A History of Anglo-American Psychiatry

It comes as something of a shock to realize that I have been researching and writing about the history of Anglo-American psychiatry for more than forty years now.  It scarcely seems possible that more than three decades have passed since I first begun burrowing around in the archives of those Victorian museums of madness that in the early 1970s were still the all-too-concrete legacy of the enthusiasms of an earlier generation – those warehouses of the unwanted whose distinctive buildings for so long haunted the countryside and provided mute testimony to the emergence of segregative responses to the management of the mad.  I can still vividly recall my first encounter with those structures: the vast and straggling character of the old, already-decaying asylums; and the elegant façades (and the not-so-elegant back stage features) of the bins catering to a more affluent clientele. It is hard to forget the sense of constriction and confinement that oppressed one’s spirit on crossing the threshold of one of these establishments.

At a slightly deeper level, one recalls that there was a frisson of fear playing at the edges of one’s consciousness, an almost daily emotion I then tried to dismiss as irrational, and now recognize was a subterranean anxiety that reflected — not any sense of physical danger from one of the pathetic, drug-addled patients who still haunted the hallways — but the barely suppressed nightmare that one might find oneself trapped permanently in one of these barracks-asylums (whereas, in fact, of course, I was always able to retreat gratefully back into the “real” world once night fell).  Above all, perhaps, I remember the smell; the fetid odor of decaying bodies and minds, of wards impregnated with decades of stale urine and fecal matter, of the slop served up for generations as food, the unsavory mixture clinging like some foul miasma to the physical fabric of the buildings.  Small wonder that the English alienist George Man Burrows once proclaimed that he could unerringly identify a madman by the peculiar odor that emanated from him.

Nowadays, such encounters with the physicality of mass segregation and confinement, with the peculiar moral architecture which the Victorians constructed to exhibit and contain the dissolute and degenerate, are increasingly fugitive and fast-fading from the realm of possibility.  Many of these institutions are crumbling into dust.  Trenton State Hospital, for example, once home to experiments on mental patients that killed hundreds and maimed thousands more, is now largely empty. The once handsome trees that adorn its grounds are tangled, neglected and overgrown.  Their sepulchral shade creates a dank and dismal atmosphere in the abandoned buildings they tower over.  Mold and putrefaction are everywhere.  Iron bars on the windows deposit brown rust stains on to the stone and brick beneath.  An eerie silence and emptiness reigns.  Rotted metal screens encrusted with nameless dirt and filth partially obscure the broken panes of glass beneath, through which the trespassing visitor can peer into empty wards, bereft of furnishings, human and inanimate.  The guardhouse that once kept out the curious is unmanned.  No-one strives any longer to sustain the previously inviolable boundary between the worlds of the mad and the sane.  Such scenes could be replicated all across what calls itself the civilized world.

Other asylums have been transformed into luxury hotels (like Venice’s former asylum for mad women on San Clemente Island) or into luxury condominiums for the well-to-do (like the former Colney Hatch Asylum in London, now re-christened Princess Park Manor, and sold to innocent buyers as “a Victorian masterpiece which has delighted and inspired aficionados of fine architecture for generations”).  With delicious irony, its developers proclaim that once introduced to the delights that await them on site, the new residents will never want to leave.

My first encounters with the sights, the smells, the sense of despair that enveloped these total institutions in earlier times, when their wards were still thronged with patients, ought surely to have been enough to put any sane person off any lingering attachment to research in such settings.  A few months of this should have sent me scurrying off in search of more salubrious subjects and objects with which to concern myself.  After all, as any sociologist worth his or her salt could tell you (and as every psychiatrist ruefully knows), one of the dubious rewards that flows from trading in lunacy is a share in the stigma and marginality we visit on those unfortunate enough to lose their wits. Yet I have resisted the temptation to abandon madmen and their keepers to their fate.  The irrational, and what I am sometimes tempted to think are our culture’s equally irrational responses to craziness, have continued to hold me in thrall.  I remain as intrigued as I was forty years ago by the puzzles that are posed by what we variously call madness, lunacy, insanity, psychosis, and mental illness, and by the elaborate social institutions we have created to manage and dispose of the mad, both before and after the age of asylumdom.

The loss of reason, the sense of alienation from the commonsense world the rest of us imagine we share, the shattering emotional turmoil that seizes hold of some of us and will not let go: these are a part of our shared human experience and of the cultures we inhabit that down through the centuries. Insanity haunts the human imagination.  It reminds us of how tenuous our own hold of reality may sometimes be.  It challenges our sense of the very limits of what it is to be human.

In the contemporary world, the dominant conceptions of madness consign it to the ministrations of medics, and pronounce it a matter of defective brains and biology.  But in all kinds of settings, mental illness resists being corralled in this fashion.  As it has over many centuries, the subject remains a source of recurrent fascination for writers and artists, and for their audiences.  Novels, biographies, autobiographies, plays, films, paintings, sculpture – in all these realms and more, Unreason continues to inspire speculation, to puzzle us, and to surface in powerful and unpredictable ways.  All attempts to contain it, to reduce it to some single essence, seem doomed to disappointment.  Madness endures, serving to frighten and to fascinate, to challenge us to probe its ambiguities and its depredations.  And despite our best efforts, we remain almost as far as ever from any adequate understanding of the roots of Unreason, let alone from effective responses to the miseries it entails.

The complexities of the human encounter with insanity, as revealed over history’s longue durée, are what tempted me to write Madness in Civilization: A Cultural History of Insanity, from the Bible to Freud, from the Madhouse to Modern Medicine.  My hope is to persuade others to share my fascination with this vast and varied territory, and to ponder anew its mysteries.