And in my solitude in England, doubting my vocation and myself, I drifted into something like a mental illness. This lasted for much of my time in Oxford. . . . I was in a state of psychological destitution when—having no money besides—I went to London after leaving Oxford in 1954, to make my way as a writer. Thirty years later, I can easily make present to myself again the anxiety of that time: to have found no talent, to have written no book, to be null and unprotected in the busy world.
V.S. Naipaul, Nobel laureate
Thousands of volumes have been written over the centuries about the true nature and definition of madness. Yet, as the medical historian Roy Porter notes, our current definitions depend on the same tautology used in the sixteenth century, when Shakespeare wrote famously in Hamlet, “What is’t but to be nothing else but mad?” (2002, p. 1). Porter’s own definition, the “generic name for the whole range of people thought to be in some way, more or less, abnormal in ideas or behaviour” (1987a, p. 6) adds nothing of consequence but suggests that the word madness does have a useful purpose: namely, to capture within a reassuringly resonating and apparently comprehensive category all those “abnormal” people who significantly disturb society and sometimes themselves. Porter importantly notes that “even today we possess no . . . consensus upon the nature of mental illness—what it is, what causes it, what will cure it. That is true even amongst psychiatrists. . . . Short of the discovery tomorrow of the schizophrenia gene, these controversial issues will not be quickly settled” (1987a, pp. 8–9, see also Andreasen, 1997; Grob, 1983, p. 36; Scull, 1993, pp. 391–394). Despite heroic or, depending on who is doing the judging, desperate and enormously expensive research efforts over many decades, no genes or reliable pathophysiology that maps schizophrenia or any other “mental disease” has been found (Andreasen, 1997; Bentall, 1990; Boyle, 2002; Kupfer, First, & Regier, 2002). But even if such pathophysiology were found and some current “mental disorders” relegated to true physiological pathologies (neurological diseases) and disappear from psychiatric concern (as occurred, say, with epilepsy, general paralysis of the insane, and pellagra), at best only some people currently diagnosed as afflicted with a mental disorder would be identifiable by relevant biomarkers. The rest would remain mystifyingly mad.
A multiplicity of theories about madness has been proposed. Is it medical disease; a person’s unfortunate, incompetent handling of greater and lesser problems in living; social labeling of disapproved behavior; social construction tout court; or, more provocatively, merely a word for a semantic category referring to all manner of behavior peculiar enough to be publically disturbing at any given time? The hypothesized causes, determinants, or contributing factors are as perplexingly varied. Are the mad mad because of unbearable social pressures; because of mental, physical, hereditary, genetic, or environmental vulnerabilities; or because of some as yet unfathomable combination of all of these (Read, Mosher, & Bentall, 2004)?
Neither the many theories nor the implied causes of madness have been scientifically validated, perhaps because mad science rests on hundreds of constantly shifting diagnostic categories of “mental illness,” which have little in common (addressed in chapters 4 and 5). Fifty years of scientific efforts revising these categories, quantifying them, and statistically calculating perceived differences among them may not be the best analytic approach for understanding what is subsumed under the word madness and its many linguistic analogs. As the developmental economist Sir Peter Bauer (1981, pp. 262–266) argues, overreliance on numbers and mathematics devalues a fundamental component of scientific development, namely, conceptual analysis. Those elements of the social world that can be quantified have taken precedence over those less amenable to quantification.
Despite the failure of scientific attempts to validate the nature or causes of madness, groups with enormous political, ideological, and economic clout have taken up one theory about madness in particular: that it is medical/bodily disease. This disease theory is supported by the government mental health bureaucracy under the leadership of the National Institute of Mental Health, the pharmaceutical companies, mental health lobby groups, the organized profession of psychiatry, and hundreds of thousands of providers of mental health services from all professional stripes. Their successful effort to reify this medical theory, which we argue is at best only a useful analogy or explanatory metaphor whose depths already have been plumbed to no scientific avail, endangers further efforts to understand whatever contents the category of madness may hold.1
But as we dive into the murky historical waters in search of the hypothesized essence or even the specific content of madness, we emphasize that before anything else, madness is a word. Like all words, it is a human artifact stitched together to represent or echo something (abstract or concrete) related to human behavior or one’s perception of this behavior. As a linguistic sign, madness becomes available for our critical manipulation, but like all linguistic signs it need not be anchored to particular aspects of the material world. The word trees, for example, does not directly locate any specific tree in the observable world, nor does it specify what the particular limiting attributes of the categorical term trees are. It serves as a label for collecting many disparate types of plants judged to belong under the category “trees,” though these plants may share few common elements other than their category name (for example banana trees and oak trees). Such a category might best be called “disjunctive.” According to Bruner, Goodnow and Austin (1986), “[w]hat is peculiarly difficult about . . . a disjunctive category is that [any] two of its members, each uniform in terms of an ultimate criterion [for example being living organisms], may have no defining attributes in common” (p. 156).
Words and categories matter. The philosopher Immanuel Kant proposed that categorizing is a fundamental and necessary act of human survival: it helps us to make sense and perhaps to respond and control the mysterious nonhuman noumena (das Ding an sich, the thing in itself) that makes up the “out there” that another philosopher, William James (1890), described as “one great blooming, buzzing confusion” (p. 462).
To recapitulate, words are semiotic tools, but they do not have any fixed meaning or direct connection to material reality or enjoy any consensus about their usefulness. They are open to variable definitions and interpretations often dependent on the learning history and cultural background of the definer. So it is with the word madness, because it is a word first and foremost and because as such it has no immanence, its meaning being primarily determined by those responding to it. Indeed, the history of social responses to madness suggests an abundance of possible meanings, some contradicting others (e.g., devil possession versus pathological personality organization versus brain disease versus inept training for social life versus a metaphoric haven for escaping from wrenching difficulties). Trying to define what madness really is—or what its verbal siblings such as mental disease, mental illness, or mental disorder really are—has been and may continue to be a failure. Based on the poor track record of progress in objectively validating madness or its contemporary semantic substitutes, we might consider admitting that ideas and behaviors, even the strange, troubling, and frightening ones we call mad, are just that: ideas and behaviors.
Unusual and scary behaviors of our own or those of others that attract our attention and elicit powerful emotions typically challenge us to provide an explanation for their existence. If no obvious explanation is found, often the best that we can do in response to our need for knowing why is to manufacture a word or phrase as an explanation that can safely contain all that puzzling and frightening content to provide ontological comfort in order to regain the existential stability we lost as a result of our encounter. In short, madness is a disjunctive category label. The term mad has been that universal remedy for disturbing behaviors for hundreds of years. It is a linguistic black hole that (metaphorically) sucks in all peculiar human behavior that society cannot digest or normalize but still feels compelled to explain in order to control. The word serves, on the one hand, to instruct reassuringly the normal that genuine boundaries distinguish the mad from the rest of us. On the other hand, the word strikes a cautionary note about what might happen if the normal are not vigilant and transgress.
The word also serves to limit inquiry. Its invocation appears to explain by mere assertion, though of course it cannot. “Why is John’s behavior bizarre?” Answer: “He is mad (mentally ill).” “How can we be sure that John is mad (mentally ill)?” Answer: “He exhibits bizarre behavior.” This circular process can be recognized by the logical thinker as tautological. However, the strength of the various institutions aligned to support and validate that logically erroneous judgment—such as government (National Institute of Mental Health), business (pharmaceutical industry), the professions (psychiatry, psychology, social work, nursing), and the academy (distinguished professors from the helping professions conducting research)—effectively discourages exploring alternative explanations for John’s bizarre behavior.
In what follows, we present an overview of how the age-old social problem of madness was transformed into the contemporary medical problem of mental illness. We also discuss the attendant attempts to ameliorate this problem in America, as reported by prominent historians of madness. We then conclude with a discussion of the possible impact of the personal beliefs regarding madness of these very historians on the shaping of their historical accounts.
The ancient Greeks were perhaps the first to discuss the problem of madness. For them it probably meant the loss of reason. The early Greek myths and legends focused on external rather than internal events to explain human action. They told of how heroes were subjected to the will of the gods who punished from on high, cursed, and sometimes drove them into madness (Porter, 1987a, p. 10). The Greek philosophers considered reason to be the noblest faculty of man. Socrates’ “know thyself” represented the highest expression of this ideal through the use of self-critical reason (Popper, 1998). For the Greeks, this faith in reason to successfully negotiate the human predicament was counterbalanced by its opposite, unreason, seen as a major threat to human survival. Conceived as made up mostly of powerful primitive forces often dark and destructive—but sometimes constructive (divine madness to explain genius for example)—madness challenged the understanding of human behavior as being reasonable behavior. Such early Greek notions have significantly shaped our contemporary Western thought. Western civilization embraces the centrality of reason for ethical and scientific development while simultaneously battling to minimize the impact of irrationality because of its assumed causal role in the “senseless” tragedies that constantly confront humankind (Porter, 1987a).
The Greeks, Porter (1987a) argues, citing another psychiatric historian, Bennett Simon, originated the West’s two principal ways of viewing and treating irrationality. The first sees the human condition as a struggle over “great unbearable elemental conflicts of life” (p. 12), such as love, hate, jealousy, and greed, and as efforts to cope with their powerful emotions of unreason, relying principally on spoken language to heal the soul or psyche. Theater in ancient Greece illustrates how treatment under this conception of irrationality could have proceeded. Greek dramatists such as Euripides, in plays like Medea and Hippolytus, through dramatic renderings of the individual’s personal struggles against himself and others, brought the demons within to the public-at-large. Not only could the complex circumstances, conflicts, and emotions required for possible self-discovery be personified on the stage, but an opportunity was presented for ritual healing of unreason through communal catharsis of the audience. The professional rhetoric (its form and content calculated to persuade and gain agreement) later used by priests in the confessional and the “talking cure” practiced by psychotherapists in modern times are direct descendents of this tradition (see Vatz & Weinberg, 1994).
The Greek physicians associated with the Hippocratic school developed the other major way of responding to madness. They relied on their earlier contention that epilepsy, rather than being a sacred and supernatural disease delivered by the gods, had more mundane physical causes. They claimed that madness too was just another medical condition caused by humoral imbalances affecting various organs including the heart and brain (Porter, 1987a, p. 12). These two approaches to madness, rendered by Porter as “madness as badness and madness as sickness” (1987a, p. 13), are diametrically at odds with one another and to this day not reconciled, but they remain the models used to conceptualize irrational and frightening behavior and its treatment.
The other constant in “mad treatment,” at least from the late seventeenth century when nation-states began to assume some formal social welfare responsibilities vis-à-vis their citizens, has been the formal, state-supported, bureaucratic coercion of public dependents. This emerged as marginal groups, consisting of criminals, the angry jobless, the unemployable, and the religious extreme, all exhibiting “dangerous and delinquent traits,” were increasingly seen as needing separation from the rest of society to prevent social unrest. They were first cast as “disturbing” the social order due to their unconventional thinking and behavior, but because this kind of behavior might be seen as appropriate criticism of the state by the discontented and powerless, it was soon followed by their being recast as personally disturbed. The calculated separation of these fringe groups from society by authorities recast them as alien in thinking and feeling as well, justifying their forced confinement (Porter, 1987a, pp. 14–16).
The deviant behaviors subsumed under the “madness as badness” model potentially justify coercive responses because the deviant’s negative behavior may be seen as intentional and harmful to the polity’s welfare, requiring forceful control by society since the perpetrator has no intention of controlling himself. The criminal justice system is society’s apparatus to confront this form of aberrant behavior. However, the second model, “madness as illness,” does not necessarily suggest the same straightforward imposition of state-sanctioned force. Illnesses (at least in more modern scientific views) are usually seen as involuntary events that happen to people and over which no self-control is posited. It is ordinarily assumed that ill individuals desire to be rid of illnesses and to seek treatments or cures proactively. The selection and acceptance of medical treatment in medical practice therefore is viewed as the prerogative of the person seeking help. The apparent disregard of this general rule by the imposition of involuntary treatment when the medical model is used to address madness presents a dilemma. The dilemma relates to how “science” is employed in the explanation and treatment of madness.
Does science and its rigorous empirical approach for fact-finding support the psychiatric claim that the troubling behaviors subsumed under various mental illnesses are real medical entities, but which, unlike other real medical entities, can nevertheless be subjected to the routine use of coercion as treatment? Or does the language and imagery of scientific medicine serve to justify the use of force by the professions vying for control over the highly politicized and contested turf of what sociologist Andrew Abbott calls “the personal problems jurisdiction” (Abbott, 1982)? Part of the answer may be informed by how mad treatment evolved in the United States.
Colonial Americans’ views of madness were shaped by those of their European predecessors relying on the two models developed by the Greeks. Theirs was a metaphysical mélange combining “religious, astrological, scientific and medical elements” (Grob, 1994b). For over two hundred years, from colonial times till the mid-eighteenth century, America’s mad folk were just one of many dependent groups designated as the “poor.” The mad were viewed simply as one segment of the population appropriate for community concern and care; others were orphans, widows, the aged, the sick, and the physically disabled. What mattered in obligating the local community to provide public assistance was each subgroup’s state of poverty leading to their dependency, not the particular causes or manifestation of their dependency (Grob, 1973; 1994b; Scull, 1985).
The community response to inexplicable, troubling behavior threatening the public safety on occasion prompted legally sanctioned coercion. Gerald Grob describes the case of a colonial soldier who murdered his mother but was found not guilty because he was adjudicated insane. The court required that he be confined for the rest of his life in a small room built for that purpose by his father, with the public bearing the cost (Grob, 1994b, p. 16).
Very few people were considered to be mad during the early colonial period, although almost no hard data are available and most of our information is anecdotal (Grob, 1973, chapter 1; also Viets, 1935, p. 395). Communities where the mad resided at first had no special facilities for their care, with families and occasionally other community members taking responsibility for their welfare. Later, as the general population and dependent populations grew, the insane were offered the same services provided all worthy dependents (almshouses and outdoor relief). The first almshouse in America was built in Boston in 1662 (Grob, 1973). Some of these mad folk worked productively, and the community generally accepted their accompanying bizarre behavior as one of the vagaries of life. Until the middle of the eighteenth century, medical considerations “played virtually no role” in how the “distracted” were handled (Grob, 1994b, p. 17).
The mad started to be formally institutionalized during the early part of the eighteenth century. Boston, one of the larger colonial communities, as early as 1729 sought to develop a separate structure for housing the mad, partly to reduce the physical conflicts arising when the sane and controllable and the mad and uncontrollable poor were housed haphazardly together (Grob, 1994b, p. 17, also Scull, 1985, p. 27). Several other communities shortly thereafter began to erect “hospitals.” These facilities were specifically designed for the care of the destitute ill, including the insane, and were meant to reflect the community’s continuing commitment to a special personal relationship with this group. But due to gradual demographic shifts and population increases, families and friends who originally bore the brunt of the care for mad community members were less able to take care of their own, and these hospitals served as professionally run “surrogate households” that “would help to train medical personnel” who would try, but rarely succeed, in curing “the sick stranger, the ill-kept resident, and wandering insane” (Rothman, 1990, p. 45). The first such official hospital was established in Philadelphia in 1752. It should be emphasized that these hospitals were more a segregating managerial response to the perceived problems of poverty and its impact on the health and welfare of the community “rather than to changes in medical theory and practice” (Grob, 1973, p. 16). The very first hospital exclusively for mad people was started in Williamsburg, Virginia, in 1773 (Grob, 1973).
The urban population of America steadily grew from just 5.1 percent of the total population in 1790 to 19.8 percent by 1860 (Rothman, 1990, p. 327, note 1). The increased societal and individual stress and displacement that resulted required the bureaucratic reorganization of the existing social welfare structure, including the approach to the care of the mad.
The specific type of organized care developed for the mad in the early 1800s and modeled on the approach taken earlier in England was the community-based decision to confine them to suburban or rural asylums (later government-funded state mental hospitals) to avoid the toxic stress of urban living (Grob, 1994a, 1990). The Asylum for the Relief of Persons Deprived of the Use of their Reason, opened by the Quakers in 1817 in the City of Brotherly Love, Philadelphia (Whitaker, 2002, p. 25) is often identified as our first nineteenth-century asylum; however, New York Hospital (opened in 1792) in 1808 constructed a building that was known as the New York Lunatic Asylum (Ozarin, 2006). The approach at these asylums was to remove the person, usually forcibly, from the hubbub and corruption of urban life, which was deemed to be primarily responsible for their insanity and, through the well-organized rustic asylum experience, allow for respite and healing before returning if possible to one’s community (Rothman, 1990).
The three principles of asylum treatment that famously became moral treatment were, first, the rapid removal of the insane from the community; second, assuring that the confining institutions were at a sufficient physical distance from the inmate’s community; and, third and most important, fulfilling, “[t]he charge of the asylum . . . to bring discipline to the victims of a disorganized society” (Rothman, 1990, p. 138). To impart order without brutality was the stated aim of moral treatment. The Quakers’ original or ideal version of this approach in America around 1817 required that the asylum would be situated in a rural setting, housing no more than about 250 people (Whitaker, 2002, p. 25) under the governance of a paternal superintendant who might be a lay or medically trained individual. This individual would have a close personal relationship with each inmate and would help guide them together with supportive staff back to reason through simple, regimented, socially useful yet healthy physical work maintained by a ward system based on rewards and punishments (Whitaker, 2002).
Over time, the reality of nineteenth-century asylums turned out to be very different than originally conceived. Their populations routinely exceeded their optimal capacities, often by many hundreds of residents. The superintendents managing these asylums were primarily trained in designing, organizing, and administering them, not in the art and science of coping with behavioral disturbance. As Rothman notes, “[The superintendent’s] skills were to be those of the architect and the administrator, not the laboratory technician” (1990, p. 134). The title of a leading textbook on insanity published in 1854 by one of the more influential superintendents, Thomas Kirkbride, of the Pennsylvania Hospital for the Insane (On the Construction, Organization, and General Arrangements of Hospitals for the Insane, with Some Remarks on Insanity and Its Treatment), reveals what professional areas were thought to be important and in what order.
Even the oft-stated goal of moral treatment, to eliminate harsh physical punishment or restraint, must be viewed skeptically. The renowned nineteenth-century French alienist, Philippe Pinel, one of the inventors of the traitement moral and considered to be a visionary who “unchained”2 the incarcerated mad, also believed that successful treatment depended on the employment of psychological terror and fear to gain the compliance of the insane (see his description in Pinel, 1962, pp. 63–91). Moral treatment at its core was coercive because it was practiced on involuntary inmates, not willing, help-seeking participants free to come and go at their leisure, and used “the pervasive authority of the alienist, and his ability to link classification with a system of rewards and punishments, constitut[ing] an extraordinarily powerful new form of ‘moral machinery,’ a superior mode of managing patients” (Scull, 1993, p. 379).
The reality was that these patients were confined against their will in (eventually) large physical plants architecturally designed to separate the inmates into a series of wards that demanded various levels of psychological and physical conformity. Making progress in this system required obedience and proper behavior by the patients. Failure to follow the rules dramatically undermined the patient’s social status, institutional privileges, and personal wellbeing by the forced transfer to more remote and less respectable and comfortable wards. Total control by the alienists/moral managers over the physical and social environment of the inmates was the mechanism that imposed discipline. Moral treatment originally was marketed by its proponents as a more humane approach for working with the mad, theoretically relying on minimal physical restraint (if one overlooks their forced sequestering in the asylums) while emphasizing other methods of behavioral control. By the end of the nineteenth century, it had transformed into a bloated, highly dysfunctional system utilizing physical punishment and that had almost no resemblance to its original psychological reeducation approach. Moral treatment became the rallying point for progressive political activists promoting the growth of government intervention in the care of the insane under the cover of medical science.
Scientific medicine became a reality only in the mid-nineteenth century. German physician Rudolf Virchow’s research, demonstrating the central role of cell pathology in human disease processes, offered for the first time medical treatment that reliably ameliorated certain physical diseases (Porter, 1997, pp. 304–347). The new scientific medical model of disease that developed as a result consists of reported (subjective) symptoms, measurable or palpable physiological signs, and demonstrable physical lesions. It replaced the ancient Greek humoural theory of health and illness prevalent until that time. Humoural theory speculates that the human organism contains four body humours, blood, phlegm, black bile, and yellow bile (choler), the balancing of which is necessary for good health (Porter, 1997, p. 9). (The intellectual debris of the humoural theory can be found in current speculations that “chemical imbalances” in the human brain cause assorted mental disorders.) The new medical disease model emboldened alienists to claim that “mental illness” was just like other medical disease entities even though “no evidence could in fact be produced to show that insanity had a somatic origin” (Scull, 1993, p. 241).
Benjamin Rush, a signer of the Declaration of Independence whose portrait appears on the emblem of the American Psychiatric Association and is considered to be the father of American psychiatry, in 1812 published the first American psychiatric textbook, Medical Inquiries and Observations upon the Diseases of the Mind. In it he declares “that the cause of madness is seated primarily in the blood-vessels of the brain” (pp. 11–17). Rush’s statement might be the first published American psychiatric assertion that “mental illnesses” are brain diseases. This position was also held by most of Rush’s contemporaries in Europe and America, even though little pathological work was undertaken to identify brain differences between normal and insane people (Rothman, 1990, p. 110). Such claims gradually shifted the thinking about the nature of treatment itself.
The early-nineteenth-century reports claimed impressive successes for moral treatment. “At McLean Hospital, 59 percent of the 732 patients admitted between 1818 and 1830 were discharged as ‘recovered,’ ‘much improved,’ or ‘improved.’ Similarly 60 percent of 1841 patients admitted at Bloomingdale Asylum (the successor to the New York Lunatic Asylum) in New York between 1821 and 1844 were discharged as either ‘cured’ or ‘improved’” (Whitaker, 2002, p. 27). This success raised expectations about the possibility of effective nonmedical treatment for insanity. As popular support grew for lay asylum treatment, physicians, feeling threatened by the potentiality of professional marginalization, intensified their efforts to acquire medical jurisdiction over these asylums. In 1824 the Connecticut State Medical Society successfully lobbied for government and private funding and built the Hartford Retreat with Dr. Eli Todd as the medical superintendent in charge. Todd argued that earlier asylum treatment had “placed too little reliance upon the efficacy of medicine . . . and hence their success is not equal to that of other asylums in which medicines are more freely employed [and as a result his institution will be adhering] . . . to the lofty conceptions of truly combined medical and moral management” (Whitaker, 2002, p. 28). As states funded public asylums, they generally supported this integrated medical/moral approach, which also led to the increased use of physical interventions. Bloodletting, physical restraint, and psychological terror, originally promoted by Rush, became key treatment components (Porter, 1997, p. 500). By 1844, thirteen physicians in charge of asylums had organized into the Association of Medical Superintendents of American Institutions for the Insane, becoming in 1921 the American Psychiatric Association. One of their declared goals was to make sure that asylums would always have doctors as their executive officers and superintendents.
The traditional roles of hospitals as poor relief institutions for the transient or homeless sick, safe havens for the indigent dying, and places for custodial care of almshouse inmates sane and mad, also began to change to better fit the emerging, nineteenth-century scientific worldview. Hospitals became experimental way stations for the new notions of scientific medicine, curative interventions, and scientific research (Leiby, 1978, p. 61). These progressive ideas provided the empirical justification for recasting some hospitals into state asylums or hospitals for the insane. The earlier general social control mechanisms of poor relief could now be merged with the more recent “scientific” claims of psychiatry about the mad, boosting both its police powers and professional stature.
This shift in the United States from the early colonial voluntary concern about social dependents to the “scientific” approach for managing human problems in the late nineteenth century turned out in practice to consist largely of acts of bureaucratic categorizing and management. The collection and analysis of quantifiable data about various dependent groups served to confirm the rationality of administrative and bureaucratic activity. The individuals who helped develop public policy regarding these groups were confident that their centralized decisions would “promote . . . rationalization and systemization . . . to enhance the presumed effectiveness of public and private institutions” (Grob, 1983, pp. 81).
The scientific management of madness under this approach, in the United States and elsewhere, required renaming and categorizing disturbing behaviors as diseases and symptoms of diseases. This led to the development in several countries of various diagnostic systems for asylum practice and record-keeping. In Germany, the psychiatrist Emil Kraepelin published his first textbook of psychiatry in 1883, containing his descriptive nosological work, which remained one of the most influential. “Indeed, his textbook can be seen as the forerunner of today’s Diagnostic and Statistical Manuals” (Porter, 1997, p. 512). Kraepelin’s influence is discussed in more detail in chapter 4.
The successful nineteenth-century transition from lay to medical control of madness in America energized the mental health reform movement as it sought to convince the population and state governments to establish more mental hospitals. One of the leading progressive proponents of hospital treatment was Dorothea Dix. She herself experienced an emotional collapse at the age of thirty-four that was in her era diagnosable as moral insanity (Gollaher, 1995, p. 105). As part of her recovery, she spent about fifteen months in England, staying at the home of William Rathbone, III, a close friend of Samuel Tuke, the grandson of the great English Quaker William Tuke, who developed the by-then famous York Retreat, providing moral treatment for the English mad. Samuel Tuke’s youngest son, Daniel Hack Tuke, was in charge of Dix’s recovery (spent in part at the Retreat), and he tutored Dix on the Retreat’s principles (Gollaher, 1995, p. 357). As a result she “adopted them as the basis for most of her later ideas about asylums and psychiatric treatment” (p. 112).
Dix’s intentions were admirable. She wanted to help a group of deeply troubled individuals who were often treated miserably by the prevailing penal authorities. Her solution was to go from state to state in an attempt to convince the legislators to fund public insane asylums. She claimed, relying on apparently irrefutable data, that insanity was curable, that effective treatment was at hand, and that only the funding of enough public institutions to take care of the indigent lunatics would eliminate this grave social problem. So effective was she that thirty-two state mental hospitals were either founded or enlarged as a direct result of her lobbying (Leiby, 1978, p. 67).
Well intentioned as her approach was, it left something to be desired. To argue her cause Dix relied on false statistics and dubious claims about the curative powers of treatment. She apparently made no effort to examine or question the scientific data because it supported her assumptions about “mental illness” (Scull, 1981, p. 112). Rothman (1990) reports, “these statistics were inaccurate and unreliable. Not only was there no attempt to devise criteria for measuring recovery other than release from an institution [which was, as we will discuss in chapter 3, an administrative decision] but in some instances a single patient, several times admitted, discharged and readmitted entered the list as five times cured” (p. 131).
This focused lobbying effort by Dix and fellow progressives to organize and institutionalize publicly funded hospital care for the insane was a resounding success, serving as an early example of how good intentions and enthusiasm for change in psychiatric treatment overrides evidence. By 1880, about 140 public and private mental hospitals were managing about 41,000 individuals (about 90 percent were in public care). Notably, even at the end of the nineteenth century the mad still represented a very small portion of social dependents, making up less than 0.2 percent of the general population. The census of 1880 listed 91,997 insane people in the United States out of a total population of fifty million (Grob, 1983).
By the start of the twentieth century, a barely nascent psychiatric profession whose tasks centered entirely on the management of insane asylums had won the argument that good science demanded the institutional control of madness via state mental hospitals. However, almost as soon as psychiatry had made this commitment, it began to reconsider this approach to the problem of madness.
The horrors of World War I traumatized humanity and served as the spawning ground for new psychiatric problems such as “shell shock” and “battle fatigue.” The phenomena of large numbers of individuals potentially opting out of their forthcoming military responsibilities during wars by claiming to be mad or by once in service developing psychiatric “disabilities” is well-known. “Everyone who served in the United States Army of World War II is familiar with the word ‘goldbricking,’ which meant, in military slang, malingering” (Eissler, 1951, p. 219). Malingering is the term for those who do not want to go and fight in a war or find the violence abhorrent once in the military and fake being ill3 to avoid participating rather than declaring themselves conscientious objectors and facing close scrutiny and potential public condemnation.
The political problem of explaining large numbers of reluctant military recruits, when the military needs all able-bodied individuals for combat, can be greatly reduced by recasting malingering as diagnosable mental disorders and medically treating or honorably discharging their “victims” rather than court-martialing hundreds, if not thousands, of dissidents. The latest of these war-related diseases is the Vietnam War–related version, posttraumatic stress disorder (PTSD, Young, 1995).
Redefining the feigning of insanity to avoid combat because of fear of killing or being killed as a mental disorder rather than a moral dilemma allowed the “ill” individuals to be “diagnosed” then “treated,” followed by either a rapid return to active duty or an exit from the military with an honorable medical discharge instead of being court-martialed. Joseph Heller’s famed novel Catch 22 tells an extended story of such maneuvers. This approach would mostly take care of those already in the military. But what to do about those at-risk individuals who were among the yet undrafted?
The passage of the Selective Service Act of 1917 had created a Division of Neurology and Psychiatry under the War Department to evaluate and reject recruits diagnosed with psychiatric disorders. Psychiatrist Thomas W. Salmon, the medical director of the National Committee for Mental Hygiene, recommended that the military exclude recruits found to be “insane, feeble-minded, psychopathic and neuropathic” (as quoted in Pols & Oak, 2007, p. 2133). His suggestion, which became the justification for military screening of draftees in both world wars, assumed that various war neuroses or mental breakdowns resulted from personal characteristics (i.e., constitution, genetic makeup, temperament, or early childhood experiences) that tended to be invariant within individuals and would undermine their ability to function effectively as soldiers (Pols & Oak, 2007). As a result, 103,000 individuals were excluded or discharged from the military in World War I for neuropsychiatric disorders (Jones, Hyams & Wessely, 2003, p. 41) out of approximately 2.8 million who were drafted (Wikipedia, 2011). This screening process was never evaluated, so we know nothing about its effectiveness or validity. The Division of Neurology and Psychiatry also oversaw “the treatment of mentally ill service personnel” already in the military (Connery, 1968, p. 15).
The federal involvement continued to grow. In 1930 the Veterans Administration was created to provide ongoing health care, including comprehensive mental health treatment, to veterans. The Division on Mental Hygiene was also organized within the Public Health Service around that time. This division’s various roles included studying drug addiction, administering some of the associated treatment facilities, providing mental health treatment to federal prisoners, and offering diagnostic services to the federal judiciary (Connery, 1968). This expanded the federal role in mental health to few other client populations beyond the military personnel. The division served as the institutional center of this still-limited federal involvement until the National Institute of Mental Health (NIMH) started its work in 1949. World War II helped make the entire nation’s mental health a federal government concern.
During World War II, the massive recruitment of millions of young draftees for the military focused the country’s attention on mental health issues as never before. According to the 1945 congressional testimony of General Lewis B. Hershey, then director of the Selective Service System, the rejections for military service based on mental difficulties included “somewhere around . . . 856,000 . . . for mental diseases, and an additional 235,000 . . . as neurological cases. In addition to that there are 676,000 that have been turned down for mental deficiency” (as quoted in Connery, 1968, p. 16), totaling approximately 1.8 million recruits rejected due to neuropsychiatric difficulties out of the 36 million men classified for military service (Flynn, 1993). These numbers aroused broad public concern among average Americans about the extent of mental illness in the United States. General Hershey presented these data as part of his dramatic testimony to Congress supporting the ultimately successful effort to pass the National Mental Health Act of 1946. This act created the previously mentioned NIMH and gave broad authority to the federal government in developing and implementing national mental health policy and programming (Connery, 1968).
The “discovery” of a staggering number of military-age men with psychiatric problems unveiled by General Hershey accomplished its intended political and pragmatic aims. It impressed both politicians and the public of the seriousness of the national menace of “mental illness” and it justified the culling of undesirable individuals from the military for “medical” reasons. The problem, not unlike the issues raised a century earlier by the efforts of Dorothea Dix to convince state governments to fund state mental health hospitals based on exaggerated claims and bad statistics, was that this successful expansion of the federal government’s involvement was based on bad methodology. The military’s diagnosing of hundreds of thousands of citizens as psychiatrically disturbed was made by understaffed and insufficiently trained personnel, relying on screening procedures and tools lacking any predictive reliability, in ludicrously brief interviews of two minutes or so, all within a social environment tainted by eugenics, racism, and homophobia. Grob (1994b) recounts that
The military feared in particular that the inadvertent recruitment of homosexual males would have a devastating effect on the armed forces and supported any measures that might exclude them. . . . Screening . . . was arbitrary and capricious; racial and ethnic considerations intruded in the process . . . and personality tests were biased and unreliable. (pp. 192–193)
The screening problems, never resolved, ultimately led to the abandonment of the entire effort under the order of General George C. Marshall in 1944 (Pols & Oak, 2007, p. 2134). These concerns were quickly superseded by the sharp increase of “nervous breakdowns” occurring in the battlefield. The most politically expedient explanation for mental problems that were described earlier as malingering was the impact of the war itself on the personalities of these men. The military psychiatrists argued that “environmental stress, that is, the actual conditions of combat played a major etiological role; predisposition was not a significant factor” (Grob 1994b, p. 193). Here was a pretentious and medical-sounding explanation for the common-sense observation that combat conditions seriously frightened and disabled some people. They recommended first aid psychiatry as the treatment of choice. Treatment was provided directly in the combat zone instead of in some more permanent but remote military medical facility that would have, it was argued, weakened the soldier’s ties to his unit and prolonged the sick role. First aid psychiatry included “mild sedation, a night of sound sleep, and warm food . . . brief psychotherapy, rest and relaxation under psychiatric guidance” (Grob, 1994b, p. 194).
The simplicity and apparent success of such treatment under war conditions (most soldiers returned to their units within a week) logically suggested to the psychiatrists returning to their practices after the war that “treatment in civilian life, as in the military, had to be provided in a . . . community setting, rather than in a remote, isolated, and impersonal institution” (p. 195). The emphasis on environmental causes of mental disturbances helped foster theories of preventing mental disorders through the control of environmental factors. These efforts fit well with the already successfully established “scientific” public health model for the prevention and treatment of infectious diseases. Since President Harry Truman’s Scientific Research Board had already expressed strong interest in having the federal government support biomedical research and insisted on the need for developing a national health policy, the incorporation of mental health policy into this broader federal health endeavor seemed a natural progression (Grob, 1994b).
The National Mental Health Act of 1946 embodied this commitment. It declared “mental illness” a serious public health problem, authorizing for the first time “extensive research, demonstration projects, training programs, and grant-in-aid to the states for mental health purposes” (Connery, 1968, p. 16). The NIMH, also a result of this act, provided the organizational infrastructure for centralizing federal authority over the nation’s mental health policy. The act, building on the arguments of the psychiatrists returning from the Second World War, put the authority of the federal government behind policy efforts to “stimulate a new form of community mental health activity. . . . [T]reating mental illness in the patient’s normal environment rather than in a mental hospital” (Connery, 1968, p. 19).
These developments were aided and abetted by the various exposés of harmful and coercive institutional psychiatric practices published in the early decades of the twentieth century. These provocative accounts further highlighted the problems of institutional care and undermined its optimistic early promise in the eyes of the general public. In the late 1940s, Albert Deutsch described a visit to a psychiatric ward:
Cots and beds were strewn all over the place to accommodate the 289 mental patients packed into wards intended for 126. Cots lined the corridors, with restless patients often strapped to them. It appeared that about one-third of all patients . . . were under mechanical restraint that night—tied down to their beds by leather thongs, muffs or handcuffs linked to chains. (as quoted in Grob, 1994b, p. 204)
Although according to Grob the actual living conditions of the nation’s state mental hospital systems were apparently improving by the 1950s, this was ignored for the most part and the emphasis was on expanding community-focused care. The post-war belief in the primacy of environmental and psychological causes of emotional disturbance supported arguments for early intervention as a way to avoid developing serious “mental illness” and the inevitable hospitalization accompanying it. This belief went well with the federal flow of dollars to community care in the late 1950s and 1960s based on the various federal legislative acts mentioned earlier. There was an intuitive common-sense logic to “curing” through supportive community caring, but it lacked empirical support (Grob, 1994b, pp. 234–236).
Such beliefs reinforced and supported the notion that fragmented state mental health services could only be mended by comprehensive federal planning and funding. These political, philosophical, and practical developments, together with the introduction in the 1950s of psychotropic drugs, which were promoted as having great “scientific” promise of managing or eliminating frightening psychiatric symptoms (and which were functionally understood as increasing socially appropriate behavior without the need for obvious coercive physical restraint), provided the justification for the commitment to treat in the community the hundreds of thousands of institutionalized psychiatric inmates. Not only was this seen as an attainable reality but as a significant moral and social good.
Deinstitutionalization, as this approach came to be known, became the focus and the political agenda of those making mental health policy from the late 1950s onward. As the federal government expanded its involvement with mental health policy through its legislative activity, the role of state governments diminished and with it the role of state-funded and -run mental hospital systems. The Mental Health Study Act of 1955 provided substantial federal dollars ($1.25 million) to “research . . . and study . . . resources, methods and practices for diagnosing, treating, caring for, and rehabilitating the mentally ill” (Connery, 1968, p. 39). Business involvement with the management of federal mental health policy began almost immediately. That year, the Smith, Kline, and French Company, a pharmaceutical powerhouse and distributor of chlorpromazine (Thorazine), the very first antipsychotic ever approved by the FDA in 1954, provided a grant of $10,000 to subsidize the planning of the coordinating committee to organize the Joint Commission on Mental Illness and Health (JCMIH). The commission originally consisted of eighteen key organizations, including representatives from the American Psychiatric Association (APA), the American Medical Association (AMA), the American Psychological Association, and the American Association of Psychiatric Social Workers. The AMA and APA had five representatives each, while all the others had one each (p. 40). The membership was skewed toward the medical perspective, which would strongly influence the commission’s development of their recommendations for mental health policy.
The stated commission agenda was to look at “mental illness” in completely new ways. The JCMIH, although instrumental in setting up the Mental Health Study Act of 1955, applied for and was selected to conduct a study authorized under it. This selection highlighted the strong ties already in place between professional interest groups and the government bureaucrats developing federal policy. The study, costing almost $1.5 million dollars, resulted in a report—Action for Mental Health. It recommended a massive program to inform and educate the public about mental health problems, and called for a dramatic increase in federal dollars to cover the cost of developing and implementing their recommendations for improved mental health services (we further discuss the commission and its report in chapter 3).
These recommendations called for increasing the authority and power of NIMH by becoming the source of the federal dollars for research on mental illness, by the establishment of academic mental health research centers throughout the country, by increasing the number of jobs available in the mental health professions, and, finally, by increasing federal spending to support mental health treatment. These recommendations helped pave the way for the federal government becoming the principal funder of mental health research and the chief arbiter of the “standards for the quality of care of the mentally ill” in the United States (Connery, 1968, p. 45).
The 1956 amendment to the Public Health Service Act under its Title V continued this effort to centralize mental health policy by authorizing grants for work improving the methods of diagnosis and treatment of mental illness and for funding NIMH to subsidize research efforts on better inpatient management and treatment techniques for state hospitals. The concentrated effort by the leadership of the NIMH to gain control over mental health research and program funding and policy development combined with the political activities of relevant professional lobbies in support of this federal takeover culminated in the passage of the Mental Health Acts of 1963 and 1965. These authorized the creation and staffing of comprehensive community mental health centers throughout the United States with the aim of seamlessly integrating and delivering the necessary mental health services in the communities where patients lived.
Robert Felix, the then-influential director of NIMH, in his pivotal US Senate testimony for the passage of the 1963 act predicted that its effect would be to facilitate “the day when the State mental hospitals as we know them today would no longer exist” (Connery, 1968, p. 51). The act was passed, and his prediction that state mental hospitals would no longer be the same, more or less has been realized. The state hospital inmate populations eventually plummeted, but the hope that community-based care would revolutionize the provision of mental health services and improve the independence and the well-being of the mad has not (Scull, 1981a). In fact, it appears that this effort merely shifted many of these inmates into other “museums of madness,” such as nursing homes and jails. Scull tells us, “By the mid-1970s, nursing homes had become ‘the largest single place of care for the mentally ill,’ [with as many as 900,000 mentally disabled residents] absorbing some $4.3 billion or 29.3% of the direct care costs associated with mental illness” (1981a, p. 747). In 1998 the US Department of Justice’s Bureau of Justice Statistics (BJS) estimated that 283,800 “mentally ill” prisoners were being held in the nation’s penal institutions (BJS, 1999).
Regardless of the actual long-term outcomes, these activities served as the birthing ground for an “interlocking directorate”—of professional groups, mental health activists/lobbyists, private individual and foundation donors, government bureaucrats, and the pharmaceutical industry—that effectively has come to shape and run the “science” of mental illness and its treatments in the United States:
As a revolution . . . passage of the mental health legislation of 1963 and 1965 had all the earmarks of a coup d’etat, carefully staged and managed, with the full implications for the country at large to come later, after changing the palace guard. . . . [T]he 1963 Act was but another episode in the continuing story of the expanding activities and influence of the National Institute of Mental Health. From its beginnings in 1949, partly the result of bureaucratic instinct, partly the result of professional dedication, NIMH’s aggressiveness in pursuing its own expansion was exceeded only by its success. . . . Strategically placed congressmen, . . . who chaired the relevant appropriations subcommittees were carefully cultivated by Dr. Felix, aided and abetted by interested private groups and individuals. Among the more important of theses surrogates were the American Psychiatric Association, the National Association for Mental Heath and its state affiliates, and—through the good offices of Mike Gorman, executive director of the National Committee Against Mental Illness—Mrs. Mary Lasker, long known for her efforts . . . through the Albert and Mary Lasker Foundation on behalf of medical advances. (Connery, 1968, p. 61)
These developments led to the strong centrally organized political structure for dealing with madness that is currently in place. NIMH has cemented its role as the principal distributor of federal mental health research funding (its research budget has grown from approximately three quarters of a million dollars in 1948 to nearly 1.2 billion dollars in 2006). It is also the agency that closely coordinates the development of mental health policy. This dual role of the federal government in determining mental health policies and doling out the research dollars seeking to validate these policies has deeply politicized psychiatric science. NIMH is committed to biological explanations of madness. Projects relying on that presumption have formal funding priority. Other theoretical perspectives (related to psychological, social, environmental, and personal explanations of mad behavior) are deemed adjunct or irrelevant approaches.
Thomas Insel, the current director of NIMH, declared in one of America’s premier academic journals:
Just as research during the Decade of the Brain (1990–2000) forged the bridge between the mind and the brain, research in the current decade is helping us to understand mental illnesses as brain disorders. As a result, the distinction between disorders of neurology (e.g., Parkinson’s and Alzheimer’s diseases) and disorders of psychiatry (e.g., schizophrenia and depression) may turn out to be increasingly subtle. That is, the former may result from focal lesions in the brain, whereas the latter arise from abnormal activity in specific brain circuits in the absence of a detectable lesion. As we become more adept at detecting lesions that lead to abnormal function, it is even possible that the distinction between neurological and psychiatric disorders will vanish, leading to a combined discipline of clinical neuroscience. (Insel, 2007, p. 757)
As we pointed out in the introduction, Insel’s rhetoric smacks of propaganda and wishful thinking rather than good science. After all, the claim that the distinctions between neurological disorders and mental disorders “may turn out to be increasingly subtle” also means that they may turn out to be exactly what they are today, categorically distinct.
This concludes the “factual” history we have gleamed, not being trained historians ourselves, from consulting the works of some of the best-recognized chroniclers of madness. But, before we summarize and conclude what this history may mean, let us take a look at what is often thought to be unnecessary when using assumed objective historical scholarship: evidence for unacknowledged personal perspectives of the prominent madness chroniclers, on whom most people rely for their historical understandings of madness.
These historians are, in alphabetical order, Norman Dain (1964), Gerald Grob (1973; 1983), Roy Porter (1987a; 1987b; 2002), Charles Rosenberg (2007), Andrew Scull (1979; 1993) and Edward Shorter (1997). Professor emeritus at Rutgers University, Norman Dain’s major work is Concepts of Insanity in the United States (1964), which Gerald Grob (1973) believes is the best academic discussion of early American psychiatric thinking (p. 153), and Andrew Scull (1993) calls one of “the best and most scholarly . . . accounts from this era” (p. 119).
Gerald N. Grob is the Henry E. Sigerist Professor of the History of Medicine (Emeritus) at the Institute for Health, Health Care Policy and Aging Research, Rutgers University. The dean of American psychiatric historians, over a thirty-year period Grob authored five major books (1966; 1973; 1983; 1991; 1994) and dozens of articles detailing the history of American psychiatric care from its colonial beginnings through the dawning of the twenty-first century. He is also a past president of the American Association for the History of Medicine (AAHM).
The late Roy Porter (1946–2002) was a professor at the Wellcome Institute for the History of Medicine in London, who edited or wrote over a hundred books and is probably, because of the rigor and prodigious academic fecundity of his writings, the most cited historian of medicine. Porter has published more than a dozen books on psychiatry and madness alone. That he managed to accomplish all of this before his early death at age fifty-five makes his achievement even more impressive.
Charles E. Rosenberg is a professor of history at Harvard University, a fellow of the American Academy of Arts and Sciences, and a past president of the AAHM and Society for the Social History of Medicine. He has written or edited more than a dozen books and numerous articles on medical and psychiatric issues.
Andrew Scull is a Princeton-educated academic who currently is the chair of the Department of Sociology at University of California, San Diego. He has published many books on the history of madness, is a recipient of the Guggenheim Fellowship, and was the president of the Society for the Social History of Medicine.
Finally, Edward Shorter, a professor of medical history at the University of Toronto, has also written several books on psychiatric history, the best known being the 1997 work, A History of Psychiatry. In addition to these principal historians, we will reference other scholars who have contributed to the writing of psychiatric history.
The field of psychiatric historiography, that is, the history of psychiatric history, is reported to be “passionate, partisan and polemical” (Micale & Porter, 1994, p. 3). Yet, despite this implied diversity of perspectives, we believe that most historians of madness accept that what is contained within the category of madness is best understood as a form of illness. That term usually is understood as medical, and some historians fully accept that madness is brain disease. However, because the term illness may be vague, its use provides wiggle room for historians who are unsure whether madness is physical disease, but nevertheless feel that “mental illness” is real illness in some sense. This strategic use of the term illness biases either weakly or strongly their presentation of the historical “facts” regarding madness. For example, Andrew Scull—in a rebuttal to a psychiatrist’s attack that he, Scull, considers madness “merely a literary or a philosophical concept”—responds thus:
If I am less inclined than Dr. Crammer to concede that the definition of madness as illness is a pre-social, “natural” feature of the universe, and instead regard the boundaries of what constitutes insanity as labile and greatly influenced by social factors, that is not at all the same thing as the assertion that “mental illness” is some sort of literary or philosophical conceit. (Scull, 1995, pp. 387–388)
Scull’s viewpoint is based, he writes, on the fact that “like many lay people I . . . unfortunately have first hand experiences of the ravages of mental disorder on those near and dear to me” (p. 387). Scull is an important historian who has through his careful scholarship exposed some of the most egregious acts of terror and coercion in the field of psychiatry. He appears to consider madness an illness but is not ready to declare that such an illness is a “natural feature of the universe,” leaving us, his readers, confused. Is madness to be considered a medical disease like any other? If not, how should his general readership think of it? Since most contemporary laypeople (with whom he identifies himself in the second quote) think of mental disorder as a medical problem, his undefined use of mental illness and mental disorder will resonate medically to many of them.
Some of our historians narrate the history of psychiatry as a triumphal progress through time. In their accounts, primitive ignorance eventually gave way to the development and implementation of a scientific psychiatry through the key “discovery” that troubling and disturbing behaviors are medical diseases (Deutsch, 1967, pp. 517–518). Other historians take a more cautious position, believing that “the history of our responses to madness . . . is . . . far from being a stirring tale of the progress of humanity and science” (Scull, 1993, p. xvii). Finally, perhaps alone among those publishing psychiatric history, Thomas Szasz (1920-2012), a psychiatrist himself although his own psychotherapeutic practice never relied on medical interventions, attempted to delegitimize psychiatry as a medical enterprise. He consistently maintained that psychiatry was not a medical discipline to heal sick people but a unique policing profession. Szasz was often dismissed or excoriated by his psychiatric contemporaries for arguing that the societal response to madness (including the medical management of madness in all its guises) is primarily a political, legal and moral endeavor. His works develop in great detail the notion that the metaphors of medicine served to convert state-supported policing activities of socially disturbing behavior into medical interventions for a public health menace (Szasz, 2007).
These differing accounts of madness and its psychiatric management expose as naïve the idea that psychiatric history proceeds by reporting the cold, hard facts and nothing but. In their book, Discovering the History of Psychiatry, Roy Porter and his co-editor Mark Micale write that “both empirically and interpretively, extant histories of psychiatry reveal a vastly greater degree of difference among themselves than historical accounts of any other [medical] discipline” (1994, p. 5). Over time, they argue, organic medicine has demonstrated dramatic scientific advances in its understanding of the nature and etiology of disease, but mental/psychological medicine has failed to provide a similarly unified explanatory framework for its targeted problems (see Micale and Porter, 1994, ch. 1).
Psychiatry is the sole medical specialty lacking physiological validation for any of its particular entities, including all the serious and persistent mental disorders (Kupfer et al., 2002). Thus, in our view it remains an open question whether the psychiatric profession is treating medical diseases, such as diabetes or heart failure (entailing impersonal pathophysiological processes), or instead responding to the moral and behavioral anguish of individuals failing in the game of life as Szasz and a few others argue.
The various historical texts referenced in the present chapter, while occasionally documenting this ambiguous ontological understanding of madness, nevertheless routinely employ medically-impregnated language to tell their stories. Expressions such as lunatic, lunacy, crazy, chronic mental illness, severe and persistent mental illness, mental illness, psychosis, insanity, the insane, psychotics, mental medicine, psychiatry, psychological medicine, mental disorder, disorder, mental disease, and disease are used frequently and interchangeably throughout this literature. The habit of comingling words that are prone to ambiguous interpretations, such as insane, crazy, or illness, with others that also have more formal medical definitions in contemporary medicine, such as disease or psychosis, has consequences. As Scull suggests, “The concepts which we use to delimit and discuss any particular segment of reality inevitably colour our perceptions of that reality” (1993, p. 376). We think that the terms that many historians have adopted in their books have a medical bias.
Micale and Porter’s own characterization of the medical field’s activities toward mad behavior as “mental medicine” exemplifies some of these conceptual difficulties. Regardless of the empirical reasons for using the phrase mental medicine, when two distinguished historians matter-of-factly use such terms it affects readers’ understanding. Are readers to think that the authors are naming and circumscribing a formal domain of medicine, or is the phrase meant as a literary flourish? If intended formally, do Micale and Porter mean that mental medicine should be held to the same scientific criteria and methodology as the other domain they identify as organic medicine? If meant metaphorically, should not the metaphorical nature of the expression be pointed out? Their essay does not provide answers to these questions, and the authors also employ expressions such as psychological medicine, further adding to the possible confusion.4 It would help if Micale and Porter had explicated their claim that psychological medicine is “[p]oised precariously between the medical sciences and the human sciences” (1994, p. 5).
As philosopher Murray Turbayne tell us in his important book The Myth of Metaphor (1970):
[w]e tend to forget that there are many subjects that we speak of only in metaphors . . . for example mind and God. The histories of the sciences of psychology and theology record . . . the unending search for the best possible metaphors to illustrate their unobservable subjects. . . .We find later theorists objecting to earlier metaphors that . . . have become obsolete. We find them substituting new metaphors for old ones that are either worn out by over-use or that present an unappealing picture. But we also find many of these theorists writing as if they were replacing false accounts of these subjects by true accounts, or as if they were replacing metaphorical accounts by literal accounts. (p. 96)
Political scientist Kenneth Minogue argues that certain words and phrases can effectively give the impression that mere opinions possess more empirical certainty and stability then they actually do because of the power of their metaphorical imagery. He identifies these terms as “perceptual metaphors” (1985, p. 141). For example, when watching people, we do not, using our senses, directly perceive the complex content suggested by the terms lunacy, madness, disease, or illness; instead we see physical behavior (such as rocking, pacing, screaming, staying immobile) or hear reports and complaints of discomfort (claims of feeling light-headed, feeling pain, seeing unseen beings and things, receiving verbal commands to commit harm to self or others) or view signs of physiological processes (hot forehead, abscess, swollen abdomen, rash, and so on).
In order to make sense of these observations, we rely on perceptual metaphors such as disease, madness, or illness to package and mold them. In choosing to attach the word disease to a set of perceptions that otherwise would be viewed as disturbing or offensive behavior, we are “implicitly claiming a conclusiveness which has not [necessarily] been demonstrated” (p. 141). And we are also notifying our audience that we expect them to perceive disease too. Thus, the use of expressions like “mental disease” or “mental illness” for describing in historical texts certain ideas or behaviors thought (by some) to be in some way abnormal or disturbing is not a neutral act. In the absence of an explicit clarifying statement by the author (i.e., “disease is here being used metaphorically”), these terms cannot but put their audiences into a medical state of mind or evoke medical conditions because most people have been taught and redundantly reinforced throughout their lives to associate those terms with medicine. If they omit such clarifications, historians may promote a medical interpretation even when striving for neutrality. (The analysis to follow in no way should be seen as a condemnation of these scholars as inept or incompetent. In fact, we have a great deal of professional respect for most of them and their painstaking scholarship, on which we rely in the present book. It is precisely because of their fine work on unearthing the available historical record that we think they should be more cautious in their use of metaphors.)
To make our point more explicit, we would like to further examine some of the work of Andrew Scull. We selected him because we admire his overall analysis of the historical plight of the mad. We use his work to make the point that even the most able and critical psychiatric historians may inadvertently promote a medical perspective. In The Most Solitary of Afflictions, Scull (1993) discusses the sad condition of one group under the purview of the modern mental health care system whom he characterizes as “younger psychotics” (p. 391). Psychosis can be the direct result of organic diseases like dementias, stroke, brain tumors, infections, and chemical overdoses, but the term is also applied to individuals who act quite strangely in the absence of any organic cause. Scull, however, offers no assistance in his text as to how he intends his readers to understand these “younger psychotics.” (Should they be considered diseased or distracted?) He writes:
Psychiatrists and other social control experts . . . negotiate reality on behalf of the rest of society. Theirs is preeminently a moral enterprise . . . I would argue that . . . the boundary between the normal and the pathological remains vague and indeterminate and mental illness . . . an amorphous all-embracing concept. Under such conditions, there exists no finite universe of “crazy” people. (pp. 391–392)
Scull in this passage seems to support the notion that psychiatry arbitrarily constructs mental illness as a way to conceptualize, respond, and control marginalized social dependents, and that the enterprise may have no logical limits, resting on an “all-embracing concept.” But in an earlier section of the book, while criticizing Szasz’s alleged position, he avers, “I cannot accept . . . that mental alienation is simply the product of arbitrary social labeling or scapegoating, a social construction tout court” (Scull, 1993, p. 5). What does Scull think mental alienation is the product of? In an earlier article, he includes a long note about the problem of using conventionally available terms that smack of a medical perspective, such as mental illness, when trying to write more or less neutrally about madness for a diverse audience. After explaining in some detail why there is no good way out of the dilemma, he concludes that “[f]aced with this problem, I have chosen to refer almost interchangeably to madness, mental illness, mental disturbance and the like” (Scull, 1990, p. 307, note 1).
Ordinarily, this would do. But Scull’s note does not just contend that the terms madness, mental illness, mental disturbance, and the like do not have generally agreed-upon definitions and thus may be in some sense interchangeable metaphorically. He also asserts that madness itself, despite its ill-defined names, is real. He maintains, “To recognize that, at the margin5, what constitutes madness is fluctuating and ambiguous . . . is very different from accepting the proposition that mental alienation is simply the product of . . . social labeling and scapegoating” (p. 307, note 1, italics added). Moreover, Scull believes that accepting mental illness as a socially-constructed reification would be denying the many visible negative outcomes associated with the problematic behaviors the mad engage in. Perhaps he is arguing that, for him, madness, when he calls it mental illness, is just another term for certain extremely troubling or troubled behavior that has dire consequences both for the person and others close to the person, and not, as often assumed by the laity, a medical problem. (It is hard to know unambiguously what kind of reality mental illness is for Scull.) Moreover, perhaps “younger psychotics” is referring not to medically ill individuals but to young people who have been waylaid by life’s exigencies and have been the victims of the failure of our social welfare safety net. If that was Scull’s intent, it might have been more useful to spell that out rather than resort to terms that have been associated with the medicalization of deviant behavior (on medicalization of deviance, see Conrad & Schneider, 1992) and therefore easily misunderstood as medical. He depicts the mad as the recipients of “the enormity of the human suffering and the devastating character of the losses” (Scull, 1990, note 1) resulting from madness. He suggests that the mad are therefore the “victims of this form of communicative breakdown” (note 1)6.
A few pages after the explanatory note, he goes on to refer to some of the severely troubled individuals he is concerned with as “chronic schizophrenics” (1990, p. 309). The use of that term usually indicates, at least in psychiatric literature, individuals who are suffering from what is asserted to be a medical disorder, schizophrenia (APA, 2000). Scull, in his role of psychiatric historian, is presumably using the term in the same way. His colleague Gerald Grob, based on his reading of Scull, also contends that Scull “accepts the reality of mental disorders” as a medical issue (1994a, p. 274). For our part, we would characterize Scull’s view as ambiguous, since as far as we know he has published no explicit statement of his position on the matter, even while continuing to discuss “those afflicted with the most serious of mental ills” in his latest work (Scull, 2011, p. 124).
Even careful scholars who are generally critical thinkers have a tough time maintaining judgmental neutrality when it comes to inexplicable human behavior and use terms in their works that have powerful medical connotations (e.g., chronic psychotics, schizophrenics, disease). This may be done by some authors because the words provide a congenial explanation of mad behavior. By other authors, medical language may be used to avoid implying any deliberate intention or moral agency on part of the “sufferers.” Others, on the other hand, may try to uncover a “method to madness,” revealing the possible intention, moral purpose, and explicit goals to someone’s “mad” behavior. All these efforts involve situating the madman within his context and circumstances, explicating the madman’s point of view, and the reactions of those around the madman and their points of view. This is historical work par excellence and of course has been attempted (Porter, 1987a), but when it has, we think that it makes it extremely difficult to account for psychiatry’s development as a profession learning to identify and treat diseases. Finally, using medical connotations may be done to ensure that one’s work is published without too much difficulty.
One further complication is these historians’ reticence to make explicit their own beliefs about madness. According to one younger historian, such reluctance may exist because “autobiography risks functioning as a ‘subversive supplement’ to the author’s scholarship, in that it can expose personal commitments and experiences which undermine professional authority” (Engstrom, 2000, p. 423). The reluctance is completely understandable, but some textual exploration can easily identify the personal biases that, left unexamined and uncontrolled, may slant these histories toward a medical perspective. Let’s turn to them next.
Roy Porter in his Brief History of Madness claims that “the . . . historical survey [of madness] which follows . . . rests content with a brief, bold and unbiased account of its history” (2002, p. 4, italics in the original). The use of unbiased seems calculated to reassure readers that he produces narratives of historical facts as he finds them, with no worrisome distorting assumptions attached. But, in a publication written some twenty years prior, Mind-Forg’d Manacles, he admits that he “necessarily” makes assumptions regarding the nature of madness/insanity (1987b, p. 15). Madness, according to him, is best treated “like heart-failure . . . as a physical fact; but . . . interpret[ed] like witchcraft . . . principally as a socially constructed fact” (p. 15). Porter wants us to think of insanity both as a “personal disorder (with a kaleidoscope of causes, ranging from the organic to the psychosocial) and . . . [as] also articulated within a system of sociolinguistic signs and meanings” (p. 16). The labeling of insanity as “personal disorder” is strictly Porter’s own invention, and we cannot tell if by it he is referring to an organic disease (he offers no references in the text supporting the substance of his claims) or something else altogether.
Fortunately, we can get some further insight regarding Porter’s beliefs in a later, edited work, A History of Clinical Psychiatry (1995). He and his co-editor, psychiatrist German Berrios, address the issue of the organic bases of madness in their introductory chapter. They write that psychiatric historians can make useful contributions to clinical psychiatry by “building on the belief that mental disorders are complex and distorted reflections of dysfunctional brain sites and states” (Berrios & Porter, 1995, p. xviii, emphasis added) to establish which past socially mediated descriptions of mad behavior can “validly” be mapped to certain abnormal biological processes and which cannot. So Porter does appear to believe that madness has a physical basis and that history can help point out what aspects of past societal labeling of disturbing behavior represents real biological illness and what “‘psychiatric phenomena’ were noise” (p. xviii). But this belief in the biological underpinnings of mental disease is just that, a belief—as Porter is careful to state. Porter’s amalgamated medical definition of madness as a condition resulting from brain and/or psychosocial abnormality and processed through a cultural and semantic filtering system is shared by most of our other historical sources as we shall see.
Albert Deutsch presumes that mad behavior is mental disease, even if early man was lost in myth and magic to explain it. His book, originally published in 1937, The Mentally Ill in America (1967) consists of his distillation of much historical material through the medical sifter. As he asserts, “it is safe to assume that mental disease has always existed among mankind” (p. 2), and, “[t]he conquest of schizophrenia . . . will surely rank among the greatest of medical triumphs when it is accomplished” (p. 506). The reality of mental disorder entities is never doubted; he simply equates madness with mental disorder as he tells us that “[i]n early Greece, as in Egypt, mental disorders were looked upon as divine or demoniacal visitations” (p. 5). As the best example of mental disorder in ancient Greek mythology, Deutsch offers the inflicting of madness on Hercules by the goddess Hera. This problem, Deutsch claims, “today would be diagnosed as epileptic furor” (p. 6). Nonetheless, like every other psychiatric historian, Deutsch also admits, despite his commitment to madness as disease, that “[a] mantle of mystery still hangs over a large area of mental disorder [although] . . . researchers . . . are striving manfully to tear apart this mantle, to bring light upon the nature of mental disease” (p. 518).
Another historian, Norman Dain, developed his classic book detailing the evolving historical Concepts of Insanity in the United States (1964) while working for three years as the research assistant to Eric T. Carlson, the associate attending psychiatrist at the Payne Whitney Psychiatric Clinic of New York Hospital (Dain, 1964). In it Dain states, “[o]f course even today no one understands the biology and chemistry of mental illness” (p. 207), but he never seems to question the appropriateness of assuming that the human problems he is describing are to be understood as mental illnesses. He regrets that most people still do not see that mad people are really “sick and helpless” (p. xii) and sees his job in Concepts of Insanity as explicating “the problems that confronted Americans in their early efforts to discard unscientific and unduly pessimistic attitudes and to place insanity under the aegis of medicine” (p. xii).
More recently, the Canadian historian Edward Shorter, among contemporary psychiatric historians perhaps the most committed believer in psychiatric disorder as brain disease, was asked if he believed that “clinical depression” was an organic illness. He responded: “Yes, I believe depression is caused by some kind of brain process. It’s a disease that is in a way just as organic as mumps or liver cancer” (Shorter, n. d.). This belief directs his presentation of historical data. In his often-cited book, A History of Psychiatry, Shorter, relying on his academic authority, states unequivocally that “[i]f there is one central intellectual reality at the end of the twentieth century, it is that the biological approach to psychiatry—treating mental illness as a genetically influenced disorder of brain chemistry—has been a smashing success” (1997, p. vii).
His uncritical commitment to the reality of biological causes of psychiatric diseases is illustrated by his discussion in A History of Psychiatry concerning the increases in the frequency of certain psychiatric illnesses during the nineteenth century. He names “in particular neurosyphilis, alcohol psychosis and . . . schizophrenia” (Shorter, 1997, p. 49). But the facts are that neither of the first two is a psychiatric disease. Neurosyphilis is a neurological disease with behavioral correlates, a brain infection caused by the bacteria Treponema pallidum, if untreated leading to death. Alcohol psychosis is caused by toxic chemical poisoning: either too much alcohol consumption or sudden withdrawal from it. The historical record is clear that both these physiological disease processes, along with a few others, were analogically applied by nineteenth-century mad-doctors to explain the phenomena they came to call schizophrenia (see especially Boyle, 2002). About the latter, some anonymous wit famously said that “unlike neurosyphilis it is a disease where the treating psychiatrists perish before the patients do.” Shorter’s silence concerning the hard empirical evidence for the reality of the first two entities and the absence of such evidence for schizophrenia (though he lumps all three together as “mental diseases,” having been demonstrated as biological diseases) can only be attributed to political calculation, not scientific judgment. What would be needed from him as an honest historical broker are the scientific facts of the matter both pro and contra, from the historical record, regarding schizophrenia. The current DSM states explicitly that “no laboratory findings have been identified that are diagnostic of Schizophrenia” (APA, 2000, p. 305). Of course Shorter knows this, as he explains in a later work when he concedes that “so little is understood about the underlying causes of psychiatric illness. Not having a solid ‘pathophysiology’ or understanding of the mechanisms of disease, psychiatry cannot rigorously delineate disease entities on the basis of anatomical pathology, as other medical fields do” (Shorter, 2005, p. 9).
The previously identified Gerald Grob is possibly the most well-known American psychiatric historian. In an extended footnote found in his 1983 book, Mental Illness and American Society, he argues forcefully that the psychiatric definition of mental illness is not fundamentally different from the medical definition of disease (pp. 35–36). Grob implies that they are both appropriately subject to medical knowledge and medical authority. Yet, in the ultimate paragraph of that footnote he admits candidly:
In fact, we know relatively little about what is designated as mental illness, and that makes it difficult to prove or disprove its existence. . . . Assertions about the existence or nonexistence of mental illness represent in large measure acts of faith which reflect commitments to a particular course or courses of action. (p. 36)
This fence-sitting allows Grob’s early writings to be variably interpreted by his readers, depending on their own individual predilections, while promoting his standing as an objective historian of mental illness.
In his 1998 presidential address delivered to the American Association for the History of Medicine, Grob states that “psychiatrists are compelled to deal with individuals whose pathologies are rarely clear cut and certainly never simple. Severe and persistent mental disorders—like cardiovascular, renal and other chronic degenerative disorders—require a judicious mix of medical and social support programs” (Grob, 1998, p. 213). This address is an apparently nuanced discussion of a type of difficult health problem. One could miss the use of perceptual rhetoric and metaphors (severe and persistent mental disorders—like cardiovascular disorders) to both define and frame his arguments. Although Grob knows that mental disorders are without any of the physiological markers of the biological diseases, he still analogizes the “severe and persistent mental disorders” to biological diseases.
This medical inclination did not necessarily result from Grob’s historical research but rather from his personal experiences. As he notes in his Mental Illness and American Society, “I would be less than honest if I did not speak of some personal views which undoubtedly influence my understandings of the past” (1983, p. xii). In preparation for the writing of his first psychiatric history, Grob attended Worcester State Hospital’s training, provided to its psychiatric residents. This instructional opportunity allowed him to become familiar with clinical cases and institutional life at least as portrayed by those running the institution. He writes that his experience “with severely and chronically mentally ill patients led me to reject many social control and deviance theories and reflexive anti-psychiatric thinking” (Grob, 1994a, p. 270). He admits that receiving instruction from psychiatrists at a mental hospital regarding patients “posed a risk of accepting conventional psychiatric claims at face value” (p. 270), but says that he was able to maintain at least partial distance from these beliefs. This is belied, however, by his use of conventional psychiatric labels to describe the inmates and their problems at Worcester State Hospital. It is worth noting that while Grob used his mental hospital experiences to accept the reality of “severe and persistent mental disorders” and to reject social control and deviance theories that conflict with such an understanding, the sociologist Erving Goffman used similar experiences while conducting ethnographic research within St. Elizabeth’s Hospital to develop the very theories that Grob rejected (Goffman, 1961).
In his later work Grob has more explicitly “come out” and committed himself to the mental illness as medical/brain disorder assumption and compromised his scholarly objectivity by getting involved with the highly politicized process of federal health-care policy. A 2006 article on mental health policy coauthored with a prominent academic psychiatrist, Howard Goldman, presumably expressing their joint views, defines mental illness according to the US Surgeon General’s Report on Mental Health (US Department of Health and Human Services, 1999). The article quotes part of that report, as follows: “Mental illness is the term that refers collectively to all diagnosable mental disorders. Mental disorders are health conditions that are characterized by alterations in thinking, mood, or behavior . . . associated with distress and/or impaired functioning” (p. 738). The surgeon general’s report adds that all diagnosable mental disorders are contained in the Diagnostic and Statistical Manual of Mental Disorders IV (1994) (DSM-IV) and claims that they are all brain disorders even though the report recognizes clearly that no physiological markers are yet identified for any of them (1999, ch. 1).
Finally, Charles E. Rosenberg is an eminent medical historian who generally tends to be judicious in maintaining an agnostic perspective toward “the particularly ambiguous status of hypothetical ailments whose presenting symptoms are behavioral or emotional” (Rosenberg, 2006, p. 408). Nevertheless, in Our Present Complaint (2007), he states that “[m]ost of us would agree that there is some somatic mechanism or mechanisms . . . associated with grave and incapacitating psychoses” (p. 39). This statement commits him to a disease model based on biopathological mechanisms for at least these psychoses. He indicates in the quote above, however, that he is skeptical of the more general trend to convert (medicalize) other behavioral deviance (i.e., homosexuality, alcoholism, or hyperactivity—see his chapter 3) into disease entities. He neglects in this otherwise critical, thoughtful, and well-documented book to tell readers why grave and incapacitating psychoses, most probably schizophrenia would be one, should have such mechanisms credited to them, lacking any current evidential support. (See, for example, APA, 2002, pp. xviii–xix, and other discussions throughout this book, especially chapters 5, 6, and 7).
Language is the filter through which public knowledge is communicated. The use of certain key words and not of others by recognized experts lubricates the expectations of audiences about how a social problem may best be understood. The consistent use of medical labels like mental illness, mental disorder, and mental disease by psychiatric historians as substitutes for the older descriptors madness or insanity tends to reify the view of madness as medical disease.
Many of these historians’ semantic choices seem to be related to their personal belief or inclination that mental illness is a real medical entity or process. That belief confuses replacing an old metaphor by a new one with progressing from unscientific beliefs to scientific facts. Since, at best, the nature of madness is as yet unclear—disease or derangement?—we think it would be better if psychiatric historians would tell their stories by using more ontologically neutral terms, although we recognize the metaphorical nature of language. These terms could include: aggression, agitation, anguish, behavioral disorderliness, defiance, demoralization, derangement, distraction, hopelessness, sadness, severe emotionally distress, stress. Historians should more closely endeavor, as some do, of course, to contextualize to the fullest extent possible the phenomena that they are attempting to describe by means of historical records. By using neutral terms in their narratives without prejudging what has been discovered and scientifically established, historians would signal to their audiences that they are also groping, like other informed citizens, though they are giving us information to come to our own deeper understandings.
The use of these neutral words would not and should not prevent historians from presenting accurately and completely the views of all historically important figures, including those who use(d) medical terms and theories to “explain” madness. If any historian believes that madness is mental illness, that historian should reveal that, so the reader may be fairly and properly put on notice, just as a believer in phlogiston should put readers on notice when presenting a history of physics or a believer in the divinity of Jesus should put his readers on notice when presenting a history of Judaism.
The determination of historical facts is always an ambiguous process, depending on a particular historian’s personal beliefs, agenda, and decisions regarding what evidence to attend to and to ignore in constructing a narrative. (As authors of this book, this insight also applies to our work and we take up this issue of our own personal or professional biases in the concluding chapter.) As Engstrom suggests, “the conceptual frameworks we have for thinking about mental anguish are (and likely always will be) woefully inadequate. That’s what the history of psychiatry has taught me” (E. J. Engstrom, personal communication, October, 9, 2008).
While keeping in mind caveat lector, due to the inevitably fallible nature of our historical facts, we can conclude that our brief historical tour of the phenomena called madness and its overall management has brought us close to where we began. The ontological status of madness remains unsolved in the twenty-first century. Both coercion and concern have periodically animated society’s treatment of the mad, sometimes concurrently. Early on in America’s history, families took care of their distracted relatives. As the US became a more economically specialized and politically organized society, the need for bureaucratic structures for social management became more pressing. The increasing population and urbanization of America led to a more mobile populace, leaving fewer families intact to take care of mad relatives. These circumstances led to the creation of institutional substitutes to provide care for these dependents. Simultaneously and in response to these developing institutions, a class of professional helpers emerged who claimed special expertise in the management of the mad. These helpers at first were lay managers using more or less authoritarian moral treatment, but over time physicians became interested in the mad trade and offered medicalesque reasonings and medical analogies for why the mad were mad, and society was persuaded. These physicians, however, offered no evidence to confirm their reasonings. By the mid-nineteenth century, state governments were gradually taking charge of mental institutions, which were increasingly medicalized. Government involvement accelerated through the twentieth century with the federal government taking control from the states by the 1950s. Over the next two decades, the federal government, psychiatric professionals, various interest groups, and Big Pharma formed an interlocking directorate that managed, through political action rather than scientifically informed strategy, to shift much of the location of mad treatments from a few very similar, distinct, and clearly identifiable walled institutions to a plethora of dissimilar, diverse, and dispersed institutions in “the community.” This well-coordinated enterprise controls the research agenda as well as the policy development in mental health today.
In Shakespeare’s time, when it came to understanding madness one could only offer a tautology. Madness was defined as being nothing but mad. Today we are left not exactly with a tautology, but with a mystery. The modern term for mad behavior is the medically encapsulated notion of mental illness, but that term really refers to many different hypothesized syndromes, most of which the DSM calls mental disorders. The term mental illness is a black box. The medically-oriented argue that these syndromes are brain diseases, Thomas Insel, the NIMH’s director, speculates that “abnormal activity in specific brain circuits” are the causes of mental illnesses. Unfortunately, after a hundred years of these hypotheses, not a single biological marker for a single psychiatric disorder has been identified to validate distress and misbehavior as a medical disease.
Insel and other psychiatric authorities (Andreasen, 1997) reassure the public, despite their continual inability to provide the evidence, that if the public is just patient for a little while longer and holds on to the descriptive DSM syndromes, diagnostic lesions underling these syndromes will definitely be identified in the not too distant future, initiating a psychiatric utopia—one in which psychiatric science will deliver specific cures for our behavioral problems. Despite the failed promises, very few people seem to be exploring alternative ways to understand and address madness.
If one accepts philosopher Karl Popper’s view that doing good science requires submitting one’s most cherished paradigms and viewpoints to rigorous empirical tests and criticism to see if they stand up to such scrutiny (Popper, 1989), then at least one important use of historical knowledge becomes evident. By examining the historical record (even with all its limitations), one can learn about the many “scientific” psychiatric paradigms and treatments that have regularly failed (e.g., the nineteenth-century asylum system, moral treatment, and the government-operated state mental hospital system). These failures suggest that all interested persons should be skeptical of the current conventional wisdom regarding madness because this may, under conceptual and empirical examination, also prove to be mistaken.
Keeping both these cautionary and hopeful concluding thoughts in mind, let us turn to the current best efforts at managing the mad: community treatment.
1.We tend to agree with Tom Szasz that the better term for the coercive paternalistic approach used by most psychiatrists is the pediatric model, since “(t)ypically physicians treat adults who seek their services. Only pediatricians and psychiatrists treat persons who do not seek their services” (Szasz, 2004, p. 323). But due to its widespread use, we will continue for the sake of expediency to refer in the rest of the book to this unique patronizing model relying on force for servicing mad adults as the “medical model” (to be explicated in more detail in chapter 3).
2.This unchaining is a complete fabrication (see Scull, 1993, p. 377, especially note 4).
3.To clarify what may sound unsympathetic or accusatory: we believe that, when facing difficult or traumatizing life circumstances, wanting to escape is a quintessentially human response. We even have descriptive terms at the ready to identify these possible responses: “heroic” or “cowardly.” How one responds to such circumstances is not knowable in advance, and claiming illness is often one of the obvious options to avoid moral condemnation from self and others. Human beings are capable of fooling themselves as easily as others; it is called “self-deception.” We suggest that the claims of feeling ill often are genuinely held by the claimants and may be just these sorts of self-deceptions rather than necessarily calculated fraudulent deceptions. Unfortunately, feeling as if we are ill in no way establishes that we have a medical illness. We go to doctors in part to help us clarify whether our felt “symptoms” are manifestations of objective physical pathological processes qualifying as medical disease.
4.This is similar to the term behavioral health, whose use in the medical and psychological literature first appeared in the 1970s and dramatically spiked starting in the mid-1990s (see, for example, Google’s ngram using this term). This obvious metaphor appears well-suited for its primary purposes, as far as we can discern them at present: to justify both the involvement of psychologists and social workers in the health care arena and the renewed involvement of physicians in changing patients’ behaviors.
5.This begs the question of what in madness’ “center” as opposed to its margins is invariable and unambiguous.
6.Thomas Szasz would agree but would also add that, as sentient moral agents involved in transactions with others, they are responsible at least in part for the breakdown in communication and their subsequent difficulties. Szasz—who has been described by Micale and Porter in their edited volume Discovering the History of Psychiatry (1994) as “offer[ing] fundamental rereadings of exemplary episodes and topics in the history of mental medicine” (p. 23) worthy of a full chapter in that book—has never asserted what Scull (1993) and many other of his critics claim to be Szasz’s position, namely, that mental alienation is merely the result of social labeling and scapegoating and is a myth. Szasz argues that emotional difficulties and tragedies are real, but result from the minor and serious problems that people experience while trying to make a life, rather than the consequence of biological pathology. He suggested that “[t]o regard ‘minor’ upheavals in living as problems in human relations, learning and so forth—and more ‘major’ upheavals as due to brain disease, seems to be a rather simple example of wishful thinking” (Szasz, 1961, p. 94). In his first and most often cited but rarely fully understood classic, the Myth of Mental Illness (1961), Szasz did not write a polemic full of simplistic claims as Scull asserts (Scull, 2011, p. 100), but rather a detailed and scholarly treatise outlining, as its subtitle states, the “foundations of a theory of personal conduct.” Using a combination of semiotic, rule-following, and game-model analysis, Szasz proposes a theory of human behavior applicable to both the “normal” and “deviant.”
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