It is the symbolic matrix of culture and how we navigate it that constitutes the main focus of a cultural psychoanalysis. In The Future of an Illusion (1927) and Civilisations and its Discontents (1930), Freud states that there is a tension between the symbolic constructs of civilisation and individuals, whereby individuals must repress and sublimate their physiological drives (and self-interest) in service of allowing others to co-exist. This sublimation opens up the symbolic space of human culture and allows individuals to operate in this now alienated forum (1, 2). This concept has since been expanded upon by authors such as Herbert Marcuse in Eros and Civilisation (1966) and Erich Fromm in The Sane Society (1955). These authors give an account of a general dynamic relationship between the individual and society, and the cost of being part of society. In the service of social cohesion, some societal authority figures and institutions exert more control than is necessary and hence come to dominate the individual by encroaching upon self-originating narratives. When this occurs, the individual is situated within a rigid symbolic narrative and must continue to perform their duty to this added dimension of identity. This burden of responsibility is placed upon the individual, and in return a sense of safety and illusion of authentic being is offered (3, 4). In essence, this is a symbolic contract between the ego and the ego ideal (5). Just as there is a psychological continuum between the individual and civilisation, so too there is the ever pervasive link to madness, and how it is categorised into mental illness and intellectual disability. To be sure, the demands of fulfilling the symbolic contract are dependent on how rigid this link is. The more demanding the relationship between the ego and the ego ideal, the more it necessitates the formation of a repressing feature that does not conform to the ideal ego, also called the persona by Carl Jung. This repression also results in the formation of what Jung referred to as the shadow (6). This archetypal axis between the persona and the shadow serves as the foundation of an intra societal boundary between the in group and the out group. Within the in group there is all the features that conform to the sense of identity that society permits, while projected onto the out-group are all the repressed aspects (7-10). To reinforce this boundary there is the existence of shame, guilt, taboo, and stigma (11).
The most nebulous and complex of these dynamic situations is the labelling of madness. How then is madness represented in terms of Irish society? According to Damien Brennan in his work Irish insanity (2013), madness in Irish life is conventional to the point of being culturally innate (12). As depicted in Joseph Lee’s classic work Irish society, 1912- 1988, Irish society operated as an insular culture due to the merging of the Catholic Church and the nation-state (13). Within that coupling, the institutional system that had been established the previous century was consolidated and the function of mental illness was bound with the theological necessities of sin (e.g. idleness) and virtue (e.g. work) and the judicial format of mens rea (12, 14). Indeed, the devotion to authority was such that during the mid-twentieth century Ireland had the highest rate of asylum residency (per 100,000) in the world (12). Joseph Robbins book Fools and Mad: a history of the insane in Ireland (1986) looks at the history of madness in Ireland from the Brehon laws right through to contemporary Ireland and concludes that ‘what contemporary Ireland has inherited is not a high level of mental illness but an excessive commitment to the mental hospital and the mental hospital bed’ (15). However, despite the many changes of Irish society since then, ignorance and stigma regarding mental health problems still exists. Indeed, the lens through which mental health problems were and often still are portrayed in Irish mental health discourse reflects the cultural labelling of lunatics and idiots (12, 14). These pejorative stereotypes and cultural clichés are masked by an apparently objective language that renders them seemingly empirically valid. Indeed, changes in public discourse have reflected the transition in terminology from these to the status of service user, but the stigma and social alienation remains (16). However, with the emergence of patient advocacy groups and anti-stigma campaigns internationally, this paradigm shift is seeping into Irish discourse (17). Psychoanalysis and a culture of personal disclosure is a practice befitting a modern and open society and may further enhance this epistemological rupture.
Psychoanalysis is a critique that is opposed to the suffocation of secrets and confessions. It sets out an ideal which seeks for an immanent analysis of the latent processes of discourse which when done successfully opens up new symbolic spaces into which the subject grows. Understanding the mechanisms of repression and how it operates at two apparently distinct but fundamentally linked domains opposes the nullification of interpretative activity which often is the result of rigid cultural narratives. However, in the process of breaking the encoded link between implicit and explicit memory encoding, the formation of complexes occurs at the individual level (18). These complexes (also known as cognitive schema) are feeling-toned neuro-cognitive structures that are involved in memory encoding at both the explicit and implicit levels (19). In addition to this conceptualisation of the complex, there is the attachment based aspect of this organisational system. This theory is clearly laid out in the work of John Bowlby, who refers to Representations of Interactions that have been Generalized (RIGS) as the basis of human interaction (20). These enable the building up of an inference based system of perceptual representation and interaction (21, 22). However, these complexes can become pronounced by recurrent repression of related encoded stimuli which then result in further dissociating these systems from ego-consciousness (6, 18). The separation between ego consciousness and these complexes render them seemingly autonomous and more troubling still, appear alien to ourselves, despite the fact that they are in fact a part of our own psyche (6, 7, 18). This alienation can occur in everyday examples, for instance, when we are dreaming we are confronted by dream characters who appear to be separate people, while in waking consciousness they can form the basis for mental health problems such as intrusive obsessions and compulsions and anxiety. Beyond the individual level complexes can form cultural taboos and contribute to stigma attribution. Mental health problems are therefore not simply medical illnesses confined to a clinical setting or discrete pathological entities, they are by definition spread into wider symbolic spaces of the individual and encroach upon their degree of agency (17).
How then are these cultural complexes managed within discourse? There are at least two major processes involved in the management of these domains, displacement and repression. Both of these processes operate within the unconscious and are exemplified by the language used to describe the discourse. Displacement (expressed as metonymy in language) seeks to direct the focus from highly anxious areas to less emotionally charged domains in an effort to regulate anxiety (23). An individual example of displacement is directing frustrations from the workplace to partners and children at home, while a cultural example of displacement is the change in focus of a discourse for example, focusing on the appropriate application of politically correct terms within a discourse rather than critically analysing the discourse itself. Repression (expressed as metaphor in language) seeks to signify and remove complex networks of discourse in such a way as to negate them. At an individual level these appear as forgotten memories of a traumatic event, but retaining a highly dense and codified implicit symptom such as symbols in nightmares, while in society they operate as densely emotional topics which are flanked by suspicious absences in discourse (24, 25). Such processes (displacement and repression) mostly work together and in public discourse, multiple issues are displaced and repressed around similar topics, hence the formation of a cultural complex. Again within the discourse of mental health, there is widespread acknowledgement that the Irish mental health system needs reforming in specific ways, but underlying this there continues to be very clear absences of even basic data based methods of how to implement minor changes or to measure the progress of minimal reforms.
This complex layering of meaning is particularly true of mental health discourse in Ireland and the recent efforts to try and introduce service users and their families into health care policy. As acknowledged by Mental Health Reform (MHR), A Vision for Change (AVFC) has a critical progressive message which situates service users and their family members as the central component of a mental health policy. The key aim can best be summarised by the expert group as ‘the need for service users to be viewed as active participants in their own recovery rather than as passive recipients of ‘expert care’’ [page 13] (16). This message seeks to establish these individuals as decision makers at all levels of service delivery. In particular, this function is optimised through the role of individual recovery/care plans at the therapeutic level and developing national and systems based policy at a state level [page 2] (26). Indeed, the expert group proposed that the best way to achieve this repositioning of service users and their families into the national mental health narrative was to firstly establish the use of individualised care plans and then support these with advocacy services, peer-led therapeutic support services, and to establish a national service user executive (this position was set up in 2007). To further strengthen this system, there would also be a complaints protocol in place as well as the provision of information for all aspects of service delivery, including legal rights, availability of services, and wider availability of social welfare. However, areas of repressed aspects of discourse have been suggested. For example, the absence of national data on the extent of family supported involvement in individual recovery plans, as well as absences and inadequacies regarding the availability of general mental health information regarding management has been identified by the expert group as often contributing to the exacerbation of mental health issues and carers experience of this service [page 2] (26). This extends into the state level, whereby The Mental Health Act of 2001, which sought to drastically update Ireland’s mental health legislation, does not include a much need right to advocacy for service users across the nation [page 3-4] (26). Meanwhile, MHR has assessed the extent of service user involvement in the mental health system and according to the HSE correspondence with MHR all areas of the mental health services have some form of service user input regarding their experience of the mental health system. However, according to a MHR survey of consumer panels there is significant inconsistency across Ireland with regard to this dialogue, with five out of seven panels agreeing that they had adequate input into their care plans and six out of seven panels highlighting the lack of funding received from the HSE [page 3] (26).
The gaps in discourse are not simply because of faults in human cognition, rather they are inbuilt into the narrative itself as part of its construction. At a societal level the gaps in discourse can also constitute the impossibility of a progressive reality. This structural edifice shapes the way patients are then viewed. In the mental health system this manifests in all efforts to refer explicitly and implicitly to the myriad obstacles that render the paradigm inoperable. A particular area of reform that has been highlighted is the issue of mental illness related stigma. In 2006, the National Disability Authority’s public attitudes survey found that “by far the lowest level of willingness to employ people was for those that had mental health difficulties, with only 7% of respondents thinking employers would be willing to hire people with this disability”. The survey also found that the general public was less comfortable working with or living near someone with a mental health disability compared to other disabilities (28). One of the ways stigma has been combated in Ireland is the launch of the green ribbon campaign in May 2014 to establish events to discuss mental health issues. Since the campaign seven out of ten Irish adults now feel more comfortable in discussing mental health (27). However, challenges still remain, as those with mental health problems are still faced with the uneasiness of their status from co-workers and neighbours (29).
One of the major steps forward regarding tackling social alienation in Ireland was the development of a social inclusion chapter to the national policy AVFC (2006) [page 7] (26). To be sure, AVFC recommended that “Services should be inclusive of all the people in Irish society and should be delivered in a culturally appropriate way… Equal opportunities for housing, employment and full participation in society must be accorded to individuals with mental health problems.”(16). Within the national discourse there is recognition that alienation can be resolved by tackling the challenges that operate at multiple levels and include stigma/discrimination, integration of children/adolescent with the educational systems, housing and employment supports, cultural sensitivity, and finally, an examination of the link between poverty and mental health. However, behind this progressive vision resides the same material conditions persist. When the service users consulted in the process of the development of AVFC, 70% were dependent on welfare payments or had no income at the time, and 47% reported having a Junior Certificate qualification as their highest educational attainment [page 7] (26). Indeed the problems continue, and according to data from CENSUS 2011, only 43.8% of working age people with a mental health disability were in the labour force compared to 61.9% in the general population over 15 years old (30). More striking still, is that it was found that people with a mental health disability are nine times more likely to be out of the labour force compared to their peers, with mental health problems having the highest rate of labour force exclusion of any other group with a disability in Ireland (31). This cultural counter-transference needs to be re-examined and the underlying prejudices regarding patients should be acknowledged and amended.
But replacing one provisional conclusion with another and disguising old ways of thinking with new information only perpetuates the illusion that progress is being made. Resolving issues surrounding social alienation have been the cornerstone of psychiatry since its beginning. Indeed, the issue of mental health was intimately interwoven with other forms of deviancy like poverty and the sin of idleness that fuelled both (12, 14). The establishment of workhouses and sheltered workshops had as their main aim to attempt to re-integrate the deserving poor and mentally ill into wider society. The justification of which was predicated on the belief that work would free them from their condition and would purify their soul (14, 15). Indeed, that same sentiment is still in place in the modern form of sheltered workshops. Such segregated sheltered workshops have shown to simply not be fit for purpose and perpetuate the problem (32, 33). Instead, it reinforced rigid forms of collective thinking, and enforced the boundaries that individuals labelled as mad continue to face. It has been proposed by the Department of Health in its policy entitled: Value for Money and Policy Review of Disability Services in Ireland (2012), that flexible supports focused on individuals and their families rather than retaining segregated services should be the guiding paradigm of reintegrating service users back into society (34).
There must be a detailed critical analysis of the cultural complex of deviancy coupled with madness, poverty and stigma. This particular narrative about mental health retains its position in Irish society in an effort to buffer the new deviants in a way that maintains the discourse on mental illness and perpetuate a system of scapegoating. Psychoanalysis as it pertains to Irish culture is not to be presented as a rare specimen of negative critiquing of the concept of a false consciousness, out of which a true consciousness forms, rather it is a theoretical dialogue that borders on the therapeutic, by exposing the individual to that which is being ignored. To restructure the problematic interpretation of events serve not only to understand the past and its impact upon the present, but empower the individual to not let these processes predetermine the future. The boundary between normality and madness is non-existent and Irish culture continues this impossibility of differentiated representation. It surrounds the Irish subject both within and without and represents not a fixed moment in time or the accumulation of paradigms, but two broad domains of social inclusion and exclusion. These ordered fields are composed of reconfigured madness found within individuals labelled as mentally ill or intellectually disabled, and within the psyche of the public as madness as a dangerous other, expressed as ignorance and stigma. The psyche under these conditions operates beyond both these points and at times struggles to balance the demands of the unconscious with the commands of the society. The individual life exists as a position of exclusion, and agency that is so restricted that the task of everyday living becomes the impossibility of reason. How then has Irish society functioned for so long under such pressure? Historically and culturally catharsis had and still has many forms in Ireland, the confessional booth, the pub, and art. According to Danielle Knafo in Dancing with the unconscious (2012) the major discoveries of psychoanalysis have always been well recognised by artists for many centuries (35). Moreover, the understanding of Ireland’s cultural narrative and discordant mental health was always known by its artists, in the past century by the figures of Swift, Joyce, Yeats, Keane, and Beckett, (and their historically neglected female contemporaries) and in the contemporary era by vocal advocates of mental health reform, Niall Breslin and Blindboy Boatclub from The Rubberbandits. The popularity of this level of advocacy is a clear vindication that expressing the unconscious through public disclosures can offer not just empowerment, but some solace.
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