Follow by Email

Monday, January 23, 2012

Excursus: The History of Psychiatry is Not the History of Madness

What difference does it make—for theory, for research, for policy, and for societal ethics—to change the border between a social and a health problem? The moral, the political, and the medical are culturally interrelated, but how do we best interpret that relationship and its implications?
—Arthur Kleinman (1995, p. 16)

Having trained at the world’s oldest psychiatric hospital, The Bethlem Royal Hospital in London (founded in 1247), associated with the Institute of Psychiatry and the Maudsley Hospital (founded in 1948) of the University of London, and at two prestigious North American psychiatric hospitals—the Allan Memorial Institute (founded in 1940) associated with McGill University in Montreal, and McLean Hospital in Belmont, Massachusetts (founded in 1811), associated with Harvard University, I have developed something of a perspective on psychiatric history. Several of my papers and books touch on aspects of psychiatric history (family therapy, Di Nicola, 1985a, 1985b, 1997, 2011; social psychiatry, Di Nicola, in press) or the history of psychiatric phenomena (anorexia nervosa and culture-bound syndromes, Di Nicola, 1990a, 1990b, 1992; posttraumatic stress disorder, Di Nicola, 1996).

Di Nicola, VF. Family therapy and transcultural psychiatry: an emerging synthesis. Part I: the conceptual basis. Transcultural Psychiat Res Rev. 1985a;27(2):81-113.

Di Nicola, VF. Family therapy and transcultural psychiatry: an emerging synthesis. Part II: portability and culture change. Transcultural Psychiat Res Rev. 1985b;27(3):151-180.

Di Nicola, VF. Anorexia multiforme: self-starvation in historical and cultural context. Part I: self-starvation as a historical chameleon. Transcultural Psychiat Res Rev. 1990a;27(3):165-196.

Di Nicola, VF. Anorexia multiforme: self-starvation in historical and cultural context. Part II: anorexia nervosa as a culture-reactive syndrome. Transcultural Psychiat Res Rev. 1990b;27(4):245-286.

Di Nicola, VF. De l’enfant sauvage à l’enfant fou: a prospectus for transcultural child psychiatry. In: Grizenko N, Sayegh L, Migneault P, eds. Transcultural Issues in Child Psychiatry. Montreal, QC: Éditions Douglas; 1992:7-53.

Di Nicola, VF. Ethnocultural aspects of PTSD and related disorders among children and adolescents. In: Marsella AJ, Friedman MJ, Gerrity ET, et al, eds. Ethnocultural Aspects of Posttraumatic Stress Disorder: Issues, Research, and Clinical Applications. Washington, DC: American Psychological Association; 1996:389-414.

Di Nicola, VF. A Stranger in the Family: Culture, Families, and Therapy. New York, NY and London, UK: W.W. Norton; 1997.

Di Nicola, V. Letters to a Young Therapist: Relational Practices for the Coming Community. New York, NY, and Dresden, Germany; 2011:149-162.

Di Nicola, V. Family, psychosocial, and cultural determinants of health. In: Sorel, Eliot, ed., 21st Century Global Mental Health. Burlington, MA: Jones & Bartlett Learning; in press.

Kleinman, A. Writing at the Margin: Discourse Between Anthropology and Medicine. Berkeley, CA: University of California Press; 1995.

History of Psychiatry

Tom Burns. Psychiatry: A Very Short Introduction. Oxford: Oxford University Press, 2006.

Diego De Caro. 1997. La Psichiatria Attraverso I Secoli. Napoli: Casa Editrice Idelson.

Edward Shorter. 1997. A History of Psychiatry: From the Era of the Asylum to the Age of Prozac. New York, NY: John Wiley & Sons.

Jurandir Freire Costa. 2007. Historia da Psiquiatria no Brasil. Rio de Janeiro: Garamond.

Michael H. Stone. 1997. Healing the Mind: A History of Psychiatry from Antiquity to the Present. New York, NY: W.W. Norton & Co.

Edwin R. Wallace IV, John Gach, eds. History of Psychiatry and Medical Psychology. New York: Springer, 2008.

Franz G. Alexander and Sheldon T. Selesnick. 1966. The History of Psychiatry: An Evaluation of Psychiatric Thought and Practice from Prehistoric Times to the Present. Introduction by Jules H. Masserman. New York, NY: Harper & Row.

The subtitle makes my argument quite clear: the history of psychiatry is not the history of madness or even of a professionally defined psychiatric disease but rather of “psychiatric thought and practice.”
A scholarly journal, History of Psychiatry, is published in collaboration with the UK’s Royal College of Psychiatrists.

Then there are more specialized histories:

Henri F. Ellenberger. The Discovery of the Unconscious: The History and Evolution of Dynamic Psychiatry. New York: Basic Books, 1970.

Eliot S. Valenstein. 1986. Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness. New York, NY: Basic Books.

Michael Shepherd, ed. Psychiatrists on Psychiatry. Cambridge: Cambridge University Press, 1982.

Robin M. Murray and Trevor H. Tanner, eds. Lectures on the History of Psychiatry. London, UK: Gaskell/Royal College of Psychiatrists, 1990.

Three volumes are of historical interest in that they document the history of “anti-psychiatry” and a mainstream academic psychiatrist’s rebuttal:

Robert Boyers and Robert Orrill, eds. Laing and Anti-Psychiatry. Harmondsworth, Middlesex: Penguin Books, 1972.

David Ingleby, ed., Critical Psychiatry: The Politics of Mental Health. Harmondsworth, Middlesex: Penguin Books, 1981.

Antony Clare. Psychiatry in Dissent: Controversial Issues in Thought and Practice. Foreword by Michael Shepherd. London: Tavistock Publicationsm, 1976.

History of Madness

The texts dealing with the history of psychiatry are quite different than these below, which attempt to outline a history of madness, such as Roy Porter’s anthology, The Faber Book of Madness (1991).

Dale A. Peterson. 1977. The Literature of Madness: Autobiographical Writings by Mad People and Mental Patients in England and America from 1436-1975. Stanford University PhD.

Dale A. Peterson, ed. 1982. A Mad People’s History of Madness. Pittsburgh, PA: University of Pittsburgh Press.

Roy Porter. 1987. A Social History of Madness: The World Through the Eyes of the Insane. New York: Weidenfeld & Nicholson.

Roy Porter, et al., eds. The Anatomy of Madness. 3 vols.

Andrew T. Scull. 1979. Museums of Madness: The Social Organization of Insanity in Nineteenth-Century England. London, UK: Allen Lane.

Andrew Scull, ed. 1981. Madhouses, Mad-Doctors, and Madmen: The Social History of Psychiatry in the Victorian Era. Philadelphia, PA: University of Pennsylvania Press.


None of the foregoing texts in this section on the history of madness, however, approaches the scope and reach of Foucault’s investigations into the discourse of madness.

Two of Foucault's original French texts have been elaborated in English editions:

1.     Maladie mentale et personnalité. Paris: Presses Universitaires de France, 1954.
Maladie mentale et psychologie. Revised edition. Paris: Presses Universitaires de France, 1962.

English editions:
Mental Illness and Psychology. Trans. Alan Sheridan. New York: Harper Colophon Books, 1976.

Madness: The Invention of an Idea. Alan Sheridan. New York: Harper Perennial Modern Thought, 2011. Reprinted with a new title.

2.     Folie et Déraison/Histoire de la Folie

First published in French as Folie et Déraison: Histoire de la
folie à l’âge classique. Paris: Librarie Plon, 1961.
A new French edition with a new preface by Foucault, along with appendices appeared as Histoire de la Folie à l’âge classique. Paris: Éditions Gallimard, 1972.

English editions:
Madness and Civilization: A History of Insanity in the Age of Reason. Trans. Richard Howard. New York: Random House, 1965; New York: Vintage Books, 1973. Abridged version of Histoire de la Folie.

History of Madness. Edited by Jean Khalfa, Translated by Jonathan Murphy and Jean Khalfa. London: Routledge, 2006. This edition is a translation of: Histoire de la Folie à l’âge classique (1972) with a Foreword by Ian Hacking, an Introduction by Jean Khalfa, the Prefaces to the 1961 and 1972 editions, as well as several scholarly appendices by Foucault:
“Mon corps, ce papier, ce feu” and “La folie, l’absence d’oeuvre” (Paris: Editions Gallimard, 1972); 
“Reply to Derrida” from Michel Foucault, Dits et Ecrits Vol II (Paris: Editions Gallimard, 1994)

Until recently, no one has actually tried to allow “madness” itself to speak, although Foucault approached this task by allowing texts to speak the discourse of madness. Foucault did give voice to the historical narrative of a murderer, adopting the first person in his title: “I, Pierre Rivière, having slaughtered my mother, my sister, and my brother”: A Case of Parricide in the 19th Century (1982). In Foucault’s footsteps, Dale Peterson edited A Mad People’s History of Madness (1982) and Roy Porter wrote A Social History of Madness: The World Through the Eyes of the Insane (1987). In that work, Porter states that:

what the mad say is illuminating because it presents a world through the looking-glass, or indeed holds up the mirror to the logic (and psycho-logic) of sane society. It focuses and puts to the test the nature and limits of the rationality, humanity and “understanding” of the normal. In that sense, the late French philosopher Michel Foucault was quite right to insist that the history of unreason must be coterminous with the history of reason. They are doubles. (Porter, 1987, p. 3)

With much appreciation for the tasks that Foucault and Porter set for themselves, I do not see history this way, much less “madness and civilization,” “reason and unreason,” or psychiatry as a profession or as a subject. As a social and cultural psychiatrist, I hold with Ivan Illich’s view (clearly informed by the anthropology of Clifford Geertz):

Man, unmodified by a particular place and companionship, simply does not exist. He has never existed in this skinned condition, nor could he, by the very nature of the case, ever survive in this way. (Illich, 1975, p. 87)

All of these terms may be usefully scrutinized using Giorgio Agamben’s (2009) method of philosophical archaeology, which owes much to both Foucault and Freud. While there are many outstanding historians of psychiatry who produce fine texts, there are few historians of madness, much less interrogations of the notion of madness as such, as is revealed in the debate between Derrida and Foucault. Foucault’s critical argument is that philosophy does not and cannot take “the event of madness” seriously, which is why he treats philosophy with disregard (“my casual indifference towards philosophy,” Foucault, 2006, p. 578). I believe that psychiatrists do take “the event of madness” seriously but Foucault was no doubt sceptical about this claim and the capacity of the profession or historians of psychiatry to capture that event or discourse. Ironically, no one has influenced the contemporary imagination of madness or its history, notably among academic psychiatrists, more than he did. Oxford social psychiatrist Tom Burns’ (2006) very short introduction to psychiatry is reasoned, balanced and recognizes this. A counter  irony is that of all the texts cited here, my fellow Canadian, Ned Shorter, who is not a psychiatrist, adopts the most positivistic, evidence-based orientation to the history of psychiatry and is most critical and dismissive of both Foucault and Laing.

My main thesis here can be stated succinctly:

The history of psychiatry is not the history of madness.

I do not believe this has been said in quite this way and quite so clearly. Historians and other scholars have carped about Foucault’s failings as a historian or scholar in his twinned history of madness and reason. Historians of psychiatry seem to consciously or unknowingly conflate the history of a profession or of the historical and cultural evolution of our understanding of madness with madness itself and its permutations over time and across cultures. Even to try to tell the “coterminous,” two-faced, twinned or mirrored history of reason and madness is not the same as the histories of these two rather separate domains. The history of unreason, as Foucault and Porter would have it, and the history of understanding and treating this unreason are not two sides of a coin, mirror images, twinned, Janus-faced “doubles” or anything of the sort. At most, the history of psychiatry reflects aspects of the age of reason, as Foucault calls its, coming to terms with madness, but this is neither the history of madness nor a history of reason.

As I will argue in another work with the working title, “Psychiatry Against Itself,” my profession is in a state of constant turmoil, inventing or redescribing traditions, where Spinoza becomes “the first modern psychologist” (I’m guilty of that), grounding itself in this or that, as Kant tried to do for philosophy, and always ready to suture itself to its methodologies or theories. Very few have the courage to resist this suturing which they confuse with a grounding. When I first met R.D. Laing in 1976, he said, “I am not an anti-psychiatrist, I am an orthodox psychiatrist.” He gave the example of an archer aiming for the mark as an image of orthodox (Latin orthodoxus, from Greek, orthodoxos, from orthos, “straight, true, correct” and doxa, “opinion”) psychiatry. This left a strong impression upon me. Laing appealed to an audience of searchers, not rebels. He did not mean to end or even radically change psychiatry but to return it to its origins in order to understand the “knots” that humans are capable of getting themselves into (cf. Laing, Knots, 1970). His early work, The Divided Self (1960), was a brilliant and accessible distillation of the mainstream psychoanalytic thought at that time. There was nothing remotely heretical, radical or anti-psychiatric in this volume. He expressed ideas every bit as dense and complex as Lacan with several notable differences: Laing made selected clinical cases available as evidence of his approach, there was a coherence between the theory and the practice, and he wrote well.

Note: Anyone who retorts that opacity is a hallmark of French writing need only read Foucault and Badiou to be refuted. Unlike Lacan, any number of French thinkers write lucidly and compellingly, from Marie Cardinal to Foucault and Badiou, not forgetting Jean-Paul Sartre, Frantz Fanon, Albert Camus and Jean-Luc Nancy. On the other hand, a handful of British psychoanalysts of Laing’s era were particularly articulate and accessible—Anna Freud, Donald Winnicott and John Bowlby; all of them Laing’s teachers at the Tavistock Institute. (Note that Melanie Klein—whose basic ideas are very close to Lacan’s—is decidedly not in this list.)

Psychiatry, as a profession, bathes in the Heraclitan flux where all is change (and nothing changes). That, in my understanding, is the real history of psychiatry. It has almost nothing to do with madness and is not in itself a chapter of reason, although it does reflect a great deal about the sociology of knowledge in Karl Mannheim’s sense.

In a forthcoming chapter on family, cultural and psychosocial determinants of health for a textbook on social psychiatry for students of public health (Di Nicola, in press), I offer a historical overview of how expressions of human distress are shaped by historical and sociocultural factors:

Madness always models itself in the image of the very civilization it 
—Cesare Lombroso (1927/1856, p. 67, my translation)  

Each era has emblematic expressions of human distress. In a prescient essay in 1856 on the reciprocal influences of madness and civilization, psychiatrist and criminologist Cesare Lombroso (1927/1856) had the germ of an idea that was taken up a century later by Michel Foucault (1973) in Madness and Civilization, elaborated in transcultural psychiatry with the notion of culture-bound syndromes (CBSs, see Di Nicola, 1990a, 1990b), and refined by Ian Hacking (1995, 1999), a philosopher of science with his notion of “looping effects.” (Adapted from the original)

Agamben, Giorgio. Philosophical archaeology. In: The Signature of All Things: On Method (trans. by Luca D’Isanto with Kevin Attell). New York: Zone Books;2009:81-111, 119-121 (Original published in Italian in 2008)

Di Nicola Vincenzo F. Anorexia multiforme: self-starvation in historical and cultural context. Part I: self-starvation as a historical chameleon. Transcultural Psychiat Res Rev. 1990;27(3):165-196.

Di Nicola, Vincenzo F. Anorexia multiforme: self-starvation in historical and cultural context. Part II: anorexia nervosa as a culture-reactive syndrome. Transcultural Psychiat Res Rev. 1990;27(4):245-286.

Di Nicola, V. Family, psychosocial, and cultural determinants of health. In: Sorel, Eliot, ed., 21st Century Global Mental Health. Burlington, MA: Jones & Bartlett Learning; in press.

Foucault, Michel. Madness and Civilization: A History of Insanity in the Age of Reason. Howard R, trans. New York, NY: Vintage Books; 1973.

Hacking, Ian. The looping effect of human kinds. In: Sperber D, Premack D, Premack AJ, eds. Causal Cognition: An Interdisciplinary Approach. Oxford, UK: Clarendon Press; 1995:351-383.

Hacking, Ian. The Social Construction of What? Cambridge, MA: Harvard University Press; 1999.

Illich, Ivan. Medical Nemesis: The Expropriation of Health. London: Calder & Boyars; 1975.

Laing, R.D. The Divided Self. London: Tavistock Publications; 1960.

Laing, R.D. Knots. London: Tavistock Publications; 1970.

Lombroso, Cesare. Influenza della civiltà nella pazzia e della pazzia nella civiltà. In: Lombroso G., ed. Psicologia e Natura. Studi Medico-Psicologico-Naturalistici. Torino: Fratelli Bocca, Editori; 1927:52-67. (Original essay published in 1856)


1 comment:

  1. As a postscript to my blog, I wanted to add this thought from a fine English writer who not only wrote Science Fiction and experimental prose (eg, The Atrocity Exhibition) but a finely wrought childhood memoir (Empire of the Sun) ...

    The history of psychiatry rewrites itself so often that it almost resembles the self-serving chronicles of a totalitarian and slightly paranoid regime. One-time pioneers are suddenly demoted and deemed to be little more than package tourists.

    —JG Ballard, A User’s Guide To The Millennium (1996)