11.04.2010

Subcultural Differences

When I wrote my thesis, there were a lot of things that didn't make it in for various reasons. One of those things was addressing subcultural differences between patients and mental health care professionals. One of the reasons this didn't make it in my thesis was that I didn't figure out a good way to research this (I wasn't sure how to get at this without getting things like emo, goth, etc; or religion and ethnicity).

What I was after in describing subcultural differences wasn't things like emo, goth, punk, straightedge types of subcultures, but smaller. Differences like the unique cultures within families, groups of friends, schools, etc. There are things that are perfectly normal within those subcultures that look weird, perhaps even crazy, to outsiders; but these things are pretty innocuous and totally acceptable on the inside.

In my social circles, most people are probably of above-average intelligence. We use words that others consider "big" and we are willing to ask if we don't know what a word means. We make puns, we tease grammar mistakes, and we acknowledge what we do not know. This is the world I live in.  In my social circles, no one ever considers that I have Asperger's because when I get confused by ambiguous grammar.

In mental health care, these things that are normal in my social circles is misunderstood and cause for them to suggest I have Asperger's:
  • When I use words they don't understand, they don't ask for clarification or definition. They seem to assume that whatever partial understanding they get is correct and then also assume that I use these big words to distance myself from people.
  • When I giggle after my doctor says, "we'll have to keep an eye on that," in response to my concern about a blurry vision drug side effect, the professionals look at me funny, just because they haven't noticed the pun.
  • When I object to the staff telling me, "today will be a better day than yesterday," while telling me that I can't know that today will be worse, they act like I'm just making trouble. They react to it like I am just doing something to annoy them and express my displeasure, not like I am reasonably criticizing the content of their treatment. Even when I explain that they can't know that today will be better anymore than I can know that today will be worse, they still don't understand me; they don't understand that they are wrong even according to their own rules.
  • When we took yarn to make a circle of how big we thought our waists are, our ideal waist size, and our actual waist size, there were exclamations about the yarn stretching when we measured our actual waists. The staff said that yarn does not stretch even after I, having spun my own yarn, explained that it does stretch, as a property of its creation.
  • After reading an article that very carefully defined and contrasted "self-worth" and "self-esteem", an art therapist told me to describe my current self-worth and what my self-worth would be if I was non-eating-disordered. However the article had defined "self-worth" as being immutable, everyone's value being infinite and unchanged by anything they did; while "self-esteem" was defined as one's appraisal of his or her value, which usually does not match their actual value, which is "self-worth". So asking me to describe my "self-worth" with and without the eating disorder made no sense. According to the article, my self-worth would be the same either way, and every person's self-worth is the same as everyone else's. I suspected this was not really what she wanted me to describe, and that I was really supposed to describe my self-esteem, but when I asked, I was accused of being needlessly pedantic. I really didn't know which to do though, since it seemed plausible that she would want us describing our self-worth to make the point that it shouldn't change between having an eating disorder and not having one. She wouldn't help me understand, so I made four lists, self-worth and self-esteem with and without an eating disorder.

In these situations, I'm right. I'm in touch with reality, I am not having any strange thoughts, I'm not pointlessly obstinate, I'm not doing anything wrong or against any rules, I am not expressing any symptoms. But I'm branded as resistant to treatment, as having Borderline Personality Disorder; they tell me I am wrong about physical facts of the world, they chide me for not wanting to get better. If their subculture was similar to mine, they would understand me better. They would understand the words I use or be willing to ask me to clarify, they would understand when I point out that they contradict themselves, they would admit that I know more about yarn than they do. If they were willing to allow for subcultural differences without knowing mine, they might ask how I know that yarn stretches or why I object to their statement that "today will be better." That is harder than asking me for my religion and ethnicity to determine subculture, but it is equally important. Mental health care is one of the places where I find it most important to be understood correctly, because the stakes are so high, and one of the places I am least understood.

(Situations like this make me wonder how most people manage to communicate. Mental health care professionals are not careful to say what they mean, even when asked for clarification, nor are they careful to listen to what I actually say. But most people don't seem to have nearly as much trouble communicating with them as I do. Are people on both ends making the same assumptions, ending with no confusion due to more or fewer assumptions? Are most people equally sloppy with grammar, that they are all making identical mistakes, therefore understanding correctly? When grammar is ambiguous, how do these people automatically assume the correct meaning?)

3 comments:

  1. I usually assume that those things indicate a power struggle, not a culture clash, but I can see that an explanation in terms of culture makes sense too. My explanation would be that whoever has more power gets to decide how language is to be used, and whoever has less power is expected to comply. Power struggles (or culture clashes) also occur between psychiatrists, psychologists, nurses and managers, and they do a lot of damage to the quality of the service. A colleague once told me she had passed two people in the corridor (of an NHS building), one with his hands around the throat of the other, pressing him up against a wall and yelling at him. She did not intervene because she knew them both — a consultant psychiatrist and a manager.

    People mostly don't communicate very accurately, I think. Yes, they just make similar assumptions and similar mistakes. You can get along most of the time just by grunting, you know. With appropriate tone of voice and body language, most people will accept it as good communication.

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  2. I think there are two primary issues here, and they are linked; the first is intelligence, and the second is an 'us vs. them' attitude that is common amongst people working in mental health. I think many people who are very intelligent come across problems with dealing with mental health professionals - I can think of several examples amongst bloggers, and have also had problems myself, although I wouldn't consider myself as intelligent as you, and some of the other people I am thinking of. I think it is partly becaue if you are of above average intelligence, you are likely to be working with professionals who basically aren't, and I think that can lead to quite a lot of miscommunication problems. The second problem, but that is very much linked, is that the culture they are working in is generally much one of 'us vs. them', and I think many professionals would consider it humiliating or beneath their dignity to ask a patient to explain a word they don't understand. I have frequently had mental health professionals ask me if I am understanding a word or a term that they use, and it is virtually always something very straightforward, that of course I understand, but it is almost as though that reinforces their position of authority. I think it is actually like teachers with children - a particularly bright child may have a far wider vocabulary than some of their teachers, but I very much doubt that many teachers would ask a child what a word they didn't know meant, as it would make them feel stupid - they are supposed to be the ones in charge. And even though it shouldn't be the same with mental health, I feel like actually the attitudes often aren't very different - nurses will treat you like a child, and they will push their position of authority onto you, and admitting that they may be wrong would go against that. I think a sign of a good mental health professional is one who will admit that they didn't know something that you have told them (ie a fact generally, not something about yourself) and admits to being human and making mistakes, and not knowing everything. It is the ones who consider themselves superior to their patients who are the problem, and whose attitude leads to the type of situations that you have described.

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  3. Yep, I have those same questions about how normal people communicate!

    I think they go more with successive approximations. They just don’t think things through completely so they don’t notice errors, inconsistencies or ambiguities. Because they don’t notice them, they think they must be too trivial or obscure to notice. It usually takes a very practical demonstration for them to see a problem, and then they will see it as clearly as anyone else.

    I like to think of how I feel when I’m with someone much more educated than I am about some aspect of daily life. For instance...

    If you were hanging out with someone who paid a lot more attention to certain kinds of detail (such as classifying commas into 26 different functions), you might be completely fascinated and want to learn about the 26 different functions of commas too. Alternatively, you might feel that the person you were talking with was focussing on the commas to the exclusion of the content — you might feel that the comma placement was trivial and not necessary for a sufficient understanding of what you were trying to communicate. They, however, might find your comma placement ambiguous.

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