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For some time now, I have been at work on a history of Unreason, a book that has just been published by Princeton University Press as Madness in Civilization. I have sought in its pages (perhaps while suffering from a surfeit of chutzpah), to provide a wide-ranging discussion of this fascinating subject, one whose mysteries puzzle us still. An inescapable part of our shared human experience and of the cultures people have inhabited down through the centuries has been our encounters with those suffering from a loss of reason, people alienated from the commonsense world the rest of us imagine we share, or enduring the shattering emotional turmoil that seizes hold of some of us and will not let go. They have drawn the repeated attention of artists and writers, as well as physicians and divines. Mental illness haunts the human imagination. It reminds us of how tenuous our own hold of reality may sometimes be. It challenges our sense of the limits of what it is to be human, and, perhaps as a consequence, the mad have all-too-often been treated as less than fully human – a peculiar response, since mental illness appears to be an inescapable part of the human condition.
But a question immediately arises: Why, in writing a cultural history of insanity, have I chosen to speak of madness? Surely that is a word that has overtones of anachronism, even of a callous disregard for the sufferings of those we have learned to call the mentally ill. Have I not engaged in an ill-mannered (or worse) resort to a vocabulary at once stigmatizing and offensive?
Heaping more miseries on the mad, adding to the stigma that has enveloped them through the ages, could not be further from my intent. The pain and misery that losing one’s mind entails for its victims, for their loved ones and for society at large is something no one who encounters this subject can or should ignore, nor minimize. Here lie some of the most profound forms of human suffering – sadness, isolation, alienation, misery and in some instances the loss] of reason and of consciousness. So once more, and more insistently this time, why do I not opt for some softer term - mental illness let us say - rather than deliberately employ what we have come to view as the harsher word, madness?
For psychiatrists, our designated authority these days on the mysteries of mental pathologies, the use of such terms is often seen as a provocation, a rejection of science and its blessings, which they claim to exemplify. (Oddly enough, precisely for that reason, madness is a word defiantly embraced by those who vociferously reject psychiatry’s claims and resist the label of psychiatric patient, preferring to refer to themselves as psychiatric survivors.) So is my choice of title and terminology perverse, or a sign that, like some influential writers - the late Thomas Szasz, for example - I consider mental illness a myth? Not at all.
In my view, madness – massive and lasting disturbances of reason, intellect, and emotions – is a phenomenon to be found in all known societies, one that poses profound challenges of both a practical and symbolic sort to the social fabric, to the lives and happiness of both victims and their families, and to the very notion of a stable social order. The claim that it is all a matter of social constructions or labels is to my mind so much romantic nonsense, or a useless tautology. Those who lose control of their emotions, whether melancholic or manic; those who do not share the commonsense reality most of us perceive and the mental universe we inhabit, who hallucinate or make claims about their existence people around them conclude are delusions; those who act in ways that are profoundly at variance with the conventions and expectations of their culture, and are heedless of the ordinary corrective measures their community mobilizes to get them to desist; those who manifest extremes of extravagance and incoherence, or who exhibit the grotesquely denuded mental life of the demented: these form the core of those we look upon as irrational, emotionally unhinged, or inhabiting an alien mental universe mostly unrecognizable to the rest of us, and are the population that for millennia was regarded as mad, or referred to by some analogous term.
I have sought to make sense of the encounter of madness and civilization over more than two millennia. For the great majority of that time, madness and its cognates – insanity, lunacy, frenzy, mania, melancholia, hysteria and the like –were the terms in general usage, not just among the masses or even the educated classes, but universally. Indisputably, “madness” was not just the commonsense term employed to come to terms with Unreason, but a terminology embraced by those medical men who sought to account for its depredations in naturalistic terms, and at times to treat the alienated. Even the first mad-doctors (for so they called themselves, and were known as by their contemporaries when they began to ply their trade in eighteenth century Europe) did not hesitate to use the word, and it persisted in polite discourse, alongside such cognates as lunacy and insanity, almost all the way through the nineteenth century, only gradually, as with “insanity,” becoming linguistically taboo. And while such change is difficult to date precisely, one convenient marker of shifting sentiments is the renaming of what previously had been the American Journal of Insanity, which in 1922 became the American Journal of Psychiatry.
As for “psychiatry,” it is a word that did not begin to emerge until the nineteenth century in Germany. It was fiercely rejected by the French (who preferred their own term aliénisme), and by the English-speaking world, which began, as I alluded to in the previous paragraph, by calling medical men who specialized in the management of the mad “mad-doctors.” Only later, when the ambiguities and implied contempt, the slur embodied in that term, came to seem too much, did the proto-profession embrace without a clear preference a whole array of alternatives: “asylum superintendent”, “medical psychologist”, or (in a nod to the French), “alienist”. The one label English-speaking specialists in mental disorders could not abide, and fought against using into the early years of the twentieth century (when it finally began to be the preferred term), was “psychiatrist.”
More broadly, the emergence of a self-conscious and organized group of professionals laying claim to jurisdiction over mental disturbance, and obtaining a measure of social warrant for their claims, is largely a phenomenon of the period from the nineteenth century onwards. Madness is now mostly viewed through a medical lens, and the language preferred by psychiatrists has become the officially approved medium through which most (but not all) speak of these matters. But this is the result of historical change, and in a wider view, a quite recent development. The creation of such professionals, their language and their chosen interventions, are phenomena that deserve close scrutiny. But they are not, and ought not to be, our starting place.
So I have chosen to speak of madness, a term that even now few people have difficulty understanding. Using that age-old word has the further advantage that it throws into relief another highly significant feature of our subject that a purely medical focus neglects. Madness has much broader salience for the social order and the cultures we form part of, and has resonance in the world of literature and art and of religious belief, as well as in the scientific domain. And it implies stigma, and stigma has been and continues to be, a lamentable aspect of what it means to be mad. If we are to grasp madness in all its dimensions, these are some of the subjects with which we must engage.
Even in our own time, definitive answers about the condition remain almost as elusive as ever. The very boundaries that separate the mad from the sane are a matter of dispute. The American Psychiatric Association, whose Diagnostic and Statistical Manual (DSM) has achieved global influence, not least because of its linkages to the psychopharmacological revolution, has subjected its Bible to seemingly endless iteration and revision. Yet despite these various efforts to achieve closure, the DSM remains enmeshed in controversy, even at the highest reaches of the profession itself. Depending upon how one counts, it is now on its fifth or its seventh revision, and the publication of its latest incarnation has been delayed by years of wrangling and public controversy over its contents. After all, despite the plethora of claims that mental illness is rooted in faulty brain biochemistry, deficiencies or surpluses of this or that neurotransmitter, the product of genetics and one day perhaps traceable to biological markers, the etiology of many mental illnesses remains obscure, and its treatments largely symptomatic and generally of limited efficacy. Those who suffer from serious psychoses make up one of the few segments of our societies whose life expectancy has declined over the past quarter century – a reflection in part of the generally poorer overall health of psychiatric patients, but also one telling measure of the gap between psychiatry’s pretensions and its performance. In this arena, at least, we have not yet learned how to cut nature at the joints.
Those who are inclined to doubt the truth of that last statement, coming as it does from a historical sociologist, might prefer the formulation offered recently by the director of the National Institute of Mental Health, Thomas Insel. Speaking less than two weeks before the publication of the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual, about whose scientific credentials he was scathing, he voiced his incredulity as the fact that his fellow psychiatrists “actually believe [that the diseases they diagnose using the DSM] are real. But there’s no reality. These are just constructs. There is no reality to schizophrenia or depression…we might have to stop using terms like depression and schizophrenia, because they are getting in our way, confusing things.” Insel was not alone. His immediate predecessor in the job, the Harvard neurobiologist and psychiatrist Steven Hyman, denounced DSM 5 as “totally wrong in a way [its authors] couldn’t have imagined…what in fact they produced was an absolute scientific nightmare.”
It is important to place these remarks in context. Insel and Hyman spoke as scientists keen to replace descriptive psychiatry with a diagnostic system built upon biological foundations, one that brings together the findings of genetics, imaging technologies, and cognitive science, as well as other potentially relevant realms of knowledge (though with short shrift given to the socio-cultural and the psychological). But in the present state of our knowledge, that prescription, embodied in Insel’s proposal to base future NIMH funding on his proposed Research Domain Criteria (RDoC), is an aspiration, not a reality, something many long for, but cannot (yet?) provide. Much as psychiatry (and many of those who suffer from mental disorders) might wish it otherwise, the etiology of most major forms of mental illness remains an enigma, a mystery we have some tentative and tantalizing clues about, but regrettably cannot seem to solve. Its depredations are still something we can at best palliate. Like the poor folks waiting for Godot (who, as it happens, were waiting for a madman), we are still waiting for those mysterious and long-rumoured neuropathological causes of mental illness to surface. It has been a long wait, and on more than one level a misguided one, I think, if the expectation is that the ultimate explanation of madness lies here and only here.
The metaphysical wager that much of Western medicine embraced centuries ago, that madness had its roots in the body, has in many respects yet to pay off. Perhaps, it never will in its entirety. Will madness, that most solitary of afflictions and most social of maladies, be reducible at last to biology and nothing but biology? There one must have serious doubts. The social and the cultural dimensions of mental disorders, so indispensable a part of the story of madness in civilization over the centuries, are unlikely to melt away, or prove to be nothing more than epiphenomenal features of so universal a feature of human existence. Madness indeed has its meanings, elusive and evanescent as our attempts to capture them have been. It remains a fundamental puzzle, a reproach to reason, inescapably part and parcel of civilization itself.
