Recognising madness in others; relativising madness in oneself from lay concepts to therapeutic itineraries Ftima Alves

(This paper in not in final version) Abstract Societies relate to madness in accordance to their dominant concepts about the world (Benedict, 1934). Modern rationality has created mental illness as an object controlled by medicine (Foucault, 1987). In lay knowledge the concepts, attitudes and practices associated with mental illness are culturally distant from the scientific representation of the body, the disease and the patient (Devereux, 1977). The semi-peripheral condition of Portuguese society (Santos, 1990) allows us to believe that inside the more universal system of modernity, the explanation of insanity and mental illness contains modern and traditional elements. This study focus lay knowledge about mental suffering and mental illness. Besides dominant explanations and interpretations, besides professions and politics, which are the lay conceptions and interpretations? Results show that the concept of mental illness includes the one of illness (there are ill people) but it always refuses it (mental suffering is not illness). Lay narratives refer to ill people and not to illnesses, placing the nosologic holistic entity before the disease. Those rationalities categorise people into three kinds: the illpeople, the weak-people (these may turn into ill-people) and the strong-people (these ones succeed in the combat with mental suffering, a normal event during life). Social representations emphasize biomedical instead of psychodynamic model. Talking is the most valued therapeutic resource. This represents a culture of resistance to psychiatrization (medicalization) of mental suffering. Mental illness narratives (concerning the others) and mental suffering narratives (concerning the self) represent a confrontation with the self and its identity. Illness and non-illness are entities allowing individual construction or destruction. Briefly, this research found that lay relationship to mental illness is made of diverse, complex and multiple logics. It proposes the concept of lay rationalities, in plural lay rationalities about mental suffering and illness are not exclusively modern, they are plural. Key Words: Sociology of Mental Health and Illness; Lay rationalities; *****

Recognising madness in others; relativising madness in oneself from lay concepts to therapeutic itineraries

__________________________________________________________________ 1. Introduction: searching socio-cultural meanings of mental illness The notion of mental illness used in psychiatry nowadays was, over the centuries, understood using different interpretations, such as the signal of wisdom, deep self-knowledge, ability to communicate with spirits, religious troubles, sins, alien forces, among others (Benedict, 1934; Bastide, 1967; Devereux, 1977; Fbregas et al., 1978; Foucault, 1987). Each historical period or each society constructs explanations consistent with their values and their social and cultural practices. It was in Europe, at the end of the XVIII century that emerged this "new" social category for people who exhibit strange and incomprehensible behaviour and that broke with social norms - the mentally ill - and, with them, Psychiatry. The mental patient takes the place of the mad as a mark of deviance, exclusion (Foucault, 1987). At the turn of the XIX century, psychiatry joins to the existent categories (the psychosis) of mental illness the neuroses, widening the scope of the concept, due to the development of the analytical theory and the more comprehensive system of dynamic psychiatry. In the XXI century, Western societies have witnessed the extension of mental illness categories to a wide variety of human behaviours, reality that Robert Castel (1976) denominated by psychiatrization of Western societies, complement of the medicalization of life (Illich, 1975; Conrad and Shneider, 1992). Medical sociology focused its analysis on the identification of social factors that precipitate the onset of mental illness. There are well-known studies that correlate the onset of mental illness with social class (Hollingshead and Redlich, 1958; Dohrenwend and Chin-Shong, 1967; Brown, et al., 1978), gender (NolenHoeksema, 1991; Hankin et al., 1998), social support (Henderson, 1988), highlighting the vulnerability (Meehl, 1962), the circumstances of the environment and socio-cultural factors in causal explanations (Dunham, 1977). These studies depart from the notion of psychiatric illness and override the social and cultural processes underlying the illness experience. In contrast to this trend, interactionist sociology studied mental illness as deviant behaviour produced by society (Goffman, 1982; Gomm, 1996; Scheff, 1999) that means and reflects, more than the intrapsychic disturbance, the way witch our society is set up and organized. In other words, reflects the social structure (Weber, 1991). Within anthropology, the study of mental illness has shifted to the cultural contexts as "builders" of meanings. Following C. Geertz (1993), Kleinman (1984, 1992) sought to focus on "the native point of view". Culture becomes the centre of reflection from which we try to understand and interpret mental illness. The focus shifts from 'disease' to 'illness', i.e. to the subjective experience of illness, with its

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__________________________________________________________________ expressive meaning in terms of the cultural code that governs the social group in which it manifests. In this line of research, social representations studies have emphasized social processes underlying the construction of mental illness. Having the label of mental illness triggers in others complex social processes that result, for the labelled person, in social exclusion and "forced" separation of everyday life (Jodelet, 1995). In general, all studies developed from the 50s of the XX century to nowadays (the period in which the community philosophies begin to develop guidelines for the treatment of mental illness) find violence, fear and danger as a common denominator in the representation of the mental illness (Cumming and Cumming, 1957; Nunnally, 1961, Phillips et al., 1969, Link and Cullen, 1983 cit. by Clarke, 2001; Bhugra, 1989; Hall et al., 1993 cit. in Clarke, 2001). However, these studies do not reveal the meanings of mental distress, since they focus on the modern paradigm of mental illness, and in doing so they tend to explain these images and representations by public ignorance. The social and cultural processes underlying the genesis and circulation of knowledge (scientific and lay) and their ownership by common sense are not taken into account. It is important to realize how common sense deals with the mental (madness, mental illness), what instruments have to interpret and to act with it? 2. The justification of the objectives - the lay rationalities are not exclusively modern, they are also traditional. The common sense thinking about mental illness incorporates forms of knowledge from various fields as science, religion, moral, magic, etc. (Rose, 1987; Bellelli, 1987; Serino, 1987; Jodelet, 1995). Not only the less complex and less developed societies have different explanations systems from modern science. These systems also populate our societies (Alves, 1998; 2011; Wagner et al. 1999; Rabelo, et al. 1999a; Charmillot, 2002). Studies on the lay knowledge centred at the origin and configuration of social representations, developed in Western societies, let us note that the lay knowledge (with its concepts, values, attitudes, etc..) incorporate both elements from the sense of science and the sense of difference and abnormality of madness, prevalent in earlier historical periods (to the psychiatric explanation). This research emerges with the question and the realization that the way lay people think about and explain the mental suffering is not homogeneous, but plural, appearing very much related to the contexts where they appear and that shape interaction. Common sense (Berger and Luckman, 1999) is a (valid) form of knowledge that produces meaning, explains the phenomena of the living world, guides and enables action and social interaction. This lay knowledge is not static and is in permanent reconstruction in the context of interaction. That is, we admit the possibility of reflexivity of action (Giddens, 2000), in the sense that the agent is

Recognising madness in others; relativising madness in oneself from lay concepts to therapeutic itineraries

__________________________________________________________________ not a passive receptacle to available explanations on the phenomena of social life. He is actively engaged in this construction, as he continuously interprets reality, experience, and negotiates in accordance with the senses of his group. The recognition of these features and the finding of coexistence of perspectives on the mental suffering, also reminds us that the Western lay rationalities are not exclusively modern. In modern societies we also find other ways to explain health issues and mental illness and to interact with them. What are these forms? What is the lay knowledge of production and reproduction of meaning on the mental suffering? What are his settings? Mass (1995) refers to this knowledge as a popular cultural subsystem that integrates the intellectual output of a group (with conceptions, representations, values, beliefs), as well his practices and experienced behaviours, whose intersections result the meanings and senses of phenomena of health and disease. The diseases are "socio-cultural constructs that can have as many meanings as there are contexts in which they are defined". This knowledge of health and illness has as primary function not to know but rather to give a sense (meaning requirement). And it is precisely this "principle of coherence, inherent to the different logics, which is the fundamental condition of all the production of meaning" (Mass, 1995:269). This need to produce meaning, to find social contextualized explanations for the disease, is common to all societies (Aug and Herzlich, 1984). The knowledge that is used by social agents in their daily lives is a very different kind of knowledge from modern science. In their arguments, lay people link the scientific information with other different information derived from rationalities that differ from the scientific rationality. These other ways of thinking made part of everyday life, where the needs to produce senses require models much closer to local symbolic universes, which are more characterized by subjectivity. As Devereux said in the 70s, the concepts and practices related to mental distress are different if captured in a perspective based on the cultural world of modern medicine, or in a popular perspective, that is culturally far from the representation of medical body, the disease and the patient. Lay people think and act in health using logics that diverge from the medical logics. It is in reference to this type of divergent thinking that we use the term lay rationalities, in the sense that it is very different from the professional or experts. Those lay rationalities are the ones that guide social trajectories of health and disease. Therein lies the explanation for going to the doctor or not, to take medication or give it up, go to the witch or the priest, etc. The central aim of the research we have carried out was guided by the need to decipher lay rationalities about mental suffering in Portugal. Beyond the explanations and interpretations of professional rationalities (which include

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__________________________________________________________________ professionals, technicians, researchers and the pharmaceutical industry), and the legal-political rationalities (which include mental health policies), which are the lay interpretations and conceptions? In this context, the developing "model" of Portuguese society that integrates characteristics both typical of developed societies and of less developed societies (which Boaventura Sousa Santos (1990) termed semi-peripheral), allows us to preview a complex and multifaceted building about mental illness. 3. Method and Sample We have focused research in the speeches that we obtained through semidirective in-depth interviews (Kaufman, 1996). Those where analyzed, in a first moment, trying to describe the information gathered. Then, we have interpreted this information having present the underlying notions of 'ontological complicity' (Bourdieu, 1993) and 'thick description' (Geertz, 1989). The content analysis (Bardin, 1979) was used to support the identification of emerging core categories. In this sense we crossed theoretical procedures (resulting from theoretical and methodological framework built in this study) with procedures resulting from an approach grounded in the information gathered - grounded theory (Glaser and Strauss, 1967). In this process weve used Nud.ist and Nvivo software that allowed us to organize information, which was a valuable aid. In this study we try to reveal not the facts, but their underlying processes as mediators of ways of thinking and acting on the mental suffering. It is this diversity and its senses and meanings that we intend to report on this analysis and not the hypothetical relationships, between the senses and the social determinants that can determine them. The sample is diverse, with the aim of covering both the social diversity and the different dimensions of the different but complementary subject matter. This is a sample that is not representative from the statistical point of view, but it can be considered representative from the viewpoint of an in-depth sociological analysis, which seeks to identify types of situations and understand the social relations that are established in them (Lima , 1981). This study is limited to the north Portuguese region. Thus we have interviews spread over 16 municipalities, namely: Bragana, Porto, Chaves, Gondomar, Maia, Matosinhos, Melgao, Miranda do Douro, Paos de Ferreira, Penafiel, Vale de Cambra, Viana do Castelo, Vila Nova de Gaia, Arcos de Valdevez, Celorico de Basto and Vinhais. The regional option turns on the importance, in such a study, of socio-cultural diversity that we can find.

Recognising madness in others; relativising madness in oneself from lay concepts to therapeutic itineraries

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Figure 1 Sample distribution by interviewees residence region. 4. Discussing Results (this paper in not in final version) Results show that the concept of mental illness includes the one of illness (there are ill people) but it always refuses it (mental suffering is not illness). Lay narratives refer to ill people and not to illnesses, placing the nosologic holistic entity before the disease. This rationality categorises people in three kinds: the illpeople, the weak-people (these may turn into ill-people) and the strong-people (these ones succeed in the combat with mental suffering, a normal event during life). Illness clearly is inscribed in the body and its causes can be organic or moral. In lay knowledge psychiatry has a control role via treatment and exclusion. Social representations emphasize biomedical instead of psychodynamic model. Talking is the most valued therapeutic resource and is the attribute of other dominant professions (psychologists) or professions from the alternative systems. This represents a culture of resistance to psychiatrization (medicalization) of mental suffering. And gives relevance to the individual agent (talking reinforces individual strength to combat the tendency for turning ill). Mental illness narratives (concerning the others) and mental suffering narratives (concerning the self) represent a confrontation with the self and its identity. Illness and non-illness are entities allowing individual construction or destruction. Briefly, this research found that lay relationship to mental illness (in medical language) is made of diverse, complex and multiple logics. It proposes the concept of lay rationalities, in plural, about mental suffering and illness. Bibliography

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