Madness and Method

Traditional histories of psychiatry, and those which preface the standard medical textbooks on the subject, are good examples of Whiggish historical writing. The dark ages for madness last until the end of the 18th century when Pinel’s dramatic removal of the chains of lunatics at Bicêtre, and the establishment of the York Retreat by William Tuke, inaugurate the psychiatric enlightenment. The development of the asylum bears witness to the increasing ability to distinguish between the mad and the poor, idle and criminal classes, and to attempts by various reformers, notably the Tukes and John Conolly, to institute a system of humanitarian care for their patients. After these early steps away from the cruel and barbarous treatment of the mad of the preceding centuries, the medical profession began the process of putting the treatment of the mental illnesses on a more scientific footing. The 19th century saw the identification of a number of organically-based mental diseases, while the early 20th century saw the development of a scientific psychological medicine, informed by the writings of both Meyer and Freud, which could integrate non-organic factors into the aetiological picture of the various conditions. More recently, the development of ECT and the post-war chemotherapy revolution have made possible the management of patients in the community and a partial phasing-out of the now decaying institutions in which they had been housed. While much remains to be done, there can be no doubt that the treatment of the mentally ill has advanced immeasurably since the dark days of the 19th century and before, when the mad were chained, whipped, imprisoned in straw-strewn cells, and exhibited to a curious public for the price of a penny.

This ‘in-house’ account of the history of psychiatry has been subjected to wide-ranging criticism by a generation of sociologists and historians who were influential in or influenced by the anti-psychiatry movement of the 1960s and early 1970s. The orthodox view has been inverted: the ‘dark ages’ are re-characterised as a period in which the existential moment of madness was allowed free play; the era of moral management led by Pinel and the Tukes is seen as substituting ‘mind-forged manacles’ of guilt and self-control for the chains of the old order; the incarceration of the insane in asylums, and their subjection to the ever watchful gaze of their keepers, emerge as part of a broader development of administrative machinery for the maintenance of social control through the surveillance and discipline of the subject populations of modern bureaucratic states. The medical profession enter the scene as empire-building moral entrepreneurs seeking to enlarge their domain of practice. Instead of being a site for the display of psychiatric expertise, the asylum is the ‘condition of possibility’ for this expertise. It acts as a receptacle for those who fail to conform to the rules and conventions of society – a heterogeneous collection of rebellious, socially inadequate, distressed and disruptive individuals. Psychiatric classification comes into being to order this polymorphous mass of the socially perverse. Medical methods are applied to a problem of social order; social deviance is taken as indicative of organic pathology; and the social and moral order is thereby transformed into a natural order of human behaviour. This transformation has wider implications: conformity signifies health, deviance sickness; to diagnose madness is to lay down the law, while to attempt to treat it is to reaffirm the unequivocally rational nature of the social order. If traditional histories of psychiatry are Whiggish, anti-psychiatry histories (particularly that of Michel Foucault) are often relentlessly pessimistic: while the former insist upon our developing grasp of psychiatric conditions, the latter see only our developing conditioning by the therapeutic state.

Anne Digby’s monograph on the history of the York Retreat, and the two volumes of essays edited by Bynum, Porter and Shepherd, pay eloquent testimony to the transformation effected in the history of psychiatry over the last twenty or thirty years. The works of Foucault, Erving Goffman, Thomas Szasz and R.D. Laing, and more recently the contributions of Andrew Scull and a new generation of historians, have made it impossible to accept the Whig view of psychiatry’s history. Yet, if these writers have managed to convince historians that work in the subject must take account both of the wider social and political context and of the methodological and philosophical problems involved in the history of ideas and the philosophy of science, they have not succeeded in establishing a convincing alternative framework for the field. One reason for this, as the editors of The Anatomy of Madness argue in their Introduction to Volume One, is that we are still sufficiently ignorant about most aspects of ‘madhouses, mad-doctors and madmen’ to leave the field wide open for substantial revaluation of existing claims. Any such revaluation must depend on detailed empirical work – much of which remains to be done – and on conceptual revision. The essays in The Anatomy of Madness, and Digby’s monograph, make valuable contributions in both respects. They are not intended to provide a single vision: the essays are aptly characterised as a ‘dispatch from the front’, and are offered as a ‘stimulus’ and ‘irritant’ for those working in the field. The result is a collection of pieces which are heterogeneous in their subject-matter, methodological commitments and conclusions. There is ample justification for this heterogeneity, as the editors indicate: ‘The mix of depth, detail and diversity to be found here reveals a complex historical fabric, and raises again and again the problems which historians must face in relating intentions to outcomes, science to ideology, knowledge to control, and the overt to the latent functions of actions and institutions.’ This is not editorial licence. The essays do indeed engage in different ways with the complex problems faced by a sociologically and philosophically-informed historiography; most do so in an informative and challenging way, some do so with considerable flair. While most pieces have some virtues, some are really exceptionally good.

Ruth Harris’s account in Volume Two of the feud between Charcot’s Paris school and Bernheim’s coterie at Nancy, over the value (and risks) of hypnosis and the nature of the hypnotic state, moves elegantly from an account of one of France’s more sordid murders, where the murderess claimed to be acting on hypnotic suggestion, to a thoroughly compelling account of the intellectual, social, political and sexual climate of late 19th-century France, and of the anxieties which fuelled the controversy and generated intense public interest. Ian Dowbiggin’s piece of hereditarianism in French Psychiatry from 1840-90 (Volume One) explains how the concept of morbid heredity served the interests of the profession at a time when it was under attack from various sections of French society. It promoted professional unity by reconciling somaticists and psychologists; it enhanced the scientific image of practitioners by allowing them to demonstrate affinities with other biomedical sciences; and it also enabled the profession to demonstrate its social, political and religious orthodoxy. Both Harris and Dowbiggin thus make strong cases for recognising the central role which social factors play in theory construction and theory choice in the history of psychiatry.

The pressures for a social analysis (or an ‘external account’) of the theories and practices of psychiatry are deftly illustrated by Andrew Scull’s contribution (Volume One) on the vicissitudes of John Conolly’s career. Conolly was one of the first psychiatrists to attack the use of asylums in the care and treatment of the mentally ill and to advocate a system of domiciliary care in their place. On the Whig view, his ideas need no further explanation, since he correctly analysed the problems posed by the asylum. However, it is only in his early work that he puts forward this view. He switched to a wholehearted defence of the asylum, and in his last years of professional activity he was moved to defend the system of private asylums which he had attacked so scathingly. Scull shows that we can account for Conolly’s change of heart in one of three ways: we can invoke self-interest, since his change of views brought him great renown and considerably improved his financial position; we might argue that the change reflected his wider experience in the treatment of the mentally ill (but this suggests that his place amongst psychiatry’s heroes has been awarded under false pretences, since the argument assumes that Conolly was right to come to see his system of domiciliary care as impractical); or we can argue that he simply came to share the beliefs of medical science as it then was. Whichever line of argument is taken, the Whig view stalls, and the historian is forced beyond the internal logic and validity of the beliefs in question to an account which recognises the influence of external, social factors in the theories and practices of psychiatry.

Martin Stone’s piece on the impact of shell-shock on British psychiatry provides further evidence against the view that changes in psychiatric theory and practice reflect the relentless progress of scientific knowledge. He argues that shell-shock played a major role in forcing the transition from a late 19th-century psychiatry with commitments to organic pathology and the concept of degeneration (also discussed from different angles by both Bynum and Dowbiggin) to a more psychologically-orientated approach which moved the diagnosis and treatment of the neuroses into the mainstream of modern psychiatry. The rapid and widespread development of forms of mental and physical breakdown at the front presented major practical problems. Symptoms included paralyses and muscular contractures of the limbs and extremities; loss of sight, speech and hearing; the development of choreas, palsies and tics, mental fugues, catatonia and obsessive behaviour; and instances of amnesia, severe sleeplessness and terrifying nightmares. Army discipline at the front was under threat, while behind the lines administrators and medical personnel faced a growing population of men unfit for any kind of work who would need to be pensioned-off. Psychiatrists also faced the task of explaining how England’s finest blood had turned out to be especially susceptible to breakdown, when they were accustomed to seeing mental illness as indicative of some form of degenerate heredity. The essay carefully traces the arguments and counter-arguments which were marshalled to explain shell-shock – and shows that their practical implications varied widely. How a man’s condition was labelled could make the difference between appearing before an Army tribunal for malingering or worse and being reported sick. Moreover, how the illness was labelled could make a substantial difference to the individual’s pension entitlements. Stone concludes with an account which locates the aetiology of shell-shock in the organisation of Army life and work and the special conditions experienced in trench warfare. He is thus able to avoid the kind of conspiracy theory generated by sociologists who combine labelling theory with agnosticism towards mental illness, and offers instead a sophisticated and persuasive account of the social construction of a mental illness.

In addition to the contributions by Stone and Harris, Volume Two of The Anatomy of Mental Illness has essays on 19th-century psychiatry in Italy and Sweden; four pieces on particular asylums (Anne Digby on the Retreat, Charlotte Mackenzie on Ticehurst, Patricia Allderidge’s trenchant corrective to some of the myths surrounding the practices at Bethlam, and John Walton’s discussion of admission and discharge practices in the Victorian era, which draws on evidence from Lancaster Asylum); work on the relationship between psychiatrists and the Lunacy Commission, psychiatry’s involvement in the 18th-century courtroom, and a brief but perceptive piece by Fiona Godlee on the transition which Quakers underwent from religious ecstatics (or ‘good madmen’, as M.A. Screech terms such states in Volume One) to humanitarian-asylum keepers.

These essays and Anne Digby’s monograph on the Retreat add to our understanding of the development and activities of psychiatric institutions in the 19th century and allow us to see the shortcomings in both the old and the newer orthodoxies of the field. In her painstaking account of the Retreat, Anne Digby takes issue with Foucault’s claim that the system of moral management initiated there released patients from their chains only to shackle them with psychological restraints. On Foucault’s view, the mad came to be seen as wayward children requiring socialisation within the ‘family’ (i.e. the Retreat) until they could behave in a way which demonstrated their attainment of the age and state of reason. Foucault’s account of the Retreat (drawn entirely from Samuel Tuke’s Description of the Retreat of 1813) forms part of a larger canvas depicting the transition from an age where madness and reason used the honest weapons of coercion in their manichaean struggle (with each paying the other its due as a worthy opponent), to the modern period, in which madness is thoroughly invalidated and the madman relentlessly subjected to the demands and rule of reason. In the clinical world of scientific rationalism there can be no place for the ‘good madness’ which Screech ascribes to Christ and St Paul. Against such wide-ranging claims, Digby takes the prudent course of attempting to construct a detailed picture of the regime in operation at the Retreat. She shows that mechanical forms of restraint were used, though sparingly, throughout the first fifty years of its existence, but that the primary emphasis was indeed upon inducing more acceptable forms of behaviour. However, while the process of socialisation did have disciplinary and moralistic overtones, this seems to have been less ‘a systematic imposition of institutional rules’ and more ‘an expression of shared Quaker values’ (shared, that is, by inmates and staff). It is only in the middle of the 19th century, as the Retreat grew in size, as its therapists changed, as ever larger proportions of non-Quaker patients were admitted, and as it faced pressure from the Lunacy Commissioners, visitors and changing public opinion, that the overt coercion of mechanical restraint is replaced by techniques of social management. And it is only from this time that claims about the psychologically coercive and punitive nature of the system of moral management can be fully justified. Digby hardly provides a cast-iron refutation of Foucault’s changes (indeed, it is not obvious that this can be done), but the central moral of her work (and that of her co-contributors) is not so much that the architectonic theorists are entirely wrong, as that an attention to detail and to dusty archives reveals a much more complex and nuanced picture of the management of madness in the 19th century. The end-result is to make a critical account of this management more persuasive, while making a wholesale denunciation of it substantially less credible.

The distinction between ‘people and ideas’ and ‘institutions and society’ which is used to differentiate the two volumes of The Anatomy of Madness is at best a rough one, as the editors admit. Yet, while there is a good deal of overlap, as the essays by Harris and Stone make clear, the division does capture an important difference. Historians of psychiatric institutions do not have to make judgments about madness; a rigorous neutrality on such questions is, up to a point, a perfectly acceptable methodological stance. But the same cannot be said of the study of ‘people and ideas’ in the history of madness. Historical accounts of the theories, terminology and classificatory schemes used in psychiatry must necessarily make judgments about the explanatory value to be attributed to the truth or falsity of the beliefs in question. This is particularly so when discussing changes in the intellectual apparatus of the discipline. To adopt a position of absolute neutrality on this question is equivalent to denying that madmen and their madness have any causal impact on the beliefs, attitudes and behaviour of those who encounter them – which is tantamount to denying that there are madmen or that there is such a thing as madness. It is not hard to see that such apparent neutrality tends to produce conspiracy theories. The historian must thus attempt to chart a course between absolute neutrality on the question of madness and a wholesale capitulation to current psychiatric orthodoxy. The former position denies an independent causal role to beliefs about madness, the latter denies that social explanation adds significantly to our understanding of the development of psychiatry: it may illuminate the byways of the field, but the main thoroughfare is amply charted by accounts of the progress of medical science.

Roy Porter’s sensitivity to this problem is acute. He prefaces his piece on Samuel Johnson’s melancholy by insisting: ‘It is not, after all, mad people who are the invention of psychiatry, but only the ways of classifying them.’ Moreover, ‘all cultures have recognised that there are individuals who are indisputably disturbed, pained, incapacitated, a danger to themselves or others. It is to do the mad a disservice, and to dissolve away the suffering of history by sleight of hand and a trick of words, to suggest that “madness” is wholly invented through just another kind of societal conspiracy.’ Porter’s insistence is doubly sensible. It makes sense given the state of the art in the sociology and history of psychiatry (one has only to read the later effusions of David Cooper to recognise that some very silly things are said about madness). But it also makes sense in that ample room remains for sceptical doubt about the existence of a set of culturally and historically-transcendent conditions of madness. One feels substantially fewer qualms about, for example, piles. With madness, once neurology has pared away those who have an identifiable lesion to show for their trouble, we are left with the problem of trying to account for the existence of a group of people who have thus far proved remarkably resistant to attempts to establish an organic basis for their differentiation from the rest of the population. In the absence of detectable organic pathology, psychiatrists turned to classifications based on observable and/or reportable disorders in psychological functioning. None of this makes the historian’s task any easier. A judgment is still required as to how far the identification of functional impairments is a culture- and observer-neutral exercise, and how far the clusters of functional signs and symptoms which form the basis for psychiatric classification really do manage to capture different groups of conditions – rather than being a case of pseudo-scientific, definitional fiat. Historians of psychiatry have to make judgments on these issues in conducting their research because the side they take in the various disputes will affect what they deem to be the central explanatory problem and the key explanatory variables.

The more solid and immutable we take madness or certain kinds of madness to be, the more it makes sense to devote the kind of careful attention to the reconstruction of successive transformations in the description and classification of given disorders which German Berrios gives to the obsessional disorders. He has no doubt that obsessional forms of behaviour ‘have been identified in most cultures and historical periods and cannot be said to be fictions created by 19th-century alienists’. Insisting on the invariable form of these behaviours allows Berrios to chart their progress from their place amongst the monomanias to their eventual classification as neurotic. Of course, if cross-cultural and trans-historical descriptions of obsessional behaviours are not possible, then there is no progress to be charted, and the changing classifications cannot be comprehended by the conceptual reconstruction which Berrios offers. Indeed, the problem can no longer be posed in the same way. Even if we acknowledge the invariability of obsessional forms of behaviour, and even if we hold that the signs and symptoms of other disorders are similarly objective, the externalist account still has a significant role to play. While the 19th century saw the establishment of an increasingly tight connection between diagnostic categories and the identification of structural disorders in neurology (a process which Bynum charts), a tighter classificatory scheme was attained in psychiatry only by breaking up the hitherto intimate connection between nosology and aetiology. (One result of their earlier intimacy had been the belief that the types and causes of madness were directly legible in the physiognomies of the insane – although, as Janet Browne points out in her account of Charles Darwin’s encounter with this approach, it seems that what the psychiatrist could see in the photographs of madmen was simply not visible to the layman.) This separation means that even if we acknowledge the objectivity of a natural history of madness, there remains the problem of accounting for the changing explanations offered of its causes and the inferred prescriptions for its treatment. Here external accounts have a natural entrée, since the explanation and treatment of madness have been notoriously underdetermined by both evidence and results. Bynum and Michael Neve’s piece on changing diagnoses of Hamlet, Anthony Clare’s examination of the clinical basis for Freud’s theoretical flights, Dowbiggin’s discussion of hereditarianism, Scull’s account of Conolly’s U-turns, and, more obliquely, J.P. Williams’s contribution on psychiatry’s brush with psychical research and Browne’s on physiognomy, all testify to this underdetermination and to the need for an externalist component in accounting for theory choice. Of course, the more doubts we harboured about the objectivity of psychiatric nosology, the further the externalist account can be extended.

The severing of classification from aetiology signalled the end of the dominance of rigidly organicist accounts of madness; it also reopened the case for attempting to understand the experience of madness, thereby beginning a fertile liaison between psychiatry and phenomenology which began with Jaspers and Binswanger and saw a considerable renaissance in the early works of R.D. Laing. In the hands of its more modern practitioners the project of understanding madness has been seen as undermining the value of psychiatric classification by providing a more authoritative account of madness itself. This approach is a tempting one for historians. It promises an account of madness free from the blinkering judgments of psychiatric classification and public prejudice. It also offers the inviting prospect of a yardstick against which to assess professional and lay judgments. Porter’s essay on Johnson bites this particular apple in attempting a reconstruction of Johnson’s first-hand experience of the terrors and anxieties which imperilled his sanity. He argues that we should not confuse the history of madness with the history of psychiatric practice, that madness is owed an attempt at an understanding free from the nomenclature and theoretical commitments of modern psychiatry, and that without this attempt we cannot attain the degree of detachment from psychiatry which is a necessary precondition for its adequate historical understanding. As we have seen, it is difficult to move far in the history of psychiatry without being forced to make judgments about the nature of madness. Porter reminds us that such judgments should be made, as far as is possible, in an informed way: ‘if we are to achieve a balanced and sensitive history of psychic affliction and its therapies we must change focus, even transpose subject and object, and start from the sufferers themselves.’

However, there is a further, inevitable twist in the study of the history of madness which Porter’s resounding conclusion rather obscures (although he himself sometimes seems aware of it). We cannot hope that the interpretative reconstruction of sufferers’ experience of madness will provide an unequivocal grounding for the critical analysis of psychiatric theories and procedures. As Johnson’s ‘case’ shows, an individual’s experience of madness cannot provide a privileged access to madness itself or to its causes. We cannot go beyond reported experience; and that experience and its expression is inevitably shaped and conditioned by the individual’s society and culture. Thus Johnson construed his disturbance in essentially theological terms, fearing that his reason – which he understood as the manifestation of his immortal soul – would be eclipsed by madness. Similarly, it would be surprising if more modern experiences of madness were not in part conditioned by our therapeutically-orientated culture (and Bynum’s piece on the nervous patient largely confirms this expectation). The experience of madness, then, cannot offer us an Archimedean point from which to evaluate our past and present practices because it is shaped by them – although it can remind us of the mental distress and torments which have been too often ignored in studies of the labelling of the mad. Moreover, the understanding of madness should not be confused with its explanation. When Porter argues that ‘it was religious fears precisely which raised those storms in Johnson’s mind and that jeopardised his reason,’ his shift from interpretative reconstruction to casual explanation relies on an unargued and ungroundable equation of symptom and cause (a conflation from which psychiatry has increasingly distanced itself).

The moral of all this is surely that no Archimedean point exists which can vouchsafe evaluations or ground judgments as to the rational acceptability of psychiatric theories or taxonomies. That this is so explains not only why there is no current methodological orthodoxy in the history of madness, but also why there can be no such orthodoxy. It is therefore entirely appropriate that no single set of commitments unites the essays in these two volumes. Each author must perforce exemplify (and thereby argue for) his or her considered judgments on the problems which frame the field of enquiry in the process of unfolding his or her narrative or explanation. It is a tribute to the acute historical and methodological sensibilities of the contributors to The Anatomy of Madness that their accounts and judgments are, for the most part, persuasive.