Gaslighting and Healthcare

The 1944 classic psychological thriller film, "Gaslight," tells the story of the fictional character Paula and her new husband Gregory, who goes about the task of isolating her and leading her to believe that she is insane. He accomplishes this by dimming and brightening the gas lights in their house and then insisting that she had been imagining it. The objective was to compromise her sense of self and environment, leading her to accept his distorted reality and doubt her sanity. In more recent terminology, "gaslighting" is a colloquial term used to describe the manipulative strategies of abusive people in intimate interpersonal and institutional relationships. Although gaslighting has been considered a psychological syndrome, in many ways, it is fundamentally a social phenomenon. Engaging in abusive mental manipulation certainly has aspects of psychological interplay, but it occurs because of social inequities. Perpetrators of gaslighting utilize gender-based stereotypes, social inequalities, and institutional vulnerabilities against their victims. Gaslighting tactics can damage the victim’s sense of reality, independence, identity, and social support.

Gaslighting occurs within power-imbalanced personal relationships. Although often recognized in domestic violence situations, it can occur in other types of interpersonal relationships. Barton and Whitehead devised the term 'gaslighting' in a 1969 Lancet article that conceptualized involuntary hospitalization as a form of abuse. The term was later popularized in a 2007 book by psychotherapist Robin Stern, in which she explained gaslighting as a phenomenon of mutual participation between perpetrator and victim. Although Stern wrote that gaslighting was gender-neutral, her case studies all involved a male partner as the gaslighter and a female as the target. The best measurable data currently available offers evidence that gaslighting is a common characteristic of domestic violence.

Whereas psychological theories suggest that gaslighting occurs in an isolated dyad, the sociological hypothesis assumes a more complicated etiology, with the primary origin evolving from power imbalances, and a secondary requirement of a close interpersonal or institutional relationship binding the victim and perpetrator. Consequently, the victim cannot readily or easily dismiss the gaslighting efforts. Trust and coercive interpersonal tactics bind the victim to the perpetrator. The sociological hypothesis of gaslighting suggests that it exists in the presence of pervasive inequalities of the allocation of social, political, or economic power.

The social concept of gaslighting in the context of healthcare also reflects a broad power dynamic and institutional inequality. Medical gaslighting is a symptom of a larger problem within healthcare, which is the continued privilege of biomedical expertise overriding and sometimes invalidating the interpretation of actual individual experiences. Central to the relationship of gaslighting and healthcare is the concept of ‘biopower’ established by French philosopher Michel Foucault. Biopower refers to the regulatory technologies of institutions used to govern human life. He describes the ways that health messaging promotes a specific and idealized image of health and of the body in which people conform and aspire to achieve. Medical gaslighting can be seen as an extension of ‘biopower’ within healthcare. An example might include a healthcare provider’s premature interpretation of a patient’s physical symptom as being solely of supratentorial etiology.

Philosopher and gender theorist Judith Butler authored the concept of ‘performativity’ as the process by which social norms are constructed through repetitive informal practices. Performativity suggests that social reality is not canon but is instead continually created and reinforced through language, gesture, and symbolic social cues. Butler also wrote of performativity and autonomy as being ‘code-constructed’ in the therapeutic relationship. This concept has applicability in the doctor-patient relationship, in the sense that biopower as established by institutional norms is maintained through performativity. In contemplating the interactions between patient and doctor during a clinical appointment, the social norms that might allow for medical gaslighting now become clearer. The doctor begins the appointment typically by asking in some manner what the patient’s concern is. At that point, the doctor’s power is briefly suspended, allowing the patient to bring forth his or her personal observations. The doctor, representing the ‘biopower’ of the institution of medicine, is empowered afterward to pronounce what is real and what is not. Operating from the hierarchical construct that science is the final verdict, the doctor can make an interpretive pronouncement of reality for which the patient has limited options to refute. In the context of Butler’s research, this relationship is performative. Within a performative interaction, there is an opportunity for resistance, which would not be without potential negative consequence to the patient, depending upon the doctor’s reaction. Within these performative interactions, resistance is uncommon regardless of the patient’s individual experiences, considering that the nature of the visit involves the doctor establishing the questions, the timeline, the sequence of events, and the examination. At that point, the patient has limited paths for resistance.

Although the terminology of medical gaslighting is contemporary, it is not a new concern, as claims of invalidation, dismissal, and disregard of patient health concerns, particularly of female, ethnic minority, LGBTQ+, and underprivileged patients, are of long-standing concern. Gaslighting is a function of power dynamics, and medical gaslighting is an example of how power dynamics operate within the healthcare institution. Butler’s theory of performativity allows for renewed insight into the ways that the biopower of modern medicine is reified as the authority in healthcare relationships, yet her research also provides an opportunity for understanding when and how these relationship dynamics should be challenged and balanced by individual experiences. In addition, the applicability of these insights can apply to other potential examples of gaslighting within the healthcare community, as in the relationships between administrators and employees, supervisors and supervisees, physicians and nurses, and medical specialists and primary care providers.

In conclusion, gaslighting is unique and is differentiated from other forms of interpersonal misconduct within healthcare, as it does not involve public humiliation, specific threats, or obvious insults. The destructive effects of all forms of gaslighting can be malignantly devastating to all aspects of life. Gaslighting is intrinsically subtle and intimate. These characteristics make it even more dangerous.

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