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ROBERT J. MURPHY
PhD, BA (Hons), MSc, CQSW, Dip Soc Admin, Dip Stress Management
Email:
rjmurphy@lammermoor.freeserve.co.uk
September 2009
SWHN Paper for 6.10.2009
UNDERSTANDING MADNESS: RESTORING THE SOCIAL MODEL OF
MENTAL HEALTH
ACADEMIC AND PROFESSIONAL BACKGROUND – UNDERSTANDING
MADNESS, THE PRACTICE
I will give a brief synopsis of my academic and professional career so far,
and I will go into some details of my professional experience in social work
because it is relevant to my theory on understanding madness and my belief
that the restoration of the social model of mental health is crucial, not only
for anyone experiencing mental health difficulties but also for all mental
health professionals including social workers.
I will then outline my research which was designed to explore personal
narratives of madness in order to explain the reasons for madness, and
understand the process involved of being in, and recovering from, such a
state of mind.
I will say something of my theory which involves my attempt to integrate
philosophical, psychological, sociological, and psychoanalytic perspectives
to create a coherent theory of the development of the mind, thereby
identifying the development of both sanity and madness.
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I applied these different disciplinary perspectives in my analysis of the
personal account of madness to demonstrate that the development of the
mind requires an understanding of individual emotional and intellectual
development through the acquisition of personal knowledge within a social
and historical context and at both a conscious and unconscious level of
being.
I conclude that individuals need to know themselves and have sufficient and
appropriate support if they are to avoid madness, and that others, such as the
mental health professionals with whom people who have been diagnosed
with mental illness come into contact for professional treatment and support,
also need to know what is on the mind of the diagnosed person, at both a
conscious and unconscious level, if the person is to recover their mental
health and the professional mental health worker is to facilitate their
recovery.
MY PROFESSIONAL CAREER
In fact my social work and team management experience reflects my attempt
to put my ideas into practice, ambitiously attempting to influence the
creation of an integrated system in the provision of mental health services in
Lambeth. I attempted this for about 13 years only to realise that integration
following the NHS & Community Care Act of 1990 meant my team’s
gradual demise over a further 3 years as it became increasingly clear that the
social work role in mental health would be ultimately absorbed once again
into a dominant medical framework. My team’s role as an initiator and
provider of community care services with an emphasis on a social model of
mental health was no longer deemed viable and the team was disbanded and
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the provision of services became gradually integrated into the health service
and focused primarily on the clinical rather than the social model of the
causes of, and treatments for, mental ill-health.
I left Lambeth and decided to give up my career in social work management,
because I believed that the only way I might be able to influence changes in
the mental health system and alter people’s understanding of how and why
people go mad was to attempt to get academic credibility for my ideas. I,
therefore, set my sights on the PhD and committed myself wholeheartedly to
writing a thesis that would persuade all who read it that there is light at the
end of the tunnel and that that light reveals a path to understanding, and is
not the proverbial oncoming train, packed as I believe it is at present with
the collective weight of academic, scientific and drug industry opinion,
headed so determinedly in an opposite direction to mine of genetic
modification of the diagnosed mentally ill and their offspring
Having
completed the PhD my mission now is to win friends amongst, and
influence, any movers and shakers in the field of mental health in particular,
but also those in any field of knowledge or professional practice which is
concerned with understanding the mind. In this respect my thesis attempts
to integrate the academic and professional frameworks of psychiatry,
psychology, sociology and psychoanalysis whilst attempting to bridge the
gap between science and art, unifying in the process currently divisive
perspectives, through providing an understanding of the relationship
between the personal and collective acquisition of tacit and articulated
knowledge. Not too ambitious then!
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Initially I completed a history degree, then a social administration diploma at
LSE, took a job as an unqualified social worker and then qualified with a
CQSW at Surrey University, submitting a dissertation there for a Masters
Degree in Applied Social Studies. I spent four years as a qualified social
worker and was then, in Nov. 1980, appointed manager of a social work
team specialising in mental health, both ‘handicap’ as it was then called, and
illness. As a social worker I developed my interest in mental health, creating
a part-time specialist role within the department from a generic caseload. I
worked closely with one of the psychiatrists at the local catchment area
hospital and we established the first local outpatient service for patients
which we ran jointly. We had different perspectives on mental illness but
worked well together and discussed all aspects of mental illness and health,
specifically in relation to patients and clients we were treating and
supporting, and more generally with respect to theory and practice.
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propounded a social model and she a biological model of causation but we
could still agree on many facets of appropriate ‘treatment’ and support. She
believed in the efficacy of ECT, especially for severe depression, and also
believed homosexuality was a mental illness. There were specialist
psychiatric services available locally, including St. George’s Hospital, which
provided psychotherapy and had world-renowned specialists in anorexia
nervosa and bulimia, and the Atkinson Morley Hospital which had
specialists performing leucotomies and lobotomies. On my social work
training course I had completed two long placements, firstly at a child
guidance clinic which provided psychodynamic interventions, and secondly
at the Henderson Hospital, famous as a therapeutic community.
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Although I developed a specialist role in mental health as a social worker
and became a warranted official under the 1959 Mental Health Act I had
trained in various counselling and psychotherapeutic methods of
intervention and support and believed that mental illness was at one extreme
of the spectrum of mental health that I affected all the clients with whom I
was working. The woman with multiple sclerosis required both practical
and emotional support, the married couples who were having marital
difficulties required counselling and with one couple conjoint family
therapy. The children in residential care homes or with foster parents
required emotional and psychological support from the carers and
professionals alike. The severity of the distress in those clients diagnosed
with mental illness required a greater depth of understanding of their
emotional and psychological difficulties which revealed the relationship
between the conscious and unconscious content of the individual’s mind.
Successful intervention typically depended both on commitment and
continuity of support over a long period of time because the diagnosis had
resulted from a cumulative process, often involving a gradual loss of
confidence and self-esteem and a fragmentation of identity. The restoration
of mental health demanded an holistic approach, utilising the strengths and
the combined efforts of both the psychiatric and social work services.
I was appointed in 1980 as manager of a boarding out team based at
Lambeth’s Social Services head office. I could have developed the team
purely as a source of accommodation for fostering people coming out of
long stay wards of the big asylums as part of the community care initiatives,
as well as for the fostering of children.
But I saw the advantages of
establishing community resources in the borough and building on the
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existing boarding out scheme and other specialist social work roles in mental
handicap and mental illness. The Community Mental Health Team (CMHT)
was born, then the only specialist social work team working specifically in
the community rather than the hospital in the UK as far as I am aware.
During the next seven years the team expanded from six to eleven social
work posts and at the point of two more being created as part of the closure
plans for two of the large hospitals, one for mental handicap and the other
for mental illness I determined that the team should separate into two
specialist teams. I had developed services in parallel for both the mental
handicap, including the change in name to learning difficulties, and the
mental health service users and was by now holding separate team meetings.
I had also initiated a specialist team working with people deemed vulnerable
due to mental health difficulties under the housing legislation and created a
specialist team of community care officers who worked alongside the social
workers in the mental health team to assist clients with learning practical
skills and acquiring knowledge to equip themselves for living independently
in the community.
The focus of the CMHT was to provide support to people in the community.
The boarding out scheme was expanded and partnerships developed with
housing associations and voluntary organisations as well as with the housing
department and local health authorities to provide shared accommodation
schemes. Though initially the landlords and landladies of the boarding out
scheme, which was renamed an adult placement scheme, took people into
their own homes, particularly those who had lived on long stay wards of the
old asylums, gradually this unwittingly patronising provision of care was
replaced by more independent accommodation with landlords/ladies living
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in separate houses from their tenants. Though the various housing schemes
were run as partnerships with a variety of independent, private, public and
voluntary agencies I managed to create a central referral system and
assessment process so that all places were filled through referrals to the
CMHT. The purpose of these schemes was to enable the clients to live
independently in shared houses with varying degrees of emotional and
practical support according to need. The social worker provided the overall
management of care and facilitated access to other services, including
educational, employment or leisure facilities, whilst the community care
officers assisted in enabling clients to acquire the practical skills and
knowledge required for living independently. The overall aim was to equip
the clients with sufficient confidence and self-esteem, through acquiring the
requisite practical skills and knowledge and emotional and psychological
strength of mind, to live in their own accommodation and establish their
lives outside the psychiatric system if possible.
The people provided with support had been diagnosed with severe mental
illnesses such as schizophrenia and manic-depression or bi-polar affective
disorder. The severity of their diagnosed illnesses meant that they were
worked with over long periods of time. This was essential if the person was
to recover their mental health and manifest this state of mind in an
independent life. Not all were able to achieve this goal but it was important
to aim for this and believe in the possibility of fulfilling potential rather than
create a framework of services which reflected an expectation of failure.
Real successes depended on facilitating circumstances which allowed
potential to be realised. But this meant establishing long term goals and then
riding the peaks of achievement and the troughs of disappointments and
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sometimes readmission. The gradual process was in recognition of the
fragmentation of identity, the loss of confidence, the low self-esteem the
damaged family relationships and friendships and job losses that had
occurred along the individual’s particular path to madness. The symptoms
of disorder in their thoughts and feelings and actions were understood as
symptomatic of emotional and psychological difficulties the clients had
encountered along the way.
The black African woman who dressed
completely in white and whitened her face and wore long white gloves and
long white socks and walked the streets of a multi-racial community,
exposing herself to ridicule, was attempting to blend in with the dominant
community as she saw and experienced it.
Once the social worker,
significantly black herself, over a long period of time had enabled the client
to regain her confidence and self-esteem and restore her identity as a black
woman so the symptoms of her madness dissolved.
The social worker had to become involved in the client’s life if they were to
effect any lasting emotional and psychological as well as material changes.
They had to build a relationship over time that was based on trust and
rapport and a genuine willingness to understand and work with the client,
accepting and acknowledging that change took more or less courage and this
depended on the individual’s particular strength of mind and on their
potential for acquiring the requisite knowledge that would equip them for a
life of mental health. The social worker had to utilise their personal qualities
of warmth and genuineness and intuition alongside their professional skills
and knowledge. A sympathetic response to the trials and tribulations, the
distress and despair, and to the multitude of obstacles facing the client was
helpful but insufficient to bring about change. Empathic responses which
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enabled the social worker to understand the client’s perspective on life, their
perceptual
and
conceptual
framework
and
to
communicate their
understanding in a non-judgemental way provided the key to the
transformation in the client’s circumstances and mental health.
I worked for sixteen years as manager of the CMHT. In that time I was
responsible either through direct work or through supervision and care group
meetings for hundreds of clients and involved in thousands of assessments,
providing analysis and advice.
I envisaged and worked towards an
integrated mental health service, combining the medical and social models
of mental illness and utilising the available resources of the health and social
services, the private and voluntary sectors and the appropriate local authority
departments and government agencies, in an attempt to facilitate the
recovery of a person’s mental health within a social context.
My research is rooted in and flows from these personal and professional
experiences which have shaped my attitudes, values and beliefs in relation to
mental illness and mental health. Having been involved for so long on a
professional basis with the impact of mental illness on the lives of people I
have known, I determined on trying to pursue a rigorous evaluation of the
dynamic relationship between the individual’s mental health and the social
context in which they develop.
The patterns of feelings, thoughts and
actions which are subsumed under the notions of identity, self, character and
personality have seemed to me to emerge from the interaction with others
who influence the personal acquisition of knowledge from which attitudes,
values and beliefs are constructed. In this regard my research focuses on the
nurture rather than the biological nature of mental health in an attempt to
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examine and expose the acquisition of madness or mental illness as it
emerges from the dynamic interaction between the individual’s identity, self,
character or personality and their particular social context.
There are several reasons for my choice of The Yellow Wall-Paper, which
was published in 1892 as Charlotte Perkins Gilman’s personal account of her
madness, as the focus of my research. It is an account which gives the inside
story, describing feelings, thoughts and actions from the narrator’s
perspective just prior to, during and as she emerges from madness. Though
personal and, therefore, a unique account of the content of her mind the
circumstances, context and process she describes resonate with the accounts
I encountered in my mental health work. I set out originally in my research
to analyse this text to demonstrate the method of analysis I intended to apply
to personal narratives acquired in taped interviews from people diagnosed
with severe mental illnesses such as schizophrenia or bi-polar affective
disorder. But as I analysed Gilman’s account I realised that her narrative
provided sufficient breadth and depth of material to highlight the causes of
the narrator’s madness, and to extrapolate from it an explanation of the
intellectual, emotional and psychological changes which are involved in
becoming, and being, mad, and emerging from madness.
My reading of The Yellow Wall-Paper is designed to be empathic and this is
the method I would have used when interviewing people diagnosed with
severe mental illnesses. I argue that an empathic relationship can and needs
to be established with a person diagnosed with a mental illness in order to
understand the reasons for their state of mind and assist them in trying to
recover their mental health. I argue that an empathic reading of Gilman’s
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text was a necessarily studied and active process, and not simply a passive
attentiveness to what she had written.
A passive reading would not, I
suggest, have identified, for instance, the different genres of Gothic and fairy
tale styles of writing which Gilman employed to tell her story, and nor
would it have picked up on the significance of the leitmotifs of religion and
independence which link the wider historical and social context of Gilman’s
inheritance to the struggle to sustain her religious faith and her search for
economic, social, and intellectual independence as a woman living within
the constraints of a post-Darwinian and patriarchal culture respectively..
I’ll just give a very brief outline of THE YELLOW WALL-PAPER
The narrative is written as a secret journal of a woman, the narrator, who,
following her marriage and then motherhood falls into despair and severe
depression which is treated by the rest cure designed by Silas Weir Mitchell
originally for the soldiers returning emotionally and physically damaged
from their experience of the American Civil War. The setting for the
narrator’s rest cure is a colonial mansion out in the country. She is confined
to a room, the erstwhile nursery, which is located at the top of the house, and
she is expected to rest completely, both physically and intellectually.
Although she wants to write she is absolutely forbidden by her
doctor/husband to do so. Confined to her bedroom the narrator begins to
write down her account of her thoughts and feelings in a diary despite the
ban on her writing. With only the room to dwell on as well as dwell in she
begins to project her feelings and thoughts into the room and focuses the
content of her mind, both conscious and unconscious into the wallpaper,
exploring the pattern and yellow colour and smell so that the literal paper is
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imbued with symbolic meaning and the story of her madness comes to be
told through it
RESEARCH – UNDERSTANDING MADNESS, MURPHY’S LAW!
The premise of my research and of the mental health services I provided is
that the content of a person’s mind and, therefore, of their madness cannot
be understood without situating them in the social and historical context into
which they are born and in which they develop. I contend that a person’s
feelings, thoughts and actions are derived from their accumulated acquisition
of knowledge which shapes their attitudes, values and beliefs into a
characteristic mind, self and identity. Any attempt, therefore, to understand
the cause(s) and determine the treatment of madness in a particular
individual must at some point focus on the personal narrative of the patient.
Indeed a diagnosis of mental illness depends on an assessment of a person’s
thoughts, feelings and actions and not on an analysis of their purely organic
and biological functions, even though a great deal of research into the causes
of mental illness focuses on the functioning of the brain and on genetic
factors. The purpose of my research was to analyse a personal narrative in
detail focusing on the thoughts, feelings and actions of one woman who
wrote about her personal experience of madness. My aim was to examine
the causes and processes involved in the portrayal of the author’s madness
through understanding the changing content of her mind. I employed an
empathic method of analysing the narrative and this method focuses on
understanding the experience of madness from the narrator’s perspective
through uncovering the explicit and implicit layers of meaning evident in the
language. My thesis includes three chapters of analysis of The Yellow Wall-
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Paper which Gilman wrote as an account of her madness and the rest cure
treatment prescribed for her.
My perspective is not rooted in a narrowly biological or clinical method of
analysis or in a developmental model of human nature prescribed by Freud
or Jung and their followers.
It is a perspective which draws together
philosophical, psychological, psychoanalytical and sociological concepts,
specifically those propounded by Michael Polanyi, G H Mead and Sigmund
Freud.
I also explored the clinical psychologist Richard Bentall’s
proposition that personal experiences of madness could be better understood
as complaints rather than as symptoms of disease. His approach challenges
the biomedical model of psychiatric diagnosis and treatment.
Polanyi
emphasised the developmental significance of the acquisition of articulated
and tacit knowledge in relation to the individual and Mead emphasised the
role of the social and cultural context in shaping the development of the
personal self and mind.
Whilst neither of these theorists applied their
notions specifically to the causes of, or recovery from mental illness their
propositions about normal human development inevitably imply the
abnormal opposite. Freud’s psychoanalytic ideas were, and continue to be,
applied to understanding the causes of, and providing a specific treatment
for, madness, as well as influencing other psychodynamic methods of
treatment. My research challenges the premises of human development on
which Freud founded his psychoanalytic theories but I accept, and find
evidence for, his identification of the critical importance of the unconscious
processes and their role in a person’s becoming mad and recovering from
their madness.
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The obvious advantage of analysing a personal account of madness is that it
provides the inside story rather than one received through the eyes and
words of others.
The story has, therefore, not been filtered through
professional perspectives and theoretical frameworks though these often
inform the telling and appear as aspects of a person’s experience.
The
personal account is also the raw material and necessary starting point for the
presentation of new perspectives which attempt to root out the causes and
explain the process experienced by a person who goes mad. My particular
analysis of one narrative is not, of course, the first attempt to do so. Freud,
for example, used the case histories of his patients diagnosed with hysteria,
neurosis or psychosis to construct his theories of human development. R. D.
Laing also used case histories to develop his theory that the symptoms and
signs diagnosed as schizophrenia were socially rather than pathologically
intelligible. Yet my theoretical assumptions about human development, my
method of analysing a personal narrative as a case history and the
conclusions I draw as to the cause(s) and processes involved in mental
illness differ from those of Freud and Laing.
My emphasis on the
importance of the acquisition of articulated and tacit knowledge in the
developmental process, for example, differs from Freud’s assertion that
difficulties in sexual development encountered as children cause neurotic or
psychotic symptoms in adults; it also differs from Laing’s original, though
later retracted, conclusion that psychotic experience is a higher form of
sanity which rivals and challenges the reality defined by the normal and the
sane. However, my premise that the analysis of a person’s use of language
in its literal and symbolic meanings provides a key to unlocking the reasons
for a person’s madness and my conclusion that disturbed thoughts, feelings
and behaviour are explicable when personal development is placed within
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the family and social context echo the use made of case histories by both
Freud and Laing.
BIO-MEDICINE AND PSYCHIATRIC DIAGNOSTIC CRITERIA
I argue that any theory which purports to explain the causes of madness or
mental illness is underpinned by a theory about the development of human
nature. Sanity and insanity are after all merely two ends of a spectrum,
which the psychiatrist separates into two distinct entities with ‘normality’ at
one end, and the diagnostic criteria and classification of mental illnesses
such as schizophrenia and severe depression at the other. Though psychiatry
as a profession claims no definitive explanations for the mental illnesses it
diagnoses, the criteria, classification and treatments reflect the principles and
premises on which its explanations are founded. Psychiatry, therefore, has a
theoretical framework by default, rooted in methods of diagnosis and
treatment which have become institutionalized in the Western world into a
body of knowledge applied by the psychiatric profession and enshrined in
textbooks and systems of mental health. Its framework is now grounded in a
biomedical model of illness forged in Western societies from a philosophical
and scientific tradition encapsulated in the notion of Enlightenment.
I
contend that this Enlightenment tradition in its quest for scientific proof of
cognitive, affective and behavioural mechanisms to support the biomedical
model of mental illness precludes rather than signposts the explanatory path
of causation. By putting to one side this biomedical perspective of madness
which aims to discover its origins in the mechanical, chemical or genetic
processes of human nature, and by focusing on one which examines the
thoughts, feelings and actions perceived and experienced as mad or
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diagnosed as disordered and abnormal I believe a different explanatory
model of madness and mental illness emerges.
My proposed model does not cover mental illnesses such as senile and presenile dementias which are defined by progressively destructive organic
changes to the brain.
It does, however, cover severe mental illnesses
because the signs and symptoms which define them are founded on the
notion of disordered thoughts, feelings and behaviour.
The distinction
between organic and non-organic is, of course, difficult to delineate because
severe mental illnesses such as schizophrenia and manic-depression (or bipolar disorder) are generally believed by psychiatrists, and indeed by
psychoanalysts and psychologists, to have an underlying genetic or chemical
cause, whilst they acknowledge that environmental factors play some
unspecified part.
The debate about causation usually focuses on
distinguishing between the natural, usually inherited, predisposition to
mental illness and the impact on a person of stressful environmental factors
which trigger or precipitate an illness. The lack of evidence for biological
predisposition, such as genetic inheritance, means that this theory of
causation is based on assumptions about the development of human nature
rather than any objective scientific proof. These assumptions are founded on
a Western scientific and philosophical tradition which has been constructed
from the seminal theoretical positions of Aristotelian logic, Cartesian
dualism, Newtonian mechanics and Darwinian evolution. These powerful
ideas have shaped an understanding of the material world and human nature,
underpinning medical science and psychiatry with the fundamental concepts
of physical and mental disease.
The concept of disease defines mental
illness as an organic failure, disturbance or disruption of physiological
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processes located in the brain.
Environmental factors are assumed to
contribute to the causes of mental illness by generating conditions, such as
physical or emotional abuse or problems of parenting, poverty or loss of
employment, in which the disease materialises, just as poor nutrition or
atmospheric pollution contribute to the causes of physical illness.
The failure of scientific methods of research to calculate the percentage of
physical and environmental factors which cause mental illness illustrates the
current failure to establish causation. The lack of a definitive theory of
causation has resulted in a mixture of psychiatric practices which have
emerged as ideas have shifted between the biological and environmental
methods of intervention. Present-day psychiatry, therefore, though founded
on a biomedical model, is less a monolithic institution and more a
conglomeration of different perspectives and structures, with a myriad of
different professionals, such as nurses, psychologists and social workers,
providing a whole range of methods of intervention aimed at the
amelioration of symptoms of mental illness as well as practical and
emotional support to patients.
However, despite the influence of
psychoanalysis on psychiatry during the twentieth century, more so in the
USA than in the UK and other European countries, and despite the challenge
to the biomedical model of psychiatry from the so-called anti-psychiatrists
during the 1960s and 1970s, psychiatry as a profession has strengthened its
belief in the biomedical origins of mental illness, especially since the 1980s
following the impact of research into DNA.
The 1970s also saw the
emergence of social and psychological models of mental illness which
rooted causation in the developmental responses to the interaction between
the individual’s psyche and their social circumstances.
Clinical
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psychologists and social workers were at the forefront of developing theories
and interventions which addressed the intrapsychic, interpersonal and
environmental difficulties which were seen to have caused the mental health
problems, and the provision of services, such as individual and family
therapies, supported housing and community care, reflected these
assumptions.
The model for understanding the causes of madness and
mental illness which I am proposing reasserts the emphasis on the
difficulties people encounter in their emotional and intellectual development
within a social context which underpinned these earlier models of
psychological and social interventions.
This emphasis challenges the
notions of the biomedical origins of mental illness and instead points to its
source in the troubled mind rather than the dysfunctions of the brain.
CONCLUSION
Rather than go into the details of my analysis of Polanyi’s theory of human
development, and Mead’s of the social construction of the self and mind
within a social context, and Freud’s theory of the unconscious I will outline
some of my conclusions which refer to the application of their respective
theories to The Yellow Wall-Paper as a personal account of madness.
Bentall’s suggestion that psychiatry scraps the diagnostic criteria which
identifies the symptoms of mental illness as a paradigm of disease and
focuses on understanding the actual experiences and behaviours of people as
‘complaints’ follows the same line that I am taking, but he sustains a general
scientific belief in the existence of biological mechanisms affected by
traumatic experiences which shape the brain whereas I do not. My shift
away from biological mechanisms and concepts of disease in relation to the
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causes of madness opens a path to understanding signposted by the
development of human nature in terms of language, the personal acquisition
of knowledge, the influence of a person’s interaction with their social
context and the relationship between the conscious and unconscious content
of the mind.
Polanyi’s emphasis on the acquisition of two types of
knowledge, articulated and tacit, provides a concept of the development of
human nature which I suggest focuses on the mind rather than on the
physiological processes of the brain. This theoretical premise challenges the
generally accepted scientific and philosophical traditions of a West
European and North American culture which is rooted in a search for
objective, impersonal, rational knowledge in a material world.
The
assumption that madness is caused by a failure of biological mechanisms
and defined organic structures and processes reflects this tradition. But my
analysis attempts to show that changes in the narrator’s conceptual and
perceptual framework are explicable through an understanding of the
changes occurring in her state of mind, reflected in the thoughts and feelings
and the actions which flow from them. The struggle for sanity, therefore,
which the narrator experiences, revolves around an ability to articulate and,
therefore, express consciously the tacit knowledge available in a state of
madness as unconscious thoughts and feelings.
The recovery of sanity from a state of madness depends not only on the
articulation of the tacit knowledge available in the unconscious but also on
integrating this knowledge into the construction of the self. The concept of
self is crucial to an understanding of human development as it represents the
formation of identity and personality which are bound together with
characteristic attitudes, values and beliefs. Mead’s emphasis on the role of
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the social context and symbolic interaction in the development of the self
and mind are reflected in the discovery of multiple layers of meaning in the
narrative.
An accurate understanding of the intended meaning of the
language used in communicating feelings and thoughts is crucial in any
human interaction, but it is especially so when a person is in a state of
madness because the symbolic, metaphorical and literal use of language
communicates a complex mixture of implicit and explicit meanings arising
from a person’s conscious and unconscious mind.
Understanding the
meaning of what may be diagnosed as a cognitive, affective or behavioural
disorder manifested, for example, by a delusion or an hallucination requires
an exploration and analysis of this mixture of conscious and unconscious
content and an empathic interpretation of their communication. As the
analysis of Gilman’s narrative tries to show the content of the diagnosed
hallucination or delusion springs from the relationship between the
narrator’s imagination and reality, not from extraneous material unrelated to
her experience. The distinction between an imagined and real self is a
critical fulcrum around which madness revolves as the self, in terms of
identity and personality, disintegrates into confusion because the
unconscious imperatives surface and overwhelm the conscious mind with
powerful contradictory feelings and thoughts. A reintegration of the self
depends on the resolution of the contradictory impulses, and of the
ambiguities and ambivalence which fuel them, and the analysis of the
narrative highlights this process. An integrated self defines the recovered
sanity and the narrator’s resolution of the internal and external conflicts
which became her madness are reflected in the compromises she was
prepared to make within her self and within her social circumstances.
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The reintegration of the self depends not only on the restoration of selfconfidence and self-esteem but also on the validation of others who confirm
the restoration of sanity. This is impossible to achieve if a diagnosis of
mental illness, such as schizophrenia, continues to be ascribed because the
ascription is central to the person’s identity and defines the self as abnormal.
The experience of madness is defined to a large extent by the culture in
which it occurs but inevitably places a person outside the cultural norms and
expectations of others because of the alteration in social self. The perception
of others, therefore, contributes to the person’s social exclusion through
being seen as abnormal and this can then both reflect and reinforce a sense
of alienation and isolation within the self as well as from others. The
mirroring of the internal state of mind externally exacerbates the loss of
belonging to the social groups such as family and community which Mead
sees as determining factors in the development of the ‘me’ component of the
self. But whilst Mead conceived of the ‘me’ and self as multiple I suggest
there is only one me and one self who enters into a social context which
changes. Madness occurs when the integrated I disintegrates and can no
longer sustain the unified me and self internally, resulting in confusion, or
externally within the social context.
The importance of the unconscious in human development and its relation to
the conscious mind was overlooked by Mead except in relation to learned
habits. Freud, however, elevated its significance in relation to madness
through originating his theory of psychoanalysis which he developed
through case studies. However, his emphasis on the primary significance of
the sexual content of the unconscious is not borne out by my analysis of The
Yellow Wall-Paper in which feelings and thoughts of, for example, fear,
22
jealousy, suspicion and anger feature far more prominently. Freud’s theory
of human development, like Mead’s, was founded on the mechanistic
assumptions of the Western scientific and philosophical tradition and so,
although my analysis supports his assumption that the unconscious content
of the mind points the way to discovering the reasons for a person’s
madness, my interpretation of the content differs according to our respective
assumptions about the development of the mind and body. My analysis
attempts to demonstrate that the causes and process involved in madness
depends on understanding the relationship between the conscious and
unconscious content of the mind and on distinguishing between the
articulated and tacit knowledge which express personal thoughts and
feelings acquired through social interaction within a social context.
As my empathic reading of her account attempts to demonstrate, the
narrator’s madness is synonymous with her confusion, which reflects the
troubled mind of a person whose attitudes, values and beliefs have been
challenged, and invalidated, as much by herself as others, so profoundly that
she lost confidence in the identity she had created up to this point in her life.
I conclude that the narrator’s recovery depended on restoring her confidence
and self-esteem, through reconstructing her identity, and that this required
her to firstly discover, and then resolve, her contradictory feelings and
thoughts, as she struggled to find, and eventually achieve, realistic
compromises within her own mind. Her rediscovery of confidence and selfesteem depended on the validation of others and she tries to estimate where
she stands in relation to other women when she wonders whether some may
23
have escaped the patriarchal pattern like her. Her question of whether her
husband will accept the changes she has made remains, however, at the end
of the narrative, as she looks anxiously over her shoulder in anticipation of
her husband’s response to the changes she has made. I conclude that, before
she could take the next step in her recovery, she needed to know that he
would accept the compromises she has decided to make in relation to him
and the constraints of a patriarchal culture, whilst now resolved to follow her
own independent intellectual path.
In reality Gilman and her husband
agreed to separate and eventually divorce, unable to achieve the necessary
compromises.
In my detailed analysis of Gilman’s narrative I have attempted to identify
the reasons for, and the causes, of the narrator’s madness. I have not,
however, applied the specifically scientific language of psychiatry,
psychology or sociology to do so, though the general concepts associated
with understanding a person’s madness within a social context can be
understood as underpinning these scientific methods of study. I have also
not used Freud’s psychoanalytic framework, though I have utilized some of
his concepts, such as repression and projection, and similarly applied them
to the unconscious content of the narrator’s mind. I suggest that my analysis
echoes Freud’s comment that in writing his case histories they “read like
short stories”, and could be seen as lacking “the serious stamp of science”,
but that “the nature of the subject is evidently responsible for this” because,
he concluded, “the local diagnosis and electrical reactions lead nowhere in
the study of hysteria, whereas a detailed description of mental processes
such as we are accustomed to find in the works of imaginative writers
enables me…..to obtain at least some kind of insight into the course of that
24
affection” (1953-74, SE 2:160-61). I have tried to demonstrate that a person
uses everyday language to communicate their feelings and thoughts, just as
Freud concluded, and whilst he then applied “a few psychological formulas”
(1953-74, SE 2:160-61), I have tried to integrate, and then apply, particular
psychological, sociological and psychoanalytical theories relating to human
development.
Scientific and professional language transforms everyday usage into
perceptual and conceptual frameworks, defining language differently in an
attempt to specify its meaning. This institutionalising process of scientific
and professional knowledge relies on transforming words into definitions,
which apply to new discoveries, such as Einstein’s theory of relativity or
Freud’s theory of the unconscious. These words then assume the authority
of a particular scientific or professional community, and are applied within
specific contexts and frameworks, adding this meaning to its general usage.
Medical terminology typically tries to refine this process further by adopting
or adapting Latin or Greek words to name organs and organic processes,
including illnesses like schizophrenia, in order to give weight and authority
to the term, and with the intention of creating a specific definitive use of a
word.
Once
the
scientific
or
professional
language
becomes
institutionalised, concepts are reified and conditions looked for that match
the theoretical assumptions. I have not applied a scientific or professional
language to explain the reasons for, or the course of, madness. Instead I
have analysed the language which Gilman has used to describe her
experience, and employed the Oxford English Dictionary to furnish the
meanings, explicit and implicit, as well as literal and symbolic, within the
text, mindful that some meanings may have changed since the book was
25
written. This has opened up the meanings, allowing the complexity of the
narrative to be revealed. I have concluded that this method of analysis has
allowed an explanation of the reasons for the narrator’s madness to be
understood in terms of her feelings and thoughts, rather than as symptoms of
a clinically defined mental illness. Her madness is, therefore, explained in
terms of how and why her conflicting feelings and thoughts arose and were
so disturbing, and why they were manifested in her action of stripping off
the wallpaper, and creeping around the room when her husband eventually
gained access to the room.
I conclude that no person’s madness can be understood, or the causes
discovered, without a detailed examination of the conscious and unconscious
content of their mind. This requires eliciting their feelings and thoughts in
order to understand the reasons for them and for the actions which result
from them.
I contend that this type of examination highlights the
fundamental contradictions, ambiguities and ambivalence, which are
manifested in the apparently distorted language and communication, as well
as the disturbed relationships and behaviour, that are currently diagnosed as
symptoms of mental illness.
I suggest that this type of examination
facilitates a potential path to recovery through acknowledging that the
restoration of sanity depends, not only on providing emotional and practical
support which can help to restore confidence and self-esteem, but crucially
on the person becoming, firstly, aware of the source of the contradictory,
ambiguous and ambivalent feelings and thoughts before, secondly, trying to
resolve, accept or learn to live with them. I conclude, in my analysis, that
the narrator has reached realistic compromises within her own mind, because
this is all that is possible within her circumstances. She realised that she
26
could not change the world as she would like, or change her husband’s
attitudes, values or beliefs, or his and society’s expectations of her as a
woman. But the mental crisis she has written about reveals the process she
went through, of forging a new identity from the remnants of the one she had
prior to marriage and motherhood, which had become, for a variety of
reasons, unsustainable.
The depth of my analysis has taken a great deal of time and effort which is
not typically available to service users from mental health professionals. I
suggest, however, that the more time and effort is put into eliciting personal
narratives, and focusing on mutual understanding of the reasons for the
users’ particular feelings, thoughts and actions, the more likely it is that
longer term solutions to their mental health difficulties will be achieved.
One of the reasons for the so-called ‘revolving door syndrome’ in mental
health, which refers to patients returning to psychiatric hospital at regular
intervals, and for the search for longer lasting medication or more permanent
biological solutions such as genetic engineering, is that the roots of a
person’s madness are never identified.
I suggest that purely biological
interventions cannot be effective except as short-term measures, designed,
for example, to suppress with anti-psychotic medication the feelings,
thoughts and behaviour of a person that are synonymous with the symptoms
of mental illness, or to lift a person’s spirits with anti-depressant medication.
The rest cure treatment, to which Gilman was subjected, is largely founded
on the same principle of treating mental illness through physical means. I
conclude in my analysis that the physical treatment of the narrator’s madness
is ineffective in the long term, except inadvertently through confining the
narrator to a place where she is confronted with her own thoughts and
27
feelings, forced, in her isolation and alienation from others, to resolve her
mental crisis herself.
I suggest that Gilman’s experience has general
application today, and illustrates how and why medical interventions based
on physical treatments, such as the pharmacological and genetic, do not
reach the source of the madness, and can only ever achieve temporary
respite from the profound emotional and intellectual distress and
disturbance, which I have analysed in her narrative. I conclude that, though
the pharmacological interventions might be effective in the short-term for
the suppression of symptoms of mental illness, a person cannot fully recover
their mental health unless the personal and professional support provided
focuses, not only on enabling the person to recover their confidence and selfesteem through practical, material and emotional support, but also crucially,
on enabling them to find the courage and determination to change, through
becoming aware of, and then confronting, their emotional and intellectual
difficulties.
Dr. Bob Murphy