Cognitive Superbug! Why is delirium an important public health issue?

March the 15th is World Delirium Day, and like all health awareness days it should be critically assessed for its relevance in our lives. Why should delirium stand out? It matters because delirium should inspire one to take the opportunity to reflect on this major public health crisis and imagine a better future. A new way of thinking about health care and mental health in Ireland needs to arise.

Delirium (also known as “acute confusional state”) is a form of brain failure, and like dementia is one of the many forms the brain/psyche takes when it is dying. As a form of brain failure, delirium is intimately associated with poor healthcare outcomes and according to many researchers delirium should be considered a cognitive superbug. As a neuropsychiatric syndrome, it is characterised by a complex variety of features and experiences which include, disturbances in memory, language, thought processing, attention, orientation, motor functioning, and even our sleep wake cycles. Together these features manifest the florid nightmares that patients have when they exist in a state between being asleep and awake. Indeed in J. Allan Hobsons classic text, Dreaming as Delirium (1999), dreaming and delirium share many features both at a psychological and neurophysiological level, and understanding one can help in understanding the other.

According to Inouye et al., (2014) the aetiology of delirium is complex and reflective of multiple contributing factors, which include critical illness, polypharmacy, and pre-existing cognitive impairment.  It is estimated to have a prevalence of 20% in general hospital inpatients, over 50% of the over 65s inpatient population, and then it can escalate to a prevalence of over 80% of inpatients in the intensive care unit and palliative care setting Research has confirmed its high prevalence in the acute Irish hospital setting, for example, Ryan et al., (2013). The high prevalence of delirium is such that there are hundreds of terms to describe delirium in the medical literature, for example it is reported in Zbigniew Lipowski’s book, Delirium: acute confusional states (1990), Hippocrates used 16 terms to describe what we now call delirium.

Despite its prevalence, it is overlooked in two-thirds of cases. Worse still, long after they have been discharged from hospital, the individual can suffer an abrupt and noticeable decline towards worsening frailty, increased risk of dementia and even death. And for those that may endure this process, there is the spectre of post-traumatic stress disorder and a lingering feeling of alienation.

In 2014, as part of the New Programme for Government 2011-2016, The National Dementia Strategy was launched which mapped out the different aspects of dementia/ delirium care in Ireland. It highlighted the economic (estimated cost €21 million) and health care burden of dementia (estimated prevalence of 29%) in the acute hospital setting. The National Strategy for Dementia identified the interface between dementia and delirium in the Irish acute hospital setting and the vulnerability of these patients to developing both. A key component to this strategy was the establishment of cognitive friendly hospitals. However, a national audit of dementia care in Irish acute hospitals (conducted by Timmons et al., 2015) highlighted the absence of delirium screening in over 70% of patient records. However, the authors highlight that this disparity between policy and practice is unfortunately a common trend internationally.

Although many of the features of a cognitive friendly hospital have been established in Ireland, there is significant room for improvement in terms of staff training and routine screening. Delirium is not an issue that can be approached without any critique of the ideas and notions surrounding it. From a wider perspective, delirium is also part of the great untold narrative of mental health problems across Ireland.

The past few decades have seen tremendous blustering and bumbling from different HSE managerial phenotypes, from the ill-informed to the melancholic, and all within the spectrum of the ineffective. An accumulative spectacle of nothingness punctuated by nastiness cannot continue in line with the fatalistic discourse that now dominates health care policy in Ireland, particularly mental health policy. The Republic of Ireland is in an excellent position to develop and implement a national screening programme for delirium as a focal point of cognitive friendly hospitals. Research from Ireland has contributed significantly to the discourse on delirium and its economy of size, offers an exciting prospect of utilising an effective strategy to enable the Irish healthcare system to tackle this major public health problem.

Orbital Madness

 

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.

 

References

 

  1. Freud, S. (1927). The future of an illusion. The Standard Edition of the complete Psychological Works of Sigmund Freud, Volume XXI (1927-1931), London, Vintage.
  2. Freud, S. (1930). Civilisation and its discontents. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XXI (1927-1931), London, Vintage.
  3. Marcuse, H. (1966). Eros and Civilization: Philosopical Inquiry Into Freud. Beacon Pr.
  4. Fromm, E. (1955/ 2012). The sane society. Routledge.
  5. Laplanche, J., & Pontalis, J. B. (1988). The language of psychoanalysis. Karnac Books.
  6. Jung, C. G. (2014). Two essays on analytical psychology (Vol. 7). Routledge.
  7. Stevens, A. (2015). Archetype revisited: An updated natural history of the self. Routledge.
  8. Sherif, M. (2015). Group conflict and co-operation: Their social psychology (Vol. 29). Psychology Press.
  9. Janoff-Bulman, R., & Carnes, N. C. (2013). Surveying the moral landscape moral motives and group-based moralities. Personality and Social Psychology Review, 1-18.
  10. Täuber, S., & Zomeren, M. (2013). Outrage towards whom? Threats to moral group status impede striving to improve via out‐group‐directed outrage. European Journal of Social Psychology, 43(2), 149-159.
  11. Neu, J. (2013). Freud, Sigmund. The International Encyclopaedia of Ethics.
  12. Brennan, D. (2013). Irish Insanity. Routledge.
  13. Lee, J. (1989). Ireland, 1912-1985: Politics and Society. Cambridge University Press.
  14. Walsh, D., & Daly, A. (2004). Mental Illness in Ireland 1750–2002. Reflections on the Rise and Fall of institutional Care, Dublin: Health Research Board.
  15. Robins, J. (1986). Fools and mad: A history of the insane in Ireland. Dublin: Institute of Public Administration.
  16. Health Service Executive (2006). A Vision for Change: Report of the expert group on mental health policy. The Stationery Office, Dublin, Ireland.
  17. Bracken, P., Thomas, P., Timimi, S., Asen, E., Behr, G., Beuster, C., … & Downer, S. (2012). Psychiatry beyond the current paradigm. The British Journal of Psychiatry, 201(6), 430-434.
  18. Abraham, K. (1988). Selected papers on psychoanalysis. Karnac Books.
  19. Edwards, D., & Arntz, A. (2012). Schema therapy in historical perspective. The Wiley-Blackwell handbook of schema therapy: Theory, research, and practice, 3-26.
  20. Schwartz, J. (2015). The Unacknowledged History of John Bowlby’s Attachment Theory. British Journal of Psychotherapy, 31(2), 251-266.
  21. Ondobaka, S., Kilner, J., & Friston, K. (2015). The role of interoceptive inference in theory of mind. Brain and cognition. 1-5.
  22. Hinne, M., Heskes, T., Beckmann, C. F., & van Gerven, M. A. (2013). Bayesian inference of structural brain networks. Neuroimage, 66, 543-552.
  23. Modell, A. H. (2014). The Evolutionary Significance of the Primary Process—The Freudian Concept and Its Revision. Psychoanalytic Inquiry, 34(8), 810-816.
  24. Billig, M. (2014). Towards a Psychoanalytic Discursive Psychology: Moving from Consciousness to Unconsciousness 35. THE DISCURSIVE TURN IN SOCIAL PSYCHOLOGY, 159.
  25. Dowerah, B. N. (2013). Lacan’s Metonymic Displacement and its Relevance to Post-Structuralism.
  26. Mental Health Reform (2015). A Vision for Change Nine years on: A coalition analysis of progress. Dublin: MHR.
  27. Change (2014). Green Ribbon Campaign, May 2014: Impact Report, p. 24.
  28. National Disability Authority (2011). Public Attitudes to Disability in 2011 available at https://www.ucd.ie/t4cms/Public_Attitudes_to_Disability_in_Irelandfinal%20Report%202011.pdf.
  29. National Disability Authority (2006). Public Attitudes to Disability in 2006 available at http://nda.ie/Publications/Attitudes/Public-Attitudes-to-Disability-Surveys/Public-Attitudes-to-Disability-in-Ireland-2006/Executive-Summary/Executive-Summary.html.
  30. CSO Census Profile 8 – Our Bill of Health – Health, Disability and Carers in Ireland.
  31. Watson, D., Kingston, G. and McGinnity, F. (2012). Disability in the Irish Labour Market: Evidence from the QNHS Equality Module, Dublin: Equality Authority/Economic and Social Research Institute, p.19.
  32. Health Service  Executive  (2011). Time to Move on From Congregated Settings A Strategy for Community Inclusion. Health Service Executive, Dublin, Ireland.
  33. Health Service  Executive  (2012) New  Directions–Personal Support Services for Adults with Disabilities: Review of HSE day Service and Implementation Plan 2012–2016. Health Service Executive, Dublin, Ireland.
  34. Department of Health (2012). Value for Money and Policy Review of Disability Services in Ireland. Dublin, Ireland.
  35. Knafo, D. (2012). Dancing with the unconscious: The art of psychoanalysis and the psychoanalysis of art (Vol. 14). Routledge.

Schizophrenia and the Irish family

In The Political Unconscious (1981), Frederic Jameson begins with the phrase ‘always historicise!’ This refers to the process of examining ideas, not simply as immutable objects outside of history, but as a collection of linked themes that evolve over time. This is the basis of a critical analysis of discourse (1). How then can it be applied to mental health discourse? Schizophrenia is the perfect concept to answer this question. Schizophrenia is a chronic enduring mental health problem of no definite aetiology and a variable outcome (2). Indeed, the prevalence in Ireland is not entirely known, but has been estimated to be approximately 3.4 per 1000 (3). More complicated still, is the shifting meaning of schizophrenia within the Irish discourse on mental health. In line with international standards, the paradigm of care for chronic enduring mental health problems has changed. This shift has been from large scale institutions to community based care (4). In congruence with this change, the burden of caring for someone with an enduring mental health problem has fallen upon their family (5). This is most particularly true for people with schizophrenia in Ireland (4). It is well known in the literature that caring for family members with enduring mental health problems can have very detrimental effects, including family dysfunction and carer burnout (6, 7). In order to parse out the complexities of having this societal arrangement, a deeper analysis of the historicity of schizophrenia is required.

In 1908, Eugen Bleuler coined the term schizophrenia in a lecture he gave on case reports of psychosis. He later coined the phrase ‘group of schizophrenias’ in a book published in 1911, and this phrase was used to denote the clinical unity of a collection of mental health problems that had dysfunctional perception, cognition, and affect (8, 9). Before this development, schizophrenia was termed dementia praecox by Heinrich Schüle in his textbook on psychiatry published in 1886. Arnold Pick continued to use this term in his well-known case report of a patient diagnosed with hebephrenia. Both these theorists proposed that dementia praecox referred to a type of cognitive failure (dementia) in young people which was distinct from Alzheimer’s disease, which occurs in much older patients (10, 11). Meanwhile, Sigmund Freud had attempted to popularise the term paraphrenia, and through a number of secondary sources attempted to describe the underlying psychology of this condition (12). Although Bleuler initially attempted to apply psychoanalytical ideas to patients with schizophrenia, it was Carl Jung, who worked with both Bleuler and Freud, who successfully synergised these perspectives. Jung not only widened the theoretical construct of schizophrenia, but he also emphasised the therapeutic alliance between doctor and patient by exploring the phenomenology of madness with them. In 1907, Jung published The Psychology of Dementia Praecox which established him as an important figure in the development of schizophrenia research. In this book he applied various methods (psychoanalysis, word association experiments, and theories from anthropology) to clinical observations of patients in his clinic. The book was an international sensation because it blended the known accounts of pathophysiology with the subjective psychology of patients experiencing psychosis (13). However, 20th century academic psychiatry divided the concept of schizophrenia along neuroscientific and psychological lines (14).

Indeed, with the findings from genome wide research studies and cognitive neuroscience, the concept is ever evolving (15). There are now thousands of candidate genes and risk factors that attempt to delineate the essential features of this condition (16). However, the wide variety of discoveries largely neglect the experience of the individual with the condition. There have also been attempts at applying psychoanalysis and other forms of psychotherapy to schizophrenia, and the results have been mixed (17). The problematic nature of this particular discourse is that in the search for an essential schizophrenia, it has become a waste basket term into which a whole host of undifferentiated forms of mental health problems have been cast (14). This challenging situation is not simply a clinical issue, but manifests in all the areas that border on the role of madness in society. Schizophrenia can then become a controversial label and fall into political discourses. Indeed, two of the most famous examples of this are to be found in The Protest Psychosis (2010) by Jonathan Metzi and The Divided Self (1960) by R.D. Laing. Both these books highlight the elasticity of the diagnosis of schizophrenia as it pertains to human existence in the twentieth century. What is also apparent is the often neglected voice of the service user amidst the efforts of society to tame this construct of unfettered madness. Indeed, the complexity of the term schizophrenia reflects a whole host of preconceived myths about the role of madness in society (18, 19). With the political development of patient advocacy groups and the service user movement, there has been a more concerted effort by academic psychiatry to incorporate clinical research into the personal narratives of service users (20).

Indeed, a successful modern approach has been the development of Open Dialogue. This method, first developed in the 1980s in Finland, focuses upon the use of a needs based approach to service user management of psychosis, especially at times of crisis. The psychotherapeutic intervention is performed in the presence of family and carers to establish a robust support system for a collaborative dialogue. Such an approach focuses on addressing the needs of the service user and their family (21). In particular, this method promotes the therapeutic alliance through psychological continuity as well as acknowledging the ever present uncertainty pertaining to the service user’s condition (22). A consensus regarding the importance of these principles in caring for vulnerable service users and their family’s is emerging in the UK’s NHS (23). In congruence with this development, the Republic of Ireland is also ripe for such innovation. In contemporary Ireland, the majority of care is delivered at the interface between community clinics and family supports. As acknowledged by A Vision for Change (2006), a modern mental health system requires partnership between all stakeholders involved in caring for the individual. This is to ensure that the individual has access to all the supports required to secure their recovery. More recent research has highlighted that the needs of parents caring for children diagnosed with schizophrenia emphasise all the key domains that are addressed by an applied Open Dialogue approach (4). Unfortunately, Irelands mental health system is severely under resourced and currently operates at 75% of staffing levels as recommended by A Vision for Change (2006) (24). According to the Mental Health Commission report (2015), it has also been found that in this context of having an inadequately resourced infrastructure, family members (23%) and Gardaí (45%) are the primary referrers for the involuntary admission of individuals (25).

Schizophrenia has significantly changed over the course of its history and is now part of a more nuanced paradigm. Despite the lack of a comprehensive account of schizophrenia, there is something to be recognised. Over a hundred years since the publication of The Psychology of Dementia Praecox, Jung’s method and theories have foreshadowed many of the discoveries from clinical research. In particular, the most noted example is the relationship between clinical neuroscience and the phenomenology of the individual who suffers from this extreme state. At the centre of this innovation is the role of the therapeutic alliance and the larger support structures needed for recovery and ultimately individuation (26). Political and societal discourses on madness coupled with the role of the service user in society have also fundamentally changed, but unresolved problems persist. What is needed now is to develop this initial application of psychoanalytical theory to exploring and appropriating into the discourse new methods of dialogue. To support this initiative, there is a much needed critical analysis of the relationship of the individual service user and their family to the term schizophrenia. This concept must further evolve upon an evidentiary basis, which includes the development of a critical analysis of psychosis. Various assumptions about this diagnosis must be challenged and an open dialogue encouraged. This theoretical appropriation will help nurture a culture of hope over fatalism.

 

References

 

  1. Fredric, J. (1981). The Political Unconscious: narrative as a socially symbolic act. UK: Methuen.
  2. (2014). Psychosis and schizophrenia in adults: Treatment and management. London: National Institute of Clinical Excellence.
  3. Youssef, H. A., Scully, P. J., Kinsella, A., & Waddington, J. L. (1999). Geographical variation in rate of schizophrenia in rural Ireland by place at birth vs place at onset. Schizophrenia research, 37(3), 233-243.
  4. McCardle J., Parahoo K. & McKenna H. (2007). A national   survey   of   community psychiatric nurses and their client care activities in Ireland. Journal of Psychiatric and Mental Health Nursing 14, 179–188.
  5. McAuliffe, R., O’Connor, L., & Meagher, D. (2014). Parents’ experience of living with and caring for an adult son or daughter with schizophrenia at home in Ireland: a qualitative study. Journal of psychiatric and mental health nursing, 21(2), 145-153.
  6. Viana, M. C., Gruber, M. J., Shahly, V., Alhamzawi, A., Alonso, J., Andrade, L. H., … & Girolamo, G. D. (2013). Family burden related to mental and physical disorders in the world: results from the WHO World Mental Health (WMH) surveys. Revista Brasileira de Psiquiatria, 35(2), 115-125.
  7. De Silva, D., & De Silva, S. (2014). A preliminary study of the impact of long term psychotic disorder on patients’ families. Ceylon Medical Journal, 46(4).
  8. Bleuler E. Die Prognose der Dementia Praecox (Schizophreniegruppe). Aligemeine Zeitschrift für Psychiatrie und psychisch-gerichtliche Medizin. 1908;31:436–480.
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  21. Seikkula, J., Aaltonen, J., Alakare, B., Haarakangas, K., Keranen, J., & Lehtinen, K. (2006). Five year experience of first episode nonaffective psychosis in open-dialogue approach: Treatment principles, follow-up outcomes, and two case studies. Psychotherapy Research, 16(02), 214–228.
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Impervious to psychoanalysis?

Representation of a subject has never been simple, and more complex still is the process that underlies that representation. Historically and culturally, most representations of being Irish function out of an ambivalent affirmation of narratives imposed by authority. The year 2016 in the Republic of Ireland offers an important opportunity to analyse this dynamic process. The ethnic national identity and the fixation on the 1916 Rebellion offers a focal point in Irish culture of a reconstituted historical and psychological process. It functions in the collective narrative as a microcosm of the Irish experience and an experiment of revolution. One hundred years later, Ireland’s ethnic national identity requires a re-examination, due to the many human rights violations that are linked inexorably to this problematic narrative. In 2006, Martin Scorsese’s film The Departed was released. It went on to win a multitude of awards and continues to be highly esteemed. However, there is one particular scene which caused amusement amongst the audience and curiosity amongst academia. It was a quote attributed to Sigmund Freud about the Irish, and that the Irish were ‘impervious to psychoanalysis’. The origin of the quote was the subject of an international research effort which included the Association of Psychoanalysts and Psychotherapists in Ireland, the American Psychoanalytic Association, and the Freud Museum of London. Eventually, it was revealed in a private email by William Monahan the screenwriter to Abdon Pallasch a writer for the magazine Irish America that it was based on a similar quote (also without an established origin in Freud’s work) which embodied the sentiment he wished to convey in the drama (1). But beyond the authenticity of the quote, there is resonance. Are the Irish impervious to psychoanalysis? Are they so stoic and irrational that they are beyond the reach of the most famous psychotherapy? Do they have such robust ego defence mechanisms that enable them to endure the hardship of life due to the centuries of colonial oppression and the petty insularity of small island psychology? Is the Irish ethnic national identity simply a combination of Celtic folk psychology and Catholic doctrine, with no room for a critical analysis of subjective experience? Or is there something else to be said? Psychoanalysis is not just a theoretical discourse, but also a critical clinical practice. This of course evokes two questions, can the Irish be psychoanalysed and more importantly, should they undergo such a process? The answer is yes on both accounts and to substantiate both positions one must also engage with the contemporary critical dialogues regarding the narrative of being Irish.

As a consequence of establishing an Irish nation-state, there has been an over reliance on the ideals of nationalism to bind subjectivity with the nation-state for the sake of social cohesion (2). This key fixture of Irish national discourse prioritises authority as the central arbitrator of subjective agency and has led to the emergence of a constellation of cultural complexes that governs a critique of the discourses that operate within that society. The individual then operates within this system as a subject/persona. To acknowledge that the persona serves to conform to social constructions of being a particular person, is to accept that there is no innate Irishness, only a set of ontologically tenuous symbolic constructs that together manifest as a coherent homogenous Irish narrative. There are of course a multitude of interpretive methods for critically analysing the subject within the cultural events of Ireland. The Marxist, feminist, liberal, Queer, and legalistic theoretical frameworks have all made a meaningful contribution (2-6). In particular, the Marxist and feminist critiques have contributed enormously and continue to do so by deconstructing and re-organising the rigid narrative of the Irish persona; both in terms of revealing how power relations operate and by giving a voice to the injustices inflicted upon specific groups (7, 8). However, in stressing the symbolic and social at the foreground of human experience there can often be an overshadowing of the individual who is situated within this culture. What is then lost is the subject itself and the voice of experience amidst the complex arrangements of identity and symbolism.

Within the contemporary intellectual pluralism there is the necessity of a psychoanalytical framework to tackle that which is not discussed within these other disciplines. Always challenging and never without controversy, a discourse of subjectivity within culture always evokes the spectre of psychoanalytical ideas being phagocytosed into the edifice of anthropology and vice versa (9, 10). Indeed Jung, Freud, and many other theorists generously adapted ideas from this discipline to identify cross cultural similarities that would provide evidence for their clinical observations (9, 11, 12). Since its inception, psychoanalysis has consistently been applied to a critique of culture, especially during moments of political change. However, the relationship between psychoanalysis and discourses of power has always been complex and not entirely benign, with particular instances when it was used as the locus of authority in state institutions (13). Jung and Freud each wrote about the temptation for psychoanalysis to be a Weltanschauung (an all-encompassing world view), but each correctly identifying that it was a hermeneutical practice of scientific discourse, rather than a secular religion (14, 15). In sharp contrast to the rest of the world, Irish psychiatry has extremely rarely or in the majority of cases never used psychoanalysis (theory or practice) despite the Irish Psycho-Analytical Association being founded in 1942 (16). Psychoanalysis is not a substitute for other forms of critiques. Instead, it is used to re-assess the presuppositions and firmly held beliefs of self-evident interpretations regarding the relationship between the individual and society (13). The richness of ideas and terms to describe the phenomenology of an Irish psychology with its cultural and historical dimensions can be defended on the basis of the necessity for a method that interprets psychology at both a personal and collective level. More poignant still, psychoanalysis highlights the role that discourse, with both its conscious and unconscious facets, operates within society and its practices. In the context of Irish culture, these centre within the collective dream of Irish nationalism.

In general, nationalism sets out to define the geography of a nation which encapsulates all experience and in so doing capture the imagination of those inhabitants. This symbolic social narrative, initially tackles anxiety at a cultural level, but then quickly escalates into enhancing and maintaining the binary psychological constructs of being a member of an in or out group. Within this narrative is the visceral attachment of the subject to the nation-state and with it the experience of civility masquerading as loyalty to authority figures (17, 18). Psychoanalysis has been applied to such authoritarian frameworks in the USSR, South America, Europe, and the United States (13). Even though a psychoanalysis of Irish culture has been neglected, the 20th century has seen a number of scholarly texts trying to explore the Irish subject, especially from the untouched rural environment, such as The One Blood (1975) by Elliot Leyton and Inis Beag (1969) by John Messenger (19, 20). However, the most detailed psychoanalytically informed cultural critique of Irish people is to be found in Nancy Shepper-Hughes classic work Saints, Scholars and Schizophrenics (1979). Here a psychodynamically informed anthropological study of Irish life was undertaken. Identifying through the psychological methods of reflective interviews, thematic apperception task cards, drawing tasks, and demographic data, the narratives of the locals in the Dingle peninsula town of ‘Ballybran’ (real name An Clochán) were explored. The author recognises that there are a number of imperfections in the work, but the discoveries pertaining to Irish culture and the Irish personal narrative still resonate, and eclipse any shortcomings. Within and between exploring the assumptions underlying the cultural narratives of Celtic folk psychology and the dominate mode of Jansenist Catholic social psychology, there is the epistemological breeding ground from which the modern Irish ethnic national identity manifests. To be sure, the key finding of the study is simply this; that within the psyche of the Irish is an anxious preoccupation with the subjective life and at the same time a robust process of censorship which categorized otherwise typical human experiences into secrets. In essence, this process renders the Irish experience of the body/psyche and all its relations to the status of other, and hence pathologized; this process of course is called repression (21). That study is now almost 40 years old and as acknowledged by the author, times have changed dramatically, both in terms of economics, but also the role of the church itself. Indeed, surrounding the role of the church is the complex role Ireland finds itself within globalisation and capitalism as it functions in unregulated and detrimental forms. From consumerism to Catholicism, the desire, wishes, and object relations, become extremely murky and the relationships between these often contradictory systems of expressing and inhibited pleasure exist as a tense cohesive lattice within the psyche of Irish people. The conflict, the form, the ever pervasive sense of doom, shame and guilt all get mixed with the endless possibility of expressions of hedonism through commodities of travel, alcohol, restaurants, fashion, and all the modern comforts of a growing economy (2). Despite the penetration of global markets and international liberal values to replace the old order of Ireland, there still exists a conflict and a merging of the relationship between the ego and the actualisation of pleasure in both these domains of identity.

Nationalism when guiding all the institutions of power within the nation-state can easily descend into Fascism. In Umberto Eco’s now classic essay Ur-Fascism (1995), the author, himself a witness to Italian Fascism, identifies the patterns and commonalities of Fascism. He proposed that it is based upon a network of exclusive and often contradictory psychological features that together make up a political edifice, but such cultural complexes defy an essentialist notion of what Fascism is. This interpretation enables one to see Fascism as a psychological process that is not rooted in some petrified past, but a potential that needs to be resisted in modern times. The features are evident in all societies and indeed in the individual themselves, and when enhanced and combined with institutional practices creates the Fascist narrative of authoritarianism (22). Many of these features operate within the Irish cultural context, in particular cultural complexes pertaining to sexuality, suffering, and servitude. Although many of the issues that have plagued the Irish psyche have also been studied by other researchers who have given a clear account of the murky past, the elemental challenges retain their potency in society and continue to dominate the national discourse for example, abortion, LGBT rights, contraception, compensation for victims of Magdalene laundries and symphisiotomies, to name a few (6, 23-25). The solution to these issues is not simply to identify a demarcation between then and now, but rather identify that there is a continuous system of psychological processes, mostly guided by repression and displacement that function in Irish society. Such processes are not simply archaic vestiges of a more primitive society or indeed primitive man, but are domesticated within the contemporary collective psyche. It is not the objects within these problematic fields themselves that is of central importance, but the system of meaning in which they are embedded. These affective objects oscillate around all the things that cannot be said, in a network of meaning, pregnant with silence. Whatever the principles or lessons that one can draw from this intermingling, one can clearly affirm that the Irish are almost pure psychoanalytical subjects.

Although psychoanalysis deals with repression and mental health problems at an individual level, it also identifies at a cultural level the link between individual repression and societal taboo. There are many taboos that form the Irish national discourse, but a critical analysis of the psyche remains the primary and most final one. It forms the foundation for all the others and acts as a network of meaning that links them together into a repressive narrative. The fields of problematization (e.g. how we talk about sex, reproduction, and pleasure) and the sacred spaces of the body (e.g. breast, genitals, mouth, anus, and womb), retain their anxious potency today (25). At the affective heart of all these cultural complexes is the residual nationalism, the thread of green that ties all the institutions of the nation-state together. Each of the contentious domains within the Irish national discourse result from a neglected engagement of the body as part of a healthy subjective life and instead relegate it to the status of other. These taboo domains are linked and separated by silence, indeed this is how repression operates. But the separation between these objects is not a static picture, rather the emotional dimensions not dealt with work ceaselessly to undermine our ideology of denial. The end result is almost a permanent state of anguish and anxiety as the default function of existence. Talking about these things links and connects them not only to the rest of the chain of significance, but links us all to a shared condition of being human. This empathic exchange is necessary, indeed mandatory for optimal human health and happiness. The converse is also true.

The Irish discourse on mental health is largely behaviourist, with no identification of a psyche that goes beyond the bounds of ego-consciousness. Focusing more directly on the Irish national discourse on mental illness and the public conceptions of madness, A Vision for Change: Report of the expert group on mental health policy (2006) is the Irish national mental health policy which aimed at revolutionising the Irish mental health system by 2016.  At a systems level, the policy sought to change the institutions and practices of mental health care in Ireland and transition its mental health services from a detrimentally fragmented system into a community based system that was both effective and compassionate (26). However, implementation of this policy continues to reveal the taboo of tackling the problems of mental health.  Indeed, after almost a decade, the key aspects of the policy remain to be enacted and the policy has no clear framework for implementation (27). There are annual reports and essays highlighting the piecemeal progress and the persistent obstacles, but at the heart of the matter remains the central issue of not considering mental healthcare on par with other domains of healthcare. More problematic still, is the focus of the policy and its representation of mental health care. Although A Vision for Change touches upon the key domains of how a compassionate modern mental health system should operate, it omits in clear form, the very obvious continuum between constructs of mental illness and the ever pervasive suffering of the human condition. In essence, the person/patient/client/service user is constituted within a probationary system of formal normalisation with no clear link for how a person once designated as a patient/service user can symbolically leave the system and interdependently recover.

However, since the publication of A Vision for Change in 2006, there has been the rudimentary formation of a discourse of mental health surrounding the notion of recovery. This construct has especially been elucidated by the Mental Health Commission’s Strategic Plan 2016-2018 (28). But the ambiguous and elastic construct does not lay out a process to ease critical suffering. It is a construct that all parties to the mental health system can project into, while at the same time the psyche can remain a black box and unknowable. This active function of our cultural past retains the psyche as a region dedicated to a predetermined narrative presented by a totalising authority, The Irish Catholic church and its religion (21, 29). Indeed the Irish Psycho-Analytical Association, which was founded by the Englishman Jonathan Hanaghan infused Christianity with psychoanalysis and openly refused to join the International Association of Psychoanalysis (which upset Ernest Jones). In one of his works entitled Freud and Jesus (1966) he situates ‘these two sons of Israel,’ in the tradition of divine healing, with psychoanalysis being a mode of actualising a modern process of Christian therapeutics (16). In the Christian religion in general and Irish Catholicism in particular, there is a complex and established narrative, forged by God and delivered by priests and other figures of authority. To function in such a society, one has to simply remember the truths, pleasure is a sin, obedience is paramount and guilt/shame are the price of being human (25, 30, 31). The broader national discourse on mental health also has another guiding principle. In line with the Jansenist style of Catholic teaching, it evokes the notion of personal responsibility over mental illness and the common notion that individuals can simply choose to overcome mental distress through an act of discipline (21, 29, 32). The rest of the branches of medicine continue to grow from innovative international sources, but psychiatry and practices of psychological wellbeing continue to be stifled by a conspiracy of silence.

Given the intimate link between the national discourse on mental health and the other cultural complexes, there is often a displacement onto legalistic debates over the mental well-being of the individual and preserving at all costs the boundary of power that the nation-state exerts. Noted recent examples include the introduction of The Protection of Life During Pregnancy Act 2013 and the national debate which largely focused on suicide and how effective psychiatrists and other mental health experts are at identifying and treating suicidal tendencies (33). Another debate was surrounding the Irish Referendum on same sex marriage, which focused upon the impact of legislation on the notion of family and child welfare (34). To accept in silent opposition a distorted, displaced, and almost sclerotic culture is to accept a method of strangling the zest for life into a form and practice that renders optimal human functioning impossible. De Tocqueville once wrote that when revolution can be considered its conditions are ripe (35). Therefore, the residual nationalism that evokes arbitrary emotional virtue in maintaining Irelands cultural complexes by separating pure citizens from treacherous others, must be challenged.

However, an active engagement with the life of the mind must be entered into with the provisional threat that sin and virtue are co-dependent. In the process of dealing with our demons and their exorcism, there is the risk that we vanquish the very best part of ourselves. However, like all psychotherapy, psychoanalysis seeks not to conquer the psyche, but to catalyse its transformation. In doing so, the individual goes on a journey of discovery and reflection, so that at the end of the journey the individual becomes who they were always meant to be. The true target of an authentic existence is not simply to become unbound from society, but to expand the horizon of the self-inflicted rigid narrative of subjectivity and hence inspire others by modelling this behaviour. To engage with the unconscious in a meaningful way invites the individual to consider their link with society, and this is the birth of empathy and a vision not just for a change, but hope. To hope is to resist the temptation that accepts the common notions and unarticulated wisdom of stasis, and with that to hold true to the motivation for change. Therefore, one must combine in the crucible of discourse the maximum of enthusiasm with the maximum of self-criticism, with the maximum of scepticism of authority and the maximum of rebellion. This practice gives the individual an experience, even for a fleeting instant, of the audacious position which recognises that an incomplete view is parallel with an incomplete reality in which one finds oneself. Such an unfinished project inspires a drive towards action by being reminded of the freedom to choose.  As long as that hope retains the threat of green.

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