Laing, R. D. The Divided Self: An Existential Study in Sanity and Madness. New York: Penguin Books, 1990.

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R. D. Laing writes in the preface of this book that his is “a study of schizoid and schizophrenic persons” with the basic goal of making “madness, and the process of going mad, comprehensible” (p. 9). At the outset, Laing uses diagnostic language that is familiar to every psychiatrist and psychoanalyst. Terms such as psychotic, schizoid, schizophrenic, and paranoid proliferate this book. Yet this is not a psychiatry text. Laing argues that psychosis is not a medical condition, but an outcome of a “divided self,” or the tension between the two personas within us: one our private, authentic, real identity and the other the false self that we present to the world. Talking in the language of existential philosophy and phenomenology (which makes this a bit of a difficult read), Laing focuses on what psychosis is like for the patient. He seeks meaning in psychotic experiences and attempts to understand them from the point of view of the patient.

Laing sets of his theory of schizophrenia with the overall aim of explaining that psychosis is a reaction to an intolerable external world. He develops the concept of “ontological insecurity.” He describes this as an indefinable feeling of something lacking for an individual and a primary disturbance of the self. According to Laing, this ontological insecurity is at the root of schizophrenia. At the inner core of a person is their self. The self is in the world and relates to the world by means of its body. Most people, most of the time, feel safe in their world. Laing refers to this as “primary ontological security.” However, for some individuals, this security becomes an ontological insecurity in that they feel persecuted by reality itself. An individual becomes concerned with preserving themselves. Their fear of their own dissolution into non-being and non-existence becomes so great that the self becomes dissociated from both its own body and from the whole external world of people and events. It is therefore unable to have a direct relationship with others and it instead relates to objects of its imagination and memory. Its own bodily experiences and actions become foreign, part of a false self system. The false self arises in compliance with the intentions or expectations of the other, or with what are imagined to be the other’s intentions and expectations” (p. 98).

[The false self] consists in acting according to other people’s definitions of what one is, in lieu of translating into action one’s own definition of whom or what one wishes to be. It consists in becoming what the other person wants or expects one to become while only being one’s “self” in imagination or in games in front of a mirror. In conformity, therefore, with what one perceives or fancies to be the thing one is in the other person’s eyes, the false self becomes that thing (pp. 98-99).

Laing argues that individuals who have their real self undermined during childhood will go on to develop a false self to interact with the world. These individuals are then at risk of developing psychosis when, under pressure, the real self dies and the false self becomes overwhelmed and is no longer able to cope. The outsider, estranged from herself and society, cannot experience herself or others as real. Therefore she invents a false self and with it she confronts both the outside world and her own despair. The disintegration of her real self keeps pace with the growing unreality of her false self until, in the extremes of a schizophrenic breakdown, the whole personality disintegrates.

Laing backs up his theory with clinical vignettes and patient histories of schizophrenic individuals. The existential lens through which he views patients is a supremely personal way of looking at people. It is like saying of the schizophrenic one is examining: “this person is not a sick person, this person is like me.” And it is this “like me” factor that makes it possible to understand and empathize with the schizophrenic. Instead of looking at clusters of symptoms, Laing seeks instead to actually talk to patients and to listen to what they have to say. These patients tell stories of their lives, their experiences, and the things that cause them anxiety in everyday life. Laing does not focus on what makes “us” (sane) different from “them” (insane), but instead focuses on what we share in common with each other. I think that is what makes this text so powerful.

For Laing, the profession of psychiatry and psychoanalysis have proven to be a barrier to truly understanding the lives of the mad. Through the use of scientific nomenclature used to classify symptoms, the professionals have alienated us by depersonalizing the odd aspects of people’s behavior. Instead of seeing these people as objects or an illness, we should view them as human beings who live inside their own worlds. What Laing is advocating is for developing a kinder and more humane way of relating to patients. As a result, even though Laing is a psychiatrist, he is highly critical of the discipline of psychiatry in treating schizophrenia and of the standard doctor/patient relationship. It has not always been the case that medical doctors have had reign over the mentally ill. According to Michel Foucault in Madness and Civilization: A History of Insanity in the Age of Reason, it is purely by accident that medical doctors became responsible for treating madness in the first place and it is only recent history that the mad were deemed mentally ill. Historically, people who acted psychotic were thought to be possessed by evil spirits. It was in the seventeenth century in Europe that people began to grow concerned for their safety as crazy people wandered the streets. As a result, they were confined as a means of protection. This lead to the creation of the lunatic asylum. It was Philippe Pinel who argued that the mentally ill should be attended to as sick people in order to humanize their treatment and it was the Madhouses Act of 1774 which saw physicians as the sole arbitrators that determined who was diagnosed as insane.

Laing’s theory of schizophrenia raises some questions. First, Laing suggests that the speech of a schizophrenic patient is intelligible. Laing interprets much of what his patients said as the consequence of disturbed family relationships or as a concealed attempt to retain some of their identity, but it remains unclear whether schizophrenic speech disorders can be explained this way. Second, the few case histories Laing provides hardly qualify as adequate scientific evidence for a theory of schizophrenia. As of today, we still not know what causes schizophrenia or indeed whether what we call schizophrenia is a single disease entity. Since Laing wrote his book we have evidence of genetic factors, structural brain damage, and intellectual dysfunction in schizophrenia, which any adequate theory about the cause and effect of schizophrenia would have to explain. This does not, of course, exclude the possibility that social factors, including the influence of the family, could play a part in such an explanation. But it seems highly unlikely that this is the sole explanation.

Lastly, psychiatrists are privy to aspects of experience which normal life is designed to hide or avoid and it seems worth paying attention to their accounts in our quest for a greater understanding of human nature. Psychiatry attracts dilettantes who read in order to find a solution to their own problems. There is even a term, the “neuronovel” to describe a genre of burgeoning literature narratives that feature protagonists with psychiatric disorders. While the author who coined this term believes that the genre is too pathological for the literary world, I think we ought to embrace it for the insights gleaned from the phenomenological accounts of those who suffer from severe mental illness. If we want our literature and science to inhabit the full measure of the human condition, it must stretch to accommodate new ways of knowing the world.

General Works

Claridge, Gordon, Ruth Pryor, and Gwen Watkins. Sounds from the Bell Jar: Ten Psychotic Authors. Cambridge, MA: Malor Books, 1998.

Foucault, Michel. Madness & Civilization: A History of Insanity in the Age of Reason. New York: Vintage Books, 1988.

Kesey, Ken. One Flew Over the Cuckoo’s Nest. New York: New American Library, 1989.

Porter, Roy. A Social History of Madness: The World Through the Eyes of the Insane. New York: Weindenfekd & Nicolson, 1987.

Bipolar Disorder

Hornbacher, Marya. Madness: A Bipolar Life. New York: First Mariner Books, 2009.

Jamison, Kay Redfield. Touched with Fire: Manic-Depressive Illness and the Artistic Temperament. New York: Free Press Paperback, 1993.

Jamison, Kay Redfield. An Unquiet Mind: A Memoir of Moods and Madness. New York: Knopf, 1995.

Martin, Emily. Bipolar Expeditions: Mania and Depression in American Culture. Princeton: Princeton University Press, 2009.

Whybrow, Peter C. A Mood Apart: Depression, Mania, and Other Afflictions of the Self. New York: BasicBooks, 1997.

Depression

Emmons, Kimberly K. Black Dogs and Blue Words: Depression and Gender in the Age of Self-Care. New Brunswick, NJ: Rutgers University Press, 2010.

Endler, Norman S. Holiday of Darkness: A Psychologist’s Personal Journey Out of His Depression. New York: Wiley, 1982.

Jamison, Kay Redfield. Night Falls Fast: Understanding Suicide. New York: Vintage Books, 1999.

Slater, Lauren. Prozac Diary. New York: Random House, 1998.

Smith, Jeffrey. Where the Roots Reach for Water: A Personal and Natural History of Melancholia. New York: North Point Press, 1999.

Styron, William. Darkness Visible: A Memoir of Madness. New York: Vintage, 1992.

Obsessive-Compulsive Disorder

Wilensky, Amy S. Passing for Normal: A Memoir of Compulsion. New York: Broadway Books, 1999.

Personality Disorder

Kaysen, Susanna. Girl, Interrupted. New York: Vintage, 1993.

Van Gelder, Kiera. The Buddha and the Borderline: A Memoir. Oakland, CA: New Harbinger Publications, 2010.

Psychosis

Cahalan, Susannah. Brain on Fire: My Month of Madness. New York: Simon & Schuster Paperbacks, 2012.

Plath, Sylvia. The Bell Jar. New York: Harper Perennial, 2013.

Slater, Lauren. Welcome to My Country. New York: Random House, 1996.

Wurtzel, Elizabeth. Prozac Nation: Young and Depressed in America. New York: Riverhead Books, 1994.

Schizophrenia

Laing, R. D. The Divided Self: An Existential Study in Sanity and Madness. New York: Penguin Books, 1990.

Nash, Carol S. Welcome, Silence: My Triumph Over Schizophrenia. New York: Avon, 1989.

Saks, Elyn R. The Center Cannot Hold: My Journey Through Madness. New York: Hyperion, 2007.

Sociological Accounts

Goffman, Erving. Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. New York: Anchor Books, 1961.

Whitaker, Robert. Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill. New York: Basic Books, 2010.

Whitaker, Robert. Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America. New York: Broadway Books, 2015.

 

 

 

 

 

 

 

 

 

Goffman, Erving. Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. New York: Anchor Books, 1961.

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The four essays in Erving Goffman’s work Asylums: Essays on the Social Situation of Mental Patients and Other Inmates were published in 1961. The vivid description of institutional life and Goffman’s account of life in a mental hospital may be considered a relic of history now that asylums have been demolished and care of the vulnerable has been transferred to community settings. However, given the reports of poor quality of care in many care organizations, it may be relevant to revisit Goffman and ask ourselves: “To what extent have modern healthcare organizations moved on from the paternalism and bureaucratic control of patients and clients in their care?”

Goffman is thought to have coined the term “total institutions” to express the fact that the rules of everyday life outside no longer have validity for the inmates of psychiatric asylums, prisons, military barracks, and concentration camps. Inmates lack the usual accoutrements of identity: they can no longer control how they dress or how they look, they are stripped of their personal possessions and are given standard institutional clothing and basic items for the purposes of bathing and sleeping. Goffman notes that people come into total institutions with a conception of themselves that is made possible by social arrangements and relationships in their home life. Upon entrance, a person is stripped of that support. The person entering a total institution begins a radical shift in what Goffman describes as that person’s “moral career,” which is a career composed of the progressive changes that occur in the beliefs held about one’s self and significant others.

For Goffman, total (i.e., all-encompassing) institutions are characterized by the bureaucratic control of the human needs of a group of people. He defines total institutions as social arrangements that are regulated according to one rational plan and that occur under one roof. The total institution is then a living space in which a group of people share a similar social situation and are cut off from the greater society for a considerable amount of time. In normal society, we normally play, work, and sleep in different places with different people. However, in total institutions, these three activities of life lose their boundaries. In total institutions, life is experienced and controlled in the same place by the same central authority. The activities of daily living are conducted in the presence of a large group of people in similar circumstances. All phases of daily activities are carefully planned and monitored, with one activity leading into the next at a prearranged time and often to meet the organizational needs of the institution rather than the individual. The institution relies upon direct surveillance of an inmate by ever-present authority figures, a panopticon-like situation.

To meet the definition of a total institution, an inmate must arrive with a presenting culture derived from their home world. Simply put, they must come to the institution with “a way of life and a round of activities taken for granted until the point of admission to the institution” (p. 12). Institutions that do not involve this element (orphanages, for example) are not considered total institutions. One of the reasons for this is the importance Goffman places on a particularly distinctive character of total institutions: “role dispossession.” Role dispossession can be understood as the general mental changes that co-occur with the erasure of one’s culture prior to arrival as well as the rapid shift to a situation, in which one’s various roles—the different roles, which individuals normally voluntarily play in accordance with different life circumstances—collapse into a single role: that of an inmate.

According to Goffman’s model, there are five types of total institutions. The first can be defined as institutions that “care for persons felt to be both incapable [of looking after themselves] and harmless” (p. 4). An example would be a retirement home. The second is a variation on the first, but includes individuals who are felt to be both incapable of looking after themselves and an unintentional threat to the community. A salient example here would be a mental hospital. The third kind of total institution is one that “protect[s] the community against what are felt to be intentional dangers to it” (pp. 4-5). The primary example here would be a jail or a prison. The forth example are institutions that “[are] designed as retreats from the world” (p. 5) such as monasteries. Finally, the fifth type of total institution falls under the category of institutions that “[are] established…to pursue some work-like task and justifying themselves only on these grounds” (p. 5). An example cited by Goffman are boarding schools.

In total institutions, there is a split between a large managed group of inmates and a small supervisory staff. Inmates typically live in the institution and have restricted contact with the outside world whereas the staff often live outside the institution and operate on an eight-hour day. Each group typically views the other through the lens of narrow hostile stereotypes. Family life is usually incompatible with total institutions where inmates participate in “batch living,” working, eating, and sleeping in the presence of a group of people that are by definition not related to each other in the intimate way that characterizes familial relationships.

These total institutions are designed to have a major assault on an inmate’s psychological sense of self. Goffman refers to this as a mortification of the self. When an inmate first enters a total institution, they bring with them a conceptions of themselves that are constructed by certain stable social arrangements in their home life. Upon their entrance, the inmate is immediately stripped of the support provided by these social arrangements. The barrier that total institutions place between the inmate and the outside wider world is the first curtailment of the self. Staff generally employ what are called admissions procedures “such as taking a life history, photographing, weighing, fingerprinting, assigning numbers, listing personal possessions for storage, undressing, bathing, disinfecting, haircutting, issuing institutional clothing, instructing as to rules, and assigning to quarters” (pp. 25-26). Additionally, since an individual’s personal possessions have a special relation to self, they are quickly removed by staff. An individual usually has some control over how they appear before others through clothing and cosmetic supplies. However, an individual is likely to be stripped of their usual appearance and the tools by which they maintain it. Goffman calls this one’s “identity kit,” and it is standard among total institutions that “the individual is likely to be stripped of his [identity kit]” upon arrival, thus “suffering a personal defacement” (p. 20). Individuals are then issued institutional clothing that is usually “of a ‘coarse’ variety, ill-suited, often old, and the same for large categories of inmates” (p. 20).

In total institutions, inmates are “induced to do things not by reward but by [implied] threat of physical punishment” (p. 24). Furthermore, the inmate is also “excluded from knowledge of the decisions taken regarding his fate,” (p. 14) in the sense that the inmate in a prison is not aware of how much paperwork has been drawn up on them or when or where they may be moving next. As another example, mental patients are often not made aware of upcoming treatments such as electroshock therapy.

In particular, Goffman discusses mental patients entering the mental hospital. He points out that “in the degree that the ‘mentally ill’ outside hospitals numerically approach or surpass those inside hospitals, one could say that mental patients distinctively suffer not from mental illness, but from contingencies” (p. 135). What follows is a description of the ways a person can be stripped of their rights and freedoms without quite knowing what is happening and end up a patient in a mental hospital with a next-of-kin transformed into a guardian. Goffman talks about the “moral career” of the mental patient by which he means the regular sequence of changes that accompany hospitalization and the patient’s sense of self. These changes occur in both the prepatient and the inpatient phases of the patient’s moral career. In the prepatient phase, an individual comes to realize that they are losing their mind. In the inpatient phase, an individual comes to realize that they have been deserted by society. They are subjected to humiliating reductions in freedoms and liberties.

Goffman catalogues the ways that mental patients manipulate the facilities and resources of the hospital to their own ends, carving out the kind of autonomy and the kind of intimate relationships that are otherwise explicitly repressed. Partly in response to the mortification of self, inmates develop “secondary adjustments,” which are defined as “any habitual arrangement by which a member of an organization employs unauthorized means, or obtains unauthorized ends, or both, thus getting around the organization’s assumptions as to what he should do and get and hence what he should be” (p. 189). “These practices together comprise what can be called the underlife of the institution, being to a social establishment what an underworld is to a city” (p. 199).

The deprivations that the involuntarily committed suffer in total institutions today makes Asylums a compelling read even now. Just because we have gotten rid of total institutions in their concrete form, that does not mean that the social processes have disappeared. These social processes arise from human interaction, which itself both constructs and is constructed by individuals based on their values, culture, and social practices. Thus banishing the concrete does not mean banishing the social. These social processes may just transfer to new concrete settings.

However, it is apparent that Goffman downplayed the the medical dimension of mental disorders. The terms “mental illness” and “sickness” were often place in quotation marks, the scare quotes meant to communicate Goffman’s disparaging attitude toward psychiatry. Mental illness was, for him, a social construction, an identity that colluding others impose on the victim. He wrote, “mental hospitals are not found in our society because supervisors, psychiatrists and attendants want jobs; mental hospitals exist because there is a market for them. If all the mental hospitals in a given region were emptied and closed down today, tomorrow relatives, police, and judges would raise a clamor for new ones; and these true clients of the mental hospital would demand an institution to satisfy their needs” (p. 384). Missing in this work is an acknowledgement that psychiatric medical treatment may benefit patients. It is worth bearing in mind that at the time that Goffman was collecting his data at St. Elizabeth’s Hospital in Washington, DC, psychoanalysis was dominating psychiatry. The development of psychotropic benzodiazepines was in its infantry and their widespread use was still over a decade away. It is in this historical context that Goffman embraced the social constructionist view of mental illness. Along with many others, Goffman decried the biological view of mental illness and sought to expose the abuses of psychiatry in the United States.

The last couple of books I have read have been very anti-psychiatry and I think it is important to provide additional perspectives on mental illness.

• A New York Times article, “Successful and Schizophrenic” is important.
• The role that early childhood plays in adult mental health is addressed in a Globe and Mail article.
• The NIMH published a study describing a genetic link between five major mental disorders.
• The New Yorker piece, “Head Case,” addresses whether psychiatry can be considered a science.
• Wired has an article, “Inside the Battle to Define Mental Illness,” that is worth reading.
• The Walrus published a piece detailing the difficulty in defining mental illness.
• The Toronto Star has an article on the controversial changes made to the DSM-V.
• The New Yorker also has a well-written article regarding the DSM.
• Another New Yorker article tackles how mental illness is defined.

Saks, Elyn R. The Center Cannot Hold: My Journey Through Madness. New York: Hyperion, 2007.

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In “The Second Coming,” Irish poet W. B. Yeats wrote: “Things fall apart, the centre cannot hold; mere anarchy is loosed upon the world.” From this evocative poem comes the title of the brave and courageous memoir by Elyn Saks. Saks provides a phenomenological account of her life with schizophrenia as an oscillating experience of excelling academically while trying to keep her mental illness from disabling her.

She begins by detailing her idyllic childhood in a loving and prosperous home. Saks grew up with two parents and two brothers and her family resembled “a Norman Rockwell magazine cover or a gentle fifties sitcom” (p. 8). However, when Saks was only eight years old, she began to experience intense compulsions and phobias. She became convinced that her family home was staked out by a malevolent figure. Around this time she also began having night terrors and her mind began to feel like “a sand castle with all the sand sliding away in the receding surf” (pp. 12-13).

As a teenager, a key life event for Saks was her early experimentation with marijuana and mescaline which led to several years of compelled enrollment in a drug rehabilitation program. During this time, she was taught that all drugs were bad and that any obstacle could be overcome with a sheer force of will. This view would become problematic later on when her psychiatrists would urge her to go on medications and she would fight these prescriptions at every turn.

When she entered Vanderbilt University as an undergraduate, her illness began to deteriorate and she abandoned any interest in personal hygiene and self-care. It was during her undergraduate years when “schizophrenia [rolled] in like a slow fog” becoming “imperceptibly thicker” as time went on (p. 35). Yet, despite her illness, she earned top grades and even took several graduate courses where she developed meaningful friendships with some older students. During this time, she also developed a love for philosophy. She writes:

Philosophy and psychosis have more in common than many people (philosophers especially) might care to admit. The similarity is not what you might think—that philosophy and psychosis don’t have rules, and you’re tossed around the universe willy-nilly. On the contrary, each is governed by very strict rules. The trick is to discover what those rules are, and in both cases, that inquiry takes place almost solely inside one’s head. And while the line between creativity and madness can be razor thin (a fact that has been unfortunately romanticized), examining and experiencing the world in a different way can lead to sharp and fruitful insights. (pp. 40-41)

At Vanderbilt, Saks was granted a Marshall scholarship to study the Classics at Oxford. During her years in England, Saks had intermittent experiences with paranoia and delusional thinking. While in England, she was twice hospitalized for depression (which resulted from her psychosis) and she detailed her experience in talk therapy with a remarkable, if austere, classical analyst. Psychoanalysis would prove to have a huge influence on Saks’ recovery. “While medication kept me alive,” she writes, “it had been psychoanalysis that helped me find a life worth living” (p. 32).

Her studies at Oxford were followed by acceptance to Yale Law School, where Saks again succeeded with distinction despite severe active psychosis and concomitant hospitalization. As a student at Yale, Saks saw various therapists, was institutionalized and physically restrained repeatedly. She also tried many different psychotropic medications, some of which had debilitating side effects. For a long time she believed that her delusional behavior resulted from her self-perceived weaknesses and worthlessness. With a raw honesty, she talks openly about her struggles with her failed attempts at managing schizophrenia without medication, realizing in the end that her disease is a biological one and that medication would be a necessary part of a life of recovery. After graduating from Yale with a law degree, Saks eventually secured tenure at the University of Southern California Law School where she specialized in mental health law and criminal law and published several articles and books. She also obtained a doctorate in psychoanalysis.

Saks is an eloquent writer who allows the reader to share in some of her most personal and painful secrets. One can only imagine how difficult it must have been to reveal so much of oneself after years of maintaining a façade of normalcy to the outside world. Her memoir is a captivating account of psychotic breakdowns, institutionalizations, progress and regression, as well as academic and professional achievements. A less determined individual might have avoided being challenged in any way, but Saks was a serious scholar who’s love for philosophy, psychology, and law kept her going and in such prestigious schools such as Oxford and Yale. She also formed and maintained close relationships and found love in a man who accepted her. Slowly, she prevailed.

My worst criticism of this book is that it suffers from repetitiousness, given the unending cycle of success followed by predictable decompensation that characterizes her life. It’s not necessarily that I would want to know less information, but the dialogue rendition of “disorganized thoughts” soon grew tired. On the other hand, her very accurate depiction of the “liberal” use of mechanical restraints at Yale New Haven Hospital made me shudder, having witnessed exactly what she described during one of my hospitalizations.

There are several great articles about Saks as well as a powerful TED Talk where she talks of overcoming the “grave” prognosis given to her by numerous doctors and provides a powerful inside view of what it is like to live with schizophrenia. In the video, she provides a first hand account of being involuntarily restrained by doctors in the United States despite the fact that she never harmed herself, anyone else, or made any direct threats against anyone. She believes that mechanical restraints are dangerous and demeaning and she does not think that they are acceptable treatment for someone suffering from a terrible illness. She says she is “pro-psychiatry, but anti-force.” She also cites three reasons for her success and high-functioning capability: excellent treatment, a strong support group of friends and family who know her illness, and a supportive workplace. She notes that the most powerful and reliable defense against schizophrenia has been occupying her mind with complex and intellectually stimulating problems. In order to overcome the stigma of mental illness, Saks argues that we need to invest more research into what causes mental illnesses in order to better treat them. She also notes that we need to stop criminalizing mental illness. Lastly, she argues that the press and entertainment industries should continue to include those who suffer from severe mental illness by hiring them or portraying them in a positive light. It’s a short video and worth watching.

There is much to learn from Saks’s brave account of her mental illness. She has spared little in describing deeply personal aspects of her life. She also displays an awareness of her privilege on the mental illness spectrum. She is aware of her position as a middle class woman who has the advantages of managing her recurrent psychotic episodes that other do not have. To be sure, Saks has resources. She benefits from five hours a week of psychoanalysis which is unimaginable for most who cannot afford even one hour a week. She is modest in her hopes for her memoir: “I hope that by writing this book I help others to take some of what they need to lead a life worth living.” Her aim is similar to that of Dr. Marsha Linehan who shares the same goal in her development of dialectical behavioral therapy. The candor and accessibility of The Center Cannot Hold will go a long way to realizing that hope. Anyone with a clinical, academic, or personal interest in mental illness will find this book both compelling and rewarding. This book is written in an engaging manner and is replete with keen observations and first hand accounts of Saks’ experiences which lift the book into the category of notable memoirs on mental illness. But as Saks herself notes, she is one of the exceptions of individuals living with schizophrenia. There are many who suffer who are not pressing forward with their lives. I wonder how they would reconcile Saks’ message of hope—for a kind of super success, even as psychosis continues unabated—with the bleak reality that they see?

 

 

Whitaker, Robert. Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill. New York: Basic Books, 2010.

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In Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill, Robert Whitaker seeks to determine why treatment outcomes for schizophrenics in America have not improved despite decades of “scientific progress” in psychiatry. Not only have outcomes not improved, but schizophrenics in America fare worse than they do in poorer nations such as Nigeria, India, and Colombia. In order to understand these failures, Whitaker chronicles the history of madness in the West and the development of American psychiatry. The results are horrifying. With the exception of “moral treatment” prescribed during the 1800s, the management of people with schizophrenia has been a series of cruel and inhumane practices that run the gamut from physical torture to chemical persecution through harsh medication.

Whitaker describes “mad medicine” as the precursor to psychiatry. During the 1700s, the mentally ill were institutionalized in unheated, dingy cells, chained, and displayed for the public’s amusement. These “lunatics” and “brutes” were punished and made to fear their keepers. American physician, Benjamin Rush was thought to be a humanitarian, but his scientific perspective on madness caused him to keep using the “therapies” of the day which included bleeding and weakening patients through purges, emetics, and nausea-inducing drugs. Private asylums in England were known to be places where a person could drop off an annoying family member or a vexatious wife. In 1774, the Act of Regulating Madhouses, Licensings, and Inspection passed which prevented anyone from committing a person unless a physician had certified them as insane (this is where the term “certifiably insane” comes from). As a result, physicians became the sole arbitrators that determined who was diagnosed as insane and the practice of “treating” madness flourished. The number of private madhouses soon doubled and insanity became a common condition.

In the early 1800s, a moral treatment movement developed among English Quakers and became the new therapy used to treat the mentally ill. Philippe Pinel believed that a nurturing environment could heal the mentally ill. This was a strikingly different from the punitive approach it replaced. This treatment was premised on the idea that the insane had a capacity for regaining self-control and that their chance for recovery lay within them, not in the external powers of medicine. It was believed that patient’s delusions and depressions resulted from life’s stressors and that a nurturing and compassionate environment could heal those who were ill.  The York Quakers, lead by William Tuke, dramatically remade treatment of the insane. A blueprint for asylums was developed that was based on keeping them limited to a small number of patients, locating them in calm of the countryside, constructing buildings with architecturally pleasing aesthetics and governing them by a superintendent who was humane, empathetic, and reasonable. However, this was not to last. American physicians saw moral treatment’s emphasis on natural healing and egalitarian relationships between patient and healer as a threat to medical science’s hierarchical culture. Physicians took control of American asylums in order to ensure that medicine and biology became the focal point for treating mental illness.

Medical therapies for the mentally ill reflect societal values. In the early 1900s, Sir Francis Galton’s work on the heredity of intelligence spawned a belief that the mentally ill were not like “normal” people in that they were carriers of “poor germ plasm.” This began the eugenics movement and its willingness to embrace anti-immigrant and xenophobic social policies had a devastating effect on the mentally ill. The only solution to stop the spread of mental illness, according to the eugenicists, was sterilization. The country’s lawmakers agreed and as a consequence gave the US the first laws for the compulsory sterilization of the mentally ill. Asylum psychiatry was focused on finding somatic therapies that could be quickly applied to patients. Women were often the victims of “asylum medicine” and in the 1890s, their madness was commonly “cured” by removing their uterus, ovaries, and through amputating their genitalia. Some doctors, such as Henry Cotton, insisted on removing people’s teeth and other organs in order to eliminate “hidden infections” that were thought to cause madness. Submersing patients in water and pummeling them with painful and forceful blasts of water became common forms of hydrotherapy for madness. The ominously-named “Bath of Surprise” and the use of painful spinning swings were considered effective medical treatments of the day. In 1933, insulin coma therapy became a popular way of making patients less psychotic. The coma caused hemorrhages in the brain and destroyed brain tissue. Next was the popular treatment of metrazol convulsive therapy which produced “explosive” seizures in which the “patient would arch into a convulsion so severe that it would break bones, cause spinal fractures and loosen teeth” (p. 93). Electroshock (ECT) was introduced into the US in the 1940s. Electrodes were placed on the patient’s temples and a current of electricity was induced which caused spasms, accompanied by memory loss and reduced cognitive functions. The procedure was repeated many times until the patient was left in a confused and nearly catatonic state. Patients who received the therapy spoke of the extreme pain it caused, in many cases, their bones and teeth would break. Those who tried to resist this treatment were restrained and shocked without their consent. ECT was a common practice for two decades to frighten, control, and punish difficult patients in state-run facilities. Whitaker reserves a special degree of horror for lobotomies. Ever since the turn of the century, psychiatry had been seeking to reform itself into an academic medical discipline and brain surgery carried with it the luster of being scientific and technologically advanced. The lobotomy was a surgery that effected the frontal lobes of the brain, an area associated with higher intelligence. Doctors realized that damage to the frontal lobes brought about a change in emotional behavior in psychotic patients. Lobotomies received a great deal of praise and were used routinely as a way to keep patients quiet and non-disruptive (by reducing them to lethargic and lifeless people).

In the 1950s, state hospitals were gradually dismantled due to the crippling costs to state budgets and there was a push towards community care that aimed to treat the mentally ill on an outpatient basis and allow them to live in “normal” society. In 1954, the first antipsychotic medication, Thorazine, was introduced in the US and thus began the modern era of psychopharmacological treatment of schizophrenia. Thorazine belonged to a class of drugs known as neuroleptics. Initially, Thorazine was hailed as a chemical lobotomy, but as increasing social distaste with lobotomies developed, the drug was recast as a healing agent. Whitaker criticizes neuroleptic drugs for their serious and sometimes debilitating side effects. In his overly harsh assessment, he fails to acknowledge the fact that neuroleptic drugs do help some people, as they themselves have attested. Whitaker also cites studies that question the long-term impact of neuroleptics on schizophrenia. Overall, he sees the treatment for schizophrenia worse than the disease itself. However, Whitaker drastically downplays the discomfort of schizophrenia in his book. He pays little attention to the hallucinations, terrifying delusions, the sense of isolation, and mental confusion that are characteristic of the disease. Because there is a lack of a clear sense of what schizophrenia looks and feels like, it undermines his argument that the costs of treatment outweighs the disease. Whitaker seems way too eager to dismiss schizophrenia as a metaphysical affliction rather than a biological disorder. In fact, he consistently uses quotation marks around schizophrenia, suggesting that the disease does not actually exist. Whitaker also fails to note that today, ECT treatment has changed drastically and is highly successful in treating medication and therapy-resistant depression and schizophrenia. Unlike during the 1950s, patients are now anesthetized during the process and the memory loss associated with the practice is often minimal. This aside, Whitaker does make some excellent points about the less-than-stellar way schizophrenia as been dealt with by mental health professionals. For example, during the 1970s, it became evident that schizophrenia was being “diagnosed” more frequently in African Americans than Caucasians. Black men were labeled paranoid, hostile, and violent at rates four to five times more than other groups. Schizophrenia became associated with violence in the 1960s, just as black men joined protests against racism. There is clearly a troubled history between race and sanity and the definition of schizophrenia has changed dramatically as societal values have changed.

In the end of this book, Whitaker reveals a major claim made by the World Health Organization that living in a developed country is a strong predictor that an individual with schizophrenia will not recover. This shocking finding has been largely ignored by American psychiatry. Unfortunately, Whitaker does not address why schizophrenics in the developing world fare better and does not suggest concretely how the West could improve. American psychiatry today, with its emphasis on the DSM and its adherence to the biomedical disease model of treatment is often criticized for being reductionist and overly focused on symptom management. Perhaps developing countries have been more successful in treating schizophrenia because they see patients as people and not as symptom clusters. Overall, Whitaker tackles a controversial and important topic with fearlessness and depth. Even if you may not agree with all of his arguments, the topic is a vital one that has been in need of being raised for quite some time.

 

Russon, John. Human Experience: Philosophy, Neurosis, and the Elements of Everyday Life. Albany: State University of New York Press, 2003.

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I have to admit, this book flew over my head quite a bit. While the text is written in a very accessible way, the concepts are complex and not always easy to comprehend. I clearly need to read this text at least one more time. In the meantime, here are some of my thoughts on what I think is going on. They are jottings from my notebook and are meant to be read that way.

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The fundamental struggle that defines the life of a person is the pursuit of self-esteem and self-understanding.

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The identities of human bodies, memories, and things are experienced as existing in relation to surroundings, other people, or past and future.

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For Russon, the core of one’s identity is the core of our embodiment and our intersubjective experiences with others. He prioritizes the body and its intersubjective relationship to the world. Our everyday bodily activities reveal who we are. The fundamental capacity of our body is the capacity to care about other things and other people. Our personality is shaped through family and social experience. In this work, he develops a sense of “I Can” (borrowed from Edmund Husserl) which is based off of Martin Heidegger’s concept of Dasein. “I Can” represents an existential and phenomenological development of existence and being. Russon’s construction of “I Can” is future-oriented and open to an array of possibilities. He writes, “We are our possibilities for interactions with things, and things are their possibilities for our interaction” (p. 31). This suggests that the core of our identity contains our unknown and embodied possibilities of interaction with others. The fundamental capacity of our body is the capacity to care about other things and other people.

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Education and therapy provide possibilities for self-transcendence. He writes that:

The project of therapy is precisely the project of engaging the erotic, expressive sphere for the sake of facilitating the self-transcendence of the neurotic determinacies of our habitual situatedness. In therapy, we use expression—we cocreate with the other—to determine what our habitual comportment already expresses, for the sake of transforming this fundamental expression. Therapy seeks empowerment through liberating our expressive capabilities, creating a new identity for ourselves beyond the repetition of our clichés of habitual behavior and self-interpretation. (p. 120)

Russon argues that neurosis is fundamental to the human condition itself, an early construction of identity based on our initial introduction to intersubjectivity. Neurosis is the conflict between two interpretations of reality. It is simply how we function as embodied, interpretative beings. This does not mean that neurosis is not unproblematic, however. Russon uses the example of a woman choosing to break a diet in which she had previously been faithful to illustrate this:

Her behavior enacts a memory—or rather, it is the memory—of who she is, but it is out of step with the self she has become. Her memory is a remembering of originary events—self-transcending, creative strategies for making contact—but it remembers them as static inasmuch as these strategies are no longer living, interactive strategies whose viability is under debate; rather, they are fixed habits. Furthermore, these are strategies based on narratives—interpretations—of her situation that other sectors of her life have superseded, but that have not themselves been superseded on their own terms, that is, in their local terrain. To eat is to remember a certain self, a certain “I can” of intersubjectivity, that is “behind the times” of her current intersubjective reality. (pp. 87-88)

When we claim that we want something, but we are compelled to do the opposite, we are frustrated and puzzled. The true problem, however, is that we are simply unaware of our habits that compel us towards actions and behavior that are at odds with what we actually wish to do with our lives. Philosophy is itself a self-conscious, educative process by which our unconscious habituation to our intersubjective reality is brought into our view for conscious deliberation.

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Interpretation focuses on the way in which we are active in making sense of our experience. Patterns of memory and expectation are crucial to understanding how we make sense of our experience. Embodiment suggests that the patterns of memory and expectation that shape our human experience have their own terms set by our bodily capacities. All modes of experience are bodily engagements with the world. Through the process of habituation, we are allowed ever more sophisticated ways of experiencing ourselves and the world.

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We have a tendency to construct our lives and our memories through the process of habituation. Our being-in-the-world must be thought of in the present as an “engagement with the world of objects” where “we are fundamentally continuing to engage with our own past” (p. 47). Habituation develops when our bodily interactions come to operate for us without reflection of self-consciousness. When we develop habits, we are able to direct our attention elsewhere because the behavior becomes automatic. We also see the progression from basic bodily actions to more sophisticated possibilities. Habituation is the process by which we build up through our embodiment progressively more complex behaviors that become automatic to us and thus the “I Can” with which we make contact with objects and the world becomes more complex and sophisticated.

Emmons, Kimberly K. Black Dogs and Blue Words: Depression and Gender in the Age of Self-Care. New Brunswick, NJ: Rutgers University Press, 2010.

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The language through which we experience and express our health or illness is crucial to preparing our physical selves to medical intervention. Much of the current language surrounding depression has gone unexamined which is very unfortunate since language fundamentally shapes cultural assumptions. Kimberly Emmons’ aim in writing Black Dogs and Blue Words: Depression and Gender in the Age of Self-Care is “to interrogate the rhetorical forms—the definitional words, metaphors, typical stories, and genres—through which depression is expressed, experienced, and treated in order to understand the gendered illness identities that are available for adoption” (p. 5). The language that Emmons rhetorically analyzes comes from a range of sources: direct-to-consumer pharmaceutical advertisements, memoirs, ethnographic interviews, and articles from newspapers, popular journals, and newsletters. Emmons seeks to remind us that words matter in the discourse of depression. By exploring language patterns, Emmons presents the persuasive power of depression as a rhetorical illness—a real and tangible condition that is both constructed and made recognizable by language. Within the current discourse of depression, a variety of rhetorical structures reflect and privilege the language of biological psychiatry.

In Chapter 1, Emmons demonstrates how rhetoric shapes the experience of depression. She discusses the language of the Diagnostic and Statistical Manual of Mental Disorders (DSM), which coordinates much of the language about depression. She argues that the patterns of expression through which individuals articulate their experiences with depression fundamentally shape their ideas of health and illness. Collectively, these patterns form a discourse of depression. She draws on Michel Foucault’s concept of discourse to mean the collection of statements a culture makes about a given subject within a particular historical moment. She advocates for an alternative to self-doctoring, which encourages individuals (mostly women) “to monitor their affective experiences closely and to suspect brain chemistry when those experiences do not meet expectations” (p. 16). As an alternative to self-doctoring, Emmons conceptualizes a rhetorical care of the self which requires paying attention to the discourse of depression in order to open avenues for dialogue, critique, and social action. She writes that “a healthy suspicion of diagnostic criteria may lead some individuals to more complex understandings of their experiences” (p. 25). She also points out the gendering of depression in which women are assumed to be at greater risk for depression than men. This “fact” encourages women to put their emotional lives under greater scrutiny and self-surveillance.

In Chapter 2, she argues that direct-to-consumer pharmaceutical advertisements represent an obvious textual site for locating practices of self-doctoring as they encourage individuals to take their ability to diagnose their depression into their own hands. In popular discourse, depression has been reduced to a biological and chemical phenomenon. The “biological turn” in psychiatry establishes the desire for a quick fix solution to depression. Advertisements portray the self as an object that has been lost and medication as the means to reclaiming it. Imprecise definitions of what depression is work to ensure the broadest possible audience for pharmaceutical companies. Emmons draws on the work of Emily Martin, who through her ethnographic study of those living with manic depression found that individuals lacked a rich vocabulary to articulate their experiences and instead relied on narrow categories of illness that are dictated by medical conventions such as the DSM. Medical discourses have traditionally been about disempowering people. She argues that self-doctoring ignores Foucault’s concept of “curiosity” which might enable individuals to act in more personally meaningful ways within the discourse of depression. A rhetorical care of the self requires a series of tactics that counter powerful texts that construct depression such as the DSM and direct-to-consumer pharmaceutical advertising. Rhetorical self-care “advocates a self-conscious critique and skeptical orientation toward the dominant discourses of biological psychiatry” (p. 59).

In Chapter 3, Emmons sets her focus on the unclear and imprecise definition of depression. Examining definitional practices within the discourse of depression becomes a first step in taking a critical stance toward these prescribed illness identities. Emmons explains her use of the term illness over disease in describing depression. She argues that disease is predominately biomedical and ignores the experiences of individuals with depression. It also suits the interests of pharmaceutical companies. The use of the term illness ensures that depression is primarily made a social phenomenon as it focuses attention on the affective status of suffers and the meanings made of their experiences. Definitional practices within the discourse of depression do not promote clarity but instead sustain porous boundaries and encourage practices of self-doctoring.

In Chapter 4, she explores the metaphors that shape identities of depression. She argues that metaphors used in the context of the discourse of depression serve to isolate the sufferer. She notes the importance of metaphors in shaping how we see the world by drawing on the work of George Lakoff and Mark Johnson who demonstrated that metaphors such as “up is good” and “down is bad” are rooted in the realities of our corporeal activity. She argues that figurative understandings of depression have the potential to direct research (for example, thinking of depression in terms of a chemical imbalance can lead to more research into neurobiology). She explores metaphors of war and mechanical metaphors, where depression is something that can be “repaired.” Mechanical metaphors usually serve two groups: those who are seeking parity between physical and mental illnesses and the pharmaceutical industry. One of the major problems with mechanical metaphors is that they render human agency second to the mechanical system. She also explores spatial metaphors and those that involve travel. Within this discourse of depression, she argues that the self is something to be mapped, studied, and traversed.

In Chapter 5, Emmons presents the gendered reality of the discourse of depression. She examines narratives of depression from popular memoirs and news reports and finds that storytelling is an integral part of the experience of depression. However, the stories that are told have certain formulas that are different for women and men. Stock characters and familiar plot lines set up gendered expectations for performances of the self. Through rhetorical analysis, she finds that women often display sadness and accommodation whereas men display anger and dominance over their depression. Women’s concern for family is often noted. Women also tend to become defined by their illness whereas this is not the case for men. Memoirs written by women are praised for their sensitivity and emotionality and memoirs written by men are praised for their objectivity and rationality. Emmons writes, “Stories of depression establish gendered dynamics of illness—angry, stoic men and tearful, emotional women—and of treatment: networked care-taking for men, solitary self-help for women” (p. 142). Dialogue and the questioning of stereotypical assumptions about women’s and men’s emotional lives offers up the possibility for a rhetorical care of the self. Emmons argues that treating narratives as objects of analyses has “the potential to open new spaces for self-articulation” (p. 154).

In Chapter 6, penultimate to the conclusion, Emmons focuses on the self-diagnosis genres of the DSM, symptoms lists and self-diagnostic quizzes. These texts, like the narratives of depression in Chapter 5, suggest that it is a woman’s duty to be aware and vigilant about her feelings in ways that men are not encouraged to be. The symptoms list is a genre that was developed in the mid-twentieth century as a means of standardizing and organizing illnesses for the purpose of research and documentation. As a tool, symptoms lists encourage practices of self-doctoring. For individuals who are experiencing depression, the symptoms list provides a way to articulate and document their experience. Another popular genre are self-diagnostic tools that are often found on pharmaceutical websites. This genre helps shape the interaction between doctors and potential patients. Though these self-diagnostic tools appear to streamline the diagnosis of depression, they do so at the expense of a dialogical engagement with experiences of depression. These tools also reinforce gendered stereotypes of depression. The women who Emmons interviewed tended to view symptoms lists as established fact and therefore did not interrogate their contents. “By doing so,” writes Emmons, “they accept the contours of the illness and gendered identities codified in the genre. Such a reduction of suffering (an experiential entity) to mere symptoms (diagnostic entities) empties suffering of its social and moral significance” (p. 173). By accepting lists of symptoms as “facts” we fail to see them for what they really are, a culturally determined set of guidelines.

In her conclusion, Emmons reiterates that what we are working towards is a rhetorical care of the self. However, the texts that appear to promote personal autonomy and dialogue tend to have gendered identities embedded in them. The discourse of depression is constantly evolving and reflects the interests of powerful social and biomedical institutions who are often the ones generating the texts on depression. In order to foster a rhetorical care of the self, what is needed is a critical engagement with texts that allows individuals to live under health and illness descriptions with more consciousness and more flexibility in how they respond to the discourses of depression. What is required is a rhetorical orientation towards the information that is presented to us. Most of all, a rhetorical care of the self requires a constant reevaluation of definitions, metaphors, stories and genres that define mental illness.

Foucault, Michel. Madness & Civilization: A History of Insanity in the Age of Reason. New York: Vintage Books, 1988.

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Chapter Five: Aspects of Madness

Foucault analyzed different conditions seen in the eighteenth century as forming madness. He explored the ways in which doctors and theorists of madness described the causes and effects of mental illness. To do this, Foucault drew from the history of medicine. Up to the seventeenth century, causes of melancholia remained fixed within a tradition of the four humors. The tradition of the humors that Foucault discussed were a central part of early modern medicine. Doctors believed there were four humors—blood, phlegm, choler, and black bile. The melancholic personality type was thought to have too much black bile. There was a shift in thinking. The result was that the causality of substances increasingly was replaced by a movement of qualities. Qualities, which can be affected by circumstances, organized and integrated melancholia (a patient’s mental state). The idea of partial delirium increasingly disappeared as a major symptom of melancholiacs and was replaced by qualitative data such as sadness, bitterness, a preference for solitude, and immobility. The analyses of mania followed similar principles to the analyses of melancholia. In the eighteenth century, most believed that mania opposed melancholia, but both were believed to be caused by a movement of animal spirits. However, this was replaced by an explanation of tension in nerve fibers. Objects did not present themselves as real to the manic and a psychological explanation replaced ideas of humors and tensions. Thomas Willis (an English physician) was credited with discovering the alternation of mania and melancholia. Another key shift was the idea that the two conditions alternated within one person (modern day manic-depressive illness). Foucault discussed hysteria and hypochondria. Two problems arose in studying these conditions. The first of which was, to what degree was it legitimate to treat them as forms of madness? Remember, that madness was a state of being linked to unreason and not a mental disease. Secondly, were we entitled to treat them together “as if they constituted a virtual couple” (p. 136) similar to how melancholia and mania were treated? During the Classical period, hysteria and hypochondria were seen as mental diseases. Two lines of development existed during the Classical period for hysteria and hypochondria. The first was that they were a “disease of the nerves” and secondly, they were “diseases of the mind” such as melancholia and mania. Hysteria was a deceptive disease because it had various symptoms. Doctors said it affected women more because they had “softer” bodies. Until the end of the eighteenth century, the uterus and the womb remained present in the pathology of hysteria. The idea that the womb rose above its place was replaced by the idea that spirits moved chaotically within the body. It was believed that the sympathetic sensibility of women predisposed them to the “vapors” and nervous disease. Too much sensibility resulted in unconscious shock. A person could fall ill from too much exposure to outside, worldly stimulation. For the first time, outside influences on the body became important. Hysteria and hypochondria were diseases that resulted from lifestyle and not an imbalance of the interior parts of the body. The nineteenth century saw the “complete identification of hysteria and hypochondria as mental diseases” (p. 158). Psychology and morality now contested the same domain. Nineteenth century scientific psychology was now possible.

Chapter Six: Doctors and Patients

The therapeutics of madness did not function in a hospital because in this context, the focus was on “correcting.” During the Classical period, treatment continued to develop and focused on curing the whole individual, body and soul: “his nervous fiber as well as the course of his imagination” (p. 159). Physical cures developed from moral perception and a therapeutics of the body. Foucault listed these cures and their philosophies. The first was Consolidation. Beneath the apparent violence of madness, there was always an element of weakness, “an essential lack of resistance; the madman’s frenzies, in fact, are only a passive violence” (p. 160). A force needed to be found in nature to reinforce nature. Lange recommended that animal spirits be subjected to sensations and movements that were both agreeable, measured, and regular (pp. 160-61). Iron was thought to be the best solution. The second cure was Purification. Madness elicited a series of therapeutics that were intended to purify. The ideal was total purification. It consisted of substituting clear, light blood for “the melancholic’s overcharged, thick blood, encumbered with bitter humors” (p. 162). Some even thought that skin diseases such as scabies, eczema, or smallpox could cure madness. The principle task, however, was to dissolve the fermentation in the body. To accomplish this, the chief agent used was bitters. Coffee was often used as was tonic (quinine). Soap products produced effects because of soap’s dissolving powers. Soluble tartar was recommended when soap didn’t do the trick. Vinegar was used. The third cure is Immersion. Here two themes were present: ablution (washing) and immersion, which modified liquids and solids. Water was the key element here as it served as “a universal physiological regulator” (p. 167). In the Middle Ages, the traditional treatment of a manic was plunging them into water. From the end of the seventeenth century, the water cure of purification was one of the major therapeutics for madness. Hot water was believed to have the risk of feminization since it lead to relaxation, general humidity, and softness which were all traits of women. It was also believed by some that cold water could do the same. At the end of the eighteenth century, the powers of water began to wane. Because water had so many values, it could confirm anything and cancel anything. The shower was used in the eighteenth century and the beginning of the nineteenth century in asylums in an effort to purify the madman. The fourth cure was Regulation of Movement. Madness was the irregular agitation of animal spirits and also the immobility of limbs and ideas. Walking, running, horseback riding, and sea voyages all were thought to help restore movement. All of these means of therapeutics were organized around two fundamental themes: the subject must be restored to their initial purity and must be wrested from his pure subjectivity in order to be initiated into the world. These techniques lasted longer than their efficacy; when madness received psychological and moral meaning, they remained.

A psychological element seemed to be present in classical techniques. Fear was one passion that was used to treat madness. It diminished the excitation of the brain. Anger was also used and it was believed that it gave the nervous fibers more vigor and restored their lost elasticity. It was not valid to use the distinction between physical medications and psychological or moral medications during the Classical period. The difference only began to exist when fear was no longer used as a method for arresting movement but as a punishment. “In short, there always existed, throughout the classical period, a juxtaposition of two technical universes in the therapeutics of madness. One, which is based on an implicit mechanics of qualities, and which addresses madness as essentially passion—that is, a certain compound (movement-quality) belonging to both body and soul; the other, which is based on the discursive movement of reason reasoning with itself, and which addresses madness as error, as double inanity of language and image, as delirium” (p. 184). Three configurations existed. 1. Awakening: A need existed to tear the delirious from quasi-sleep. Awakening could be violent or proceed from wisdom. Slowly, authoritarian awakening became only a return to the good or moral law. 2. Theatrical representation: This appeared to be opposed to awakening. Here, therapy operated in the imagination. It continued the delirious discourse. Theatrical representation drove out the madness of delirium. 3. The return to the immediate: If madness was an illusion, the cure of madness could be brought by its suppression. Delirium was contradicted by nature. But the return to the immediate was not simple or absolute because madness was the experience of the most basic human desires. Nature had a fundamental power in the suppression of madness; it could force man from his freedom. In nature, man was freedom from social constraints and passion, but he was bound by a system of natural obligations. A liberation of madness was possible in which madness was opened to the constraints of nature. But the return to the immediate was effective only if the immediate was controlled.

The Classical perception of madness was reduced to the moral perception of madness, which was the core of the nineteenth century positive, scientific, and experimental concepts. This change began in the techniques of cure. Psychology was born as a sign that madness was detached from truth (unreason) and was adrift.

Freud studied madness at the level of its language. He restored the possibility of dialogue with unreason. Psychology was not involved with psychoanalysis; rather, it was the experience of unreason that psychology was supposed to mask.

Chapter Seven: The Great Fear

For the first time since The Great Confinement, the madman had become a social individual. By letting madmen back into the light, classical reason admited its closeness with unreason. Reason allowed people to drift into the margins, but fear and anxiety were close. People had a fear of being confined. Confinement was seen as the birthplace of evil. People feared contagion from these places. It was feared that the atmosphere “laden with maleficent vapors” would infect entire cities with “rottenness and taint” (p. 204). Houses of confinement were seen as sites of corrupted air and old fears of leprosy seemed to synthesize unreason with the medical universe. The eighteenth century reform movement sought to organize and purify the houses of confinement. “The hospital, the house of correction, all the places of confinement, were to be more completely isolated, surrounded by purer air” (p. 206). Morality and medicine tried to defend themselves against the dangers of confinement. People wanted asylums where unreason could be contained without a threat to the spectators who wanted to watch the spectacle. The Classical period confined not only criminals and madmen, but also the fantastic. In the Classical period, awareness of madness and unreason had not separated from each other. The fear of madness grew at the same time as the fear of unreason so the two worked to reinforce each other. Concern grew that the more man perfected himself, the more delicate he became. The threat of madness was ever-present. Foucault discussed madness and liberty. Madness was seen by other writers as the result of liberty enjoyed in England. It was thought that liberty alienated man from the essence of his world. Religion was suspected of arousing madness. Old religion was a positive force, but modern religion eventually allowed madness to function freely. Civilization was a milieu suitable for the development of madness. The progress of knowledge allowed for a mania for study and dangerous excitement of the mind to develop. Sensibility also detached man from feeling because it was a sensibility “no longer controlled by the movements of nature, but by all the habits, all the demands of social life” (p. 218). Novels and theatre excited people in a dangerous way. “The novel constitutes the milieu of perversion, par excellence, of all sensibility; it detaches the soul from all that is immediate and natural in feeling and leads it into an imaginary world of sentiments violent in proportion to their unreality, and less controlled by the gentle laws of nature” (p. 219). The eighteenth century developed a new range of concepts around madness. In the sixteenth century, the secrecy of madness related to sin and animality. Now madness was situated in a place where man’s relation to time, sentiment and other people was altered.

Chapter Eight: The New Division

The “new division” that Foucault discussed was the split that emerged between madness and other forms of confinement in the late eighteenth century. At the beginning of the nineteenth century, psychiatrists and historians condemned confinement. The age of positivism claimed to be the first to dissociate the madman from the criminal. The nineteenth century felt that madmen should be treated better than criminals and the eighteenth century felt that prisoners did not deserve to be treated like the insane. The consciousness of madness was transformed in the eighteenth century within the context of confinement. A new awareness of madness came from within confinement. Madness was denounced and isolated. The presence of the mad became an injustice for others. At the same time, confinement suffered another crisis from within. Poverty became an economic phenomenon, it had a necessarily role in life because it made wealth possible. The pauper now had a place in society unlike in the mercantilist economy. Confinement was an economic error because poverty had to be suppressed by removing or maintaining a poor population. The need was to use the poor for the labor market. Poor people could be put to work and therefore confining them was a mistake. Confinement could be criticized for its effects on the labor market and for the way it was financed. Setting aside wealth to pay for confinement actually led to an increase in poverty. The necessity of confinement disappeared in the eighteenth century. People no longer knew where to situate madness. There was a need to separate the insane from criminals. An ambiguous need existed to protect the population from madness and to give it special treatment. There was great confusion over how to determine the place of madness within a social sphere that was being restructured. Reforms intended to treat the mad, but there were no facilities in place for this treatment. Problems with madness and confinement arose from social uncertainty. As society changed, the role of the madman had to change along with it.

Chapter Nine: The Birth of the Asylum

Foucault suggested that the images of asylums are a strategy aimed at showing psychiatry as a positive force that could understand and cure the problem of madness. But this was merely a facade and Foucault dug deeper to see what was really happening. Foucault chose two people to represent the development of the asylum: Philippe Pinel and Samuel Tuke. Tuke was not a philanthropist. He founded the York Retreat as a rural, Quaker institution. This institution was focused on enlightenment through self-examination. He saw the exercise of religious principles over the mad as a cure. Patients were not locked up or chained away. Instead, their keepers reasoned with them. The aim was an attempt to awaken the madman’s conscience. Work was important to Tuke. In the asylum, work was deprived of any productive value, but it was imposed only as moral rule and an engagement of responsibility on behalf of the patient. Through a combination of guilt and observation, the madman began to behave in a normal way. Observation became a form of control. Because he knew he was being watched, the madman restrained his behavior. Observation was related to judgement. Those doing the observing would be in the position to judge what was good or bad, normal or abnormal. Thus the combination of observation and judgement made the modern science of psychiatry possible: “The science of mental disease, as it would develop in the asylum, would always be only of the order of observation and classification” (p. 250). It was not based on dialogue until the development of psychoanalysis. Everything at the Retreat was organized so that the insane were transformed into children. The concept of family became important as it “placed the patient in a milieu both normal and natural; in reality it alienated him still more: the juridicial minority assigned to the madman was intended to protect him as a subject of law; this ancient structure, by becoming a form of coexistence, delivered him entirely as a psychological subject, to the authority and prestige of the man of reason, who assumed for him the concrete figure of adult, in other words, both domination and designation” (pp. 252-253). The family became normal and reasonable. Pinel’s asylum was the opposite of Tuke’s in terms of religion. Pinel condemned religion as a dangerous irritant and thought it to be a potential cause of madness. He aimed to enforce moral standards that drew from the outside world on the madman. The asylum denounced everything that opposed the essential virtues of society. Ignoring or exceeding the world’s morality became madness. The social values of the family and work reigned in the asylum. Pinel’s asylum was a place where insanity as social deviancy was eliminated. The life of the patient was organized so that moral syntheses could operate in three ways. First, keeping the madman silent confined him and shamed him in front of others. Second, mirrors allowed madness to see itself. By causing the mad to recognize their condition, Pinel thought he could cure it. Third, madness was called upon to judge itself and was judged constantly by an invisible tribunal. The system of judgement and observation was supported by the appearance of the doctor-figure. Madness had now become a medical complaint, in the sense that the authority of science and medicine justified the treatment of madmen in asylums. The doctor-figure developed a great power over his patients. Tuke and Pinel opened the asylum to medical knowledge. The presence and words of a doctor-figure were often enough to illicit a cure. Psychiatry assumed priority for the first time. Positivism imposed itself more on medicine; the doctor became more powerful in the patient’s eyes. All of the nineteenth century psychiatry converged on Freud because he attempted to recognize the importance of the doctor-patient couple. Freud transferred Tuke and Pinel’s structures to the doctor. The doctor was key to psychoanalysis.