Madness denied

Madness: A Very Short Introduction - Andrew Scull 2011

Madness denied

The exceptional violence and mass slaughter that characterized much of the 20th century had dramatic effects on cultural perceptions of madness, and on the fortunes of the professionals who claimed the authority to define and treat it. The two world wars in particular, and the post-colonial wars in Vietnam and the Middle East to a still significant extent, were marked by epidemic levels of mental breakdowns among the fighting forces - the shell shock of trench warfare; the combat exhaustion and war neurosis of the fight against Hitler and Hirohito; the post-traumatic stress disorder among the defeated American army in Vietnam; and the mysterious ailments that were gathered together under the catch-all title of ’Gulf War syndrome’ in the 1990s and beyond. All posed huge problems for the military machines during the fighting, and for the civilian authorities in war’s aftermath. They simultaneously did much to transform the psychiatric enterprise, and to alter the terms of psychiatric discourse. The Second World War, in particular, prompted a massive expansion of the psychiatric profession, the creation of competing kinds of psychotherapists and clinical psychologists, and the beginnings of a massive shift in the locus of psychiatric care - to say nothing of its effects on the way ordinary people looked at mental illness.

The ’shell shock’ crisis of the First World War had provided the first inkling that modern industrialized warfare was not ideally suited to the maintenance of mental health among the troops. Within months of the start of the fighting, a military stalemate had ensued. Trapped in the Flanders mud, soldiers in trenches waited for death - from high-explosive shells, from flesh-tearing bayonets, from machine-gun bullets, from poison gas. No army was spared the epidemic of nervous disorders that followed. By their thousands and tens of thousands, soldiers were struck dumb, lost their sight, became paralysed or incapable of normal motion, wept, screamed uncontrollably, lost their memories, hallucinated, were rendered sleepless and incapable of fighting. As the very name ’shell shock’ suggests, many military psychiatrists initially thought, in keeping with the somatic theories that still were the ruling orthodoxy of their profession, that the disorders were the manifestation of real damage to the nervous system produced by the blast from high explosives. But such claims increasingly seemed implausible and even untenable. Soldiers who had not even reached the front lines became symptomatic. Those who became prisoners of war, and thus immune from the tensions of life in the trenches, never did. The military high command on both sides of the fighting saw in these findings evidence that the victims were simply cowardly malingerers, and some of the sadistic treatments meted out by their physicians - torture with electric currents applied to tongues and genitals, for instance - seem to have reflected a similar hostility on their therapists’ part, or a simple determination to force them back to the fighting. But the preternatural tenacity with which shell shock victims clung to their symptoms made simple claims of malingering hard to sustain. The Germans adopted the label Schreckneurose, or terror neurosis. Trauma and psychological stress, it seemed, could cause even the apparently stable to break down, to become maddened with fear, disgust, horror.

History repeated itself less than a quarter-century later, when total war erupted once more, and it did so despite efforts by the psychiatric profession to screen out the emotionally unstable before conscripting them for military duty. Once more, the horrors of the battlefield caused men to break down. Once more, madness came to seem a psychological disorder, and one not confined to the degenerate and defective, but a condition to which all were susceptible if placed under sufficiently appalling psychological stress. At war’s end, 50,000 psychiatric casualties were crowded into American military hospitals alone, and nearly half a million GIs were receiving pensions for psychiatric disabilities by 1947.

If the epidemic of shell shock had given broader credibility to the idea that at least some forms of mental breakdown had a psychodynamic aetiology, the experience of the Second World War (and of Vietnam some decades later) appeared to confirm it. Nowhere was that more the case than in the United States. Indeed, the almost unique power and cultural authority psychoanalysis obtained for a time in America - a hegemony it won almost nowhere else except for peripheral exceptions like Argentina - was in substantial measure a product of the impact of war on American troops, and the efforts of military doctors to treat them.

Freud’s 1909 visit to Massachusetts had won psychoanalysis some influential converts - men like the Harvard neurologist and New England Brahmin James Jackson Putnam, William Alanson White, the superintendent of the enormous federally run St Elizabeth’s mental hospital in Washington, DC, and his friend Smith Ely Jeliffe, editor of the Journal of Nervous and Mental Disease. Though clearly a minority taste among the nation’s psychiatrists, psychoanalysis had established a significant bridgehead among the rich and chattering classes, and the numbers of analysts (and their internal divisions) had multiplied in the late 1930s as psychoanalytic émigrés fleeing Hitler’s murderous regime arrived as refugees in New York. But it was the Second World War that transformed its standing, and vaulted it from the sort of marginal position it occupied in most European societies into a commanding position at the apex of American psychiatry, a position it would sustain for a quarter-century and more after the end of hostilities. By 1960, every major academic department of psychiatry in the United States would be chaired by a psychoanalyst or a psychoanalytic fellow traveller, with the single exception, if exception it be, of the department at Washington University in St Louis, Missouri. And the link between psychiatry and the couch had been firmly established in the popular imagination, where it remains to this day, as the cartoons about mad-doctors in the New Yorker regularly remind us.

William Menninger, a charismatic figure from Topeka, Kansas, had been appointed as head of military psychiatry at the outbreak of the war. At his family asylum in the 1930s, which he ran with his brother Karl, a bowdlerized, Americanized version of psychoanalysis had been the therapeutics of choice, and faced with a new massive epidemic of what were seen as psychological casualties, it was to brief, rapid, and simplified psychotherapeutics that Brigadier General Menninger’s underlings now turned. New medical recruits were rapidly trained to administer the treatments, and the number of psychiatric practitioners exploded, doubling over the course of the war years. Nor did psychiatric problems disappear with the outbreak of peace (or rather of the Cold War). In many ways, they appeared to intensify, and those who had entered upon psychiatric practice as a matter of wartime necessity sought in many instances to make the transition to civilian practice - a transition greatly aided by the substantial sums the federal government began to provide to pay for the training of apparently urgently needed professionals.

It was Menninger’s Young Turks who seemed to be the promising future of a new, psychoanalytically inclined profession. In battles with the old guard who still lurked in traditional mental hospitals, and who were now treating a half million in-patients and more on an average day, they exhibited their intellectual disdain and their numerical muscle, electing Bill Menninger as the president of the American Psychiatric Association in 1948. Later that year, a portrait of the great man appeared on the cover of Time magazine, alongside a diagram of a human brain, complete with key and keyhole. It was a fitting symbol of the rapidity with which psychoanalytic ideas about madness had captured the American imagination and spread into American popular culture. To be sure, there were dark mutterings among Freud’s displaced circle of European exiles in New York that the crude American and his badly trained followers were betraying the sophisticated pessimism that their revered father-figure had articulated, in favour of a feel-good, emasculated version of psychoanalysis. But beyond that small circle of true believers, some more attractive, optimistic version of Freud’s ideas was on the march, spilling out of the realm of the pathological into discussions of the psychopathology of everyday life, and then into the arts - into painting, novels, and movies. Above all, into movies.

As early as 1919, the German director Robert Wiene had produced a classic picture of madness on the screen. The plot of The Cabinet of Dr Caligari originally portrayed the psychiatrist at the local lunatic asylum as a sinister figure using a sleepwalker who is under his control to commit serial killings. Visually, the impression of entering the nightmare world of the violent madman was heightened by setting the action in front of painted sets, all sharp angles, surreal architecture, deformed views, and distorted shapes. Late in the production, the director opted for a different, twisted ending, revealing that the portrait of the murderous mad-doctor was in ’reality’ the delusion of one of the asylum’s patients (a twist in the plot that would resurface in other films with more mainstream appeal, for example, in Hollywood’s version of the schizophrenia of the founder of game theory John Nash, A Beautiful Mind). The Cabinet of Dr Caligari prefigured an enduring fascination with the theme of madness among film makers. It was a fascination in full flower throughout the period when psychoanalysis dominated American psychiatry, and Freudian images of psychiatry would persist in American film even when the profession itself moved on.

The back wards of America’s decaying state hospitals were the setting for one of the five most popular movies of 1949, The Snake Pit, starring Olivia de Havilland as a housewife with a father fixation. Unable to perform her wifely duties, she tumbles into madness, and seems destined to rot in an overcrowded asylum, till she is rescued by a handsome young psychiatrist. Lying on his couch, with a portrait of St Sigmund in the background, she relives her childhood, comes to see the sources of her breakdown, and is miraculously cured, though not until she has displayed an unseemly erotic interest in her doctor - a Freudian transference - from which she finally emerges a happy and suitably loving spouse, strolling off into the sunset with her husband, presumably towards domestic bedded bliss.

Three decades later, Joanne Greenberg’s roman-à-clef, I Never Promised You a Rose Garden, was transferred to the screen, and audiences were treated to another portrait of a schizophrenic young woman, this time in a ritzy private asylum (in reality Chestnut Lodge in Maryland). Hallucinating, self-mutilating, angry, and uncooperative, trapped in an alternative world of fantasy, pain, and self-imposed degradation, the adolescent Deborah Blake is delivered to her confinement by her parents - an ineffectual father figure dominated by an icy, controlling wife. Again, she is rescued by a caring Freudian - Bibi Anderson playing Dr Fried (in real life Frieda Fromm-Reichmann) - and by talk therapy that, in revealing the traumatic sources of her breakdown, brings her back to a world of sanity.

Best-selling pot-boilers like Robert Lindner’s The Fifty Minute Hour purported to give a less glossy and fictionalized, but in reality equally manicured and romantic, view of the magic that could be wrought on the couch. Americans learned that madness could touch even the affluent, that modern psychiatry could make sense out of seeming nonsense, and that the surgical probes of the analyst could reveal the unconscious roots of mental disturbance and magically help patients discover the repressed memories that had made them psychotic - a catharsis that at once made them better. It was a lovely fantasy.

Freudian notions were embodied, too, in such otherwise remarkably different films as John Frankenheimer’s The Manchurian Candidate (with Angela Lansbury’s chilling portrait of the brainwashed Robert Shaw’s mother); Nicholas Ray’s Rebel Without a Cause (with James Dean’s rebellious teenager the product of his overbearing mother and his weak, emasculated father); and Robert Redford’s Ordinary People (in which Mary Tyler Moore plays the bitter and soulless Beth Jarrett and Donald Sutherland her hopeless, ineffectual husband Calvin): all embody some of the central themes running through post-war Freudian speculations about madness and antisocial behaviour more generally. Psychiatry was expanding by leaps and bounds in the quarter-century after the war - from a total of fewer than 5,000 psychiatrists in 1948, their numbers had grown to more than 27,000 by 1976. Most of the new specialists were psychiatrists of the couch, practising on affluent and well-educated out-patients with neurotic symptoms, and disdaining contact with the poorer and more desperately disturbed patients who still crowded the wards of the state hospitals.

By the end of the 1950s, psychoanalysts comprised one-third of the nation’s psychiatrists, and by 1973, they were numerically in the majority. Moreover, these raw numbers underestimate their impact, for those working within this tradition occupied the commanding heights of the profession, dominating most academic departments of psychiatry, and creaming off the most talented of the profession’s new recruits for their chosen approach to treating mental illness, one that was almost entirely psychological. Their patients were less disturbed and much more socially desirable, and their incomes higher than those accruing to many other branches of the medical profession. Meanwhile, the less talented half of those emerging from psychiatric training were packed off to practise in the mental hospitals and public clinics where, for a stigmatized clientele, they provided a stigmatized, second-class variety of psychiatry (so-called ’directive-organic psychiatry’), perforce relying on brief contacts with patients for whom they prescribed pills and administered shock therapy.

But the psychotic were, after all, the maddest of the mad, and a few brave (or foolhardy) analysts like Harry Stack Sullivan and Frieda Fromm-Reichmann sought to treat them (or the more well-to-do among them), while still others sought to provide Freudian accounts of the sources of their disturbance. Articulated most persuasively perhaps, and certainly at greatest length, by Silvano Arieti, in a book whose second edition won a National Book Award for science in 1975, the psychoanalytic account of the most feared and pernicious of psychiatric diagnoses, schizophrenia, predictably is rooted in the psychopathology of family life. Drawing on a notion first advanced by Leo Kanner in 1949, that the roots of autism lay in absent fathers and mothers who displayed ’a distinct lack of maternal warmth’ (parents who, as he put it a decade later, unfortunately ’just happen[ed] to defrost enough to produce a child’), psychoanalysts like Fromm-Reichmann had articulated the notion of ’the refrigerator mother’. This schizophrenogenic figure, ’domineering, nagging, and hostile,… gives the child no chance to assert himself, [and] is married to a dependent, weak man, who is too weak to help the child’. Hence, Arieti claimed, ’adolescence was a crescendo of frustration, anxiety, and injury to self-esteem’, followed by a collapse into inertia and madness. Living in an unbearable reality, the schizophrenic retreated into an alternative, pathological territory of his or her own making, a world whose meanings could only be teased out by carefully tracing their origins in the cruelties of the domestic sphere - cruelties the parents, of course, did their utmost to deny, to themselves quite as much as to outsiders.

These notions are all oddly reminiscent on some level of ideas advanced by the controversial Scottish psychiatrist R. D. Laing - oddly, because Laing’s perspective is more usually seen as deriving from his romance with existential philosophy, and he is widely regarded as one of the founders of what others came to call ’anti-psychiatry’. Certainly, he was no ordinary British psychiatrist, for the mainstream of the profession in that country continued to embrace an eclecticism that nonetheless implicitly endorsed biological perspectives on major mental disorders. But the Freudian overtones of Laing’s early work, and its overlap with the theorizing of American psychoanalysis trying to account for schizophrenia, should really occasion little surprise, for after all, Laing had trained at the centre of the embattled English psychoanalytic establishment, the Tavistock Clinic.

The Divided Self, published in 1960, saw the schizophrenic as suffering from a profound ontological insecurity, itself produced by a toxic upbringing whereby parents, particularly mothers, placed children in impossible double binds (a concept he had borrowed from Gregory Bateson). Schizophrenics’ seemingly nonsensical symptoms (beliefs that they were made of glass, that they were Jesus reincarnated, that they were being persecuted, that they were already dead), could in reality be rendered meaningful by a suitably sympathetic observer, for they expressed in distorted form patients’ struggles to cope with an unbearable, impossible interpersonal environment. Their symbolism needed decoding, and that process could conduce to a cure. A few years later, he and Aaron Esterson would further implicate the lies and deceptions, the pathological patterns of communication and exclusion, they alleged were to be found among the parents of schizophrenic girls in the genesis of ’madness’, or rather the process of collusion through which, they claimed, the child was labelled pathological and then locked in that role.

Laing would in short order move in stranger directions, towards the claim that the mad were somehow the super-sane; that schizophrenia was a voyage towards a superior reality; that it was society that was sick, not the mental patient. ’Future generations’, he predicted, ’will see what we call “schizophrenia” was one of the forms in which, often through quite ordinary people, the light began to break through the cracks in our all-too-closed minds’. In steadily more vituperative terms, he assaulted the neurobiological accounts of mental illness and its treatment that were embraced by most of his nominal colleagues, and attacked mainstream psychiatry. When as patients we are marched into the psychiatric case conference, he claimed, ’We are mentally dismembered. Raw data go into the machine, as once raw human meat into the mouth of Moloch.’ It was a doctrine that in the 1960s and into the 1970s brought Laing worldwide fame outside the ranks of his profession, where suspicion of psychiatry was steadily on the rise. But his fellow psychiatrists mostly responded by branding his work as self-indulgent and methodologically flawed. Why, they asked, had he and Esterson only studied patterns of interaction among families with a mentally ill member? How did they know that the behaviours they claimed to observe had produced the illness, rather than emerging in response to it? Where were the control studies of interactions in ’normal’ families? His ideas, they sniffed, were the product of a narcissist, interesting fairytales of little or no practical value when it came to grappling with the grim realities of life on the mental hospital ward.

The gibe that as therapy Laing’s ideas were useless carried considerable weight, for his efforts to put into practice the idea that schizophrenia was a voyage of discovery that should be indulged in and encouraged generally had disastrous results. It was, however, a criticism that equally could be (and increasingly was) levelled against Freudian psychiatry as a whole, however attractive it seemed to many as an intellectual system. Even among the mildly disturbed, its ministrations seemed interminable, and the relief it supplied from mental distress ephemeral at best. Among the more seriously distressed, it had promised much and delivered little. Just as Freud himself had predicted, the talking cure (impractical as it would in any event have been in asylums that locked up indigent patients in their thousands) proved spectacularly incapable of relieving the miseries of most schizophrenics and manic-depressives. Laing’s criticisms were only one symptom of an emerging crisis of psychiatric legitimacy, one that for a time seemed to deny, not just the status of psychiatrists as our society’s credentialed experts on madness, but madness itself.

From many sides, the 1960s and 1970s saw assaults on psychiatry’s pretensions and its claims to expertise in the management of mental illness. An emerging mental health bar launched scathing attacks on the profession’s diagnostic competence. It was a soft target. Psychoanalysts evinced little concern for diagnostic labels and for ’descriptive’ psychopathology of a Kraepelinian sort (yet another point of convergence with Laing), and psychiatric diagnoses were notoriously unreliable. As the issue began to be systematically studied in the 1960s, partly at the behest of pharmaceutical corporations trying to secure homogeneous populations on which to test new drugs targeted at treating the mentally ill, so a set of embarrassing findings piled up. Even with respect to what were regarded as the most serious forms of psychiatric disturbance, different psychiatrists agreed upon the diagnosis about 50% of the time. International comparisons demonstrated that what British psychiatrists diagnosed as manic depression, their American counterparts were prone to label schizophrenia, and vice versa. One prominent law review article suggested that psychiatric ’expert’ testimony was nothing of the sort, but was rather akin to ’flipping coins in the courtroom’, and marshalled an abundance of references to prove it. Soon the lawyers moved on to other targets. The involuntary commitment of psychiatric patients was likened to incarceration, only justifiable (if at all) in return for effective treatment. But the situation in many state hospitals was so parlous that there was essentially no treatment being provided. So there were lawsuits urging that states be required to provide therapy or else to discharge the patients, and suits over the right to treatment were soon followed by suits urging the recognition of a right to refuse treatment.

Feminists entered the fray. They had much to work with. The forces of sex and madness have been historically linked together in a multitude of ways. Notoriously, psychodynamic theories of mental disorder, particularly those of a Freudian provenance, accorded pride of place to sexuality in accounting for the aetiology of mental disorder. Freud’s doctrine of penis envy, his bullying and worse of his female patients, and his evident puzzlement about what women wanted made him a target (though simultaneously, and perhaps perversely, some feminist theorists like Juliet Mitchell and Nancy Chodorow proclaimed themselves Freudians). Organically inclined 19th-century psychiatrists had provided their own accounts of the linkage, ranging from neurological portraits of females as possessed of nervous systems of greater refinement and delicacy (and hence more susceptible to breakdown) to gynaecological theorizing about the peculiarly intimate connection that supposedly existed between a woman’s reproductive organs and her brain, theories that on more than one occasion had licensed mutilating operations to ’cure’ female madness.

A new generation of feminist writers came to view psychiatrists as quintessential male oppressors, utilizing psychiatry to reinforce patriarchy. On the one hand, women were portrayed as disproportionately victimized by a male-defined double standard of mental health, which unwarrantedly and disproportionately, so it was claimed (though the evidence for this proposition was weak) assigned them to the highly stigmatizing status of the psychiatric patient (particularly if they behaved in ways that challenged masculine stereotypes about female propriety). Alternatively (though some found ways to advance both propositions), the oppressions, constrictions, and limitations of the female role in a patriarchal society were so damaging to the psyche, so stressful and harmful, that they drove a large number of women mad. Madness, the eminent literary critic and psychiatric historian Elaine Showalter proclaimed, was ’the female malady’.

In the realm of fiction and film, some international best-sellers later made into movies brought such ideas to a still wider audience. Jean Rhys’s Wide Sargasso Sea (1966) reworked one of the most powerful literary portraits of female madness, Bertha Mason from Charlotte Brontë’s Jane Eyre, into a colonial context. Her remarkable re-imagining of the earlier novel recast it into a very different context, the Caribbean of the 1830s as well as the Thornfield House of England and Jane Eyre; and her central character, Antoinette/Bertha Cosway/Rochester, brought questions of other kinds of oppression - colonialism, and race - into the equation, alongside the portrait of a woman stripped of her name and her very identity who ultimately plunges into madness, her spirit crushed by an oppressive male world.

Wide Sargasso Sea enjoyed extraordinary critical success. But its influence was perhaps exceeded by Sylvia Plath’s roman-à-clef, The Bell Jar (1963), originally published under a pseudonym. Plath’s own depression and hospitalizations, as well as her treatments with electroconvulsive therapy, are central elements in the story, as is her battle to become a woman in the world of the 1950s, where the choices on offer - suburban motherhood, or blue-stocking spinsterhood - seem equally unappealing. Self-hatred and confusion, ambition and a sense of worthlessness, fear of death yet acting in ways that court it, and in the background a ’self-sacrificing’ vampire mother whom she finds hateful in ways she has a hard time acknowledging - these are some of the themes that run through the novel. But it was not so much its literary qualities as it was Plath’s tragic death from suicide that ensured the book’s iconic status. Just weeks after its appearance, to what she judged a cool critical reception, oppressed by financial worries and a failing marriage to the poet Ted Hughes, Plath put her children to bed and her head into a gas oven. A victim - but of what? Of the feminine mystique? Of a philandering husband? Of a refrigerator mother? Or of psychiatry’s failures, and (male) psychiatric power and oppression?

There seemed to be no end to the assaults and the embarrassments psychiatry suffered in these years. A Stanford psychologist, David Rosenhan, conducted a study subsequently published in the august pages of Science that made use of pseudo-patients to impeach psychiatry’s clinical competence. The research subjects showed up at their local mental hospital claiming to be hearing voices. Once admitted, they were instructed to behave perfectly normally. Most were diagnosed as schizophrenic, and their subsequent conduct interpreted through that lens, so the chart of one subject who wrote down details about the ward recorded that ’patient engages in writing behavior’. Fellow patients saw them as shamming, but not their psychiatrists, and when eventually discharged, many were given the parting gift of being labelled as ’schizophrenic in remission’. Psychiatrists protested loudly that the study was unethical and the methodology flawed, but ’On Being Sane in Insane Places’ was widely seen as yet another black eye for the profession.

In the immediate aftermath of the Second World War, when conditions in mental hospitals were particularly dire, a series of sensational journalistic exposés had appeared, most famously Albert Deutsch’s Shame of the States. Many were written by people who had recently visited the German death camps, and they explicitly compared the state of the back wards of America’s asylums to Dachau, Belsen, and Buchenwald. Deutsch, for example, described the male incontinent ward at Philadelphia’s Byberry State Hospital as:

like a scene out of Dante’s Inferno. Three hundred nude men stood, squatted, and sprawled in this bare room, amid shrieks, groans, and unearthly laughter… Some lay about on the bare floor in their own excreta. The filth-covered walls were rotting away.

For all the hyperbole that marked their critiques, these muckraking journalists had sought the reform, not the abolition, of the asylums. Their explicit goal was to pressure politicians to spend more money on the system, so as ’to put an end to concentration camps that masquerade as hospitals and to make cure rather than incarceration the goal’, as Alfred Maisel put it in the pages of Life magazine. Not so their sociological successors, who produced a string of monographs on mental hospitals through the 1950s and into the 1960s that evinced a steadily mounting hostility to such places, and towards the psychiatrists who ran them.


15. The men’s chronic ward at Byberry State Hospital, a surreptitious image taken by Charles Lord, a Quaker conscientious objector assigned, like 3,000 others during the Second World War, to work as attendants in state mental hospitals. This was merely one of a series of searing images Lord published in Life magazine in May 1946. He subsequently became a social worker and a professional photographer

The emerging consensus among the sociological fraternity was articulated most forcefully and powerfully, however, by Erving Goffman. Following three years on staff at the NIMH Laboratory of Socio-Environmental Studies, including a year of Institute-supported fieldwork at St Elizabeth’s Hospital in Washington, DC, long considered one of the nation’s finest, and the only mental hospital operated directly by the Federal Government, Goffman provided a wide-ranging condemnation of the mental hospital as an anti-therapeutic invention. It was, he asserted, a ’total institution’, one where the normal boundaries between work, sleep, and play were broken down, and where the caste-like interactions between different levels of the staff and between staff and patients created an artificial and massively damaging environment. Indeed, Goffman asserted, the most crucial factor in forming the mental patient was his institution, not his illness. Life on the mental hospital ward tended inexorably to damage and dehumanize its inmates, who were ’crushed by the weight’ of what, on close inspection, was essentially a ’self-alienating moral servitude’. Their reactions and adjustments, pathological as they might seem to an outsider, were best seen as the product of their cruel circumstances. And since the defects that produced these behaviours were structural features of all such establishments, they were not removable by any conceivable set of reforms.

A decade later, Goffman was no kinder about these places. They were, he asserted:

hopeless storage dumps trimmed in psychiatric paper. They have served to remove the patient from the scene of his symptomatic behavior… but this function has been performed by fences, not doctors. And the price that the patient has had to pay for this service has been considerable dislocation from civil life, alienation from loved ones who arranged the commitment, mortification due to hospital regimentation and surveillance, permanent post-hospital stigmatization. This has not merely been a bad deal; it has been a grotesque one.

In Asylums, Goffman’s other examples of total institutions included prisons and concentration camps. The implied rebuke of psychiatry’s therapeutic pretensions could scarcely have been more pointed or blatant, and it was intensified in the book’s final chapter, where psychiatrists are derisively mocked as members of a ’tinkering trade’ in whose hands ’reality must be considerably twisted’ to maintain the polite fiction that they are performing a therapeutic role. Day after day, hour after hour, ’inmates and lower staff levels are involved in a vast supportive action - an elaborate dramatized tribute - that has the effect, if not the purpose, of affirming that a medical-like service is in progress here and that the psychiatric staff is providing it’. But it has all the characteristics of a shell-game, and ’something about the weakness of this claim is suggested by the industry required to support it’. For, to venture ’a sentimental sociological generalization …: the farther one’s claims diverge from the facts, the more effort one must exert and the more help one must have to bolster one’s position’.

The growing intellectual distance, even outright hostility, between the two disciplines that is evident in both the language and the substance of this harsh assessment would only intensify over the next two decades. For if Goffman had scorned one of psychiatry’s central institutions and attacked the capacities of psychiatry itself (and done so in a book that enjoyed an enormous audience in his own profession and even beyond), within a few years, other sociologists were advancing a still more radical notion, that mental illness was not an illness at all. Rather, it was simply a matter of labelling.

Drawing on the resources of so-called ’societal reaction theory’, the California sociologist Thomas Scheff provided the most elaborate version of this ’fresh look at the problem of mental disorder’. ’There is as yet’, he asserted, ’no substantial, verified body of knowledge… there is no rigorous knowledge of the cause, cure, or even the symptoms of functional mental disorders’. The whole body of psychiatric ’knowledge’ was thus a carefully constructed sham. We would do better to adopt ’a [sociological] theory of mental disorder in which psychiatric symptoms are considered to be labeled violations of social norms, and stable “mental illness” to be a social role’ - and to recognize that ’societal reaction [not internal pathology] is usually the most important determinant of entry into that role’. Psychiatrists were just the most powerful official labellers. And so far from being a condition akin to tuberculosis or cancer,

mental illness may be more usefully considered to be a social status than a disease, since the symptoms of mental illness are vaguely defined and widely distributed, and the definition of behavior as symptomatic of mental illness is usually dependent upon social rather than medical contingencies.

Psychiatrists confronting the pathologies that accompany severe mental disturbance saw such claims as absurd, if not insulting. In their eyes, such talk was not just anti-psychiatry, but anti-science, and dialogue with those espousing views of this sort was essentially pointless. But they had a traitor in their own midst: Thomas Szasz, trained as a psychoanalyst, and Professor of Psychiatry at the State University of New York at Syracuse. In 1960, Szasz published a polemic whose very title, The Myth of Mental Illness, signalled his dismissal of the whole notion of psychiatric illness as ’scientifically worthless and socially harmful’. Illness, he declared, was a simple defect of the body, and that was what doctors treated. ’Mental illness’ was a metaphor, for there was no underlying somatic disease, and the concept referred only to ’problems in living’, or difficult people whom society needed to control. Under the guise of ’helping’, psychiatrists were actually agents of social control, nothing more than gaolers who masked what they were up to with medical language. And these simplistic claims, endlessly repeated by Szasz and his epigones over the decades that followed, inflicted yet further damage on psychiatry’s public image.

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. By the mid-1970s, mad-doctors must have thought they had received the largest share. Hollywood echoed the mood. Milos Foreman’s One Flew Over the Cuckoo’s Nest, based on Ken Kesey’s cult novel with the same title, appeared in 1975 and promptly swept all five major Academy Awards: best picture, best director, best actor, best actress, and best screenplay. Here was a damning portrait of the mental hospital and those who ran it. The patients are victims of the mental health machine, not of their psychopathologies. The hospital is an inhuman environment that damages and destroys. Psychiatric treatment is at best punishment, whether in the form of the dehumanizing group therapy sessions sadistically employed to destroy patients’ sense of self, or in the convulsions produced by the electroshock machine that are used to punish misbehaviour. At worst, as with the lobotomy visited upon the otherwise indomitable character of Randle P. McMurphy, played by Jack Nicholson, it is a device to tame, to eliminate the individual, by reducing him to a human vegetable. Psychiatry, in short, is a sham, and perhaps something far worse, the ultimate means of enforcing conformity.