The following essay was submitted in January 2024 for the sixth module on the MSc Mad Studies at Queen Margaret University, NM369 - Person Centred Practice.
INTRODUCTION
It is argued that the person-centred approach ‘does not sit comfortably within our culture, dominated as it is by materialist values, the quest for efficiency, cost-effectiveness and hitting targets’ (Freeth, 2017, p.16). However, despite person-centredness being fundamentally incompatible with the ‘medical nemesis’ (Illich, 1976) of Western healthcare that relies on the categorical denial of personhood, this discourse provides the ideology necessary for its function. As Metzl argues, ‘appealing to health allows for a set of moral assumptions that are allowed to fly stealthily under the radar’ (Metzl, 2010, p.2), I will argue that the appeal to person-centredness operates in a very similar way.
DEMYSTIFYING PERSON-CENTRED PRACTICE
Person-centred healthcare practice (PCP) here is understood as an aspect of a wider person-centredness discourse that has emerged in Western culture, particularly from the work of the humanistic psychology of Carl Rogers, that can be taken to apply into any situation involving human beings (Freeth, 2017, p.15). It has been applied in the context of therapy (Tudor and Worrall, 2006), education (Gray and Woods, 2022) and social care (Beresford et al., 2011), but its proliferation within healthcare is where it has been most notable (Freeth, 2017, p.13). It emerges here in response to the belief that ‘the person was getting lost in the predominant service focus on disease, deficit, and medicalization’ (Desai et al., 2023).
Person-centredness is the ‘operationalisation of personhood’ (Anker-Hansen et al., 2020, p.130). It’s therefore important to consider how this discourse understands what, or more importantly, what does not, constitute a “whole person”, personhood, in the first place.
The leading ideologues of PCP, argue that the idea of “what matters to us” – seen as the sum total of all our feelings, desires, motivations and values – ‘is possibly the closest we can get to a neutral understanding of personhood’ (McCormack and McCance, 2020, p.8). This, these authors claim, enables us to move beyond the traditional criterial view of personhood, in which a certain set of attributes – such as rationality and cognition – are seen as ‘necessary and sufficient for the status of a person’ (Chappell, 2011, p.1). Nevertheless, equating personhood with “what matters to us” presupposes both the existence of an individual self (an “I”) and their capacity to meaningfully communicate what matters to them in some way – both common criteria of personhood (Chappell, 2011, p.3). What about those who do not see themselves as a self (Buddhists?), or what matters to them as important (altruists?), or simply those who cannot express their wishes in any way (unresponsive patients?). Equating the person with their preferences still begs the question, what matters to who? It is not adequate to answer with circular reasoning, as these authors do, that ‘persons are persons because of their personhood’ (McCormack and McCance, 2020, p.9).
Ultimately, by setting up person-centredness as something that needs to be practised in the first place, PCP clearly acknowledges that the existence of personhood is not the default assumption (Blain-Moraes, Racine and Mashour, 2018) of healthcare. Even if it tries to avoid criteria, PCP necessarily entails a positive conception of a “person” that is to be centred rather than treating all human beings as persons ‘in advance’ (Chappell, 2011, p.7) of any displays of them expressing “what matters to them”. In doing so, it admits the possibility of it treating persons as non-persons: ‘the tendency to deny the metaphysical personhood of those whom we want to treat without respect is a product of the humanist, egalitarian tradition and cannot, therefore, serve as the foundation for it’ (Sapontzis, 1981, p.613). The problem is that ‘instead of encouraging the development of morality as an all-pervasive, fundamental world outlook, [the concept of personhood] justifies restricting moral concern’ (Sapontzis, 1981, p.618). If the purpose of PCP ‘translates most simply as dignified and respectful care’ (Desai et al., 2023) the starting point should not be the person at all.
PURE IDEOLOGY
This focus on ensuring that “what matters” to those subject to healthcare is foundational to care explains why PCP ‘comes to be equated with notions of personal and personalised care’ (Freeth, 2017, p.13). Person-centred practice becomes preference-centred practice. This is an example of what Zizek famously calls ‘pure ideology’ (Sternstunde Philosophie, 2019), this is ideology understood not in terms of Marx’s false consciousness, ‘not that of an illusion masking the real state of things but that of an (unconscious) fantasy structuring our social reality itself’ (Žižek, 2009, p.30). The discourse of PCP facilitates a narrative for those within the healthcare system to feel as if they are doing their duty towards those subject to their care: 'they know that, in their activity, they are following an illusion, but still, they are doing it' (Žižek, 2009, p.30). Indeed, ‘evidence shows that people tend to believe they are being person-centred, whether this is the case or not’ (Miller, 2021, p.34). They know that their idea of person-centredness is masking a particular form of dehumanisation central to the operation of health-care, but they still continue to follow this idea of person-centredness. The problem is that PCP does nothing to fundamentally alter the underlying biopower at the heart of healthcare, it literally “person-alises” the problem, locating the failure to provide dignified care in the failure of the carer to adequately treat patients as persons. This obfuscates the fact that the issue is systemic not “person-al”, that for meaningful change to occur then it must be more about ‘active system-decentered care’ (Desai et al., 2023) that actually deals with ‘the coercive structures of health-capitalism’ (Adler-Bolton and Vierkant, 2022). Without doing this, PCP becomes yet another example of ‘global capitalism with a human face, while behind the face the same reality will remain’ (Žižek, 2020). Nowhere is this more evident than in mental healthcare.
DEATH CENTRED
If ‘the ultimate expression of sovereignty resides, to a large degree, in the power and the capacity to dictate who may live and who must die’ (Mbembe, 2003, p.2) then healthcare, as the primary agent of such decisions, must be understood as the central institution of social control. Indeed anthropologically speaking care and control appear inseparable: ‘perhaps this is what a state actually is: a combination of exceptional violence and the creation of a complex social machine, all ostensibly devoted to acts of care and devotion’ (Graeber and Wengrow, 2021, p.408). This is clearest in the essential role coercive psychiatry plays in facilitating a permanent state of exception necessary to state sovereignty (Reeve, 2008). The state can only be truly sovereign if it retains the extra-legal and extra-moral power to reduce those made subject to its “care” to ‘bare life’, which is to say the loss of their humanity in their reduction to a mere biological object (Agamben, 1998) as an involuntarily detained and treated “patient” (Ashe, 2019). The interests – “what matters to us” – of the patient ‘play virtually no role in initiating detention and, in most places, involuntary treatment in mental health care’ (Szmukler, 2018, p.230). But this should be understood not simply as a negative deprivation of personhood but rather the positive creation of non-persons, the ‘creation of death-worlds…forms of social existence in which vast populations are subjected to conditions of life conferring upon them the status of living dead’ (Mbembe, 2003, p.40). Psychiatric patients are subject to person-al death in the hospital context in the form of incarceration and torture (Minkowitz, 2015), and social death beyond the hospital in the form of diagnostic labelling and community treatment that make them ‘unworthy of social participation’ (Brannelly, 2011). Fundamentally mental healthcare is explicitly involved in generating ‘zones of non-being’ (Turcotte and Holmes, 2024). How can person-centredness function when the person being centred is already dead? It’s surely for this ‘reason it is so rare to find person-centred psychologists, counsellors or psychotherapists working in mental health services’ (Freeth, 2017, p.42). Without challenging its central bio- and necro-political functions, PCP in the context of mental healthcare is clearly pure ideology.
AGAINST HEALTH
It’s been argued that there is ‘a vast gulf between the principles governing the detention and involuntary treatment of those with a mental disorder compared to those with a physical disorder’ (Szmukler, 2018, p.72). In the latter, liberal personhood is seemingly respected in accepting their absolute right to refuse treatment (Szmukler, 2018, p.71). One might thus conclude that even if PCP is incompatible with mental healthcare it is otherwise possible in other parts of the healthcare system. However, it’s important to recognise that psychiatry is not ‘qualitatively different to (and worse than) the rest of medicine’ (Tietze, 2022, p.viii). Ultimately both are bound by the same ‘individualizing, privatizing, and atomizing concepts and practices’ (Sedgwick, 1974, p.73) that make ‘health under capitalism…an impossibility’ (Adler-Bolton and Vierkant, 2022). That in this system, healthcare is ‘understood only as a more effective way to enhance capitalism, there is no intrinsic value attached to human individual existences’ (Pele and Riley, 2021). No personhood.
Any current form of healthcare continues to transform a person into a patient in the care of a doctor or other medical professional. This ‘fracture results in a healthcare relation optimised for processes of extractive abandonment [the commodification of illness] and not for the process of care, rendering the doctor into the signifier of state power and the patient into “pure object”’ (Adler-Bolton and Vierkant, 2022). So long as this division exists, the large asymmetries of knowledge and power it entails between them precludes the kind of relationship that would make PCP in any way meaningful. Unfortunately, PCP seems to think that health professionals need to ‘have their own personhood acknowledged as equals to that of patients’ (Edgar, Wilson and Moroney, 2020) without recognising that it continues to see those roles as prior to personhood. Simply put, the clinician is not a person when they act as a clinician that in some way imposes, consensually or otherwise, something on a patient. Instead what is required is a breaking of ‘the boundaries imposed on care by the artificial scarcity of gatekept expertise’ (Adler-Bolton and Vierkant, 2022), rejecting the hierarchy of doctor-patient in favour of a radical solidarity in which they work collaboratively ‘to reshape the society that has made them sick’ (Illich, 1976).
Any attempt at centering the person is futile when the medical model that has an epistemic monopoly in healthcare continues to rely on biological reductionism that is fundamentally antithetical to the complexity of the human condition by transforming the person into ‘mere mechanism’ (Wynter, 2003, p.330). Despite PCP ostensibly emerging as a response to medicalization, and social determinants of health increasingly being taking seriously, the system remains tied ‘to the processes of natural causation, rather than to the ontogeny/sociogeny or nature-culture modality of causation’ (Wynter, 2003, p.330). Ill health remains understood to be a physical phenomenon located in the individual’s body, rather than a ‘socially determined phenomenon at the population level’ (Adler-Bolton and Vierkant, 2022). This ignores ‘the culture and class-specific relativity of our present [biocentric] mode of being human’ (Wynter, 2003, p.282) which in ‘the language in which people could experience their bodies is turned into bureaucratic gobbledegook’ (Illich, 1976) dictates the phenomenology of health. The essence of illness, mental or physical, is not organic, but constituted by ‘intersocial relations’ (Fanon, 2020). So long as the problem of health is causally located in or through the person rather than society, dignified and respectful care is impossible.
POLITICALLY CENTRED PRACTICE
It is surely true that a ‘society which can reduce professional intervention to the minimum will provide the best conditions for health’ (Illich, 1976). The only way this can be achieved is by recognising that care must be tied to the social movements of oppressed people, which is to say that person-centredness must become politically-centred in working to sever health ‘from the capitalist political economy’ (Adler-Bolton and Vierkant, 2022) and its exploitative mechanisms that are the root of so much of the suffering healthcare attempts to alleviate. In failing to see the necessary political nature of our predicament, PCP is complicit in creating ‘a false dichotomy between health and justice that hides the social factors that determine health not only for individuals, but for the entire nation’ (Roberts, 2010)
CONCLUSION
All that person-centred practice does in practice is further sanitises the authoritarianism at the heart of the socio-politico-economico-medico order. There is no possibility for the person within capitalism. The facade of person-centredness is akin to that of the friendly boss. It is just a moral veneer: pure ideology. PCP is a reformist position, what we need is a revolutionary one. Ultimately, ‘humans cannot simply disengage from this system and unilaterally choose to be good’ (Turcotte and Holmes, 2024).
REFERENCES
Adler-Bolton, B. and Vierkant, A. (2022) Health Communism: A Surplus Manifesto. Brooklyn: Verso, p. 240.
Agamben, G. (1998) Homo Sacer: Sovereign Power and Bare Life . 1st ed. Stanford, Calif: Stanford University Press, p. 228.
Anker-Hansen, C. et al. (2020) “Collaboration between home care staff, leaders and care partners of older people with mental health problems: a focus on personhood.,” Scandinavian Journal of Caring Sciences, 34(1), pp. 128–138. doi:10.1111/scs.12714.
Ashe, L. (2019) “Where is the Camp? Psychiatry and the State of Exception,” in Shifting Power: Human Rights Law Confronts State and Psychiatry. International Congress on Law and Mental Health, International Congress on Law and Mental Health.
Beresford, P. et al. (2011) Supporting people: Towards a person-centred approach. First Edition. Bristol: Policy Press, p. 448.
Blain-Moraes, S., Racine, E. and Mashour, G.A. (2018) “Consciousness and personhood in medical care.,” Frontiers in Human Neuroscience, 12, p. 306. doi:10.3389/fnhum.2018.00306.
Brannelly, T. (2011) “Sustaining citizenship: people with dementia and the phenomenon of social death.,” Nursing ethics, 18(5), pp. 662–671. doi:10.1177/0969733011408049.
Chappell, T. (2011) “On the very idea of criteria for personhood,” The Southern journal of philosophy, 49(1), pp. 1–27. doi:10.1111/j.2041-6962.2010.00042.x.
Desai, M.U. et al. (2023) “System-Centered Care: How Bureaucracy and Racialization Decenter Attempts at Person-Centered Mental Health Care.,” Clinical psychological science : a journal of the Association for Psychological Science, 11(3), pp. 476–489. doi:10.1177/21677026221133053.
Edgar, D., Wilson, V. and Moroney, T. (2020) “Which is it, person-centred culture, practice or care? It matters,” International Practice Development Journal, 10(1), pp. 1–17. doi:10.19043/ipdj.101.008.
Fanon, F. (2020) The Psychiatric Writings from Alienation and Freedom. Reprint. Bloomsbury Academic, p. 504.
Freeth, R. (2017) Humanising Psychiatry and Mental Health Care: The challenge of the person-centred approach. CRC Press. doi:10.1201/9781315385051.
Graeber, D. and Wengrow, D. (2021) The Dawn of Everything. International Edition. Allen Lane, p. 608.
Gray, A. and Woods, K. (2022) “Person‐centred practices in education: a systematic review of research,” Support for Learning, 37(2), pp. 309–335. doi:10.1111/1467-9604.12410.
Illich, I. (1976) Medical Nemesis: The Expropriation of Health. New York: Random House, Inc., p. 294.
Mbembe, A. (2003) “Necropolitics,” Public Culture, 15(1), pp. 11–40. doi:10.1215/08992363-15-1-11.
McCormack, B. and McCance, T. (2020) Fundamentals Of Person-centred Practice. First. Hoboken, NJ: Wiley & Sons, Incorporated, John, p. 240.
Metzl, J.M. (2010) “Introduction: Why against health?,” in Metzl, J.M. and Kirkland, A. (eds.) Against Health: How Health Became the New Morality. 1st ed. New York: NYU Press, pp. 1–11.
Miller, E. (2021) How is person-centred care understood and implemented in practice? Healthcare Improvement Scotland. Available at: https://ihub.scot/media/8367/20200621-person-centred-care-review-v20.pdf (Accessed: December 31, 2023).
Minkowitz, T. (2015) Forced Psychiatry is Torture - Mad In America, Mad In America. Available at: https://www.madinamerica.com/2015/04/forced-psychiatry-torture/ (Accessed: November 20, 2023).
Pele, A. and Riley, S. (2021) “For a right to health beyond biopolitics: the politics of pandemic and the ‘politics of life,’” Law, Culture and the Humanities, p. 174387212097820. doi:10.1177/1743872120978201.
Reeve, D. (2008) Biopolitics and bare life: Does the impaired body provide contemporary examples of homo sacer? Routledge.
Roberts, D. (2010) “The Social Immorality of the Gene Age: Race, Disability and Inequality,” in Metzl, J.M. and Kirkland, A. (eds.) Against Health: How Health Became the New Morality. 1st ed. New York: NYU Press, pp. 61–71.
Sapontzis, S.F. (1981) “A Critique of Personhood,” Ethics, 91(4), p. 607. Available at: http://www.jstor.org/stable/2380296 (Accessed: September 25, 2023).
Sedgwick, P. (1974) “Medical Individualism,” The Hastings Center Studies, 2(3), p. 69. doi:10.2307/3527493.
Sternstunde Philosophie (2019) Down with ideology? Talk with Slavoj Žižek. SRF Kultur Sternstunden. Available at: https://www.youtube.com/watch?v=Zm5tpQp6sT4 (Accessed: January 4, 2024).
Szmukler, G. (2018) Men in White Coats: Treatment Under Coercion. illustrated ed. Oxford University Press.
Tietze, T. (2022) “Introduction to the New Edition,” in Sedgwick, P. (ed.) PsychoPolitics. Pluto Press, pp. vii–xvi.
Tudor, K. and Worrall, M. (2006) Person-Centred Therapy: A Clinical Philosophy (Advancing Theory in Therapy). 1st ed. London: Routledge, p. 320.
Turcotte, P.-L. and Holmes, D. (2024) “The shadow side of occupational therapy: Necropower, state racism and colonialism.,” Scandinavian journal of occupational therapy, 31(1), p. 2264330. doi:10.1080/11038128.2023.2264330.
Wynter, S. (2003) “Unsettling the Coloniality of Being/Power/Truth/Freedom: Towards the Human, After Man, Its Overrepresentation--An Argument,” CR: The New Centennial Review, 3(3), pp. 257–337. doi:10.1353/ncr.2004.0015.
Žižek, S. (2009) The Sublime Object of Ideology (The Essential Žižek). Second Edition. Verso, p. 304.
Žižek, S. (2020) Slavoj Žižek: We Need a Socialist Reset, Not a Corporate “Great Reset,” Jacobin. Available at: https://jacobin.com/2020/12/slavoj-zizek-socialism-great-reset (Accessed: January 4, 2024).