"Det sitter i veggene" : materialitet og mennesker i distriktspsykiatriske sentra
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ABSTRACT Title: “IT’S EMBEDDED IN THE WALLS” -Materiality and people in district psychiatric centres This dissertation examines the impact that the materiality of institutions has on patients and staff. Fieldwork has been carried out at five district psychiatric centres (Distriktspsykiatriske sentra, DPS) that were originally built as tuberculosis institutions. The patients’ and employees’ experiences of being present in the physical and social space of these institutions has been examined, interpreted and reflected upon. The paper provides knowledge about the significance institutions’ materiality and inner life has on the informants, and how the informants influence the materiality. Background Mental health care has moved away from institutions and towards the local community. The treatment district psychiatric centres offer is limited to short term stays. Norwegian health policy stresses the user’s perspective and the coping perspective as necessary preconditions for undergoing change. At the same time the need for specialist training is emphasized. On the one hand there is a wish for a transformation that requires change in the understanding, recognition and treatment of persons with mental health problems. On the other hand the wish for further specialization and closer commitment to existing medical standards is highlighted. This implies an ambiguity that is both distancing itself from the belief that specialists know the patients’ needs best, parallel with maintaining the role and importance of the expert. The role of today’s institutions for the mentally ill within this ambiguous picture is thus an underlying issue in my discussion. The primary aim of the dissertation is to contribute to building knowledge of the reciprocity and interaction between materiality and people within mental health care. At the same time the research will show that an institution does not exist independently of its history, including the health policies and knowledge that prevailed when the institutions were formed. Theory The theoretical starting point of the dissertation is the work of the Norwegian architect Christian Norberg-Schulz, and that of the French historian, philosopher and epistemologist Michel Foucault. The former represents a phenomenological approach to the link between the importance of public places and people’s self-awareness. Foucault looks at different institutions’ material, mental and social space as representational of the power- and knowledge relationship. This relationship makes patients and employees both disciplined by others and self-disciplined. Methodology The dissertation is grounded in a reflective research tradition referred to as ‘multisited fieldwork’. Data has been gathered through participant observation in five DPS. The observations led to different approaches and sources like interviews, photography and documentary analysis. These sources provided information about today’s practice within mental health care, in addition to insights into the practices of tuberculosis treatment in the first half of the 20th century. The analysis of the data involves repetitive text analysis. This resulted in identification of the following key themes addressing the relation between people and materiality, here entitled: 1) “To get away to recover,” 2) “To feel at home on the way home,” 3) “History in novelty,” and 4) “The obvious medication.” The interpretation has moved from looking closely at phenomena to abstraction. This demonstrates that DPS’ are parts of an extended context relating to history and politics. Findings The research confirms that institutions affect people’s lived experiences to a considerable extent. In relation to the patients, institutions become places attracting them when they are ill. Location and materiality shield and protect them from the outside world. This research demonstrates that patients think rest is an important part of their recovery process. Small rooms and homelike atmospheres contribute to relaxation and recovering. Conditions relating to consideration and caring comprise what encourages health. In relation to the employees, institutions become places where they can adjust to a new and active treatment ideology. ‘New’ is interpreted as a further specialization within the medical perspective. The employees use the rooms as a way of distinguishing themselves from the patients. They work towards disposing of the traditions from the era of tuberculosis. The research shows that employees’ understanding of ‘active treatment’ is in conflict with the patients’ need for rest in homelike atmospheres. Other key findings show that the institutions represent an authoritarian understanding of mental problems as illnesses. This understanding of illness is related to the view of contagious illnesses in the early 20th century. This view seems to be ingrained in today’s institutions. Remote locations, guardrooms, and medicine dosage systems are important elements that support this view. This shows that the understanding, recognition and treatment of tuberculosis can be regarded as a general medical way of thinking that is still present in today’s practice. The findings demonstrate that medicine as a discipline has great influence on patients, employees and the local community. The discipline protests against trends toward decentralisation, user perspectives and the coping perspective. Discussion The theoretical basis of the dissertation is merged with a discussion of the empirical findings. The findings are examined using Norberg-Schulz’ reflections on the meaning of places, and Foucault’s power-knowledge perspective. I show how institutions become places where patients can live when illness alienates them from their homes and local communities. To dwell in an institution becomes an important way to promote health. However, I also question whether patients are bond to the institutions because of their illness, and whether the institutions’ role in a powerknowledge network traps them into an understanding of illness that prevents recovery. Furthermore I examine the significance of tradition. I look at how practices relating to tuberculosis can provide places, hence people, with a more distinctive identity that can result in patients more readily finding their own place in society. In this respect I show how a lack of tradition on the other hand can cause poor health. Through a power-knowledge perspective I discuss how the history of tuberculosis can construct understandings of mental problems involving disciplined and self-disciplined strategies and techniques. In addition I question whether the history of tuberculosis is ingrained in the walls of the institutions and may prevent new ways of understanding mental health.
Doktorgradsavhandling (p.hd.) fra Univsersitetet i Bergen, 2009