Transforming subjectivities in psychiatric care

Toril B. Terkelsen, Senior Lecturer, Phd

University of Agder, Institute of health- and nursing science

Box 509, 4898, Grimstad, Norway

E-mail: Toril.Terkelsen@uia.no

.
This is a post-peer-review, pre-copyedit version of an article published in Subjectivity. The
definitive publisher-authenticated version: Transforming subjectivities in psychiatric care,
Subjectivity, Vol. 27, 195–216 , 2009, Palgrave Macmillan
is available online at:
http://www.palgrave-journals.com/sub/journal/v27/n1/full/sub20096a.html

Abstract:

This article is based upon ethnographic fieldwork in a Norwegian psychiatric unit practicing a

psycho- educational treatment of young adults diagnosed with schizophrenia. An aim of the

programis that patients learn to detect and monitor their ‘symptoms’ in order to obtain ‘insight

into their own illness’, thus transforming themselves into self-governed and self-responsible

subjects who are able to cope with life outside institutions. The program is constituted within

a medical framework with strong emphasis on medicine-compliance. I explore the dynamics

of power relations inherent in the program, referring to Foucault’s descriptions of discipline

and normalisation through pedagogy and examinations. His concepts of governmentality and

self-technologies have proved useful as a frame for a critical evaluation of such programs.

However, subjectivities cannot be read off directly from educational technology, and my data

from everyday, mundane settings in the institution reveal paradoxes and contradictions which

are accounted for in this study.

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Keywords: Schizophrenia

Psycho-education

Foucault

Power-knowledge

Governmentality

Subjectivity

Introduction

In this article I focus on how subjectivities emerge and transform in relation to a psycho-

educational program treating people diagnosed with schizophrenia; in this particular case a

Norwegian educational program labelled ‘An Independent Life’ (AIL hereafter).The article is

based upon eight months of ethnographic fieldwork in a Norwegian rehabilitation unit.

Referring to Michel Foucault, I explore the creation and expression of power relations

through AIL and how the programme aims at teaching patients self-observation, self-

classification and self-examination in accordance with the psychiatric diagnostic vernacular.

The objective of the program is self-governance and independency, and through a specific

knowledge-regime designed for regulating psychotic thoughts, feelings and behaviour,

patients are supposed to ‘detect and manage symptoms with the help of professionals from the

psychiatric field’ (from the introduction of the AIL- program’s workbook, in Gråwe, 1991,

my translation). I will discuss how this takes place in everyday practice in the institution and

how the program affects the people there.

To say that psychiatric knowledge and technology represent power is hardly controversial

today. However, we are not dealing with a ‘one to one’ exploiting/exploited perspective, but a

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rather large and ambiguous field of power-knowledge relations, as laid out by Foucault (1972,

2001a). This complex type of power is displayed, not mainly through a centralised state or

‘the law’, but through governmental apparatuses, institutions and procedures (the psycho-

educational program is a particular example), aiming at the welfare, security and governance

of the population, where the mental health field seems to pose a particular challenge.

Foucault (2001b, p. 220) states that ‘we live in the era of a “governmentality” first discovered

in the eighteenth century’. His writings on self-technologies and governmentality are perhaps

even more relevant today. Self-governance and self-care are traditional Western liberal ideals.

Thus, psycho educational programs may be associated with the increasing neo-liberalism in

Western societies. On the one hand, patients are expected to be self-governed and

independent, to live a life outside an institution. On the other hand, such ‘freedom’ outside the

institution is limited and constricted in several ways. In addition to social and economic

limitations of ‘freedom’, people with mental health difficulties are not free to think or speak

as they wish. They are expected to accept having a stigmatising chronic psychiatric illness

(Estroff, 1993) and taking medicines which have a severe impact on their cognitive functions

(Breggin and Cohen, 1999). What is to be done with individuals who do not accept the

definition of illness presented to them, who are not able to or willing to govern themselves i.e.

to comply with the program set up for them? What about people who do not see their

problems as illness and claim their right to refuse medication? These questions are indeed

political, ethical and economic. The various rehabilitation programs aiming at helping patients

to govern themselves are perhaps not solely expressions of democracy and liberation. As Rose

points out, ‘modern individuals are not merely “free” to chose, but obliged to be free’ (Rose,

1999, p.87). The change from taking care of ill people to teaching them responsibility for their

own health has become a technology of ‘responsibilisation’ (Rose, 1999, p.74). For example,

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the introduction of the concept of ‘self-care’ in nursing literature in the 1970s (Orem, 1971)

almost created a revolution in nursing theory and practice. To be able to cope, to be

independent and autonomous are highly valued properties described in nursing literature

today. The individual has a ‘duty to feel well’, a moral responsibility to ‘stay well’ (Greco,

1993, p.357) and an obligation to have self-esteem. Cruikshank (1993 p.330) argues that

‘those who have failed to link their personal fulfilment to social reform are lumped together as

“social problems”, diagnosed as “lacking self-esteem” and charged with “anti-social”

behaviour’. Responsible, worthy patients on the other hand, comply with experts’ advice in

order to obtain self-care and independence. Such ‘freedom’ is referred to by Rose (1999,

p.137-166) as ‘advanced liberalism’; in order ‘to govern better, the state must govern less’

(Rose, 1999,p.139). A different kind of subject emerges, i.e. an individual who does not need

to be governed by others but are ‘free’ to govern him/herself; as expressed in this study by the

term ‘An Independent Life’.

However, my objective is also to go beyond a power-knowledge perspective. My field data

reveal that subjects are not only passively formed or produced by psychiatric discourses or

governmental apparatuses. I focus on human agency and lived experience, reflecting on how

subjects create and re-create themselves in local interactions (Biehl et al 2005, p.14). Not

leaving Foucault’s and Rose’s works aside, I address the issue of experience; how

subjectivities emerge, are shaped and reshaped through a flow of multiple, diverse and

sometimes paradoxical everyday experiences in a psychiatric institution. Studies of lived

human experiences in local, mundane settings in the present have not been issues in Rose’s or

Foucault’s analyses. Blackman et al (2008, p.15) state that ‘Experience […] was always an

important element for understanding subjectivity’ and ‘the role of experience […] has always

accompanied the concept of subjectivity ‘

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Kleinman and Fitz-Henry (2007) deal with the issue of subjectivities and experience in a

recent anthology. They point out that subjectivities are interactive, multiple, never static,

always in-flux (p.55), writing that ‘Experience is intersubjective inasmuch it involves

practices, negotiations and contestations with others with whom we are connected. It is also

the medium within which collective and subjective processes fuse, enter into dialectical

relationships, and mutually condition each other’ (p 53).

Through examples from my fieldwork, I describe how such practices, negotiations and

contestations take place in a psychiatric institution. I also aim at illustrating the ambiguity and

bewilderment in psychiatric care today, and how people, both patients and helpers, interact

and influence each other in everyday settings

Psycho- educational programs

Psycho- educational programs in psychiatry emerged at the end of 1970. The impetus for the

creation of such treatment programs was the explicit aim of many Western countries to

reintegrate psychiatric patients into society. This development also took place in Norway.

Inspired by the de- institutionalisation reform in Italy, several large psychiatric hospitals and

asylums in Norway were closed down during the 1980s, and patients were transferred to open

care in their communities. Independence, self-care and ability to cope with life became highly

valued properties during this reform. However, many communities did not have the resources,

competence or ability to take care of these patients in a proper way. Although Norway has a

well developed, public welfare system compared to many other countries, several of these

patients became marginalised and were left alone in poor conditions without the ability to care

for themselves. The introduction of psycho- educational programs should also be viewed

against this background. The programs are for the most developed within a biomedical

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framework where acceptance of drug intervention is crucial in coping with illness (Falloon et

al, 1996, Terkelsen et al 2005). Recent research in genetics and pharmaceuticals, and the

refinement of psychiatric classification systems such as the Diagnostic and Statistical Manual

of Mental Disorders (DSM-IV, APA 1995) and the International Classification of Diseases

(ICD-10, WHO1992) have contributed to this development. Within this framework

schizophrenia is regarded as a distinct disease, caused by imbalance in chemical

neurotransmitters in the brain, characterized by ‘well-defined’ symptoms, such as

hallucinations, delusions, ambivalence, thought disorders and social withdrawal. These

symptoms are perceived as essential and self-evident. Extensive literature show that

schizophrenia is an incoherent, invalid concept, and no consistent evidence for a brain

malfunction or disorder has yet been identified (Bentall, 2003, Boyle, 2002, Johnstone, 2001,

Thomas, 1997). Nevertheless, patients are expected to adopt the biomedical explanation,

accept that they are ill and adjust themselves through education and medicine compliance.

A limited body of research and evaluation of the psycho-educational programs exists,

focussing on reduction of symptoms and prevention of relapse. The authors, mostly

psychologists and psychiatrists, emphasise what they consider positive effects on symptoms

and relapse (e.g., Hogarty et al 1991, Goldstein & Miklowitz 1995, Bentsen 2003). A review

of 10 studies concludes that psycho education is useful in the treatment of schizophrenia.

Usefulness is measured by medicine compliance and decrease in readmission (Pekkala &

Merinder, 2006). Ethical aspects associated with this treatment are, however, not discussed,

nor questions related to the dynamics of power - knowledge in educational programs.

According to my study, usefulness should be measured by how patients define it. Field data

reveal that several patients object to the AIL program and do not find it useful at all.

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Context and methodological challenges

The rehabilitation unit (Sunhilli hereafter), is nicely situated, surrounded by a large garden,

close to a medium-sized Norwegian town. The institution is characterised by a homely, light

atmosphere with tasteful furniture and art on the walls. The staff points at surroundings as

important in order to make patients feel ‘normal’. Each patient has his/her own room. There

are no locked doors except in the staff’s offices, and patients are free to leave the institution in

their ‘spare’ time, as long as they tell the staff where they are going and when they will return.

The staff is well educated; most of the nurses have had 1-2 years of specialisation in advanced

psychiatric nursing. My impression was also that both nurses and therapists were highly

motivated and engaged in the welfare of the patients.

The institution has the capacity to treat 10 patients diagnosed with schizophrenia at the one

time. 36 (of 40) people gave their informed consent to participate in the field-work: 11 male

patients between the age of 19-40, 4 female patients between 20-30, 10 female and 2 male

nurses, 4 male and 1 female therapistsii, and 4 female student nurses in their twenties. All

participants were white ethnic Norwegians living in the southern part of Norway.

I stayed in the institution several times a week throughout the fieldwork period, carrying out

participant observation and having conversations with varying degrees of formality with all

participants. I observed and systematically recorded people’s verbal and non-verbal

interaction inside and outside the institution. I had access to an office where I could retire to

write my field-notes regularly several times a day. I told all participants that I was taking

field-notes, and in the beginning they seemed uneasy, but they told me that they got used to it

after a while. I participated in all the activities of the unit, such as meetings, individual

psychotherapy sessions with therapists and patients, physiotherapy sessions, and informal

7
social interaction, taking notes either simultaneously or immediately after the sessions. In

addition to informal conversations, interviews with 9 patients, 2 ex-patients who visited the

institution regularly and 11 professionals were tape- recorded, transcribed verbatim and

analysed according to ethnographic methodology (Miles and Huberman 1994, Agar 1980).

Some of the patients were interviewed several times. I also had access to and reviewed

hospital records and had regular contact with some of the patients after they were discharged.

Having previously been a nurse working in psychiatric hospitals, I easily got access to all

rooms in the institution. This was an advantage, but also a challenge, because as a fieldworker

aiming at an ethnographic space, I had to distance myself as a nurse. I was treated by the

nurses as ‘one of them’ and balanced between observation and participation. Thus my data

were of a different kind than the data collected by the staff. A particularly useful space in the

field was the smoking room where staff seldom came. I was impressed by how openly the

patients spoke about themselves. An ethical issueiii was raised when some patients wanted to

make appointments with me as if I were a staff member, although it seemed that they

distinguished my role as a researcher from the role of the professional staff.

Psycho-education

The psycho-educational program (AIL) at Sunhill consisted of three courses: the first on

managing symptoms, the second on social conversational skills and the third on body

awareness. There were three sessions a week, each lasting about one and a half hours. The

program was based on ideas of American psychiatrists (Liberman et al 1985) and translated

and modified by the Norwegian psychologist Gråwe (1991). The assumption was that people

with psychosis have particular problems in these three areas, and that they would manage

daily life in a better way if they learned about their illness through theoretical lessons and

8
practical exercises within these areas. Nurses were in charge of the first two courses, while a

physiotherapist ran the final course.

The aim of the first course was to teach patients to detect symptoms of a relapse into

psychosis and to manage ‘persistent symptoms’ of schizophrenia. Gråwe (1991) has compiled

a workbook which patients in this unit were expected to use under nurse guidance. In the

second course patients were trained to enhance their conversational skills. The body

awareness course consisted of simple physical exercises and relaxation techniques.

It seemed that the ‘Managing symptoms course’ (MSC hereafter) was rather unpopular among

several patients, but that they were more willing to attend the ‘Social conversation skills

course’, probably because they felt they had problems in this area. Many patients complained

about lack of concentration, that their thoughts just stopped, that they did not know what to

talk about in an ordinary conversation. I felt the atmosphere in the Social-conversation course

was less tense than in the MSC. Patients appeared to be more engaged, talking and laughing

more, seemingly enjoying the funny situations that sometimes appeared during role-plays.

I will particularly focus on the MSC because it involved questions of governance and

regulation to a much larger extent than the other two courses All three courses were

compulsory, but staff could decide that a patient should attend one, all, or none of the courses,

depending on an assessment of the patient’s condition.

In the MSC, patients were to achieve skills related to the following four areas:

1) To recognise warning symptoms of relapse

2) To manage warning symptoms

3) To manage persistent symptoms

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 4) To avoid alcohol and drugs (Gråwe1991, p.65, my translation).

Patients were thoroughly tested with multiple choice questionnaires, in which they were asked

what they would do in the case of symptoms of a relapse. An example of one of the questions

was:

I can reduce the danger of relapse by:

1) Learning to manage my disease

2) Ignoring my symptoms

3) Stopping taking medicine

4) Taking painkillers every day (Gråwe, 1991:65, my translation).

It is implied that some of the answers are ‘right’ and some are ‘wrong’. The three latter

alternatives are obviously ‘wrong’ answers.

Symptoms were divided into ‘warning signs’ of relapse and ‘persistent symptoms’ of

schizophrenia. For each sign and symptom, the workbook describes examples, and patients

are expected to monitor their own symptoms. ‘Warning signs of relapse’ were classified as

deviations in sleep, appetite, mood, thought, feeling or behaviour. Examples of ‘changes in

thoughts and feelings’ were ‘being suspicious’ or ‘becoming excessively religious’. The

‘persistent symptoms’ of schizophrenia were described as ‘hearing voices’, ‘suspiciousness

towards other people’ and ‘depressive feelings’(Gråwe1991). Patients were given a

registration and classification formula with squares to fill in every day. They were supposed

to grade the strength of their signs and symptoms on a scale from strong, moderate, and weak

to none. In this way patients were expected to measure and record their own feelings.

10
The AIL program in action and how it affects people

An extract from a session in MSC gives insight into the concrete workings of the AIL

program. It is the eighth session. In the room are two patients, two nurses, and myself, sitting

outside the circle as an observer, taking notes. The patients have brought their workbooks.

They are going to learn about warning signs of psychosis:

Nurse, (directed to the patients): Today we’re going to learn how to recognise and grade warning signs.

You have to register the warning signs every day, and you begin here at day one (points at the formula

in the workbook). When you’ve registered for one week, a pattern will emerge. If the curve is

completely flat, you’ve perhaps had a good period. You also have to compare the curve with what

you’ve done. This is also a registration of stressful events. The homework for the next session is to fill

out the form.

Following this teaching session, a video is shown about a boy, Anders, who is worried about

hearing voices and sleeping poorly. The lesson to be learnt from the video is that Anders

should contact a person he knows well or a doctor to get help (which usually means increased

medicine dosage). After the video session, the nurses try to establish a conversation with the

patients about Anders’ problems, but that proved to be difficult. The nurses asked whether the

patients had similar problems as Anders’, but they hardly said a word. They looked down and

replied politely when spoken to. I felt the atmosphere in the room to be tense. For some of the

patients, with whom I spoke later, I think the silence was an expression of avoidance, a subtle

resistance by retreating.

Some of the patients in the rehabilitation unit did not have the kinds of symptoms that were

expected of psychotic individuals. The course however was still compulsory. The following is

an extract from a session where this is the case.

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 Nurse to the patient: Do you record your symptoms daily as requested?

P: No, I haven’t come that far.

N: What stops you from doing so?

P: I don’t have such symptoms.

N: Does Peter (the nurse who is in charge of him) agree?

P: Yes, he does. I don’t have symptoms, and it’s not my fault.

N: Yes, but it’s important anyway to be observant about symptoms […]What do you benefit most from

here?

P: I’m looking for an apartment to rent.

N: It’s okay that you use your energy on this. But it’s important that you can recognise symptoms when

you’re going to live alone.

It appears as if the nurse's obligation to follow the program overshadows the patient’s actual

experience. When the session was over, the patient rushed out in a hurry. He was red in his

face and clearly upset. A nurse said after the patients left: ‘It’s difficult to make the group

dynamic now. Nevertheless I think they benefit from it’. Later I spoke with the patient in the

smoking-room. He said that he had nothing to learn from this program. He had been living for

years in his own apartment and need not learn to live alone, he said. His problem, according

to himself, was drug abuse that went out of control when his girlfriend died. He explained his

psychotic episodes as a result of using too much amphetamine.

Patients often interpret ‘symptoms’ differently from the professionals. At Sunhill,

professionals and patients often disagreed about having warning signs or not. Professionals

more often than patients believed that patients experienced warning signs, therefore

disagreeing about the usefulness of AIL. In general the nurses considered the program as

more useful and beneficial than the patients did. Below is an excerpt from an interview with

one of the nurses (Anna) who was active in introducing the AIL at Sunhill several years ago.

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 Anna: Many of the patients had developed strange coping strategies… before they came here …in order

to learn to live with themselves. It takes time to make them unlearn and relearn new coping strategies..

[…]

T: There may be some who think they aren’t so ill? Is it difficult if you…?

A: Yes, that is difficult. There are many who think they are not ill. But…usually they want to join

anyway[…] Even if they don’t admit that they’re ill, they have a slight suspicion that something is

wrong ( laughs a bit). […] There are very few who don’t want to attend the AIL course. They want it.

And it’s so good. They learn a lot on that course about coping with symptoms. It’s so useful, and such a

good course.

Indeed, some patients thought there was ‘something wrong’ with them, in spite of the fact that

they were sceptical to the AIL program and reluctant to label themselves as schizophrenic.

Like Danny, who told me of his ‘strange ideas’

I thought that the the Leonids ( a meteor shower, my comment) from space should come and take me

away. Although it was frightening, it was a thrilling experience too. I looked at a pattern on the wall and

was convinced that it was the Leonids formatting on the wall. I asked one of the nurses if she could see

it too, and she said yes, she saw it. However, I did not dare to tell most people about my experiences,

because they would believe I was mad. So I kept it to myself.

Such ‘strange ideas’ and ‘wrongness’ were dealt with differently. Some of the staff did not

object to the patients’ experiences. They even joined the ‘strange ideas’, particularly outside

the serious atmosphere of the MSC. Moreover, it seemed that some of the nurses were

attracted to the ‘strangeness’ and the ‘wrongness’. One nurse said about a patient: ‘He is so

psychotic. It’s beautiful. What that guy can see in the stars’. Thus, along with suffering, there

was beauty and excitement, but this was not recognised by the AIL program. Patients are

simply not supposed to enjoy their illness (Barrett, 1996). When patients did not express their

psychotic experiences in an open manner, they were usually perceived as ‘better’. Therefore

13
many patients soon learned how to hide their thoughts. One patient said to one of the

therapists: ‘When I look down and say nothing, you think I’m well, when I start to speak, you

think I’m ill’. In the psychiatric unit and in the AIL program, patients are supposed to speak

about themselves, but when speaking freely about ‘strange’ things, they are perceived as ‘very

ill’. There is a common expectation that people should reveal their inner thought when they

are assigned for psychiatric treatment, but the opposite can be the case. The nurses were

expected to limit ‘psychotic talk’ by making the patient talk about something else, or by

secluding the patient in his room. Usually the staff followed this unwritten rule, presumably

having been taught that patients may get worse if psychotic experiences are given attention

(Leudar & Thomas, 2000). Sometimes, however, the nurses just let ‘madness’ flourish,

joining into the ‘craziness’, laughing and joking together with patients. Such kind of humour

seemed to ease tension for both patients and staff.

On the other side, the nurses were occupied with motivating the patients to attend to the AIL-

course, while patients were occupied with different matters, such as getting money or

cigarettes, which was a big issue in the smoking-room. Talks about girls was also a common

theme there, as most of the clientele were young men. Indeed, I had the impression that lack

of a girl-friend was one of the biggest problems. Impotence as a side-effect of psychotropic

drugs was also a problem, but these issues were not raised in the AIL sessions, probably

because the conversations in the sessions were restricted by the AIL workbook which did not

hold such topics.

Sometimes the professionals made deviations from the AIL program. There were many events

which were ‘merely’ social. At times I felt that I was part of a cosy, not very disciplined

family, particularly during Christmas preparations when patients and nurses were engaged in

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baking and making Christmas sweets. There was no AIL program for several weeks. Even

some of the shy patients now voluntarily chose to participate, looking more spontaneous and

less tense in these situations. Quite often the nurses and the physiotherapist made trips outside

the institution with a group of patients. Such activities included seeing a movie, walking and

strolling in the woods, swimming in a nearby pool, going to a cafeteria etc. In such relaxed

contexts, the patients laughed, participated and seemed to enjoy themselves. The staff pointed

out that patients often changed for the better when they went on trips outside the institution,

and staff themselves seemed to enjoy these occasions too. Normal communication in

everyday settings seemed to contribute more to patients’ well-being than the AIL program.

Several patients became friends during their stay at Sunhill, thus strengthening their network

resources.

Transforming subjectivities through classification, normalisation and examination

One of the key objectives in the AIL program is to make patients unlearn and relearn new

coping strategies, as outlined in the conversation with Anna. Such coping strategies imply that

patients learn, accept and integrate the psychiatric definition of illness. Moreover, coping with

life is learning about medicines in order to become medicine-compliant. Through these

strategies, patients are supposed to obtain a larger degree of self-management.

A relevant question is whether these coping strategies can be associated with the disciplinary

techniques described by Foucault in Discipline and Punish (1977) and with his later work on

self-technologies (1997). The core elements in the AIL program can be understood as

technologies of management and self-management, as a way of training and transforming

subjects, and as ‘a conduct of conduct’ (Foucault 2001a, p.341). Foucault (1977, p.170-196)

describes ‘the means of correct training’ through various disciplinary techniques. At Sunhill,

15
with its strong emphasis on pedagogy, patients’ ‘conduct is ‘conducted’ particularly through

the techniques of classification, normalisation and examination. I think that the AIL program

can be viewed in this perspective, and in the next paragraphs I will elaborate such attempts at

transforming subjectivities, however afterwards pointing at the limitations of such an

approach.

Classifications/observations: AIL cannot be disentangled from international psychiatric

classification systems, such as DSM-IV (APA, 1995) or ICD-10 (WHO, 1994). These

systems enable psychiatrists world-wide to define and diagnose symptoms of mental disease.

The medical gaze is trained to scrutinize and classify. To examine, diagnose and to monitor

the patient’s movement from illness to normality or vice versa is part of a medical education.

The classifications of symptoms in the AIL program are much the same as outlined in the

illness categories described in the DSM-IV and ICD-10, where every disease is perceived as a

distinct entity with its own symptoms. A successful outcome of the educational program

largely depends on the patient’s acceptance of such perceptions of disease.

Diagnoses have several effects. For instance, some patients in the present study said it was a

relief to be able to put a name to their problems; others resisted strongly the diagnosis of

schizophrenia. Besides, having a diagnosis is needed in order to gain certain advantages in the

welfare system, such as sick-leave or disability pension. On the other hand, such classification

systems may be understood as a part of a governmentalising enterprise, as powerful tools of

configuring and surveying people. Patients are expected to adopt new strategies by learning to

‘manage symptoms’. When a patient is diagnosed with schizophrenia, the professionals

automatically look for and report pre-defined symptoms. Moreover, anti-psychotic medicines

were almost always prescribed for patients in this study without debate. The term

16
‘schizophrenia’ triggers some automatic responses in the staff (and in patients too, as long as

they accept their illness). This is perhaps an example of what Gordon calls ‘techniques of

power designed to observe, monitor, shape and control the behaviour of individuals’ (Gordon

1991, p.3). I will argue that Foucault’s notion of governmentality has even more significance

today in the way standard classifications (such as the DSM and ICD) and standard programs

(such as the AIL) have been elaborated in detail in order to govern people from a distance. It

is to govern ‘each and all’ (Gordon 1991, p.3) through micro programs which the experts are

taught to administer. It is to totalise and individualise, to see and control each individual as

well as teaching people to monitor themselves. In such a way the health and welfare of the

collective is governed by letting the expert authorities teach the marginalised people to govern

themselves.

Normalisation: The idea of normality is pervasive in Norwegian society: e.g. national

standards for educational programs, for social aid and for medical practice. The AIL program

aims at improving the quality of life of suffering patients. However, viewed from another

angle, it can also be conceived of as a normalisation program. Patients have to accept the

standard psychiatric definition of mental illness, also termed ‘insight into one’s own illness’.

Paradoxically, patients are told that in order to get well, they have to accept that they are ill.

To obtain ‘insight into one’s own illness’ is by most health professionals regarded as an

important step on the way to recovery (Flyckt et al, 1999). Estroff’s studies of the relation

between the self-concept and explanations of suffering are relevant in this context. Her work

indicates that psychiatric patients who define themselves as ill lose their sense of themselves

as competent individuals and gradually come to see themselves as incompetent. She suggests

that learning to be a patient is a way to chronicity (Estroff 1993). Thus the price of

‘normality’ could be chronicity, paradoxical as it may seem.

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Examination and self-examination: Examination is a clue in Foucault’s analysis of discipline.

The examination, according to Foucault (1977) is a method of control that combines

hierarchical observation with normative judgment. It is a prime example of power-knowledge

in Foucault’s terms, since it combines into a unified whole the deployment of force and the

establishment of ‘truth’. It both elicits the truth about those who undergo the examination,

(tells what they know/should know or what the state of their health is) and controls their

behaviour (by directing them to a course of treatment). Control and registration of every detail

of individual behaviour was indeed the aim of the new strategies of discipline, as described by

Foucault (1977).

The relationship between power-knowledge and examination is significant in the AIL

program. Warning signs and persistent symptoms are predefined, and the multiple-choice

exam requires the ‘right’ answer. In this way it is possible to control whether patients have

accepted the knowledge presented to them or not. Patients’ bodies or souls are minutely

registered day by day. The system’s efficacy is further developed when patients learn to self-

examine and self-report themselves on the registration formula. Patients are supposed to

monitor their own ‘symptoms’ every day by writing down the strength and duration of

symptoms in the registration formula. If they have a ‘good’ period, the curve is flat. If it is

not, they are expected to seek help, usually to be persuaded that they need more medicines.

Thus, they are governed not only as objects of psychiatric disciplines but also as self-

scrutinizing and self-forming subjects.

Resistance strategies to the AIL program

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However, as I suggested, this analysis has its limitations. According to my field experiences,

people are not as easily formed as the AIL presupposes. Both patients and helpers proved to

be unpredictable and complex, as the many paradoxes in the data reveal.

Foucault in his later work to a larger degree acknowledged the individual’s freedom and

resistance. He focused on the mobility and instability of power relations, making statements

such as ‘there is no relationship of power without the means of escape or possible flight’

(Foucault, 2001a, p.346). Relations of power and strategies of resistance are intertwined, and

the freedom that is a necessary condition for relations of power is therefore the very thing that

allows the possibility of resistance.

Several patients developed resistance or avoidance strategies in different ways. Sometimes

they did not show up to the AIL-session without any excuse, even though it was obligatory, or

they appeared mentally absent during the session, looking down, not really participating. The

staff tended to interpret such withdrawal as part of the illness syndrome. However, even some

of the nurses were sceptical about the courses, but they said it was part of their job to go

through with the program. They pointed out that many of the patients were highly educated

people, and thought that the program was a way of patronising them. One nurse said: ‘It’s a

bit like looking down on them from above’. Another stated: ‘It’s a bit banal, I feel almost

embarrassed to present such stuff to the patients. But, on the other hand, it’s been developed

by highly competent people. They say they’ve used the program with good results in other

countries. They’ve done research …but I’m a bit ambivalent’.

Patients seldom voiced their resistance against the AIL program directly in the ‘public’ areas,

but they discussed the program when the staff was not present, for instance in the smoking

19
room. These patients did not necessarily disagree that mental illness existed, but they did not

think the diagnosis was appropriate for them. They did not accept that the problems they had

were symptoms of schizophrenia. Reluctance to accept the illness definition was called ‘lack

of insight’ by most of the staff and was interpreted as part of the illness (see also Blackman,

2007, p.8). When I was talking with the patients alone or in the smoking room, they would tell

me about all sorts of problems. The smoking room was a ‘free area’ in the eyes of the

patients. They played ‘underground’ rock music, smoking cigarettes incessantly, sometimes

cannabis too, I heard, which was a reason to close down what the doctor called ‘an

unacceptable subculture within a psychiatric institution’, however against fierce protests

from several patients. The smoking room was a site through which very different stories

started to emerge, circulate and gain currency. Patients told me that they had problems or

experiences such as being anxious, hearing voices, having difficulties in sleeping, worrying

about their financial situation, being unemployed, having no girl-friend, being lonely, being

abducted by UFOs at night (Terkelsen, et al 2005) or being controlled by neighbours through

satellites in space. Such issues were not discussed during the AIL lessons. One girl spoke

about her feelings of depression and despair during three suicide attempts. She had dropped

out of school, because the voices inside her head were so loud that she could not hear what the

teacher said. However, she did not define herself as schizophrenic. Thus, several patients

simply did not integrate the knowledge presented by the psychiatric staff, which in turn

tended to see resistance against the diagnosis as a symptom of the illness itself. One patient,

who was quite articulate in formulating his dislike for both medication and the AIL program,

said that he was being exposed to ‘thought control’. ‘I am 100% sure that I am not

schizophrenic, I need vitamins instead of those brain medicines’, he declared several times.

When he was confronted with the schizophrenia diagnosis in a therapy session, he opposed

the therapist fiercely by saying that ‘you try to take away my thoughts, why do you do that? I

20
feel it’s almost a violation’. Claiming his right to believe in UFOs, angels and vampires, he

said ‘I believe in what I believe in, no matter what you say’. The therapist commented after

the session that the patient’s prognosis was gloomy, because of ‘his complete lack of insight

into his illness, his drug abuse and his refusal to take antipsychotic medicines’.

Throwing medicines into the toilet was also a strategy used by patients. Some of the nurses

felt they were being manipulated or cheated by patients who tried to spit out the tablets when

the nurses were not watching them. This was usually detected by blood-tests which revealed

medicine non-compliance. In these cases the therapist tried to persuade the patient to accept

depot medication, an injection with effects that last for three months.

However, relations of power and resistance were not necessarily characterised by a ‘staff

against patients relation’ and vice versa. On the contrary, patients often spoke well of both

therapists and nurses, and many patients seemed to be particularly attached to ‘their’ therapist

or nurse. I was at first surprised by this paradox: patients who revealed resistance and non-

compliance at the same time seemed to have good relations with their nurse or therapist.

Moreover, professionals often gave in to patients’ will. Sometimes a nurse or a therapist

together with a patient would create a powerful dyad against other professionals. The nurse or

therapist commonly defended ‘his’ or ‘her’ patient’s interests at staff meeting. At times this

staff member also functioned as ‘a lawyer’ for a patient, towards other institutions, such as the

bank, the social security office, other hospitals etc. The patients were very interested in having

such a defence to promote their interests, and they might even take medicines in return. A

patient said straight out: ‘I don’t like the pills, but I will take them for the sake of my nurse’.

Negotiating illness and health

21
I will argue that subjectivity should not be reduced to a question of disciplinary technologies

on one side and resistance, escape or freedom on the other side. As Cohen points out (1994, p.

23)’ the self is not a monolith, it is plastic, variable and complex’. It is ‘inconsistent, a

chameleon, adapting to specific persons with whom it interacts and to the specific

circumstances of each interaction’ (p. 98).

Patients are throughout the AIL program urged to accept that they are ill. According to my

field notes, they respond to this by rejecting or accepting that they are ill. A third response is

ambivalence and uncertainty about being ill or not, trying to judge themselves on a scale from

‘normal’ to ill. Indeed, the same person may shift between rejection, acceptance and

ambivalence. Thus, being a patient can be considered a practice which involves slipping

between different, multiple subjectivities, negotiating between ‘normality’ and illness.

As I pointed out, several patients resisted the diagnosis schizophrenia. At the same time many

felt that there was something ‘wrong’ with them. Patients heard and saw things that nobody

else did, and sometimes they became confused of what was in their head, and what was ‘real’.

Yet, they so much wanted to be ‘normal’ and do the same things as ‘normal’ people were able

to do, however not wishing to give in to the normalisation-technologies described in the AIL.

Both patients and staff made negotiations about the boundaries of normality; they asked

themselves whether certain thoughts, behaviour or feelings would match the criteria of being

ill or not. The following is an example of such negotiations. Billy, a 19 year old boy and I,

are sitting in Billy’s bedroom, talking about his problems hearing male, angry voices mocking

him. ‘They all the time tell me I’m stupid, gay and worth nothing’ he says. His therapist has

recently told him that he is suffering from schizophrenia. Billy puts an information-booklet

22
about schizophrenia in front of me on the table, drawing a line on the sheet, dividing it into

two pieces, about ¼ and ¾, saying: ‘I’m perhaps that much ill (pointing at the smallest part),

but the rest of me is healthy. So, I’m only one fourth ill’. He tells me that he is relieved to

learn what is wrong with him. Finally there is an explanation to his suffering and a label on

his condition. Later however, he complains that the diagnosis did not solve anything, he still

feels miserable. In the smoking room he said to me: ’I’m afraid that I’m never going to be

normal, that I will not be able to work or do other normal things’.

After a while the therapists and nurses become bewildered regarding what kind of illness

Billy is suffering from. In a staff meeting the nurse Lisa says ‘Billy doesn’t have the look of a

schizophrenic. I think his voices are more thoughts in his head than real voices’ The therapist

agrees and says that Billy is not able to be psychotic more than half an hour when he is given

no attention. ‘That’s not schizophrenia’, he claims. He writes in the medical record that: ‘It

seems that Billy is manipulating himself in and out of a psychotic condition’. The

antipsychotic medication (Zyprexa) is terminated, and the nurses are told not to focus on his

‘symptoms’ anymore, because it may worsen his condition. Besides, Billy is not to attend the

MSC, because it is assumed that he does not have those symptoms. His condition does not fit

into the program anymore. According to the therapist’s written record, there were no

‘psychotic breakthroughs’ reported after this change of treatment strategy. Consequently, the

problem ‘auditory hallucinations’ was deleted from the treatment plan. One month later,

however, the problem returned, formulated as ‘inexpedient ways of coping with voices’. In

the meantime, the therapist tries to find the right diagnosis for Billy. He does not resume the

schizophrenia diagnosis, but decides on post-traumatic stress syndrome (PST). Billy tells me

that he is relieved to get a diagnosis which he perceives as less serious than schizophrenia.

Nevertheless the nurses report in the record that ‘he is worried that he might not be a normal

23
boy’. After a while, the PST diagnosis is abandoned too. The therapist writes that Billy does

not match the criteria of PST because ‘he lacks an extreme stressful situation’. Instead, he

writes that Billy ‘satisfies the criteria of adjustment disorders, code F43.2’ (in the ICD-10, my

comment), due to the fact that ‘extended psychological stress and poor coping abilities may

have provoked a similar illness’.

This story is an example of the ambiguity of illness categories and the unclear boundaries of

normality. Billy’s illness was negotiated from ‘schizophrenia’ to PST, to the less stigmatizing

‘adjustment disorder’. It seems that the ICD- classification system find spaces for conditions

that do not fit traditional illness categories. Billy was indeed relieved; he could maintain his

self-concept as a normal boy, and in his own eyes he was now only a badly adjusted person

due to stress, which might be the fate of many ‘normal’ people. Moreover, the professionals

told him that his voices more likely could be unpleasant thoughts than real voices. Billy

found this reassuring; he more easily could look at himself as ‘normal’ iv. In this way one of

the main symptoms of schizophrenia, ‘auditory hallucinations’ were transformed to

‘thoughts’. The story is also an example not only of resistance to diagnostic categories but

also of how the validity of the categories themselves is to some extent accomplished through

successful attempts by professionals to apply them and by the acceptance of Billy (i.e. of the

situated construction of schizophrenia itself). It shows the complexities of power relations

and how power can be reproduced at the micro-level of individual diagnoses.

Hearing voices was sometimes a subject in the smoking room. It did not happen very often,

because it seemed to be a very private matter. Billy however, spoke openly about his voices in

24
the smoking room. He was comforted to hear that several of the other patients heard voices

too. He thought he was the only one. One of the ‘veterans’, who had heard voices for years,

gave Billy advice how to cope with them: ‘Don’t let them bother you, they won’t hurt you.

Just yell back and tell them to shut up. Probably they won’t go away, but after a while you

don’t care about them anymore.’ Billy told me afterwards that this conversation had been of

great help, mostly because he learned that hearing voices was common among the other

patients too. Thus, ‘hearing voices’ in the smoking room is different from 'hearing voices' in

the treatment plan or in the staff’s meeting room.

Lisa Blackman’s research on the Hearing Voices Network (HVN) is interesting in this context

(Blackman, 2001, 2007). This network, initiated by the works of Romme and Escher (1993)

encourages people to become friends with the voices, to enter into a dialogue with them, and

to use the positive voices to deal with the unwanted voices instead of denying the voices.

Blackman describes a technology and a workbook developed by and for voice-hearers, i.e.

how to cope with voices, how to use them as a resource and how to incorporate them instead

of working against them. This is a different frame of reference than the approach described in

the case of Billy where professionals interpret voices as symptoms of psychopathology. HVN

seems to offer a kind of agency which allows voice-hearers to actively take part in the shaping

and reshaping of voices. I assume that such a network may contribute to reframe voice-

hearing from a symptom of schizophrenia to a ‘normal’ activity.

According to my field experiences it seemed that at least two kinds of subjectivities co-exist

side by side within the same subject. One was the resistant subject, rejecting the

patologisation of the AIL program, refusing to integrate a chronic ill identity. The other

subjectivity was aspiring for a ‘normal’ identity, ‘being normal, doing what normal people

25
do’. Billy was relieved when he could define himself on the ‘right’ side of normality. Several

of the other patients in my study had the same aspirations as Billy. Such a duality is described

in Luhrmann’s portrait of homeless women in Chicago. They live within two codes, she

writes: ‘One code is appropriate to the middle-class world to which they aspire, the other one

enables them to survive on the street’[…] ‘The subjectivity they share is the challenge of

negotiating two competing and contradictory sets of display rules’ (Luhrmann, 2006, p.347).

The question at hand is how patients suffering from severe mental health difficulties are

negotiating competing display rules. They live in two different worlds, in which one is a

shared ‘normal’ world; a world comprised of ‘normal talk’ display rules, which they try to

comply with. The other world is their ‘psychotic’ world which they often try to keep secret,

hiding their experiences of UFOs, Leonids, voice-hearing etc. The suffering, according to my

field experiences, lies in the struggle of constantly negotiating between the demands of these

two worlds. It is a lonely quest. I therefore do believe that more attention should be given to

the struggle of living in two worlds/realities, creating a space for both patients and

professionals to explore such experiences in depth. The Hearing Voices Network I believe is

an example of the creation of such a space.

Movements of resistance

There are and have been other networks and movements too that challenge mainstream

psychiatry. Just to mention a few: The anti-psychiatric movement in the nineteen-sixties

(Laing, 1967, Cooper, 1967), the Soteria project (Mosher 1999) and the contemporary Mad

Pride (2008) and Mind Freedom International (2009).The latter is an international coalition of

more than hundred grassroots groups. According to Wikipedia (2008), Mind Freedom has

been recognized by the United Nations Economic and Social Council as a human rights non-

26
governmental organisation with a consultative status to the UN. Thus, Mind Freedom

International has gained considerable formal influence.

Nick Crossley gives an historic account of how such movements have evolved, and how

patients, or survivors as they prefer to call themselves, have developed strategies to resist

psychiatric domination by making efforts to present themselves as ‘not being mentally ill’

(Crossley, 2004, p. 161). A ‘survivor’ creates other mental images than a ‘victim’. A survivor

is not a person who is weak, helpless and dependent, but a strong and potent person who has

had the nerve and strength to ‘survive’ the stressors of modern psychiatry. According to these

movements (for instance ‘Mad Pride’) one needs courage to survive both chemo-therapy,

ECT and the stigma associated by being labelled ‘schizophrenic’. In this way the survivors

have transformed their negative experience from weakness to strength, to something they can

be proud of, something worthy the admiration of others. Moreover, they reclaimed the

stigmatizing word ‘mad’ into their own vocabulary as ‘mad pride’. By this, they reconfigure

the very content of ‘madness’ by situating it into another context, for their own benefit, just

like for example the gay-movement has done before them (Crossley, 2004, pp.61-180). Some

of these movements have transformed themselves from representing an underprivileged class

without a voice to become a voice of power (at least to a certain degree) among politicians

and health – planners, as well as in the media and in organisations such as the UN.

Conclusion:

Psychiatric knowledge with its predefined concepts of illness has become so powerful that not

only professionals but also patients tend to become its defenders. Concepts like ‘thought

disorders’ and ‘delusions’ are taken for granted in a biomedical psychiatric power-knowledge

27
framework. Patients are expected to subdue their perceptions of reality in order to accept and

integrate medical knowledge and understanding, where medicine-compliance is a crucial part

of the education. The AIL program, the ICD-10 classifications of mental illness (WHO,

1992), and the expert knowledge that such technologies represent, are entangled parts of a

large system of governmental technologies, institutions and procedures, not only located at

Sunhill or in Norway, but globally spread. Thus, psycho- educational programs can be viewed

as a part of a larger social enterprise or governmentality. Foucault’s descriptions of discipline

and normalisation through training and examinations have proved to be relevant in this

context.

One conclusion is therefore that modern psychiatry succeeds in recruiting self-forming

subjectivities that master and monitor themselves - but only partly. Many patients who seek

help to find out what is wrong with them, do not/will not integrate the explanation offered to

them by the psychiatric profession. Even professionals are bewildered about what is wrong,

and sometimes they even doubt their own explanations. Often the patients’ stories about

hearing voices, being abducted by UFO’s etc are not listened to in depth and interpreted on

the premises of the patient, partly because doctors are trained to concentrate on the ‘right’

diagnosis and the ‘right’ medicine, including monitoring the effects of medicines.

Although subjectivity and experience are both regulated by power relations, they have the

potential to exceed and subvert them. According to Dean (2007, p.9), ‘Power is […]more like

a duel than a total system of subordination.’ AIL as a technology of self-production or

responsibilisation shows that subjectivities cannot be read off directly from an analysis of the

techniques themselves, because people often act in a different manner than what they are

expected to do. Thus more research should be done in this area of the mental health field, i.e.

to study how people accept or reject biomedical power-knowledge and how power-relations

28
are enacted in everyday settings. Power creates resistance (and avoidance) on an individual

level, as revealed in my empirical material, but also on a larger scale, as shown by the

formation of various movements initiated by patients, ex-patients and professionals, who in

one way or the other have negative experiences with mainstream psychiatry. Stories about

such experiences are for example to be found under ‘Personal Stories’ on the Mind Freedom

web-site (2008).

It seems that some user- groups contribute to another kind of self-conception in patients/ex-

patients/survivors, because the very notion of illness is contested. These groups are based on

different kinds of self- technologies than the ones described in the AIL-program. Although

these movements also have developed programs, they are different, because they are

grounded in people’s own experiences and conceptions.

In spite of enactments of resistance which I have described in this paper, many patients feel

that something is wrong with them, even though they do not accept the illness-definition

presented to them by psychiatric professionals. They try to find out what is going on with

them, why they see and hear things that others do not perceive. They want to be ‘normal’ in

the eyes of themselves and others. However, the AIL’s normalisation-, self-observation- and

self-examination- techniques, designed to normalise and ‘conduct people’s conduct’

(Foucault,2001a, p. 341), are of a different kind than the normalisation technologies

developed in the context of the consumer/ex-patient/survivor movements. The difference lies

in the deconstruction of illness itself. In the survivors’ eyes, their experiences are perhaps

unusual, but they are not signs of illness, and can be dealt with as normal human expressions

of stressful events. Moreover, being ‘unusual’, can be transformed to something positive, for

example being unique and creative (see the Mad Pride 2008 website). In this way, the

reshaping of one’s self- concept seems to be at the very core of such movements.

29
I do not claim that joining user movements is a suitable solution for everyone, or that serious

mental health problems do not exist. What I ask for however, is less emphasis on psychiatric

diagnoses, medicine compliance and ‘insight into own illness’, less emphasis on standard

programs designed by professional health experts, more political and economical support to

user-movements, more freedom for patients and professionals to explore the multiplicity of

subjectivities in an open manner, and finally, a different epistemology based on categories

more in line with how patients/users describe their experiences, which again would imply

radical changes in professionals’ education and training.

Notes:

i All names are pseudonyms.

ii I did not ask the explicit ages of the professionals, but they were between 30 and 60, with

the majority between 35 and 45.

iii The research project has been reviewed and accepted by the Norwegian Committee of

Medical Ethics.

iv Shortly afterwards, Billy was discharged. Six months later he phoned me. He was now

admitted in an acute unit in another town. He was really sad, he told me, because he had got

back his first diagnosis schizophrenia by the new therapists.

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