d t h i s d e l u s i o n a l e n t i t y "the paranoid pseudo-community." Thus, not sharing the same set of s o c i a l meanings, o r , as Cameron sees i t , s o c i a l r e a l i t y as those around them, "paranoids," i n Cameron's view, engage i n a spurious symbolic r e c o n s t r u c t i o n of r e a l i t y . Cameron summarizes h i s argument t h i s way: What the paranoid p a t i e n t does i s as f o l l o w s : Into the organiza-t i o n of s o c i a l r e a l i t y , as he perceives i t , he unconsciously p r o j e c t s h i s own p r e v i o u s l y unconscious m o t i v a t i o n s , which he has denied but cannot escape. This process now requires a perceptual and conceptual r e o r g a n i z a t i o n of object r e l a t i o n s i n hi s surroundings i n t o an apparent community, which he represents to h i m s e l f as organized wholly with respect to him (delusion of s e l f - r e f e r e n c e ) . And since the p a t i e n t ' s erupted, denied, and pro j e c t e d elements are overwhelmingly h o s t i l e and d e s t r u c t i v e , the motivation he as c r i b e s to the real persons he has now organized i n t o his conceptual pseudp-community i s bound to be extremely h o s t i l e and d e s t r u c t i v e . ° My own use of the symbolic i n t e r a c t i o n i s t perspective began with the premise that the "paranoid" might not be d e l u s i o n a l , but rat h e r the v i c t i m of persecution. I formulated an explanation of paranoia t h a t 81 u t i l i z e d the concept of shared s o c i a l meanings, but, drawing upon the evidence from Tomkins, r e j e c t e d Cameron's view that the "paranoid" r e s o r t s to an inaccurate r e c o n s t r u c t i o n of r e a l i t y (the paranoid pseudo-community) i n order to preserve h i s / h e r personal e q u i l i b r i u m . As I b e l i e v e d t h a t the environment of an i n d i v i d u a l was the key to under-standing h i s / h e r p e r s o n a l i t y , I f e l t t h a t the paranoid d i s o r d e r derived from the nature of the r e l a t i o n s h i p between an i n d i v i d u a l and h i s / h e r environment. Thus, the behaviour of the "paranoid" c o u l d , I b e l i e v e d , be seen as an expression of h i s / h e r own l i f e experiences. His/her behaviour c o u l d , t h e r e f o r e , be seen as '' r a t i o n a l " w i t h i n the context of the i n d i v i d u a l ' s own set of s o c i a l meanings derived from h i s / h e r l i f e experiences, although other i n d i v i d u a l s w i t h d i f f e r e n t l i f e experiences, and, t h e r e f o r e , not i d e n t i c a l sets of s o c i a l meanings, might view i t as i r r a t i o n a l or i n d i c a t i v e of a disease of the psyche; paranoia. Thus, I di d not accept the view that persons whose behaviour i s not i n accordance with the s o c i a l meanings shared i n a s o c i e t y are n e c e s s a r i l y d e l u s i o n a l . Nor d i d Cameron, as pointed out e a r l i e r , but he q u a l i f i e d h i s a n a l y s i s s i g n i f i c a n t l y , as he s t i p u l a t e d that the delusions of "normals" are delusions t h a t are shared by others i n the same c u l t u r e and are there-37 f o r e based upon what he terms "group i d e n t i f i c a t i o n . " To him, a l l other delusions were a si g n of i n s a n i t y , whereas I b e l i e v e d that a l l s o - c a l l e d paranoid delusions p o s s i b l y were accurate r e f l e c t i o n s of l i f e experi ences. From my perspective at t h a t time, I viewed the d i s o r d e r as a " r a t i o n a l " response of an i n d i v i d u a l t h a t i s c o n s i s t e n t with h i s / h e r symbolic r e c o n s t r u c t i o n of r e a l i t y ; i . e . , a " l o g i c a l " response based on 82 h i s / h e r set of s o c i a l meanings which were derived from past or present experiences of persecution. Thus, I b e l i e v e d that the "paranoid" was an i n d i v i d u a l who was responding to genuine p e r s e c u t i o n , r a t h e r than projected i n t r a p s y c h i c problems. Instead of searching f o r defects of the i n d i v i d u a l which would account f o r f e e l i n g s of p e r s e c u t i o n , i t seemed to me t h a t one should look f o r the actual occurrence of persecu-t i o n . The determination t h a t an i n d i v i d u a l ' s views were paranoid c o u l d , I b e l i e v e d , be understood as a decision-making process that took the f o l l o w i n g form: i f i n d i v i d u a l "A," f o r example, has been subjected to the s t r e s s of p e r s e c u t i o n , i t seems conceivable that h i s set of s o c i a l meanings would d i f f e r from those of i n d i v i d u a l "B" who has not undergone such an experience. "A" would i n c l u d e persecution as part of his sym-b o l i c r e c o n s t r u c t i o n of r e a l i t y , and, t h e r e f o r e , would behave d i f f e r -e n t l y than "B." To "B," the actions of "A" may appear i r r a t i o n a l , and t h e r e f o r e lead "B" to b e l i e v e that "A" i s mentally i l l - - p a r a n o i d . Thomas Scheff (whose work I had encountered e a r l i e r ) pointed out the consequences of t h i s type of process: . . . the more the rule-breaker enters the r o l e of the mentally i l l , the more he i s defined by others as mentally i l l ; but the more he i s defined as mentally i l l , the more f u l l y he enters the r o l e , and so on.38 I d i d not r u l e out from my a n a l y s i s the p o s s i b i l i t y t h a t a perse-cuted i n d i v i d u a l or s o c i a l group may not have an awareness o f , or may be prevented from responding t o , t h e i r persecutor. This could l e a d , I b e l i e v e d , to m i s d i r e c t e d anger and f e e l i n g s of persecution which, when viewed from Norman Cameron's p e r s p e c t i v e , would seem to confirm his concept of the paranoid pseudo-community. While I recognized that some 83 paranoid disorders may i n v o l v e genuinely i r r a t i o n a l and even dangerous behaviour, I f e l t , however, that one could not overlook the f a c t t h a t these behaviours may be responses of i n d i v i d u a l s who have l o s t s i g h t of the source of t h e i r p e r s e c u t i o n , and are, t h e r e f o r e , b l i n d l y a c t i n g out t h e i r j u s t i f i a b l e anger. Thus to me, at that point i n time, i t seemed that "paranoids" could be seen as i n d i v i d u a l s who have been put i n a double bind. Some element i n t h e i r environment persecuted them. They responded i n a normal fashion by f e e l i n g persecuted. In t u r n , s o c i e t y responded to them with f u r t h e r p e r s e c u t i o n — t h e y were deemed to be p a r a n o i d — m e n t a l l y i l l . I f e l t t h a t my formulation of the paranoid d i s o r d e r derived l o g i c a l l y from my more general c r i t i q u e of p s y c h i a t r y . I f p s y c h i a t r i s t s , u t i l i z i n g an i n t r a p s y c h i c approach such as Freud's or Cameron's d i d not take i n t o account the p o s s i b i l i t y t h a t t h e i r "paranoid" p a t i e n t i n f a c t was a v i c t i m of p e r s e c u t i o n , then t h e i r therapy might turn out to be s e r v i n g the f u n c t i o n of s o c i a l c o n t r o l . Therapy would adjust the d i s t u r b e d i n d i v i d u a l to the s o c i a l w o r l d , despite the f a c t that i t was t h i s s o c i a l w o r l d , or some element w i t h i n i t , t h a t was the source of the disturbance. There was, I b e l i e v e d , an a u t h o r i t a r i a n and r e p r e s s i v e p o t e n t i a l i m p l i c i t w i t h i n t h i s process. Evidence of a b l a t a n t abuse of p s y c h i a t r y 39 i n the S o v i e t Union had r e c e n t l y been revealed, and I f e l t t h a t these p r a c t i c e s , the l a b e l l i n g of s o c i a l and p o l i t i c a l d i s s e n t as mental i l l -ness, were simply l o g i c a l extensions of the problem that I had i d e n t i f i e d . In my view, Cameron expressed the problematic o r i e n t a t i o n d i s t i n c t l y , when he s t a t e d : 84 The th e r a p e u t i c process now involves another r e c o n s t r u c t i o n of r e a l i t y , one which undoes the r e s t i t u t i o n a l pseudo-community. . . . The p a t i e n t can begin to e n t e r t a i n doubts and consider a l t e r n a t i v e i n t e r p r e t a t i o n s . . . . In t h i s way the conceptual s t r u c t u r e of h i s pseudo-community may be gradually replaced by something approaching the conceptual s t r u c t u r e of s o c i a l r e a l i t y . 4° I t appeared to me that Cameron advocated the undermining of the "para-noid's" d e f i n i t i o n of r e a l i t y , and the im p o s i t i o n of a " c o r r e c t " d e f i n -i t i o n of r e a l i t y i n i t s place. I b e l i e v e d t h a t t h i s task was predicated upon the erroneous view that the "paranoid's" d e f i n i t i o n of r e a l i t y was n e c e s s a r i l y f a l s e ; a view which stemmed from the adherence by Cameron and other psychotherapists to the i n t r a p s y c h i c perspective which d i r e c t e d them to search, i n an attempt to account f o r the "paranoid's" b e l i e f s , f o r defects w i t h i n the i n d i v i d u a l r a t h e r than accepting the "paranoid's" d e f i n i t i o n of r e a l i t y as c o r r e c t , and loo k i n g f o r the source of the i n d i v i d u a l ' s b e l i e f s i n the s o c i a l environment of that i n d i v i d u a l . Cameron's approach represented the essence of what I took to be a funda-mental f a u l t inherent w i t h i n psychotherapy that was based upon an i n t r a -psychic explanation of human behaviour. Consolidating the Perspective Having developed an a n a l y s i s of paranoia which I f e l t provided an adequate explanation of the d i s o r d e r i n terms of my understanding of mental i l l n e s s , I set out to l o c a t e more evidence to support my perspec-t i v e . With the help of one of my professors who had an i n t e r e s t i n mental i l l n e s s , I lo c a t e d i n the l i t e r a t u r e f u r t h e r references which viewed paranoia as a d i s o r d e r t h a t derived from the r e a l l i f e e x p e r i -ences of an i n d i v i d u a l , r a t h e r than from i n t r a p s y c h i c problems. These 85 sources d i d not l a b e l the "paranoid's" f e e l i n g s of persecution as delu-s i o n s , but r a t h e r asserted t h a t the "paranoid" was a v i c t i m of persecu-t i o n , and t h e r e f o r e had good reason to b e l i e v e that he/she was being persecuted. The discovery o f other sources t h a t supported my perspective helped to confirm my b e l i e f s t h a t the p o l i t i c a l c r i t i q u e of p s y c h i a t r y was v a l i d , and that I had s e l e c t e d an appropriate d i s o r d e r to use as a means of i l l u s t r a t i n g the v a l i d i t y of the c r i t i q u e . Thus, these sources made f u r t h e r c o n t r i b u t i o n s to the development of my c o n s t r u c t s , and I s h a l l , t h e r e f o r e , discuss the knowledge that I gained from them. The f i r s t o f these a d d i t i o n a l authors t h a t I d e a l t w i t h , Edwin Lemert, had produced one of the better-known s o c i o l o g i c a l studies of 41 paranoia. As the extent of s o c i o l o g i c a l l i t e r a t u r e on the d i s o r d e r was l i m i t e d , I f e l t f ortunate t h a t one of the major st u d i e s a l s o turned out to be c r i t i c a l o f the i n t r a p s y c h i c e x p l a n a t i o n , and, t h e r e f o r e , was 42 not incompatible with my perspective on the d i s o r d e r . In essence, i t was Lemert's contention t h a t the "paranoid" i n d i v i d u a l was, i n f a c t , a v i c t i m of a conspiracy which, i n Lemert's view, forced one to d i s c a r d explanations of the d i s o r d e r t h a t focused on i n t r a p s y c h i c problems, and forced one to look, r a t h e r , at the s o c i a l s e t t i n g of the d i s t u r b e d 43 i n d i v i dual. According to Lemert, paranoia had to be conceived i n terms of "a relationship.,and\ a p r o c e s s r a t h e r than s e e i n g . i t "as a disease, a 44 s t a t e , a c o n d i t i o n , or a syndrome of symptoms." To me, t h i s was f u r t h e r confirmation of the a n a l y s i s that I had o r i g i n a l l y begun to develop out of the work of Tomkins. Lemert o f f e r e d not only his own research f i n d i n g s as evidence, but a l s o c i t e d other studies t h a t pointed 86 to a s o c i a l basis to the d i s o r d e r , concluding that " . . . paranoia sug-ges t s , more than any other forms of mental d i s o r d e r , the p o s s i b i l i t y of 45 f r u i t f u l s o c i o l o g i c a l a n a l y s i s . " Reading Lemert, I f e l t t hat I was on the r i g h t t r a c k , as i t appeared that others also recognized the a l t e r n a t i v e s o c i e t a l explanation of the d i s o r d e r . I t seemed to me, t h e r e f o r e , that I had chosen an appropriate d i s o r d e r to use as a means 46 of v a l i d a t i n g the p o l i t i c a l c r i t i q u e of p s y c h i a t r y . In h i s a r t i c l e , Lemert presented a c r i t i q u e o f Norman Cameron's perspective on paranoia, which was of p a r t i c u l a r i n t e r e s t to me, as Cameron's work seemed to stand out i n the l i t e r a t u r e as a s i g n i f i c a n t 47 example of an i n t r a p s y c h i c explanation of the d i s o r d e r . Furthermore?, I had a l r e a d y , as discussed above, developed my own a n a l y s i s of Cameron's pe r s p e c t i v e , and thus I was most i n t e r e s t e d to study Lemert's, i n l i g h t of i t . As has already been pointed out, Lemert's perspective d i d not c o n t r a d i c t my own. Based upon hi s research of e i g h t cases of persons seen to s u f f e r from some form of paranoia, he concluded, f o r example, tha t : . . . members of communities and o r g a n i z a t i o n s do unite i n common e f f o r t against the paranoid person p r i o r to or apart from any v i n d i c t i v e behavior on h i s part. The paranoid community i s real r a t h e r than pseudo i n t h a t i t i s composed of r e c i p r o c a l r e l a t i o n -ships and processes whose net r e s u l t s are informal and formal e x c l u s i o n and attenuated communication.48 Thus, contrary to Cameron's p e r s p e c t i v e , i n Lemert's view: . . . the "pseudo-community" associated with random aggression ( i n Cameron's sense) i s a sequel rather than an i n t e g r a l part of paranoid p a t t e r n s . They are l i k e l y products.o.f d e t e r i o r a t i o n and fragmentation of p e r s o n a l i t y appearing, when and i f they do, i n the paranoid person a f t e r long or intense periods of s t r e s s and complete s o c i a l i s o l a t i o n . 4 9 87 Lemert's a n a l y s i s was of s i g n i f i c a n c e to me, as he too r e j e c t e d Cameron's concept of a paranoid pseudo-community. I f e l t that our views were compatible, as our common r e j e c t i o n also acknowledged the p o s s i -b i l i t y that such a d e l u s i o n a l e n t i t y could at times e x i s t i n the mind of the d i s t u r b e d i n d i v i d u a l (see, f o r example, my e a r l i e r reference to m i s d i r e c t e d anger and f e e l i n g s of p e r s e c u t i o n ) , but t h a t i t was not the primary component of the d i s o r d e r , as, a f t e r a l l , t h i s community was i n most cases a r e a l , not a pseudo, e n t i t y . This confirmation of my analy-s i s was, I f e l t , important, as i t was based upon actual research with "paranoids," as opposed to my own l o g i c a l s p e c u l a t i o n derived from my 50 study of the l i t e r a t u r e . Thus, my own views of the d i s o r d e r were, i n my eyes, developing c r e d i b i l i t y , as I now could add Lemert's research to t h a t of Tomkins and Karon with together, I thought, c o n s t i t u t e d consid-erable evidence i n support of my p e r s p e c t i v e . According to Lemert, one d i d not have to r e l y at a l l upon i n t r a -psychic explanations i n order to account f o r f e e l i n g s of persecution. He notes, f o r example, t h a t : . . . a number of studies have ended with the conclusions that external circumstances — changes i n norms and values, d i s p l a c e -ment, strange environments, i s o l a t i o n , and l i n g u i s t i c separation --may create a paranoid d i s p o s i t i o n i n the absence of any s p e c i a l character s t r u c t u r e . The r e c o g n i t i o n of paranoid r e a c t i o n s i n e l d e r l y persons, a l c o h o l i c s , and the deaf adds to the data g e n e r a l l y c o n s i s t e n t with our t h e s i s . The f i n d i n g that d i s p l a c e d persons who withstood a high degree of s t r e s s during war and c a p t i v i t y subsequently developed paranoid reactions when they were i s o l a t e d i n a f o r e i g n environment commands s p e c i a l a t t e n t i o n among data r e q u i r i n g explanation i n other than organic or psycho-dynamic terms.51 The evidence that Lemert presented helped to confirm my own b e l i e f s . A f t e r a l l , to postulate that persecution could be a causative f a c t o r , as I d i d , seemed, i n l i g h t of the evidence which i m p l i c a t e s other 88 e x t e r n a l f a c t o r s , to be a sound explanation of the source of the d i s -order. Thus, views that argued that a "paranoid's" f e e l i n g s of perse-c u t i o n were n e c e s s a r i l y d e l u s i o n a l d i d not, from my p e r s p e c t i v e , take i n t o account what I saw to be the very rea l p o s s i b i l i t y that the "paranoid" was a v i c t i m of persecution. Lemert al s o argued t h i s p o s i t i o n , which he s t a t e d t h i s way: The general idea that the paranoid person s y m b o l i c a l l y f a b r i c a t e s the conspiracy against him i s i n our estimation i n c o r r e c t or incomplete. Nor can we agree that he lacks i n s i g h t , as i s so freq u e n t l y claimed. To the co n t r a r y , many paranoid persons properly r e a l i z e that they are being i s o l a t e d and excluded by concerted i n t e r a c t i o n , or that they are being i .manipulated.52 To me, Lemert's statement was of some s i g n i f i c a n c e , as i t was based upon h i s actual study o f cases of paranoia; a study which he c h a r a c t e r i z e d as f o l l o w s : The i n v e s t i g a t i o n of the cases were as exhaustive as i t was p o s s i b l e to make them, reaching r e l a t i v e s , work a s s o c i a t e s , employers, a t t o r n e y s , p o l i c e , p h y s i c i a n s , p u b l i c o f f i c i a l s and any others who played s i g n i f i c a n t r o l e s i n the l i v e s of the persons involved.53 Thus, I f e l t t h a t my own conclusions as to the nature of the d i s -order were v a l i d a t e d by hi s thorough study of i t . Lemert's evidence made c l e a r what I took to be of c r u c i a l importance. He revealed the presence of persecution d i r e c t e d toward the "paranoid" i n d i v i d u a l . Lemert s t a t e s , f o r example, t h a t : . . . wh i l e the paranoid person reacts d i f f e r e n t i a l l y to h i s s o c i a l environment, i t i s al s o t r u e that "others" react d i f f e r -e n t i a l l y to him and t h i s r e a c t i o n commonly i f not t y p i c a l l y i n v o l v e s c o v e r t l y organized a c t i o n and c o n s p i r a t o r i a l behavior i n a very r e a l sense.54 Lemert's a n a l y s i s r a i s e d once more f o r me the theme of s o c i a l c o n t r o l . His research i n d i c a t e d t h a t i n d i v i d u a l s who were taken to be 89 paranoid, were, i n f a c t , responding to actual persecution. The conse-quences f o r t h e i r l i v e s were s i g n i f i c a n t . Lemert points out that nearly a l l of the i n d i v i d u a l s t h a t he s t u d i e d had been admitted or committed to 55 mental h o s p i t a l s , and a l l of them were seen to have "prominent para-56 noid c h a r a c t e r i s t i c s . " As t h e i r f e e l i n g s of persecution were taken to be signs of i n s a n i t y , I f e l t sure that psychotherapy with these i n d i v i d -uals would u t i l i z e an i n t r a p s y c h i c approach, and would attempt, t h e r e f o r e , to adjust them to t h e i r s o c i a l w o r l d , thereby s e r v i n g the f u n c t i o n of s o c i a l c o n t r o l . The next author t h a t I d e a l t with was introduced to me by the same professor who had a l e r t e d me to the work of Lemert. He had r e c e n t l y received the g a l l e y proofs of a new book by Morton Schatzman, that was to be published s h o r t l y , and made them a v a i l a b l e to me, as the book was devoted to a c r i t i c a l a n a l y s i s of paranoia. Upon reading the g a l l e y p r o o f s , I was pleased to f i n d that Schatzman, l i k e Lemert, a l s o viewed paranoia as a d i s o r d e r t h a t stemmed from the r e l a t i o n s h i p between an i n d i v i d u a l and h i s s o c i a l world. He, too, r e j e c t e d an i n t r a p s y c h i c formulation of the d i s o r d e r . As Schatzman's views d i d not c o n t r a d i c t my own, I again had the experience of f e e l i n g that I had developed a perspective on the d i s o r d e r t h a t r e a l l y d i d make sense of i t . Once more, I f e l t t hat my views were v a l i d a t e d , as another researcher had a r r i v e d at the same conclusions as I had. Schatzman noted, f o r example: I think many people whom p s y c h i a t r i s t s c a l l paranoid are or have been persecuted and know i t , but they do not recognize t h e i r r e a l persecutors or how they have been persecuted. To c a l l them paranoid which presupposes they are not r e a l l y perse-cuted, but imagine i t , i s f a l s e and misleading.57 90 He went on to add that "what i s c l i n i c a l l y c a l l e d paranoia i s often the p a r t i a l r e a l i z a t i o n - - a s through a glass d a r k l y - - t h a t one has been or i s p e r s e c u t e d . A s he viewed the "paranoid's" f e e l i n g s of persecution to be j u s t i f i e d , I placed Schatzman's a n a l y s i s together with that of Tomkins and Lemert, and saw them c o l l e c t i v e l y as sources of f u r t h e r information and support f o r my pe r s p e c t i v e . I greeted a l l evidence t h a t di d not c o n t r a d i c t my viewpoint e n t h u s i a s t i c a l l y , as most p s y c h i a t r i s t s (whom I saw to :be the "experts" with respect to mental i l l n e s s 5 9 ) , and most of the l i t e r a t u r e on the d i s o r d e r d i d c o n t r a d i c t my understanding of i t . Schatzman made t h i s p o i n t , when he noted with respect to h i s perspective t h a t "I part company here with prevalent views about para-60 noii.a." Schatzman's a n a l y s i s of paranoia, t h e r e f o r e , may be seen as another source which served to determine my expectations as to the nature o f the d i s o r d e r . I t too was a c o n t r i b u t o r to my "map." Schatzman summarizes the s t r u c t u r e of h i s book t h i s way: . . . I l i n k the strange experiences of Daniel Paul Schreber, f o r which he was thought mad, to his father's c h i l d - r e a r i n g p r a c t i c e s . I b r i n g f o r t h and match two sets of f a c t s - - t h e son's b i z a r r e experiences as an adult and his father's techniques of educating children--and I conjecture about how they may be connected.61 The Daniel Paul Schreber whom he r e f e r s t o , was the subject upon whose 62 memoirs Freud based h i s theory of paranoia (thus, the s i g n i f i c a n c e of Schatzman's book). In response to Freud's study of Schreber's auto-b i o g r a p h y j , Schatzman, i n t u r n , had examined the w r i t i n g s of Schreber's f a t h e r ; a well-known German educator and p h y s i c i a n . He (Schatzman) made a s i g n i f i c a n t d i s c l o s u r e . Schreber's f a t h e r advocated i n his w r i t i n g s (and we may assume p r a c t i s e d i n his f a m i l y ) what amounted to a program of persecution against the c h i l d by his parents. Schatzman concludes 91 from h i s f i n d i n g s t h a t Daniel Paul Schreber's "paranoid" d i s o r d e r cannot be understood without viewing i t i n terms of the p r a c t i c e s of h i s f a t h e r . Freud's study of the Schreber case was not only the basis of h i s theory of paranoia, but a l s o , as discussed p r e v i o u s l y , became the cornerstone of the e n t i r e i n t r a p s y c h i c explanation of the d i s o r d e r , as expressed i n the work of Norman Cameron and many others. Schatzman's study s e r i o u s l y questions the v a l i d i t y of Freud's a n a l y s i s . Schatzman describes h i s c r i t i q u e of Freud t h i s way: I have placed Freud's theory of paranoia w i t h i n what I t h i n k i s i t s r e l e v a n t i d e o l o g i c a l s e t t i n g , shown that the theory by-passes the issue of parents' persecution of children.63 Thus, h i s work casts doubt upon the v a l i d i t y of the i n t r a p s y c h i c explan-a t i o n i n general. To me, Schatzman's a n a l y s i s was, t h e r e f o r e , s i g n i f i -cant, as i t provided me with a s p e c i f i c response to Freud's conceptual-64 i z a t i o n o f paranoia. As Edwin Lemert gave me a c r i t i q u e of Norman Cameron t h a t f i t t e d with my p e r s p e c t i v e , so too d i d Morton Schatzman give me a c r i t i q u e of Freud. Thus, I f e l t t h a t I was b u i l d i n g an explanation of paranoia that was l o g i c a l l y derived from my more general understanding of mental i l l n e s s , and t h a t could c r i t i c a l l y account f o r the i n t r a p s y c h i c views that I r e j e c t e d . This a l t e r n a t i v e explanation would, i n t u r n , allow me, I f e l t , to i l l u s t r a t e the v a l i d i t y of the p o l i t i c a l c r i t i q u e of p s y c h i a t r y . Schatzman not only r a i s e d the p o s s i b i l i t y t h a t the f e e l i n g s of persecution experienced by a "paranoid" are not n e c e s s a r i l y d e l u s i o n s , he a l s o explored the i m p l i c a t i o n s of denying the t r u t h of a "paranoid's" claims. I , t h e r e f o r e , was able to r e l a t e my own views on psychotherapy and s o c i a l c o n t r o l to h i s a n a l y s i s . Schatzman, too, recognized the 92 problem that I had i d e n t i f i e d with respect to psychotherapy with "para-noids," t h a t was based upon an i n t r a p s y c h i c perspective on the d i s o r d e r . He pointed out the consequences of an i n t r a p s y c h i c approach, which t y p i c a l l y regards the onset of paranoia, as discussed p r e v i o u s l y , to be l i n k e d to the i n a b i l i t y to repress impulses from the i d . A t h e r a p i s t , he notes, r e l y i n g upon t h i s c o n f i g u r a t i o n o f the d i s o r d e r , would aim i n therapy to r e s t o r e r e p r e s s i o n ; a t a c t i c which Schatzman views t h i s way: I f I am r i g h t i n my theory, to re s t o r e repression could mean to move people from the category of being persecuted and knowing i t to being persecuted and not knowing i t . 6 5 Schatzman's p e r s p e c t i v e , to me, was f u r t h e r confirmation of dny b e l i e f t h a t p s y c h i a t r i c p r a c t i c e which was based upon i n t r a p s y c h i c theory would i n e v i t a b l y lead to the e x e r c i s e o f s o c i a l c o n t r o l . I a l s o drew support from another aspect of Schatzman's a n a l y s i s . I discovered t h a t he, too, conceptualized the decision-making process, which l e d up to the l a b e l l i n g o f an i n d i v i d u a l as paranoid, i n terms of 66 r e a l i t y d e f i n i t i o n s . He pointed out, i n ways s i m i l a r to my own, that the f a i l u r e to acknowledge the v a l i d i t y of the "paranoid's" d e f i n i t i o n o f r e a l i t y stems d i r e c t l y from the i n f l u e n c e of the i n t r a p s y c h i c per-s p e c t i v e upon the p r a c t i c e of psychotherapy. As t h i s p e r s p e c t i v e r e j e c t s the "paranoid's" view as a d e l u s i o n , searching instead f o r defects w i t h i n the i n d i v i d u a l , and a s s e r t i n g that he/she i s , i n f a c t , p r o j e c t i n g i n t r a p s y c h i c problems, the t h e r a p i s t who holds an i n t r a -psychic p e r s p e c t i v e cannot help but see the "paranoid's" d e f i n i t i o n of r e a l i t y to be i n v a l i d , and, t h e r e f o r e , would i n e v i t a b l y attempt to impose a " c o r r e c t " d e f i n i t i o n of r e a l i t y upon him/her. Schatzman describes t h i s process i n these terms: "They say he i s l e s s conscious 93 6 7 than they of ' r e a l i t y 1 ; t h a t i s h i s ' i l l n e s s ' they say." Schatzman's a n a l y s i s strengthened my c o n v i c t i o n s . His perspective helped to convince me t h a t not only was the s o c i a l c o n t r o l - p o l i t i c a l c r i t i q u e o f p s y c h i a t r y c o r r e c t , but a l s o t h a t i t could be most r e a d i l y a p p l i e d i n cases of "paranoia." Here, more so than i n any other form of d i s o r d e r , there appeared to be an imposition of one d e f i n i t i o n of r e a l i t y ( s o c i e t y ' s , as represented by and through the p s y c h i a t r i s t ) , at the expense of another (the "paranoid" i n d i v i d u a l ' s ) ; a c l a s s i c example, i n my view, of s o c i a l c o n t r o l . Schatzman helped, I f e l t , through his a n a l y s i s of therapy with "paranoid" p a t i e n t s , to deepen my understanding of t h i s process. One i d e a , i n p a r t i c u l a r , i n f l u e n c e d my t h i n k i n g . Schatzman expressed i t t h i s way: Many people f e e l persecuted but no one ever f e e l s paranoid. Paranoia i s not an experience; i t i s an a t t r i b u t i o n one person makes about another. I t i s a judgment that someone else ' s f e e l -ings of persecution do not r e f e r to anything real.68 His point r a i s e d my awareness of the a u t h o r i t a r i a n and r e p r e s s i v e poten-t i a l inherent i n any instance of a p s y c h i a t r i c diagnosis of paranoia, and prompted me to proceed with my study of the d i s o r d e r confident that I had i d e n t i f i e d a key example of the s o c i a l c o n t r o l "phenomenon" that I b e l i e v e d was b a s i c to psychotherapy t h a t r e l i e d upon an i n t r a p s y c h i c explanation of behaviour. Schatzman al s o o f f e r e d what I took to be a v i a b l e a l t e r n a t i v e to t h e r a p i e s , such as Norman Cameron's, th a t sought to adjust "paranoids" to t h e i r s o c i a l environment. His approach seemed to me to o f f e r a t h e r a p i s t the means to l i b e r a t e i n d i v i d u a l s d i s t u r b e d by f e e l i n g s of persecution. Rather than imposing a " c o r r e c t " d e f i n i t i o n 94 of r e a l i t y upon the "paranoid" p a t i e n t , s u b s t i t u t i n g the p s y c h i a t r i s t ' s version o f the s o c i a l world f o r the p a t i e n t ' s , Schatzman o f f e r e d the f o l l o w i n g : Presume i n cases of "paranoia," i n which no i n t o x i c a t i o n or organic disease i s present, that the person who f e e l s perse-cuted i s responding to behaviour, past or present, of other people who are or have been near him. S t a r t i n g from t h i s p o i n t , i n v i t e everyone i n h i s s o c i a l world to j o i n i n a search f o r the o r i g i n of h i s f e e l i n g s of persecution.69 95 Footnotes ^1 developed an o u t l i n e of features such as: what paranoia i s ; what forms i t takes; the nature of the "paranoid" p e r s o n a l i t y ; how paranoia i s handled; how i t should be handled; e t c . 2 In a d d i t i o n to the authors noted i n footnote number 17, chapter one, I a l s o s t u d i e d the work of Paul Robinson, Ashley Montagu, Frantz Fanon, B.F. Skinner, H. Schoeck and J.W. Wiggins, Michel Foucault, Ernest Becker, and others. Paul Robinson, The Freudian Left (New York: Harper and Row, 1969). Robinson includes i n t h i s group, amongst o t h e r s , E r i c h Fromm, Herbert Marcuse, and Wilhelm Reich. 4 Freud's most thorough statement of h i s perspective i s set out i n Civilization and Its Discontents (London: Hogarth Press, 1939). 5 See, f o r example, Marcuse's d i s c u s s i o n of " s u r p l u s - r e p r e s s i o n " and "performance p r i n c i p l e " i n Herbert Marcuse, Eros and Civilization (New York: Vintage Books, 1955); and Reich's theory of "sex-economic s o c i o l o g y " i n Wilhelm Reich, The Mass Psychology of Fascism (New York: F a r r a r , Straus and Giroux, 1971). Wilhelm Reich, The Mass Psychology of Fascism, p. x x v i i . 7 E r i c h Fromm, Beyond the Chains of Illusion: My Encounter with Marx and Freud (New York: Simon and Schuster, 1962), chapter v i . 8 I b i d . , p. 61. g My use of t h i s term, at that time, stemmed from my understanding of Marx's formulation i n The German Ideology (New York: I n t e r n a t i o n a l P u b l i s h e r s , 1947), and Karl Mannheim's formulation i n Ideology and Utopia (New York: Harcourt, Brace and World, 1936). ^Marcuse, Eros and Civilization, p. 225. ^ S e e , f o r example, the perspectives expressed i n : H. Schoeck and J.W. Wiggins, eds., Psychiatry and Responsibility ( P r i n c e t o n : Van Nostrand, 1962). 12 For a h i s t o r y and a n a l y s i s of these movements, see: Jack New-f i e l d , A Prophetic Minority (New York: New American L i b r a r y , 1967), and T. Roszak, The Making of/.a Counter Culture (Garden C i t y , N.Y.: Doubleday, 1969). 96 1 3 J . Age!, ed., The Radical Therapist (New York: B a l l antine Books, 1971, p. xv. 14 I b i d . , p. x v i . 15 Seymour H a l l e c k , "Therapy Is the Handmaiden of the Status Quo," Psychology Today, A p r i l 1971, p. 32 (excerpted from a chapter i n The Politics of Therapy (New York: Science House, 1971). ^ 1 used the terms " l i b e r a t i o n " and " s o c i a l c o n t r o l " i n the same sense as they were used i n the a n t i - p s y c h i a t r y l i t e r a t u r e . Thus, I employed p o l i t i c a l , r a t h e r than the more widely held s o c i o l o g i c a l or moral, d e f i n i t i o n s of these terms. See, f o r example, the co n t r a s t between the d e f i n i t i o n of s o c i a l c o n t r o l found i n any i n t r o d u c t o r y sociology t e x t , and my p e j o r a t i v e use of t h i s term. ^ P e t e r Maidstone, unpublished manuscript, Santa Barbara, C a l i -f o r n i a , December 1972, p. 4. The term "get through the day," was used i n the course to denote the p r a c t i c a l a c t i v i t i e s which comprise one's working day. 18 S i l v a n Tomkins, Affect—Imagery—Consciousness (New York: Springer P u b l i s h i n g , 1963). 1 9 I b i d . , p. 552. 2 0 I b i d . , p. 481. 2 1 I b i d . , p. 572 and pp. 565-566. 2 2 I b i d . , pp. 567-568. 23 Sigmund Freud, "Psycho-Analytic Notes upon an Autobiographical Account of a Case of Paranoia (Dementia Paranoides)(1911)," Collected Papers, Volume I I I (London: Hogarth Press, 1950); "Some Neurotic Mechan-isms i n Jealousy, Paranoia and Homosexuality," Standard Edition (London: Hogarth Press, 1955). 24 Sigmund Freud, "On the Mechanism of Paranoia," Collected Papers, Volume I I I (London: Hogarth Press, 1950), pp. 444-445. 25 S i l v a n Tomkins, Affect—Imagery—Consciousness, p. 576. 26 '•• • See, f o r example, Norman Cameron, "The Paranoid Pseudo-Community," The American Journal of Sociology, XLIX ( J u l y 1943-May 1944):32-38; The Psychology of Behavior Disorders (New York: Houghton M i f f l i n , 1947); "The Paranoid Pseudo-Community R e v i s i t e d , " The American Journal of Sociology, LXV ( J u l y 1959):52-58; and Personality Development and Psycho-pathology (Boston: Houghton M i f f l i n , 1963). 97 27 Norman Cameron, Personality Development and Psyehopathology (Boston: Houghton M i f f l i n , 1963), p. 508. 2 8 I b i d . , p. 472. 2 9 I b i d . , p. 473. 30 Norman Cameron, The Paranoid Pseudo-Community R e v i s i t e d , " The American Journal of Sociology, LXV ( J u l y 1959):54-57. 31 Norman Cameron, Personality Development and Psyehopathology, p. 504. 3 2 I b i d . , p. 485. 33 Norman Cameron, "The Paranoid Pseudo-Community," pp. 35-36. 34 The o r i g i n s o f t h i s concept l i e i n the work of George Herbert Mead. See, f o r example: G.H. Mead, Mind, Self and-Society, C.W. M o r r i s , ed..(Chicago: U n i v e r s i t y of Chicago Press, 1934); and G.H. Mead, George Herbert Mead on Social Psychology, Anselm S t r a u s s , ed..(Chicago: Uni-v e r s i t y of Chicago Press, 1964). 35 See: Norman Cameron, "The Paranoid Pseudo-Community , and "The Paranoid Pseudo-Community R e v i s i t e d . " Norman Cameron, "The Paranoid Pseudo-Community R e v i s i t e d , " p. 56. 37 Norman Cameron, Personality Development and Psyehopathology, p. 473. 38 Thomas Scheff, Being Mentally III (Chicago: A l d i n e P u b l i s h i n g Co., 1966), pp. 97-98. 39 N.B. H i r t , "Medical E t h i c s and the Misuse of P s y c h i a t r i c Hospit-a l s i n the USSR," unpublished b r i e f , Vancouver, B.C., 1970; P. Reddaway, ed., Uncensored Russia (New York: American Heritage Press, 1972). 40 Norman Cameron, "The Paranoid Pseudo-Community R e v i s i t e d , " p. 58. 41 Edwin Lemert, "Paranoia and the Dynamics of E x c l u s i o n , " Sociometry, 25 (1962):2-20. 98 42 I t i s perhaps important to e x p l a i n why I had not yet encountered Lemert's work. The explanation l i e s i n the f a c t that I was, at th a t point i n time, j u s t beginning to accumulate f u r t h e r knowledge of the l i t e r a t u r e on paranoia. Aside from my study o f Tomkins, Freud, and Cameron, I had u n t i l then focused my a t t e n t i o n only on ps y c h i a t r y and mental i l l n e s s i n general. 43 Edwin Lemert, "Paranoia and the Dynamics of E x c l u s i o n , " Mental Illness and Social Processes, i n .Mental:.'.Illness and Social Processes, ed. Thomas Scheff (New York: Harper and Row, 1967), p. 273. 44 ^ I b i d . , p. 273. 4 5 I b i d . , p. 274. 46 I t i s important to note t h a t I d i d not b e l i e v e t h a t the c r i t i q u e was i n a p p l i c a b l e to other types of disorders such as sc h i z o p h r e n i a . Rather, i t was my b e l i e f , having read Lemert and o t h e r s , that i t was po s s i b l e to i l l u s t r a t e the v a l i d i t y of the c r i t i q u e more c l e a r l y by focusing on paranoia, as t h i s d i s o r d e r , more so than o t h e r s , had an obvious s o c i a l b a s i s . 47 As I became more f a m i l i a r with the l i t e r a t u r e , i t became apparent to me that other authors who d e a l t with the d i s o r d e r t y p i c a l l y made reference to h i s work. 292. 48 Edwin Lemert, "Paranoia and the Dynamics of E x c l u s i o n , " pp. 291-49 4 y I b i d . , p. 293. 50 I i n c l u d e t h i s p o i n t , as i t may help to c l a r i f y the s t a t e of my t h i n k i n g at that time. Although I f e l t t hat my understanding of paranoia was b a s i c a l l y sound, as i t derived l o g i c a l l y from what I f e l t was a v a l i d understanding o f p s y c h i a t r y and mental i l l n e s s , I was, ne v e r t h e l e s s , somewhat unsure o f my views, as I had not done any research beyond my ongoing study of the l i t e r a t u r e , nor had I even met an i n d i v i d u a l who was diagnosed to be "paranoid." Thus, Lemert's research represented to me an important c o n t r i b u t i o n to my knowledge, as i t helped to i n s t i l l i n me more confidence i n my own views. 51 Edwin Lemert, "Paranoia and the Dynamics of E x c l u s i o n , " pp. 273-274. Lemert c i t e s the f o l l o w i n g studies i n support of h i s c l a i m : S. Pederson, "Psychological Reactions to Extreme S o c i a l Displacement (Refugee Neuroses)," Psychoanalytic Review, 36 (1946):344-354; F.F. Kine, " A l i e n s ' Paranoid Reaction," Journal of Mental Science, 98 (1951):589-594; and I. L i s t i v a n , "Paranoid S t a t e s : S o c i a l and C u l t u r a l Aspects," 99 Medical Journal of Australia, 1956, pp. 776-778. 52 Edwin Lemert, "Paranoia and the Dynamics of E x c l u s i o n , " p. 287. 5 3 I b i d . , p. 276. 54 0 4 I b i d . , p. 273. 5 5 I b i d . , p. 275. 5 6 I b i d . , p. 275. ^ M o r t o n Schatzman, Soul Murder (London: Penguin Press, 1973), pp. 130-131. 5 8 I b i d . , p. 131. 59 I held t h i s b e l i e f about p s y c h i a t r i s t s despite my c r i t i c a l a n a l -y s i s of the t h e o r i e s t h a t I b e l i e v e d they r e l i e d upon, and the p r a c t i c e t h a t I f e l t emanated from the t h e o r i e s . Although I f e l t t h a t they ignored the s o c i a l component i n t h e i r t h e o r i e s , and, t h e r e f o r e , i n t h e i r work, I d i d not take t h e i r p r a c t i c e to be f r a u d u l e n t . Rather, I saw i t to be m i s d i r e c t e d . Thus, I f e l t t h a t p s y c h i a t r i s t s had f a r more exper-t i s e than I wi t h respect to paranoia and mental i l l n e s s , p a r t i c u l a r l y as I had not, at t h a t p o i n t , as p r e v i o u s l y mentioned, even done any actual research i n a p s y c h i a t r i c s e t t i n g , or met a person diagnosed to be "paranoid." To uncover evidence which supported my counterview was, t h e r e f o r e , s i g n i f i c a n t to me, not i n the sense t h a t i t showed i n t r a -p s y c h i c a l l y based p s y c h i a t r i c p r a c t i c e to be a f r a u d , but rather i n the sense that i t gave c r e d i b i l i t y to my a l t e r n a t e conception of the d i s -order. Such a conception would d i r e c t a t h e r a p i s t , I b e l i e v e d , toward l i b e r a t i n g , r a t h e r than a d j u s t i n g , t h e i r "paranoid" p a t i e n t s . 60 Morton Schatzman, Soul Murder, p. 136. 6 1 Ib id . , p. x. Sigmund Freud, "Psycho-Analytic Notes upon an Autobiographical Account of a Case of Paranoia (Dementia Paranoides)(1911)." 63 Morton Schatzman, Soul Murder, p. 115. 64 By t h i s , I mean th a t Schatzman o f f e r e d a c r i t i q u e of Freud t h a t not only argued t h a t persecution c o u l d , i n f a c t , induce paranoia, as Tomkins d i d ( i t i s i n t e r e s t i n g to note, f o r example, t h a t Schatzman, 100 l i k e Tomkins, al s o reasons t h a t the l i n k , i d e n t i f i e d by Freud, between homosexuality and paranoia need not be seen i n i n t r a p s y c h i c terms. He argues t h a t : "Given the way a c t i v e and suspected homosexuals have been and are persecuted, i t i s no s u r p r i s e that ' l a t e n t ' homosexuals f e a r persecution" [Morton Schatzman, Soul Murder, p. 124]), but a l s o was able to show th a t Freud's study had a c t u a l l y ignored t h i s p o s s i b i l i t y , t h a t persecution causes paranoia, when i t presented i t s e l f i n the case upon which he formulated h i s theory. 65 Morton Schatzman, Soul Murder, p. 132. 66 I r e f e r here to my e a r l i e r d i s c u s s i o n of s o c i a l meanings and the symbolic r e c o n s t r u c t i o n of r e a l i t y . 67 Morton Schatzman, Soul Murder, p. 138. 6 8 I b i d . , p. 130. I b i d . , p. 157. 101 CHAPTER 3 FIELDWORK BEGINS: THE RESEARCHER ENTERS THE RESEARCH SETTING The Format of the "Story": Use of the Narrative Style Having discussed my constructs or preconceptions which I formu-l a t e d from the l i t e r a t u r e p r i o r to e n t e r i n g the research s e t t i n g , i t i s now time to set out what I a c t u a l l y experienced w h i l e i n the s e t t i n g . This material c o n s t i t u t e s the fieldwo r k data of the t h e s i s , and i s presented i n order to document what I found, or any other c u l t u r a l l y competent member (with the exception of t h e r a p i s t s ) who had also s t u d i e d the l i t e r a t u r e on paranoia would have found; i . e . , that there e x i s t e d a s i g n i f i c a n t "gap" between a "map" derived from the l i t e r a t u r e , and what one a c t u a l l y observed w h i l e i n the research s e t t i n g . Thus, my data w i l l show t h a t my constructs that c o n s t i t u t e d my "map" d i d not f i t with my fieldwork experiences and observations. P r i o r to s e t t i n g out these data, i t would, I b e l i e v e , be useful to o f f e r an explanation and j u s t i f i c a t i o n of the format which I have adopted i n order to present my data. Thus, I s h a l l b r i e f l y o u t l i n e t h i s format. I have chosen to discuss the format of t h i s part of the t h e s i s , as I f e e l t h a t i t i s h e l p f u l f o r the reader to have an i n s i g h t i n t o not only how my ideas w i t h respect to paranoia were developed and u l t i m a t e l y were transformed as a consequence of my fieldwor k experience, but al s o i n t o the process through which I developed a s u i t a b l e s t r u c t u r e f o r demonstrating t h i s transformation of my t h i n k i n g . Thus, I f e e l t h a t , as 102 t h i s i s an et h n o g r a p h i c a l l y based t h e s i s , i t i s incumbent upon me to describe f o r the reader how I decided to handle my data. When I began to t h ink about how to present my data, I f e l t unsure of how to proceed, and I decided, t h e r e f o r e , to review the formats of other ethnographies i n order to a s c e r t a i n what would c o n s t i t u t e a s u i t a b l e s t r u c t u r e f o r presenting my data. I discovered that many authors handled t h e i r data i n what might be termed a t r a d i t i o n a l format. T y p i c a l l y , t h i s i n v o l v e s s t r u c t u r i n g the ethnography i n terms of chapters that represent sequential elements of the c e n t r a l argument of the work, and data t h a t support or document the theme o f each chapter i s then taken from the ethnographer's "pool" of data and i n s e r t e d i n the appropriate parts of the r e s p e c t i v e chapters. I considered adopting t h i s approach, and attempted to formulate appro-p r i a t e chapter themes that might lend themselves to i l l u s t r a t i n g my argument. I contemplated s e l e c t i n g , from my a n a l y s i s e a r l i e r i n the t h e s i s , my major c o n s t r u c t s , i n order to use them as the cores of s p e c i f i c chapters. I considered, f o r example, adopting a construct such as the i n v a l i d a t i o n of a "paranoid's" d e f i n i t i o n of r e a l i t y as the basis of a theme f o r a chapter. My i n t e n t was to juxtapose such a construct with data derived from my fieldwo r k i n order to i l l u s t r a t e the "gap" discussed e a r l i e r . I d i d not, however, adopt t h i s approach. Instead, I adopted what may be termed a more "organic" approach. By t h i s , I mean th a t I r e j e c t e d what may be c h a r a c t e r i z e d as an a r t i f i -c i a l order f o r presenting my data. Rather than c o n s t r u c t i n g chapters d i c t a t e d by the need to convey to the reader the v a l i d i t y of my argument, and then i n s e r t i n g data to uphold t h i s s t r u c t u r e , I opted to simply t e l l , 103 i n a ch r o n o l o g i c a l form, the s t o r y of my fieldwork experiences. Thus, the s t r u c t u r e of t h i s part of the t h e s i s resembles the previous s e c t i o n , as i t too i s organized i n terms of a chronology of my research i n t o paranoia. In t h i s case, however, I w i l l be o u t l i n i n g my observations derived from experiences i n the research s e t t i n g , r a t h e r than presenting my i n s i g h t s i n t o paranoia deduced from the l i t e r a t u r e . I s h a l l , t h e r e f o r e , t r a c e from my data what I encountered i n the research s e t t i n g , i n the time sequence i n which I a c t u a l l y encountered i t J I want to emphasize t h a t the " s t o r y " of my experiences i s , i n f a c t , a l s o the argument o f the t h e s i s , as the " s t o r y " d e t a i l s my experiences over the duration of my f i e l d w o r k , and, t h e r e f o r e , has inherent w i t h i n i t a record of the subsequent changes i n my understanding o f paranoia, t h a t emerged as I became aware o f a "gap" between my "map" and what I was a c t u a l l y encountering i n the s e t t i n g . Thus, I b e l i e v e that the record of my experiences t h a t I s h a l l present not only v a l i d a t e s the argument that I am making, but al s o i s i n a sense the argument i t s e l f , as the reader of the " s t o r y " i s , I b e l i e v e , confronted by the argument of the t h e s i s , simply as a consequence o f reading the " s t o r y . " Thus, I am a s s e r t i n g t h a t i t i s n e i t h e r necessary nor h e l p f u l f o r me to organize the presentation of my data according to a more t r a d i -t i o n a l s t r u c t u r e . My_ approach allows f o r a more accurate p o r t r a y a l of one's fieldw o r k experiences, as the data t h a t document these experiences do not have to be s l i c e d up and taken out of context i n order to s a t i s f y the demands of a t r a d i t i o n a l l y - s t r u c t u r e d p r e s e n t a t i o n . I s h a l l , i n s t e a d , simply s et out my experiences and observations c h r o n o l o g i c a l l y , h i g h l i g h t i n g those parts of my " s t o r y " that best i l l u s t r a t e the argument 104 i m p l i c i t w i t h i n i t . First Impressions The " s t o r y " of my experiences i n the research s e t t i n g begins e a r l y i n the new year of 1975. Having received t e n t a t i v e approval to proceed from the Head o f the p s y c h i a t r i c h o s p i t a l i n which I was to conduct my f i e l d w o r k , I contacted the p s y c h i a t r i s t who had been appointed to f a c i l i t a t e my entry i n t o the h o s p i t a l . We arranged t h a t I should drop o f f an o u t l i n e o f my research plans f o r him at the h o s p i t a l , which gave 3 me my f i r s t opportunity to enter the f a c i l i t y . I was e x c i t e d i n the way t h a t a n t h r o p o l o g i s t s must be e x c i t e d at the prospect of beginning t h e i r f i e l d w o r k i n a f o r e i g n c u l t u r e . Like the a n t h r o p o l o g i s t , I too was thoroughly prepared f o r my e n t r y , having e x t e n s i v e l y s t u d i e d the l i t e r a t u r e on "my f o r e i g n c u l t u r e , " as discussed i n the previous s e c t i o n of the t h e s i s . However, i n a d d i t i o n to my "map," derived from the l i t e r a t u r e , I was al s o armed with other preconceptions with respect to the h o s p i t a l , as i t was an i n s t i t u t i o n that e x i s t e d w i t h i n my own com-munity. Thus, u n l i k e the a n t h r o p o l o g i s t , I had already been exposed to various s t o r i e s , remarks, and references with respect to t h i s " c u l t u r e " ( f a c i l i t y ) , simply as a consequence of l i v i n g w i t h i n the same domain. The opportunity to enter the h o s p i t a l was a type of experience that Peter Berger has a p t l y described t h i s way: A person who l i v e s i n such a c i t y w i l l time and again experience s u r p r i s e or even shock as he discovers the strange p u r s u i t s t h a t some men engage i n q u i t e unobtrusively i n houses t h a t , from the o u t s i d e , look l i k e a l l the others on a c e r t a i n s t r e e t . Having had t h i s experience once or t w i c e , one w i l l repeatedly f i n d oneself walking down a s t r e e t , perhaps l a t e i n the evening, and wondering what may be going on under the b r i g h t l i g h t s showing through a l i n e of drawn c u r t a i n s . An ordinary 105 family engaged i n pleasant t a l k with guests? A scene of desper-a t i o n amid i l l n e s s or death? Or a scene of debauched pleasures? Perhaps a strange c u l t or a dangerous conspiracy? The facades of the houses cannot t e l l us, proclaiming nothing but an a r c h i -t e c t u r a l conformity to the tas t e s of some group or c l a s s t h a t may not even i n h a b i t the s t r e e t any longer. The s o c i a l mysteries l i e behind the facades. The wish to penetrate to these mysteries i s an analogon to s o c i o l o g i c a l c u r i o s i t y . In some c i t i e s that are suddenly struck by calamity t h i s wish may be abruptly r e a l -i z e d . Those who have experienced wartime bombings know of the sudden encounters with unsuspected (and sometimes unimaginable) f e l l o w tenants i n the a i r - r a i d s h e l t e r of one's apartment b u i l d -i n g . Or they can r e c o l l e c t the s t a r t l i n g morning s i g h t of a house h i t by a bomb during the n i g h t , n e a t l y s l i c e d i n h a l f , the facade torn away and the p r e v i o u s l y hidden i n t e r i o r m e r c i l e s s l y revealed i n the d a y l i g h t . But i n most c i t i e s t h a t one may normally l i v e i n , the facades must be penetrated by one's own i n q u i s i t i v e i n t r u s i o n s . S i m i l a r l y , there are h i s t o r i c a l s i t u a -t i o n s i n which the facades of s o c i e t y are v i o l e n t l y torn apart and a l l but the most i n c u r i o u s are forced to see that there was a r e a l i t y behind the facades a l l along. Usually t h i s does not happen and the facades continue to confront us with seemingly r o c k - l i k e permanence.4 To me, the h o s p i t a l had, f o r many y e a r s , been such a facade. Now, f o r the f i r s t time, I would be able to a c t u a l l y witness what went on w i t h i n This f a c i l i t y , as mentioned e a r l i e r , had been dubbed the "Psych i -a t r i c H i l t o n " ; a t i t l e which seemed appropriate to me upon en t e r i n g the b u i l d i n g . My f i r s t r e a c t i o n to the h o s p i t a l was a f e e l i n g of being i n a hotel r a t h e r than a medical s e t t i n g . As noted e a r l i e r , the f l o o r s were w e l l carpeted, the f u r n i t u r e was f a s h i o n a b l e , the w a l l s were panelled i n wood, the l i g h t i n g was subdued, and background music was p l a y i n g . I crossed the lobby o f the b u i l d i n g and addressed a woman seated at a reception desk. Again, I had no sense of being i n a medical f a c i l i t y . The woman was not wearing a medical uniform, and the s t a t i o n t h a t she manned could have been mistaken f o r the f r o n t desk of a s t y l i s h h o t e l . I i n q u i r e d as to the l o c a t i o n of the ward where I was to drop o f f my 106 o u t l i n e , and was d i r e c t e d to what the woman termed the "nursing s t a t i o n " o f the ward to which the p s y c h i a t r i s t was attached. As I made my way to the ward, down what could have been taken as the hallway of a modern h o t e l , I thought o f the overt c o n t r a s t between my surroundings and those of two other p s y c h i a t r i c f a c i l i t i e s t hat I had had an occasion to v i s i t . I was curious to discover i f the lobby and f r o n t desk were only e x t e r i o r t r a p p i n g s , and i f the wards, which I took to be the work s e t t i n g s of the h o s p i t a l , would be more u t i l i t a r i a n and medical i n appearance. I was surrounded by background music as I made my way to a h o t e l - l i k e recep-t i o n area that I recognized, knowing: that I was i n a h o s p i t a l , to be a nurs i n g s t a t i o n . None of the s t a f f i n the s t a t i o n wore uniforms, and I had no way of knowing which of them were medical personnel. The woman i t h a t I addressed might have been a s e c r e t a r y , or could have been a nurse.' I explained who I was, and gave her my o u t l i n e . In response, she s t a t e d that she knew me w e l l from previous phone c a l l s ; a remark which I was not sure how to i n t e r p r e t , as I was s e n s i t i v e to making a favourable i n i t i a i r impression i n the s e t t i n g . I wondered to what extent I had already e s t a b l i s h e d my presence i n the s e t t i n g , p r i o r to even e n t e r i n g g i t . My task completed, I l e f t the h o s p i t a l , r e f l e c t i n g on whether the h o s p i t a l would continue to f e e l l i k e a non-medical f a c i l i t y once I became more immersed i n i t . Two days a f t e r my f i r s t v i s i t , I returned to the h o s p i t a l to consult w i t h the p s y c h i a t r i s t who had been appointed to a s s i s t me. We met i n hi s o f f i c e , and a f t e r b r i e f i n t r o d u c t i o n s , we began to discuss my plans f o r doing research i n the h o s p i t a l . He s t a t e d that a f t e r reading my o u t l i n e , he s t i l l was not sure what I wanted to do, and how I would 107 do i t . His lack of understanding was, I f e l t , a f u n c t i o n of the nature of my research design; a problem that I encountered a number of times w h i l e doing my f i e l d w o r k . I discovered that the l i m i t e d knowledge t h a t most medical personnel had of s o c i a l research methods was r e s t r i c t e d mainly to an epidemiological-survey research o r i e n t a t i o n . They had l i t t l e understanding o f , and sympathy f o r , what they saw to be my " u n s c i e n t i f i c " methodology. To them, a l l research required a t i g h t l y s t r u c t u r e d research design, based upon instruments such as r a t i n g and a t t i t u d e s c a l e s , q u e s t i o n n a i r e s , i n t e r v i e w schedules, e t c . , which would, i n t h e i r view, allow the researcher the p o s s i b i l i t y of gathering "hard data," i n order to prove the v a l i d i t y of his hypothesis. As I was to discover on a number of occasions, my ethnographic approach simply d i d not f i t with t h e i r q u a n t i t a t i v e o r i e n t a t i o n toward research. To them, my research plans were unstructured and unformulated, and t h e r e f o r e d i d not f a l l w i t h i n the domain of the s c i e n t i f i c method. This p s y c h i a t r i s t , and others t h a t I met, had the impression, I b e l i e v e , t h a t my proposed ethnographic approach was l i t t l e more than a cover f o r my f a i l u r e to adequately define a " s c i e n t i f i c " research design f o r myself. As soon as I became aware of the p s y c h i a t r i s t ' s a t t i t u d e toward my research plans, I s h i f t e d the conversation i n t o a d i s c u s s i o n of the s p e c i f i c d e t a i l s of the proposals t h a t I had to submit to the Research Committee of the h o s p i t a l and the E t h i c s Committee of the Faculty of Medicine of my u n i v e r s i t y . Here, he seemed to f e e l more at ease, and his c r i t i c a l comments gave way to a h e l p f u l , and, to me, most i n t e r e s t -ing d i s c u s s i o n on how I should proceed. Our d i s c u s s i o n was of i n t e r e s t to me not only because the p s y c h i a t r i s t conveyed to me information that 108 might help to expedite the o f f i c i a l approval f o r my research, but a l s o because our meeting was al r e a d y , I r e a l i z e d , the s t a r t of my f i e l d w o r k . By t h i s , I mean th a t t h i s encounter was not only useful i n order to f a c i l i t a t e my f uture research, but a l s o was, i n f a c t , i n a d d i t i o n to my f i r s t v i s i t to the h o s p i t a l , an a c t u a l f i e l d w o r k experience, t h a t c o n s t i t u t e d part of my d a t a . 7 I came to t h i s r e a l i z a t i o n s h o r t l y a f t e r we began our a n a l y s i s of how to w r i t e up the E t h i c s Committee proposal. The p s y c h i a t r i s t s t a t e d t h a t we were inv o l v e d i n a b u r e a u c r a t i c game; the r u l e s of which demanded the production of a document which promised that my research procedures would be e t h i c a l , and would uphold p a t i e n t s ' r i g h t s . He noted that i t was an important e t h i c a l c o n s i d e r a t i o n t h a t I respect patients', p r i v a c y , that I obtain t h e i r voluntary agreement to observe them, e t c . , but i t was h i s view that these procedures were, as he put i t , somewhat unreal-i s t i c . I sensed him to be s k e p t i c a l about the demand th a t I work out elaborate statements of my commitment to e t h i c a l research procedures. He pointed out t h a t there was a gap between the e t h i c a l considerations to which I had to pledge myself, and some of the p r a c t i c e s that were pursued i n the h o s p i t a l . His commentary was of s i g n i f i c a n c e to me. I f e l t t hat his comments represented v i t a l i nformation about the " r e a l " workings of the h o s p i t a l . The a h t i - p s y c h i a t r y l i t e r a t u r e came to mind, and I could not help but l i n k the s o c i a l c o n t r o l theme of the l i t e r a t u r e to what I had j u s t found out. I was, i n the course of my f i e l d w o r k , to encounter, at times, a gap between o f f i c i a l p o l i c i e s w i t h respect to e t h i c a l procedures, and 109 the actual p r a c t i c e s t h a t I observed. The p s y c h i a t r i s t ' s comments proved to be c o r r e c t . As I o u t l i n e my " s t o r y , " I w i l l describe these events, as they were part of my f i e l d w o r k experiences. I t i s not my i n t e n t , however, to develop an a n a l y s i s of t h i s "gap," not only because t h i s t h e s i s i s not meant, as p r e v i o u s l y pointed out, to stand as a c r i t i q u e of the p r a c t i c e s pursued i n the h o s p i t a l , but a l s o , more im p o r t a n t l y , because i t i s my i n t e n t to present the reader w i t h an account of another "gap" that I , as has been p r e v i o u s l y discussed, came . to recognize. A f t e r some f u r t h e r d i s c u s s i o n re the content of my proposals, the p s y c h i a t r i s t and I worked out a f i n a l d r a f t of the material t h a t he f e l t should be i n c l u d e d . He suggested t h a t I should i n s e r t an o u t l i n e of the steps that I would take to ensure t h a t my research would not only avoid i n f r i n g i n g on the r i g h t s of p a t i e n t s , but a l s o would not i n t e r f e r e with the normal f u n c t i o n i n g of the h o s p i t a l ; a point that the Research Commit-tee of the h o s p i t a l subsequently made an e f f o r t to impress upon me. I began to wonder i f the many r u l e s to which I pledged myself would adversely a f f e c t my freedom to pursue my research, but these doubts d i d not, at t h a t time, dominate my thoughts. I t was not u n t i l a f t e r I had met w i t h the h o s p i t a l Research Committee that I came to f e e l pressured by these commitments. Having d r a f t e d an o u t l i n e of the proposals, our d i s c u s s i o n then turned to how I should approach and deal w i t h the "paranoid" p a t i e n t s that I planned to i n t e r v i e w . I had my own i d e a s , derived from the l i t e r a t u r e , but had not as yet d i s c u s s e d , with the p s y c h i a t r i s t , how I should u t i l i z e them, i n my encounteres with "paranoids." His a d v i c e , n o to my s u r p r i s e , seemed very pragmatic and commonsensical. He s t a t e d that I should a l s o t r e a t t h i s a c t i v i t y as a "game." I expected him to give me a t h e o r e t i c a l l y - b a s e d account of how to i n t e r a c t , which would l i n k up to the constructs of my "map." Instead, he o f f e r e d a s t r a i g h t -forward e x p l a n a t i o n , t h a t seemed to me to be one that a l a y person might al s o o f f e r i n response to the question: how should one i n t e r a c t w i t h persons who have i n c a p a c i t a t i n g or i r r a t i o n a l fears? His explanation d i d not, i n other words, sound p a r t i c u l a r l y p s y c h i a t r i c , and, t h e r e f o r e , d i d not resemble the accounts t h a t I had read i n the l i t e r a t u r e . The essence of the "game," he s t a t e d , was to be honest with the "paranoid," y e t , at the same time, not to be completely open with them. One must play t h i s "game" c o r r e c t l y , he advised, i n order to avoid becoming a conspirator:- i n the eyes of the "paranoid." He noted, f o r example, t h a t I should never c o n t r a d i c t a "paranoid's" a s s e r t i o n , y e t at the same time I should a l s o avoid agreeing with him. He s t r e s s e d that I must be s u b t l e i n my approach, and i n order to i l l u s t r a t e h i s advice, he acted out a dialogue between a "paranoid" and a person attempting to obtain h i s permission to study him. During the course of h i s d r a m a t i z a t i o n , I began to laugh, as I envisioned myself c a r r y i n g on such a dialogue with a "paranoid" p a t i e n t . I found the c o n t r i v e d q u a l i t y of the dialogue to be humorous. He agreed, but st r e s s e d that i t was necessary f o r me to f o l l o w such a format, i f I hoped to obt a i n a "paranoid's" consent. Upon r e f l e c t i o n , I continued to be puzzled by the common sense q u a l i t y of hi s advice. The "game" that he o u t l i n e d , I thought, d i d not d i f f e r from one an i n d i v i d u a l might opt to play i n order to a s s i s t a in f r i e n d who froze w h i l e climbing on a rocky or i c y face. This analogy came to mind, as I had, i n the past, t a l k e d people out of an immobilized s t a t e , and had persuaded them to descend or ascend from t h e i r perch. The " t a l k " that I had used was not derived from the study of p s y c h i a t r i c theory, y e t was, I r e a l i z e d , not d i f f e r e n t i n q u a l i t y from the " t a l k " t h a t the p s y c h i a t r i s t advocate'd one use i n encounters with "paranoids." Why, I wondered, d i d his advice not f i t with my "map?" Why d i d i t , u n l i k e the material from the l i t e r a t u r e , have a mundane, common sense q u a l i t y ? I d i d not spend a great deal of time m u l l i n g over these q u e s t i o n s , as I a r r i v e d s h o r t l y with an answer to my puzzle. I decided that the p s y c h i a t r i s t had purposely transformed p s y c h i a t r i c theory i n t o common sense l a y concepts i n order to f a c i l i t a t e my grasp of the c o r r e c t way to i n t e r a c t . This transformation was, I b e l i e v e d , necessary, because I had no p s y c h i a t r i c t r a i n i n g . I f e l t sure that i f I had been a psychia-t r i s t , our d i s c u s s i o n with respect to how to approach and handle "paranoids" would have sounded much l i k e the t h e o r e t i c a l material i n the l i t e r a t u r e , as no tra n s f o r m a t i o n , f o r l a y purposes, would have been necessary. At t h a t point i n my f i e l d w o r k , I was unaware that s i m i l a r puzzles would continue to re c u r , and would become a recognizable "gap" that would u l t i m a t e l y c o n s t i t u t e the focus o f my t h e s i s . Becoming Oriented to the Setting My second v i s i t to the h o s p i t a l ended with a tour of the psychia-t r i s t ' s ward. Before we l e f t h i s o f f i c e to take the t o u r , we discussed how I should dress while i n the h o s p i t a l . I had r a i s e d the question 1 1 2 because I was anxious to blend i n t o the environment, as I f e l t t h a t a Q "low p r o f i l e " would f a c i l i t a t e the c a r r y i n g out of my research. The p s y c h i a t r i s t , who was wearing a t i e , dress s h i r t , sweater, and s l a c k s , responded to my question t h i s way: "Dress l i k e a doctor; l i k e me. That way, you w i l l seem l e s s l i k e an o u t s i d e r . " I subsequently made a con-scious e f f o r t to "look l i k e a doctor" whenever I was i n the research s e t t i n g . In a d d i t i o n to dressing l i k e the p s y c h i a t r i s t , I a l s o cut my h a i r s h o r t e r , and c a r r i e d a b r i e f c a s e i n s t e a d of a shoulder pack. Our tour of h i s ward again l e f t an impression t h a t the h o s p i t a l aimed to create a modern, pleasant atmosphere. I once more had the f e e l i n g of being i n a non-medical s e t t i n g . While background music played, I was introduced to nurses who were c a l l e d "team leaders , " and was given an explanation of the s t r u c t u r e of the wards, which were c a l l e d " t h e r a p e u t i c communities." Despite the absence of uniforms and other obvious signs of a medical s e t t i n g , I was able to i d e n t i f y some of the p a t i e n t s . They stood out from the s t a f f , as they, i n many cases, appeared dazed (a consequence of m e d i c a t i o n s ) , and tended to dress d i f f e r e n t l y than the s t a f f , who seemed,to me, to have the appearance of s o c i a l workers. By now, I was aware that the h o s p i t a l attempted, by design, to create an amicable atmosphere on i t s wards. Although I could not iden-t i f y the reasons, I n o t i c e d , by c o n t r a s t , that the p s y c h i a t r i s t had become tense when we a r r i v e d on the ward, and the nurses to whom I had been introduced, were not p a r t i c u l a r l y f r i e n d l y towards me.^  I subse-quently discovered t h a t there e x i s t e d a controversy w i t h i n the i n s t i t u -t i o n w i t h respect to i t s "progressive" o r i e n t a t i o n , which may have 113 accounted f o r the s t r a i n e d atmosphere that I sensed then, and at other times, on the wards. I d i d not enter the research s e t t i n g again f o r a month, as I was involved i n o f f i c i a l l y n e g o t i a t i n g permission to conduct my research. I have already discussed the nature of these proceedings. I am d e a l i n g w i t h them once more, i n order to b r i n g out a d i f f e r e n t aspect from my data. My e a r l i e r d i s c u s s i o n focused on the procedures i n v o l v e d i n o b t a i n i n g consent to conduct my research. I wish, at t h i s point,, to set out the advice t h a t was given to me i n the course of the proceedings, and to describe the i n f l u e n c e of these events upon me. The experiences of n e g o t i a t i n g approval to proceed with my research had a negative emotional impact. Despite my new-found aware-ness of my involvement i n a b u r e a u c r a t i c game, and the coaching t h a t I had r e c e i v e d , I was unprepared f o r the events t h a t took place. I f e l t insecure to begin w i t h , as I wished to obtain approval to enter an i n s t i t u t i o n t h a t , by i t s nature, d i d not welcome i n t r u s i o n s of "out-s i d e r s . " Furthermore, I had to deal w i t h p s y c h i a t r i s t s whom, I assumed, by v i r t u e of t h e i r t r a i n i n g , would be more prone to subject me to a probing study of my plans, motives, e t c . The events that t r a n s p i r e d confirmed my f e a r s , and had a l a s t i n g impact upon my outlook throughout the course of my f i e l d w o r k . Contrary to my e x p e c t a t i o n s , however, I was not subjected to a s c r u t i n y by the c l i n i c a l s u pervisors of the h o s p i t a l . I t was, r a t h e r , the a d m i n i s t r a t o r s of the i n s t i t u t i o n who challenged my i n i t i a l request to conduct my research, and who subsequently demanded extensive r e g u l a t i o n of my . . . 9 a c t i v i t i e s . 114 I had begun my research e x c i t e d at the prospect of doing f i e l d w o r k , and f i n d i n g out what the paranoid d i s o r d e r and psychotherapy were r e a l l y a l l about. I f e l t t h a t I had an e x c e l l e n t opportunity to use my i n t e l -l e c t u a l s k i l l s to f u r t h e r the understanding of a t o p i c of long-standing i n t e r e s t to me. I had not, however, a n t i c i p a t e d the s t r e s s i nvolved i n the fie l d w o r k experience. The f o l l o w i n g i s an example of the type of i n t e r a c t i o n that damp-ened my excitement, and created tension w i t h i n me. At a c r u c i a l stage of the n e g o t i a t i o n s to obtain my entry to the h o s p i t a l , the p s y c h i a t r i s t who had been assigned to a s s i s t me suddenly refused to w r i t e a l e t t e r of support to one of the committees to whom I had to present my proposals. C i t i n g the absence of the head of the h o s p i t a l as grounds f o r his stand, he s t a t e d : This i s out of my hands. I t ' s not my r e s p o n s i b i l i t y . I helped you to prepare the proposals, but that's the l i m i t of my involvement. I can't do more. This l e f t me i n a precarious p o s i t i o n , as t h i s i n d i v i d u a l was, at t h a t p o i n t , my primary contact i n the h o s p i t a l . I was forced to turn to one of the h o s p i t a l a d m i n i s t r a t o r s f o r support. He r e j e c t e d my request, however, and furthermore admonished me f o r what he saw to be my attempt to circumvent o f f i c i a l h o s p i t a l procedures. I was perturbed as I had been proceeding i n good f a i t h according to my best judgement. Suddenly, I had been denied a s s i s t a n c e , and my methods has been c h a r a c t e r i z e d as 10 improper. The r e g u l a t i o n s t h a t had been imposed upon my work, together with the type of experience discussed above, i n h i b i t e d me. Throughout the course of my f i e l d w o r k , I f e l t compelled to r i g i d l y observe the o f f i c i a l 115 protocol which, at times, prevented me from pursuing my research objec-t i v e s , and denied me the enjoyment inherent i n doing f i e l d w o r k . The f o l l o w i n g i n c i d e n t may i l l u s t r a t e my po i n t . The f i r s t time t h a t I went to the Medical Records O f f i c e of the h o s p i t a l to look at the c l i n i c a l records of a "paranoid" p a t i e n t t h a t I was observing i n therapy, the medical l i b r a r i a n gave me a long l e c t u r e on the n e c e s s i t y of adhering to the re g u l a t i o n s l a i d down by the Research Committee of the h o s p i t a l . The l e c t u r e was then followed by a s t e r n warning t h a t was put to me t h i s way: I w i l l be checking to see that the consent forms are a l l i n order. Don't underestimate the importance o f t h i s ! I know tha t some of the res i d e n t s are sloppy when i t comes to the c h a r t s , e s p e c i a l l y Dr [doctor's name]. That w i l l be no excuse. I expect them a l l to be complete. The l i b r a r i a n ' s remarks were threatening to me, i n part because they came across as an acc u s a t i o n , but al s o because the r e s i d e n t t h a t she r e f e r r e d to happened to be the t h e r a p i s t of the p a t i e n t whose chart I had requested. Despite my e f f o r t s , t h i s r e s i d e n t had not followed the proper consent procedures f o r t a p i n g , c l a i m i n g that the p a t i e n t s a l l signed a general consent form when they entered the h o s p i t a l . The l i b r a r i a n placed the r e s p o n s i b i l i t y f o r the charts upon me, y e t I had been unable to convince the r e s i d e n t and other t h e r a p i s t s to f o l l o w the procedures c o r r e c t l y . This r a i s e d anxiety i n me, as I a n t i c i p a t e d the l i b r a r i a n d i scover-ing the incomplete c h a r t s , and r e p o r t i n g me to the Research Committee. I had v i s i o n s of being cast . i n the r o l e o f a l i a r ; being seen as one who makes commitments that he chooses not to keep. My u l t i m a t e f e a r was t h a t I might be denied the r i g h t to continue my research. I h a s t i l y 116 phoned the r e s i d e n t at hi s home, and requested t h a t he complete the chart as soon as p o s s i b l e . He responded t h i s way: Don't worry! She i s nothing to worry about. Her bark i s bigger than her b i t e . This experience, and others l i k e i t , l e f t me f e e l i n g i n s e c u r e , which tended to make me l e s s aggressive i n my p u r s u i t of research m a t e r i a l , as I was ov e r l y conscious of the re g u l a t i o n s to which I had pledged myself. I t brought back the f e e l i n g s t h a t I had experienced when I was seen, by the a d m i n i s t r a t o r , to be attempting to circumvent i n s t i t u t i o n a l procedures. Again, I had been proceeding i n a l l honesty according to the best of my a b i l i t y , y e t circumstances l e f t me i n the p o s i t i o n of being portrayed as underhanded. I s h a l l now deal with the f i n a l step i n my month-long ne g o t i a t i o n s f o r entry to the h o s p i t a l ; my meeting with the Research Committee, and I s h a l l focus on the remarks of the c l i n i c a l supervisors at the meeting. I w i l l mainly discuss t h e i r p a r t i c i p a t i o n , as they i n v o l v e d themselves with the substantive elements of my proposal i n con t r a s t to the concerns of the a d m i n i s t r a t o r s , which have already been o u t l i n e d . At the beginning of the meeting, I was asked "to take the hot seat"; a most appropriate term, which I was f a m i l i a r with from G e s t a l t therapy. In my case, however, I was deal i n g w i t h my i n t e l l e c t u a l r a t h e r than my emotional concerns, and with a group made up of a number, rather than one, t h e r a p i s t . I was tense, as I r e a l i z e d t h a t I would have to e x p l a i n and j u s t i f y my t h e o r e t i c a l l y based approach to paranoia to a body of p r a c t i t i o n e r s , w e l l - v e r s e d not only i n the th e o r i e s of the d i s -order. At t h a t p o i n t , I f e l t l e s s confident of my views. Who am I , I wondered, to a s s e r t a c r i t i q u e of p s y c h i a t r y to a group of p s y c h i a t r i s t s , 117 r e l y i n g upon nothing more than my t h e o r e t i c a l understanding? I was asked how I a r r i v e d at my t o p i c , and then asked by two of the c l i n i c a l supervisors about my t h e o r e t i c a l perspective on paranoia. I responded with my s o c i a l c o n t r o l a n a l y s i s of the d i s o r d e r , c i t i n g the work o f Lemert, Schatzman, and o t h e r s , which prompted the f o l l o w i n g question from the c l i n i c a l s u p e r v i s o r s : "What do you think goes on i n a therapy session with a paranoid p a t i e n t ? " Again, I r a i s e d the theme of s o c i a l c o n t r o l , n o t i n g , as an example, Cameron's work on the recon-s t r u c t i o n of r e a l i t y . They, i n t u r n , responded t h i s way: No, you have misconstrued what goes on. You seem to f e e l that t h e r a p i s t s t r y to t a l k paranoids out of t h e i r ideas. You w i l l f i n d out t h i s i s n ' t done. I t would threaten the paranoids' b a l a n c e - - t h e i r inner dynamic. The i r answer made me question my understanding of what t r a n s p i r e d i n therapy. I d i d not, however, r e j e c t my own p e r s p e c t i v e , as I was, upon r e f l e c t i o n , able to account f o r t h e i r response. S e n s i t i v e to the a n t i - p s y c h i a t r y p e r s p e c t i v e , they were attempting to defend p s y c h i a t r y from the s o c i a l c o n t r o l c r i t i q u e by focusing t h e i r remarks on the task at hand i n any one therapy s e s s i o n . One might not attempt to i n v a l i d a t e a "paranoid's: views i n the course of any p a r t i c u l a r s e s s i o n , but over the course o f the therapy, t h i s would be the g o a l ; a goal which they had not acknowledged. My views remained unchanged. I assumed that my perspective would be confirmed by my observation of therapy s e s s i o n s . One o f the adm i n i s t r a t o r s then asked i f I would be prepared to accept a member of the Department of Ps y c h i a t r y on my Graduate Committee. Before I answered, another a d m i n i s t r a t o r added t h a t he f e l t t h i s member should have a vote. I responded t h a t i t was a l l r i g h t , as long as they 118 recognized t h a t the s o c i o l o g i c a l perspective of the other members of my committee might d i f f e r from t h e i r p s y c h i a t r i c p e r s p e c t i v e . I was asked f o r an example of what I meant, and I , i n t u r n , c i t e d the d i f f e r e n c e s between a l a b e l l i n g theory and an i n t r a - p s y c h i c explanation of mental i l l n e s s . This prompted a strong response from one of the a d m i n i s t r a t o r s : You are mistaken! No one i n t h i s room i s a Freudian. You are unaware of our o r i e n t a t i o n . I explained t h a t I had not meant to imply a s t r i c t l y Freudian perspec-t i v e , but rather the v a r i e t y of i n t r a - p s y c h i c views t h a t derived from i t , which I had encountered i n my study of the l i t e r a t u r e . At t h a t p o i n t , the t o p i c was dropped, but I again f e l t the need to make sense o f t h e i r remarks. Th e i r source a l s o .lay, I decided, i n . a need to defend psychotherapy from what they perceived to be an unjust c r i t i q u e . The." t h e r a p i s t s were not Freudians, nor d i d they i n v a l i d a t e t h e i r p a t i e n t s ' d e f i n i t i o n s of r e a l i t y . This was t h e i r view of t h e i r e n t e r p r i s e . I s t i l l questioned t h i s i n t e r p r e t a t i o n , as the l i t e r a t u r e pointed toward other conclusions. This exchange heightened my d e s i r e to f i n a l l y observe what r e a l l y d i d ensue i n psychotherapy with "para-noids," as the p r a c t i t i o n e r s denied what the l i t e r a t u r e asserted. A d i s c u s s i o n then ensued with respect to the procedures that I would f o l l o w to obt a i n informed consent. In c o n t r a s t to the adminis-t r a t o r s , the c l i n i c a l s upervisors were i n t e r e s t e d i n the i n t e r p e r s o n a l aspects o f these procedures. One of them, i n a j o k i n g tone, s t a t e d : "The t h e r a p i s t s w i l l be more paranoid than the p a t i e n t s . " Another added, al s o i n a j o k i n g manner: Getting a p a t i e n t ' s approval each time? Then the fun w i l l r e a l l y s t a r t ! Bloody noses! 119 I was unsure how to i n t e r p r e t these remarks, but I made the assumption t h a t they were r e l a t e d .to the:advice t h a t the p s y c h i a t r i s t (who was my primary contact) had given me. I assumed that they i m p l i e d the f o l l o w -i n g : I needed to gain consent from i n d i v i d u a l s who by d e f i n i t i o n (or i n the case o f the t h e r a p i s t s by v i r t u e of t h e i r r o l e ) would be suspicious of my requests. In order f o r me to be s u c c e s s f u l , I would have to t r e a t t h i s problematic i n t e r a c t i o n as a "game," and act accordingly. None of the remarks had been s t a t e d i n t h e o r e t i c a l terms, nor d i d they r e f l e c t a d i r e c t r e l a t i o n s h i p to the l i t e r a t u r e on paranoia. This was another puzzle t h a t could be solved by viewing the remarks as material t h a t had been transformed from the t h e o r e t i c a l to the mundane i n order to f a c i l i t a t e communication with a lay person. These common sense remarks were, I deduced, veally t h e o r e t i c a l l y informed. I l e f t the meeting with the impression t h a t the committee had decided to grant i t s approval p r i o r to my p a r t i c i p a t i o n . I t s purpose had been to introduce me to the s e n i o r s t a f f , and to impress upon me the need to abide by the p r o t o c o l . I was confident t h a t I had broken through what I saw as a "smokescreen" that was put up to keep " o u t s i d e r s " from meddling with the i n s t i t u t i o n . Having penetrated t h i s cover, I was ready to continue my f i e l d w o r k , burdened, however, with the regula-t i o n s to which I was committed. I spent a month, f o l l o w i n g the o f f i c i a l approval of my research proposals by the two committees, e s t a b l i s h i n g my presence w i t h i n the h o s p i t a l . During the course of the h o s p i t a l Research Committee meeting, one o f the adm i n i s t r a t o r s had s t a t e d : 120 Once you gain approval f o r your work, you w i l l have to make contact with t h e r a p i s t s on your own. This i s part of the research process. Although I d i d not f i n d i t as t r y i n g as the previous month, t h i s p eriod was not easy f o r me, and c e r t a i n l y c o n s t i t u t e d an i n t e g r a l , and one of the more demanding parts of my f i e l d w o r k . I t proved to be a d i f f i c u l t t a s k , as I had to e s t a b l i s h a network of s o c i a l t i e s to the wards without being able to move f r e e l y w i t h i n them. I could not simply walk onto a ward, and s t a r t c h a t t i n g with the s t a f f . The wards were a "closed" t e r r i t o r y i n which a l l i n d i v i d u a l s were accountable f o r t h e i r presence. As I d i d not have a r o l e such as an aide or c l e a n e r , e t c . t h a t would allow me to l e g i t i m a t e l y enter t h i s s o c i a l space, and as no one on the wards knew me except the c l i n i c a l s u p e r v i s o r s (who often were not t h e r e ) , my task was formidable. During t h i s e a r l y period of my f i e l d w o r k , I had, t h e r e f o r e , to negotiate each entry i n advance by phone, often i n the face of a defensive s t a f f who ex e r c i s e d the same p r o t e c t i v e f u n c t i o n over t h e i r wards as the Research Committee d i d over the h o s p i t a l . My aim was to introduce myself to the t h e r a p i s t s on the wards where I was to do my research, and to f a m i l i a r i z e them with my research plans. As t h e i r p a r t i c i p a t i o n was v o l u n t a r y , I then sought agreement to take p a r t , from those who showed i n t e r e s t i n my research, and I requested a commitment from them to l o c a t e from t h e i r wards, p a t i e n t s t h a t had been diagnosed to be "paranoid." The l a t t e r step was necessary, as I d i d not have free access to the c l i n i c a l records on the wards, and th e r e f o r e could not keep track of the "paranoid" admissions. I s h a l l now recount my experiences during t h i s p eriod. 121 The f i r s t meeting t h a t I arranged was with the p s y c h i a t r i s t who was my primary c o n t a c t , and the c l i n i c a l s u p e r v isor of h i s ward, who had not been present at the h o s p i t a l Research Committee meeting. I had set up the meeting, as I f e l t t h a t i t was important f o r a l l of the c l i n i c a l s u pervisors to meet me, s i n c e t h e r a p i s t s on t h e i r wards might wish to discuss my research plans w i t h them. I f the c l i n i c a l s upervisors were f a m i l i a r with my work, then my chances of gaining the t h e r a p i s t s ' co-operation would, I b e l i e v e d , be improved. I had sent a copy of my research proposal to the c l i n i c a l super-v i s o r ahead of the meeting, and was, t h e r e f o r e , s u r p r i s e d at h i s f i r s t q uestion: "What i s i t t h a t you want to do? Please e x p l a i n your plans." This l e f t me wondering i f : he had not gotten the proposal; not read i t ; or perhaps wanted me to v e r b a l i z e i t i n order f o r him to have the opportunity to evaluate me."''' As I o u t l i n e d i t s contents, I came to the r e a l i z a t i o n that he viewed s o c i a l s c i e n t i f i c research i n q u a n t i t a -t i v e terms, and d i d not f u l l y understand my q u a l i t a t i v e approach: C l i n i c a l Supervisor: What e x a c t l y i s your hypothesis? What are your v a r i a b l e s ? Other P s y c h i a t r i s t : I wonder too. We are always t r y i n g to press him on h i s hypothesis. I continued to o u t l i n e my t h e o r e t i c a l and methodological o r i e n t a t i o n , w h i l e f e e l i n g concerned t h a t once more my primary contact had not sup-ported .me i n the face of c r i t i c i s m from a s e n i o r s t a f f member. Our d i s c u s s i o n turned to the problem of f i n d i n g p a t i e n t s whose diagnosis f e l l w i t h i n the category DSM-11-297 {The Diagnostic and Statistical Manual of Mental Disorders c l a s s i f i c a t i o n ) . 122 Other P s y c h i a t r i s t : He hasn't taken note of the f a c t t h a t there are very few p a t i e n t s with t h i s d i a g n o s i s . C l i n i c a l Supervisor: Yes, w e l l there have been no p a t i e n t s i n the l a s t eighteen months on the ward who didn't a l s o e x h i b i t symptoms beyond those of paranoia. None without other d i s o r d e r s . E-l [ o u t p a t i e n t ward] would be a more l i k e l y place to f i n d such people. I was not deterred by t h e i r statements, nor d i d I f e e l i l l - a t - e a s e using d i a g n o s t i c nomenclature, and d i s c u s s i n g the c h a r a c t e r i s t i c s of the d i s -order. From my study of the l i t e r a t u r e I was f a m i l i a r with the termin-ology, and was aware of the rare incidence of "true paranoia" (DSM-11-297.0). I f e l t c o n f i d e n t , as t h e i r remarks made sense i n terms of my "map." I knew that "true paranoids," with the exception of t h e i r delu-s i o n s , d i d not s u f f e r from disturbances of t h i n k i n g and p e r s o n a l i t y , and often could f u n c t i o n w i t h i n the community. I was not s u r p r i s e d , t h e r e f o r e , that the c l i n i c a l s u p e r v i s o r had suggested the o u t p a t i e n t ward. Furthermore, I had a n t i c i p a t e d the problem of l o c a t i n g s u f f i c i e n t numbers of "true paranoids," and had already decided t h a t observing therapy with p a t i e n t s s u f f e r i n g from v a r i a n t s of the paranoid d i s o r d e r such as paranoid s c h i z o p h r e n i a (DSM-11-295.3), or paranoid p e r s o n a l i t y (DSM-11-301.0), would s t i l l allow me the opportunity of w i t n e s s i n g the t h e o r e t i c a l l y determined processes of i n v a l i d a t i n g the p a t i e n t ' s version of r e a l i t y t h a t I b e l i e v e d ensued i n therapy. No puzzles presented themselves. Unlike e a r l i e r remarks re the "game" I was advised to play w i t h "paranoids," t h e i r statements sounded p s y c h i a t r i c , and t h e i r reasoning could be l i n k e d back to the l i t e r a t u r e . In a f u r t h e r attempt to e x p l a i n my understanding of r e a l i t y d e f i n -i t i o n s , and how one might go about studying them, I c i t e d Joan Emerson's 123 research on gynecological examinations, as her work stood as an example of a n o n - p o s i t i v i s t approach to the study of r e a l i t y d e f i n i t i o n s and the 12 r e l a t i o n s h i p between p a t i e n t and p r a c t i t i o n e r . I had no sense, how-ever, whether my explanation of her work c l a r i f i e d my own i n t e n t i o n s . Our meeting ended with a promise from the c l i n i c a l s u p e r v i s o r to n o t i f y me of the admission of s u i t a b l e p a t i e n t s . I contacted the o u t p a t i e n t ward next, p l a c i n g a phone c a l l to the c l i n i c a l s u p e r v i s o r . When I spoke to him, I i d e n t i f i e d myself, and s t a t e d that I wished to e s t a b l i s h whether there p r e s e n t l y were any "paranoid" o u t p a t i e n t s , and asked how I might go about observing them i n therapy. He answered that he d i d n ' t know who I was, and gave the phone to h i s s e c r e t a r y . Secretary: I am s o r r y . You cannot j u s t come i n t o the h o s p i t a l and do research! There are s t r i c t r u l e s about t h i s . Go and see Dr. ..., or Dr Researcher: I have already been granted permission to do research i n the h o s p i t a l . Dr. ... j u s t doesn't remember me. I would l i k e to speak to him again. Secretary: L i s t e n ; there have been problems with people doing studies i n the h o s p i t a l . Researcher: Please l e t me t a l k to Dr I can assure you t h a t I have permission. At that p o i n t , the c l i n i c a l s u p e r v i s o r returned to the phone, and 13 apologized. He had remembered me from the h o s p i t a l Research Committee meeting, and i n a f r i e n d l y tone he q u i c k l y proceeded to l i s t p a t i e n t s who . he thought might prove to be s u i t a b l e candidates f o r my research purposes. He mentioned an I s r a e l i male who had l i v e d i n the c i t y f o r twenty y e a r s , and had owned a scrap metal business which he had abandoned, or 124 l o s t by d e f a u l t , as a consequence of his "paranoia." This episode had followed h i s return from a t r i p to I s r a e l , at which time, he had p u b l i c l y expressed c r i t i c i s m of I s r a e l i government p o l i c y . His business and residence had subsequently been broken i n t o , which he saw to be a response to h i s statements. He b e l i e v e d t h a t some Jews and Z i o n i s t s were "out to get him." This b e l i e f was, the c l i n i c a l s u p e r v i s o r s t a t e d , the core of h i s delusions. He described the p a t i e n t t h i s way: I t h i n k that you would f i n d him an e x c e l l e n t subject f o r your study. His previous diagnosis was psychotic depressive r e a c t i o n ; paranoid p e r s o n a l i t y . In f a c t , he i s a r e a l paranoid. The c l i n i c a l s upervisor's comments d i d not perplex me. I was able to account f o r them, as would o t h e r s , i n terms of knowledge derived from the l i t e r a t u r e . I knew what he meant when he s a i d t h a t the p a t i e n t was a " r e a l paranoid," and I could r e l a t e h i s remarks back to the advice of the other c l i n i c a l s u p e r v i s o r . The o u t p a t i e n t ward would, i t appeared, y i e l d , as p r e d i c t e d , i d e a l s u b j e c t s ; "true paranoids" ( p a t i e n t s who d i d not s u f f e r from other disorders i n a d d i t i o n to those of the "paranoid" v a r i e t y ) . Things seemed to be f a l l i n g i n t o place despite my anxiety. I had l o c a t e d a p o t e n t i a l s u b j e c t , and my t h e o r e t i c a l knowledge (derived from my research of the l i t e r a t u r e ) had given me the means to communicate with p s y c h i a t r i s t s . Furthermore, the c h a r a c t e r i s t i c s of t h i s p a t i e n t (as described to me by the c l i n i c a l s u p e r v i s o r ) seemed to lend themselves to a n a l y s i s i n terms of my perspective on paranoia. Perhaps h i s "delu-s i o n " was, i n f a c t , a " l o g i c a l " response to h i s present or past l i f e s i t u a t i o n . I knew from the l i t e r a t u r e t h a t members of persecuted m i n o r i t y groups, and immigrants, both had a higher incidence of "paranoid" 125 d i s o r d e r s . T h e i r f e e l i n g s of persecution were s a i d to be d e l u s i o n a l i n nature, but some had argued t h a t the source of these f e e l i n g s l a y i n the exter n a l environment o f the i n d i v i d u a l r a t h e r than i n some psychic 14 defect. The p a t i e n t i n question was both a member of a persecuted m i n o r i t y and an immigrant. In a d d i t i o n , h i s n a t i o n a l i t y and his p o l i -t i c a l views had been described as prominent elements of hi s s i t u a t i o n . I wondered, t h e r e f o r e , what would t r a n s p i r e i n therapy. Would the t h e r a p i s t , r e l y i n g upon an i n t r a - p s y c h i c p e r s p e c t i v e , ignore the pos-s i b l e s o c i a l basis o f his disorder? Would the t h e r a p i s t r e j e c t h i s p o s s i b l y accurate ( r a t h e r than d e l u s i o n a l ) explanation of h i s s i t u a t i o n ? As h i s c h a r a c t e r i s t i c s seemed to make him, according to my p e r s p e c t i v e , a l i k e l y r e c i p i e n t of the e x e r c i s e o f s o c i a l c o n t r o l , I looked forward to observing him i n therapy. The c l i n i c a l s u p e r v i s o r noted a second male p a t i e n t who he thought would a l s o prove to be a s u i t a b l e subject. He, too, he s t a t e d , was a " r e a l paranoid." The p a t i e n t was described as a former member of the German n o b i l i t y . The d e s c r i p t i o n r a i s e d two points i n my mind. Again, the subject was an immigrant. I wondered i n t h i s case, however, i f he was seen to have delusions of grandeur r a t h e r than persecution. Once more, a p s y c h i a t r i c account prompted r e c a l l of material discussed i n the p s y c h i a t r i c l i t e r a t u r e . I assumed that being f a m i l i a r with the l i t e r -ature had allowed me, as i t would have o t h e r s , to make p s y c h i a t r i c sense of the c l i n i c a l s upervisor's remarks. We were able to communicate e f f e c t i v e l y , I decided, because we held i n common a knowledge of the l i t e r a t u r e . At th a t p o i n t , I was unaware th a t I would s h o r t l y encounter numerous s i t u a t i o n s i n which my knowledge would not f i t with my exper-126 iences and observations. I would again confront mundane material that could not be explained i n terms of my understanding of psychotherapy or paranoia. The c l i n i c a l s u p e r v i s o r concluded by s t a t i n g t h a t he would check the case l o a d , as he thought t h a t there would be other s u i t a b l e p a t i e n t s . He then i n v i t e d me to meet, and have lunch w i t h , the t h e r a p i s t s of the ward. Further Puzzles Emerge: The Problems of Making Sense . Two days l a t e r , I v i s i t e d the o u t p a t i e n t ward. My v i s i t began i n "rounds"; a d a i l y meeting of the c l i n i c a l s u p e r v isor and the t h e r a p i s t s of the ward, at which each t h e r a p i s t presented a report on the status of t h e i r p a t i e n t s , and the therapy sessions that they had conducted that day. I was s u r p r i s e d at the informal atmosphere of the meeting. I t d i d not resemble what I perceived to be a "normal" or t y p i c a l meeting of t h e r a p i s t s . I t d i d not have a m e d i c a l - p s y c h i a t r i c q u a l i t y ; which seemed to have l i t t l e to do with the absence of uniforms or the modern decor. I t was the way t h a t people communicated with each ot h e r , that caught my a t t e n t i o n . T h e i r i n t e r a c t i o n lacked the c l i n i c a l q u a l i t y that I expected. They made l i t t l e use of p s y c h i a t r i c concepts, reasoning, or terminology i n t h e i r conversations. Consider, f o r example, the f o l l o w i n g : C l i n i c a l Supervisor: How long has i t been since ... [ p a t i e n t ' s name] worked? Th e r a p i s t : Over one year. C l i n i c a l Supervisor: That's bad, very bad. We had b e t t e r get him back i n t o c i r c u l a t i o n before i t ' s too l a t e . Get him going! 127 T h e r a p i s t : Yes, I think so too. C l i n i c a l Supervisor: Otherwise, he w i l l spend the r e s t of his l i f e on w e l f a r e . How about our f r i e n d ... [ p a t i e n t ' s name]? Is he working? The r a p i s t : Yes, I arranged a part-time cleaning job through Manpower. I t ' s not much, but i t ' s a s t a r t . C l i n i c a l Supervisor: W e l l , i t ' s a good s i g n . In r e a c t i o n to t h i s type of d i a l o g u e , I j o t t e d down i n my f i e l d -notes: No Mystique. I was puzzled. Why didn't they t a l k l i k e thera-p i s t s ? There was no p s y c h i a t r i c q u a l i t y to t h e i r conversations. There was no psycho-dynamic element i n t h e i r a n a l y s i s of the p a t i e n t s . They seemed to discuss them i n the same way that concerned r e l a t i v e s would discuss the problematic l i f e s i t u a t i o n of a family member. They employed common sense reasoning. I could not understand, f o r example, why so much emphasis was placed on the employment problems of p a t i e n t s . I could appreciate that having a job might put some s t a b i l i t y i n t o an i n d i v i d u a l ' s l i f e , but r e s o l v i n g one's employment problems d i d not seem to be the domain of t h e r a p i s t s . Therapists were supposed to r e s o l v e i n t r a - p s y c h i c problems, not f i n d people jobs. T h e i r reasoning with respect to the value of working puzzled me. I t seemed to stem from a mundane concept not u n l i k e " i d l e hands make waste." Where was, I wondered, the t h e o r e t i c a l l y informed a n a l y s i s that the l i t e r a t u r e had l e d me, or might lead anyone, to expect? What d i d psychotherapy amount t o , h e l p i n g people f i n d jobs? That evening, I mulled over my observations, attempting to f i n d some answers to my puzzles.- I a r r i v e d at the f o l l o w i n g conclusions. The c l i n i c a l s u p e r v i s o r held the power on the ward, and t h e r e f o r e was 128 able to determine the s t y l e of "rounds." As he l i k e d to maintain an informal atmosphere, the t h e r a p i s t s a l l adopted h i s "unp r o f e s s i o n a l " approach f o r purposes of the meeting. Despite i t s mundane q u a l i t y , t h e i r conversations r e a l l y were t h e o r e t i c a l l y informed. The pragmatic, common sense c h a r a c t e r i s t i c s t h a t I had i d e n t i f i e d were deceptive. Underneath t h i s facade, a psycho-dynamic perspective was guiding t h e i r remarks. The p s y c h i a t r i s t s had been able to transform m a t e r i a l from the t h e o r e t i c a l to the mundane i n order to f a c i l i t a t e communication with me. S i m i l a r l y , the t h e r a p i s t s were able to transform t h e i r remarks i n t o a 15 s t y l e t h a t was compatible with t h a t s et by the c l i n i c a l s u p e r v i s o r . I had one other e x p l a n a t i o n , which I developed at t h i s p o i n t , but al s o u t i l i z e d l a t e r i n my fieldwor k to e x p l a i n s i m i l a r puzzles. Some t h e r a p i s t s were not as w e l l t r a i n e d as others. On t h i s ward, f o r example, some o f them were r e g i s t e r e d nurses. Lacking t h e o r e t i c a l know-ledge, these t h e r a p i s t s , I concluded, were unable to communicate i n t h e o r e t i c a l terms, and p r a c t i s e d poor or s u p e r f i c i a l therapy. As prac-t i t i o n e r s , they engaged i n something more akin to c o u n s e l l i n g than to psychotherapy as p r a c t i s e d by h i g h l y t r a i n e d t h e r a p i s t s . Part of the mundane q u a l i t y of the meeting, then, could be a t t r i b u t e d to t h e i r l a c k of p s y c h i a t r i c t r a i n i n g . P u t t i n g aside the question of the c l i n i c a l s u p e r v i s o r ' s personal s t y l e , I f e l t sure that I would have observed what my constructs had l e d me to expect, i f more of those present at the meeting had been h i g h l y t r a i n e d t h e r a p i s t s such as p s y c h i a t r i s t s . I was introduced by the c l i n i c a l s u p e r v i s o r a f t e r the t h e r a p i s t s ' r e p o r t s . He asked the t h e r a p i s t s who were t r e a t i n g "paranoids" how they f e l t about my research plans. An o l d e r r e s i d e n t s t a t e d : " I f he were to 129 get i n v o l v e d , I f e e l t h a t my p a t i e n t might terminate therapy." The c l i n i c a l s u p e r v i s o r responded t h i s way: "Many paranoids would welcome his presence. I t would, provide them with another i n t e r e s t e d l i s t e n e r . " ^ ' A nurse and another r e s i d e n t who were t r e a t i n g "paranoids" picked up on his cue, s t a t i n g t h a t they were ready to p a r t i c i p a t e . The younger of the two, the nurse, appeared to be p a r t i c u l a r l y i n t e r e s t e d , s t a t i n g : "Sure, I'd l i k e to give i t a t r y . " I noted that the responses of the three t h e r a p i s t s to my plans v a r i e d according to t h e i r age and t h e i r p r o f e s s i o n a l s t a t u s . The o l d e r the t h e r a p i s t (which i n t h i s case was l i n k e d to t h e i r l e v e l of t r a i n i n g ) , the l e s s e n t h u s i a s t i c they were to p a r t i c i p a t e , and the more formal was the s t y l e of t h e i r r e p l y . I a t t r i b u t e d the variance i n responses to the two f a c t o r s d i s -cussed above. The o l d e r , more h i g h l y t r a i n e d t h e r a p i s t s were, I concluded, l e s s i n c l i n e d to adopt the informal unprofessional s t y l e set by the c l i n i c a l s u p e r v i s o r , as to do so would minimize the d i f f e r e n c e i n status between them and the other t h e r a p i s t s . Secondly, they were le s s e n t h u s i a s t i c about p a r t i c i p a t i n g , as they had, by v i r t u e of t h e i r advanced t r a i n i n g , a more h i g h l y developed sense of the importance of maintaining the i n t e g r i t y of the t h e r a p i s t - c l i e n t r e l a t i o n s h i p . They had a propensity f o r d e f i n i n g t h e i r p a t i e n t s as t h e i r own domain. The c l i n i c a l s u p e r v i s o r ' s remark with respect to the a t t i t u d e of "paranoids" was, I b e l i e v e d , an attempt on my behalf to use h i s power to undermine the s e n i o r t h e r a p i s t s ' p e r s p e c t i v e . The common sense q u a l i t y of h i s statement could be e x p l a i n e d , I decided, i n terms of t h i s pragmatic purpose. 130 A f t e r i t had been e s t a b l i s h e d which t h e r a p i s t s were i n t e r e s t e d i n p a r t i c i p a t i n g i n my study, the c l i n i c a l s u p e r v i s o r asked me to e x p l a i n i n more d e t a i l my research o b j e c t i v e s . I saw his request to be educa-t i o n a l l y o r i e n t e d . I t was a means of e l i c i t i n g f u r t h e r d i s c u s s i o n of the d i s o r d e r . A f t e r I had completed my p r e s e n t a t i o n , he s t a t e d : Paranoid i s a nasty term to put on someone. People can have r e a l reasons f o r being paranoid. His remarks struck me as unusual, as I d i d not expect him to a s s e r t a perspective which acknowledged the p o s s i b l e l e g i t i m a c y of i n d i v i d u a l s ' f e e l i n g s of persecution. Although h i s view sounded much l i k e my own, I decided t h a t i t was u n l i k e l y that we shared a common perspective. I knew from the l i t e r a t u r e , that very few p s y c h i a t r i s t s accepted the c r i t i c a l ideas which I held. I decided that h i s statement was d i d a c t i c i n o r i g i n . He wished to poi n t out (to the t h e r a p i s t s ) the need to e x e r c i s e care when making a diagnosis. I assumed that he was not compromising, what I took to be, h i s t h e o r e t i c a l stance. Despite the op p o r t u n i t y , at f i r s t none of the t h e r a p i s t s asked me questions, which was a f u n c t i o n , I presumed, of the c l i n i c a l super-v i s o r ' s power. As he had accepted the l e g i t i m a c y of my work, they d i d not venture to question i t . F i n a l l y , a question was asked. Th e r a p i s t : Do you want to get involved with the pa t i e n t s ? Researcher: No; not at a l l . That's not my i n t e n t . C l i n i c a l Supervisor: [Joking tone] Seems l i k e he's a f r a i d . Too t i m i d ? I had responded n e g a t i v e l y , as I wished to make c l e a r t h a t I would not threaten the t h e r a p e u t i c r e l a t i o n s h i p . I d i d so f o r two reasons. I 131 did not want to a l i e n a t e the t h e r a p i s t s whose consent I wished to g a i n , nor d i d I wish to contravene my commitment to avoid i n t e r f e r i n g with the f u n c t i o n i n g of the h o s p i t a l . The c l i n i c a l s u p e r v i s o r d i d not share my concerns. He thought t h a t I should get i n v o l v e d with the p a t i e n t s that I would observe. He expressed h i s f e e l i n g s to me a f t e r the meeting. C l i n i c a l Supervisor: The h o s p i t a l i s a s i l l y place. They make too many r e s t r i c t i o n s . I t makes i t hard f o r people to do research. Researcher: The protocol makes me f e e l l i k e I must walk on t i p t o e s . C l i n i c a l Supervisor: You should go ahead and get some data. Get your fee t wet! Find out what paranoia i s about. The c l i n i c a l s u pervisor's a t t i t u d e confirmed my e a r l i e r observation. U n l i k e the h o s p i t a l a d m i n i s t r a t o r s , the c l i n i c a l s upervisors were not o v e r l y concerned about p r o t o c o l . I was unsure, however, why the c l i n i -c a l s u p e r v i s o r encouraged me to "get i n v o l v e d " w i t h paranoid p a t i e n t s . I knew that i t would be useful f o r my research, but I had a f e a r (derived from my study of the l i t e r a t u r e ) of becoming part of the p a t i e n t ' s paranoid "pseudo-community." I d i d not want to put myself i n a p o s i t i o n where t h i s might become a p o s s i b i l i t y , as I was not sure t h a t I could deal w i t h such a s i t u a t i o n . The references i n the l i t e r a t u r e to the p o t e n t i a l t h r e a t posed by "paranoids" had tempered my d e s i r e to get 17 d i r e c t l y i n v o l v e d i n t h e i r l i v e s . I a t t r i b u t e d h i s a t t i t u d e , once more, to a pragmatic stance. As he f e l t t h a t my research might prove to be worthwhile, he decided to overlook the problems which (I knew from the l i t e r a t u r e ) would be generated by my involvement, and pushed instead f o r me to "get my f e e t wet." As the h o s p i t a l was meant to be a research 132 f a c i l i t y , he was prepared to ignore what he knew to be p o t e n t i a l prob-lems. In order to f a c i l i t a t e my research, he was w i l l i n g to persuade his t h e r a p i s t s to ignore them a l s o . I was unsure how I should proceed. Apparently, the protocol was not as important as I had been made to b e l i e v e , nor were my constructs as a p p l i c a b l e as I had expected. I was l e f t f e e l i n g i n s e c u r e , and was tempted to withdraw r a t h e r than f o l l o w up the contacts t h a t I had estab-l i s h e d t h a t day. Before l e a v i n g the h o s p i t a l , however, I "made the plunge," and arranged to meet with the nurse ( t h e r a p i s t ) to discuss her "paranoid" p a t i e n t , who turned out to be the I s r a e l i male that the c l i n i c a l s u p e r v i s o r had described on the phone. We met the next day i n one of the therapy rooms of the o u t p a t i e n t ward. The t h e r a p i s t a r r i v e d l a t e , as she had been delayed at a community mental health c l i n i c . She apologized, and then began to present a case h i s t o r y of the I s r a e l i "paranoid." I was f a m i l i a r with c a s e - h i s t o r i e s " from the l i t e r a t u r e , but aside from the c l i n i c a l s u pervisor's b r i e f remarks on the phone, I had never been party to a p s y c h i a t r i c account of a "paranoid" p a t i e n t . I was e x c i t e d , as I was ta k i n g another step 1 g toward a c t u a l l y observing "paranoids" i n therapy. I was given the f o l l o w i n g f a c t u a l information about the p a t i e n t . He was f o r t y - e i g h t years o l d , s i n g l e , and he l i v e d alone. He was unemployed, and he spent hi s days at the main l i b r a r y where he read newspapers. His main meal was lunch, which he ate at a department s t o r e , and he spent his evenings watching t e l e v i s i o n at home, r e t i r i n g at 8 p.m. He had no s o c i a l l i f e , as he had no f r i e n d s . His f a m i l y had been a c t i v e i n I s r a e l i p o l i t i c s , and he had been i n the B r i t i s h A i r Force. 133 Having given me an overview of h i s l i f e , the t h e r a p i s t began to present her a n a l y s i s of h i s s i t u a t i o n . I had already formed an i n i t i a l a n a l y s i s of his problems from the c l i n i c a l s u pervisor's account. I expected that the t h e r a p i s t would present an i n t r a - p s y c h i c a l l y based counter i n t e r p r e t a t i o n which would ignore the s o c i a l v a r i a b l e s , such as his immigrant and m i n o r i t y s t a t u s , that I had i d e n t i f i e d . To my sur-p r i s e , she d i d not discuss the p a t i e n t i n e i t h e r s o c i a l or i n t r a - p s y c h i c terms. Consider the f o l l o w i n g : I s t a r t e d him i n occupational therapy. I wanted to put him i n contact with other t h i n g s , but he f e l t demeaned by i t ; which I understand. He wants to get a truck and go back i n t o the junk business. That worries me. Another f a i l u r e would r e a l l y upset him. Dr. ... [ c l i n i c a l s u pervisor's name] s a i d that t h i s was s t i l l a b e t t e r choice than continuing his present e x i s t e n c e . I was not sure what to make of t h i s t a l k . I had expected an i n t r a - p s y c h i c a l l y based a n a l y s i s focusing on his delusions. The content, focus, and s t y l e of the t h e r a p i s t ' s a n a l y s i s , i n s t e a d , reminded me more of a l a y person's d i s c u s s i o n of the personal problems of a f a m i l y member or a f r i e n d . For example: He seems to have a t h i n g against women. I t comes out i n remarks about the way I dress. When I wear pants, which I u s u a l l y do, he comments on my improper a t t i r e , but he a l s o makes remarks and i s uncomfortable when I wear s k i r t s . Or, consider the f o l l o w i n g : I see him l e s s often now, only once every two weeks. One of h i s problems i s that he has become too dependent on the h o s p i t a l . I t s l i k e a womb f o r him here. I hope to get him to stand on h i s own f e e t ; to get out i n t o the world. Although the t h e r a p i s t ' s remarks had a d i s c e r n i b l e p s y c h o l o g i c a l content, they lacked the p s y c h i a t r i c q u a l i t y that I had expected. I a t t r i b u t e d t h e i r mundane pr o p e r t i e s to the f o l l o w i n g reasons which I had 134 already r e l i e d upon to make sense of previous observations. The thera-p i s t , I decided, had purposely chosen to discuss the p a t i e n t i n common sense r a t h e r than psycho-dynamic terms, i n order to communicate more e f f e c t i v e l y with me. Her a n a l y s i s was s t i l l t h e o r e t i c a l l y informed, but i t lacked the c h a r a c t e r i s t i c s t h a t I had expected, because i t had been transformed i n t o common sense terms. I f she had been c o n f e r r i n g with a col l e a g u e , I would have heard the kind of t a l k that my constructs had l e d me to a n t i c i p a t e . Another p r e v i o u s l y used explanation a l s o occurred to me. As she had l i m i t e d t r a i n i n g i n psychotherapy, i t was p o s s i b l e that she was more i n c l i n e d to give a common sense account, as she lacked the extensive t h e o r e t i c a l knowledge of a p s y c h i a t r i s t . I was unsure which of the two explanations o f f e r e d a more accurate answer to my pu z z l e , but f e l t t h a t together they provided a reasonable s o l u t i o n . In the l a t t e r part of our meeting, we got i n t o a d i s c u s s i o n of the c h a r a c t e r i s t i c s o f "paranoids." I was again s u r p r i s e d , as the t h e r a p i s t made a "switch" i n her t a l k from the mundane to the p s y c h i a t r i c , which I could not account f o r , p a r t i c u l a r l y because I had assumed that she was d e f i c i e n t i n t h e o r e t i c a l knowledge. Her d i s c u s s i o n o f paranoia d i d not sound l i k e her d i s c u s s i o n of her p a t i e n t . I t lacked common sense references to job f a i l u r e , uncomfortableness, " g e t t i n g on one's f e e t , " e t c . I t e x h i b i t e d , i n s t e a d , psycho-dynamic knowledge derived from p s y c h i a t r i c theory. Consider the f o l l o w i n g : 'As you may know, there are a number of c l a s s i c paranoid t r a i t s such as delusi o n s . Some of the p a t i e n t s ' delusions may be r e a d i l y apparent to you, others may not. They are a l l engaging i n p r o j e c t i o n . They are unable to manage t h e i r i n ner c o n f l i c t s . They p r o j e c t t h e i r anger onto those around them. The t h e r a p i s t s t a t e d , i n response to a question I had about the way 135 delusions were handled: We don't always work d i r e c t l y on the p a t i e n t ' s d e l u s i o n a l m a t e r i a l . I f the p a t i e n t has some s a n i t y , then we can confront his paranoid d e l u s i o n s , but i f he becomes too angry, then we can only encapsulate them. I was f a m i l i a r , from the l i t e r a t u r e , with these p e r s p e c t i v e s . They made sense i n terms of my knowledge of the theory, but I was unable to a r r i v e at a s a t i s f a c t o r y explanation of the "switch." Her t a l k was d i v i d e d between a t h e o r e t i c a l d i s c u s s i o n of the d i s o r d e r and a mundane di s c u s -sion of her p a t i e n t . She d i d not, and I was unable;to, - i n t e g r a t e the two. I wondered why, f o r example, I could not d i s c e r n , from her com-ments about her p a t i e n t , the c l a s s i c symptoms th a t she described as d e f i n i n g the d i s o r d e r . I decided t h a t the d i s p a r i t y stemmed from my own lack o f knowledge, and would be resolved when I had the opportunity to a c t u a l l y observe psychotherapy with "paranoids." I f e l t t h a t at th a t time I would become aware of a l i n k between the mundane and the theore-t i c a l , which would allow me to both e x p l a i n her "switch," and make sense of the mundane m a t e r i a l , i n terms of my knowledge of p s y c h i a t r i c theory. At the conclusion o f our meeting, the t h e r a p i s t introduced me to 19 a woman i n the nursing s t a t i o n who I took to be a s e c r e t a r y . Upon hearing t h a t I planned to observe "paranoids," she made a joke (that had a d i s t i n c t n o n - p s y c h i a t r i c q u a l i t y ) about the i m p o s s i b i l i t y of my tas k , given t h e i r f e a r s . I d i d not i n t e r p r e t the joke to be t h e o r e t i c a l l y 20 informed, as I f e l t sure t h a t she was not a t h e r a p i s t . My judgement was confirmed when I was t o l d that she handled the appointments and the c l i n i c a l records o f the o u t p a t i e n t ward. I found out from her th a t a l l of the I s r a e l i "paranoid's" c l i n i c a l records were i n the nursing s t a t i o n , 136 and, being conscious of my commitment to avoid d i s t u r b i n g the f u n c t i o n -ing of the ward, e s t a b l i s h e d t h a t 2:30-4:00 p.m. was the best time to examine them, as rounds were held d a i l y at that time. I a l s o gained a promise from her to n o t i f y me of any p a t i e n t assessments that included a diagnosis of some form of paranoid d i s o r d e r . I noted with i n t e r e s t , given t h a t she was a s e c r e t a r y , that she seemed to know which diagnoses I was making reference to. My i n t e r e s t stemmed from my d e s i r e , throughout the course of my f i e l d w o r k , to e s t a b l i s h the r o l e s played by i n d i v i d u a l s i n the h o s p i t a l . As the s t a f f d i d not wear name-plates or uniforms, I was unable to e a s i l y d i f f e r e n t i a t e between c l i n i c a l s u p e r v i s o r s , other p s y c h i a t r i s t s , r e s i d e n t s , i n t e r n s , n u r s e / t h e r a p i s t s , a i d e s , s e c r e t a r i e s , and even p a t i e n t s . I needed to do so, however, as e s t a b l i s h i n g t h e i r r o l e s allowed me to make sense of t h e i r behaviours. The common sense jokes of the c l i n i c a l s u p e r v i s o r and the s e c r e t a r y are a good example. Although both jokes had the same q u a l i t y , I i n t e r p r e t e d them d i f f e r e n t l y , as I was aware of the t e l l e r s ' d i s s i m i l a r r o l e s . By e s t a b l i s h i n g r o l e s , I was able to place my observations i n t o a meaningful context. The process was not, however, unambiguous, as often the material that I used to d i f f e r e n t i a t e a r o l e such as dress, manner of speaking, demeanour, et c . was the same as t h a t which, upon having confirmed an i n d i v i d u a l ' s r o l e , I subsequently placed i n t o a r e l e v a n t context. I was a b l e , f o r example, to make adequate sense of the s e c r e t a r y ' s remarks. They were a clue to her r o l e , yet at the same time, i t was only upon e s t a b l i s h i n g her r o l e 21 t h a t I was able to make meaningful sense of them. 137 The f o l l o w i n g day, I returned to the h o s p i t a l to examine the I s r a e l i "paranoid's" c l i n i c a l records. Before going to the o u t p a t i e n t ward, I met with a r e s i d e n t from another ward who had read my research proposal, and was prepared to n o t i f y me of any "paranoids" admitted to his ward. I now had e s t a b l i s h e d a l i n k with a s t a f f member on each of the wards which the h o s p i t a l Research Committee had recommended as s u i t a b l e f o r my research (two inpatient and the o u t p a t i e n t ward). The r e s i d e n t introduced himself as Doctor ... (his name), and s t a t e d t h a t a f t e r having read my proposal he had two questions, which he put to me t h i s way: There aren't many p a t i e n t s with a diagnosis of paranoia who come on the ward. Almost always, they are a l s o diagnosed to be manic or s c h i z o p h r e n i c . What type of p a t i e n t are you lo o k i n g for? Have you considered the emergency ward and the assessment u n i t of ( i n i t i a l s o f the l a r g e s t h o s p i t a l i n the c i t y ) ? I am sure that you would f i n d more c l e a r - c u t cases of paranoia there. I was s t r u c k by the s i m i l a r i t y between h i s questions and the remarks of the c l i n i c a l s u p e r v i s o r , and my primary contact from the other i n p a t i e n t ward. He, too, pointed out the s c a r c i t y of i n p a t i e n t s who were "true paranoids," and a l s o suggested an a l t e r n a t e source that drew upon "true paranoids" from the community. Once more, I was con-f r o n t e d with and able to make sense of these i d e a s , i n terms of my know-ledge of the l i t e r a t u r e , which gave me confidence. The r e s i d e n t ' s questions helped to confirm my b e l i e f t h a t the l i t e r a t u r e would provide me w i t h a "map" of the research s e t t i n g . Although I had encountered a number of p u z z l e s , I had been a b l e , a f t e r a l l , to account f o r them w i t h i n my t h e o r e t i c a l framework. 138 I responded to the r e s i d e n t as I had p r e v i o u s l y r e p l i e d to the other p s y c h i a t r i s t s . I noted t h a t I was aware of the rare incidence of cases of "true paranoia," and t h a t "true paranoids" were more l i k e l y to be found i n an o u t p a t i e n t s e t t i n g , as they often were able to f u n c t i o n i n the community. I pointed out t h a t I was prepared to study p a t i e n t s s u f f e r i n g from v a r i a n t s of the paranoid d i s o r d e r . The r e s i d e n t s t a t e d that t h i s would improve my chances of f i n d i n g p a t i e n t s on his ward, and promised to inform me of any s u i t a b l e admissions. The Puzzles Are Compounded I was pleased t h a t I had now secured an informant on each ward. I proceeded to the o u t p a t i e n t ward, curious to explore the contents of a p a t i e n t ' s c l i n i c a l records. My c u r i o s i t y was heightened by my p r i o r knowledge of the I s r a e l i "paranoid," a t t a i n e d from h i s t h e r a p i s t and the c l i n i c a l s u p e r v i s o r . I wondered i n what ways hi s c l i n i c a l records would add to the p i c t u r e L a l r e a d y had of him. I wondered i f they would help me to make f u r t h e r sense of the "switch" and other ambiguities t h a t I had encountered i n my d i s c u s s i o n with h i s t h e r a p i s t . I a r r i v e d at the nursing s t a t i o n , and was met by the c l i n i c a l s u p e r v i s o r , who was standing i n the entranceway. I n s i d e , the s e c r e t a r y and a number of t h e r a p i s t s that I recognized from the rounds which I had attended, were working at desks. Conscious of my promise to avoid i n t e r f e r i n g with the work done on a ward, I mustered up my courage, and announced th a t I had come to examine the I s r a e l i "paranoid's" c l i n i c a l r e cords, on the advice of h i s t h e r a p i s t . The c l i n i c a l s u p e r v i s o r seemed pleased t h a t I was t a k i n g an i n t e r e s t i n the p a t i e n t , and motioned me 139 toward the s e c r e t a r y who handed me hi s f i l e . I was then taken by the sec r e t a r y to a room, clo s e to the nursing s t a t i o n , used as a study area by students i n p r o f e s s i o n a l programs who were working i n the h o s p i t a l . I sat down at one of the desks i n the unoccupied room, and began my examination of the p a t i e n t ' s records. The records were organized c h r o n o l o g i c a l l y , and were dated from the present back to his f i r s t admission to the h o s p i t a l . In a d d i t i o n to e n t r i e s made at the h o s p i t a l , the format of which has been o u t l i n e d 22 e a r l i e r , the records a l s o contained material from the c l i n i c a l records of other h o s p i t a l s to which he had been admitted. The p a t i e n t had a voluminous f i l e , as the records contained a h i s t o r y , an admitting d i a g n o s i s , and a problem l i s t f o r each time he was admitted to the h o s p i t a l , and a discharge summary f o r each time he was discharged. As he had been admitted a number o f times, these s e c t i o n s of the records added many pages to the extensive d a i l y records t h a t were kept. A f t e r reading approximately o n e - t h i r d of the eighty-odd pages, I a r r i v e d at a general impression of t h e i r character. Much o f the pa t i e n t ' s f i l e was made up of documents such as consent forms which were included f o r l e g a l purposes; n o n - p s y c h i a t r i c medical h i s t o r i e s which contained, f o r example, lengthy d e s c r i p t i o n s of surgery and non-psychi-a t r i c d i a g n o s t i c t e s t s t h a t had been performed on the p a t i e n t ; and extensive l i s t s o f medications which had been p r e s c r i b e d f o r the p a t i e n t i n the h o s p i t a l . The second feature t h a t I noted, was the r e p e t i t i v e nature o f the c l i n i c a l notes t h a t were made d a i l y by the various s t a f f t hat worked with the p a t i e n t . The notes v a r i e d l i t t l e i n t h e i r content, appearing to f o l l o w a pattern set i n the i n i t i a l e n t r i e s made a f t e r the 140 p a t i e n t was admitted. F i n a l l y , I observed t h a t parts of the records gave meamore composite view of the I s r a e l i "paranoid" than I had gained from his t h e r a p i s t , as they discussed the extent and character of h i s delu-s i ons. The f o l l o w i n g day, I f i n i s h e d reading the p a t i e n t ' s records, and began to mull over t h e i r contents, i n an attempt to make sense of them i n terms of the l i t e r a t u r e . As I thought more about them, I r e a l i z e d t h a t I was confronted w i t h m a t e r i a l that both d i d and d i d not f i t with the l i t e r a t u r e on psychotherapy and paranoia. I was able to make sense of the p a t i e n t ' s admitting d i a g n o s i s , h i s t o r y , and problem l i s t ; h i s discharge summary; and the "Assessment" s e c t i o n of the d a i l y e n t r i e s , as the s t y l e i n which they were w r i t t e n , and the m a t e r i a l w i t h which they d e a l t , were s i m i l a r to t h a t found i n the l i t e r a t u r e . The " S u b j e c t i v e , " "Objective," and "Orders" sec t i o n s of the d a i l y e n t r i e s were, however, a puzzle. The f i r s t two s e c t i o n s were meant to stand as a record of the s t a t e of the p a t i e n t ' s d i s o r d e r , w h i l e the l a t t e r s e c t i o n was meant to be an o u t l i n e of the t h e r a p i s t ' s psychotherapeutic s t r a t e g y f o r dealing with the d i s o r d e r . To my s u r p r i s e , the contents of the three s e c t i o n s did not make sense i n terms of the analyses of paranoia, or the d e s c r i p -t i o n s of psychotherapeutic approaches to the d i s o r d e r , that I had 23 encountered i n the l i t e r a t u r e . They had, i n s t e a d , a d i s t i n c t common sense q u a l i t y . I s h a l l now set out some material from the p a t i e n t ' s c l i n i c a l records that I found I could make sense o f , and some that I found p u z z l i n g . I s h a l l , furthermore, show how I f i t t e d together my i n i t i a l impressions of the records w i t h my subsequent thoughts on them, that were developed i n the days t h a t followed my f i r s t reading of them. 141 The material from the p a t i e n t ' s records that I was able to under-stand i n terms of the l i t e r a t u r e on paranoia included both a s e c t i o n of the d a i l y e n t i r e s (the "Assessment"), and the summaries of the p a t i e n t ' s c o n d i t i o n (the admitting d i a g n o s i s , h i s t o r y , problem l i s t , and the d i s -charge summary) which were noted r e s p e c t i v e l y at the time of a d m i t t i n g , and upon discharge of the p a t i e n t . These e n t r i e s d i d not pose problems of i n t e r p r e t a t i o n , as they were made up of t h e o r e t i c a l l y based analyses of the p a t i e n t . In both t h e i r form and content, they resembled material t h a t I had read i n the l i t e r a t u r e . Consider, f o r example, the f o l l o w i n g , taken from "Case H i s t o r y " and "Discharge" e n t r i e s made at another h o s p i t a l to which the I s r a e l i "paranoid" had been p r e v i o u s l y admitted: Case H i s t o r y : .... [name of the h o s p i t a l ] T h e r a p i s t : Dr [name of the p s y c h i a t r i s t ] This p a t i e n t was r e f e r r e d by Dr. ... a f t e r he had presented hims e l f at Emergency on several occasions. He again came to Emergency on the morning of his admission to h o s p i t a l and appeared confused, d i s t u r b e d and r e l a t e d three d i f f e r e n t names--none of which could be v e r i f i e d . I t was f e l t by Dr. ... [ p s c y h i a t r i s t ' s name] t h a t he was a s c h i z o p h r e n i c and he was a c c o r d i n g l y admitted. When seen, h i s conversation was rambling and d i s j o i n t e d and he t a l k e d about threa t s having been made but would not s p e c i f y what they were. When out of the room he was heard to be t a l k i n g l o u d l y to himself and shouting p e r i o d i c a l l y . He claims that he owns a junk yard i n ... [name of neighbouring c i t y ] and has been here f o r 2 or 3 days. He says t h a t he has been under considerable emotional s t r a i n and was to get r i d of the business. He r e l a t e d that he t h i n k s he has been pr o j e c t e d i n t o saying t h i n g s , has been t a l k i n g to himself a l l n i g h t , and has been under compulsion to t a l k . He r e l a t e s that he has been i n ... [name of h o s p i t a l i n the USA] f o r two years--'58-'60 but does not r e l a t e any other hospi-t a l i z a t i o n f o r mental d i s o r d e r . He was not able to give much information about his f a m i l y , i n t h a t , he says h i s parents are l i v i n g i n I s r a e l . . . . Diagnostic Impression: Paranoid Schizophrenia. 142 "Discharge Note" ... [name of the h o s p i t a l ] Ther. Dr. ... [name of the p s y c h i a t r i s t ] This p a t i e n t responded q u i t e r a p i d l y to treatment i n the h o s p i t a l and was discharged on T r i l a f o n 8 mgms. b . i . d . He was to take the bus and return to h i s business running a junkyard i n ... [name of neighbouring c i t y ] and he was discharged at h i s own request. He s a i d he had business dealings that he had to get back to at once. He s a i d t h a t he would contact his f a m i l y doctor when he was t o l d that he should have some f o l l o w up care. There were no delusions or h a l l u c i n a t i o n s e l i c i t e d at the time of h i s discharge. I t was f e l t t h a t t h i s was a relapse of a chronic sc h i z o p h r e n i c i l l n e s s . D iagnostic Impression: Acute Schizophrenic Reaction These e n t r i e s d i d not c o n t r a d i c t my expectations of what t h e r a p i s t s would have to say about "paranoid" p a t i e n t s , or how they would express t h e i r views of them. The material had a p s y c h i a t r i c rather than mundane q u a l i t y , another i l l u s t r a t i o n of which i s found i n the f o l l o w i n g , taken from an entry made at the time of a previous discharge from the h o s p i t a l (where I conducted my f i e l d w o r k ) : Discharge Summary, T h e r a p i s t s : Dr. ... [name of a c l i n i c a l s u p e r v i s o r ] and ... [name of a fourth-year medical s t u d e n t ] . Condition on admission and r e l e v a n t h i s t o r y : His p s y c h i a t r i c h i s t o r y has spanned 20 y e a r s , but during the l a s t 2 years he has been admitted on 4 occasions. This l a s t c l u t c h of admissions was p r e c i p i t a t e d by p o l i t i c a l l y o r i e n t e d l e t t e r s he had mailed to the press concerning Jewish r e a c t i o n to Russian domination. He has gross g u i l t f e e l i n g s regarding these l e t t e r s . Mr. ... [ p a t i e n t ' s name] was pleasant, vocal with no loosen-ing of a s s o c i a t i o n . However he d i d have mild f i x e d delusions concerning the l e t t e r s described above. P a t i e n t s Problems: i Depression: This was t r e a t e d with a combination of suppor-t i v e psychotherapy and A m i t r i p t y l i n e 50 mg. b . i . d . and 100 mg. h.s. As part of the depression ... [ p a t i e n t ' s name] was aggres-s i v e when approached and shunned company of any type. This s t a t e g r a d u a l l y decreased with time. 143 i i I n t r o v e r s i o n : To s t a r t with ... [ p a t i e n t ' s name] was very s t i n g y i n a l l respects. He sat by himself and r a r e l y t a l k e d except to c a s t i g a t e someone. He s a i d he was a loner--and he was. I t was made easy f o r him to s o c i a l i z e and he was g r e a t l y helped by other p a t i e n t s . i i i Paranoid: Right u n t i l discharge ... [ p a t i e n t ' s name] refused to be taped and d i s l i k e d being i n a room with a 2 way mi r r o r even though i t was not a c t i v a t e d . This paranoid s t a t e was reduced by g i v i n g T r i f l u o p e r a z i n e 5 mg at noon and 10 m.g. h.s. Discharge I n s t r u c t i o n s : Medications: A m i t r i p t y l i n e and T r i f l u o p e r a z i n e i n dose i n d i c a t e d above. He has been asked to j o i n i n O.T. d a i l y .... He r e t r e a t e d r a p i d l y from any suggestion of "Team" f o l l o w up. F i n a l Diagnosis Psyc h o t i c Depressive Reaction. Paranoid P e r s o n a l i t y . Both sets of e n t r i e s "sounded r i g h t , " as they described and anal-ysed the p a t i e n t ' s thought and behaviour i n the same t h e o r e t i c a l and conceptual terms t h a t I had a n t i c i p a t e d I would encounter. I was (and I assumed t h a t others f a m i l i a r with the l i t e r a t u r e would al s o be) able to i d e n t i f y i n the references to h i s delusions and "paranoid" thought the t h e o r e t i c a l perspectives t h a t had guided the t h e r a p i s t s ' formula-t i o n s of t h e i r accounts, which enabled me to see the t h e o r e t i c a l s i g n i f i c a n c e of the material i n them. I co u l d , f o r example, l i n k phrases such as "no loosenings of a s s o c i a t i o n , " or terms such as "mild f i x e d " used to describe h i s d e l u s i o n s , back to the body of t h e o r e t i c a l knowledge on paranoia which I had s t u d i e d , and which guided (I assumed) the t h e r a p i s t s ' understanding of the d i s o r d e r . Although I d i d not have much evidence to support my premise, as there was minimal d e s c r i p t i o n i n the e n t r i e s o f how the p a t i e n t ' s d i s o r d e r was t r e a t e d , beyond a l i s t i n g of medications, I concluded that the the r a p e u t i c work done with the p a t i e n t must a l s o have been t h e o r e t i c a l l y guided. I d i d not view 144 references such as " t h i s was t r e a t e d w i t h a combination of supportive psychotherapy," and "there were no delusions or h a l l u c i n a t i o n s e l i c i t e d " as i n d i c a t i v e o f a common sense approach to handling the d i s o r d e r . There was no question i n my mind t h a t these e n t r i e s r e f l e c t e d a theo-r e t i c a l l y based approach. I was a b l e , t h e r e f o r e , to make sense of them i n terms of the l i t e r a t u r e . The "Assessment" s e c t i o n of the c l i n i c a l records was w r i t t e n up each time a t h e r a p i s t met with the p a t i e n t . This part of the records was a l s o a t h e o r e t i c a l l y based account of the p a t i e n t ' s c o n d i t i o n , and di d not, by i t s e l f , present me with problems of i n t e r p r e t a t i o n . I had no d i f f i c u l t y i n i d e n t i f y i n g the t h e o r e t i c a l s i g n i f i c a n c e of the material w i t h i n i t . I t a l s o had the s t y l e and content of the p s y c h i a t r i c l i t e r -a t u r e , which i s evident i n the f o l l o w i n g examples taken from the pa t i e n t ' s c l i n i c a l records: ... [ p a t i e n t ' s name] i s p a r t i a l l y suppressing, denying and unconsciously p h y s i c a l l y expressive of anger. He has set himself up f o r f r u s t r a t i o n v i a r e j e c t i o n . Mr. ...'s [ p a t i e n t ' s name] paranoid thought i s becoming more evident. He w i l l f e e l threatened by so many people around him ( i . e . ) the no. on the ward; and by many of the close r e l a t i o n -ships being s et up among s t a f f and p a t i e n t s . Because of h i s paranoia he would n a t u r a l l y be r e s i s t i v e to many of the suggestions and become h o s t i l e or angry not even being able to release t h i s anger. Throughout the I s r a e l i "paranoid's" records, I was able to l o c a t e examples of "Assessments," such as those c i t e d above, which analysed his character i n psycho-dynamic terms. I t was obvious to me that the thera-p i s t s had r e l i e d upon p s y c h i a t r i c theory to a r r i v e at t h e i r conclusions i n t h i s s e c t i o n . I was puzzled, however, by the material that the ther-a p i s t s c i t e d as the source of t h e i r "Assessments." 145 The p u z z l i n g m a t e r i a l was found i n the "Subjective" and "Objective" s e c t i o n s of the d a i l y e n t r i e s . I t was w r i t t e n up at the same time as the "Assessments," as i t was meant to stand as evidence f o r the views expressed i n the "Assessment" s e c t i o n . I could not, however, make sense of i t . To me, the material was mundane. I d i d not view i t as evidence of a paranoid d i s o r d e r , yet the t h e r a p i s t s were able to read i n t o t h i s m a terial the psycho-dynamic content t h a t they then discussed i n the "Assessment" s e c t i o n . I was able to see the t h e o r e t i c a l s i g n i f i c a n c e of the m a t e r i a l i n that s e c t i o n , but f a i l e d to see how i t could be understood i n terms of the contents of the other two s e c t i o n s . Consider, f o r example, the f o l l o w i n g , which i s r e p r e s e n t a t i v e of the "puzzle" t h a t confronted me: #9 Paranoid, #10 I n t r o v e r s i o n , T h e r a p i s t : ... [ t h e r a p i s t ' s name] Su b j e c t i v e : "I walked around"--"No--I saw no one I knew" "No--I know I'm to get a job and I ' l l s t a r t on i t Monday" "I have an idea" "No I won't t e l l you i n f r o n t of everyone" "No I won't go to my room—why should I t e l l y o u ? — I t ' s simply t h a t I won't stay here a day longer than I have to—won't leach o f f your system any longer" O b j e c t i v e : very angry tone Assessment: --remains paranoid re: exchanging information i n f r o n t of pts. on t o p i c s even as general as "Did you shop?" — remains defensive re: problem sharing with t h e r a p i s t s . --although the topography i s not a thought d i s o r d e r but presenting p a r t l y as a c u l t u r a l behavior type, ...'s [ p a t i e n t ' s name] i n a c c e s s i b i l i t y to therapy the past weeks could be due to a deeply submerged b i z a r r e thought p a t t e r n . I was able to i n t e r p r e t the content of the " S u b j e c t i v e " s e c t i o n , as the t a l k of a person who was upset, angry, and u n w i l l i n g to share his f e e l i n g s . I f e l t t hat any other c u l t u r a l l y competent member might a l s o 146 have viewed h i s conversation t h i s way, and would have agreed t h a t the statement of the "Objective" s e c t i o n was compatible with the mat e r i a l of the " S u b j e c t i v e " s e c t i o n . I f a i l e d to understand, however, how the t h e r a p i s t viewed t h i s t a l k as t h e o r e t i c a l l y r e l e v a n t . Although emotional, none of i t struck me as c h a r a c t e r i s t i c of a person who was n e c e s s a r i l y paranoid, defensive, or dis t u r b e d by "a deeply submerged b i z a r r e thought pa t t e r n . " I could e n t e r t a i n the persp e c t i v e t h a t the conversation stood as evidence of a disturbed i n d i v i d u a l , but could not go beyond th a t l e v e l of a n a l y s i s , and pick out mat e r i a l of t h e o r e t i c a l s i g n i f i c a n c e . I f a i l e d to see how the t h e r a p i s t viewed such mundane t a l k to be t h e o r e t i -cal l y meaningful. I was l e f t f e e l i n g confused, as I had be l i e v e d t h a t my knowledge of the t h e o r e t i c a l l i t e r a t u r e would enable me to see things the way th a t t h e r a p i s t s saw them. I could not grasp why I was unable to do so. I had thought t h a t a knowledge of the l i t e r a t u r e on paranoia would allow one to make p s y c h i a t r i c sense of cases of the d i s o r d e r . I had f a i l e d , however, i n my f i r s t attempt to apply my knowledge. I could not l o c a t e , i n the p a t i e n t ' s t a l k , the t r a i t s t h a t the t h e r a p i s t had i d e n t i f i e d as c h a r a c t e r i s t i c o f the p a t i e n t ' s d i s o r d e r . This "problem" presented i t s e l f each time I compared a t h e r a p i s t ' s "Assessment" with the "Subjec-t i v e " s e c t i o n o f the r e s p e c t i v e entry. I decided t h a t the answer l a y i n my own inexperience. Once I had the opportunity of observing a number of "paranoids" i n therapy, I would be able to make sense of t h e i r con-v e r s a t i o n s i n terms o f my t h e o r e t i c a l knowledge. T h e i r t a l k only seemed mundane because I had not yet heard "paranoids" converse i n the context 24 of a therapy s e s s i o n . 147 I was confused not only by the "Objective," and p a r t i c u l a r l y by the "Subjecti.ve";.sections, however, but also by the "Orders" s e c t i o n which was the f i n a l part of a t h e r a p i s t ' s d a i l y entry. I t was here t h a t a t h e r a p i s t o u t l i n e d a plan f o r d e a l i n g with the d i s o r d e r that they had noted and discussed i n the previous s e c t i o n s of the entry. I was per-plexed, because t h i s s e c t i o n , which I assumed would r e f l e c t a t h e o r e t i -c a l l y d i r e c t e d psychotherapeutic s t r a t e g y , i n s t e a d was a l s o made up of common sense m a t e r i a l . The t h e r a p i s t s ' "Orders" d i d not sound l i k e the orders of t h e r a p i s t s , j u s t as the "paranoids'" t a l k had not sounded l i k e the t a l k of "paranoids." They sounded l i k e the mundane advice of a h e l p f u l l a y person attempting to deal with the problems of someone they knew. They resembled the p u z z l i n g statements that I had heard i n rounds, and from the p a t i e n t ' s current t h e r a p i s t . The "Orders" di d not "come across" as d i r e c t i v e s issued by one versed i n p s y c h i a t r i c theory. Consider, f o r example, the "Orders" t h a t concluded the entry discussed above: Orders: Remains su s p i c i o u s of s t a f f i n t e n t i o n s . --use f r i e n d l y greetings i n h a l l , day room, e t c . to increase h i s sense of "OK" v i a s t a f f . — c o n s i d e r p h e n a l t h i a z i n e therapy to render pt. more a c c e s s i b l e to therapy. I was unable to grasp how the use of " f r i e n d l y greetings" c o n s t i -tuted a psychotherapeutic response to what the same t h e r a p i s t had already described as a "paranoid" d i s o r d e r , p o s s i b l y c h a r a c t e r i z e d by a "deeply submerged b i z a r r e thought p a t t e r n . " The common sense q u a l i t y of the d i r e c t i v e astounded me. The reference to a medication (which w i l l be discussed f u l l y below) sounded medical, but I was unable to 148 understand how the f i r s t order could be seen as a psychotherapeutic d i r e c t i v e . I was not faced, however, with an i s o l a t e d example. In a d d i t i o n to i n s t r u c t i o n s re medications, the "Orders" sections t y p i c a l l y contained mundane d i r e c t i v e s , as the f o l l o w i n g examples w i l l i l l u s t r a t e : Orders: Help him set up short term goals t h a t he can achieve while here, i . e . g e t t i n g a j o b , f i n d i n g places he can j o i n f o r after-work entertainment. Orders: Increase A m i t r i p t y t h i n e up to l i m i t . - - I f t h i s f a i l s to change h i s mood use a combination of A m i t r i p t y t h i n e + Maoi. [a t h e r a p i s t ' s name] w i l l contact Drs. ... and ... re h e l p f u l areas i n the Jewish community. --explore ways of developing community support i n men's clubs (Lions e t c . ) . Orders: Recognize h i s d i f f i c u l t i e s i n r e l a t i o n s h i p s and t a l k to him about h i s ideas of how to overcome t h i s i n h i s way. --Support him re no re a l f e e l i n g s of belonging to any one country or s o c i e t y , e.g. " I t ' s p r e t t y unpleasant not to have any r e a l 'roots' anywhere." I found the mundane q u a l i t y of the t h e r a p i s t s ' "Orders" even more p u z z l i n g than the common sense conversations of the p a t i e n t that were noted i n the "S u b j e c t i v e " s e c t i o n s of the p a t i e n t ' s records. I could at l e a s t f i n d an answer f o r my f a i l u r e to see the t h e o r e t i c a l s i g n i f i c a n c e of the p a t i e n t ' s t a l k , but I could not e x p l a i n the mundane character of the t h e r a p i s t s ' d i r e c t i v e s . As they had engaged i n t h e o r e t i c a l l y based analyses i n the "Assessment" s e c t i o n s , I had expected the t h e r a p i s t s to issue i n s t r u c t i o n s that i n t h e i r s t y l e and content a l s o resembled the 25 ma t e r i a l found i n the p s y c h i a t r i c l i t e r a t u r e . Instead, the "therapy" they ordered, as i l l u s t r a t e d by the examples, d e a l t with f i n d i n g the p a t i e n t jobs and i n t e r e s t groups, g i v i n g him common sense advice re r e a l i s t i c g o a l s , and understanding h i s ideas and f e e l i n g s . Could t h i s 149 be psychotherapy, I wondered? I had p r e v i o u s l y been able to e x p l a i n my primary contact's mundane advice on how to approach and deal w i t h "paranoids." In t h a t i n s t a n c e , I had accounted f o r the common sense q u a l i t y o f a t h e r a p i s t ' s remarks i n terms of h i s conscious transforma-t i o n of the mat e r i a l f o r the purpose of f a c i l i t a t i n g communication. In t h i s case, however, that explanation would not work. The "Orders," a f t e r a l l , were w r i t t e n f o r other t h e r a p i s t s , and ther e f o r e had no need to be transformed. Thus, I was l e f t w i t h another puzzle. How d i d j o i n i n g a Lions c l u b , f o r example, c o n s t i t u t e psychotherapy? I could not grasp the p s y c h i a t r i c meaning of the d i r e c t i v e s . Only one part of the "Orders" seemed t h e r a p e u t i c i n the sense that the l i t e r a t u r e had l e d me to expect. The i n s t r u c t i o n s re the p a t i e n t ' s medications were not common sense m a t e r i a l . They were unquestionably medical i n character. Therapists often l i n k e d these p r e s c r i p t i o n s to the course of the p a t i e n t ' s "therapy," using terms such as: "render p a t i e n t more a c c e s s i b l e , " "change h i s mood," " c o n t r o l depression with medication," e t c . These references d i d not, however, solve the "problem" of the mundane charac-t e r of the other parts of the "Orders," as they were, a f t e r a l l , examples of chemotherapy. I had been unable to l o c a t e i n the "Orders" what I took to be examples o f psychotherapy. I spent a number of days t r y i n g to make sense of the I s r a e l i "paranoid's" c l i n i c a l records. They were, at th a t p o i n t , the most comprehensive and r e a d i l y a v a i l a b l e body of data on paranoia that I had access t o. As I am, by p e r s o n a l i t y , i n c l i n e d to s t r i v e to create order, I attempted to organize my various observations of the c l i n i c a l records 150 i n t o a framework th a t made sense i n terms o f the t h e o r e t i c a l perspec-t i v e s on the d i s o r d e r found i n the l i t e r a t u r e . I discovered, however, that I was unable to i n t e g r a t e a l l of my i n s i g h t s . I set out at f i r s t to c l a r i f y my i n i t i a l impressions of the records, i n terms o f my subsequent thoughts on them. My a n a l y s i s l e d me toward :the major problem t h a t emerged i n my study of them. The records i n e x p l i c a b l y seemed to be both a r e l e v a n t , t h e o r e t i c a l l y based account of the p a t i e n t ' s d i s o r d e r and i t s treatment, and yet at the same time, an unimportant common sense document kept only f o r bureaucratic reasons. I unaccountably was able to i n t e r p r e t the records both ways, depending on which s e c t i o n s I focused upon. Two of my i n i t i a l observations pointed toward the l a t t e r charac-t e r i z a t i o n . I came to see that my e a r l i e r observations of the l e g a l / b u r e a u c r a t i c character o f the records, and the r e p e t i t i v e n e s s of the e n t r i e s , derived from what I had subsequently discovered was the mundane character of the "S u b j e c t i v e , " "Objective," and "Orders" s e c t i o n s . I was not aware at the time of my f i r s t reading of the records, however, t h a t the source of my impressions l a y i n the common sense material of these three s e c t i o n s . I t was only upon subsequent a n a l y s i s , t h a t I connected my impressions with my i n t e r p r e t a t i o n of the three s e c t i o n s , and a r r i v e d at one view of the records. Adopting t h i s approach l e d me to conclude t h a t the records bore no r e l a t i o n to p s y c h i a t r i c theory e i t h e r of the t r a d i t i o n a l v a r i e t y , or of the c r i t i c a l p e rspective which I held. My concerns with respect to the s o c i a l c o n t r o l p o t e n t i a l that I saw to be inherent w i t h i n an i n t r a - p s y c h i c explanation of the d i s o r d e r were of no relevance to the c l i n i c a l records. They were not meant to 151 stand as a p s y c h i a t r i c account of e i t h e r the s t a t e of the p a t i e n t , or the course o f hi s treatment. They were, i n s t e a d , a l e g a l / b u r e a u c r a t i c document kept by the i n s t i t u t i o n f o r l e g a l / b u r e a u c r a t i c reasons, such as the p o s s i b i l i t y o f law s u i t s . According to t h i s i n t e r p r e t a t i o n of the records, my "problem" of making p s y c h i a t r i c sense of the p a t i e n t ' s mundane t a l k , and the t h e r a p i s t s ' mundane orders, was r e s o l v e d , as the records were not to be understood as p s y c h i a t r i c accounts. My l a r g e r problem was not r e s o l v e d , however, by t h i s i n t e r p r e t a -t i o n , as not a l l parts of the records were mundane. I was s t i l l l e f t w i t h my other impression t h a t the records had given me a f u l l e r p i c t u r e of the p a t i e n t ' s d e l u s i o n s , and my view, which I decided was the source of t h i s impression, t h a t the "Assessment" s e c t i o n and the intake and discharge summaries were t h e o r e t i c a l accounts that d i d provide a psyc h i -a t r i c record o f the p a t i e n t ' s d i s o r d e r and h i s ther a p e u t i c progress. Together, these i n t e r p r e t a t i o n s formed a counter explanation of the c l i n i c a l records. From t h i s p e r s p e c t i v e , the records were to be seen as t h e o r e t i c a l l y based documents v i t a l to a p s y c h i a t r i c understanding of the p a t i e n t , and amenable, t h e r e f o r e , to a n a l y s i s i n terms of my s o c i a l c o n t r o l p e r s p e c t i v e . Using t h i s approach, I was l e f t , however, with a reverse problem. This time, I had to make sense of the mundane m a t e r i a l , p a r t i c u l a r l y that found i n the t h e r a p i s t s ' orders. I was faced w i t h another instance of a "switch," as I had been i n my e a r l i e r d i s c u s s i o n with the p a t i e n t ' s t h e r a p i s t . The c l i n i c a l records had not, as I had hoped, c l a r i f i e d the ambiguities that had emerged from t h a t d i s c u s s i o n , but r a t h e r had compounded them. I now faced another confusing s h i f t ( w i t h i n the context of a segment of my observations) 152 from the mundane to the t h e o r e t i c a l . I found the s h i f t (or as I saw i t : the d i s p a r i t y i n my data) i n e x p l i c a b l e , and sought refuge i n my e a r l i e r answer. I decided that I would e v e n t u a l l y l o c a t e a s a t i s f a c t o r y explan-a t i o n t h a t would allow me to resolve the p u z z l e s , and f i t the parts together. My f a i l u r e to do so stemmed, I thought once more, from my lack of r e a l l i f e encounters with "paranoids." Observing them i n therapy would, I decided, provide me w i t h an explanation f o r the prob-lems of i n t e r p r e t a t i o n t h a t continued to confront me. 153 Footnotes ^1 am not alone i n adopting a n a r r a t i v e format. There are other precedents i n the s o c i o l o g i c a l and p s y c h i a t r i c l i t e r a t u r e , i n a d d i t i o n to that s e t by Freud, f o r u t i l i z i n g the n a r r a t i v e s t y l e . See, f o r example: E l a i n e Cummingand John Cumming, Closed Ranks (Cambridge: Harvard U n i v e r s i t y Press, 1957); and Alexander H. Leighton, My Name Is Legion (New York: Basic Books, 1959). 2 I use the term " h i g h l i g h t i n g " i n the sense that I w i l l dwell more e x t e n s i v e l y on c e r t a i n parts of the " s t o r y " (experiences that I took to be of s i g n i f i c a n c e while doing my f i e l d w o r k ) than on others. I t i s my contention t h a t these s i g n i f i c a n t experiences are a l s o those t h a t best i l l u s t r a t e the v a l i d i t y of my argument. 3 I had walked and driven many times past the h o s p i t a l , but had never had an occasion to enter i t . P s y c h i a t r i c h o s p i t a l s , l i k e p r i s o n s , are p u b l i c b u i l d i n g s that deny one the opportunity of unscheduled v i s i t s . One must, i n other words, have some reason, deemed l e g i t i m a t e , f o r e n t e r i n g t h i s type of s o c i a l space. 4 Peter Berger, Invitation to Sociology: A Humanistic Perspective (Garden C i t y , N.Y.: Anchor Books, 1963), pp. 31-32. 5 I assumed that she was not a doctor or an i n t e r n , as she appeared to be " s e r v i c i n g " the f r o n t counter of the nursing s t a t i o n . g L i k e a l l ethnographers, I worked hard to e s t a b l i s h a p o s i t i v e r e l a t i o n s h i p w i t h the members of the " c u l t u r e " t h a t I was studying. My task, as was and w i l l be discussed elsewhere, was not made e a s i e r , as t h i s was a p s y c h i a t r i c and, t h e r e f o r e , "closed" f a c i l i t y . ^1 had, i n f a c t , begun to keep f i e l d n o t e s and a j o u r n a l from the time of my f i r s t v i s i t , but i t was not u n t i l t h i s p o i n t t h a t I came to recognize that I was r e a l l y p l a y i n g the r o l e of an ethnographer. g In r e t r o s p e c t , I b e l i e v e t h a t my d e s i r e to maintain a "low p r o f i l e " stemmed as much from my need to " f i t i n " and thereby reduce s t r e s s and i n s e c u r i t y , as i t d i d from my need to e f f e c t i v e l y pursue my research. One could argue, of course, that the reduction of s t r e s s d i d , i n i t s e l f , help to f a c i l i t a t e my endeavour. 9 I was s u r p r i s e d that the c l i n i c a l s upervisors d i d not concern themselves with the r e g u l a t i o n of my a c t i v i t i e s . I assumed that they, as the p s y c h i a t r i s t s i n charge of the wards where I would be conducting my research, would be the ones who would be prone to imposing c o n t r o l s over my f i e l d w o r k . That i t was the a d m i n i s t r a t o r s who adopted t h i s 154 stance, can, I b e l i e v e , be explained i n terms of the "gap" between o f f i c i a l p o l i c i e s and actual p r a c t i c e s on the wards. I t i s the task of a d m i n i s t r a t o r s i n any i n s t i t u t i o n to generate and maintain a framework of o f f i c i a l p o l i c i e s f o r t h e i r i n s t i t u t i o n , and to c o n t r o l the i n t e r -a c t i o n between t h e i r i n s t i t u t i o n and the "outside" world. I t i s the task of personnel working w i t h i n an i n s t i t u t i o n , however, to get t h e i r work done. I discovered t h a t the two tasks were not n e c e s s a r i l y com-p a t i b l e . As an " o u t s i d e r " a c t i v e w i t h i n the i n s t i t u t i o n , I was f r e q u e n t l y faced with the c o n t r a d i c t o r y demands of these d i f f e r e n t t a s k s , which created s t r e s s f o r me. I t i s important to point out once more that I recognize the source of the a d m i n i s t r a t o r s ' demands, and hold no negative f e e l i n g s toward them, nor do I seek to develop a c r i t i q u e of the i n s t i t u t i o n based upon my discovery of t h i s "gap." The f o l l o w i n g i s taken from the research proposals that I submitted to the h o s p i t a l and to the E t h i c s Committee of my u n i v e r s i t y , and from the minutes of the meeting of the h o s p i t a l Research Committee at which my proposal was reviewed. I t may serve to inform the reader of the extensive regula-t i o n s to which I was f o r m a l l y committed. (1) The researcher w i l l not use the records i n the nursing s t a t i o n , but rather w i l l peruse them i n the Medical Records O f f i c e upon discharge of the p a t i e n t . Thus, there w i l l be no i n t e r f e r e n c e w i t h the work normally c a r r i e d on i n the nursing s t a t i o n . The p a t i e n t s w i l l be chosen i n c o n s u l t a t i o n with the C l i n i c a l Supervisors of the three wards and the primary t h e r a p i s t s of the p a t i e n t s who are s e l e c t e d . Written consent to p a r t i c i p a t e i n the study w i l l be obtained from both the t h e r a p i s t s and the p a t i e n t s i n accordance with the r e g u l a t i o n s of the Faculty of Medicine Committee on Research I n v o l v i n g Human Subjects. The research w i l l be conducted under the s t r i c t s u p e r v i s i o n of the p a t i e n t ' s primary t h e r a p i s t , the C l i n i c a l Supervisor of the ward, and the other p s y c h i a t r i c s t a f f of the ward. The researcher w i l l be check-ing regularly, with the Head Nurse and C l i n i c a l Supervisor to make sure th a t the research i s not d i s r u p t i n g the r o u t i n e of the ward. The researcher w i l l make every e f f o r t to ensure that h i s presence and work does not i n t e r f e r e w i t h the f u n c t i o n i n g of the p s y c h i a t r i c h o s p i t a l . (2) The primary t h e r a p i s t s w i l l be contacted by the i n v e s t i g a t o r through t h e i r c l i n i c a l s u p e r v i s o r s . The i n v e s t i g a t o r w i l l inform them of the nature of the study, as o u t l i n e d above, and w i l l gain t h e i r w r i t t e n consent to observe and tape t h e i r i n t e r a c t i o n with the p a t i e n t s i n therapy sessions. In a d d i t i o n , the i n v e s t i g a t o r w i l l gain t h e i r w r i t t e n consent to examine the c l i n i c a l records that they keep. The paranoid subjects w i l l be contacted through t h e i r primary t h e r a p i s t s . They w i l l be informed by the i n v e s t i g a t o r that he i s a u n i v e r s i t y student who i s c a r r y i n g out a study of the i n t e r a c t i o n between p a t i e n t s and t h e i r t h e r a p i s t s . In the presence of the subject's t h e r a p i s t , the i n v e s t i g a t o r w i l l inform the subject t h a t h i s / h e r thera-p i s t has agreed to p a r t i c i p a t e i n the study, and the i n v e s t i g a t o r w i l l put forward the idea t h a t the subject might a l s o p a r t i c i p a t e . The s u b j e c t w i l l be t o l d that the i n v e s t i g a t o r i s i n t e r e s t e d i n f i n d i n g out 155 the way that the subject and hi s / h e r t h e r a p i s t communicate and what d i f f i c u l t i e s e x i s t i n t h e i r communication. The i n v e s t i g a t o r wil;li note th a t he i s i n t e r e s t e d i n how the subject and hi s / h e r t h e r a p i s t " s o r t out" these d i f f i c u l t i e s . The subject w i l l be informed that the inves-t i g a t o r would l i k e to f i n d out these things by observing and taping the subject's therapy s e s s i o n s , and by examining the subject's c l i n i c a l records. Should the subje c t request a f u l l e r d e s c r i p t i o n of the study, then t h i s w i l l be given. I f the subject agrees to p a r t i c i p a t e , then the i n v e s t i g a t o r w i l l gain h i s / h e r w r i t t e n consent. (3) Mr. Maidstone was a l s o submitting the proposal f o r co n s i d e r a t i o n by the Screening Committee f o r I n v e s t i g a t i o n s I n v o l v i n g Human Subjects of the Faculty of Medicine. The f o l l o w i n g points were e i t h e r contained i n the o r i g i n a l proposal or emerged i n the course o f d i s c u s s i o n : (a) Each of the p a t i e n t s would sign a v a l i d consent form permit-t i n g the recording and observation. (b) Each o f the primary t h e r a p i s t s would a l s o s i g n a v a l i d consent form on each occasion t h a t a session was recorded and/or observed. (c) For each p a t i e n t , Mr. Maidstone would obtain the approval of the c l i n i c a l s u p e r v i s o r and of the head nurse before proceed-ing to record and/or observe the sessions. (d) In response to a s p e c i f i c question from the chairman, Mr. Maidstone undertook that the tapes would be t r a n s c r i b e d only by himself or h i s w i f e , t h a t they would be erased immediately a f t e r t r a n s c r i p t i o n and th a t no one other than he or his w i f e would have access to the tapes. Neither p a t i e n t nor primary t h e r a p i s t would be i d e n t i f i e d by name i n the t r a n s c r i p t or i n any record made from the t r a n s c r i p t o r , i n p a r t i c u l a r , i n Mr. Maidstone's Ph.D. t h e s i s . (e) For each taping s e s s i o n , the primary t h e r a p i s t would record h i s c l i n i c a l opinion that the p a t i e n t understood the nature of the consent he had given. This statement by the primary t h e r a p i s t together w i t h the primary t h e r a p i s t ' s own w r i t t e n consent would be entered i n the p a t i e n t ' s chart at the time of the taping. ( f ) Mr. Maidstone would a l s o r e q u i r e access to the charts of the four p a t i e n t s whom he was i n v e s t i g a t i n g . I t was agreed by the Committee that t h i s was reasonable subject to the usual safe-guards. ^ 1 subsequently found out that my primary contact had f a i l e d to inform the a d m i n i s t r a t o r of my research plans, and when questioned about them, had not given his support. ^My i n t e r a c t i o n with p s y c h i a t r i s t s was, at that p o i n t , subject to some s u s p i c i o n on my p a r t , with respect to the p s y c h i a t r i s t s ' motives. L i k e other lay persons, I often f e l t t h a t I was being p r o f e s s i o n a l l y evaluated by them. The source of my f e e l i n g l a y i n my b e l i e f that a 156 t h e r a p i s t would i n v a r i a b l y assess others i n terms of h i s / h e r p s y c h i a t r i c t h e o r e t i c a l knowledge. Being steeped i n a body of knowledge, he/she could not help but use i t to evaluate others. 12 Joan Emerson, "Behaviour i n P r i v a t e Places: S u s t a i n i n g D e f i n i -t i o n s of R e a l i t y i n Gynecological Examinations," i n Recent Sociology No. 2, ed. Hans D r e i t z e l (New York: Macmillan, 1972). 13 This experience confirmed my view that the h o s p i t a l saw i t s e l f as a "closed" e n t i t y , and f e l t the need to p r o t e c t i t s e l f from i n t r u -sions by " o u t s i d e r s . " 14 See, f o r example: S i l v a n Tomkins, Affect—Imagery—Consciousness (New York: Springer P u b l i s h i n g , 1963); and Libuse Tyhurst, "Displacement and M i g r a t i o n , " American Journal of Psychiatry , 107 (1951). 15 In a r r i v i n g at t h i s e x p l a n a t i o n , I took i n t o account the f a c t t h a t a l l the t h e r a p i s t s were women, and the c l i n i c a l s u p e r v i s o r was a male. I b e l i e v e d that the sex d i f f e r e n c e gave him f u r t h e r power to d i c t a t e the s t y l e of the proceedings. 16 His response s u r p r i s e d me, as he described "paranoids" as com-p u l s i v e s t o r y - t e l l e r s who f o r e v e r sought an audience. The l i t e r a t u r e had l e d me to expect that they would d i s t r u s t a l l i n t r u d e r s , p l a c i n g them i n t o what Cameron termed the paranoid "pseudo-community." ^7My f e a r was, i n p a r t , a t h i r d f a c t o r i n my negative response to the t h e r a p i s t ' s question re my involvement with p a t i e n t s . I Q Having spent much time reading and t h i n k i n g about "paranoids," I was eager to f i n a l l y observe one. Although i t may sound c a l l o u s , and despite my lack of commitment to the d i a g n o s t i c nomenclature, I had a f e e l i n g akin to t h a t of a z o o l o g i s t who, having e x t e n s i v e l y studied the c h a r a c t e r i s t i c s o f a s p e c i e s , was on the verge of f i n a l l y seeing one of i t s members. 19 My d e c i s i o n was based upon her c a s u a l , unprofessional s t y l e of d r e s s i n g , and manner of speech, which stood i n c o n t r a s t to t h a t of the t h e r a p i s t s . 20 By c o n t r a s t , see my e a r l i e r d i s c u s s i o n of the c l i n i c a l super-v i s o r ' s joke made during the meeting of the h o s p i t a l Research Committee. 21 I am drawing a d i s t i n c t i o n between adequate and meaningful according to the d i s t i n c t i o n between any c u l t u r a l l y competent member's i n t e r p r e t a t i v e schema and my own schema, which was a l s o made up of my 157 t h e o r e t i c a l p e r s p e c t i v e . Thus, I use the term "meaningful" or " r e l e v a n t " i n the sense t h a t I was able to place the material i n question w i t h i n my own t h e o r e t i c a l p erspective. 22 For a more d e t a i l e d o u t l i n e o'f the s t r u c t u r e of the c l i n i c a l records, see chapter one. I t i s important to note that I am not r e f e r r i n g s o l e l y to my own t h e o r e t i c a l perspective on the d i s o r d e r ; but r a t h e r to any or a l l theo-r e t i c a l perspectives to be found i n the l i t e r a t u r e . 24 I f e l t t h a t my t h e o r e t i c a l knowledge of the d i s o r d e r was ade-quate, but my lack of p r a c t i c a l experience hampered me i n my e f f o r t to make p s y c h i a t r i c sense of "paranoid's" t a l k . I d i d not a n t i c i p a t e e v e n t u a l l y being able to c o n s t r u c t , as t h e r a p i s t s d i d , a t h e o r e t i c a l account of "paranoids'" conversations, but d i d assume t h a t I would be able to i d e n t i f y such t a l k as t a l k c h a r a c t e r i s t i c of "paranoids," rather than viewing i t as the common sense t a l k o f upset, d i s t u r b e d , and f r i g h t e n e d i n d i v i d u a l s . 25 I put the term "therapy" i n quotation marks i n order to express the extent of my d i s b e l i e f . The m a t e r i a l i n the "Orders" d i d not even approximate what I had expected. 158 CHAPTER 4 THE PUZZLES ARE NOT RESOLVED: THE RESEARCHER OBSERVES PSYCHOTHERAPY The "Paranoid's" Uncharacteristic Talk: The Patient's Talk Does Not Make Sense as Expected I f i n i s h e d my study of the I s r a e l i "paranoid's" c l i n i c a l records two days before I was to observe him i n therapy. The records had brought me one step c l o s e r to my f i r s t encounter with a "paranoid." Despite the puzzles that I had discovered i n them, and had experienced e a r l i e r , I remained confident t h a t my "map" would u l t i m a t e l y prove to be an accurate guide to my observations. I b e l i e v e d t h a t my "problems" of i n t e r p r e t a t i o n would be r e s o l v e d , once I had the opportunity to observe therapy s e s s i o n s . I assumed t h a t I would witness t h e o r e t i c a l l y d i r e c t e d psychotherapy, which would take a p a r t i c u l a r form. My assumption was based upon my understanding of the r e l a t i o n s h i p between p s y c h i a t r i c theory and prac-t i c e . ^ The therapy would be based on an i n t r a p s y c h i c perspective which would lead the t h e r a p i s t to ignore the re a l persecution experienced by the p a t i e n t , and search i n s t e a d f o r inner d e f e c t s , which would culminate i n an i n v a l i d a t i o n o f the p a t i e n t ' s d e f i n i t i o n of r e a l i t y . The theory would give r i s e , t h e r e f o r e , to the e x e r c i s e of s o c i a l c o n t r o l . The psychotherapy p r a c t i s e d by the t h e r a p i s t would be a response ( a l b e i t , i n my view, a misguided response) to a p a t i e n t whom I , and others f a m i l i a r with p s y c h i a t r i c theory, would be able to i d e n t i f y as e x h i b i t i n g 159 2 behaviour c i t e d i n the l i t e r a t u r e as c h a r a c t e r i s t i c of the d i s o r d e r . I continued to hold t h i s view i n s p i t e of my "problems" of making sense of t h e r a p i s t s as t h e r a p i s t s , and making sense of the I s r a e l i "paranoid" as a "paranoid." Although these problems put i n t o question both the t r a d i t i o n a l and my own c r i t i c a l perspectives on the d i s o r d e r , as they r a i s e d doubts about the taken-for-granted r e l a t i o n s h i p between p s y c h i a t r i c theory and p r a c t i c e , my commitment to my views d i d not waver... I t stemmed from my b e l i e f that my inexperience with the "prac-t i c a l " s i d e of p s y c h i a t r y obscured my understanding of i t . Furthermore, I had been able to f i n d other s a t i s f a c t o r y explanations f o r some of the p u z z l e s , such as the transformation of material f o r the purposes of communication. F i n a l l y , I had, a f t e r a l l , encountered material that d i d f i t w i t h my expectations. Therapists t h a t I had met were w e l l versed i n the l i t e r a t u r e , and had given me p s y c h i a t r i c accounts of p a t i e n t s , and analyses of the d i s o r d e r that were t h e o r e t i c a l l y based, and i n t r a p s y c h i -c a l l y o r i e n t e d , as I had a n t i c i p a t e d . In the c l i n i c a l records, I had read t h e r a p i s t s ' e n t r i e s that d i d make p s y c h i a t r i c sense (even i f I had been unable to) of the p a t i e n t ' s conversations. Thus, at that p o i n t , I had no reason to doubt the v a l i d i t y of my perspective on the d i s o r d e r , or to fundamentally re-evalue my understanding of the r e l a t i o n s h i p between p s y c h i a t r i c theory and p r a c t i c e . I continued to be confronted with puzzles through the course of my f i e l d w o r k , but I d i d not r e j e c t my views o u t r i g h t u n t i l some time a f t e r I f i n i s h e d i t , as I p e r s i s t e d i n seeking and l o c a t i n g s u i t a b l e explana-t i o n s f o r the "problems" of i n t e r p r e t a t i o n t h a t I faced. I t was not u n t i l I had time to r e t r o s p e c t i v e l y r e f l e c t upon my f i e l d w o r k experience 160 t h a t I came to see t h a t the doubts which I had explained away while i n the research s e t t i n g , c o l l e c t i v e l y undermined the perspective which I 3 had been r e l y i n g upon. Two days a f t e r f i n i s h i n g my study of h i s c l i n i c a l records, I was introduced to the I s r a e l i p a t i e n t , and had my f i r s t opportunity to observe psychotherapy with a "paranoid." The p a t i e n t , whom I met i n one of the therapy rooms of the o u t - p a t i e n t ward, was a middle-aged male who, to my s u r p r i s e , i n appearance, looked p e r f e c t l y normal, and could perhaps have been described as somewhat d i s t i n g u i s h e d . ^ I had hoped t h a t the therapy session would be conducted i n one of the observation rooms, which would have allowed me to observe without being seen, but the p a t i e n t had not agreed to t h i s procedure. Obtaining h i s consent to even tape the s e s s i o n , and to observe him i n the same room, had been problematic. As had been p r e d i c t e d by the c l i n i c a l s u p e r v i s o r and the s e c r e t a r y i n t h e i r j o k e s , the p a t i e n t was most r e t i c e n t to allow me to 5 become involved with his therapy s e s s i o n . The t h e r a p i s t had to introduce the p a t i e n t to my proposed study on a step by step b a s i s , i n order to overcome hi s negative responses. A f t e r having been presented with a summary of what I intended to do, he declared that i t would be an " i n v a s i o n of h i s p r i v a c y . " Upon prodding from the t h e r a p i s t , he agreed to be observed and taped, but not i n an observation room. I t was, he s a i d , " d e f i n i t e l y out of the question there." He would only agree at a l l , he s t a t e d , i n order to "keep h i s good r e l a t i o n s h i p with the h o s p i t a l . " The t h e r a p i s t then t o l d him that he had to s i g n a consent form, which appeared to upset him f u r t h e r , as he saw the form not as a document f o r h i s own p r o t e c t i o n , but, as he put 161 i t : "something that could be used against me." The t h e r a p i s t o f f e r e d him assurances, and a f t e r much h e s i t a t i o n , he signed. One more issue was then r a i s e d . The t h e r a p i s t asked permission, on my b e h a l f , f o r me to observe a number of h i s sessions. The p a t i e n t again responded nega-t i v e l y , agreeing to only two, but the t h e r a p i s t t o l d me a f t e r the session t h a t she thought she could persuade him to agree to more (I e v e n t u a l l y observed four sessions with t h i s p a r t i c u l a r p a t i e n t ) . I was unsure how to i n t e r p r e t the pa t i e n t ' s responses to my requests. I t was d i f f i c u l t to decide how to c h a r a c t e r i z e them, as they could be seen to be based upon both r e a l i s t i c and u n r e a l i s t i c concerns. On the one hand, anyone might r e j e c t a request to be taped and observed, given the c o n f i d e n t i a l nature of the psychotherapy s e s s i o n . Looking at h i s a c t i o n s from t h i s p e r s p e c t i v e , they could be i n t e r p r e t e d to be of no psyc h o l o g i c a l s i g n i f i c a n c e . On the other hand, h i s behaviour could have been viewed as t h a t c h a r a c t e r i s t i c of a "paranoid," who, by d e f i n i t i o n , was a f f l i c t e d by u n j u s t i f i e d f e a r s . This was the view that I assumed the c l i n i c a l s u p e r v i s o r had been a l l u d i n g to ( i n a transformed common sense form) i n h i s joke made during my meeting with the h o s p i t a l research committee. Neither of these i n t e r p r e t a t i o n s f i t with my observations, however. I sensed t h a t the p a t i e n t was f r i g h t e n e d to an u n r e a l i s t i c e x tent, y e t I d i d not have to r e l y upon my knowledge of the l i t e r a t u r e on paranoia to r e a l i z e t h i s . I knew i n t u i t i v e l y , by the sound of his v o i c e , and the look i n h i s eyes, t h a t I was observing an i n d i v i d u a l who was dw e l l i n g on more than merely the p r o t e c t i o n of h i s p r i v a c y , y e t at the same time, he d i d not behave i n ways th a t I could i d e n t i f y to be c h a r a c t e r i s t i c of a 162 "paranoid." I w a s p u z z l e d by t h i s , as I had expected that I would be able to d i s t i n g u i s h between normal and abnormal behaviour, s o l e l y by making reference to the d e s c r i p t i o n s of the di s o r d e r o u t l i n e d i n the l i t e r a t u r e . I was unable to view h i s f e a r as reasonable by drawing upon my perspective on the d i s o r d e r , and seeing him as a p o s s i b l e v i c t i m of past or present p e r s e c u t i o n , nor d i d I draw, however, upon other theo-r e t i c a l perspectives i n making my judgement about h i s mental s t a t u s . I t was strange f o r me because i t was as i f a l l the l i t e r a t u r e on the d i s o r d e r was i r r e l e v a n t to what I was observing, w h i l e , at the same time, I had the expectation that what I observed would make sense by v i r t u e of my knowledge of the l i t e r a t u r e . I put these thoughts aside once the f o r m a l i t i e s of o b t a i n i n g con-sent were completed, and focused my a t t e n t i o n on the dialogue that had begun between the p a t i e n t and the t h e r a p i s t . I was seated to the side of the p a t i e n t and the t h e r a p i s t , who faced each other across a coffee t a b l e , which allowed me to avoid making eye contact w i t h e i t h e r of them. I concentrated on t h e i r c o n v e r s a t i o n , searching f o r material of theore-t i c a l s i g n i f i c a n c e , w h i l e at the same time making f i e l d n o t e s and keeping t r a c k of my tape recorder. By half-way i n t o the hour-long s e s s i o n , I had developed an o v e r a l l impression of what I was observing. Foremost i n my mind was the sense o f normality t h a t p r e v a i l e d ; a middle-aged I s r a e l i man and a young woman were s i t t i n g i n a modernly furnis h e d room, d i s c u s s i n g a range of t o p i c s , i n c l u d i n g his personal problems. The f o l l o w i n g i s t y p i c a l of t h e i r dialogue: P a t i e n t : Jews do not allow anybody to t a l k c a t e g o r i c a l l y against them. I have yet to see i n the paper anybody that has w r i t t e n against a l l t h i s commotion about 163 Jewish, Russian Jewish people to I s r a e l . I t i s j u s t a part of the propaganda, the long scare that has to do with the cold war. Therapist: Urn hum. P a t i e n t : And a l l the r e s t of i t . And th a t was b a s i c a l l y i t . I came up to speak at the time that the So v i e t Premier was i n Vancouver. I don't know i f you remember. Ther a p i s t : Yes, I do. P a t i e n t : They t r i e d to attack him, and i n f a c t they d i d attack him i n Toronto, and i t was t h i s time that I r e a l l y , I was consciously f e l t who the h e l l do you think you are f o r heaven's sake? How are you going to attack a person who comes as a v i s i t o r i n your country? Where i s your h o s p i t a l i t y ? Well a l l that's what r e a l l y burned me up. (( ) ) . Thera p i s t : So that r e a l l y , i t , i t ah, was p r e t t y u p s e t t i n g to you was i t ... [ p a t i e n t ' s name]? P a t i e n t : Very much so. Therapist: Were you upset, were they Jewish, the people who were a f t e r him? The Premier? P a t i e n t : I beg your pardon? Ther a p i s t : W e l l , the a t t a c k e r s , were they Jewish? P a t i e n t : No. Thera p i s t : They weren't. P a t i e n t : They were Hungarian. T h e r a p i s t : So i t was kind of against anyone who would a t t a c k . P a t i e n t : Yeh, but at the same time there were w r i t t e n reports about some Jews who were a t t a c k i n g and shooting at the Soviet Embassy i n New York. The r a p i s t : Yes. P a t i e n t : And they i n j u r e d a few c h i l d r e n . A l l those things together. T h e r a p i s t : Urn hum. 164 P a t i e n t : Were a group c a l l e d who themselves the Jewish Defence League l e d by a rabbi who wrote a book, and ... T h e r a p i s t : Yes, I've heard. P a t i e n t : And he went to I s r a e l and propagated to kick the Arabs out of I s r a e l . He i s a r a b b i . He i s a born New Yorker who goes to I s r a e l and he t e l l s them to get r i d of the Arabs of I s r a e l ! T h e r a p i s t : That's as bad as an I s r a e l i t e l l i n g the Russians what to do, huh? Right? P a t i e n t : Yeh. That's r i g h t . I am p r e t t y upset about i t . I'm an I s r a e l i . N e ither the segment quoted above, nor the r e s t of t h e i r dialogue, provided me with the means, as I had hoped, to resolve my e a r l i e r puz-z l e s . I was l e f t , i n s t e a d , w i t h the impression t h a t there s t i l l was an i n e x p l i c a b l e gap between the l i t e r a t u r e on paranoia, and my observations. The p a t i e n t d i d not, f o r example, come across i n the session as the type of person i d e n t i f i e d i n the l i t e r a t u r e as a "paranoid." His conversation was mostly mundane, e x h i b i t i n g few of the c h a r a c t e r i s t i c s t h a t I had expected to f i n d . There was nothing "paranoid" per se i n h i s strong views on Zionism, Russian Jewish emigration, or Jewish n a t i o n a l i s m . Being an I s r a e l i who dissented from the commonly held views of Z i o n i s t s , he n a t u r a l l y f e l t emotional about these t o p i c s and others that he r a i s e d i n the s e s s i o n , which i n c l u d e d , amongst o t h e r s , an a n a l y s i s of the r e l a t i o n s h i p between being Jewish, and being a Z i o n i s t . These were themes that dominated the existence of many I s r a e l i s and Jews, and I could not, t h e r e f o r e , c h a r a c t e r i z e h i s d i s c u s s i o n of these t o p i c s as "paranoid." I had, a f t e r a l l , heard o t h e r s , who had not been l a b e l l e d "paranoid," presenting views i d e n t i c a l to h i s . 165 I was unable to apply an i n t r a p s y c h i c a n a l y s i s to h i s behaviour. I could not make sense of i t i n terms of excessive p r o j e c t i o n , and other i n t r a p s y c h i c d e f e c t s , as the t h e r a p i s t s had done i n the " t h e o r e t i c a l l y based" sections of the c l i n i c a l records. Nor could I apply my own counter perspective to h i s behaviour. I f the p a t i e n t had seemed sane, then I could have made use of my own t h e o r e t i c a l perspective to analyse his d i s o r d e r . This approach would have "worked," as h i s claims of being persecuted by Z i o n i s t s , i f taken at face value, would have placed him d i r e c t l y w i t h i n the t h e o r e t i -cal framework that I had evolved p r i o r to en t e r i n g the research s e t t i n g . I might a l s o have searched i n h i s past f o r i n c i d e n t s of an t i - s e m i t i s m that could have unconsciously motivated h i s f e e l i n g s of persecution. I could have seen him as a v i c t i m of persecution. There was a problem, g however. I i n t u i t i v e l y knew him to be insane. I had a r r i v e d at t h i s c o n c l u s i o n , without r e l y i n g upon e i t h e r a t r a d i t i o n a l i n t r a p s y c h i c e x p l a n a t i o n , or my own t h e o r e t i c a l c o n f i g u r a t i o n . Neither perspective helped me to make sense o f hi s behaviour, as my i n s i g h t i n t o h i s mental status was d e r i v e d , I r e a l i z e d , from my own " f e e l i n g s " that h i s behav-i o u r was abnormal, r a t h e r than from some t h e o r e t i c a l perspective that I had acquired from the l i t e r a t u r e . I knew the p a t i e n t to be insane, because I r e a l i z e d t h a t he was att a c h i n g personal s i g n i f i c a n c e to l a r g e r s o c i o - p o l i t i c a l issues i n ways t h a t were u n r e a l i s t i c . ' ' Segments of the above noted conversation were clues to h i s i n s a n i t y . Take f o r example, the f o l l o w i n g statement: And a l l the r e s t of i t . And that was b a s i c a l l y i t . I came up to speak at the time. . . . 166 I i n t u i t i v e l y l i n k e d t h i s passage to others i n the therapy s e s s i o n , i n which the p a t i e n t discussed h i s "downfall" (the loss of hi s business). He a t t r i b u t e d h i s l o s s to the acti o n s of Z i o n i s t s who were seeking, he b e l i e v e d , to s i l e n c e him because he had sent c r i t i c a l l e t t e r s to a number of Jewish and non-Jewish newspapers and o r g a n i z a t i o n s . The phrase " b a s i c a l l y i t " t h a t he used, was, I r e a l i z e d , a reference to his delusion t h a t he had come under s u r v e i l l a n c e , and h i s property had been entered and damaged, as a consequence of hi s l e t t e r w r i t i n g . Some of these ideas are expressed i n the f o l l o w i n g passages taken from the se s s i o n : A. Th e r a p i s t : There was another issue there too. Right? P a t i e n t : That's r i g h t . T h e r a p i s t : You were p r e t t y concerned a f t e r you s a i d t h a t . That people, some of the people i n the Jewish o r g a n i z a t i o n s e t c . were being, ah, somehow out to get you. P a t i e n t : Yup. I've t a l k e d to a f r i e n d of mine inv o l v e d i n the B e t t e r Business Bureau. He t o l d me one of the th i n g s . A Jewish person approached him, and asked him about me. Thera p i s t : And that l e d you to b e l i e v e that perhaps people were against you? P a t i e n t : I t was the very same period of time that I have sent, ah, some of the l e t t e r s to Jewish o r g a n i z a t i o n s . I made a copy of the l e t t e r s , and I spread i t across the country. P a t i e n t : That's what happened to me. I worked f o r years. I di d my business. I worked so hard to make ends meet. For years I d i d without t h i n g s . F i n a l l y , I was manoeuvred, and forced to give i t up. I s a c r i f i c e d my ( ( ) ). I had to s e l l my tr u c k . Every night I go through treachery. Constantly i t bothers me that I gave up my business and so on. ( ( ) ). The r a p i s t : You were f e e l i n g t h a t the, ah, the business was, ah, ( ( ) )? 167 P a t i e n t : Sure, I was broken i n t o my place. T h e r a p i s t : Urn hum. P a t i e n t : And I was broken i n t o my place of business. And I've been bugged, home and places l i k e t h a t ... Ther a p i s t : How d i d you know that ... [ p a t i e n t ' s name]? P a t i e n t : Because I have contacted my. I have approached the Attorney-General, and I am w i l l i n g to t a l k to him, Mr. ... [Attorney-General's name], bull he refused to l e t me t a l k to him. Th e r a p i s t : Because you wanted to t a l k to him about ... P a t i e n t : I asked him f o r p r o t e c t i o n , because I s a i d I have w r i t t e n l e t t e r s ... Ther a p i s t : Urn hum. P a t i e n t : That are q u i t e s e r i o u s , and I'm a f r a i d f o r my l i f e , and asked him, from him f o r p r o t e c t i o n . They laughed at me. Therapist: You wrote l e t t e r s to Jewish newspapers, r i g h t ? P a t i e n t : Jewish o r g a n i z a t i o n s , r i g h t . T h e r a p i s t : Here i n Canada. P a t i e n t : Here i n Canada, r i g h t . T h e r a p i s t : What, what made you think that your telephone was tapped ... [ p a t i e n t ' s name]? P a t i e n t : I b e l i e v e t h a t my phone was being tapped. ( ( ) ). I may be wrong, but ... Ther a p i s t : Is i t now? P a t i e n t : No;3 i t i s not now. I may be wrong, but I s t i l l b e l i e v e that i t has been. Therapist: Would you, would you t e l l me what made you b e l i e v e that? What things made you b e l i e v e that? P a t i e n t : As I s a i d before, I may be wrong ... Th e r a p i s t : Okay, I see ... 168 P a t i e n t : I'm, i t ' s q u i t e p o s s i b l e that my phone has been tapped and the reason t h a t my place has been broken and my place of business has been broken i n , i n an attempt to scare me out, and they succeeded. I've given the business away. I r e a l i z e d that I d i d not have to r e f e r to the l i t e r a t u r e , or be t r a i n e d as a t h e r a p i s t , to i d e n t i f y the p a t i e n t as insane, but when I d i d t r y to match my observations of him with the l i t e r a t u r e , they d i d not f i t . I could not make sense of the material that I had i d e n t i f i e d as p o i n t i n g to h i s i n s a n i t y , i n terms of the l i t e r a t u r e on paranoia. I knew him to be insane, but my:.knowing d i d not derive from my knowledge of the l i t e r a t u r e . I was l e f t i n a quandary, as I was unsure of how to i n t e r p r e t my observations and impressions. In the nursing s t a t i o n a f t e r the s e s s i o n , I discussed my experiences with the c l i n i c a l s u p e r v i s o r : C l i n i c a l Supervisor: So, were you convinced by ... [ p a t i e n t ' s name] ideas? Researcher: W e l l , taken away from him, they are not d e l u s i o n a l . I t s j u s t the way that he r e l a t e s them back to h i s own l i f e that the delusion comes i n . C l i n i c a l S upervisor: Yes, that's i t . Our conversation d i d not help me to s o r t out the problems of i n t e r p r e t a t i o n that I faced. I knew th a t I had i n t u i t i v e l y i d e n t i f i e d the p a t i e n t to be insane, but had been unable to make sense of h i s "paranoia" i n terms of my own or other t h e o r e t i c a l p e r s p e c t i v e s . As the c l i n i c a l s u p e r v i s o r was a p s y c h i a t r i s t , I a l s o "knew" that he must have i d e n t i f i e d the p a t i e n t to be insane by r e l y i n g upon his knowledge of p s y c h i a t r i c theory. He a l s o was able to u t i l i z e h i s t h e o r e t i c a l know-ledge to give a p s y c h i a t r i c account of the nature of the p a t i e n t ' s 169 d i s o r d e r . I f he could use the th e o r i e s of the l i t e r a t u r e , and I could not, how, I wondered, d i d we manage to agree about the p a t i e n t ' s delu-sion? Since I had been unable to make sense using my knowledge of p s y c h i a t r i c theory, I took i t that we were using d i f f e r e n t l i n e s of reasoning, y e t we both a r r i v e d at the same c o n c l u s i o n ; the p a t i e n t was insane. My i n a b i l i t y to make sense of hi s d i s o r d e r , or to i d e n t i f y h i s t a l k as t a l k c h a r a c t e r i s t i c of a "paranoid," had not hampered the accur-acy o f my judgement of his mental s t a t u s . I had been able to pick out of h i s conversation the clues which pointed to h i s i n s a n i t y , yet I had done so without making reference to p s y c h i a t r i c theory. To my s u r p r i s e , the p s y c h i a t r i s t had agreed with my assessment. I f we were using d i f f e r e n t l i n e s of reasoning (common sense and p s y c h i a t r i c ) , why,