Psychiatric Diagnosis in a Woman’s Personal Narrative: Possibilities of Semiotic Analysis
Motherhood is a potentially disruptive experience in the life cycle. When the psychiatric diagnosis is added to this experience, it can become even more complex. Understanding the diagnostic categories as semiotic mediators, the present article seeks to analyze, through a narrative, the ways in which a woman diagnosed with a mental disorder gives meaning to her psychic suffering and the ways she integrates it into her conception of herself. It is proposed that in the case studied, in the face of a situation permeated by ambivalence, the diagnosis appears as a strong generalized sign which, while encompassing a series of personal experiences, inhibits the possibility of new subjective constructions. It is concluded that, as a sign, the psychiatric diagnosis should be analyzed in its various microgenetic semiotic dimensions, in order to better clarify its implications for the experience of the diagnosed person.
KeywordsMental health Psychiatric diagnosis Semiotic mediator
Maternity and Psychiatric Diagnosis as Potentially Disruptive Experiences in the Life Cycle
The transition to motherhood is one of the most profound and significant challenges in the family’s life course (Carter and McGoldrick 1995). In this period, characterized as unique and intense, important changes are experienced (Cabell et al. 2015). These changes influence the intra- and interpersonal dynamics of women, and may in some cases result in conflicts and, consequently, dramatic transformations of their identity. However, it is important to emphasize that, in addition to the organic activity of generating a child, motherhood assumes contours that are also socio-culturally determined.
Authors like Zittoun (2015), Abbey (2011), and Bastos, Santos, Araujo e Meneses (2015) proposed that motherhood could be understood as a complex and dynamic psychological and sociocultural construction whose meanings change over time and between generations. It is an experience, therefore, greatly affected by the social control exerted by political and religious groups, educational institutions, and corporations, which usually establish prescriptions about how women’s lives should be, in order to regulate their thoughts, feelings, and actions. According to Abbey (2011), the very establishment of standardized maternity labels serves this attempt at control, since they make it possible to construct valuable boundaries around maternity and, consequently, a homogeneous symbolic category that masks the intersubjective variability of the experience of being a mother.
According to Zittoun (2015), these boundaries of motherhood can be questioned when one explores non-normative cases, which are often silenced in the name of normative narratives that promote the stereotype of the pregnant and happy woman. The author states that non-normative experiences of motherhood can be lived with great difficulty, related both to the specific care directed to the baby, and to situations of social vulnerability. Speaking specifically about the cases of Brazilian women living in situations of vulnerability, Zittoun (2015) states that one must admit that their lives may seem very limited, or that they may be faced with few options. Such limits, according to the author, can be of a material nature, for example, women living in violent environments where their children may be killed or their partners may be physically aggressive; a social nature, such as the restriction of access to work and education; and a symbolic nature, like feeling that they cannot reveal such desires as to not be mothers or to not breastfeed. However, the author acknowledges that, even in the face of these disruptive contexts, some women can develop personal strategies of resistance, opening new and possible developmental routes.
Maternity lived by women with severe mental disorders may present very disruptive contours. Studies show that they seem to live this experience with a lot of ambivalence, associated with positive feelings as well as difficulties and tensions. Among the positive experiences, the following points are highlighted: (1) children are often seen as important parts of the mothers’ self and a source of great stimulus for adherence to and maintenance of psychosocial treatment (Blegen et al. 2014; (2) mothers demonstrate a great commitment to the effort to be “good mothers” and to be present in caregiving relationships with their children (Blegen et al. 2012); (3) the possibility of having family support is characterized as an important resource for coping with these situations (Perera et al. 2015).
Among the difficulties and tensions, the research points out (1) that women diagnosed are used to feeling guilt, shame, and low self-confidence related to motherhood (Perera et al. 2015); (2) that they face practical difficulties in dealing with the symptoms and the care of their own and their children’s health (Blegen et al. 2014); (3) that they recognize the social stigma attached to “madness” (Dolman, Jones and Howard 2013; Carteado 2008); (4) their frequent involvement with child protection agencies and their constant fear of the threat of losing custody of their children (McCauley-Elsom and Kulkami 2007); and (5) the difficulty that some families face in providing adequate support, which usually generates relational conflicts (Carvalho et al. 2007). However, while such studies provide an important understanding of the personal experience of these women, the conception of mental disorder presented by the authors, as well as an analysis of the ways in which these women signify their own psychic suffering and integrate it into their narratives about themselves, are not clear.
Brinkmann (2016) points out that there seems to be no consensus in literature about what could be conceived as a mental disorder. According to the author, while some adopt more essentialist perspectives, conceiving diseases as entities with their own existence, others defend a more sociological perspective, according to which diseases can only be understood from a social and normative context. However, for the author, it is necessary to develop a perspective that considers the representations offered by people who are themselves diagnosed with mental disorders. Thus, the author makes use of the assumptions of cultural psychology and proposes a “situated disease theory” capable of illuminating, through the qualitative approach, the personal life of the subjects and the ways in which the diagnoses relate to their experiences and the social contexts in which they are inserted.
Illness, in this context, appears as a real, concrete dispositional phenomenon, whose dimensions are relational, performative, and radically situated. Brinkmann (2016), then, emphasizes the importance of understanding the mediators involved in presenting a particular mental disorder, and the ways in which these mediators might be changed in ways that favor people. Considering the relevance of the aforementioned notions, this study proposes to clarify, from the narrative of a mother diagnosed with a mental disorder, the semiotic configurations that the diagnosis, as a sign, assumes in her experience, analyzing, then, the modes in which it is integrated into her personal synthesis of herself.1
The Narrative as a Resource for the Construction of the Personal Synthesis of Oneself
Human beings are embedded in a semiotic universe that mediates the relationship between their personal experiences and culture. Thus, they internalize and create signs capable of organizing and giving meaning to phenomena, self-regulating their mental functioning (Valsiner 2012; Zittoun et al. 2013). According to Zittoun et al. (2013), even the experience can be conceived as a holistic field created by socially recognized signs as part of a given language, and which give us the feeling of being in touch with the world beyond the here and now.
Bruner (2001), discussing the processes of constructing the senses of self, states that the self is constructed autobiographically as people become capable of transforming the primary qualities of experience into secondary qualities of higher knowledge. In this process, narratives appear as a resource capable of organizing the lived experience, putting sequential events into a meaningful context. According to the author, the narrative process arises when the subject needs to account for an exceptional event, an occurrence that in some way violates what is considered canonical by implicit popular psychology, thus guaranteeing a process of individualization.
Such a process, at a microgenetic level of analysis, can be understood from the developmental model of the emergence of meanings proposed by Valsiner and Abbey (2005). According to the authors, humans use signs as resources to deal, at present, with the uncertainty of the future. In this case, once established, the sign is understood as something that, for an interpreting mind, is in the place of an object, and can assume the iconic representational (image representations that maintain similarity to the object), indexical (when the sign emerges from the impact of the represented object), and symbolic (sign conventionally and arbitrarily established by the verbal community to designate an object) natures (Valsiner 2012; Silva 2017).
Valsiner and Abbey (2005) further suggest that, once established throughout experience, the sign not only designates its own field (A) and limits, but also refers to its opposite field of signification (Non-A), in which changes that it may suffer in the future would be included. Thus, they assume that it is the ambivalence contained between fields A and Non-A which guarantees to human beings, in the developmental path, the flexibility to deal with the uncertainty of the future and the possibility of overcoming it through the creation of new meanings. The authors also point out that different levels of ambivalence may lead to different conditions for the emergence of signs. In a condition where a situation does not set itself up as an unsettling or exceptional event, ambivalence and the construction of new meanings would be avoided. However, being more and more accentuated, the ambivalence could lead to a bifurcation in the trajectory, or to the extinction of the semiotic emergency due to the high level of uncertainty or the search for new meanings. In the latter case, the new meanings can be understood as elements that will compose the new narratives capable of giving meaning to the events felt as exceptional.
The moment of bifurcation, thus, appears as an important place for social interventions, since it can assist the individual in the construction of new senses, providing signs, cultural suggestions that diminish or help the individual to tolerate the level of uncertainty. Thus, Bruner (2001) emphasizes that narratives can follow certain cultural limits, certain linguistic rules present in each context, thus relating to the interpretations that other people provide for the narrated history. In this sense, narratives are highly negotiable and sensitive to the reference group. In other words, it is possible to assume that people create signs under the guidance of other human beings who are, in turn, collectively guided by other social institutions (Pontes 2013, p.33).
Therefore, assuming motherhood and psychic suffering as conditions that can lead to the interruption of the continuous process of identity construction, to the discontinuity of the sense of self (Pontes 2013, p. 34), it is important to analyze canonical cultural narratives about the psychic suffering that are available in the collective culture (Valsiner 2012). These narratives seem to be described in Brinkmann’s work (2016) as languages about suffering, as will be explained below.
Canonical Cultural Narratives of Suffering and Psychiatric Diagnosis as a Semiotic Mediator
Considering that human beings are always trying to interpret their own experience through language, Brinkmann (2014) grounds his work in some pragmatic and hermeneutic framing. He agrees that linguistic resources function as tools that enable us to act and deal with the world, mediating the relationships between personal and collective cultures.
In this way, he has proposed what he has called “languages of suffering”—meaning the vocabulary we use to give sense and to regulate our experience of stress. For the author, these languages “work in our lives through social practices, with various associated rituals and symbols and are inscribed into the human body and its habitus” (2014, p.634). In his work, Brinkmann examined five different languages—the diagnostic, the religious, the existential, the moral, and the political.
According to him (Brinkmann 2014), the diagnostic language understands suffering in terms of symptoms described in diagnostic manuals. Following this language, people are supposed to believe that there is a clear boundary between the normal and the sick and that it is possible to conceive discrete illnesses, which can be explained mainly in their biological aspects. In this perspective, it is also possible to comprehend human beings as instances of general laws, and find some causal relations between the disorder and the behaviors, devaluating other social and psychological aspects. By diagnostic culture, in its turn, the author means a tendency to increase the use of psychiatric diagnoses when people have to deal with different forms of distress.
Recognizing the criticisms that traditional psychiatry has received from the social sciences, Brinkmann (2014) affirmed that critics often fail to comprehend the personal and “significant experience of being diagnosed, or the various roles that the psychiatric diagnoses play in the lives of the diagnosed today”(2014 p. 122). Therefore, trying to go deeper, the author proposed that it is possible to conceive the psychiatric diagnosis as a semiotic mediator people use to comprehend themselves. He also added that, as a semiotic mediator, it could have three different functions in the lives of the diagnosed person—an explanatory function, a self-affirming function and a disclaiming function. By the explanatory function, Brinkmann (2014) means that people may use the descriptions of some diagnosis to explain—in a circular way—the causes of these symptoms. The self-affirming function happens when people begin to read numerous phenomena as symptoms, and the last one, the disclaiming function, refers to the possibility of using the diagnosis to medicalize aspects of the moral life and to excuse and disclaim responsibility.
Although the description of these functions may be an important heuristic tool to describe the multiplicity of implications of the subject’s use of a psychiatric diagnosis, once it is conceived as a sign, it would be interesting to situate this understanding within the microgenetic semiotic studies. In this way, it would be possible to characterize the psychiatric diagnosis based on its representational nature, structural complexity, representational power, mediating function, and level of generalization (Silva 2017).
In relation to the representational nature, as already mentioned, signs can be configured as icons, indexes, and symbols. In relation to their structural complexity, they could be organized as point-type or field-type signs. The point-type signs are those that derive from schematic processes and are characterized as simple logical-formal categories (Silva, 2017, p. 13), but useful, for example, for the sharing of experiences between humans. Field-type signs, on the other hand, can be characterized as more complex representations of reality.
The dimension of semiotic representational power refers to the degree to which the signs embody the represented reality. In this dimension, signs can be understood as fragile, when they do not stand in confrontation with reality, meaning, when they satisfactorily represent reality, although they maintain a certain level of flexibility for change, and strong, when they monologize the possible representations of reality and the advance of the dialogical process (Silva 2017, p.10).
In relation to semiotic functions, the signs can be characterized as catalysts and regulators. According to Cabell (2010), catalysts are signs that provide the necessary conditions for the operation or future employment of semiotic regulators, while the latter act directly in the ongoing psychological process, inhibiting or promoting its continuation and development. Thus, catalysts serve as a background, as a condition for other mediation processes (semiotic regulation), without, however, acting directly on the psychological process.
Semiotic regulators, on the other hand, can be classified as intra-mental devices (such as affective signs) or extra-mental devices (symbolic resources), which act directly and simultaneously on psychological processes, personal cultures, and the collective cultural field. As promoter semiotic regulators, they are characterized as field-type abstract signs, whose action is based on the orientation of the possible construction of meaning in the future (Valsiner 2012, p.53). Acting as inhibitory semiotic regulators, signs block or inhibit the emergence of alternative senses, making it difficult to orient oneself toward the future (Mattos 2013, p.52).
Finally, in relation to the level of generalization, signs can be classified by what Valsiner (2014) denominated the hierarchical model of semiotic regulation. The author proposed that it is possible to identify, in the experience of affective regulation, differentiated levels of experience. The first corresponds to the primary physiological activation, the second to the immediate pre-semiotic feeling, the third to the categorial designation of feelings, the fourth to the generalization of aspects of experience, and the fifth to the hypergeneralized field. At the level of hypergeneralized signs, according to the author, no word is necessary.
However, for the analysis represented in this study, only the narratives indicated by the participant through the body-mapping process were selected. More specifically, the narrative episodes selected (Silva 2017) were those in which the participant referred to signs of illness, “madness,” normality, and medication, since these signs were considered events relevant to our attempt to understand the ways in which psychic suffering and psychiatric diagnosis are meant.
Family frame narrated by Maria
Does not refer the name—dead at one-year-old
Rita (31 years) and Júnior (28 years)
Lívia (20 years) and Daniela (22 years)
Mariana (16 years)
Luzia (12 years)
Currently, Mary lives with her youngest daughter, Luzia. Six years ago, she lived with her partner, André, with whom she had no children. Rita, Daniela, and Lívia are in stable relationships and reside with their husbands and children. Júnior lives alone and Mariana with her paternal family. Except for Rita, who resides in another state, each one has a very close relationship with Mary, and Daniela is the main person responsible for accompanying her to medical appointments at the psychosocial care center. Although Mary has worked as a house cleaner at times, she does not work presently. She maintains herself with only the resources of her partner and from the governmental financial benefit that she receives on behalf of her youngest daughter.
Throughout the meetings, Mary narrated episodes of her personal trajectory, such as her move to Salvador, her relationships, pregnancies, and maternal experiences. These episodes are marked by situations of extreme social and economic vulnerability—such as moments when she was the victim of domestic violence by her partners, moments in which she did not have her own residence or job, and when she faced the absence of assistance by the fathers in the provision for children—as well as by a series of personal coping strategies—such as personal decisions she made to end abusive relationships—that seem to have allowed her to build some continuity in her personal experience. However, as has been said previously, the focus in this study will be on her experience of being diagnosed with a mental disorder.
I felt a lot of sadness, my heart broke. I felt it was frozen, I felt like I was going to faint, a lot of things at the same time. I felt pain in my body, a lot of things, a lot of sensations. (Mary)
I do not know if he got it from my way of speech, or because of my sadness. I do not know what I have taken to arrive at this thought, but it should be it... Then he said, “Are you experiencing some separation?” And I said, “Yes, I am.” Then he said, “Probably it is why you are feeling this way. Search for a psychiatrist.” And I said, “OK.” (Mary)
Although Mary does not present a precise understanding of the reasons that led her physician to propose the psychiatric consultation, her pre-semiotic experience, through this suggestion, came to be signified under the label of a psychiatric problem and conceived as emotional, psychomotor, and cognitive alterations. Among the emotional changes, Mary highlights a feeling of deep sadness and anhedonia. Among the psychomotor alterations, there are complaints such as feeling “the cold body,” shortness of breath, feeling faint, belly pain, and insomnia. Finally, among cognitive changes, she reports that when she is in crisis, her thoughts “do not go the same” and that she has “horrible dreams.”
Diagnoses of mental disorders, as symbols, were arbitrarily established by the medical community to represent, through a syndrome-related classification, a collection of behaviors built on the assumption that there is a common etiological basis and then a prognosis and a specific indication for treatment. They are therefore aimed to identify abnormal functional units of behavior. Despite their blurred boundaries and obscure principles of organization (even for health professionals), and the fact that they have already been recognized as flawed regarding the specificity of the established classificatory criteria and the indication of specific prognostics and treatments (Hayes and Follette 1992), such signs seem to be taken by the population embedded in a diagnostic culture (Brinkmann 2016) as a generalized point-of-view of psychic suffering which, by proposing to totalize human experience, acquires enormous regulatory power.
Valsiner (2000) states that human life is a constant novel and that it is not possible to find a repetition of the same experience. The author claims the transformation of dynamic processes of development into the static use of descriptors of language, to which he attributes a causal sense, to be an obstacle to science. Thinking about the heterogeneous classes as if they were homogeneous, “has made it difficult to appreciate the central feature of biological and social realities, namely their variability of forms which belong to the same general class” (Valsiner 2000, p.11). The researcher also denounces that one of the reasons that phenomena with high variability has been conceived as belonging to the categories of homogeneous classification relates to the interest of institutions in exercising social control. The most appropriate position, according to the author, would then be to consider human development as an open system whose dynamic stability is built over time, and from the exchange relations that the individual exercises with his or her biological, psychological, and social development.
I think most of my kids were not planned. I think I’d already had this disease in my twenties. I was already in trouble. Then, I started to do a lot of wrong thing. She was grateful, she had her children, she was going... (Mary)
Dependency on others (passively assumes, or demands, that others take responsibility for his/her own life; unwilling to decide on important issues related to own actions or future (…) Social withdrawal or isolation secondary to a conviction (not delusional) or feeling of being “changed” or stigmatized as a result of the illness. (…) Passivity, reduced interests and diminished involvement in previously entertained leisure activities (which may reinforce the social isolation (…) A change in the person’s perception of self leading to a frequent or constant claim of being ill. This feature may be associated with hypochondriacal behaviour and an increased utilization of psychiatric or other medical services. (5) A demanding attitude toward other persons in which the subject expects special favours or consider himself/herself deserving special attention or treatment.2
I think it's bad, I wanted to stop these drugs, I do not like it... (silence) I think it’s horrible!(...) There are some people who have prejudice... Because it takes medicine, calls that medicine crazy, these things... (Mary).
In addressing the subject of madness, Foucault (1972) points out the impacts that cartesian epistemology has brought to the conception of it. The author reports that, starting from Descartes, madness has been placed alongside the dream and all forms of error (Foucault 1972, p.52). The possibility of doubt, attributed to the subjects of reason as a criterion for the exercise of rationality itself, would therefore be excluded from the experience of madness, and the mad man precluded from the possibilities of detaining his rights to the truth (Foucault 1972).
I talked to the doctor here, what he said ... he said something like this, “You shouldn’t leave the medicines, should you? Do you think you have nothing?” I said, “No, I think I have something.” He said, “So happy for you that you still have the medicine to take.” (Mary)
I slept one night there, without taking medicine! But I was not sleeping all night(…) From 10 o’clock to 5 in the morning, sitting, but for me it was a happiness! I was going to take medicine, but Livia said, “Do not take it, because if you take it...” Daniela is waking up every 10 minutes, 15 minutes, to change diapers, to nurse, to drink water... Then someone had to get up right, to get... Then, I stayed there... (Mary)
There at home I am not, they don’t see me in this way. There, my children do not think of me like that... They see me as a normal person, they do not see me as crazy. (Mary)
I’ve already had a crisis, already with Junior, already ... He kept telling me to take water... I was naked... He said, “Calm down, Mother,” and I wanted to leave. He said, “Calm down, go and take a shower, go, go get some water.” He picked up a bottle of cold water for me to drink... I was drinking water, then I had a stomachache. I had it all at the same time... Then he took me to the bathroom (…) He suffered a lot on that day that I had this crisis. He said, “Tomorrow you will, I will take you into the center of psychosocial attention. Stay there.” Then, I took it and took the water. He said, “Then, I will give you medicine. Take the cold water that will pass, be quiet there.” Then, I put on my clothes, then he told me to lie down. I picked him up and went to bed. Then, he went, he went and it passed, I took medicine and passed him. (Mary)
Researcher: If you were to introduce yourself... and say, your personal characteristics... what would you say?
Figure 2 illustrates a graphical attempt to represent the elements highlighted in this analysis.
Mary: I am Mary, I do treatment at CAPS. I have my children and I will tell you how many children I have, how long I have been treating here. I am much better here, thank God. Only that.
At the primary physiological activation level of experience, the strangeness of Mary’s sensations, decoded as symptoms through the psychopathological bias, came to be understood as an element that confirms the psychiatric diagnosis, which appears culturally imbricated with the hypergeneralized field of madness. At the same time, her experience of motherhood and the legitimacy of her social place by her family demarcate a border between mental disorder and madness, placing Maria within the field of normality in which she has preserved her autonomy and the possibility of self-management of her treatment, including the possibility of not using the medicines. The use of psychiatric medications, in this way, seems to occupy an ambiguous place in her trajectory. If, on the one hand, this use confirms the diagnosis and promotes a series of unwanted side effects, on the other hand, it aids her process of emotional regulation and the attenuation of her ambivalence.
The analysis carried out in this article proposed that psychiatric diagnosis, as a sign, can be configured in different ways regarding its nature, power, representational structure, and its semiotic function. Such configurations will depend on the modes in which the subject signifies them throughout their interaction with significant social others. It emphasized that, given the prevalence of what Brinkmann (2016) called the diagnostic culture, the psychiatric label presents great potential to be configured as a strong and inhibitory regulatory sign, implying in future and very restricted possibilities of signification. The imposition of continued medical treatment, as well as the paltry supply of other languages to deal with suffering, seem to support the monologization of experience. In the case presented, we sought to analyze the ways in which the participant integrates diagnosis and maternity, as potentially disruptive events in her notion of herself. It was proposed that family microculture appears as an important resource in promoting a personal synthesis that, if on the one hand recognizes illness, on the other establishes reasonably clear boundaries between what is conceived as mental disorder and the hypergeneralized field of madness, guaranteeing certain personal integrity and legitimacy of her social function as a mother.
Finally, it was proposed that the configuration of the psychiatric diagnosis, as a semiotic mediator, on a microgenetic level, can help in understanding the processes involved—alongside the contingent relationships that holistically characterize the experience of the people—the psychiatric diagnosis functions described by Brinkman (2016): explanatory, self-affirming, and disclaiming.
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