People categorised with SMI (serious mental illness) are invited for annual physical health checks. In this post taken from her own experience, Becca Pyne reflects on measurement harms and conversational silences.
Not 30 minutes ago I was in a rape counselling session online. Today we finished ten minutes early for data extraction, sorry, collection. The charity’s impact measurement strategy determines my mandatory participation, its purpose being performance statistics for funders. I know this because it has been explained to me.
Along with the unspoken acknowledgement that the survey essentially has no other function and “so we just need to get through it”. I make a mental note that it's the first time I have been asked to score from 1-10 how homicidal I’m feeling. I’m now at my GP’s office and I’m sat with the nurse for the first part of my annual physical health check. And for the second time in 30mins I am required to score myself from 1-10 on the likelihood of my intent to commit suicide.
I’m distressed and highly activated. I inform the nurse where I have just been. She says nothing. At first I think perhaps she doesn’t hear me. So I repeat myself, apologising for troubling her with my distress. And again I state that I have just come from a rape counselling session. But she continues not to hear me.
And in that moment I want the ground to open and swallow me up. I both want to die and think I that already am, the shame comes so thick and fast. My paranoia is activated and I believe that she hates me. That I’m disgusting. ‘Who do I think I am, how dare I be so inappropriate’ is swirling round my head. I have been triggered into such a state of trauma that I’m not sure I will make it through the appointment.
Then she starts talking. Asks me if I’m working? I manage to get out the words that I’m studying a MA. She asks me what I’m studying and tells me she studied for her Masters, whilst working full time. I feel even more pathetic as I can barely cope and mine is only part time. Now, I’m even more confused. I feel really disorientated. Did she mishear me? I conclude that whatever just happened, that it must be all my fault.
It was only months later that I began to get a grip what had happened. I was so affected by this incident it took me a long time to make sense of it. In essence, this nurse was only prepared to carry out the procedural requirements of my health check. She refused to acknowledge or meet me in my vulnerability and instead focused on the employment and education section of the health check form and she employed silence to control and reinforce that agenda.
New public management theory encompasses principles from economics, business and organisational theory and applies them to the healthcare sector. This creates an audit culture shaped by the modern techniques and values of financial audit. These then become the governing principles of human conduct. Justified as interventions of efficiency, transparency and greater accountability, they displace informal relations of trust.
The result is dehumanisation - between members of staff and between staff and patients. Calculative practices such as performance indicators and benchmarking are structural impediments to linguistic exchanges, as the fetishisation of data collection takes precedence over staff-patient interactions. Indeed, I cannot count the number of times I have been faced with someone who doesn’t even look at me, so focused are they on the task of recording my data that they forget I am an actual person.
The medical encounter by its very nature is made up of an imbalance in power and authority. Frequently, vulnerable disclosures are met with silence and emotional withdrawal which result in felt shame. Unequal power relations are a key feature of the terrain of epistemic injustice as dominant groups often employ silencing practices to preserve epistemic control.
Data collection causes epistemic harm. Even though I am sympathetic to the charity’s funding plight I overwhelmingly experience rage and powerlessness at what feels like another violation or transgression - being forced to acquiesce to more misrepresentations of my self and experience. The scale is overly complicated and there is no ‘measure’ I can relate to in these questions. It is distressing and there is no opt out. The same is true of the NHS. Nobody cares what my answer is, just that I do it. And once again the measure becomes the goal.
Further reading:
Cris Shore and Susan Wright, ‘Performance management and the audited self’, In Brihaj Ajana, ed., Metric Culture: Ontologies of Self-Tracking Practices, Bingley: Emerald Publishing Limited, 2018, pp. 11-36.
Cris Shore, ‘Audit Culture and Illiberal Governance: Universities and the Politics of Accountability’, Anthropological Theory 8, 2008, 278-298.
Kristie Dotson, ‘Tracking Epistemic Violence, Tracking Practices of Silencing’, Hypatia, 26(2), 2011, 236–57.
