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Madness in civilisation

2015; Elsevier BV; Volume: 385; Issue: 9973 Linguagem: Inglês

10.1016/s0140-6736(15)60591-8

1474-547X

Andrew Scull,

Historical Psychiatry and Medical Practices

For some time now, I've been at work on a history of unreason. An inescapable part of our shared human experience and of the cultures people have inhabited down through the centuries has been our encounters with those suffering from a loss of reason, people alienated from the commonsense world the rest of us imagine we share, or enduring the shattering emotional turmoil that seizes hold of some of us and will not let go. They have drawn the repeated attention of artists and writers, as well as physicians and divines. Mental illness haunts the human imagination. It challenges our sense of the limits of what it is to be human, and, perhaps as a consequence, the mad have all-too-often been treated as less than fully human. But a question immediately arises: why, in writing a cultural history of insanity in my book Madness in Civilization, have I chosen to speak of madness? Have I not engaged in an ill-mannered resort to a vocabulary at once stigmatising and offensive? Adding to the stigma that has enveloped people affected by mental illness through the ages could not be further from my intent. For psychiatrists, our designated authority these days on the mysteries of mental pathologies, use of the word madness is often seen as a provocation, a rejection of science and its blessings. (Oddly enough, precisely for that reason, madness is a word defiantly embraced by those who vociferously reject psychiatry's claims and resist the label of psychiatric patient, preferring to refer to themselves as psychiatric survivors.) So is my choice of title and terminology perverse, or a sign that, like some influential writers—the late Thomas Szasz, for example—I consider mental illness a myth? Not at all. In my view, madness is a phenomenon to be found in all known societies, one that poses profound challenges of both a practical and symbolic sort to the social fabric, to the lives and happiness of both those affected and their families, and to the notion of a stable social order. The claim that it is all a matter of social constructions or labels is to my mind so much romantic nonsense. Those who lose control of their emotions, whether melancholic or manic; those who do not share the commonsense reality most of us perceive, who hallucinate or make claims about their existence people around them conclude are delusions; those who act in ways that are profoundly at variance with the conventions and expectations of their culture, and are heedless of the ordinary corrective measures their community mobilises to get them to desist; those who manifest extremes of extravagance and incoherence, or who exhibit the denuded mental life of the demented: these form the population that for millennia was regarded as mad, or referred to by some analogous term. I have sought to make sense of the encounter of madness and civilisation over more than two millennia. For much of that time, madness and its cognates—insanity, lunacy, frenzy, mania, melancholia, hysteria, and the like—were the terms in general usage. Indisputably, madness was not just the commonsense word used to come to terms with Unreason, but a terminology embraced by medical men who sought to account for its depredations in naturalistic terms, and at times to treat the alienated. Even the first mad-doctors (for so they called themselves, and were known as by their contemporaries when they began to ply their trade in 18th-century Europe) did not hesitate to use the word, and it persisted in polite discourse, alongside such cognates as lunacy and insanity, almost all the way through the 19th century, only gradually, as with insanity, becoming linguistically taboo. And while such change is difficult to date precisely, one convenient marker of shifting sentiments is the renaming of what previously had been the American Journal of Insanity, which in 1922 became the American Journal of Psychiatry. As for psychiatry, it is a word that did not begin to emerge until the 19th century in Germany. It was fiercely rejected by the French (who preferred their own term aliénisme), and by the English-speaking world, which began by calling medical men who specialised in the management of the people with mental health problems “mad-doctors”. Only later, when the slur embodied in that term came to seem too much, did the proto-profession embrace without a clear preference an array of alternatives, including asylum superintendent, medical psychologist, or, alienist. The one label English-speaking specialists in mental disorders could not abide, and fought against using into the early years of the 20th century (when it finally began to be the preferred term), was psychiatrist. More broadly, the emergence of a self-conscious and organised group of professionals laying claim to jurisdiction over mental disturbance, and obtaining a measure of social warrant for their claims, is largely a phenomenon of the period from the 19th century onwards. Madness is now mostly viewed through a medical lens, and the language preferred by psychiatrists has become the officially approved medium through which most (but not all) speak of these matters. But this is the result of historical change, and in a wider view, a fairly recent development. The creation of such professionals, their language, and their chosen interventions, are phenomena that deserve close scrutiny. But they are not, and ought not to be, my starting place. So I have chosen to speak of madness, a term that even now few people have difficulty understanding. Using that age-old word has the further advantage that it throws into relief another important feature of the subject that a purely medical focus neglects. Madness has much broader salience for the social order and the cultures we form part of, and has resonance in the world of literature and art and of religious belief, as well as in the scientific domain. And it implies stigma, and stigma has been and continues to be, a lamentable aspect of what it means to be mad. If we are to grasp madness in all its dimensions, these are some of the subjects with which to engage. Even in recent times, definitive answers about mental illness remain almost as elusive as ever. The very boundaries that separate the mad from the sane are a matter of dispute. The American Psychiatric Association, whose Diagnostic and Statistical Manual of Mental Disorders (DSM) has achieved global influence, not least because of its linkages to the psychopharmacological revolution, has subjected its bible to seemingly endless iteration and revision. Yet despite these efforts to achieve closure, the DSM remains enmeshed in controversy. Depending upon how one counts, it is now on its fifth or its seventh revision, and the publication of its latest incarnation was delayed by years of wrangling over its contents. After all, despite the plethora of claims that mental illness is rooted in faulty brain biochemistry, deficiencies or surpluses of this or that neurotransmitter, the product of genetics and one day perhaps traceable to biological markers, the aetiology of many mental illnesses remains obscure, and its treatments largely symptomatic and generally of limited efficacy. Life expectancy among people with serious psychoses, for example, has declined over the past quarter century—a reflection in part of the generally poorer overall health of psychiatric patients, but also a telling measure of the gap between psychiatry's pretensions and its performance. In this arena, at least, we have not yet learned how to cut nature at the joints. Those who are inclined to doubt the truth of that last statement, coming as it does from a historical sociologist, might prefer the formulation offered by the Director of the National Institute of Mental Health, Thomas Insel. Speaking before the publication of DSM-5, he questioned how his fellow psychiatrists “actually believe [that the diseases they diagnose using the DSM] are real. But there's no reality. These are just constructs. There is no reality to schizophrenia or depression…we might have to stop using terms like depression and schizophrenia, because they are getting in our way, confusing things”. Insel was not alone. His immediate predecessor, the Harvard neurobiologist and psychiatrist Steven Hyman, described DSM-5 as “an absolute scientific nightmare”. It is important to place these remarks in context. Insel and Hyman spoke as scientists keen to replace descriptive psychiatry with a diagnostic system built upon biological foundations, one that brings together the findings of genetics, imaging technologies, and cognitive science, as well as other potentially relevant realms of knowledge. Although we have some tentative and tantalising clues, in the present state of our knowledge that prescription is something many long for, but cannot yet provide. Like the poor folks waiting for Godot (who, as it happens, were waiting for a madman), we are still waiting for those long-rumoured neuropathological causes of mental illness to surface. It has been a long wait. The metaphysical wager that much of western medicine embraced centuries ago, that madness had its roots in the body, has in many respects yet to pay off. Perhaps, it never will in its entirety. The social and the cultural dimensions of mental disorders, so indispensable a part of the story of madness in civilisation over the centuries, are unlikely to melt away, or prove to be nothing more than epiphenomenal features of so universal a feature of human existence. Madness indeed has its meanings, elusive and evanescent as our attempts to capture them have been. It remains a fundamental puzzle, a reproach to reason, inescapably part and parcel of civilisation itself.