issue 209 - July 1990
Madness speaks to us with
a voice we'd rather not hear.
David Ransom listens.
This is a picture of my great-uncle Fred. It was taken in 1902, when he was working at an engineering factory in West London. He lived in poverty and became a socialist. In his spare time he sold copies of The Clarion, a socialist newspaper, on street corners.
In middle age he was offered a job with the management of the factory and he took it. He found it difficult. Before long, overtaken by 'melancholia', he was admitted to a mental hospital and never came back. He died there 30 years later.
I think my family concluded that Fred had been led astray by his idealism, his 'foolishness'. He had shouldered the troubles of the world and been crushed. For my part I prefer to imagine that he made a mistake. Socialists have an uneasy relationship with management. Perhaps remorse at having joined it had tipped the balance of Fred's mind.
All of us have someone like my great-uncle Fred in our family history. But not all of us know it. By the time Fred died I was old enough to have known that he existed. But I didn't. Not in the same way that I knew of his brother, who made money in biscuits and owned a gleaming Daimler car which he drove very cautiously over the potholes in the road outside our house. It's not that my family deliberately kept Fred's existence a secret. What, after all, can be said to a child about a man who lives in a mental hospital?
Today madness is called mental illness. Tomorrow it may be called something else. But the chances are it will still be there, and the evidence is that it has existed in a recognizable form throughout human history, everywhere in the world.
What is it? The most straightforward definition I've come across is 'unusual or undesirable behaviour'. But there is a problem with using the term 'illness' to describe behaviour. Illness is identified or diagnosed by medical practitioners. But society decides what makes behaviour unusual or undesirable. Illness may be what motivates or causes this behaviour. But what causes illness? Here the problems get even bigger.
In crude terms, the causes of mental illness seem to be of three main kinds. The first is biological - what we inherit through our genes. The evidence is overwhelming that there is some kind of genetic factor involved in the most serious forms of mental illness, the 'psychoses' like schizophrenia.
The second cause lies in the other part of our inheritance - the treatment we receive as our personalities form in childhood. The sad fact is that we do not always treat our children very well. We were not always well treated as children ourselves. Abuse can cause mental illness.
But it is not just children that are abused. We can abuse or be abused by anyone. And we can join together in groups and as a society to treat other people or other groups very badly indeed. Poverty, hunger, violence or homelessness, our social conditions, are the third main cause of mental illness and the least acknowledged.
It is, however, very difficult indeed for any one of these causes to produce mental illness on its own. Even a genetic predisposition to psychosis usually has to be 'potentiated' by one or both of the other causes. They interact together in a continuous, incredibly complex and unpredictable process.
The trouble with using the term mental illness to describe this process is that illness and 'the mind' only encompass a part of it. They live out their lonely existence entirely within the individual sufferer. They cannot easily be used to describe those events outside of us, like our social circumstances or what psychiatrists call 'life events', that have such a critical impact on our emotions. Nobody says 'It's a mentally-ill world!' even when it is.
I can find no term other than 'madness', with all its abusive connotations, that embraces the whole process, the interaction between 'internal' and 'external' factors. We seem to have lost a common language.
We have lost it, I think, because we have been trying to lose the people and feelings it used to describe. We have locked them away, in the vain hope that by doing so we could make them disappear. But we couldn't. The result is that we have been steadily betraying mentally-ill people for at least a century.
The mental hospital where my great-uncle Fred spent the last 30 years of his life was one of a chain built around the fringes of London in the second half of the nineteenth century. Similar chains enclosed all the new industrial cities of Britain as they grew up. They appeared soon afterwards in the United States as the biggest institutions ever built, incarcerating as many as 10,000 people. They have been appearing more recently in Japan. They seem to appear as if by magic wherever industrial capitalist society grows.
At first they were called asylums - a Greek word for a place of sanctuary and refuge. The word is still used today, of course, to describe something desirable to which political refugees are entitled. This is what the people of the old 'madhouses' were led to expect when they were taken there. What they found were prisons. They were betrayed.
Slowly the asylums were taken over by the medical profession. Wardens became psychiatrists, guards became nurses, asylums became hospitals - and madness became mental illness. But there was no cure, though the hospitals carried on as if there were. Another betrayal.
Today the hospitals are closing (or just falling) down. 'Psycho-active' drugs can replicate the walls of the old institutions within our heads. The institutions are becoming superfluous. Mentally-ill people are being moved out into 'the community'.
But this bogus community, spirited up to serve administrative convenience, does not exist. The resources, money and commitment needed to make 'care in the community' work have all been withheld. The closure of the hospitals has proved too tempting an opportunity to be missed by the cost-cutting Right. And, because we have tried to exile madness, to exclude mentally ill people from society, as a community we no longer know anything about them. Yet another betrayal.
It was betrayal, too, when in the 1960s and 1970s many people like me who thought of themselves as 'progressive' came to believe that mental illness did not exist. There was a strange comfort in the idea that a society of everyone except ourselves was 'manufacturing' mental illness. But when we faced its devastating impact on the lives of people we knew, we had no idea what to do. Too often we chose to forget they existed rather than acknowledge that they were mentally ill. We blamed 'psychiatry' and ran away.
Why all this betrayal? The reason is, I think, that madness has something to say to us that we prefer not to hear. It is not dumb. It speaks with its own voice about things we can only vaguely sense because we are afraid.
We have good reason to be. The kind of society we live in - broadly the industrial capitalism which is being embraced by more and more of the world - is making us prone to the alienation and isolation on which madness feeds.
A friend once told me about a Xingu 'Indian' he met in Brazil who went to Sao Paulo, a gigantic city, for the first time. He began to cry. He could not bear to walk past other people without any sign of recognition. To the locals he would have appeared to be crying for no reason at all. The Xingu man fled back to the forest, unable to believe that anyone could wish to live in such a place.
Over the years Western society has been casting off many of the more obvious outward signs of inner distress. The conditions known as catatonia and hysteria were once quite common. They are still common almost everywhere else in the world. They are characterized by extravagant gestures, posturing and the like. For that reason, they are hard to ignore, easy to identify with distress.
But they have all but disappeared in the West. The distress they show has been subsumed into other more modern conditions like schizophrenia, which cannot be so readily seen.
The bodily expression of inner distress needs a framework of bonds between people if it is to have any meaning. In the West, such bonds have been broken by industrial capitalist society. Even the nuclear family is in the process of disintegrating. The reason is the increasing emphasis on individualism that this kind of society imposes.
The possible consequences of this are very disturbing indeed. As Julian Leff points out: 'it seems likely that if the uniqueness of the individual's inner experience became the dominant value in society, the bonds between people would be so attenuated that such a society would probably not be viable.'
It sounds like a society writing a suicide note to itself. And suicide too has something important to tell us. Social trends in suicide are not always what you'd expect. For example, they decline sharply in times of war, as they did in Europe during both the two World Wars. The common threat of war produces greater cohesion in a community, reducing the risk of individual isolation and the level of suicide too. Social cohesion is the most powerful defence against madness, and is the most important single contributor to mental health.
But the West is losing its cohesion. Suicide rates are rising everywhere. The last time they fell, bucking the global trend, was in Britain in the 1960s, when faith in the National Health Service was at its height. Now they are rising sharply again. Self-destructive, suicidal war may wield an irresistible and largely subconscious appeal to a society that is locked into headlong and seemingly involuntary flight towards individualism.
We are, in fact, in the midst of a 'pandemic' of mental illness, a genuine crisis, spreading across the world with the isolation and 'alienation' of the individual in industrial society.6
So there is some urgency to the search for a better future. What is needed is nothing short of a complete, gentle revolution against what we have been taught. We have to learn how to reconstruct the bonds between people. We have to learn how to live with our own fear of madness, not of its captives.
All we have to go on is what other societies do. But again Western culture is failing us. For instead of learning, it is teaching. Global organizations like the World Health Organization (WHO) are dominated by Western medical science, and their work on mental health by psychiatric medicine. Worldwide initiatives concentrate on how to 'validate' or apply Western methods across the globe - not on how to learn from each other.
There are at least two important barriers to this enterprise within Western culture. One is racism, the notion that one culture, one race, is innately superior to another. Racism has permeated Western society, and Western psychiatry is no exception. While interest in 'transcultural' issues blossoms, blindness to racism remains as pervasive as ever, obscuring what is of value in other cultures.
The second barrier is the Western attitude to mentally-ill people themselves. We have acquired the habit of assuming that they don't know what they want, don't want to decide anything about their own lives and have nothing to contribute. So we have lost all hope of communication with them, and thus any prospect of learning from their experience and what they have to say. Their participation, particularly in the planning of new 'community care' schemes, is more of a good principle than a working practice.
Added to this, while the bogus community invented to accommodate the closure of mental hospitals does not exist, another one actually could. For most mentally-ill people are being looked after in the community anyway, by relatives and friends who cannot bring themselves to have the people they love locked away. They pay a terrible price in the same currency - their own isolation from society, the prospect of guilt if they fail. They should be cherished, respected and, above all, learned from.
I began to learn something myself when I was working with a group of homeless people trying to Get Something Done. I shall call him Jack, the man we watched slowly disintegrate as the excitement of the campaign mounted. One day he fell to the floor at my feet, shaking violently.
I rang the local mental hospital. Did they know him? Yes, they did. Could they help? No they couldn't. Why not? Untreatable personality disorder. (It was just as well I didn't know then that Jack would once have been called a psychopath, which to most people effectively means 'murderer'.) Untreatable? That's right. But there had to be something they could do! No, there really wasn't. What was Ito do? Simply stay with him until he got better.
He did, after a fashion. He wandered off when we weren't looking and we never saw him again. But I can still see myself, trembling with fear of Jack (and yes, for him, too), desperately ringing a mental hospital I thought should not be there to ask for help with an 'illness' I thought didn't really exist. Believe me, there are thousands of men and women like Jack in every Western society. For them the issue is not how good or bad the treatment' they receive is, but that they receive no treatment at all.
So I got a bit more interested. I went on a course for amateurs. A kind and intelligent psychiatrist (one of the few we ever saw outside the hospital) came to talk to us about schizophrenia - the most feared mental illness of all. What was it we wanted to know? Did we want to be able to identify a 'schizophrenic' at ten paces? What for?
Reluctantly he began to describe common symptoms. 'Flatness' and 'Delusions of Persecution'. 'Perplexity', 'Self Neglect', 'Obsessive Thoughts'. I began to feel uneasy. These were all, the psychiatrist assured us, very precise diagnostic terms. OK, fine. 'Poor Rapport', 'Hopelessness', 'Situational Anxiety', 'Negativism' and, yes, 'Lack of Insight'. I really did feel very uneasy indeed. Surely, I had them all!
Then it came to me. Yes, maybe I did have them all, or a good number of them anyway. Things go wrong when you have too few, or when one gets out of proportion to the rest. Trying to stay sane is a delicate balancing act: it's easy to overbalance, particularly if you're pushed. Not, perhaps, a very precise or scientific conclusion. But I could at least sense that even the most feared and serious of all the mental illnesses did have something to do with me, however disturbing that may have seemed at the time.
For I too have the same taint of 'foolishness' upon me as my great-uncle Fred, though I've so far escaped the anguish of his illness. His 'melancholia', with all its evocative associations for me, no longer even exists as a diagnosis - it's been swept away into the vast, featureless ocean of modern 'depression'. It may have taken me a long time to find out about him. But now that I have I can sense him as a personality much better than his biscuit-rich brother.
'Come along, now, Fred! Shake yourself by the hand!' my grandfather used to say to him when he went on a visit.
'My trouble is,' Fred would say,' I'm the only one in here who knows he's mad.'
1 See, for example, the controversial results of a World Health Organization (WHO) study of schizophrenia published in Psychological Medicine, no 16, 1986.
2 Psychiatry Around the Globe, Julian Leff (Royal College of Psychiatrists 1988).
5 Changing patterns in suicidal behaviour, WHO EURO Reports and Studies 74 (Copenhagen 1982).
6 The rising pandemic of mental disorders and associated chronic diseases and disabilities, M Kramer (paper supplied by WHO Geneva).
7 Race and Culture in Psychiatry, Suman Fernando (Tavistock/Routledge 1988).
8 Roland Little in British Journal of Psychiatry no 156, 1990.
He keeps a dark shed by the beachhuts and boathouses
Rigged out in nets and tackle, he carries a trident
The villagers tell how once, years back,
He was washed up here like the rest of us
It's said that sometimes he sights a ship
This special report appeared in the the fear of madness - mental health issue of New Internationalist. You can buy this magazine or, to get stories like this one through your door every month, subscribe.