Abstract: This paper argues that in their trainings health professionals are encouraged to use language naively as if it were a transparent medium of scientific communication. We contend that language use, particularly in the field of mental health care, should be studied in terms of its social functions and attention should be paid to the inevitably constructive nature of language in patients' records, such that a 'fictional distance' opens up between patients and the records which are kept about them. Recent developments in literary theory and narrative analysis can be deployed as theoretical frameworks to understand this process and we suggest that more attention to the use of language should be included in the educational programmes for health care professionals to counteract the risk of 'linguistic entrapment' or 'incarceration'.

The acquisition of a technical language is frequently seen by health care professionals as an important step in becoming an 'insider'. An `insider' states Tajfel (1982) is one who is familiar with cultural mores of a particular group. Being able to display a range of technical terms and engage in 'scientific discourse' about patients, clients and relatives is regarded as a sign that professionals have access to esoteric and potentially empowering knowledge. Health care professionals in their trainings are introduced to language, concepts and discourse which they are encouraged to believe will enable them to understand the rational scientific basis of mental health care. The assumption on the part of training organisations is that if people are able to acquire and utilise the discipline's nomenclature and appropriate terminologies in verbal and written discourse then they will have an understanding of the meanings embedded in certain words and ideas. In this paper we will argue that there is a need to study the language of health care, in terms of its inadvertent social functions, its assumptions and presuppositions and the impact these can have on the work they do particularly as few opportunities are available to students of any health care discipline to examine the language they use.

Nurses acquire a technical language as early as their first clinical placement, primarily as a coping mechanism in an unfamiliar world and as a means of giving the appearance to their professional colleagues that they are more competent then they actually are (Kahn et al, 1994). An examination of the language used by these nurses to construct the patients they came into contact with had three different cultural sources. First was the language they encountered in the Nursing School which was mainly used by teachers and that found in textbooks. Second, was the language used by practising clinical nurses and third was language used in the wider Western Culture. The study identified that there was no unifying theory of meaning utilised by nurses to represent patients and their problems. We shall examine the issue of language in medical and nursing records, drawing on our own interests in mental health care, but we hope our observations will apply to other branches of medicine and the 'caring professions' as a whole.

We would argue that as well as the ostensive functions of language to describe and communicate, the technical language of nursing may also serve to consolidate the power of professionals over their patients. Insofar as the technical vocabulary of nursing is the standard form of language in the health care setting, deviations from this standard vocabulary by clients can serve to place them at a disadvantage (Ng and Bradac, 1993). Moreover, having a rich or diverse lexicon (as health care professionals do) also connotes power (Bradac and Wisegarver, 1984), particularly having a richer one than the patient. In the past some attempts have been made to describe the effect of diagnostic 'labelling' on patients (e.g. Scheff, 1966) but these were relatively easy for sceptics to dismiss (Kimble et al, 1980). We advocate a more thoroughgoing examination of language, reasoning, interaction and record keeping in all fields of health care, but particularly mental health. This involves the patient or client, professionals and their culture, and enduring traces left in the form of medical and nursing records.

Just as nurses need to construct their worlds by means of linguistic symbolism, so too do patients. In so doing, patients select what to reveal or not reveal about their realities. How clients and patients articulate their experiences of illness and health care is now proving to be a fruitful but as yet uncritical field of enquiry. So far work has concentrated on the importance of language, narratives and story-telling. For example Epston et al (in McNamee & Gergen, 1992) assert that:

and:

In this formulation, the authors liken therapy to giving the client -

Whereas this concern with the narratives of self in therapy is becoming increasingly modish, there is much less concern with how the language of the carers or researchers is constituting the therapeutic process. In work such as the above we are presented with accounts of therapy which are relatively unreflexive about the way that the authors have organised and constructed their narrative of the client's narrative.

Following the client's disclosures the nurse has to identify what constitutes a 'problem' or a 'pathology' and interpret it against the particular paradigm of care he or she is using (Garro, 1994). The complexity of this transaction has been overlooked. Previous authors have tended to reduce the therapeutic relationship to a set of techniques, a list of moral imperatives or a statement of bland rhetoric. This version of the helper has him or her:

Instead of Saleebey's tongue in cheek characterisation of the naive professional we wish to substitute a more nuanced account which sees therapeutic language as a way of constituting the patient and as a potentially controlling medium (Ng and Bradac, 1993). In therapeutic discourse, in the form of interactions between therapists and clients, for example, Labov and Fanshel (1977) refer to 'challenges' in conversation. Challenges are 'any reference (either by direct reference or more indirect reference) to a situation which if true, would lower the status of the other person' (p. 64), which may be present overtly in statements or may be buried in requests or statements about events. For example making a diagnostic statement makes an implied challenge to the client who has described his or her symptoms, in that it is saying that the events thus described can be accounted for in medical or and nursing terminologies.

Diagnosis and the imposition of technical vocabularies on individuals' distress acts rather like the issue of topic change and topic control in conversation. That is, to reconceptualise a reluctance to go shopping on one's own as 'agoraphobia' is to perform a shift in topic which is potentially empowering for the therapist. Moreover it is using what Crow (1983) called a 'topic shading device' in that it accomplishes a linkage between the professional vocabulary and what the therapist implies has been present in the 'patient's' talk. Topic shading devices also function to reduce the uncertainty inherent in the future of the conversation (Berger and Bradac, 1982) impelling the process of interaction towards 'closure', where some alternatives and interpretations are preferred over others. Particularly if the topic change and topic shading devices are done by therapists, this becomes relevant in terms of what linguists sometimes call a 'preference structure'. One utterance tends to imply that certain kinds of answer would be preferred. That is, usually the preference structure prefers agreements and positive responses over negative responses. In everyday talk when we disrupt the preference structure we often do this by means of prefacing our response, delaying, expressing things indirectly and giving an account of why the response is not of the preferred kind (Heritage, 1988). In a sense then, it's much easier to agree. In the sense of therapy, it's much easier to agree with the therapist.

As an antidote to the way in which professional language can gloss over the patients' narratives we could suggest that there are two essential characteristics of being human that health care professionals need to be constantly aware of:

Clinical practice is the intersection where meanings of the world converge. The health worker (theories), the client (stories and narratives) and culture (myths, rituals and themes) all converge in the linguistic interaction. Acknowledging this enables the health care worker not to pathologise or psychologise problems which might better be conceptualised in political or social terms. Doing this has been difficult because until recently much of the work of constructionist practitioners has failed to do two things:

In relation to this latter point it is important to note that even scientific accounts of mental or physical illnesses have a 'metaphorical' quality (Sontag, 1979). When people describe symptoms, these descriptions are freighted with other meanings - they are a way of communicating a good deal of other business. This statement might seem a little far-fetched when dealing with apparently scientific categories like alcoholism, agoraphobia or auditory hallucinations, but if we shift the cultural frame of reference only slightly the metaphoric nature of symptoms and disease categories becomes apparent. For example Migliore (1993) describes the way Sicilian-Canadians use the idea of 'nerves' to structure their distress and to 'express feelings of concern and distress over their social situation. They translate social problems into the metaphorical language of psychic and somatic distress' (p. 343).

Without an understanding of how language can be used to subjugate patients and their accounts of the world, health care professionals need alerting to the damaging effects of inappropriate use of language. Freire (1973) urged professionals who are largely dependent on language for the delivery of their service to:

To begin to understand the professional construction of illnesses and disorders it is perhaps worth considering the work which is done within the profession to establish the apparent concreteness of diagnostic categories. To begin to excavate this issue let us examine the critical re-reading of Aubrey Lewis's classic work on the concept of paranoia (Lewis, 1970) provided by Harper who argues that Lewis 'depicts the history of paranoia as continuous, scientific, coherent and empirically optimistic' (Harper, 1994 p. 89). The different historical accounts of the topic are selected from, smoothed out and the original authors' idiosyncrasies are glossed over. This does not just happen accidentally but affords the scientific project of psychiatry, to establish the constancy and concreteness of the phenomena it studies. As a result Lewis's psychiatry condenses the diversity of different accounts of paranoia into a 'dominant and essentialist view of history' (Harper, 1994, p. 97). That is, a view is established where there is a single self evident truth at the core of these different accounts.

A similar search after truth surrounds the collection of information about patients. This also recollects the 'dominant essentialist view of history' where a single set of events is assumed to underpin the incomplete and sometimes conflicting accounts that are the raw material of psychiatry. Some textbooks explicitly orient to this difficulty in discussing case histories:-

Here, the work which has to be done to establish the dominant version of psychiatric thought is particularly visible in terms of how the picture is filled in. The goal of 'accurate information' is hampered by processes which are accounted for as 'subjective opinion', the fluctuations of patients themselves and the way in which details may be omitted. This 'error accounting' process is very important for the scientific enterprise and has also been observed in studies of biochemists' talk by Mulkay (e.g. 1985; Mulkay and Gilbert, 1985; Gilbert & Mulkay, 1984). If there is a real world of biochemistry, or patients' symptoms we have to explain why different people have arrived at different conclusions. This hovers in the background of many case history accounts. Contradiction is problematic and is explicitly refined by this 'act of meaning' (Bruner, 1990).

Once records are being made of the interactions between patients and health care professionals perhaps an instructive way in which to consider them is to compare them with other accounts of people which are found in the more literary genres of biography and autobiography. In the realm of mental health care, professionals are involved in creating biographies of patients. Such 'corporate biographies', are not quite what they appear and are just as much literary accomplishments as other kinds of biographies. Rather than being objective accounts of an individual, they are little more than fictions. We would suggest that such fictional biographies ultimately entrap or linguistically incarcerate many individuals. In effect, the potential toxicity of language has been overlooked. Psychiatry has couched itself in language, yet has been slow to adopt a critical perspective towards it. Therefore let us explore the implications of this view of patients' records a little further, in particular by reference to ideas from literary theory and the social sciences as to what biographies are and how they are constructed.

We wish to go beyond the issue of 'labelling' (Scheff, 1966) to suggest that the whole fabric of nursing and medical reports can be viewed as repositories of fiction. Professionals acting as corporate biographers add fictional representations of patients to cumulative records, and may effectively deflect or dislocate meaningful therapeutic interventions based on such written records. The flesh and blood person is lost and replaced by a fictional character. Care interventions therefore, may be directed at fictional characters bearing little resemblance to patients. The potential for patients to be fictionalised into text, and subject to the authority of that text, may lead to entrapment. Written text is often regarded as more authoritative and reliable than the spoken word, and inaccurate, damaging representations may be carried into the future (Goody, 1977; Brown and Yule, 1983; Montgomery, 1986) and an individual's treatment and even liberty may be greatly affected. As such written text is transactional rather than interactional (Stubbs, 1980), and relatively permanent. Therefore the way in which corporate biographies accrete fictions, and are guaranteed a permanent, unchallenged future deserves to be exposed. The linguistic straitjacket of medico-nursing reports needs to be acknowledged and countered.

The fictionality of patient files, of rolling amalgams of individual life stories involves a range of fictional distortions in the process of corporate biography. We can speak of fictional distance opening up between the person and his/her biographical representation. The fictionalisation of an individual occurs in several ways. .

Firstly we wish to highlight the problematic nature of self and autobiographical self. As Olney (1980) states: "phenomenologists and existentialists have joined hands with depth psychologists in stressing an idea of self that defines itself from moment to moment amid the buzz and confusion of the external world and as security against the outside whirl." (ps. 23-24). If this is the case do we not like Julian Barnes's character Geoffrey Braithwaite in Flaubert's Parrot "demand violently: how can we know anybody?" (p. 155). Furthermore, an individual's account of him or herself is problematic. Conway (1990) has highlighted the reconstructive nature of autobiographical memory: "How wrong can an autobiographical memory be before we conclude that it is a fantasy?" (p. 2). He demonstrates that autobiographical memory is not a Xerox machine of our past experience. Disturbingly, it appears to recreate or fictionalise experiences of the past or even wipe out experiences from consciousness. Maybe the self's life narrative is altered and reconstituted from moment to moment. Autobiographical memories, Conway insists, "will never be wholly veridical but rather will (usually) be compatible with the beliefs and understanding of the rememberer and preserve only some of the main details of experienced events." (p. 11). Even Conway however seems reluctant to abandon the notion that there is some sort of essential self underlying autobiographical memory. In psychological thought the idea of a self as something that can indeed be represented, for example in a corporate biography (De Man, 1984, p.71) has been extremely persuasive.

Secondly, some authors (e.g. Middleton and Edwards, 1990; Edwards and Potter, 1992) have recently undertaken a more complete questioning of these largely unexamined psychological models and have reconceptualised memories as things that we accomplish collectively in particular social situations. This suggests that the processes going on in diagnostic encounters where patients perform their stories to clinicians, therapeutic interventions, and case conferences are unruly, 'dialogical' activities (Bakhtin, 1984) from which it is difficult to discern a transparent, veridical account of the patient. Detecting a single true nature of the patient's self or problems from these materials is an activity which we might characterise as 'monological'. This is an extremely easy mistake to make, particularly as the alternative, a fully 'dialogical' understanding of memories, seems disturbingly vague.

In many ways then, our memories are what we make them. This argument must be taken very seriously by anyone involved in clinical practice or research. In a fundamental and continual way we invent or 'fictionalise' ourselves, so that a 'fictional distance' opens up. Certainly, it is no wonder that Olney (1980) highlights "an anxiety about the self, an anxiety about the dimness and vulnerability of that entity that no one has ever seen or touched or tasted." (p. 23). Like the film-maker Bunuel, we might only speak of autobiographical memory as "wholly mine - with my affirmations, my hesitations, my repetitions and lapses, my truth and my lies." (Conway, 1990, p. 10). Indeed, like the English Romantic poet John Clare we might consider biography to be a total 'pack of lies' (Foss and Trick, 1989).

Thirdly, when autobiographical accounts are consigned to corporate biographies, fictional distance is significantly increased. In the written text, autobiographical and biographical information merges, accretes and essentially becomes a constructed, accomplished representation of the flesh and blood individual, whose integrity of self, is as already noted, in some doubt. Hence a double fiction operates: the fictional representation of past events and experiences in autobiographical memory and the fiction of such representations constructed as text. As Elbaz (1988) indicates:

The same argument applies to biography, as contemporary literary theory demonstrates. Representations of an individual biographee by multiple biographers, amounting to a corporate biography, is necessarily an amalgam of narrative arrangements of 'reality'.

Many literary critics, de Man among them, have highlighted lifewriting as fiction, and propose the contentious view that its interest is "not that it reveals reliable self-knowledge - it does not - but that it demonstrates in a striking way the impossibility of closure and of totalization (that is, the impossibility of coming into being) of all textual systems made up of tropological substitutions." (de Man, 1984, p. 71). That is, where a figurative medium like language is used there is an inevitable inability to characterise something completely and exhaustively in terms of what de Man calls a totalization. Olney (1980) mirroring the ideas of Jacques Derrida, Michel Foucault, Roland Barthes and Jacques Lacan, states that the autobiographical text

What corporate biographies 'achieve' is the construction of an individual's 'face' which " deprives and disfigures to the precise extent that it restores " (de Man, 1984, ps. 80 -81). They are an amalgam of perspectives, judgements, opinions, embellishments regarding patients' lives and experiences which are funnelled into a narrative, part fact, part fiction which supervenes over any image of the real flesh and blood person.

Treating lifewriting or biography as fiction highlights an area of debate which is relevant to understanding accounts of the self in clinical settings. That is, peoples' accounts of themselves may well be ambiguous, contradictory or ambivalent. In effect they may be asking the fundamental question - who are we? Again, writings by scholars of literature may offer some insight into the problem. Sontag (1982) notes in her introduction how Barthes's autobiography is a "book of his resistance to his ideas, the dismantling of his own authority" or what Thody (1977) has called an 'anti-biography'. For Barthes, "who speaks is not who writes, and who writes is not who is" (Sontag, 1982). This is a threat to the authority of the corporate biographer. The biographee, the subject of the biographer, in effect, is not resolvable to textual representation.

Fourthly, another complication to this picture of a constructed narrative of patients is added when we consider what happens to the records when they are read. Again, this is an area which has been a major area of literary study in the form of reader reception theories, which are concerned with the nature of people's varying interpretations of the same text (Ingarden, 1973; Iser, 1974; 1978; Fish, 1980; Eco, 1981). Future readers of any medico-nursing biography will interpret the text in different ways. The fictional character caught in the text will fragment into multiple fictional 'personalities' with the interpretative activities of individual readers. It is also recognised that readers have a shared network of culturally available understandings which constitute a 'literacy' with that particular medium (Buckingham, 1993a; 1993b).

Finally, fictional distance is at its greatest when readers - of any health discipline - re-tell the story of a client/patient to themselves or others. These reconstructions and re-verbalisations can amount to Chinese whispers. Consequently, flesh and blood patients may receive interventions directed at a 'personality' quite unrelated to them - their shadow biographees.

For the above reasons, it would be naive to view corporate medico-nursing biographies as transparent representations of individuals. But in psychiatry patient files are naively read as authoritative biographies, not fictions. It is tempting for clinicians to prefer to read case notes in a 'centripetal' fashion as referring to a definite, integrated biological individual, and not to grasp the 'centrifugal', fragmented, multiple picture. Consequently, interventions made with flesh and blood individuals may be tailored to such fictional representations. If this is the case, flesh and blood patients may be subject to inappropriate interventions, or not receive treatment at all. This process lends weight to the notion of patients getting better on their own. It also supports the notion of linguistic entrapment, where fictional representations may incarcerate, compromise liberty or subject an individual to deleterious identification and stigmatisation. A patient who gains access to his or her medico-nursing biography may feel like the protagonist, Jordan in Winterson's Sexing the Cherry: "I discovered that my own life was written invisibly, was squashed between the facts, was flying without me..." (Winterson, 1990, p. 10).

Our concern with the fictionality of the corporate biographies created within psychiatry is partly based on the experience of two of us (PN and PC) in nursing where the peculiarities of record keeping and written communication have aroused some anxieties. No doubt this kind of experience is common to many people in the caring professions. To illustrate our approach let us consider a couple of examples:

Events like this prompt a range of further concerns about how inferences, opinions, judgements and summaries of an individual are made. What about more deleterious information such as descriptions of 'promiscuity', 'deviousness', 'manipulative', or 'antisocial' behaviour? What about the ideological freight (Althusser, 1971) carried in the words of corporate biographers? Ultimately, we need to ask ourselves how much of the information in corporate biographies is fictional, and counter uncritical readings, or readings along the grain. The above example also highlights the many advantages of spoken text over written text.

A further example is provided by the experience of another of us (PN), highlighting the problematic nature of inferences and judgements in communications between health professionals:

There was potential here for the person, if she persisted with seeing her GP, to be damaged by the health care system. We would argue that these examples are more than sloppy record keeping or hasty judgement. They are inherent in the system of creating narratives about patients for these necessarily differ from the narratives which will emerge from other kinds of interaction with the same person (Smith, 1994). In particular, this latter example invites issues of gender and men interpreting women's lives. It recollects the concerns of the Personal Narratives Group (1989) and their interest in the often fraught relationship between the narrator and the interpreter of an individual's life.

Amidst the 'centrifugality' of fictional accounts of patients lies a 'centripetal' entrapment. The flesh and blood person, like the so-called 'prostitute', evaporates but is simultaneously incarcerated as the living replica of a fictional construction, although she bears no resemblance to it. She may, unless the linguistic incarceration itself is 'treated', be subject to future misinterpretations by professionals. In the Bakhtinian sense, fictionality and non-totalization is attained by gross dialogism - by the multivoiced, multi-biographical amalgam of patient history - and such dialogism serves a monological gesture of entrapment - the patient undefined and indefinable becomes defined. What is monological is the illusion of a textual subject that corresponds to an external person. This monological blindness of the positivist, reductionist kind suits the power of psychiatry. Psychiatry relies upon fictional constructions while demanding objectivity. It must clear up its fictions, promote sceptical readings of corporate biographies and take steps to reduce fictional distance.

The potential for linguistic incarceration is high in corporate biographies and begs the question of how patients can escape entrapment? How can fictional distance be countered or minimised? How can corporate biographers or word-wardens be alerted to the problematic nature of their productions?

We cannot of course dispense with language altogether. However, some of the negative effects might be reduced if we attended more to spoken text over written text, because it is the durability of written information and its passage into the future which promotes linguistic incarceration and the preservation of fictional biographies. The flesh and blood individual must be privileged over doubtful biography. We need to focus on the word in its natural, oral habitat (Ong, 1982). Active scepticism about the content of corporate biographies should be encouraged - so-called reading against the grain. Written information should be kept to its most skeletal, relevant, non-judgmental and embellishment should be resisted. Where biographers feel fictional distance has opened up within any text, they should be able to make a written rebuttal of doubtful, ideologically 'loaded' or deleterious information in the form of annotated rejoinders. Rather like Michelle Fine (1994) suggesting that the social sciences need more 'rupturing texts with uppity voices' (p. 75) Asking patients to validate written records may be useful to counter fictional distance and would have profound implications for democratising health care.

Professional trainings in all health care disciplines should seek to incorporate linguistic awareness: addressing the problematics of self, autobiographical self, the 'other' created in the art of biography (Denzin, 1989), reader reception and re-verbalisation. An understanding of the power of language, its ideological freight and the consequences of written text appearing 'authoritative' is essential. Since people with mental health problems have more biographers than the most famous of Hollywood stars, we should be even more rigorously sceptical than we are with scandal stories. Psychiatry needs to resist more comprehensively the naive use of transparent and scientific language. Instead, admitting the way that our psychiatric knowledge is informed by the gender, race, class and the sexuality of those who write it may form part of the strategy for preventing it overlaying the voices of people we place in the role of patients. The debates over 'labelling' have deflected psychiatry away from paying sufficient attention to the very fabric of its language base and the dangers of corporate biographies linguistically entrapping individuals.

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