Diagnostic Identity and the Legitimisation of Mental Health Problems: An Ethnographic Study with a focus on Bipolar Disorder Rhiannon Lane School of Social Sciences Cardiff University This thesis is submitted in fulfilment of the degree Doctor of Philosophy 2018 DECLARATION This work has not been submitted in substance for any other degree or award at this or any other university or place of learning, nor is being submitted concurrently in candidature for any degree or other award. Signed …Rhiannon Lane…………… (candidate) Date …02/10/2018….…………….……… STATEMENT 1 This thesis is being submitted in partial fulfillment of the requirements for the degree of ……… (insert MCh, MD, MPhil, PhD etc, as appropriate) Signed…Rhiannon Lane……………………(candidate) Date …02/10/2018…………………… STATEMENT 2 This thesis is the result of my own independent work/investigation, except where otherwise stated, and the thesis has not been edited by a third party beyond what is permitted by Cardiff University’s Policy on the Use of Third Party Editors by Research Degree Students. Other sources are acknowledged by explicit references. The views expressed are my own. Signed…Rhiannon Lane…………………(candidate) Date …02/10/2018….………………… STATEMENT 3 I hereby give consent for my thesis, if accepted, to be available online in the University’s Open Access repository and for inter-library loan, and for the title and summary to be made available to outside organisations. Signed…Rhiannon Lane………………………(candidate) Date…02/10/2018………………… Acknowledgements Many individuals have helped and contributed to this thesis. Firstly, thank you to all of those professionals and service users who kindly gave up their time to be interviewed and allowed me to observe their appointments; I am extremely grateful. Several key people also provided invaluable support both before and during my fieldwork: I’m thankful to John Tredget and his team for making the fieldwork experience so enjoyable and to Andrew Vidgen for providing helpful guidance during the early planning stages of the study. My academic supervisors – Adam Hedgecoe and Michael Arribas-Ayllon - I’d like to thank for their patience and kindness throughout the process, and for only ever giving the most constructive feedback on my work. Thanks also to members of the Cardiff MeSC group for providing helpful feedback on one of my data chapters. I owe a special thankyou to Katy Greenland, who has provided me with invaluable mentoring and guidance over the past few years, and who has definitely gone far above and beyond her duties as progress reviewer: the importance of this support cannot be overstated. Lastly and most importantly, thank you to my family for their patience and support throughout the process of completing this work. In particular, thanks to my amazing son Connor and partner Darren for making me smile every day. iii Abstract Psychiatric diagnosis has become a pervasive aspect of modern culture, exerting an increasing influence on forms of personhood, identity practices, and modes of self- governing. Debates surrounding the classification of psychiatric disorders are also prevalent, with particular disputes surrounding the relative merits of ‘biomedical’ vs ‘psychosocial’ understandings of mental health difficulties. There is arguably a need for further empirical exploration into the social and cultural implications of psychiatric classification and categorising practices within mental health service interactions. Drawing on ethnographic research conducted within several UK mental health settings, this thesis considers the role of diagnosis in constituting patient identities and in shaping professional categorisation practices, with a particular focus on bipolar disorder. Observations were conducted within sites where diagnostic identities are particularly salient: Psychiatric diagnostic and screening assessments, and a psychoeducation programme for bipolar disorder. Focusing on the formal and informal categorisation practices of service users and professionals, this study highlights the way in which psychiatric classifications can be negotiated, ascribed, and withheld in order to legitimate and contest particular kinds of suffering; in particular, it explores the way in which diagnostic categories – in particular bipolar disorder - can be used to interpret and medicalise morally problematic forms of experience and behaviour. Whilst diagnosis itself can function to medicalise aspects of moral life, its ability to perform this function is also shown to depend upon its conceptualisation as a biomedical disease entity. Findings suggest that bipolar disorder gives rise to particularly somatic concepts of personhood; its conceptualisation as an essentialised and reified illness category, with its cause located within the brain, enables a legitimisation of psychiatric ‘symptoms’ for both patients and professionals. In seeking access to more specialised mental health services with limited resources, potential patients can face trivialisation and deligitimisation of their problems by professionals, which at times manifests in the withholding of diagnosis. This is particularly the case within a mental health policy context which has increasingly moved towards the prioritisation of those with ‘severe mental illness’. As such, the study shows how the legitimising function of diagnoses such as bipolar disorder, can lead to a tendency for it to be both sought after by patients, but contested by professionals and amongst patients. In light of the apparent advantages conferred by this diagnosis, the moral and personal consequences of diagnostic membership, exclusion, and uncertainty are considered; in particular, the potential for this essentialised category to create divides between those considered to ‘have’ the disorder and those who are not, is contemplated. iv Table of Contents Declarations……………………………………………………………………………………………………………………….ii Acknowledgments……………………………………………………………………………………………………iii Abstract……………………………………………………………………………………………………………………iv Contents…………………………………………………………………………………………………………………..v Chapter 1: Research Context & Background ............................................................................. 1 Introduction ........................................................................................................................... 1 Key Developments in the Classification of Bipolar and Affective Disorders .......................... 3 The development of modern psychiatric classification ..................................................... 4 The splitting of ‘unipolar’ and ‘bipolar’ depressions ......................................................... 6 The emergence of bipolar disorder as a distinct entity ..................................................... 9 Current controversies surrounding psychiatric diagnosis ............................................... 13 Conclusion ........................................................................................................................ 15 Thesis Outline & Structure ................................................................................................... 16 Chapter 2: Psychiatric Diagnosis and its Explanatory Function ............................................... 19 The Sociology of Diagnosis ................................................................................................... 20 Negotiating Diagnosis ...................................................................................................... 22 Diagnostic cultures of psychiatry ..................................................................................... 23 Diagnosis, medicalisation, and deviance ......................................................................... 26 Biomedical expertise and neurochemical selfhood ............................................................. 29 Stigma & Causality ............................................................................................................... 32 Blame and ‘volitional stigma’ ........................................................................................... 33 Social distancing and perceived dangerousness .............................................................. 36 Prognostic pessimism ...................................................................................................... 39 Psychological Essentialism ............................................................................................... 40 Optimisation, Self-Determination & Responsibility ......................................................... 43 Summary .......................................................................................................................... 44 Beyond biomedical /psychosocial binaries .......................................................................... 45 From static causal models to context-specific explanatory discourses ........................... 48 Conclusions and research aims ............................................................................................ 51 Chapter 3: Methodology .......................................................................................................... 53 v Research Methodology: Ethnography ................................................................................. 53 Choice of Research Settings ................................................................................................. 56 Case sampling within & beyond ‘settings’ ......................................................................