Phd, BA (Hons), Msc, CQSW, Dip Soc Admin, Dip Stress Management

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ROBERT J. MURPHY

PhD, BA (Hons), MSc, CQSW, Dip Soc Admin, Dip Stress Management

Email:

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.

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 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!

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 SurreyUniversity, 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. I 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’sHospital, which provided psychotherapy and had world-renowned specialists in anorexia nervosa and bulimia, and the AtkinsonMorleyHospital 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.

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 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 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 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 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 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 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..