Personal Narrative And The Social Reconstruction Of The Lives Of Former Psychiatric Patients ROBIN M. GILMARTIN This study explores ways in which high functioning former patients in tegrate the experience of prior psychiatric hospitalization into their lives and find meaning from that event. The narratives of two individuals are presented and discussed in relation to social role theory, social construc tionism, and labeling theory. The narratives underscore that the process of integrating and making meaning of important life events such as psychi atric hospitalization occur within a social context. Understanding mental illness and psychiatric hospitalization in familial, social, and political terms was instrumental in helping these individuals to reconstruct personal narratives in order to overcome shame and internalized stigma and to integrate their experiences in meaningful ways. This paper explores ways in which high functioning former psychiatric patients integrate the experience of psychiatric hos pitalization into their lives and find meaning from that event. In a broader sense, it illustrates the importance of narrative in enabling individuals to reconstruct critical life events so that they can become meaningful experiences. As a non normative event, psychiatric hospitalization (the critical event of primary focus here) presents problems and challenges for ex patients because of the fact that mental illness is often stigmatizing, particularly if it results in hospitalization. As such, it may significantly affect how others regard or behave towards the former patient, the former patient's perceptions of how others regard or treat him or her, and finally the ex patient's own self concept and understanding, all of which may be intricately and complexly connected. Formerly hospitalized individuals must somehow negotiate or redefine themselves within the context of family, social networks, and Journal of Sociology and Social Welfare, June, 1997, Volume XXIV, Number 2 77
78 Journal of Sociology & Social Welfare society at large in light of this non normative and stigmatizing event in their lives. The purpose of this article is to present the personal narra tives of two high functioning former psychiatric patients who reflect on the process of making meaning from their experiences of hospitalization and other related critical life events. Loosely structured interviews provided a forum for these individuals to reflect on how these events shaped their lives and influenced their concept of self and sense of place in the world. Several relevant social theories social role theory, social constructionism, and labeling theory are also discussed. There is a notable absence of existing research on the signifi cance and meaning of institutionalization for ex patients through personal narratives. While the narratives presented here reflect only the personal experiences of two individuals and are not assumed to be representative of the population of ex patients, these in depth accounts may tell us something of the processes of coming to new understandings about a non normative and often difficult life event. In depth narratives such as these can aid clinicians in working with former patients who seek therapy later in their lives as well as in helping current patients prepare for discharge. The narratives may also remind us of our resiliency and ability to find meaning in painful events or periods of our lives. Social Role Theory Inspired by the work of Mead (1934), who emphasized social interchange and role taking as key to the development of iden tity and personality, and drawing from Goffman's (1959; 1961) studies, Sarbin and his colleagues (Sarbin & Allen, 1968; Sarbin & Scheibe, 1983) describe a process whereby the individual's identity and self concept derive from social roles and the valu ation of such roles. Three dimensions status, involvement, and valuation are key with respect to identity vis a vis social roles. One's status within a social structure may be either granted or attained; granted roles (e.g., mental patient) are ascribed while attained roles (e.g., psychiatrist) are those which are achieved. Involvement refers to the degree to which the individual is in volved in the role or "plays the part." When involvement is low, the individual and the role are clearly differentiated. While the
Personal Narrative 79 individual's involvement in any given role may vary temporally or situationally, granted roles typically require more total involve ment than attained roles which "may be put on and off like cloaks" (Sarbin & Scheibe, 1983, p. 13). According to Goffman, nowhere are granted roles more absolute than in what he termed "total institutions," that is, "a place of residence and work where a large number of like situated individuals, cut off from the wider soci ety for an appreciable period of time, together lead an enclosed, formally administered round of life" (Goffman, 1961, p. XIII). Cut off from wider society, the individual is not only precluded from assuming other social roles, but his or her identity in the granted role, e.g., mental patient, is secured through a process of acculturation within the total institution. If the individual's stay is sufficiently long in duration, a process of "disculturation," often complicated by social stigma, must occur in order to successfully integrate into life on the outside. Valuation of social roles bears a close relationship to status and involvement. Importantly, the individual's social identity may be devalued either through a process of derogation or demotion. While demotion is the stripping away of attained status which deprives the individual of previously enjoyed social esteem, dero gation involves a devaluation of who the person is by virtue of his granted roles. According to Sarbin and Scheibe: The most degrading processes are those which combine derogation and demotion. If a person is relieved of all achieved statuses professional and avocational and is derogated with respect to all ascribed roles, including sex, age, kinship, and citizenship roles he or she is reduced to the lowest possible value. (1983, p. 21) Institutionalization typically involves some degree of dero gation and demotion. Even if the individual enters an institu tion willingly, he or she loses achieved statuses and connected social esteem, as well as certain rights or freedoms ascribed to individuals by virtue of being adults, citizens, or of sound mind. Once released from the institution, individuals may resume or regain their jobs, family roles, and so forth; however, they do so from the standpoint of one whose social identity is most likely changed, whose involvement in roles prior to institutionaliza tion is interrupted, who may need to become "reculturated," and whose status may be greatly diminished.
80 Journal of Sociology & Social Welfare Having been institutionalized perhaps for months or years, individuals may experience certain losses while away as irrevo cable and deeply painful, even if the ex patient regards his or her institutional stay as time well spent in terms of recovering. For example, in the case of a father who was not present to see his children reach important milestones or an adolescent who was unable to graduate with her high school class. Institutionaliza tion which leads to a prolonged absence from active engagement in normal social roles may also result in an ex patient feeling unpracticed or uncertain in his or her ability to resume those roles. Problems adjusting to normal roles may be compounded by others either expecting the ex patient to "pick up where he or she left off" on one hand, or disavowing the ex patient's capacity to resume normal roles altogether on the other hand. How ex patients manage to negotiate their social roles following discharge is certainly vital to their post hospital functioning. Finding mean ing, however, from the experience of institutionalization is likely more involved and complex than the negotiation of social roles, vital and often difficult though that may be. Social Constructionism Like social role theory social constructionism derives from the field of social psychology though it differs from role theory in significant ways. While role theory tends to "assign govern ing or directive functions" as a psychological basis for human behavior, social constructionism offers a broader understanding of the individual in interaction with the environment (Gergen & Gergen, 1983, p. 256). Rather than simply being defined by social roles, individuals are seen as having a reflexive capacity for self understanding and an ability to build themselves into the world by creating meaning from experience. Language is the vehicle for finding meaning as words themselves help us to "both name and shape our experiences of the world" (Dean, 1993, p. 129). As the keystone of culture, it is through language that we find meanings collectively, for example, through histories and mythology, and as individuals, through life narratives. Language and culture are inextricably a part of who we are and how we as agents build ourselves into the world. While the individual may actively shape
Personal Narrative 81 his or her concept of self and world and place within it, culture is seen as providing a fundamental basis for understanding. Social constructionism offers a meaningful framework for un derstanding the narratives of former psychiatric patients because these individuals must find personal meaning and self definition from their experiences within the context of broader social as sumptions and beliefs about mental illness and psychiatric hos pitalization. How we structure self narratives, how we order and relate and prune life events in the act of creating a life story, involves a process which the Gergens (1983) refer to as "social ne gotiation." They argue that social negotiation occurs throughout the process of storytelling through anticipation and articulation. When a person tells a story of his or her life, that person is not simply recounting events one by one in sequence, but he or she is actively engaged in a process of interpretation in which meaning is ascribed to events in relation to one another and in a way which seems intelligible and acceptable to narrator and listener. The narrative takes form and is ascribed meaning through an inter active process of discourse between teller and listener (including oneself as listener) within a larger cultural context of meaning (Cohler, 1994). For ex patients, social negotiation of narratives may be complicated by several factors. First, institutional living itself differs so significantly from life on the "outside" that the ex patient may experience a sense of two worlds, a fact which may contribute to a feeling of discontinuity. Second, he or she may be reluctant to talk with others for fear of being misunderstood or stigmatized. Such stigmatization may be subtle and insidious or take pernicious forms resulting in loss of friends, job opportuni ties, or housing. In addition, the ex patient may lack contact with other ex patients with whom to share experiences and explore meanings. Stories of stigmatized or non dominant groups often go un told. Laird (1989), for example, talks about the fact that in many cultures, including our own, women's stories have remained largely private as our history consists primarily of the stories of men. In the case of ex psychiatric patients, the decision to disclose or to do so selectively and judiciously may have more to do with that individual's "reading" of how others might hear the story than with his or her ability to tell it in a meaningful and cohesive
82 Journal of Sociology & Social Welfare way. Similar to stories of non dominant groups within society, individuals may experience events which do not easily fit within the dominant stories of their lives. Those experiences which fall outside of the dominant self narratives which Goffman (1961) calls "unique outcomes" are most challenging or problematic for us. One characteristic response to such unique outcomes is to exclude them from our personal narratives. We do this through the structuring of self narratives which, according to White and Epston (1990), is "a selective process in which we prune, from our experiences, those events that do not fit with the dominant evolving stories that we and others have about us. Thus over time and of necessity, much of our stock of lived experience goes unstoried and is never 'told' or expressed" (pp. 11 12). Because they are so incongruent with the dominant stories, unique outcomes may represent such personal dissonance that it may be necessary for the individual to keep such events unstruc tured and unincorporated. Conversely, unique outcomes which remain amorphous and unincorporated may, like a burr under a saddle blanket, prove to become problematic over time. Unique outcomes which remain "unstoried" are often accompanied by pervasive but little understood feelings of guilt or shame and personal narratives with unsettling gaps, somehow unclear or deficient in meaning. In structuring self narratives, we may find it necessary to prune certain events from our stories; however, it is only through examining unique outcomes that they take form and become available to us as meaningful experience. Somehow the experience of hospitalization must be reconciled with the life story in order to overcome feelings of disjointedness and produce a life narrative with meaning and a sense of continuity. How ex patients incorporate their experiences must take into account broader social beliefs about mental illness and what it means to have been psychiatrically institutionalized. Labeling Theory Labeling theory is a sociocultural model in which mental illness is understood not as individual psychopathology but in terms of social deviancy. Drawing on various empirical studies of psychiatric patients, including Goffman's (1961) work, Scheff
Personal Narrative 83 (1966) made a case that mental illness is, in fact, a label attached to certain individuals who engage in socially deviant behaviors or who are somehow in violation of social norms. Labeling theorists regard mental illness as a social construct with mental health professionals acting as agents of social control in explicating what forms of deviant thoughts and behaviors constitute mental ill ness. Importantly, Scheff outlined ways in which labeling has particularly dire, self fulfilling consequences for the individual who, once labeled as mentally ill, is subject to uniformly negative responses from others based on ingrained sociocultural attitudes about mental illness. The behavior of the so labeled individual conforms to those attitudes and expectations through a process whereby behaviors consistent with those expected are "rewarded" in the individual while behaviors which are inconsistent are "pun ished," thereby constraining the individual to the role of a men tally ill person. Chronic mental illness is established finally when the individual fully internalizes the role and assumes it as his or her central identity. Chronic mental illness is thus seen as a social role. One need not reject belief in the existence of psychopathol ogy in favor of the notion of the social construction of mental illness in order to acknowledge the existence and detrimental effects of social stigma on the mentally ill. However, critics of labeling theory have not only tended to hold fast to the notion of psychopathology, but they have also tended to de emphasize the negative effects of labeling and to question the extent of social stigma. Gove and Fain (1973), for instance, question the extent of social stigma as they found that current and formerly hospitalized psychiatric patients sampled were rarely able to provide concrete examples of social rejection or discrimination. Gove (1982), in a later study, concluded that for the "vast majority of mental patients stigma appears to be transitory and does not appear to pose a severe problem" (p. 280). Other studies (for a summary see Link, Cullen, Frank, & Wozniak, 1987) suggest that any social rejection experienced by the mentally ill is more likely due to odd or deviant behavior they exhibit rather than to the label of mental patient.
84 Journal of Sociology & Social Welfare While the late 1960s and 1970s saw a preponderance of studies challenging labeling theory, more recent studies have revisited the issue of social rejection of the mentally ill and the negative impact of labeling. Link and colleagues (Link, 1987; Link, Cullen, Frank, & Wozniak, 1987; Link, Cullen, Struening, Shrout, & Dohren wend, 1989; Link, Mirotznik, & Cullen, 1991) challenge the con clusions of many previous anti labeling studies, provide new evidence that labels are significant, and, finally, offer a modified theory. Their findings call into question the validity of previous studies which asserted that behavior rather than stigma resulted in social rejection. By "artificially mak labeling uncorrelated with behavior, miss the possibility that labeling may be a more distal cause of rejection" (Link, 1987, p. 110). Internalized negative conceptions about the mentally ill and the expectation and fear of social rejection may lead to the very be haviors (withdrawal, anxiety, depressive symptomatology, etc.) that may cause anyone to be rejected. While modified labeling theorists reject Scheff's (1966) notion that labeling directly pro duces mental illness, they acknowledge the ill effects of labeling in decreasing self esteem and contributing to behaviors which impair social functioning and place individuals at risk for future onset of illness (Link, 1987). Overview of Study A qualitative study was undertaken to explore ways in which high functioning former psychiatric patients integrate and find meaning in their experiences of hospitalization. The study ex amined the narratives of five individuals obtained through in depth interviews using an open ended interview guide.(Figure 1) The interviews, which were face to face, audiotaped, and later transcribed, were each approximately 90 minutes in length. An exploratory study such as this with a small purposive sample seeks depth rather than breadth, that is, richly informative nar rative data rather than meaningful quantitative data. This article focuses on only two of the narratives in order to preserve adequate depth. The narratives presented here are those of the two oldest participants. In contrast to the three younger participants, all of whom were in their 20s when interviewed and discharged five to
Personal Narrative 85 Figure 1 Interview Guide 1. Could you tell me about your hospitalization(s) and your life since then? How do you think the experience of hospitalization has influenced your life? 2. Has the way you've thought or felt about your hospitalization changed over time from discharge to the present? 3. Has the experience of being hospitalized changed or influ enced any specific areas of your life, for example: your values, life goals, the way you relate to family members or others, your spiritual beliefs, choice of careers or any other areas of your life? 4. Has the experience of being hospitalized changed the way you think or feel about yourself or the way you perceive others think or feel about you? 5. In general, do you feel there is a social stigma associated with psychiatric institutionalization? Have you experienced stigma personally and how have you dealt with it? 6. Since discharge, have you sought therapy, pastoral or religious counseling or participated in any self help groups? How has this been/is this beneficial to you? 7. Is there anything you feel is important for therapists/coun selors/pastors/rabbis to know to better understand and work with individuals who are former psychiatric patients? ten years prior, these individuals were middle aged having both been discharged approximately 30 years ago. The advantage of presenting their narratives lies in their ability to articulate the changing meanings of their experiences over time. Both individuals whose narratives are presented here were referred to me by a mental health professional previously in formed about the study's purpose and selection criteria. For the purposes of the study, "high functioning ex patients" were indi viduals who were hospitalized for a psychiatric illness for at least three months, who were last discharged for at least four years, and who were determined to function at a level of 70 or higher