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In the beginning
Cultural history and poetry of madness
Babylon in all its despoliation is a sight not so awful as that of the human mind in ruins.
(Scrope Davies 1783â1852, Letters)
In all cultures and in all times, the perception of madness, possession or mental disorder has created a conflict between fear and compassion (Porter 1993). Scrope Davies, viewing the ruins of a once proud empire, Babylon, reflected this ambivalence and the tragedy of the âhuman mind in ruinsâ. This goes to the heart of the practice problem which, in a civilised society, should excite sympathy and a search for understanding. From the Old Testament, which feeds into the Christian, Islamic and Jewish faiths, we hear the psalmist hope that he will not be smitten by âthe moon at nightâ (Psalm 121). For to be âmoonstruckâ was a description of madness that echoed well into the nineteenth century, seen in the word âlunaticâ. Hence, in 1820, the Lunatic Asylum Act sought to give refuge to the afflicted, not least in recognition that even the highest in the land, the late King George III, like King Lear, had admitted that âI fear I am not in my perfect mindâ. The term âlunacyâ was used as late as 1890 in the Lunacy Act, which was concerned with the compulsory admission of âpoor lunaticsâ, and the term was not abandoned until the 1935 Mental Health Act.
The designation âlunaticâ reflected the assumption that the mad had been affected by malign lunar influences and, in this sense, was a diagnostic category. Another term which started as descriptive but became pejorative is âasylumâ. Originally meaning a place of ârefugeâ, a laudable concept for vulnerable people, the word and place rapidly became stigmatised.
Mental disorder remains one of the most stigmatised conditions throughout the world, even in modern Western societies (Shooter 2002). Our language and culture are still littered with earlier ideas that have become counterproductive, and the title of Kate Millettâs book The Looney Bin Trip, describing the old âasylumsâ, was both a challenge and an evocation for sympathy, reminding us that:
The old order changeth, yielding place to new;⌠Lest one good custom should corrupt the world.
(Tennyson, The Passing of Arthur)
For example, another progressive piece of legislation was the 1913 Deficiency Act, which took the âlearning disabledâ out of the old workhouses and gave them greater protection. Yet, no-one today would use the Actâs language of âmoron, feeble minded or idiotâ to describe another human as all civilised societies ascribe to one of the greatest monuments to human advancement, the United Nations Declaration of Human Rights 1948. True, the declarationâs principles are often ignored, but it is a measure of how we should behave towards each other, when it asserts that all people are equal, irrespective of any âcategoryâ:
Article 1: All human beings are born free and equal in dignity and rights.
They are endowed with reason and conscience and should act towards one another in the spirit of brotherhood.
Article 2: Everyone is entitled to all the rights and freedoms set forth in this Declaration, without any distinction of any kind such as race, colour, sex, language, religion, political or other opinion, national or social origins, property, birth or other status (my emphasis).
This bookâs search for an effective mental health practice is based upon this declaration. Since 1948, society has made great strides in recognising and renouncing discrimination against people of other ethnicities, religions, physical disability and differing sexual orientations, as well as beginning to recognise discrimination related to age, but there is a long way to go. In holding fast to our common humanity, the UN Declaration demands that we use the âintellect and reasonâ with which we are endowed to respond to anotherâs distress. This is heard in Robert Burtonâs (1577â1640) dramatic evocation of the wronged and manacled âlunaticâ in Anatomy of Melancholy:
See the Madman rage downright
With furious looks, a ghastly sight.
Naked in chains bound doth he lie
And roars amain, he knows not why!
Observe him; for as in a glass
Thine angry portraiture it was.
His picture keep still in thy presence;
âTwixt him and thee thereâs no difference.
Although Robert Burtonâs great classic is limited by the confines of late Tudor and Jacobean science, his approach was essentially humane, and was coterminous with Shakespeareâs great insight into the phenomena of the human mind, when he said:
Though this be madness, yet there is method inât.
(Hamlet; commonly quoted as âthere is meaning in his madnessâ)
Certainly, cultural factors have always fed a societyâs concept of madness or mental disorder (Pilgrim and Rogers 1998). This is seen in the example of âdelusionsâ. A popular cartoon image is of a deluded person believing they are Napoleon, yet I have never met such a person. But, among elderly patients, one could meet those who thought they were being persecuted by the Kaiser (Wilhelm II). Religious delusions are not uncommon, being taken over by God, the Virgin Mary or the Devil from those of a Christian culture; or the God Khali from those of a Hindu tradition; or Shaitan by Islamic people. Delusions reflect the contemporary culture, hence people express fear of âextraterrestrial aliensâ, of being controlled by television or of persecution by spies reflected in the brilliant film starring Russell Crowe, A Beautiful Mind. This film was based upon the true story of a Nobel laureate, John Nash, who suffered from what we now designate schizophrenia. In the film, you initially enter John Nashâs mind-set, so you believe, like him, that you are being kidnapped by the KGB, or was it the CIA?
It was Richard Titmuss who said, âreality begins with historyâ. In order to understand why our culture reflects such dissonance, we need to be aware of the origins of ideas about madness and the often contradictory and conflicting themes that came from earlier religious and scientific thinking.
As early as the second century BC, we hear the âpaganâ Terence (195â159 BC) declaim that, âNothing in mankind is alien to meâ. But the early Christian fathers found such acceptance of differences in others terrifying, as they feared that the mad were associated with witchcraft and demonic possession. Indeed, there was an association between possession and heresy in a society that increasingly demanded adherence to âorthodoxyâ, a forerunner of modern totalitarian ideas. Saints Augustine and Jerome have much to answer for; and the arch-Protestant, Martin Luther, was quite convinced that his low moods came from the devil and is reputed to have thrown an inkpot at âOld Nickâ. These archaic attitudes litter Western culture and, weekly in the tabloids, there are examples of unwelcome or socially disapproved of behaviour being described as mad, psychopathic and/or coterminous with evil.
Even in the twenty-first century, when reason and science rule, the typical Hollywood film creates an immediate fearful rapport with its audience when, to a background of tremulous strings, amidst the Victorian gloom, we see a man with staring eyes, muttering meaningless expressions and rambling fears of persecution: âThey are here, donât let them get me.â Then, looking directly at the audience, he asks, âHave you sent them?â And from his fear, we fear, as our subliminal cultural ambivalence about the mentally disordered is evoked.
We are still in the company of Euripides who said, âWhom the Gods wish to destroy, they first make madâ, echoing Daviesâ idea of the desolation and destruction that madness causes in humans. Yet, even in the Old Testament, not always associated with progressive ideas, we hear the call for a rational and knowledge-based approach in our dealings with each other, when Job declared:
Who is this that darkeneth counsel by words without knowledge?
It is salutary to consider how relatively recent is our science that began to sever us from some of the old superstitions. For example, it was only in 1859 that Charles Darwin published his Origin of Species and, previously, the majority of humankind had few doubts that they were the centre of the universe. Yet, within a hundred years of Darwin, we have atomic power and rocket propulsion and recognise that our little planet orbits âan unconsidered star at the edge of an unremarkable galaxy amongst billions of galaxiesâ (Greenpeace 1980). Indeed, we think nothing of recognising that some of these galaxies have distances across that we measure in thousands of light years (Bryson 2003), and even the late Pope, John Paul II, said that heaven and hell are not places but states of mind.
However, mental disorder has often been associated with apparent irrationality; hence, the contradictory issues of care and/or control have never been far below the surface. Furthermore, over the last 50 years, the pendulum has swung between âcertificationâ, which proved a person was âmadâ and was not capable of reasoning and self-control under the 1890 Lunacy Act, to the major breakthrough of concepts about âtreatmentâ, which was at the core of the 1959 Mental Health Act. This is still an important aspect of the present legislation, the 1983 Mental Health Act, although, unlike legislation concerning physical illness, âmental disorderâ still has elements of compulsion for a minority. The seminal breakthrough came in 1959, which was all about de-incarceration and treatment and the concept of âcare in the communityâ.
Younger colleagues who have never seen the horrors of the old mental hospitals, the old Bins, portrayed in Ken Loachâs film The Music Lovers, can have little idea of what they became. By the mid-twentieth century, those well-intentioned places of refuge had become dreadful palaces of despair. It is hard to imagine the sum of human misery they accumulated. Under the 1890 Act, tens of thousands of people were de facto locked up for life because they had been âcertifiedâ mad by a magistrate, not a physician, but no-one had considered how one âprovesâ oneâs sanity or which, if any, people should be discharged. The main approach was for a patient to abscond and survive outside for seven days without committing a crime; this was then taken as evidence that the person was mentally competent and therefore âsaneâ. The âasylumsâ were simply overwhelmed by the numbers of people admitted. Without any provision for discharge, admission under certification had created a cul-de-sac. People understandably feared and resisted admission, and posed a threat to staff who were afraid they would abscond, so staff and patients were on âdifferentâ sides, undermining any latent âtreatmentâ ideal. While numbers grew, resources shrank relatively. The overcrowding became so bad that many of the large county mental hospitals had their own TB hospital, as the incarceration took its toll in avoidable deaths (Jones 1959). In the old days, one would escort families to their dying relative in a psychiatric hospitalâs own TB hospital.
The idea of caring for people in the community was an incredible change. It was possible, in part, because of public confidence in the new psychotropic drugs. So that, within a little more than a decade, the number of people more or less permanently locked up in our mental hospitals was reduced from 220,000 to fewer than 70,000 in the 1990s, and now fewer than 30,000 (Department of Health 2002). It is a tribute to improved public perception, although it is still easy to evoke the old attitudes.
Both Mental Health Acts of 1959 and 1983 stressed âcare in the communityâ, which closed the large institutions, creating âpsychiatric unitsâ within the general hospital service. Although this was not perfect, it has gone a long way to reducing some of the stigma against the mentally ill, but there are still some areas that need improvement, not least adequate resources (Jones 1959; Pritchard et al. 1997a).
The 1960s and early 1970s were periods that coincided with challenges to established âauthorityâ and its nostrums and, specific to our interest, saw the burgeoning of anti-medicine and, in particular, an âanti-psychiatryâ movement (Szasz 1960; Laing and Esterton 1968; Illich 1971).
One such critic, Ivan Illich, had much to commend him, because he reminded medicine of the need to go back to its originsâthat its art needs to be humane as well as science basedâwhile the media-colourful Ronald D.Laing reminded us of Shakespeareâs dictum that there is âmeaning in madnessâ and, therefore, we should consider the content of the personâs apparent âramblingâ (Laing and Esterton 1968). However, Laingâs work deteriorated into a diatribe of mystical metaphysics, although he was quite a good minor poet, but he left his science far behind. He later had to renounce his idea that psychosis, or the schizophrenias, was a form of clearer sanity, culturally and/or family induced (Sedgwick 1982). Sadly, some of his unsupported metaphysical theories were taken up by popular culture and can still be found in certain areas of psychobabble, where anecdote and conjecture get mixed up, ignoring the need for evidence-based practice (Skinner and Cleese 1994). One of many practice experiences that taught me to think a little clearer came from this period.
It concerned âAlanâ, a nine-year-old diagnosed as autistic. He was âtypicalâ in that, while functioning at a severely learning-disabled level, he was a very handsome child, with none of the physical disabilities associated with the genetically linked learning disabilities, such as Downâs syndrome. We were considering Alan for possible admission to an inpatient child psychiatric unit. His parents sat quietly and calmly with the consultant and me as Alan literally gyrated around the room in a startling exhibition of extreme autistic behavi...
