Madness: A Brief History (19 page)

And psychosurgery seemed to work. Rescued from crippling agitational states, some lobotomized patients were discharged from institutions and went on to hold down jobs and family roles—becoming, in the classic Adlerian sense, well adjusted. Lobotomy was claimed to be particularly effective at turning the troublesome into ‘quiet, placid, uncomplaining persons who showed little concern about their troubles’—submissive souls who, even if they never achieved institutional discharge, would nevertheless thereafter be model patients.

Psychosurgery and other shock therapies signal the wish of well-meaning psychiatrists to do something for psychiatry’s forgotten patients; they have, in turn, been criticized for being grotesque, quackish, brutal, and hubristic. Invasive treatments equally reflect the powerlessness of patients in the face of arrogant and reckless doctors, and the ease with which they became experimental fodder. In a now notorious experiment, hundreds of black mental patients at the Tuskeegee Asylum in Alabama were guinea pigs without their knowledge or consent in an experiment to test longterm responses to syphilis, a minor echo of the atrocities committed by Nazi psychiatrists.

The chemical revolution

Penicillin was introduced in the 1940s, and in the wake of the antibiotics miracle, great expectations rose for psychopharmacology. Replacing the old standby blank cartridges like bromides and croton oil, and also the dangerous amphetamines widely used in the 1930s, lithium, the first psychotropic (mood-influencing) drug, was introduced in 1949 to manage manic-depression. Anti-psychotic and anti-depressant compounds, notably the phenothiazines (chlorpromazine, marketed as ‘Largactil’—called by critics the ‘liquid cosh’) and Imipramine (for depression) were developed by the research laboratories of drugs companies in the early 1950s. They made it possible for many patients to leave or avoid the sheltered but numbing environment of the psychiatric hospital, and maintain life, under continuing medication, in the outside world. The top British psychiatrist William Sargant heralded the new drugs as a blessed deliverance from the shadowland of the asylum and the follies of Freud— they enabled doctors to ‘cut the cackle’, he crowed, boldly predicting that the new psychotropics would eliminate mental illness by the year 2000. Psychopharmacology certainly brought a therapeutic boost to the psychiatric profession, promising as it did a cost-effective method of alleviating suffering without recourse to lengthy hospital stays, psychoanalysis, or irreversible surgery. It would also promote psychiatry’s wishful identity as a branch of general medicine.

The new drugs enjoyed phenomenal success. The tranquillizer Valium (diazepam) became the world’s most widely prescribed medication in the 1960s; by 1970 one American woman in five was using minor tranquillizers; and by 1980 American physicians were writing ten million prescriptions a year for antidepressants alone, mostly ‘tricyclics’ like Imipramine. Introduced in 1987, Prozac, which raises serotonin levels and so enhances a ‘feelgood’ sense of security and assertiveness, was being prescribed almost ad lib for depression; within five years, eight million people had taken that ‘designer’ anti-depressant, said to make people feel ‘better than well’. Central nervous system drugs are currently the leading class of medicines sold in the USA, accounting for a quarter of all sales. With the immense success of the anti-psychotic, anti-manic, and anti-depressant drugs introduced in the last half of the twentieth century, organic psychiatry is arguably in danger of becoming drug-driven, a case of the tail wagging the dog.

By permitting treatment of the mentally disturbed on an outpatient basis, psycho-active drugs have substantially reduced the numbers of those institutionalized. But problems of side-effects and dependency are perennial, and their long-term effects are necessarily unknown. Major ethical and political questions hang over recourse to pharmaceutical products to reshape personalities, especially when the development, manufacture, and marketing of such drugs lie in the hands of monopolistic multinationals.

Anti-psychiatry and the asylum

Psychotropic drugs seemed to offer hopes of delivery from the asylum problem as psychiatrists in Europe and America grew increasingly critical of the old mental hospitals pitting the landscape. Deficiencies in the day-to-day management of English asylums had long been exposed, ever since the damning indictment of neglect and casual cruelty contained in Montagu Lomax’s
The Experiences of an Asylum Doctor, with Suggestions for Asylum and Lunacy Law Reform
(1921), a sobering work written not by a protesting patient but by a disillusioned doctor. ‘Our asylums detain’, he complained, ‘but they certainly do not cure.’

Not least, the rigid segregation of the sane from the mad which the asylum had implemented no longer seemed to make epidemiological sense. Modern psychiatry came to the conclusion that the greatest proportion of mental disorders was in reality to be found not in the asylum but in the community at large—emphasis was newly falling upon neuroses not severe enough to warrant certification and long-term hospitalization. ‘Gone forever’, insisted the American psychiatrist Karl Menninger in 1956, ‘is the notion that the mentally ill person is an exception. It is now accepted that most people have some degree of mental illness at some time’—cynics might say that psychiatry was thus making a pitch for the entire population.

Attention shifted to ‘milder’ and ‘borderline’ cases, and mental abnormality began to be seen as part of normal variability. A new social psychiatry was formulated, whose remit extended over the populace at large. This dissolving of the divide between sane and insane had momentous practical consequences for custody and care. As attention shifted from institutional provision per se to the clinical needs of the patient, policy pointed in the direction of the ‘unlocked door’ prompting experiments with outpatients’ clinics and psychiatric day hospitals, and encouraging treatments with an eye to discharge. Such developments presaged the end of custodial management as the routine course of action.

The transition took many forms, presided over by many philosophies of change. Some hoped to effect a modernization of the mental hospital from within. From the late 1940s a few English mental hospitals unlocked their doors, and ‘therapeutic communities’ were also set up, units of up to a hundred, in which physicians and patients were to cooperate in the creation of more positive therapeutic environments, which would erode the old authoritarian hierarchies dividing staff and inmates and encourage shared decision-making in a more relaxed atmosphere.

Others demanded something far more drastic, notably the champions of what became labelled as the ‘anti-psychiatry movement’, which won such a high profile in the 1960s and 1970s. Its tenets were varied and controversial: mental illness was not an objective behavioural or biochemical reality but either a negative label or a strategy for coping in a mad world; madness had a truth of its own; and psychosis could be a healing process and, hence, should not be pharmacologically suppressed. What was common to anti-psychiatry, however, was the critique of the asylum. The leading American spokesman Thomas Szasz, as we have seen, exposed
The Myth of Mental Illness
(1961) and
The Manufacture of Madness
(1970), as part of a thoroughgoing critique of ‘compulsory psychiatry’—turning patients into prisoners. The Chicago sociologist Erving Goffman meanwhile exposed the evils of ‘total institutions’ in his
Asylums
(1961). In Italy, leadership was assumed by the psychiatrist Franco Basaglia, who helped engineer the rapid closure of institutions (chaos resulted), while in the Netherlands the glamorous and mystically inclined Jan Foudraine was to the fore in a movement which enlisted the sympathies of students protesting against state and professional power.

In Britain anti-psychiatry’s leader was the equally charismatic Ronald Laing (1927-89), a Glaswegian psychiatrist influenced by Sartre’s existential philosophy. ‘Madness’, he wrote in a characteristic aphorism, ‘need not be all breakdown. It may also be break-through. It is potential liberation and renewal as well as enslavement and existential death.’ In 1965 he established Kingsley Hall, a community (‘hospital’ was avoided) in a working-class East London neighbourhood where residents and psychiatrists lived under the same roof. The latter were to ‘assist’ patients in living through the full-scale regression involved in schizophrenia. A brilliant writer, Laing won a cult following at the time of the counter-culture and student protests against the Vietnam War. Films like
Family Life
(1971) and
One Flew Over the Cuckoo’s Nest
(1975) meanwhile mobilized opinion against gothic asylums and the policing and normalizing roles of psychiatry.

Mainly associated with left-wing politics, antipsychiatry thus urged de-institutionalization. At the same time, and from a wholly different angle, politicians of the radical right, including Ronald Reagan in the USA and Margaret Thatcher in the UK, lent their support to ‘community care’, being hostile to welfarism and keen to cut costly psychiatric beds. As early as 1961 Enoch Powell, the then Conservative British Minister of Health, had announced that the old mental hospitals—-‘isolated, majestic, imperious, brooded over by the gigantic water tower and chimney combined, rising unmistakable and daunting out of the countryside’— should be closed down or scaled down.

Inmate populations were rapidly reduced—in Britain from around 150,000 in 1950 to just a fifth of that number by the 1980s. Whether community care worked, however, was another matter, and public fears were voiced about patient welfare—and the dangerousness of poorly supervised ex-patients.

By the close of the twentieth century, the psychiatric hospital and orthodox Freudian psychoanalysis, both inextricably identified with psychiatry at mid-century, were equally out of favour and on the wane. The West had meanwhile seen, however, an explosive growth in the supposed incidence of a fast-growing profusion of supposed psychiatric conditions—post traumatic stress disorder (PTSD) and repressed memory syndrome being just two amongst dozens. Partly to counter them, there had also arisen a constellation of psychotherapies which had transformed the handling of mental problems through techniques involving group sessions, family therapy, consciousness-raising, sensitivity training, game- and role-playing, and behaviour modification through stimulus and reinforcement. Clinical psychology and cognitive therapy had been born and boomed. These days clinics and techniques for psychosocial problems, sexual dysfunctions, eating disorders, and personal relations continue to proliferate—while prospects are held out of a pill for every psychological ill.

Business as usual

Meantime, mainstream academic and hospital psychiatry remained committed to the programme of describing and taxonomizing the mental disorders stemming from Kraepelin. The
Diagnostic and Statistical Manual
of the American Psychiatric Association—the profession’s diagnostic handbook—was first published in 1952. In 1980, a revised version,
DSM-III,
mapped the following broad categories of mental disorder: disorders of childhood or infancy (hyperactivity, anorexia, retardation, autism); known organic cause (disease of old age, drug-induced); disorders of schizophrenia (disorganized, catatonia, paranoid, undifferentiated); paranoid disorders (without schizophrenic signs); affective disorders (bipolar, major depressive); anxiety disorders (phobias, obsessive-compulsive); somatoform (conversion disorder, hypochondriasis); dissociative (fugue states, amnesia, multiple personality); and personality disorders. The publication in 1994 of
DSM-IV
confirmed the trend away from the psychogenic theories dominant in America a generation before, towards a more organic orientation. It also brought a fresh crop of disorder labels. Indeed, a glance at successive editions of the
DSM
, which requires energetic revision every few years, reveals different, and often incompatible or overlapping, terminologies, coming and going from edition to edition. A notorious postal vote, held by the American Psychiatric Association in 1975, led to the belated removal of homosexuality from its slate of afflictions. It is not only cynics who claim that politico-cultural, racial, and gender prejudices still shape the diagnosis of what are purportedly objective disease syndromes. Most telling of all has been the sheer explosion in the enterprise’s scale: the first edition was some hundred pages;
DSM-II
ran to 134 pages,
DSM-III
to almost 500; the latest revision,
DSM-IV-TR
(2000) is a staggering 943 pages! More people seem to be diagnosed as suffering from more psychiatric disorders than ever: is that progress?

This very brief survey hasn’t attempted to probe the anthropological or social causes of mental illness—of civilization and its discontents; nor has it sought to show the social functions of madness and psychiatry, or to resolve any number of similarly historically impalpable questions. In a far more focused, down-to-earth way, I have concentrated on a narrative of notions of mental illness, and treatments of the mad, since records began.

As the twentieth century dawned, the
British Medical Journal
sounded an upbeat note: ‘in no department of medicine, perhaps, is the contrast between the knowledge and practice in 1800 and the knowledge and practice in 1900 so great as in the department that deals with insanity.’ Not so the specialist—and hence more authoritative
?—Journal of Mental Science.
Pointing in the very same year to the ‘apparent inefficacy of medicine in the cure of insanity’, it seemed depressed: ‘though medical science has made great advances during the nineteenth century, our knowledge of the
mental
functions of the brain is still comparatively obscure.’
Lancet
for its part managed to look in both directions at once, claiming in an editorial in 1913 that only then and belatedly was ‘British psychiatry beginning to awake from its lethargy’.