Respect and Adaptive Preferences

Before I started taking psychiatric patients on ‘escorted leave’, I’d never felt like I was being looked at so much by strangers.

(That’s not to say I was never looked at. Sadly I’ve had my fair share of everything from odd looks to homophobic abuse for being physically affectionate to members of the same sex in public. But for me it was nothing as isolating or pervasive as this.)

I’m sure I thought about this when I started 5 months ago, but somehow it got pushed from my mind until something happened which made me think about it again. Yesterday I accompanied a patient into the town centre so she could attempt to sort out some of the problems she was having with her phone. She was on top form; flirting outrageously with the taxi driver all the way there, and telling increasingly more far fetched (psychiatrists would say “delusional”) stories the more I laughed at the previous one. Sure, often it was hard to follow her train of thought or sometimes even understand what she was talking about, but this did not hamper either of our enjoyment of the interaction.

However it became much more of a problem when she was trying to explain to the sales-assistant in the phone shop exactly what it was she wanted. She got progressively confused and confusing, and kept firing of these half-put-together sentences that mostly had nothing to do with phones or contracts. She started laughing very loudly, hands and arms going everywhere, and steadily behaving in more and more erratic ways.

But this is where the story becomes unusual. Throughout all of this, the sales-assistant was patient, respectful and professional. He didn’t give any sign that he had even noticed there was anything out of the ordinary about their interaction. He joked with her and reassured her when she got frustrated about not being able to work out or articulate what it was she wanted. He chatted easily with her whilst the computer was loading, about their shared love of B-horror films and bad lager.

Just before we were about to leave the shop, I had this overwhelming urge to give him a hug or something, I just felt so grateful and warm towards him. I think if I was a different sort of person I would have written a letter to the phone company, telling them how sensitive and understanding their staff were, but instead I’m going to go on a rant about how awful society is.

Because it was only after reflecting on my reaction towards what had just happened that I properly realised how abnormal it was. Often when I go out with patients they are treated like they are a member of a different  and dangerous species. You think I’m exaggerating? Non-conventional hand- movements mean that people move two seats away from you on the bus. Disordered speech sends sales-assistants scuttling for their managers. Walking in a strange way, muttering to either yourself or someone who no-one else can see? People would rather walk in the road than be anywhere near you. I always have to be really careful to remove my hospital badge before going out with patients, because it alone causes a radical deterioration in how strangers treat them.

But it took me less than 5 months of occasional outings with patients to become so desensitized to there being anything bad about this, that my reaction to a patient being treated with human respect was one of stupidly disproportionate gratitude. I’m not saying I stopped noticing the bad treatment; it’s so pervasive and obvious that there’s no way you could ever not notice it. But you do stop being painfully aware that there’s something wrong with it. You stop thinking, every time it happens, “This is awful. This is not how people should be ever treated.” You just take it as given that the patient you’re with is going to be dehumanized and isolated in pretty much every single social interaction they have.

Most of the patients will get better, or at least better enough that people in supermarkets don’t look at them funny. But some of them are never going to be able to “pass” as someone who has never experienced mental health problems. Them being “well” is never going to be equivalent to them being, or appearing, “normal.”  If, after only 5 months, I have come to expect poor treatment for the people I’m out with, what would it be like having that experience for years or decades?

Most of the philosophy I’ve come across on this issue looks at it from the angle of women’s rights, so I’d welcome any recommendations.  Anyway, the below is from the philosopher Martha Nussbaum, quoting Rabindranath Tagore at the beginning of an article on “adaptive preferences” (Nussbaum, 2001.)

“To those with low self-regard, neglect does not seem unjust, and so it does not cause them pain. That is why women feel ashamed to be upset about the injustice they encounter. If a woman must accept so much injustice in the life ordered for her, then it is perhaps less painful for her to be kept in total neglect; otherwise, she is bound to suffer, and suffer pointlessly, the pain of injustice, if she cannot change the rules governing her life.”

She follows this up with a non-fictional example of this process:

“Vasanti stayed for years in an abusive marriage…. Like many women, she seems to have thought that abuse was painful and bad, but, still, a part of women’s lot in life, just something women have to put up with as part of being a woman dependent on men, and entailed by having left her own family to move into a husband’s home. The idea that it was a violation of rights, of law, of justice, and that she herself had rights that were being violated by his conduct she did not have these ideas at that time, and many many women all over the world still do not have them.”

If you’ve never been treated with respect, then it becomes much harder to articulate a demand for it, or to have a “preference” about being treated respectfully when you go out in public or when you interact with other individuals. Systematic discrimination shapes (or adapts) your preferences in such a way, that respect or equality of treatment or dignity no longer always even make sense to you as things to want. You simply don’t consider them. Especially since respect-  unlike decent sanitation or protection from physical abuse-  is a slippery concept to get hold of, if it’s not something you’ve ever really known.

Institutionalisation is a serious problem in mental health. People get so used to being in hospital after an extended admission, that when they’re discharged they find themselves unable to cope ‘outside’ and end up having some kind of crisis and being re-admitted. Of course there are lots of things which contribute to this, but I want to put forward the view that “respect” is one of them. If you, as a patient, can’t get your head round the idea that there could possibly be a society where everyone is treated respectfully regardless of mental health issues, then the best possible strategy is just to retreat to a micro-society where that looks more like the case. I’m not saying that treatment in psychiatric hospitals here is wonderful, far from it, but at least you’re surrounded by other people who don’t look at you as if you’re something strange, or other. Whether those are patients, or- if things are working as they should be- members of staff, you still aren’t made to feel uncomfortable and out of place the entire time.

I feel that this post should end with some kind of recommendation on how we change this fairly dismal state of affairs. I don’t have anything like that yet, apart from the stupidly obvious.

Treat people with respect. Whoever they are. And bear in mind that- given the systematic oppression of various groups of people written into the fabric of our society- it’s not going to be something which always comes naturally to you.

Post Script

I stole this shamelessly from an excellent post on a friend’s blog, but I couldn’t help including it here:

“If citizenship is to mean anything in an everyday sense it should mean the ability of individuals to occupy public spaces in a manner that does not compromise their self-identity, let alone obstruct, threaten or even harm them more materially. If people cannot be present in public spaces (streets, parks, cinemas, churches, town halls) without feeling uncomfortable, victimized and basically “out of place,” then it must be questionable whether or not these people can be regarded as citizens at all.” (Painter and Philo, 1995)


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