Can the history of madness change the way we think about mental illness today?This is one of the questions that led Andrew Scull, distinguished Professor of Sociology at UC San Diego, to write his new book Madness in Civilization, a study of over 3000 years of madness as documented throughout history.
Beginning with the Bible and the Ancient Greeks, moving through the Middle Ages, and bringing the reader all the way up to contemporary psychiatry, Scull's book notes how, although madness may have been stigmatized over the past millennia, it has also, at times, been considered a path to truth.
Scull warns that, when it comes to mental illness, our biochemical understanding of it isn't necessarily exhaustive. Rather, he argues, it has multiple dimensions that can be understood through culture and politics. As such, there is and probably never will be one "happy pill" that can create a blissful state for all of us, like some sort of real-life soma. However, considering how overmedicated we are as a society, maybe we want just that.
We caught up with Scull to find out more about his historical and sociological investigation into mental health.
VICE: Hi, Andrew. Firstly, why did you choose the term "madness" instead of, say, "mental illness"? What do you mean by "mad"?
Andrew Scull: I thought long and hard about whether it would be the right choice. It's a complicated issue. Language surrounding mental illness is very complex and, very often, one of the central features of "madness" through history is that it comes with stigmas attached. On top of the initial suffering of the afflicted person who loses touch with our consensual reality or becomes profoundly and emotionally disturbed, there is this extra level of societal condemnation that often comes with the use of words like "madness."
But I think the reason "madness" is the appropriate term rather than "mental illness" is that, for much of history, "mad" or some cognate of it really was the word that was used. It was really only in the modern era, in the 19th and more importantly in the 20th century, that we began to move away from it.
The stigma surrounding mental illness still very much exists, though. Even if it is getting better.
I think it is unfortunately a recurring feature, yes. Many of us have experienced moments or even periods of deep emotional turmoil or have made odd experiences of reality—if you get drunk, for example. So we are all, in a way, aware that our own taken-for-granted assumptions about the world are actually much more fragile than we like to let on. And often, people who are disturbed act in ways that really upset these assumptions that we need to communicate with one another. Some mentally ill people may be threatening in a direct sense—for example, when they seem to be violent. But even if not, there is a kind of damage to the texture of relationships that is very disturbing to most of us around him or her.
Do we need that segregation, though, on some level? By labeling someone as "mentally ill" or "mad," we can reassure ourselves—wrongly or rightly—that we are "normal"?
That is a common trope within academic thinking of all kinds of deviances. We define who we are not so much positively as negatively. A bit like this: "Whatever we are, we're not like that or them." Obviously madness can be an exemplar of that. But what troubles me with going down that route is that there is a reality of mental disorder which seems to be denied in that kind of thinking. In the 1960s and 70s parts of the social sciences denied the reality of mental disorder. That was present also within psychiatry. Some would think madness was a myth. Others would claim that schizophrenia was a kind of super-sanity. I refer to that kind of talk as romantic nonsense.
One of the great themes of the book is how much culture and politics influence who gets defined as mad and how they get treated, and I try to bring across the amount of suffering that mental illness brings both on the patient and their peers. It's also interesting to look at the Soviet Union in its declining years, and how the "madness" label was used as a political weapon. People were defined as "mad" simply for being willing to critique the powers. Something like that is very dangerous.
Over time, most industrialized countries have deinstitutionalized those with mental illness by closing the asylums, and that increasingly became regarded as part of the problem. So those who were deemed "mad" before, and therefore had to be locked away, are now free again.
The asylums have widely been replaced by what is called "community care." There was much to be troubled about in the asylum world. Patients were shut away, were extraordinarily vulnerable, and were deprived of their legal rights. They had no voice. Much of it was truly frightful.
The other side of the coin, though, is that the old asylums did provide some help. They gave people a roof over their head, provided some food, clothing, and some degree of attention. "Community care" has proven to be a bit of an Orwellian term, though. There isn't much community and certainly no care for many mental health patients.
In California, the largest conglomeration of mental patients is in the Los Angeles County Jail, and it's not clear whether that setting really is an improvement of the old state hospitals. Many homeless people have mental health issues, too, but they've been abandoned to their fate. We've grown accustomed to people in psychosis living on the streets. It's a neoliberal hell we've invented.
Is madness a universal disease, then, or only a problem of civilized man?
Obviously I'm no expert on every single society, but in most of the societies I know of there are people with mental health conditions. In terms of either extreme emotional distress and withdrawal or people whose sense of the world is clearly radically different from the rest, this is, in some sense, a universal. Although obviously the nature of somebody's hallucinations or delusions vary according to the culture.
But you wouldn't flatly dismiss the idea that mental illness is a social construct?
I don't completely dismiss the notion that there is some arbitrariness in the way in which we come to use labels like "mentally ill." Nor am I saying that the social and the cultural aren't terribly important. One of my main criticisms of contemporary psychiatry is that it has eviscerated the notion of madness having meaning. In fact, it has resorted to this very crude biological reductionism...
Which means that everything is explained merely according to biology...
We need to try to walk a middle ground. Merely treating these disturbances as an indication that the brain is "wrongly" wired or that you were born with the "wrong" genetic make-up ignores that, in many ways, the disturbances are socially and culturally embedded conditions.
The idea that we will find some simple biochemical cure like a psychiatric penicillin is, I think, a pipe dream.
How, then, should we think about the power of something like the American Psychiatric Association (APA)? Because their guidelines on psychiatry are pretty much implemented throughout the world.
That's a fair point. One of the reasons I think the APA's view has become hegemonic is because of the way it links up with drug treatments and the way in which the treatment of mental illness has tended to be associated purely with trying to manipulate brain-biochemistry. Often in very crude ways, actually. That is an important concern.
The APA is mostly in favor of biological reductionism. The problem for the reductionists, though, is that they don't have clear-cut biological explanations. They keep saying they're right around the corner, but we've been hearing that song for hundreds of years. I'm skeptical that we'll ever be able to explain mental illness exclusively in terms of biology.
So there might never be this "cure" for madness that many of us seem to be looking for?
Right. What we have at present is a series of patches: symptomatic treatments that work more or less well. Some work badly and inflict further harm. For many people, medication means that they can have an almost normal life, but mental disorders have multiple causes and multiple dimensions, so the idea that we will find some simple biochemical cure like a psychiatric penicillin is, I think, a pipe dream.
Do you think we're starting to pathologize normal, everyday problems more?
There is some truth to that idea. Psychiatry is not just an imperialistic profession pushing its will on a resistant population. Often people are authors of their own involvement with psychiatry. Not always, of course, but we have grown up in a world where, for the last 20 years, we've been taught that the reason people get depressed is because their brain chemistry is messed up, so they need more serotonin. Some people think: Wouldn't it be nice to have some pill to be happy all the time? But anyone who deals with philosophy knows that there are deep debates about whether it's better to be fake-happy or, rather, to allow some suffering and maybe even gain wisdom from it.
Madness, as you mention in the book, was sometimes even seen as a path to truth.
Yes, for some people that was certainly the view. It's also true if you look at ancient Judaism and their prophets—it was highly ambiguous whether to regard the "mad" as divinely-inspired or, simply, crazy. Likewise, in the Christian tradition there is the idea of the "holy fool." In some indigenous or shamanistic cultures people like to ingest hallucinogenic mushrooms because they see that as a valuable expansion of their minds.
Then there's the enduring debate on the relationship between madness and the "genius." In the 18th century, people often regarded madness or nervousness as something that afflicted only those with the most elaborate nervous systems. But just a century later the relationship between madness and civilization is completely flipped. In the aftermath of Darwin, the idea becomes widespread that those with mental illnesses are an evolutionary throwback. We know all too well where that logic led in Nazi-era Germany.
Absolutely. Reading about how people have reacted to madness in your book over time—particularly in the 20th century with lobotomy and electroshock therapy—it made me wonder: Why have we reacted in such cruel ways when confronted with mental illness?
It's extraordinary. Very often, the treatments for mental illness seemed to have a sadistic component to them. But that's not universally true. There were periods where people tried to approach the matter diligently, with understanding, and humanity. But much of the time we have seen spinning devices, near-drowning, lobotomy, electroshocks applied to tongues and genitals—all inflicting immense pain. Maybe it was because we were so afraid of what the mentally disordered represented. So we seemed—and still seem, to some extent—determined to force them back to the same common-sense reality that we think we all share. One of the things I hope the book puts across is that mental illness is, for the most part, still such a profound mystery. We have only the most tentative of understanding of it.
'Madness in Civilization: A Cultural History of Insanity' by Andrew Scull is published by Princeton