Early release, published at www.cmaj.ca on March 29, 2016. Subject to revision. CMAJ Humanities Medicine and society Madness in historical perspective CMAJ Podcasts: author interview at https://soundcloud.com/cmajpodcasts/151418-medsoc our decades have past since I began to work on the history of F psychiatry, examining the rise of the asylum in Victorian England and the transformation of “mad-doctors” into a profession that eventually called itself psychiatry.1 In 1970, most aca- demic and elite psychiatrists in North America thought that madness and meaning were intimately intertwined. Psychoanalysis had initially made inroads in America following Freud’s visit to Clark University in 1909. Hit- ler’s persecution of Jews led to an influx of refugee analysts from the early 1930s onward, and World War II provided a further impetus for psycho- dynamically oriented psychiatry — in part the fortuitous consequence of the appointment of the psychoanalytically inclined William C. Menninger as chief of psychiatry in the US Army, and in part the impact of the link between modern industrial warfare and mental breakdowns. The existence of mass psychiatric casualties in the military gave new cred- ibility to theories of mental illness that linked its origins to the social and the psychological. Between 1945 and the 1970s, psychoanalysis occupied the commanding heights (such as they were) of psychiatry in the United States. Freud’s doctrines also heavily influ- enced popular culture during these years: the visual arts; literature and drama; advertising; and that quintessen- tially American dream factory, Holly- wood. When it came to understanding mental illness, most pointed to the exis- tence of half-murdered memories and repressed traumas, whose pernicious effects on the human psyche surfaced in all sorts of heavily disguised but deeply Courtesy Wellcome Library, London disturbing and distressing symptoms. Frontispiece from John Charles Bucknill and Daniel Hack Tuke’s A Manual of Psychological Medicine (1858), one of the first widely used textbooks on the diagnosis and treatment of If the origins of madness lay buried insanity. Like other alienists, Bucknill and Tuke believed that madness took different forms in the recesses of human (un)con- and that distinct types of insanity could be read on the countenances of their patients. ©2016 8872147 Canada Inc. or its licensors CMAJ 1 Humanities sciousness, its cure likewise revolved suggesting that biological factors will tween the realms of the sociocultural and around questions of meaning. It was turn out to have no role in at least the the biological is profoundly misplaced, at by making the unconscious conscious major forms of mental illness — the odds with what the best neuroscience has and by reconfronting meanings we had sorts of disturbances, for example, that to teach us about human nature. fruitlessly sought to repress that we we now call bipolar disorders or the Human brains are not immutable or- could successfully overcome the de- schizophrenias. Quite the contrary, I gans that we are born with. To the con- mons that lurked within us. Madness would be astonished if biology were trary, they are remarkably plastic, and was indeed all about meaning. not part of the picture, although this re- they remain so through our lifespan. Contemporary psychiatry has a very mains more of a metaphysical wager Our social and psychological environ- different view. Where an earlier genera- than established scientific truth. I have ment continuously influences how our tion of psychiatrists sought brains develop and function to disentangle and make in the most profound ways, sense of the disturbed be- such that the social be- haviours, emotions and cog- comes built into, and helps nitions of their patients, to shape and transform, the their modern-day counter- biological. Thus, the socio- parts are disposed to dis- cultural environment cannot miss these surface manifes- be simply dismissed in fa- tations of mental illness as vour of a presocial biologi- so much epiphenomenal cal determinism. Any at- noise. Madness, they claim, tempt to disentangle the two is brain disease tout court. and to resort to pure biolog- Its origins lie in distur- ical determinism is doomed bances of the chemical soup to failure. It rests upon a that bathes our brain cells, category mistake. in defects in our hereditary More tellingly still, the endowment or in some neuromaniacs, as one critic mysterious mix of the two. has called them,3 are in my Breakthroughs in psycho- view deeply mistaken when pharmacology are sought to they address the problem of repair these underlying so- human consciousness in matic lesions and make the mechanistic terms and assert mad sane. The symptoms of that we humans are simply mental illness are of no en- automatons, nothing more during significance or in- than complicated machines terest, save as the surface who live fully determined manifestations of a bodily lives along pathways prepro- disease and the visible grammed into our bodies Ward of the Madwomen at St Bonifacio’s Hospital, Florence (1865), markers that permit the pro- by Telemaco Signorini (1835–1901). St. Bonifacio’s Hospital was and our brains. We are not fession to identify the (very founded in Florence in 1377, becoming an asylum for the insane in just somewhat more intelli- many) who need its inter- the 18th century under the rule of Grand Duke Piertro Leopoldo I. gent chimpanzees. The ways ventions. Psychiatric treat- we think, behave and feel ments are resolutely directed at defec- no truck with the Szaszians or the soci- are deeply dependent on the extraordi- tive bodies, not unhinged minds. ologists who insist that mental illness is narily complex culture human beings I am no apologist for Freud or for all a matter of labels, let alone the crazy have created over many millennia. That psychoanalysis, whose intellectual vul- calumnies of the Scientologists. What I remains the case even when those cogni- nerabilities and therapeutic shortcom- do insist, however, is that mental illness tions, behaviours and emotions are ings I think are legion. Still, on the remains “the most solitary of afflictions deeply disturbed and profoundly at odds question of madness and meaning, I to the people who experience it; but … with “normality.” think that generation of psychiatrists the most social of maladies to those On theoretical grounds, I find biologi- was more insightful than the somatic who observe its effects.”2 cally reductionist accounts of mental ill- reductionists who currently rule the The departures from the common ness deeply unsatisfactory. A broader ac- psychiatric roost. I hasten to make two sense reality most of us imagine we quaintance with the place of madness in points to avoid misunderstanding: I share (and that we collectively call human culture only serves to amplify the have no truck with those who dismiss “mental illness”) are thus inextricably point. As the title of my book makes mental illness as a myth or the social bound up with the surrounding culture. clear — Madness in Civilization: a Cul- construction of a malevolent psychiat- Furthermore, the very distinction that tural History of Insanity from the Bible ric profession; and I am equally not biological reductionists seek to make be- to Freud, and from the Madhouse to 2 CMAJ ©2016 8872147 Canada Inc. or its licensors Humanities Modern Medicine4 — I have broadened share neither Foucault’s nor Scientolo- unlikely to sell, it published only a trun- my interests in the history of madness far gy’s dismissal of the whole enterprise. In cated paperback version. The publisher beyond my original focus on 19th-cen- addition, Foucault appears to dismiss the created the new title, Madness and Civi- tury England. I have sought to examine depredations and the suffering that are lization. As a marketing device, that the place of madness across millennia, indubitably bound up with bedlam mad- proved to be a stroke of genius. It also and not just in the West, but also in Is- ness, a stance I cannot share given my ensured that an anglophone audience lamic societies, in China, in India and in acquaintance with the realities of the would assume that the links between the vast portions of the planet that fell graver forms of mental distress. As will madness and civilization were the cen- under the sway of Western imperialism. become apparent to those who read my tral point of Foucault’s researches. I offer an empirical rebuke to those who book alongside Foucault’s, we also differ By contrast, I chose the title Madness would reduce mental illness to no more sharply in our analyses of the complex in Civilization for my book. Rather than than a malfunctioning brain. links between madness and civilization. seeing madness as something separable In choosing to call my book Mad- If the titles of our two books are from civilization, the prefix “in” reflects ness in Civilization, I was deliberately superficially similar, the arguments we my view of madness as inextricably a referencing arguably the most famous each advance are very different. Some part of it, sometimes liminal, but some- book on the history of psychiatry to may chastise me for criticizing Fou- times quite central to human experience. have appeared in the past three quarters cault’s handling of how the relationship Both madness and civilization are com- of a century, Michel Foucault’s Mad- between madness and civilization is to plex phenomena. Just how they have ness and Civilization.5 Foucault’s book be unpacked. After all, the title of his been related to one another over the mil- first appeared in English translation in original French edition suggests that lenia and across vastly different societies 1964, the version I first read as a gradu- this was not the task he set for himself.