Szmigiero, K. (Ed.) 2011. Probing Madness. Inter-Disciplinary Press

Edited by
Katarzyna Szmigiero
Probing Madness
Probing the Boundaries
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A Probing the Boundaries research and publications project.

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The Making Sense Of: Hub

‘Madness’
2011
Probing Madness
Edited by
Katarzyna Szmigiero
Inter-Disciplinary Press
Oxford, United Kingdom
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Table of Contents
Introduction vii
Katarzyna Szmigiero
PART 1 Diagnosis and Treatment
Mad Tourists: The ‘Vectors’ and Meanings of City Syndromes 3

Nadia Halim
Auditory Hallucinations in Schizophrenia: Collaborating with 15

the Voices from Without
Rochelle Suri
Carving Dreams on Marbles Lost: The Transatlantic Research 25

Network on Mental Health and the Arts (TRAMHA)
Gonzalo Araoz
Institution Defining Madness: A Place for the Individual 33

Emmanuelle Rozier
‘Your Drugs Take away the Love’: A Resident Psychiatrist’s 45

Discussion of Involuntary Psychiatric Commitment
and Treatment
Christine Montross
PART 2 Madness, State and Law
Redrawing the Boundaries of Psychiatry and Mental Illness 55

in the Post-Soviet Period: The Case of Latvia
Agita Lūse and Daiga Kamerāde
Intimacy and Control, Reciprocity and Paternalism: Madness 67

and the Ambivalence of Caring Relationships in a Post-Soviet
Country
Agita Lūse and Lelde Kāpiņa
Determining Insanity in New Zealand Courtrooms 81

Katey Thom
State-Made Madness: Official Knowledge, (Anti)Stigma and 93

the Work of the Mental Health Commission of Canada
Kimberley White
PART 3 Madness, Philosophy, History and Language
Madness-Group Feelings in the Pre-Socratics’ Fragments 105

Robert Zaborowski
Religious Insanity and the Limits of Religious Tolerance 117

in Nineteenth-Century America
Loren A. Broc
From Jameson to Badiou: Madness and Critical Theory 129

Alexander Dunst
History of the Present Illness: Is Foucault still Relevant 143

to the Understanding of Mental Disorder?
Jonathan Sunley
‘Madness’ and ‘Brain Disorders’: Stigma and Language 153

Christian Perring
PART 4 Cultural Representations of Madness
They Wouldn’t Make Good Ophelias: Reality of Experience 165

in Women’s Madness Narratives
Katarzyna Szmigiero
Hanago in Distress: The World of Hanjo in the Noh Theatre 177

Keiko Kimura
Lunatics and the Asylum: Representations of ‘The Loner’ 185

Patrick Bryson
I Can’t Get Off the Stage: Public Space, Acting Out and 195
Delusions of Grandeur
Eddy Falconer
Introduction
Katarzyna Szmigiero
From times immemorial people have been simultaneously fascinated and
terrified with the experience of mental illness. The proof of these contradictory
feelings can be found in religion, mythology, philosophy, literature and visual arts.
Recently, there have been many discussions about the nature of mental disorder
originating from such distant fields as medicine, psychology, sociology,
anthropology, gender studies and broadly defined humanities.
The reasons for this interest are easy to understand. If rationality has been
perceived since the Enlightenment as an essential, or even determining factor of
humanity, mental disorder seems to be the negation of this very core property.
Moreover, though modern medicine can prevent or at least delay the onset of many
physical diseases and ease their course, the prevention of an outbreak of a
psychiatric complaint is largely beyond the capacities of science. Despite the
introduction of many drugs, their effectiveness is still disputable. Paradoxically,
though insanity is the opposite of what defines our humanity as essentially
different from the rest of the world, it is also a distinctly human complaint. Thus, it
intrigues people, causing both abhorrence and awe.
This growing interest in ‘mad studies’ was reflected by the 1st Global
Conference on Madness, organised by Inter-Disciplinary.Net and hosted at
Mansfield College, Oxford, in September 2008. It was a truly global and
interdisciplinary event. It literally gathered over thirty representatives from every
continent (either by nationality or affiliation) and included psychiatrists, therapists,
literary scholars, historians and historians of art, activists, social workers,
philosophers and lawyers. Relatives and partners of people with mental problems
as well as those diagnosed themselves were also present introducing a p ersonal
note into the otherwise academic debate. For three days, as the conference theme
stated, they all ‘probed the boundaries’ of illness and health, sanity and madness,
representation and distortion, help and intrusion. The heated discussions proved
that different backgrounds, viewpoints and opinions do not necessarily contradict,
but rather complement and enrich each other. The present volume reflects the
major issues addressed at the conference since it contains sections on madness and
medicine, law and state, history and philosophy as well as on cultural
representations of madness.
The first part, entitled ‘Diagnosis and Treatment’, contains five chapters
dealing with problems caused by unusual symptoms. First, Nadia Halim in ‘Mad
Tourists: The ‘Vectors’ and Meanings of City-Syndromes’, discusses strange
psychotic outbursts connected with Paris, Florence and Jerusalem. Their puzzling
appearance causes many controversies among psychiatrists, as for many they do
not deserve separate diagnosis despite their endemic character. Then, Rochelle Suri
suggests in ‘Auditory Hallucinations in Schizophrenia: Collaborating with the
viii Introduction
__________________________________________________________________
Voices from Without’ an alternative approach to schizophrenia. Instead of viewing
auditory hallucinations as an undesirable pathology that should be eliminated by all
costs, she believes, following the ideas of Dr Marius Romme, that patients could
benefit from incorporating their ‘voices’ into the recovery process. Likewise,
Gonzalo Araoz’s ‘Carving Dreams on Marbles Lost: The Transatlantic Network on
Mental Health and the Arts (TRAMHA)’ probes alternative methods of treatment
offered by artistic expression. Creativity can help to overcome emotional
numbness experienced by many mentally ill, boost their self-esteem and foster
their recovery. Araoz also discusses the role of Transatlantic Network on Mental
Health and the Arts in encouraging intercultural discussion on the links between
creativity and wellbeing. Next, Emmanuelle Rozier looks at factors enhancing
recuperation in ‘Institution Defining Madness: A Place for the Individual.’ The La
Borde psychiatric clinic in France, instead of being a total institution destroying its
patients’ individuality, is a true asylum, offering shelter and peaceful conditions.
Its staff treats each patient with respect and warmth as the clinic’s mission assumes
these are the necessary factors leading to mental stability. Finally, in a p ersonal
reminiscence written by a psychiatrist ‘Your Drugs Take away the Love’: A
Resident Psychiatrist’s Discussion of Involuntary Psychiatric Commitment and
Treatment,’ Christine Montross ponders on the ethics of medical intervention. Her
short story, moving and humorous at the same time, asks important questions about
the use of forced hospitalization and medication. Will her patient be happier when
his religious delusions subside, or merely more functional?
The section entitled ‘Madness, State and Law’ presents the complex
interactions between mental health and legislature and/or state policy. It includes
four chapters. The first two chapters look at the situation of psychiatry in post-
Soviet Latvia, focusing on the transition from state control to community care.
First, in ‘Redrawing the Boundaries of Psychiatry and Mental Illness in the Post-
Soviet Period: The Case of Latvia’ Agita Lūse and Daiga Kamerāde present the
shifting attitudes towards the mentally ill before and after independence as seen by
practitioners and laypersons. Previously, the perception of what constitutes a
mental disorder was shared by doctors and society as both groups alike viewed
major psychosis as illness, focusing less attention on ‘minor’ psychiatric
complaints. Now, the medical understanding of illness has also engulfed neurotic
behaviours while lay people resist this tendency. The second text, ‘Intimacy and
Control: Madness and the Ambivalence of Caring Relationships in a Post-Soviet
Country,’ co-authored by Lelde Kāpiņa and Agita Lūse, analyses nursing care
offered by mental institutions in Latvia. The authors record the progress from
Soviet paternalism in which care was understood as surveillance and attending to
physical needs of the mentally ill to more patient-oriented approaches in which
emotional needs are also taken into consideration. Issues connected with insanity
defense and defining madness for legal purposes are dealt with by Katey Thom in
‘Determining Insanity in New Zealand Courtrooms.’ Using an example of a
Katarzyna Szmigiero ix
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notorious case of ‘X’, who went on a killing spree under the influence of drugs,
Thom argues the lines between madness, badness and responsibility for one’s
deeds is not an easy one to draw, even for experienced forensic psychiatrists.
Finally, Kimberley White’s ‘State-Made Madness: Official Knowledge,
(Anti)Stigma and the Work of the Mental Health Commission of Canada’
deconstructs the anti-stigma campaign undertaken by the Canadian government.
Ironically, the initiative that was meant to be helpful might legitimise only one
possible knowledge about mental health offered by the biomedical model of
psychiatry.
The third section, comprising five chapters, is devoted to the way language
constructs and shapes our perception of health and disease as well as to the
employment of psychiatric vocabulary in non-medical contexts. It also contains
chapters offering a historical perspective on the attitudes to what constitutes
insanity. First, Robert Zaborowski in ‘Madness-Group Feelings in the Presocratics’
Fragments’ presents various expressions denoting emotional and mental states in
early ancient Greek philosophy. Their richness, complexity and precision are
indeed overwhelming – they offer much more accuracy and flexibility in naming
the shades of reason and unreason than contemporary vocabulary in many
languages. The second chapter looks at the way madness was diagnosed in 19th
century America. As Loren A. Broc observes in ‘Religious Insanity and the Limits
of Religious Tolerance in Nineteenth-Century America,’ some forms of religious
belief, such as Millerism, ‘new measures’ revivalism, spiritualism and Christian
Science, were seen as unacceptable and signified the loss of reason. Nevertheless,
religious insanity was not diagnosed subjectively as psychiatrist also looked at
impaired social functioning. Still, holding unconventional beliefs that went against
the established Protestant worldview could put a person at risk. The three chapters
that follow, written by Alexander Dunst, Johnathan Sunley and Christian Perring
respectively, make use of cultural theories and ways in which madness has been
appropriated, defended and reclaimed. Dunst’s ‘From Jameson to Badiou: Madness
and Critical Theory’ presents the use, or even abuse, of psychiatric and
psychoanalytic vocabulary in cultural discourse, asking a question why
contemporary philosophers resort to the language of psychopathology to describe
the condition of modern man. He focuses on the employment of the term
‘schizophrenic’ by such thinkers as Jaques Lacan, Gilles Deluze, Felix Guattari
and Fredric Jameson. Sunley in ‘History of the Present Illness: Is Foucault Still
Relevant to the Understanding of Mental Disorder?’ argues that the ideas of the
French thinker can still be applied to modern understanding of psychiatry and
community care, which are based on ‘biopower’. Power is no longer imposed and
coercive, but it is expressed more subtly, through deeply internalized ideas.
Finally, Perring’s ‘‘Madness’ and ‘Brain Disorders’: Stigma and Language’
compares colloquial, medical and politically correct expressions denoting mental
illness and users of mental health services, taking into account their stigmatizing
x Introduction
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and offensive potential. Ironically, the words officially meant to be neutral are seen
by many as sterile and restrictive while those previously perceived as offensive are
now reclaimed as powerful by the survivors’ movements who strive for self-
definition. Dunst’s, Sunley’s and Perring’s chapters are all joined by their deep
concern for the rapidly growing medicalisation and pathologisation of every day
life and the state of modern society.
The last section contains analyses of cultural, mainly literary, representations of
mental anguish. It opens with Katarzyna Szmigiero’s presentation of women’s
madness narratives in ‘They Wouldn’t Make Good Ophelias: Reality of Experience
in Women’s Madness Narratives.’ Despite the claims made by radical feminists,
anti-psychiatrists and liberal academics, the majority of testimonies written by
women suffering from mental disorders are filled with moving accounts of the
shattering reality of madness. The examples include such classics of the genre as I
Never Promised You a Rose Garden, Prozac Nation and Janet Frame’s
Autobiography. The analysis of female insanity is continued by Keiko Kimura’s
‘Hanago in Distress: The World of Hanjo in the Noh Theatre,’ a study of a
medieval play. She uses Melanie Klein’s theories to explain the heroine’s
desperation and misery while she awaits the return of her lover. The Japanese play,
unlike many Western stories about deranged women disappointed in love, has a
happy ending as the lovers eventually reunite. Patrick Bryson’s ‘Lunatics and the
Asylum: Representations of ‘The Loner’’ looks at the pain and loneliness of a male
protagonists of autobiographical novels by an Australian writer Peter Kocan: Fresh
Fields, The Treatment and The Cure. The trilogy shows the gradual descent into
psychosis of an impoverished and isolated youth, his homicidal plans and his
subsequent incarceration and recovery at a p rison for the criminally insane. The
section closes with a witty piece of creative writing by Eddy Falconer. ‘I Can’t Get
Off The Stage: Public Space, Acting Out and Delusions of Grandeur’ is a
rambling, first-person narrative dealing with politics, identity, confusion, mania …
and much more.
All the texts included in this electronic collection endeavour to probe madness,
comprehend it, and accept it as one of many human experiences – sometimes
terrifying, sometimes baffling, sometimes even beneficial. They offer a myriad of
approaches to mental illness, truly reflecting the interdisciplinary character of the
conference at which they were delivered. The task of understanding madness is
impossible to be completed; yet, it enriches our understanding and compassion,
teaches us humility and also gives hope.
PART I
Diagnosis and Treatment

Mad Tourists: The ‘Vectors’ and Meanings of City-Syndromes
Nadia Halim
Abstract
In several of the world’s most revered travel destinations, over the last few
decades, a cluster of psychiatric syndromes has emerged - what I will call ‘city-
syndromes.’ These disorders strike tourists, usually shortly after their arrival in a
city, and appear to be triggered by the historical, aesthetic, or spiritual intensity of
the place. Outside the cities in which they occur, the syndromes have attracted little
scholarly interest. This chapter will consider how and why these syndromes arise
as psychiatric diagnoses, and why they are regarded with suspicion or disinterest
by much of the psychiatric community. Ian Hacking, in his book Mad Travelers:
Reflections on the Reality of Transient Mental Illnesses, notes that mental disorders
sometimes develop suddenly in a specific historical time and place, and lays out a
set of ‘vectors’ which allow this to happen. City-syndromes can be mapped onto
these vectors; the vector of medical taxonomy is of particular interest, as the
disagreements about city-syndromes tend to hinge on how they fit into our
psychiatric taxonomy, or if there is a place for them at all. Underlying this question
is the issue of whether the meaning a place has for a patient can play a causal role
in the course of that patient’s illness.
Key Words: Acute psychological disorders, diagnosis, Florence, Jerusalem,

psychosis, religion, Stendhal syndrome, travel.
*****
In several of the world’s most revered travel destinations, over the last few
decades, a cl uster of psychiatric syndromes has emerged – what I will call ‘city-
syndromes.’ These disorders strike tourists, usually shortly after their arrival in a
city, and appear to be triggered by the historical, aesthetic, or spiritual intensity of
the place. Symptoms range from anxiety and panic attacks, through visual and
aural hallucinations, to full-blown psychotic episodes. Outside the cities in which
they occur, the syndromes have attracted little serious interest. Newspapers around
the world periodically run ‘News of the Weird’ stories about them, with headlines
like ‘Visiting Jerusalem Can Spark a Psychotic Reaction’ 1 or ‘Florence’s Art
Makes Some Go to Pieces,’ 2 but scholarly articles are rare. This chapter will
consider how and why these syndromes arise as psychiatric diagnoses, and why
they have been regarded with suspicion or disinterest by much of the psychiatric
community. Ian Hacking, in his book Mad Travelers: Reflections on the Reality of
Transient Mental Illnesses, notes that mental disorders sometimes arise in a
specific historical time and place, and lays out a set of ‘vectors’ which allow this to
happen. City-syndromes can be mapped onto these vectors; the vector of medical
4 Mad Tourists
__________________________________________________________________
taxonomy is of particular interest, as the disagreements about city-syndromes tend
to hinge on whether they fit into our psychiatric taxonomy, or whether it is more
appropriate to read them as cultural phenomena.
1. Overview of the Syndromes

City-syndromes are acute, (usually) short-lived disorders that have in common
a similar set of symptoms and pattern of onset and recovery. 3 Each is associated
with a specific city that is popular as a tourist destination, and has been identified
and named by psychiatric clinicians working in that city’s hospitals. They include
Paris syndrome, Stendhal syndrome (Florence), and Jerusalem syndrome. 4 Of
these, the Jerusalem syndrome has been studied and discussed in greater depth than
the others. The majority of patients have some previous psychiatric history, but for
each syndrome there appears to be a significant minority who do not. The nature
and severity of the symptoms vary widely, from relatively minor affective
disturbances through full psychotic episodes.
A. Paris Syndrome
Paris syndrome is unique among the city-syndromes in that it is reported to
affect only one cultural group: tourists from Japan. A 2004 paper in the French
psychiatry journal Nervure reports that 63 Japanese patients have been hospitalized
with the condition since 1988; the Japanese embassy in Paris has arranged for a
Japanese psychiatrist to work with the staff of the Hôpital Sainte-Anne in dealing
with these cases. 5 The authors of the 2004 pa per note that Paris holds a ‘quasi-
magical’ attraction for many Japanese tourists, being symbolic of all the aspects of
European culture that are admired in Japan. 6 They report that patients stricken with
the syndrome arrive in Paris with high, romanticized expectations, sometimes after
years of anticipation, and are unprepared for the reality of the city. The language
barrier, the pronounced cultural differences in communications styles and public
manners, and the quotidian banalities of contemporary Paris - the ways in which it
is like any other 21st-century Western city - induce a profound culture shock which,
the authors contend, triggers the syndrome. Symptoms range from anxiety attacks
accompanied by feelings of ‘strangeness’ and disassociation, to psychomotor
issues, outbursts of violence, suicidal ideation and actions, and psychotic delusions
on themes of paranoia, megalomania, erotomania or mysticism. 7
The Paris authors identify two types of the syndrome: type 1) classic, and type
2) with delayed expression. Type 1 patients usually have a history of psychiatric
problems, and may travel from Japan to Paris for ‘strange’ or delusional reasons,
but they do not present with symptoms until arrival. Once they reach Paris,
however, the onset of symptoms happens immediately, sometimes while the patient
is still in the airport. The authors give as an example the case of a 3 9-year-old
female patient who suffered a psychotic break upon her arrival in Paris, and was
hospitalized. In interviews she declared that she was going to be queen of ‘Sweden,
Nadia Halim 5
__________________________________________________________________
Finland or Denmark.’ 8 Further investigation revealed that she had been
hospitalized for schizophrenia repeatedly from the age of 19, and that she had
travelled to Paris because an advertising campaign in Tokyo built around the
slogan ‘France is waiting for you’ had convinced her that she had a special destiny
there. 9 Type 2 patients do not necessarily have any personal or familial psychiatric
history; their reasons for travelling to Paris are usually unremarkable. Their
symptoms do not appear until 3 months or longer after arrival. As an example of
this type, the authors cite the case of a 3 0-year-old man with no previous
psychiatric history who came to France to study at Reims. After 3 months he
ceased to attend classes; after 2 more months, he moved to a hotel in Paris. Hotel
staff had him admitted to hospital shortly thereafter; he was experiencing severe
anxiety, anorexia, and insomnia, and he heard voices threatening to kill him and his
family. 10
B. Stendhal Syndrome
Stendhal syndrome (Florence) has been named and studied in depth by
Graziella Magherini, a p rominent Florence psychiatrist and psychoanalyst.
Magherini frames the syndrome as a r esponse to an overwhelming aesthetic
experience, which, in theory, could happen in any place where tourists are
immersed in environments that are intensely beautiful to them: ‘La confrontation
du sujet avec la cité d’art, avec son image écrasante, demure l’élément constant
[The subject’s confrontation with the city of art, with its overwhelming image,
remains the constant element]’ in these cases. 11 Nonetheless, it is only in Florence
that Magherini has studied and treated the syndrome. The name she has chosen for
it reflects this, referring to an emotional disturbance reported by the French
novelist Stendhal during a visit to Florence in 1817. Upon leaving the Basilica of
Santa Croce, he was so profoundly aesthetically moved that he experienced a
racing heartbeat, and a feeling of exhaustion, as though he was about to collapse. 12
Stendhal’s experience is at the mild end of the spectrum of symptoms Magherini
has observed in her patients at Santa Maria Nuova Hospital. She breaks down the
106 cases observed from 1977 to 1986 into three types: 1) patients with
predominantly psychotic symptoms (‘troubles de la pensée’), representing 70 of
the 106 cases; 2) patients with predominantly affective symptoms, of which there
were 31; and 3) patients whose predominant symptoms are somatic expressions of
anxiety, eg. panic attacks, of which there were only 5. 13 Only 38% of Type 1
patients had a prior psychiatric history, while 53% of Type 2 pa tients did. 14 In
many of the case histories presented by Magherini, patients report some sense of
disintegration or fragmentation of self: A 53-year-old male patient, stricken after
gazing for a p rolonged time at Caravaggio’s Bacchus, had a s ense that he was
suspended between two major phases of his life, in an undefined, transitional state
(‘il n’y a alors plus rien de défini précisément’). 15 A 20-year-old female patient,
after spending some time in the Uffizi Galleries, was seized by a terror that she was
6 Mad Tourists
__________________________________________________________________
breaking into pieces (‘l’angoisse de se casser en mille morceaux’), screamed, ‘Help
me!’ over and over, and was so agitated she had to be physically restrained. 16
C. Jerusalem Syndrome
Jerusalem syndrome was first named in the 1930s by Israeli psychiatrist Haim
Herman, 17 but psychiatrists did not begin keeping comprehensive clinical and
statistical information on these cases until 1979 18. Here, tourists become
overwhelmed by the religious and spiritual significance of being in the Holy City.
A 2000 pa per 19 lays out three main categories of the syndrome. In type 1, the
syndrome is ‘superimposed on a previous psychotic illness;’ 20 much like patients
with the classic form of Paris syndrome, patients with this diagnosis often travel to
Jerusalem for strange or delusional reasons, and begin presenting with symptoms
shortly upon arrival. In type 2, the syndrome is ‘superimposed on and complicated
by idiosyncratic ideations.’ 21 Here, the patient does not have a history of psychosis,
but does have a history of religious and/or ideological thinking that is extreme or
bizarre by the standards of her society; no clear mental illness is present, but the
patient may have a personality disorder, or an ‘obsession with a fixed idea.’ 22 The
patient’s behaviour upon arrival initially falls within the bounds of normal (if
extreme) religious expression, then veers into the pathological. As an example the
authors offer the case history of a 45-year-old male patient who had been obsessed
for some years with ‘the idea of finding the ‘true’ religion.’ 23 He came to
Jerusalem to study at a Jewish religious seminary, but soon rejected Judaism in
favour of ‘primitive Christianity.’ 24 He was hospitalized after suffering a
breakdown in a ch urch, where he had ‘an attack of psychomotor agitation,’
shouting at the priests and destroying artefacts. 25 Type 3 pa tients have no prior
psychiatric history when they arrive in Jerusalem, but once there, the syndrome
develops according to an unusually consistent and specific sequence. The patients
first become anxious and agitated, then separate themselves from any travelling
companions. They begin to bathe and groom themselves compulsively. They then
devise toga-like garments from white hotel linens, and, shouting out hymns or
passages from the Bible, proceed to a holy site, where they deliver confused and
rambling sermons. The authors saw 42 cases fitting the diagnostic criteria of Type
3 between 1980 and 1993. 26
2. City-Syndromes and Hacking’s Theory of Transient Mental Illnesses

None of these syndromes have been studied outside their locales, and in most
cases, the reports from the clinical teams who first named and collected data on the
syndromes are virtually the only scholarly articles about them to have been
published. Partly, this is a function of the highly localized nature of the phenomena
- it would be impossible to do independent clinical research on Paris syndrome
outside of Paris, for example - but there is also a r eluctance to accept these
syndromes as legitimate, ‘real’ disorders. Media coverage of the disorders usually
Nadia Halim 7
__________________________________________________________________
includes commentary from sceptics, who point to the fact that most patients have a
previous psychiatric history as evidence that their city-specific syndrome attacks
are, in fact, merely manifestations of an already-present disorder, and that the
connection to the city is not clinically significant. Interviewed for a 1989 New York
Times article on Stendhal syndrome, New York psychiatrist Elliot Wineburg takes
this line, arguing that the patients were already sick and their psychotic symptoms
‘would have come out sooner or later.’ 27 Similarly, in an online article about
Jerusalem syndrome, American psychiatrist Melissa Hunt is quoted as saying that
‘Jerusalem syndrome does not actually exist as a distinct diagnosis in any formal
nosological system,’ and that sufferers are simply psychotic. 28
This scepticism has fuelled an ongoing debate between two groups of
researchers who have studied the Jerusalem syndrome. A 1991 paper, ‘Psychiatric
Hospitalization of Tourists in Jerusalem,’ examines data on tourists admitted to
Jerusalem’s Kfar Shaul Psychiatric Hospital since 1979. The cases discussed
resemble those associated with city syndromes, as described above. The authors
conclude that ‘tourist psychopathology’ is a specialization worthy of study, 29 and
that ‘religiosity’ seemed to function as both a risk factor and a ‘stabilizing’ factor
in the cases considered, 30 but the phrase ‘Jerusalem syndrome’ is never used. The
2000 paper ‘Jerusalem syndrome,’ cited above, builds on the research used in the
1991 paper, but here the authors explicitly state that their aim is ‘to describe the
Jerusalem syndrome as a u nique acute psychotic state.’ 31 In a response to this
article, M. Kalian and E. Witztum – two of the authors of the 1991 paper – write:
In view of our accumulated data, Jerusalem should not be

regarded as a pathogenic factor, since the morbid ideation of the
affected travelers started elsewhere. Jerusalem syndrome should
be regarded as an aggravation of a chronic mental illness, and not
a transient psychotic episode. 32
When they wrote a similar response to a case history published by the Jerusalem
syndrome group, those authors wrote a reply in which they pointed out that their
original paper clearly acknowledged that Type 1, the most common form of the
syndrome, is ‘superimposed on a previous psychotic illness,’ adding, ‘As a
syndrome rather than as a distinct nosological entity, Jerusalem syndrome may
appear in the context of other major psychiatric disorders or as a de novo psychotic
condition.’ 33
Note that the debate is not over whether the patients are ill – both sides agree
that their symptoms are real. It is also not an argument about the course of the
illness. Both sides agree that there is usually a pre-existing, sometimes latent
condition that is aggravated in some way by the intensity of the patient’s response
to unfamiliar surroundings. Kalian and Witztum seem inclined to deny that the
symptoms may appear de novo, but Hunt points out that such cases may simply be
8 Mad Tourists
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classified as Brief Psychotic Disorder, which is often triggered by stress and sleep
deprivation, both common afflictions of tourists. 34 The debate is really over what
to call the phenomenon – whether to give it a name of its own, and whether to give
it a place in the taxonomy of disorders, or to classify it, as Kalian and Witztum
propose, as a ‘cultural phenomenon’ instead. 35 It is this kind of question that Ian
Hacking finds at the core of debates around what he calls ‘transient mental
illnesses.’ 36
In his book Mad Travellers, Hacking closely scrutinizes an outbreak of fugue -
compulsive travelling, with amnesia - in France in the late 19th century, in order ‘to
provide a framework in which to understand the very possibility of transient mental
illnesses.’ 37 These are illnesses which arise abruptly in a specific historical and
geographical context, persist for some time, then seem to fade away. To Hacking,
the question of whether these illnesses are ‘real’ is difficult to answer, because ‘our
conceptions of real illnesses are of necessity being… renegotiated at present,’ 38 in
large part because of confusion over the implications of recent advances in our
understanding of the role biology plays in these illnesses. He focuses instead on the
social and historical factors that allow a diagnosis to take hold in a particular time
and place. He uses the ‘metaphor of an ecological niche in which mental illnesses
thrive.’ 39 An outbreak of an illness like fugue happens when the diagnosis strikes a
chord both with disturbed people in a s ociety, and with clinicians searching for
patterns and meaning in patients’ symptoms. In the same way that a particular
animal species will thrive and multiply in an ecosystem that provides it with
favourable conditions, a diagnosis, once conceived, will take hold and spread in a
society that is receptive to it. Hacking lays out four ‘vectors’ which contribute to
the formation of such an ‘ecological niche;’ 40 the circumstances in which city-
syndromes arise can be mapped onto these.
A. Observability
‘In order for a form of behaviour to be deemed a mental disorder, it has to be
strange, disturbing, and noticed,’ Hacking notes. 41 In other words, the behaviour
must have a public, socially visible dimension; it must generate official records, a
body of statistical data. City-syndromes certainly fit this requirement. The
theatricality of Type 3 Jerusalem syndrome is an extreme example, but victims of
Paris and Stendhal syndromes are highly visible as well: as foreigners, they stand
out, and they tend to have attacks in busy public places. In most case histories,
patients are brought to hospital by police or by hotel staff.
B. Release
The disorder must, in some way, offer ‘an inviting escape’ to people who feel
trapped and alienated within their circumstances. 42 Again, this applies to city-
syndromes. It is not hard to see how, thousands of miles away from friends, family
and co-workers, individuals who have been struggling to repress unacceptable
Nadia Halim 9
__________________________________________________________________
ideations and behaviours may feel suddenly freed from the threat of social
consequences. The Paris authors, in particular, note that patients are often fleeing
stiflingly conservative home environments in search of an ‘ideal elsewhere
[ailleurs ideal].’ 43
C. Cultural Polarity
Hacking proposes that the behaviours associated with a transient mental illness
tend to fall between ‘two social phenomena… one virtuous, one vicious’ that
preoccupy the society in which the illness arises. As an example, fugue lay
between ‘romantic tourism and criminal vagrancy’ - admired and feared activities,
respectively, in late-19th-century France. 44 Such a polarity is strikingly present with
Jerusalem syndrome, which falls between passionate spirituality and religious
fanaticism, both phenomena of intense interest to citizens and visitors of that city.
It is less obvious with the other, correspondingly less-notorious city-syndromes,
but it c an still be detected. Stendhal syndrome falls between an expression of
refined aesthetic sensitivity - good - and an excessive, voluptuous preoccupation
with beauty - bad, although not the focus of a prevalent social anxiety to the extent
that fundamentalism is. Magherini does emphasize, in many of her case histories,
that patients tend to come from emotionally repressed backgrounds where an
intense interest in beauty is frowned upon. A similar polarity seems to be at work
in Paris syndrome, although a proper analysis would require a thorough familiarity
with Japanese culture.
D. Medical Taxonomy
This vector is in place when a diagnosis fits into the current system of
classification, but there is controversy over how it does so. In Hacking’s example,
fugue was regarded by some experts as a form of hysteria, and by others as a form
of epilepsy, making it a point of contention between two of the major research
communities of the day, and therefore ‘theoretically interesting.’ 45 In the case of
city-syndromes, the debate is over whether the syndromes belong in the current
psychiatric taxonomy as discrete illnesses, or whether they are simply instances of
established disorders and not representative of any clinically interesting new
pattern, or whether they are not discrete disorders but are worthy of recognition
and study as cultural phenomena.
3. Discussion
If fugue generated taxonomic controversy because two conflicting psychiatric
paradigms each wanted to claim it, what is behind the debate over the medical
taxonomy of city-syndromes? What motivates researchers in some cities to argue
for their inclusion in the taxonomy of illness? There are almost certainly many
cities where similar events occur but no such arguments have been made. ‘Talk to
the guards who work at Elvis’ tomb year-round about people who are overcome
10 Mad Tourists
__________________________________________________________________
when visiting an emotionally evocative site. If we worked at it, we could probably
define a ‘Graceland Syndrome,’’ remarks Hunt. 46
One factor is perhaps the psychodynamic orientation of many city-syndrome
researchers. Looked at from a strictly biomedical perspective, the patients’
aesthetic or spiritual responses are epiphenomenal. That is, the meaningful content
of the ‘stress’ that brings about the pathological episode is not really part of the
causal explanation of the event. In a psychodynamic explanation, however,
meaningful content is paramount; an intense aesthetic response may induce a crisis
within the patient’s personality, a t hreat to the integrity of the self, precisely
because of the meaning it has in the context of that person’s life history.
Furthermore, such a crisis may become part of a therapeutic narrative in which the
patient is led, finally, to a strengthened and enhanced self-understanding. As such,
although it is painful and dangerous, it has an ultimately positive value. This is
evident in the work of Magherini, whose analysis of the Stendhal syndrome is
psychoanalytic (and deeply romantic). Repeatedly, in the case histories she
describes, tourists who have had emotionally repressed upbringings in northern
Europe, or aesthetically impoverished lives in the U.S., suffer breakdowns when
they are immersed in the extravagant beauty and sensuality of Florence. During
these crises, they experience a kind of fragmentation of personality; if they are able
to tolerate a period of ambiguity and uncertainty (‘un intervalle d’incertitude’) in a
treatment facility, they are rewarded with ‘the restoration of order, and a
broadening of mental range [la remise en ordre et l’élargissement du champ
mental].’ 47 For example, the male patient from Bavaria who, after gazing at
Caravaggio’s Bacchus, had a sense that his inner self was fragmenting, and
experienced strange perceptual distortions - ‘colours never seen before’ -
subsequently was able to come to terms with his own latent homosexuality. 48 It is
unclear whether the Paris and Jerusalem researchers have any psychodynamic
orientation, although the Paris authors hint at this when they describe Type 2 of the
syndrome as a ‘crisis of identity’ that manifests in individuals with ‘fragile, limited
personalities,’ 49 and the Jerusalem authors make note of Freud’s ‘sense of
derealization while visiting the Acropolis.’ 50
Some practitioners value psychodynamic interpretations but do not believe they
provide causal explanations for illness; following Jaspers, they view these
interpretations as offering a hermeneutic, interpretative understanding of the
psyche, not a scientific, generalizable one. The position of Kalian and Witzum, the
Jerusalem syndrome skeptics, seems to be grounded in this position. They employ
a psychodynamic approach in examining the syndrome; a 2002 paper, ‘Jerusalem
Syndrome as reflected in the pilgrimage and biographies of four extraordinary
women from the 14th century to the end of the second millennium,’ closely
examines the personal histories of its subjects ‘to reach a deeper understanding of
the dynamics of their eccentric behaviour.’ 51 In rejecting the validity of Jerusalem
syndrome as a unique psychiatric diagnosis, Kalian and Witztum seem to be
Nadia Halim 11
__________________________________________________________________
rejecting, not the idea that the experience of being overwhelmed by Jerusalem is
meaningful in these cases, but the idea that it is causal. The ‘religious atmosphere
of the Holy City’ - the experience of being immersed in an environment of
historical and spiritual significance - is ‘not the primary cause’ of the illness, 52 but
it seems to have contributed to the symbolic idiom these women used to express
their inner turmoil. The authors characterize the syndrome as ‘an outcome of deep
individual psychological needs, at times reflecting a production of
psychopathology coloured by the individual’s cultural background.’ 53 They read
their historical subjects’ behaviours as attempts ‘to translate delusionary ideations
into earthly endeavour,’ and see ‘creativity’ in them. 54 Their position appears
therefore to preserve the positive narrative value of the patients’ Jerusalem crises,
while locating this aspect of the phenomenon outside a psychiatric taxonomy.
To Hacking, transient mental disorders offer ‘a way to be mad, or to be thought
of as mad’ to people in their geographical and historical context. 55 Kalian and
Witzum’s position on Jerusalem syndrome can be read in this way as well. But
Hacking’s model implies, ambivalently, a causal role for meaning in illnesses of
this kind: a complex array of social and physical factors make it inevitable that the
patient will become sick, but the form that sickness will take is determined by the
diagnoses available to the patient and her doctors. (Hacking might say that
Jerusalem syndrome is triggered not so much by the atmosphere of the Holy City
as by the tourist’s awareness of Jerusalem syndrome as something that might
happen to her.) In the case of fugue, he takes a negative view of this phenomenon,
noting that now that the diagnosis has faded from view, his ‘hope is that the vector
of medical taxonomy never succeeds in making space for it again.’ 56 Should it be
our hope that Jerusalem and other city-syndromes, too, will be eliminated?
Certainly, it is the job of psychiatry to reduce the suffering caused by mental
illness, and in that sense, it should seek to prevent attacks of the kind experienced
by these ‘mad tourists.’ But psychiatric prevention is far from perfect, and in cases
where these attacks cannot be prevented, reading them as incidents of city-
syndromes may invest them with a certain dignity and meaning. To be
overwhelmed by the beauty of the art in the Uffizi galleries, or by the spirituality of
the Holy City, or even by a wounding sense of alienation in the streets of Paris, is
less humiliating than to simply crack up under the stress of travel, and perhaps
more likely to lead the patient to worthwhile self-reflection. Whether this meaning
– the content of the stress that triggers the incidents – is taken as part of the causal
history of the illness, or whether this cultural, interpretative reading of the illness is
separate from psychiatric accounts of it, is the larger issue underlying the
controversy over how to classify city-syndromes.
12 Mad Tourists
__________________________________________________________________
Notes
1
O. Ross, The Toronto Star, June 7, 2008.
2
C. Haberman, The New York Times, May 15, 1989.
3
It should be noted that for all these syndromes, it is difficult or impossible to
track patients’ long-term progress, because they return to their home countries as
soon as they are well enough to travel; language barriers also pose a p roblem.
However, there appears to be a rough consensus among researchers that patients
without a history of serious psychiatric problems tend to recover quickly.
4
A laguna syndrome (Venice) has also been proposed, but will not be discussed in
this chapter, as no detailed information on it is available. (Steiner et al.)
5
A. Viala et al., ‘Les Japonais en voyage pathologique à Paris: un modèle original
de prise en charge transculturelle’. Nervure (supplement), Vol. 17, No. 5, June
2004, p. 32.
6
Ibid., p. 31.
7
Ibid., pp. 31-32.
8
Ibid., p. 33.
9
Ibid., p. 33.
10
Ibid., p. 33.
11
G. Magherini, Le syndrome de Stendhal,1989, trans. F. Liffran, Usher, Florence,
1990, p. 51.
12
Ibid., p. 31.
13
Ibid., pp. 171, 178.
14
Ibid., p. 179.
15
Ibid., p. 54.
16
Ibid., p. 103.
17
M. Kalian and E. Witztum, ‘Jerusalem Syndrome as Reflected in the Pilgrimage
and Biographies of Four Extraordinary Women from the 14th Century to the End
of the Second Millennium’, Mental Health, Religion & Culture, 2002, p. 15.
18
I. Bar-El et al., ‘Psychiatric Hospitalization of Tourists in Jerusalem’,
Comprehensive Psychiatry, Vol. 32, No. 3, May/June 1991, p. 239.
19
I. Bar-El et al., ‘Jerusalem Syndrome’, British Journal of Psychiatry, Vol. 176,
2000, pp. 86-90.
20
Ibid., p. 86.
21
Ibid., p. 87.
22
Ibid., p. 88.
23
Ibid., p. 88.
24
Ibid., p. 88.
25
Ibid., p. 88.
26
Ibid., p. 88.
27
C. Haberman, ‘Florence’s Art Makes Some Go to Pieces’, The New York Times,
Section A, May 15, 1989.
Nadia Halim 13
__________________________________________________________________
28
A. Oltuski, ‘Syndrome City’, New Voices: National Jewish Student Magazine,
undated, Viewed on 15 J uly 2008, http://newvoices.org/web-wire/syndrome-
city.html.
29
I. Bar-El et al., p. 238.
30
Ibid., p. 243.
31
32
M. Kalian and E. Witztum, ‘Comments on Jerusalem Syndrome’, British
Journal of Psychiatry, Vol. 176, 2000, p. 492.
33
N. Fastovsky et al., ‘Jerusalem Syndrome or Paranoid Schizophrenia?’ (letter),
Psychiatric Services, Vol. 51, No. 11, November 2000, p. 1454.
34
Oltuski.
35
Kalian and Witztum, ‘Jerusalem Syndrome as Reflected…’, op. cit., pp. 1-16.
36
I. Hacking, Mad Travelers: Reflections on the Reality of Transient Mental
Illnesses, University Press of Virginia, Charlottesville, 1998, p. 1.
37
Ibid., p. 1.
38
Ibid., p. 95.
39
Ibid., p. 1.
40
Ibid., p. 1.
41
Ibid., p. 82.
42
Ibid., p. 82.
43
A. Viala et al., p. 33.
44
I. Hacking, p. 81.
45
Ibid., p. 81.
46
A. Oltuski.
47
G. Magherini, p. 169.
48
Ibid., pp. 53-56.
49
A. Viala et al., p. 33.
50
51
M. Kalian and E. Witztum, 2002, p. 1.
52
Ibid., 2002, p. 1.
53
Ibid., 2002, pp. 1-2.
54
Ibid., 2002, pp. 14-15.
55
I. Hacking, p. 55.
56
Ibid., p. 94.
Bibliography
Bar-El, I., Witztum, E., Kalian, M. and Brom, D., ‘Psychiatric Hospitalization of
Tourists in Jerusalem.’ Comprehensive Psychiatry. Vol. 32, No. 3, May/June 1991,
pp. 238-244.
14 Mad Tourists
__________________________________________________________________
Bar-El, I., Durst, R., Katz, G., Zislin, J., Strauss, Z. and Knobler, H.Y., ‘Jerusalem
Syndrome.’ British Journal of Psychiatry. 176, 2000, pp. 86-90.
Fastovsky, N., ‘Jerusalem Syndrome or Paranoid Schizophrenia?’ (letter).

Psychiatric Services. Vol. 51, No. 11, November 2000, pp. 1454.
Haberman, C., ‘Florence’s Art Makes Some Go to Pieces.’ The New York Times.
May 15, 1989.
Hacking, I., Mad Travelers: Reflections on the Reality of Transient Mental

Illnesses. University Press of Virginia, Charlottesville, 1998.
Kalian, M. and Witztum, E., ‘Comments on Jerusalem Syndrome.’ Letter. British

Journal of Psychiatry. 176, 2000, pp. 492.
–––, ‘Jerusalem Syndrome or Paranoid Schizophrenia?’ Letter. Psychiatric

Services. Vol. 51, No. 11, November 2000, pp.1453-1454.
–––, ‘Jerusalem Syndrome as Reflected in the Pilgrimage and Biographies of Four

Extraordinary Women from the 14th Century to the End of the Second
Millennium.’ Mental Health, Religion & Culture. Vol. 5, 2002, pp. 1-16.
Magherini, G., Le syndrome de Stendhal. trans. Liffran, F., Usher, Florence, 1990.
Oltuski, A., ‘Syndrome City.’ New Voices: National Jewish Student Magazine
(undated). Online: http://newvoices.org/web-wire/syndrome-city.html.
Viala, A. et al., ‘Les Japonais en voyage pathologique à Paris: un modèle original

de prise en charge transculturelle.’ Nervure (supplement), Vol. 17, No. 5, June
2004, pp. 31-34.
Nadia Halim is a Ph.D. candidate in Philosophy at York University in Toronto,

Canada. Her research interests include the history and philosophy of psychology
and psychiatry.
Auditory Hallucinations in Schizophrenia: Collaborating with
the Voices from Without
Rochelle Suri
Abstract
Differentiating between the pathological, and possible religious or spiritual
connotations of schizophrenia sheds light on t he possible mechanisms of coping,
useful in developing clinical strategies in the treatment of schizophrenia. While
many studies have focused on the nature and treatment of auditory hallucinations
within modalities such as cognitive-behavioural therapy and/or psychiatric
interventions, these modalities aim at eliminating the auditory hallucinations in
patients with schizophrenia, perceiving them as a pathological symptom. Research
has also been undertaken in understanding the cultural and religious components of
schizophrenia, as well as how religion and spirituality have been incorporated in
the coping mechanisms of this population. However, there appears to be very little
research on how auditory hallucinations themselves may be incorporated in the
recovery process, in the development of new meaning and purpose as one grows
beyond the catastrophe of mental illness. It also implies that the individual may not
necessarily be cured or be symptom free. Hence, this chapter suggests
reconsidering the role of auditory hallucinations in schizophrenia, an area in the
field of psychology that has a dearth of information. This theoretical perspective is
supported by the survey of the literature, which suggests that for many centuries,
individuals experiencing auditory hallucinations have been given much more
credence than their counterparts in modern society. Most recent studies on auditory
hallucinations indicate that auditory hallucinations themselves are not debilitating.
Romme proposes instead that the fear of not being able to control or manage the
auditory hallucinations can be disabling to the individual. It is hoped that a more
refined understanding of the present literature regarding auditory hallucinations
will promote a basis for the relevance of researching auditory hallucinations in the
recovery process of individuals with schizophrenia.
Key Words: Auditory hallucinations, meaning, recovery, research, schizophrenia.
*****
1. Introduction
An introduction that may be best suited for this chapter lies in a statement that
depicts the complexity and obscurity of schizophrenia: ‘Hey- when you talk to God
it’s called prayer, but when he talks back, it’s schizophrenia.’1 The etymology of
the word schizophrenia suggests schiz to mean ‘broken’ and phrenos to mean
‘soul’ or ‘heart.’2 One could say that this chapter may in essence reflect the story of
the broken hearted.
16 Auditory Hallucinations in Schizophrenia
__________________________________________________________________
The purpose of this chapter is a brief review of the current literature on auditory
hallucinations in schizophrenia whereby it is hoped that a case for re-examining the
role of auditory hallucinations in the recovery process of individuals with
schizophrenia will be established. In essence, this chapter begs the question: Can
auditory hallucinations in patients with schizophrenia be incorporated in the
recovery process? In other words, is it p ossible that instead of viewing auditory
hallucinations as a p athological symptom of schizophrenia, we ‘re-view’ them as
having meaning in an individual’s life?
Auditory hallucinations in schizophrenia are no different than auditory
hallucinations as experienced in other contexts. However, my primary focus is on
schizophrenia solely because schizophrenic patients have often been overlooked,
classified as ‘untreatable’ and ‘hopeless’ by mainstream psychology, providing a
very poor framework for the need to understand auditory hallucinations in a
positive light.
Schizophrenia is one of the most prevalent psychological illnesses in the USA.
A description that would suffice for the purposes of this chapter can be drawn from
the Diagnostic and Statistical Manual of Mental Disorders-IV-TR. Having been
considered the most widely employed definition in clinical psychology, the DSM-
IV-TR describes schizophrenia as a mental disorder that lasts for at least 6 months
and includes at least 1 month of active-phase syndromes (i.e. two or more of the
following: delusions, hallucinations, disorganized speech, grossly disorganized or
catatonic behaviour.3
According to the National Institute of Mental Health, Schizophrenia afflicts
approximately 2.4 million American adults.4 The World Health Organization has
reported that approximately 24 million people worldwide suffer from
schizophrenia.5
2. Auditory Hallucinations in Schizophrenia

In layperson’s terms, hallucinations are simply defined as perceptions (can
be sound, sight, touch, smell, or taste) that occur in the absence of an actual
external stimulus. According to the DSM-IV-TR, hallucinations may occur in any
sensory modality (e.g. auditory, visual, olfactory, gustatory and tactile), but
auditory hallucinations are by far the most common in schizophrenia.
Several factors such as sleep deprivation, use and ingestion of psychedelics or
the use of psychoactive drugs such as marijuana or LSD, have been accounted for
in the experience of hallucinations. Hallucinations have also been known to occur
due to certain infectious diseases such as HIV or Lyme disease, due to the
imbalances of various chemicals or neurotransmitters in the brain, or in patients
suffering from delirium or dementia. Similarly, studies on brain temperature and
the effects of hyperventilation on auditory and visual hallucinations have provided
crucial clues to the causes of hallucinations.
Rochelle Suri 17
__________________________________________________________________
There have been varying opinions and perspectives on the causes and nature of
hallucinations, some viewing them as equivalent to insanity, while others regard
them as being stimulating and inspirational. Lelut believed that hallucinations were
inherently pathological, and an indisputable sign of madness.6 On the other end of
the spectrum, the German psychoanalyst Fromm-Reichmann spoke of psychosis
and hallucinations as being:
useful to the mentally healthy in really finding their minds,

which are all too frequently lost, as it were, in the distortions, the
dissociations…and all the painful hide-and-seeks which modern
culture forces upon the mind of man.7
One of the most prevailing paradigms of auditory hallucinations in

schizophrenia is the psychiatric or medical model that has its roots in the late
Middle Ages, and whose attitudes have been reflected in the establishment of
asylums for the mentally ill of the seventeenth and eighteenth centuries. The
medical model views mental illness as a problem concerned with chemicals, and
the solution is likewise a ch emical one.8 The opinion of the proponents of the
medical model is that mental illness should be viewed as a disease, a dysfunction
of the brain. According to modern psychiatry, people who are experiencing major
mental illness are having ‘broken brains’ and cannot possibly take a stand towards
what is ailing them except to take medications.9
Karl Jaspers, the German psychiatrist, claimed that it is not possible to
discern meaningful content in psychosis: ‘Much has been explained as meaningful
which in fact was nothing of the kind.’10 This view continues to be upheld in
today’s society, for the majority of patients who experience auditory hallucinations
are under the direction of psychiatric care.
The National Alliance of Mental Illness (NAMI) was founded in the USA in
1979. The mission statement asserts that its purpose is the ‘eradication of mental
illness,’11 thereby expressing and promoting the view that mental illness is
something society should aim to eliminate. This idea is in direct opposition to the
views of Laing12 and Jung,13 who believed that people who suffer from mental
illness can offer insights into human processes that are fundamental to living in a
world shared with others. NAMI holds that schizophrenia is a ‘treatable medical
condition,’14 an illness caused by the biochemical disturbances of the brain.
Time and again, auditory hallucinations have acquired a rather negative
reputation, often looked upon as the language of the insane; a language least
understood even after decades of research and investigations. Seldom are auditory
hallucinations taken seriously and looked upon as possibly being a psychological
aid in the healing process of the individual. Psychiatry, the predominant model of
treatment, recognizes minimal or no value in auditory hallucinations, rendering
__________________________________________________________________
them a b ane or a futile aspect of the human condition. Romme succinctly
illuminates this idea when he says:
… psychiatrists and others who insist that such voices do not

exist are missing the point. It is wrong to deny them… these
voices represent real influences, and they have something to say;
sometimes the message maybe unwelcome and uncomfortable;
sometimes wise and instructive.15
From the current research and literature on the treatment of schizophrenia, there
seems to be an absolute reliance on psychiatric medications, particularly because of
the belief that psychosis is a biological or a medical disease. Psychiatric services
rely exclusively on neuroleptic medication, which make little or no effort to
respond to patients’ psychological needs.16 This idea is echoed by Fadiman and
Kewman17 who state that in the last fifteen years, neuroleptic agents have replaced
most forms of treatment for psychoses and other serious mental ailments.
3. Auditory Hallucinations in the Recovery Process of Schizophrenia

About a cen tury ago, Carl Jung spoke on the significance of auditory
hallucinations in individuals with schizophrenia, stating that:
… there is no symptom which could be described as

psychologically groundless and meaningless. Even the most
absurd things are nothing more than symbols for thoughts which
are not only understandable in human terms but dwell in every
human breast.18
The above quote affirms and indicates that indeed there is meaning and
symbolism in auditory hallucinations of patients with schizophrenia, suggesting
that an inquiry into the same may be of grave relevance. Auditory hallucinations
continue to be viewed as a symptom to be eliminated, thereby providing minimal
context for exploring the efficacy of assimilating them within the treatment of
schizophrenia. Smith explicates the notion that the probability of seeking meaning
in auditory hallucinations is very scarce. This opinion is exemplified in the
following sentences:
What matters most to the contemporary clinician is the

experience’s form - what grammatical tense and ‘person’ it
speaks in … whether it speaks continuously and intermittently.
This information is the key to making a correct diagnosis, and
therefore to prescribing the most effective treatment. Discussions
of meaning are commonly thought to distract from this work.19
Rochelle Suri 19
__________________________________________________________________
For centuries, and particularly in western cultures, auditory hallucinations have
been pathologised and viewed in a negative light, with a very bleak future in sight.
Bentall & Slade20 have commented that hallucinatory experiences are assumed to
be strictly pathological in nature. However, over the last few decades a significant
number of researchers have challenged the dominant paradigm of mental illness by
altering and re-constructing their perceptions of the same. There appears to be an
emphasis on ‘the potential adaptive value of the experience of madness or the
possibility for positive change.’21 This paradigm shift can be noted in the
emergence of the relatively new concept of ‘recovery,’ having being described by
Anthony as:
… a deeply personal, unique process of changing one's attitudes,

values, feelings, goals, skills, and/or roles. It is a way of living a
satisfying, hopeful, and contributing life even with limitations
caused by illness.22
The idea of recovery challenges the existing notion that mental illness is
debilitating and of very little significance to the patient. In reference to individuals
with auditory hallucinations in schizophrenia, recovery may imply that such
individuals may be in a position to cultivate a more favourable attitude towards
their auditory hallucinations, thereby possibly viewing them as an aid to
psychological healing instead of something to be completely extinguished from the
human experience.
The recovery model seems to be of great relevance to individuals with auditory
hallucinations, though there appears to be a paucity in the literature regarding the
same. In fact, the process of recovery has not been researched23 and only
assumptions have been made regarding the process. This indicates that there is a
crucial need for exploring the value and utility of research regarding the
incorporation of auditory hallucinations in the recovery process of schizophrenia.
The outlook towards auditory hallucinations determines to a great extent, the
level and kind of treatment that is undertaken for patients with this experience. So
far, treatment of auditory hallucinations has been approached in numerous ways.
Operant conditioning, systematic desensitization, thought stopping, counter-
stimulation, aversion therapy, and ear plug therapy, as well as self monitoring,24
are some of the treatment models that have been developed and implemented over
the years.
All of the above methods have consistently aimed at eliminating the auditory
hallucinations of patients. But what if we were to change our perspective and shift
our focus from eliminating auditory hallucinations to assimilating them into the
recovery from schizophrenia? In other words, what if the goal of treatment was the
development of a relationship with the auditory hallucinations so as to collaborate
with them rather than eradicate them in order to promote psychological healing?
__________________________________________________________________
The above perspective has been adopted by the Dutch psychiatrist Marius
Romme who possesses a r ather non-pathological view of auditory hallucinations,
emphasizing the importance of controlling or managing them. In a study by Dr.
Romme,25 where patients (diagnosed with a mental illness) and non-patients who
experienced auditory hallucinations were compared, it was found that there were
few differences in the two groups. Both patients and non-patients experienced a
combination of positive and negative voices, but the non-patients often felt they
had some control over their voices. This suggests that it is not the hallucinations
per se that determine whether people seek help from psychiatric services, but how
well they are able to cope with these experiences.26
4. Conclusion
Extensive research has been undertaken with respect to auditory hallucinations
within psychiatric populations (e.g.: schizophrenia, bi-polar disorder, dementia,
etc). In the same vein, there has been some research conducted with non-
psychiatric populations, thereby indicating that auditory hallucinations are not
necessarily a pathological phenomena, but part of the human experience.
There appears to be two schools of thought that are key players in providing a
theoretical understanding of auditory hallucinations in schizophrenia. The medical
model or psychiatric perspective deems it i mportant to eliminate auditory
hallucinations via neuroleptic medications. Therefore, it c ould be suggested that
according to this world-view, the suppression or elimination of auditory
hallucinations is an indication of successful treatment, and therefore a necessity in
order for an individual to resume a normal life.
The second school of thought suggests that auditory hallucinations are a
significant part of the individual’s experience, and therefore should not be
eliminated. The proponents of this paradigm, who include Romme, Jung and
Laing, have indicated that auditory hallucinations have a purpose in the
individual’s life, and have meaning or relevance for the individual concerned.
Romme, on speaking of the importance of accepting auditory hallucinations, which
he refers to as ‘voices,’ states:
… hearing voices has been considered solely as a s ymptom of

illness, and the psychiatric intervention has paid no attention to
the possible meaning of voices to the patient’s life history.27
It appears that there is meaning in auditory hallucinations; meaning that cannot

be ignored, but explored. What I believe is missing from the current literature is
research relevant to the incorporation of auditory hallucinations within the
treatment or recovery process, specifically in the case schizophrenia. The literature
reviewed does not provide any indication that this idea or concept has ever been
Rochelle Suri 21
__________________________________________________________________
looked into or researched before, or that the idea is of any significance to the
treatment of schizophrenia.
With time, it is becoming evident that perhaps even a slight modification in our
attitude towards auditory hallucinations and their possible significance in the
recovery from schizophrenia is what are most needed. This is not to say that such
an attitude is a p anacea for schizophrenia. Yet, instead of viewing auditory
hallucinations solely as a symptom, it may be of certain benefit to the patient to
‘re-view’ auditory hallucinations in a more progressive light. James Hillman
illuminates this idea in stating that we need to approach the concept of pathology
afresh.28 In fact, he describes symptoms, such as auditory hallucinations, as the
psyche’s yearning to heal.
It is crucial to re-state that recovery (for the purpose of this chapter), does not
necessarily equate to cure, but is more related to the patient/client developing a
new understanding of his/her life circumstances, and living a satisfying and
hopeful life. This idea is best illustrated through the case example of L.P, a 26 year
old woman who was diagnosed with schizophrenia, and is now the chairwoman of
the organization Survivors Speak Out. In speaking with Romme, she described her
felt experience of acknowledging and understanding her visual hallucinations (of
snakes crawling around her bedroom):
It helped that somebody believed me. Somebody was taking me

seriously and doing something. It did not necessarily help the
snakes to disappear, but I didn’t feel totally alone. It does not
help to tell me they are not real, because they are.29
Fadiman & Kewman note that decades of research on auditory hallucinations,

especially in schizophrenia, have focused on ‘more basic examinations, especially
at the neurological and behavioural level.’30 Research has sought to understand
auditory hallucinations from a rather scientific and material basis, viewing the
suppression of auditory hallucinations as a s uccessful indication of treatment in
schizophrenia. In shifting our attitude, it may be hoped that an acknowledgement
of the role of auditory hallucinations may pave the path to a less pathological
perspective. Furthermore, from the current research and literature, it seems that a
progressive and tolerant attitude towards auditory hallucinations in schizophrenia
may be beneficial in deepening our appreciation and perception of this widely
studied phenomenon.
Notes
1
J. Jenkins & R. Barrett, Schizophrenia, Culture, and Subjectivity: The Ddge of
Experience, Cambridge University Press, 2004.
__________________________________________________________________
2
B. Radder, Beyond Countertransference: The Therapist’s Experience in a
Clinical Relationship with a Schizophrenic Patient, UMI Company, Michigan,
2006.
3
American Psychiatric Association, Diagnostic and Statistical Manual of Mental
Disorders, 4th ed., Washington, DC, 2000.
4
The Numbers Count: Mental Disorders in America, Viewed on April 2, 2008,
http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disord
ers-in-america.shtml#Schizophrenia.
5
World Health Organization, Mental and Neurological Disorders, 2001, viewed
on April 2, 2008, http://www.who.int/whr/2001/media_centre/en/whr01_fact_
sheet1_en.pdf.
6
F. Lelut, Du demon de Socrat, Trinquart, Paris, 1836.
7
F. Fromm-Reichmann, Psychoanalysis and Psychotherapy, The University of
Chicago Press, Chicago, 1959.
8
R. Shorto, Saints and Madmen: How Pioneering Psychiatrists are Creating a
New Science of the Soul, Owl Books, 1999.
9
Jenkins & Barrett, 2004.
10
K. Jaspers, General Psychopathology, Manchester University Press,
Manchester, 1963, p. 408.
11
About NAMI, Viewed on April 8, 2008, http://www.nami.org/Content/Nav
igationMenu/Inform_Yourself/About_NAMI/About_NAMI.html.
12
R. Laing, The Divided Self, Tavistock Publications, London, 1960.
13
C. Jung, On the Psychogenesis of Schizophrenia, Princeton University Press,
Princeton, New Jersey, 1960.
14
About Mental Illness, viewed on April 8, 2008, http://www.nami.org/Template.
cfm?Section=By_Illness&Template=/TaggedPage/TaggedPageDisplay.cfm&TPLI
D=54&ContentID=23036.
15
M. Romme & S. Escher, Accepting Voices, Mind Publications, London, 1993.
16
R. Bentall, Madness Explained: Psychosis and Human Nature, Penguin Books
Ltd, London, 2003.
17
J. Fadiman & D. Kewman, Exploring Madness: Experience, Theory and
Research, Brooks/Cole Publishing Company, California, 1973.
18
R. Lockhart, ‘Voices of Psychosis’, Psychological Perspectives, Vol. 6 , 1975,
pp. 146-160.
19
D. Smith, Muses, Madmen and Prophets: Rethinking the History, Science, and
Meaning of Auditory Hallucination, Penguin Press, 2007, p. 11.
20
R. Bentall & P. Slade, Sensory Deception: Towards a Scientific Analysis of
Hallucinations, Croom Helm, London, 1988.
21
Fadiman & Kewman, 1973, p. 1.
Rochelle Suri 23
__________________________________________________________________
22
W. Anthony, ‘Recovery from Mental Illness: The Guiding Vision of the Mental
Health Service System in the 1990’s’, Psychosocial Rehabilitation Journal, Vol.
16, 1993, pp. 11-23.
23
Anthony, 1993.
24
Bentall, 2003, p. 65.
25
Romme & Escher, 1993, p. 45.
26
Bentall, 2003, p. 96.
27
28
J. Hillman, Re-Visioning Psychology, Harper Collins Publishers, New York,
1977.
29
30
Fadiman & Kewman, 1973, p.175.
Bibliography
Disorders. 4th ed., Washington, DC, 2000.
Bentall, R., Madness Explained: Psychosis and Human Nature. Penguin Books
Ltd, London, 2003.
Bentall, R. and Slade, P., Sensory Deception: Towards a Scientific Analysis of

Hallucinations. Croom Helm, London, 1988.
Fadiman, J. and Kewman, D., Exploring Madness: Experience, Theory and

Research. Brooks/Cole Publishing Company, California, 1979.
Fromm-Reichmann, F., Psychoanalysis and Psychotherapy. The University of

Chicago Press, Chicago, 1959.
Hillman, J., Re-Visioning Psychology. Harper Collins Publishers, New York, 1977.
Jaspers, K., General Psychopathology. Manchester University Press, Manchester,

1963.
Jenkins, J. and Barrett, R., Schizophrenia, Culture, and Subjectivity: The Edge of
Experience. Cambridge University Press, 2004.
Jung, C., On the Psychogenesis of Schizophrenia. Princeton University Press,

Princeton, NJ, 1960.
__________________________________________________________________
Laing, R., The Divided Self. Tavistock Publications, London, 1960.
Lelut, L., Du demon de Socrat. Trinquart, Paris, 1836.
Lockhart, R., ‘Voices of Psychosis’. Psychological Perspectives. Vol. 6, 1975, pp.

146-160.
Radder, B., Beyond Countertransference: The Therapist’s Experience in a

Clinical Relationship with a Schizophrenic Patient. UMI Company, Michigan,
2006.
Romme, M. and Escher, S., Accepting Voices. Mind Publications, London, 1993.
Shorto, R., Saints and Madmen: How Pioneering Psychiatrists are Creating a New
Science of the Soul. Owl Books, 1999.
Smith, S., Muses, Madmen and Prophets: Rethinking the History, Science, and
Meaning of Auditory Hallucination. Penguin Press, 2007.
The Numbers Count: Mental Disorders in America. Viewed on April 2,

http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-isorders-
in-america.shtml#Schizophrenia.
World Health Organization (2001). Mental and Neurological Disorders. Viewed

on April 2, 2008, http://www.who.int/whr/2001/media_centre/en/whr01_fact_
sheet1_en.pdf.
Rochelle Suri is a l icensed Marriage and Family Therapist (NFT) in the state of
California and is currently pursuing a Ph.D. in East West Psychology at the
California Institute of Integral Studies.
Carving Dreams on Marbles Lost: The Transatlantic Network
on Mental Health and the Arts (TRAMHA)
Gonzalo Araoz
Abstract
TRAMHA is an international network devised to foster and develop
interdisciplinary dialogues, research and exchange on creativity and mental health.
One of our main aims is to broaden our knowledge and understanding of the
relationship between individuals and their environments in the assessment of the
factors affecting people’s mental health in specific contexts. General emotional
numbness is a notable social symptom of mental ill health, and madness can be
seen as an effect or a reflection of socio-economic and political circumstances. We
believe that if severe means are to be employed in order to deal with severe mental
health problems, the implementation of artistic activities in strange contexts might
complement (and perhaps even replace) the use of extreme medication (e.g.
lithium) and extreme therapy (e.g. electro-convulsive therapy). Similarly, it is
expected that the deployment of artistic work by ‘madmen’ in public spaces could
contribute to undermine the emotional numbness of society. The benefits of
creative activities for mental health have been increasingly acknowledged in recent
years, because of the transforming capacity of the arts and because of their general
positive effects on wellbeing. Participation in the arts has been identified as an
effective route for personal growth, leading to enhanced confidence and self
esteem, which are important achievements towards mental health. There is clearly
a huge potential for transformation in the interstices between madness and the arts,
and we propose to take the advantage (and the risks!) of using it. One of our main
aims is to integrate creative, investigative and reflective activities beyond the
established boundaries, through interdisciplinary and intercultural dialogues on
wellbeing and creativity. These are not only two broad concepts that include
mental health and the arts, but they are also states that epitomise a harmonic fusion
of being and meaning, of acting and reflecting.
Key Words: Art, creativity, madness, mental health.
*****
Navigation delivers man to the uncertainty of fate; on water,

each of us is in the hands of his own destiny; every embarkation
is, potentially, the last. It is for the other world that the madman
sets sail in his fool’s boat; it is from the other world that he
comes when he disembarks. 1
26 Carving Dreams on Marbles Lost
__________________________________________________________________
1. Introduction
According to Foucault confinement marked in 17th century Europe a decisive
event in the history of unreason, as the moment when madness was ‘perceived on
the social horizon of poverty, of incapacity to work, of inability to integrate to the
group.’ 2 In England it was feared that the country could be overrun by the poor,
and it was proposed that ‘they be banished and conveyed to the New-Found Land,
the East and the West Indies.’ 3 The above epigraph illustrates the practical and
symbolic effectiveness of deporting ‘madmen’ overseas, but what effects would
their transatlantic re-location have in our contemporary post-modern world? Could
the Medieval Ship of Fools be re-interpreted today through itinerant dramatic,
poetic, pictorial and musical performances?
Foucault’s contributions to the social study of health and illness are multiple
and varied, and his views on madness, illness, confinement and the gaze may also
be combined in different ways. He suggested that the deployment of the clinical
gaze and the pathology-based approach that sees the patient as a r epository in
medical practice contribute to the emergence of (and are part of) individual identity
in the Western stage. 4 In reference to the role of the gaze in a co ntext of
confinement, Foucault proposed that those who are knowingly subjected to a field
of visibility become the principle of their own subjection within the Panoptic. 5
However, we would argue that the transformation of a context of surveillance into
one of spectacle might allow us to subvert, and even reverse such relations in
contemporary urban societies, where information technology, the worldwide web,
closed circuit TV and other similar technological developments have given rise to
contexts in which we are all subjected, at least potentially, to constant surveillance.
This can be extremely stressful for individuals who are particularly sensitive about
their privacy, and who might find it intimidating to be observed by others. On the
other hand, it has been noted that the use of masks, face-paint and costumes may
provide a ‘ protective shield’ against an intrusive gaze, and it can even revert the
situation.
Furthermore, it is important to stress that the artistic value of masks and other
art-objects resides specifically in such powerful potentialities of transformation.
Thus instead of taking a semiotic approach, we propose to take an anthropological
action-centred approach to art, which is ‘pre-occupied with the practical mediatory
role of art objects in the social process, rather than with the interpretation of
objects ‘as if’ they were texts.’ 6
These are some of the issues that must be taken into account in the exploration
of creativity and mental health, but we also need to be aware of highly sensitive
issues concerning the stigmatisation of people who have suffered from mental
distress, and thus need to clarify Foucault’s (and our own) use of the word
‘madness,’ particularly in relation to passion and the arts: In the closing pages of
Madness and Civilisation, he asserts that
Gonzalo Araoz 27
__________________________________________________________________
[t]here is no madness except as the final instant of the work of art
- the work endlessly drives madness to its limits; where there is a
work of art, there is no madness; and yet madness is
contemporary with the work of art, since it inaugurates the time
of its truth. 7
2. The Transatlantic Network on Mental Health and the Arts

TRAMHA is an international network devised to foster and develop
interdisciplinary dialogues, research and exchange on creativity and mental health.
One of our main aims is to broaden our knowledge and understanding of the
relationship between individuals and their environments in the assessment of the
factors affecting people’s mental health in specific contexts. The diverse
backgrounds of our members contribute to the creation of a multidisciplinary
intercultural forum to discuss the complex nature of our subject, including the
ways in which we conceive ourselves, our surroundings, our work, our methods
and our own mental (ill) health.
The benefits of creative activities for mental health have been increasingly
acknowledged in recent years, because of the transforming capacity of the arts and
because of their general positive effects on wellbeing. Participation in the arts has
been identified as an effective route for personal growth, leading to enhanced
confidence which is an important achievement towards mental health. 8 More
specifically, in their evaluation of the Start/Whitworth Project (Getting to Know
Alfred Wallis), Tortora et al (2003) remind us about the arts’ unique capacity to
access and integrate the affective and cognitive sides of the brain simultaneously,
and how creativity ‘melds associative and analytical modes of thinking to produce
high conceptual fluidity, by which is meant the ability to think fluently and
laterally.’ 9 Furthermore, it has been highlighted that the cultural events that
psychiatric survivors organisations (like Mad Pride, Mad Women, Survivors
Poetry and others) put on i n the UK seem to demonstrate the potential of the
creative energy of art which can, as White and Angus have argued, ‘push against
barriers, boundaries and preconceptions in mental health and really engage with the
madness of art and its making.’ 10
It is such creative energy and such movement against barriers and boundaries
that we aim to exploit through our efforts to implement research and development
activities across and between disciplines, across and between contexts, and across
and between dreams and reality. It could be objected that this absence of a clearly
defined discipline and object of study is a weakness, yet we see it as our strength.
By focusing our efforts beyond classification, we break new paths in an eclectic
approach to theory and method. According to Foucault,
[p]assion indicates, at a new, deeper level, that the soul and the
body are in a perpetual metaphorical relation in which qualities
__________________________________________________________________
have no need to be communicated because they are already
common to both; and in which phenomena of expression are not
causes, quite simply because soul and body are always each
other’s immediate expression. 11
The above citation, which refers to the relationship between madness and the
arts, also symbolises a general challenge against dichotomy that we take on stride.
We must be however aware of the varied levels of interaction and the delicate-yet-
intense relations between mental health and the arts. According to Gadamer
(1986), the symbolic rests upon an intricate interplay of showing and concealing,
and he argues that the work of art’s true being lies in the fact that it becomes an
experience changing the person experiencing it. 12 He goes on to assert that such
experience is constituted precisely by the fact that we do not distinguish between
the particular way the work is realised and the identity of the work itself. 13 There is
clearly a huge potential for transformation in the interstices between madness and
the arts, and we propose to take the advantage (and the risks!) of using it. One of
our main aims is to integrate creative, investigative and reflective activities beyond
the established boundaries, through interdisciplinary and intercultural dialogues on
wellbeing and creativity. These are not only two very broad concepts that include
mental health and the arts, but they are also states that epitomise a harmonic fusion
of being and meaning, of acting and reflecting.
Shared experience does not only constitute the foundation for the development
of our activities, but it is also an important subject, method and outcome of our
work. Our long and distinctive professional engagement in diverse disciplinary
fields has taught us that research questions, processes, ideas and results are
enriched and rendered useful when developed in collaboration with members of the
public. Likewise, the dynamic nature of social and cultural processes demands a
constant awareness of the changes taking place in the contexts of study, and the
capability to adapt to them and to reframe our observations and actions according
to them.
The positive effects of the arts for physical and mental wellbeing have long
been acknowledged and documented, 14 but there is a tension between the need of
implementing objective evaluation, which tends to be an indispensable requirement
from research and development funding institutions, and the relevance of
qualitative transformation in the processes experienced and observed.
Certain aspects of creativity and wellbeing lie beyond the scope of scientific
evaluation. Although it is possible to identify relevant indicators of wellbeing and
to measure their fluctuations within a period of time, such measurements can be
misleading because the endless factors affecting peoples’ lives (which are the
contexts within which wellbeing or its absence must be observed), the constant
processes of transformation and the non-linearity of the phenomena observed
suggest that the object of enquiry is far too complex to quantify.
Gonzalo Araoz 29
__________________________________________________________________
Our approach also introduces the challenge to overcome academic hierarchical
structures and to develop truly horizontal/participatory communication, which is
indispensable for the effective development of the network. This also implies the
need to identify a common language, a language that is liberated from specialised
jargon and that enables at the same time intercultural communication. The arts are
widely recognised as a universal language for cross cultural communication, and
our academic outputs will always be complemented by simplified (both abridged
and exemplified) versions and translations to Spanish and Portuguese. This will be
achieved through the combined expertise of our international team, whose
interaction will give rise to a distinctive body of knowledge that will be reflected,
discussed and disseminated in both academic and community based settings.
There still is great concern about the stigmatisation of people who have
suffered from mental ill health and a diversity of interests is reflected in the
contested nature of the subject itself, which has produced different interpretations
of (and preferences for) the notions of Arts for Health, Arts and Health, Arts into
Health and Arts in Health. Arts for Health might be conceived for instance as
stigmatising, because people with mental health challenges do not necessarily
consider themselves to be ill. We chose to use the notions of Creativity and
Wellbeing, because they are most flexible and inclusive.
Discrimination must be tackled alongside its forms of expression, but it is
notable that there are different ways in which it is generated and expressed.
Proposed dialogues between scholars with diverse views and experiences of
contexts in which creativity and mental health are observed will contribute to a
general reflection upon such issues. The alliance of a wide range of academic
institutions and individual researchers is strategically supported by the
participation of experienced anthropologists who have also worked on both sides
of the Atlantic. By developing its research activities in different subjects and
contexts, anthropology constitutes a useful discipline to bridge communication
between the perceptions, ideas and experiences of scholars representing different
countries and professions. This is particularly relevant considering the myriad of
factors affecting people’s mental and physical health.
The exchange of ideas and experience between academic institutions of the
United Kingdom and South America will be complemented by visits across the
Atlantic of artists, scholars, service users and carers from different backgrounds.
We will also encourage discussions on the relationship between individuals and
their environments, to assess different factors affecting people’s mental health in
different contexts. The more we adapt to our surroundings the more difficult it is
for us to see them, and the direct experience of other cultures will prompt questions
and reflections on our own societies and living conditions. As much as our health
can be conditioned or determined by environmental factors, a change of context
would enable us to see alternative perspectives, and it may even trigger a sense of
awe.
__________________________________________________________________
One of the peculiar features of our Research Network is that it will not only
facilitate academic exchange, allowing researchers from different disciplinary and
socio-cultural backgrounds to share their work, but it will also support the active
participation of mental health services users and their carers in the development of
our activities. The artists involved in the network who (or whose work) will travel
between different locations are often also individuals who suffer or have suffered
from mental distress or mental illness. We have already ensured the participation
of representatives from various stakeholders, particularly those involved in mental
health care in the UK and South America, to facilitate processes of collective
research, action, reflection and communication.
General emotional numbness is a notable social symptom of mental ill health,
and madness can be seen as an effect or a r eflection of socio-economic and
political circumstances. We believe that if severe means are to be employed in
order to deal with severe mental health problems, the implementation of artistic
activities in strange contexts might complement (and perhaps even replace) the use
of extreme medication (e.g. lithium) and extreme therapy (e.g. electro-convulsive
therapy). Similarly, it is expected that the deployment of artistic work by the
‘mentally ill’ in public spaces will contribute (to a certain extent) to diminish the
emotional numbness of society.
Notes
1
M. Foucault, Madness and Civilisation: A History of Insanity in the Age of
Reason, Routledge, London, 1971, p. 7.
2
Ibid., p. 64.
3
Ibid., pp. 49-50.
4
D. Armstrong, ‘Foucault and the Sociology of Health and Illness: A Prismatic
Reading’, Foucault: Health and Medicine, A. Petersen and R. Bunton (eds),
Routledge, London, 1997, p. 23.
5
M. Foucault, Discipline and Punishment: The Birth of the Prison,
Harmondsworth, Peregrine, 1977, pp. 202-203.
6
A. Gell, Art and Agency: An Anthropological Theory, Oxford University Press,
Oxford, 1998, p. 6.
7
M. Foucault, op. cit., pp. 288-289 (original emphasis).
8
F. Matarasso, Use or Ornament? The Social Impact of Participation in the Arts,
Stroud, Comedia, 1997.
9
Tortora et al, Getting to Know Alfred Wallis, Start/Whitworth Gallery, 2003.
10
J. Secker et al., Mental Health, Social Inclusion and the Arts: Developing the
Evidence Base. Final Report from Phase 1: The State of the Art in England.
APU/UCLAN, 2005, p. 13.
11
M. Foucault, op. cit., p. 88.
Gonzalo Araoz 31
__________________________________________________________________
12
H.G. Gadamer, The Relevance of the Beautiful and Other Essays, Cambridge
University Press, Cambridge, 1986, p. 33.
13
H.G. Gadamer, Truth and Method, Sheed and Ward, London, 1975, p. 92.
14
F. Matarasso, 1997, Angus 2002, White and Angus 2003, Secker et al., 2005.
Bibliography
Angus, J., A Review of Evaluation in Community-Based Arts for Health Activity in
the UK. CAHHM/HAD Report, Durham/London, 2002.
Armstrong, D., ‘Foucault and the Sociology of Health and Illness: A Prismatic
Reading’. Foucault: Health and Medicine, Petersen, A. and Bunton, R. (eds)
Routledge, London, 1997.
Balogh, R., Lloyd S. and Whitelaw, S., Research and Development Activity Skills
in Mental Health in North Cumbria. On Behalf of the Mental Health Institute for
Cumbria and North Lancashire, Report to the Department of Public Health and
Primary Care. St Martin’s College, Carlisle, 2000.
Department of Health, National Service Framework for Mental Health – Modern

Standards and Service Models. Department of Health Report, London, 1999.
–––, Delivering Race Equality in Mental Health Care: An Action Plan for Reform
inside and outside Services and the Government’s Response to the Independent
Inquiry into the Death of David Bennett. Department of Health Report, London,
2005.
Foucault, M., Madness and Civilisation: A History of Insanity in the Age of

Reason. Routledge, London, 1971.
–––, Discipline and Punishment: The Birth of the Prison. Peregrine,

Harmondsworth, 1977.
Gadamer, H.G., Truth and Method. Sheed and Ward, London, 1975.
–––, The Relevance of the Beautiful and Other Essays. Cambridge University
Press, Cambridge, 1986.
Health Development Agency, Arts for Health: A Review of Good Practice in

Community-Based Arts Projects and Interventions which Impact on Health and
Well-Being. Health Development Agency, London, 2000.
__________________________________________________________________
Huxley P., Arts on Prescription. NHS Trust, Stockport 1997.
Jermyn, H., The Arts and Social Exclusion: A Review Prepared for the Arts
Council of England. London, 2001.
Joseph Rowntree Foundation, Findings: Poverty and Social Exclusion in Britain.

Available online at http://www.jrf.org.uk, 2000.
Matarasso, F., Use or Ornament? The Social Impact of Participation in the Arts.
Comedia, Stroud, 1997.
Neihart, M., ‘Creativity, the Arts, and Madness’. Roeper Review. September 1998
Vol. 21, No. 1, pp. 47-50.
ODPM, Mental Health and Social Exclusion. Office of the Deputy Prime Minister,
London, 2004.
Rothenberg, A., Creativity & Madness: New Findings and Old Stereotypes. John
Hopkins University Press, Baltimore, MD, 1990.
Secker, J. et al., Mental Health, Social Inclusion and the Arts: Developing the
Evidence Base: Final Report from Phase 1: The State of the Art in England.
APU/UCLAN, Preston, 2005.
Tortora et al., Getting to Know Alfred Wallis. Start/Whitworth Gallery, 2003.
White, M. and Angus, J., Arts and Adult Mental Health Literature Review.
Durham, 2003.
Gonzalo Araoz is an anthropologist (PhD) who has worked in different rural and
urban areas of Bolivia and the UK. He is currently a Research Fellow at the
Faculty of Health and Social Care, University of Cumbria, and founder of the
Transatlantic Research and Development Network on Mental Health and the Arts,
http://www.tramha.org.
Institution Defining Madness: A Place for the Individual
Emmanuelle Rozier
Abstract
The type of psychiatric institution we dedicate to people having mental problems
completely changes the way they experience madness. In a pragmatist perspective,
I will try to show how the organisation participates in the definition of those who
are affected by madness: both patients and staff. To introduce this question, I shall
present the study of Alfred H. Stanton, and Morris S. Schwartz, American
researchers who spent three years at the institution of Chestnut Lodge (Maryland,
USA). In The Mental Hospital (1954) they focus on the fact that patients do not
stop to live once admitted to the hospital. They try to find out the differences
between the hospital and the outside world that make the patient feel better. The
background in which the patient is living is the institution: the authors show that
most of the time, the clinical episode is a part of the overall institutional context.
Here, I would like to find out how organization type of the institution defines the
concept of person involved in both perception and experience of madness. Two
fields of research will help us to answer this question: La Borde, institutional
psychiatric clinic in France, and Chestnut Lodge in the USA. I want to show how
La Borde (est. in 1953), this particular collective place, brings together concepts
and practical tools in order to be able to deal with the patient as a person involved
both in therapy and in everyday life. Having spent there nearly one year, I shall try
to make clear how the therapy and sociological considerations are brought closely
together. Nevertheless, these practical questions should be put in a wider
interdisciplinary perspective, by means of reflection on language and action,
inspired by Wittgenstein, ethnomethodology and sociology of organisations.
Key Words: Ethnomethodology, fieldwork, institutional psychotherapy,

interactions, inquiry, La Borde clinic, philosophy of caring, pragmatism, psychosis.
*****
1. Introduction
I shall start with the following hypothesis: the type of psychiatric institution we
create for people having mental problems changes totally the way they experience
their madness. From a pragmatist perspective, I will try to show how the structure
of organization participates in the definition of those who are concerned by
madness: both patients and staff.
To introduce this question, I shall present the study conducted by Alfred H.
Stanton (psychiatrist and psychoanalyst), and Morris S. Schwartz (sociologist),
American researchers who spent three years at the institution of Chestnut Lodge
(Maryland, USA). In The Mental Hospital (1954), they focus on the fact that
34 Institution Defining Madness
__________________________________________________________________
patients do not stop to live once admitted to the hospital. They try to find out the
differences between the hospital and the outside world that make the patient feel
better. The background in which the patient is living is the institution: the authors
show that most of the time, the clinical episode is a part of the overall institutional
context. Most people (even the researcher) whose work brings them into a
genuinely close contact with patients, come to assume that the immediate
environment is of great influence on the course of the patient’s illness. As the
authors say
our study […] is of the hospital as a whole, as a highly organized

functioning institution, in both its formal and its informal aspects.
It is based on the reasonable hypothesis that at least some aspects
of the disturbances of the patients are a part of the functioning of
the institution. 1
Here, I would like to find out how organization type of the institution defines
the experience of madness. Two fields of research will help us to answer this
question: La Borde, institutional psychiatric clinic in France, and the Chestnut
Lodge Hospital in the USA. I want to show how La Borde, this particular
collective place, brings together concepts and practical tools in order to be able to
deal with the patient as a person involved both in therapy and in everyday life.
Having spent there nearly one year upon my five years of enquiry, I shall try to
make clear how the therapy and sociological considerations are brought closely
together and result in the engagement of the people (both patients and staff) who
become a part of the organization.
In this chapter, having mentioned Stanton’s and Schwartz’s work on the
Chestnut Lodge and examined a case they develop, I will present my own
investigations on the institutional construction at La Borde. Nevertheless, these
practical questions should be put in a wider interdisciplinary perspective, by means
of reflection on language and action, inspired by Wittgenstein and
ethnomethodology. This last part of my work will aim at defining the conceptual
framework of this type of study.
2. Stanton and Schwartz a Socio-Psychiatric Study in Chestnut Lodge

Chestnut Lodge was built in 1886 as a hotel. It was subsequently purchased by
Dr. Ernest L. Bullard, who renovated the building and re-opened it in 1910 as a
sanatorium for nervous and mental diseases, re-naming it Chestnut Lodge after the
125 chestnut trees surrounding the place. In the Foreword to The Mental Hospital,
Dexter M. Bullard, psychiatrist in charge at the Chestnut Lodge, delivers his view
upon purpose of the hospital: ‘our concept was that the essence of hospital
treatment lay in the interpersonal relations of patient and therapist.’ 2 The study
here reported changes totally this conception; it was conducted during the stage of
Emmanuelle Rozier 35
__________________________________________________________________
development at the Chestnut Lodge, when there was still a separate administrator
for each floor. It aims at showing that exchanges of opinions and the resultant
acceptance of mutually satisfying objectives lead to clinically significant changes
in patients’ behaviour. To Dexter M. Bullard, this study is ‘disturbing because it
highlights so many of the imperfections of current hospital practices, and
encouraging because it indicates how change and improvement may be brought
about;’ 3 Stanton and Schwartz’s work was going to promote the development of a
new administrative psychiatry built upon the fact that many of the symptoms of
patients are expressive of a pattern of interaction with the hospital staff and
personnel.
Stanton and Schwartz show that the patients do not stop living upon admission
to the hospital. They go right on living, and, for many, hospitalization means a new
beginning rather than an end. But how does the hospital differ from ‘outside’ so
that the patient improves? For the authors,
it became clear that many times administrative, therapeutic or

nursing procedures reflected personal needs of those involved
rather than really needs of the patients. As our recognition of
such sources of continuing conflict became clearer we began to
wonder if staff procedures and attitudes contributed to and helped
maintain chronic patterns of behaviour among patients and staff
members. 4
They worked with the hospital staff not that differently from the way they did
with patients in psychotherapy. They preferred to focus on the institutional context
as a whole rather than studying the psychotherapist’s work conducted face to face
with the patient. Their purpose was to show that the separation from the intense
problems of the individual patient, when coupled with a primary concern with the
practical, has produced a divorce between ‘administrative’ and ‘psychotherapeutic’
psychiatry.
I want to look closer at the case study proposed by the authors because it
highlights so many problems of the institution. I quote:
A young female patient has been in the hospital for twenty-two

months with an illness most commonly labelled as acute
catatonic excitement, when a series of events abruptly changed
the course of illness. Before these events, the patient seemed
much the same as usual. She had to spend much of her time away
from other patients. When she was with a staff member, she
talked in an almost unceasing stream of words. Even if the
individual words had been enunicated correctly, the rate of
speaking would have made it impossible for anyone to follow the
__________________________________________________________________
meaning. In addition, the expression of thought was broken and
unclear.
In spite of the difficulty of understanding her, a number of people

actually took time for what was apparently profiteless listening.
She was seeing a p sychiatrist regularly; the administrator of the
ward, the nurses, and the attendants would sit with her whenever
practical. A community of feeling about the patient, with no
adequate verbal validation, grew up among the people attending
her, in turn, contributed to the interest in her. Needless to say, the
personnel who listened to her also talked about her. Superficially,
they agreed and disagreed about what the patient was saying and
compared notes on what she was saying, but they could not get
very far because none of them was able to communicate any
sense of certainty or verifiability about his opinions. But certains
themes in the patient’s talking could be singled out. The patient
spoke about clothing, about having a baby, about particular
attendants or doctors ; and she sang fragments of songs.
One day, the administrator of the ward was struck by the

reccurence of the word clothing in the patient’s talk and asked the
patient: ‘are you mixed up about your clothes?’ The patient
nodded hastily and went on. The nod seemed unrelated to the
things she was saying, as if it were a desperate gesture made in a
great hurry before the torrent of words overwhelmed her. This
special character of the nod prompted the administrator, who was
already concerned about the patient’s inability to communicate,
to ask several nurses about her clothes. The administrator was not
immediately responsible for the care of patient’s clothing and this
formed a subtle but appreciable barrier to detailed questioning.
However, he pursued the matter until he finally reached the
superintendent of nurses. Since she also was interested in the
patient and knew the really intricate hospital procedure realating
to patient’s clothing, she agreed to talk with the patient, to try to
explain her where her clothes were kept and, if possible, to find
out what further questions she might have about them. The
administrator discovered that they were kept in a locker, as is
customary in mental hospitals. The patient saw them only when
the locker was unlocked by the nurse as the patient was dressing
or undressing. But in this instance only part of the clothing was
in the locker; the rest, which the patient herself had torn up at the
time she came into the hospital, had been disposed of. The nurses
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on the ward remembered, under questioning by the administrator,
that the patient frequently raise a confused objection when certain
clothing was beeing selected for a g iven day. Because of her
incoherence and the fact that there usually were other patient
waiting to be dressed, the nurses paid no particular attention to
her objections.
After the talk with the superintendent of nurses, the patient was
noticeably more coherent, althought by no means completely so.
Her sentences became longer, her words more understandable,
and the presure of speech lessened. This improvement was noted
independantly by many people and continued for two or three
days after the conversation. It was not progressive, however, and
presently the patient again seemed to be getting more tense. The
asministrative physician, encouraged by his previous experience,
now set out to make a persistent inquiry. Half-jesting, he asked
the superintendent of nurses, with whom he was on good terms,
why she had not ‘straightened out’ the patient. She answered
spiritedly that she has straightened out everything about the
clothing. He asked for details but learned nothing useful. A short
time later, when he presumed, upon his friendship to raise the
question of the clothing again, the superintendent was frankly
annoyed and again protested that she had done exactly what she
had been told to do. The administrator nevertheless made an
arbitrary statement: he suspected that the patient had not been
told everything about her clothes. The superintendent was
provoked into stating that the patient was told everything except,
of course, about the clothes she herself torn up. The administrator
was puzzled and asked why the patient had not been told about
this too. The superintendent answered with conviction that the
administrator himself had told her not to. But, as she was saying
this, her expression altered, with a sudden realization: it had
actually been the patient’s psychotherapist, not the administrator,
who said it might be wise not to mention the incident to the
patient. The administrator now asked the superintendent to tell
the patient about it. After this second conversation, the patient’s
excitement disappeared almost completely, so much that her
language became entirely coherent and responsive. Her worry
about clothing was understandable: since her familiy had had to
watch every penny, and every item of wearing apparel
represented a significant expense. Her anxiety about the clothing
was linked with anxiety about the cost of her hospitalization,
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which, she knew, was out of all proportions to the family means. 5
For Stanton and Schwartz, the incident was a c lear turning-point and a
favourable one. In this example, if the misunderstanding was a prerequisite for the
excitement, the excitement was a collective social construction to which the patient
and the staff made continuous contribution. It must be emphasized that the clinical
episode was a part of the total institutional context. Let us see what points in the
organization may be emphasized to take care of people also in their everyday life;
as the authors show, the following factors played a part in the building and
maintenance of the misunderstanding and contributed to the patient excitement:
- the patient’s defect in communication

- the failure to recognize and follow the theme of clothing
- the general attitudes reflected in conventional psychiatric
language which tend to divert interest from specific personal
problems to the more general and impersonal concepts of
psychopathology
- the lack of interest of the physician about the clothing
- the tendency of the physician not to ask the superintendent of
nurses a second time about her talk with the patient
- the decision of the psychotherapist that a matter of import should
not be told to the patient, and the fact he does not inform the
physician directly responsible for the patient’s general care
- the locking up of the patient’s clothing
- the superintendent’s inability to remember which physician had
given her directions
- and in general, the time pressure of the nurses on the floor.
Staff members who become skilful in bringing up changes in the patient’s

behaviour comes to be known as having a way with patients. We can ask what kind
of part the talk with the superintendent as to do in the patient’s illness? Two
considerations support the assumption that her intervention was directly important
and show the role of the whole institutional context: first, the talk with the patient
about clothing saw improvements as for her excitement, and it happened twice;
secondly, the talk included several people involved in the patient’s care. This case
highlights the fact that the institutional aspect plays a great deal in patient’s life and
in his ‘madness,’ by instituting the relationships between the members of the staff
(the nurses, the physician, the psychotherapist) and between the staff and the
patient. The question of relationship seems to be the key to a psychiatry concerned
by the global context of the care. For Stanton and Schwartz, the point is to break
the misunderstanding, not to make continuous contribution to his maintenance. For
them, some aspects of the patient’s disturbance contribute to the functioning of the
__________________________________________________________________
institution, whereas in hospitals, patients are not usually considered as an integral
part of the institution but are ‘the unrelated objects of its efforts.’ 6
Is it then possible to imagine a d ifferent type of organization, where the
patient’s day to day life would play a role in his treatment? What kind of
conception can deeply changes the psychiatric institution?
3. La Borde Clinic and My Own Experience: The Collective Conception

Oury’s clinic, La Borde, was born in lineage of a p sychiatric practice which
would be ever-searching in its analysis of the relations between the ‘patients’ and
the ‘psychotherapists.’ It borrowed a H ermann Simon’s idea that it is
simultaneously necessary to look after the institution and to look after each patient,
while returning initiative and responsibility to him, by developing situations in
which they can work and express their creativity. The La Borde Clinic was
established with the goal of becoming everything the word asylum once meant: a
shelter, a place of refuge, a sanctuary. Still in operation today, La Borde has been a
defining model in the field of institutional psychotherapy. It is an innovative
psychiatric clinic where patients are liberated to actively participate in the running
the facility. Its principles come on the one hand from the recognition of asylums’
pathogenic effects - which led to the crushing of the patient’s being - and on the
other, through the recognition of the uniqueness of each person and the subjectivity
of mental suffering. This movement called for the use of the institution in its
dynamic aspect, which promotes exchanges and allows patients to situate or
resituate themselves in historic and symbolic dimensions. It privileges a high level
of transversality, maximum communication, favouring speaking out loud and
responsibility. It requires a permanent analysis of the institutional counter
transference (emotional reactions of the caregivers involved, their interrelations
and the social and material organization of the institution) which determines the
therapeutic action itself.
In my research, what I focused on is that at La Borde people’s participation to
the everyday life changes totally the way they experience their madness. They are
free to move from one place to another and to involve themselves in activities. To
follow our example of clothing, they can work in the linen room and take care of
the washing of clothes. Usually a few residents work there with other employees
devoted to this task. Anyway, they can keep their own personal clothes and ask at
anytime about them. Mostly, people are considered able to act and to decide about
their own everyday life into the collective context. If someone disagree with the
running of the institution, he or she has opportunities to share her or his distress:
there is a n ewspaper of the clinic, meetings where daily problems are being
discussed. Moreover, people can ask the caregivers for help when needed.
Everything is done to give them autonomy and the possibility of initiative. The
collective organization is here to protect and to build a pattern in order to propose
some help and therapy tools. For me, the key is the collective pattern. My first
__________________________________________________________________
hypothesis was to demonstrate that the collective organization changes totally the
way to define people and to practice the care into the institution. ‘Collective’
means here two types of things:
- firstly, that there is no hierarchy between staff members and

patients: all of them are a part of the clinic and participates to its
organization; it facilitates talking upon people regardless to his
place into the hierarchy;
- secondly, the collective is a specific way to put together concepts
and practice, theory and actions: in my opinion, it is a pragmatist
and practical concept because it links the theory tools and
practical issues in a way to consider the global institutional
context. In this way, the definition of the patient is much more
closed to a player in a collective game than as an object to cure.
Most of the important meeting into the clinic life are with equal
representations of both sides.
The method I choose to conduct my enquiry at La Borde and answer the

question of a p ragmatist specificity of the concept of collective is fieldwork. The
fact of stating, as Stanton and Schwartz do in The Mental Hospital, that personality
is as a part of institutional functioning, highlights the way individuality can be lost
in this composite of relationships within the institutional way of living. In the
institution, madness is not an abstract entity but a factor that determinates the way
an individual can still develop himself. A strong relationship and the ability to act
can modify entirely the individual’s experience. The institutional context is
considered at La Borde as a part of the therapy.
In order to conduct my enquiry and to be subsequently able to propose an
analysis of it, I felt the need to get involved in the work with patients and staff. So,
I tried to focus on the influence of the concept of ‘collective action’ in the purpose
of taking care. I worked as caregiver, cleaning the rooms, helping people with
taking a shower, giving the medicines, and especially helping them by talking and
being there for them. Institutional psychotherapy tries to answer the question of the
global context of the institution and to built an organization where the care
includes two faces: administration and therapy. In my own experience as a
researcher studying the psychiatric field, I learned from the psychiatrist Jean Oury
that we have to consider two sides when we plan to take care of people who are (or
are said to be) insane: alienation is both social and psychopathologic.
I formed a second hypothesis regarding that the collective organization at La
Borde develop particularly cooperative action: the therapy and sociological
considerations are brought closely together because the patient is put into the
course of it. People participate equally to actions and can develop their own
purposes and desires. It is then important to study what kind of actions are
__________________________________________________________________
conducted there to see in a pragmatist way how the organization influences the
individual. And to study actions, a good way is to perform actions with people in
the field. For example, I used to teach people how to take care and to ride a horse
at La Borde. It is a special therapeutic activity there: with a f ew caregivers, we
accompany with people to feed the horses, to clean their loose-boxes, etc. For this
task, which needs to carry things, to get involved in relationship with others, it is
important that residents are conducting a cooperative action, because taking care of
animals is also a part of the institutional therapy. It allows a dialectic dynamic
when people takes care of animals they work upon their own need of care. It
creates a transference among the fact they need care and they also can give care to
others, even animals.
My third hypothesis is to show that the collective way to build an institution
where individual can develop and live correctly is to be noticed into the course of
day to day actions. Collective organization is not an abstract concept, it is much
more a pattern for the care: I formed the idea of a practical-concept to describe the
collective in a pragmatist way. I find out that the collective can only be discovered
into the examine of effects and consequences. It is not an ideology or a text guiding
actions, it is a conception, in a pragmatist meaning, we can discover in her effect
produced upon people.
My method is closely connected to the so-called ‘pragmatic maxim,’ different
versions of which were formulated by Peirce and James in their attempts to clarify
the meaning of abstract concepts or ideas. This maxim points to a b roadly
verificationist conception of linguistic meaning according to which no sense can be
made of the idea that there are facts which are unknowable in principle (that is,
truths which no one could ever be warranted in asserting and which could have
absolutely no bearing on our conduct or experience). Moreover, theories and
models are to be judged primarily by their fruits and consequences, not by their
origins or their relations to antecedent data or facts. The basic idea is presented
metaphorically by James and Dewey, for whom scientific theories are instruments
or tools for coping with reality. As Dewey emphasized, the utility of a theory is a
matter of its problem-solving power; pragmatic coping must not be equated with
what delivers emotional consolation or subjective comfort. What is essential is that
theories pay their way in the long run - that they can be relied upon time and again
to solve pressing problems and to clear up significant difficulties confronting
inquirers. To the extent that a theory functions or ‘works’ practically in this way, it
makes sense to keep using it - though we must always allow for the possibility that
it will eventually have to be replaced by some theory that works even better.
In my opinion, and this is the key of my study at La Borde, the institutional
psychotherapy develops itself a pragmatist methodology: practice is closely linked
to theory of psychosis. The collective pattern is the expression of the psychosis
which shows dissociation and problems to get involved in a transference with a
single person. Psychotics need to have relationship with several persons and to find
__________________________________________________________________
back a way to express one selves and we never know the way they will manage to
do so. It is a pragmatist method to consider the effects of what we do rather than an
ideology of psychiatry.
4. Conclusion
A few remarks to conclude our chapter: the institution made continuous
contribution in the course of patient’s illness. So, the institutional psychotherapy
focus on the fact that we have to be aware of the double alienation: social
alienation and insanity. The hospital and its organization has to distinguish the two
types of problems in the patient life first by making a sharp diagnosis. Two, by
allowing a free circulation of words and reports between different range of staff
and also patients themselves. Integrating the whole institutional context to take
care of people, includes to change organization and relationship between people
involved there. To study this kind of institution, getting involved in the day to day
work permit to follow the Wittgensteinian call for a philosophy close to practice.
Remembering the Wittgensteinian claim that meaning is immanent to practices,
I tried to follow him when he invites us to find a method appropriate to study them:
how can we analyse lived practice? Related to this question, what Harold Garfinkel
saw was that what we call society is built up from the way people actually relate to
each other. Garfinkel is interested in analysing the methods used by people in
everyday life to describe and make sense of their own activities. I worked in this
two ways at La Borde trying to show how a collective conception can modify the
way the care is given and the way people involved there develop specific method
where the patients is mostly a person rather than a mad person. By working as a
caregiver, I found that to cooperate with people into activities of everyday life can
modify totally our conception of psychiatry and practice of philosophy. Co-action
can be the way to develop a pragmatist method and to build a conception of care
where the global context of the institution can play a role in a good way.
Notes
1
A. Stanton and M. Schwartz, The Mental Hospital, Basic Books Publishers, New
York, 1954, p. 12.
2
Ibid., p. v.
3
Ibid.
4
Ibid., p. 3.
5
Ibid., pp. 4-6.
6
Ibid., p. 12.
__________________________________________________________________
Bibliography
Garfinkel, H., Studies in Ethnomethodology. Englewood Cliffs, NJ, Prentice-Hall,
1967.
Oury, J., Le Collectif. Édition du Scarabée, Séminaire de Sainte Anne, Paris, 1986.
Stanton, A. and Schwartz, M., The Mental Hospital. Basic Books Publishers, New
York, 1954.
Wittgenstein, L., Investigations Philosophiques. Paris, Gallimard, 1961.
Emmanuelle Rozier obtained her PhD at the Pierre Mendès France University in
Grenoble, France. While interested in the philosophy of psychiatry, currently her
research and writing are devoted to the methodology of the pragmatism and to the
social sciences.
‘Your Drugs Take away the Love’: A Resident Psychiatrist’s
Discussion of Involuntary Psychiatric Commitment and
Treatment
Christine Montross
Abstract
A young potter is brought into the hospital after walking miles backward to a local
airport, sleeping and eating little, effusively proclaiming his love for all living
things, and holding bizarre poses for long periods of time. His parents recount that
he has recently returned from a pilgrimage in the western United States where he
went on mountain treks following a woman called Amma, the Hugging Saint. He is
assessed in the emergency room as psychotic, though he claims to be joyfully
engaging in his own form of intense meditation and spiritual devotion. The young
man is brought into the hospital against his will, and treated by me - a psychiatrist-
in-training -with psychotropic drugs which do little to change his frame of mind.
Upon discharge, he tells me that he does not plan to continue his medication
regimen, stating that medicine dulls the ecstatic happiness which he absorbs from
the universe. Psychiatrists are constantly called upon in our encounters with
patients to differentiate madness from sanity. From depression to psychosis, the
diagnoses and treatments my fellow doctors and I employ are based on often-
subjective criteria that have fluctuated dramatically over the course of history.
These criteria have depended not only on scientific discovery, but also on socio-
political trends and cultural perceptions. What does a person such as this young
man require of his health care providers? What rights does he have to determine -
or refuse - his own care? And how do we reconcile our classification and treatment
of this patient in light of Joan of Arc and similar figures who have achieved
greatness or martyrdom by following beliefs which could arguably be classified as
psychotic? This chapter will discuss the complexities of involuntary psychiatric
commitment from the perspective of a young doctor who is called upon to treat
individual patients in an imprecise and ever-shifting field.
Key Words: Clinical judgment, institutionalization, involuntary commitment,

paternalism, psychiatry, psychopharmacology, psychosis.
*****
Late nights in the Psychiatric Emergency Room, it’s not unusual to meet
someone who claims to be Jesus. But the night that I first saw Jeremy 1 the patients
had been pretty ordinary by psych ER standards: a demented elderly man who kept
asking me to lie down in his reclining chair with him; a fifty-something woman
withdrawing from alcohol; a forty-five-year-old lawyer and father of two who had
been so depressed that he wanted to drive his car off a bridge and die.
46 ‘Your Drugs Take away the Love’
__________________________________________________________________
I was typing my assessment of the suicidal lawyer when Jeremy wandered
through the metal detector, past the blood pressure cuff and breathalyzer, up to the
doorway of the ER’s administrative area where he would stand, staring straight at
me, for maybe twenty minutes. At first, I felt the sensation we’ve all had of eyes
upon us. And when I turned to find the source of the feeling, I saw Jeremy: a
young man; I’d have put him in his early twenties. His skin was tanned. He had
long, tousled, light brown hair that had been sunbleached to blond in streaks, and
he was wearing a white, embroidered tunic smudged with dirt. Unlike the many
patients I’d met during my months as a p sychiatric resident who’d claimed to be
Jesus, or to receive direct communication from him, this guy actually looked the
part.
When my own glance met his stare, there was no self-conscious shift of his
gaze, no quick look downward, no turn away. Instead, his eyes continued to bore
straight into mine. His face was expressionless, intent, and haunting. Eventually,
one of the security guards gently guided him back into the waiting area. I finished
typing and began to interview another patient. The next time I walked through the
waiting area, Jeremy was gone.
Frequently when leaving a shift in the ER, cases and clinical questions from the
night linger in your mind. Did I double check the lab work on the demented patient
to rule out a delirium-inducing infection? Was the woman who had been cutting
the insides of her thighs with a razor blade really safe enough to go home? This
night, the image of Jeremy’s motionless stare stayed with me as I left the hospital.
In general, psychiatrists don’t scare easy. We become accustomed to patients
telling us their thoughts will kill us, just as they’ve killed nations; that they know
we are part of a conspiracy to place satellites in their houses, and that we will have
to be brought to justice. Sometimes, I’ve been uncomfortable enough to bring a
security guard into the room with me - as when an enormous man who’d spent a
decade incarcerated for murder was released from prison, caught a bus straight to
the psychiatric hospital, and told me the red eye that had commanded him to kill
was hovering around the room in which he and I were talking - but more typically
these stories are the ones we share with our colleagues whose shifts begin as ours
end and who ask how the night was. Nonetheless, something about Jeremy’s silent
intensity had unnerved me, and not knowing whether he had been admitted or
released, I found myself skittishly looking around expecting to see him as I walked
to my car, and drove home.
The next morning, I walked into the locked inpatient ward where I had been
working for the past month, and gathered the charts of the patients for whom I was
caring. In the current privatized health insurance system in the United States, only
the most ill patients are admitted to the hospital; even then the average length of
stay is five days. So every morning my stack of charts included a fair number of
patients whose names were new to me. I’d situate myself with the charts in one of
the small, private interview rooms on the unit, and while the medical student would
Christine Montross 47
__________________________________________________________________
go rouse a patient from her bed and usher her into the room to talk, I’d skim
quickly over the evaluation done at admission so I would have at least some small
idea of the circumstances that had brought the patient to the point of psychiatric
hospitalization.
This morning was no different. The med student said, ‘I’ll start with room
32B,’ and walked out. I picked up the chart, flipped it open, and saw the three-inch
by three-inch admission photograph of Jeremy, eyes staring into the camera just as
intently as he had been staring into the administrative workspace of the ER; just as
intently as he’d been staring at me.
For my fellow psychiatrists-in-training and me, those admission photos are a
perfect example of how certain realms of medicine can come to be devoid of
empathy. Late nights, or early mornings after we’ve worked twelve, twenty-four,
even thirty hours straight, we sometimes make a game of those snapshots. They’re
universally grainy and off-center, taken by a camera attached to the hospital’s
intake computer, but the shared belief of all psychiatric residents is that the further
along one gets in one’s training, the more likely one is to be able to hone in on a
patient’s precise diagnosis just by looking at the picture. It’s a ridiculous assertion,
of course, and one that elucidates the stereotypes we develop as providers more
than any consistently discernible physical traits of mental illness, but we buy into
the idea of it anyway.
When I see Jeremy’s snapshot in the front of his chart, I hear in my mind an
imagined banter between residents:
‘On the run from the Branch Davidians’ compound. A nd angry about the
government raid, which he feels interfered with his ascension to join the Hale-
Bopp comet, or whatever bullshit that was,’ one resident would begin.
‘Ooooh, that’s good,’ the other would reply. ‘Diagnosis?’
‘He’s all Axis I. Delusional disorder. Maybe with some Intermittent Explosive
Disorder mixed in to account for the uncontrollable anger. Do you want to just
agree and give up now, or do you have a better theory?’
‘Nope. Listen to this: first psychotic break, exacerbated by heavy pot use and
occasional assorted hallucinogens. Mostly shrooms. He thinks he’s Jesus, and is
receiving personal messages from God. He believes he can see through to our
souls, and he doesn’t like what he sees.’
‘O.K., Diagnosis?’
‘Too soon to say. He’ll get Axis I: Psychosis NOS. And then in six months,
when it’s lasted long enough to meet criteria, he’ll be schizophrenic, like some
uncle on his mom’s side that lived in the hospital for thirty years.’
And then I read Jeremy’s emergency room evaluation, to lay any snap
judgments to rest. It’s written in the awkward, fragmented language that medicine
employs. ‘Patient’s Chief Complaint: ‘There is a good energy here.’ History of the
Present Illness: Patient is a twenty-five year old male who was brought to the
hospital by his parents secondary to an increase in bizarre behaviour. The patient
__________________________________________________________________
eloped from the Emergency Department and was brought back by the police.
Patient’s parents describe ‘catatonic-like’ behaviour at home, including walking
backwards, and walking in a circle before picking an item up, both of which the
patient explains as actions that ‘untrack energy.’ The patient has also urinated in a
Coke bottle and says he is ‘sleeping without sleeping.’ Patient has refused meds
from his psychiatrist, who he has seen twice weekly for the past six weeks. He says
he is having trouble expressing his thoughts, and that ‘I have a lot of things I need
to accomplish.’ Finally, on the bottom of the page, the doctor who had done the
evaluation had scrawled a quote from Jeremy: ‘I am functioning normally; I don’t
know why people think I’m not.’
The medical student walked in, and gestured for Jeremy - still dressed in his
stained tunic - to follow. He did, and first stared at me with the familiar gaze from
the night before. Then, he stared with the same intensity at the empty chair to my
left, then the locked window with no shade, and finally the Monet poster encased
in plastic, and bolted to the wall. When asked to, he sat, and smiled. ‘Hi Jeremy,
I’m Dr. Montross,’ I said, ‘and you’ve already met Vijay, the medical student on
our team. If it’s OK with you, I’m going to let Vijay start, and then I might pipe in
at the end with a few more questions. How does that sound?’
‘Sure,’ replied Jeremy. And then to Vijay, he said, ‘Welcome.’ I could tell the
student wasn’t exactly sure how to respond.
‘Uh, thanks. Why don’t we start by hearing why it is that you came to the
hospital?’ Jeremy sat quietly for what was probably a minute, but what seemed like
much more. Then just when I was on the verge of asking again, the silence broke.
‘I’m having trouble communicating my life journey to others,’ he said.
‘Tell me what you mean by that,’ Vijay asked, leaning forward in his chair.
‘Well,’ Jeremy responded, smiling, ‘I think you know this.’ Vijay smiled back,
perplexed, then shrugged. Jeremy continued. ‘The most important thing for all of
us to know is that life is joy. I’m experiencing a soulful happiness and I think it is
hard for everyone to comprehend.’
As the interview went on, I jotted my own rough clinical assessment for the
file. ‘Wide-eyed, malodorous young man in tunic, unshaven. S peech is slow.
Thought process is disorganized and circumstantial; content is grandiose. Patient
denies auditory or visual hallucinations, but does endorse elated mood. Affect is
expansive. Insight and judgment are poor as evidenced by the fact that patient does
not see the need for help.’
Vijay finished gathering some final information. Jeremy had graduated from a
prestigious liberal arts college and was now occasionally working as a sculptor. He
had recently spent a month following a woman called Amma the Hugging Saint in
the western mountains of the U.S. During that time he had smoked pot and used
some hallucinogens, but he said there had been no drug use for a month or more,
and his clean toxicology screen from admission supported this claim. We had
many more patients to see. I decided it was time to wrap things up.
__________________________________________________________________
In my mind, I had a differential diagnosis. Drugs, a primary psychotic disorder
like schizophrenia, or bipolar mania. Given the results of the tox screen, drugs
were rather convincingly out, and the other two options were diseases for which
medication would be the treatment of choice in an acute flare of symptoms like this
one.
‘Jeremy, thank you so much for sharing your thoughts with us,’ I said. ‘I know
you’ve felt misunderstood recently, so we’re going to work very hard to
understand what you’re experiencing.’ This was true, but it was also all a part of
my well-rehearsed tap dance for psychotic patients. Establish trust, convey
empathy; establish trust, convey empathy. Then get them to take their meds. ‘We
have some medicines that I think could help you communicate that experience
more clearly.’ Jeremy looked at me quizzically.
‘Why would I take medicine?’ he asked. ‘I’m in love with the feeling I have
right now. This joy is better than any drugs.’ And this is how our conversations
went that morning, and for the next few mornings. The nursing notes in the chart
were similar from one shift to the next.
‘Patient is pleasant. Dreamy and detached. He continues to pace on the unit, or
stand in place until redirected. Refusing meds.’ A few days in, during our morning
session, Jeremy began asking to leave.
‘It’s not that there isn’t plenty to love in here,’ he said, gesturing toward a metal
filing cabinet, and then a plastic, institutional chair. ‘But I’m not sure how much
longer this place needs me.’ And here is where things for Jeremy - and for me -
became a good deal more complicated than they already were.
Jeremy had been brought into the hospital involuntarily. In every state in
America, a physician may commit a patient to psychiatric care against his will if
the doctor believes there is an imminent danger that the patient will harm himself
or others. In 1992, the United States Supreme Court ruled in the case of Foucha v.
Louisiana that ‘[t]he state may…confine a mentally ill person if it shows by clear
and convincing evidence that the individual is mentally ill and dangerous.’ 2 More
recently, in the 2002 case of Kansas v. Crane, the U.S. Supreme Court reiterated,
‘[w]e have consistently upheld such involuntary commitment statutes when…1)
the confinement takes place pursuant to proper procedures and evidentiary
standards,’ 2) there is a finding of ‘dangerousness either to one’s self or others,’
and 3) that proof of dangerousness is ‘coupled…with the proof of some additional
factor, such as ‘mental illness’ or ‘mental abnormality.’’ 3
The consequences of such an action vary from one state to the next. In Rhode
Island, where I practice, once a p atient is involuntarily committed, they can be
hospitalized against their will for up to ten days before a court hearing is mandated.
Many states are not so drastic, but some are more so. In West Virginia a p atient
may only be held against her will for one day; in Georgia, no hearing is required
until twenty days of inpatient hospitalization have passed.
__________________________________________________________________
In addition, even in the absence of imminent danger, many states allow a
physician to commit a patient against his will if he is classified as ‘gravely
disabled.’ In 1975, the Supreme Court asserted in O’Connor v. Donaldson that the
inability to care for oneself does not sufficiently demonstrate danger unless
survival is at stake. ‘[A] State,’ the court ruled, ‘cannot constitutionally confine…
a nondangerous individual who is capable of surviving safely in freedom by
himself or with the help of willing and responsible friends.’ 4
Jeremy’s emergency certification form cited just this sort of ‘grave disability.’
‘Patient not eating, not drinking adequate fluids. Delusional. Periods of bizarre
posturing. Twenty pound weight loss in six to eight weeks.’ And with that, he was
in.
It’s not a stretch to say that simply by virtue of his position, Jeremy was
powerless, to a certain degree. We had the legal right to keep him inpatient for ten
days. As long as he did not take any of the medications we offered, we had little
grounds upon which to discharge him. Jeremy was caught in a logical circle. If he
continued to deny that he had a mental illness that was in need of treatment, we
could continue to assert that his insight and judgment were impaired, and that
therefore we had grounds to hold him against his will.
It’s easy in a situation such as Jeremy’s to cast the institution of psychiatry as
the authoritarian, paternalistic, legacy of One Flew Over the Cuckoo’s Nest; to
think of psychiatrists as cartoonish egomaniacs who thrive on their abilities to take
away the agency of others, or who leave no room for divinity, for difference. Yet in
reality, psychiatrists, like their colleagues who go into various other medical
specialties, have a s pecific desire to help people heal. And so behind all of the
posturing and joking about the admission photographs of our patients is the hope
that we really are honing our diagnostic abilities, and in doing so, that we might be
able, every now and then, to lead a patient out of the throes of depression, or the
haunted hallways of psychosis.
When emergency certifications come into play, it is almost always because
study after study demonstrates that we, as doctors, are terrible at predicting which
of our patients - be they depressed or delusional - will kill themselves. And in a
profession whose every aim is to heal and help, the assurance of protection often
feels more precious than the preservation of autonomy. Without a crystal ball to
show us which patients will be safe and which will not, we must rely on our
clinical intuition. We meet patients for, perhaps, thirty minutes, and must, in that
period of time, determine whether they are telling us the truth; whether they are
able to follow a safety plan, or whether they are impulsive enough - or disturbed
enough - to jump off a bridge or push a bystander in front of a train.
In other realms of medicine, there are strict criteria for competency. A patient
may refuse a car diac procedure, or chemotherapy, or a l ung transplant, or even
CPR, as long as he can communicate both an understanding of the choice that he is
making, and a comprehension of the consequences that refusing the treatment may
__________________________________________________________________
have on his health. But how to gauge competency when the afflicted organ is not
the heart, or the marrow, but the mind?
And how much of my clinical decision-making is influenced by my own sense
of identity within the framework of society? I can say quite clearly, and with great
certainty, that if I ever began feeling love emanating from filing cabinets and
following a Hugging Saint through the western mountain ranges, I’d want to be
wrestled into the hospital and fed antipsychotic after antipsychotic until my mind
had righted itself. Is my own perspective any more inherently valid that that of a
member of the British Hearing Voices Network who views psychiatric attempts to
quiet his auditory hallucinations as a discriminatory imposition of too-narrow
social mores? W ould my clinical views of a young man holding long poses and
fasting allow for a p rophet or a s aint—or would I try to medicate away his
perceived connection with divinity? Do I rob a patient of his autonomy and
spirituality by persuading him to be treated pharmacologically, or am I helping to
steer a careening mind back into a welcome sanity?
In Jeremy’s case, the answers were unsatisfying and unclear. He acquiesced,
and began taking our medicine, but only after I asked him: if he loved all that was
of the world, than why would he not also love these small, blue pills? I’m not sure
how much of his agreement had to do with my colluding argument, and how much
with his growing understanding that going along with the treatment plan would
speed along his discharge.
After a day or two of the antipsychotics, the nursing notes reflect a subtle
change. ‘Patient more lucid; states he is communicating more clearly. Patient also
states he no longer feels the love he once did from inanimate objects. The patient is
less grandiose, more subdued. Sometimes seems confused.’ As we prepared him
for discharge, Jeremy said he couldn’t promise us that he would continue the
medication once at home, and if I’m honest, I can’t say that I’m convinced it had
helped him.
These years later, I look back at that grainy admission snapshot in Jeremy’s
archived chart and wonder what’s become of that young sculptor. I think about my
fear of Jeremy that first night in the ER as he stared at me, and then my imagined
diagnoses for him from the photo only, both of which pegged him as angry or
dangerous. Knowing what I do n ow about his expansive happiness and joy, I
wonder if something about that much openness - that willingness to really look
with love at each of us - was somehow, on some deep level, actually terrifying. I
think about if I had been so wrong in my snap judgment of his photo, then how can
I feel that I had any more accurate a view of him, or his experience, in the snapshot
views of him I saw during our brief conversations on the inpatient ward?
As I close Jeremy’s chart and walk with it through the hospital’s underground
tunnels to the medical records office, I know my fear is that today Jeremy is lost
somewhere with full blown psychosis; that his happy delusions have turned to
horror, or worse, that he resumed a spiritual fast that his body eventually could not
__________________________________________________________________
withstand. But if I’m honest, some part of me hopes that there are people like
Jeremy whose symptoms do not necessarily indicate a debilitating illness, but
rather a p rophetic gift, or deep connectedness to the world. Perhaps there’s some
small part of each of us, rooted in our practical sanity, that would do well climbing
mountains with a saint whose message was an abundant and ubiquitous love.
Notes
1
Not his real name. Other identifying details have also been changed to protect
patient privacy.
2
Foucha v. Louisiana, No. 90-5844, Supreme Ct. of the US,18 May 1992.
3
Kansas v. Crane, No. 00-957, Supreme Ct. of the US, Argued 30 October 2001,
decided 22 January 2002.
4
O’Connor v. Donaldson, No. 74-78, Supreme Ct. of the US, Argued 15 January
1975, decided 26 June 1975.
Bibliography
Foucha v. Louisiana. No. 90-5844. Supreme Ct. of the US.18 May 1992.
Kansas v. Crane. No. 00-957. Supreme Ct. of the US. Argued 30 O ctober 2001,
decided 22 January 2002.
O’Connor v. Donaldson. No. 74-8. Supreme Ct. of the US. Argued 15 January
1975, decided 26 June 1975.
Christine Montross is a House Officer in Psychiatry at Brown University, and the

author of the nonficton book Body of Work: Meditations on Morality from the
Human Anatomy Lab.
PART II
Madness, State and Law

Redrawing the Boundaries of Psychiatry and Mental Illness in
the Post-Soviet Period: The Case of Latvia
Daiga Kamerāde & Agita Lūse

Abstract
This study questions the assumption that the considerable difficulties that ex-Soviet
countries encounter in transition from an institutionalised mental health care
system to a co mmunity based one are mainly due to their experience of socialist
regimes that distinguishes them from the Western Europe. To challenge this
assumption this study employs the review of some Soviet-times’ sources and draws
on three studies conducted in Latvia in 2004 and 2008. The main conclusion of the
study is that the conceptual boundaries of both mental illness and psychiatry in
Latvia (and presumably in other ex-Soviet countries) since the 1980s have
expanded and that a corollary has been an increasing discrepancy between lay and
professional understanding of them. In general, while mental health professionals
have broadened the boundaries of psychiatry by inclusion of less severe mental
problems, the general public is hesitant to translate issues of personal unhappiness
into forms of mental abnormality. In this respect Latvia (and presumably other ex-
Soviet countries) might not be as different from Western European countries as is
usually assumed.
Key Words: Mental disorders, post-Soviet countries, psychiatry.
*****
1. Introduction
Scholars often have pointed to substantial differences between mental health
care systems in Western Europe and the post-socialist Eastern European countries
after WWII as well as between the respective attitudes towards psychiatry and
people with mental disorders. I t has been argued that ex-Soviet countries, in
particular, encounter considerable difficulties in transition from an institutionalised
mental health care system to a community-based one. These difficulties have been
attributed to relatively long existence in these countries of socialist regimes and
policies according to which not only people with mental illnesses but ‘substandard
individuals’ in general were locked away from the society and psychiatry was
politically abused.1 Thus, in general, it is believed that these Soviet-time
experiences have brought about a specific notion (and definition), among the
professionals as well as the laypersons, of the boundaries of mental illness
(abnormality) and psychiatry and fostered specific public attitudes towards the
mentally ill. The specificity of these notions and attitudes as well as the enormous
socio-political changes of the early 1990s and absence of political goodwill that
has resulted in lack of resources in the public health sector, among other factors,
56 Redrawing the Boundaries of Psychiatry and Mental Illness
__________________________________________________________________________
are thus believed to have contributed significantly to the fact that most of the ex-
Soviet countries lag behind the Western European countries as far as introduction
of community-based mental health care systems is concerned.2
This chapter presents a preliminary discussion that questions these assumptions
by reviewing some Soviet- times’ sources and drawing on three studies conducted
in Latvia in 2004 and 2008. The main argument promoted in this chapter is that the
conceptual boundaries of both mental illness and psychiatry in Latvia (and
presumably in other ex-Soviet countries) since the 1980s have expanded and that a
corollary has been an increasing discrepancy between lay and professional
understanding of them. In general, while mental health professionals have
expanded the boundaries of psychiatry by inclusion of less severe mental problems,
the general public is hesitant to translate issues of personal unhappiness into forms
of mental abnormality. In this respect Latvia (and presumably other ex-Soviet
countries) might not be as different from Western European countries as is usually
assumed.
2. Broadening the Boundaries of Psychiatry

In the early 1990s, citizens of the three Baltic states recalled the Soviet period
as abnormal times3 that exacted ‘a toll from one’s health both mental and
physical.’4 Lack of normality in the modes of feeling was a co llectively shared
experience with distinct moral and political overtones. Even some Soviet-period
publications support this proposition. For instance, in his book written for lay
readership, a Latvian psychiatrist enumerates the following traumata
(psihotraumas) as widespread sources of neuroses among individuals in Soviet
Latvia: encounters with ill-mannered and uncultured superiors, conflicts with
unbalanced or rough-spoken individuals in overcrowded trams or buses,
miscommunication with foreign-speaking (meaning Russian-speaking) state
officials, and tensions in communal flats.5 The psychiatrist’s advice to his readers
was to master techniques of relaxation that would allow them remain calm in
socially and politically charged situations. Under the guise of promoting
psychohygiene, the author alluded to social injustices, lack of free expression, and
uneven access to power and resources as common threats to mental balance.
Widespread forms of distress, such as neurasthenia, vegetative dystonia, and
depression generally remained outside the folk categories of the abnormal and/or
madness in Soviet Latvia. Even chronic sufferers from these forms of distress
managed to adapt to a variety of social and vocational roles. The lay and
professional notions of mental abnormality, moreover, markedly overlapped. The
impact on medical science and clinical practice in the Soviet Union of an
ideologised form of I. Pavlov’s teaching as well as most doctors’ unfamiliarity
with psychoanalytical concepts for a l ong time retained the whole category of
neuroses within the sphere of neurologists’ expertise. As neurologically understood
conditions, neuroses had little chance to be associated with madness or mental
Daiga Kamerāde & Agita Lūse 57
__________________________________________________________________________
abnormality, then the proper subject matter of psychiatry. The psychiatrists, at least
until the 1980s, were indeed predominantly concerned with the cases that fell into
the domain of the ‘major psychiatry,’ namely, those defined as the psychotic ones
(including sufferers from schizophrenia, manic-depressive psychoses, and alcohol
psychoses).
The term ‘major psychiatry’ (bolshaya psihiatriya) came into usage after the
Russian psychiatrist P. B. Gannushkin the early 20th century had introduced the
concept of ‘minor psychiatry’ (malaya psihiatriya). Gannushkin coined the latter
term to refer to his theory of ‘constitutional pscyhopathies.’ His special interest
was ‘inherited and enduring personality features (..) that, firstly, leave an imprint
on the individual’s entire mental constitution and, secondly, situate him/her on the
borderline between mental health and illness.’6 It was acknowledged that in order
to develop such a typology of characters one needed to study not just psychiatric
inpatients but mostly individuals in their ordinary life, in interaction with their
milieu.
The area circumscribed by Gannushkin as the minor psychiatry for a long time
remained rather marginal among the leading Soviet psychiatrists’ theoretical and
practical concerns. Thus, the leading Soviet school of psychiatry, the Moscow
school, focused on the concept of psychosis while neuroses or psychoneuroses
attracted much less attention. B y the mid-1980s, however, the number of people
suffering from psychotic disorders reportedly had stabilised whereas the number of
registered non-psychotic or ‘borderline’ disorders was growing, in Latvia7 as well
as in Estonia and Russia.8 For example, a study, conducted in Estonia for the period
between 1970 and 1984, demonstrated that neuroses constituted 16.8 per cent of all
psychiatric illnesses.9 In particular, it was acknowledged that ‘long-standing
neuroses account for psychogenic development of personality that subsequently
could result in the need for prolonged hospitalisation.’10 Of all neuroses, their
hypochondriac and depressive sub-types were reported most frequently.
Gannushkin’s concept of borderline psychopathologies regained currency. From
1978 on, also the concept of psychosomatic illness was promoted among Latvian
psychiatrists and doctors of other specialities.11 At about the same time, some
psychiatrists in Latvia came forward with a prevention initiative, namely, a model
of psycho-hygiene clubs for general population. Thus neuroses were gradually
reclaimed as psychiatrists’ rather than neurologists’ area of expertise. It is
noteworthy that the ‘minor psychiatry’ in Soviet Latvia at that time was understood
as dealing not just with psychopathies and pathologies of character, as it did for
Gannushkin, but also with neuroses.12
Since the late 1970s and even more so since restoration of the country’s
independence in 1991 ps ychiatrists in Latvia have taken considerable steps to
expand the number of social and personal ills that can be construed as falling into
their field of expertise. Intensive contacts with colleagues in the West as well as
increasing accessibility of contemporary psychiatric literature were an additional
__________________________________________________________________________
stimulus to revise common patterns of psychiatric reasoning. Once Western
training programmes in psychotherapy had been introduced, psychodynamic and
psychosomatic concepts could be further evolved. The mental health practitioners’
attention increasingly focussed on disturbances that could be interpreted as
psychogenic or sociogenic in their origin (‘psycho-neuroses’ in the Freudian sense
or reactive conditions as distinguished from endogenous ones, i.e., those stemming
from disorders of the brain in the Kraepelinian sense).
In 2004 a group of privately practicing psychiatrists offered, with the help of
psychotherapists and psychologists, to ‘dismantle the fence’ that in Latvia still
segregated the ‘major psychiatry’ in the psychiatric hospital. That fence, they
claimed, instilled in general population fear of psychiatry, and hindered people
from utilizing psychiatrists’ help as ‘an adaptive means towards achievement of
mental comfort.’13
3. Discrepancies between Professional and Layperson Understanding of

Boundaries of Mental Illness/Abnormality
Such emphasis on ‘mental comfort’ recently proposed by psychiatrists in Latvia
echoes the neo-liberal ideology that favours individual self-mastery. The mental
health specialists have come to view difficulties in mastering one’s mental and
emotional states as deviations from the ‘normal.’ Whereas for the most of the
Soviet period in Latvia the lay ideas of madness and the professional psychiatrists’
notions of mental abnormality tended to overlap (understood as the field of the
‘major psychiatry’), during the post-Soviet period they increasingly began to
diverge. One can observe hesitance, on the part of general population, to translate
issues of personal unhappiness into forms of mental abnormality, and, for that
matter also unwillingness to come under the scrutiny of even the ‘minor
psychiatry.’ This hesitance was observed in focus group interviews with members
of general public conducted in Latvia in 2004. The sample for this study was forty-
one individual in the age range from 16 - 62, who read newspapers or magazines at
least once per week and who had not had a d irect experience with persons with
mental disability/ illness. The purposeful sampling method was used. The purpose
of sampling was to obtain a sample that would constitute diversity of people in
respect of age, gender, nationality, region of living and type of settlement,
educational level, occupation and media usage. This sample qualitatively
represented the population of Latvia in the age range of 15-62. All participants
were divided into groups and a focused interview was conducted with each of the
groups. The agenda for interviews contained three main topics: (1) general
representations of people with mental health problems and attitudes towards them;
(2) sources of information on mental health issues and the role of mass media; (3)
attitudes towards integration in society of people with mental health problems.
Every focus group lasted for around 1.5 - 2 hours. The data from the focus groups
were analysed employing the grounded theory approach.14
__________________________________________________________________________
The study demonstrates that madness and mental illness are still viewed in
Latvia as sheer ‘otherness,’ manifest in socially unacceptable behaviour, emotional
utterances, or even thoughts but not in emotional disturbance and suffering. The
focus group participants defined madness and mental illness purely in external
(behavioural and observable) terms, not in terms of mental experiences,
emphasising the inadequacy of the mentally ill a nd their deviance from general,
widely agreed social norms. Inadequacy in respect of social norms in focus group
interviews was mainly articulated in three ways: (i) as general inadequacy; (ii) as
unusual, inadequate behaviour, (iii) as emotional instability related to
aggressiveness and dangerousness to other people and as one’s inability to control
oneself.
(i) General inadequacy of people with mental illness is described as ‘something
is not as it’s supposed to be’ and ‘…strange and different’
(ii) Out of the ordinary verbal expressions, like ‘talking with himself’ and
‘singing without reason’ also were considered as symptoms of mental illness.
Similarly, arguments that are perceived by others as unbelievable, laughable, for
example, ‘when an old lady is claiming that she will be the next president of Latvia
and organizing an election campaign in a shop,’ are classified as signs of madness.
Moreover, even people whose opinions either differed from opinions of the
majority or who were critical towards those opinions were perceived as having
mental problems. Finally, the third most often mentioned inadequacy, as a sign of
mental health problems was externally observable emotional instability, such as
‘swinging mood’ or nervousness.
(iii)The third folk criterion used to define madness and mental illness was one’s
inability to control oneself as well as perceived dangerousness to others that
allegedly arises from that inability. The mentally ill were described as ‘aggressive,
able to harm themselves and others,’ ‘…dangerous because aggressive,’ and it was
suggested that it i s ‘better to keep away from them because they are dangerous.’
Moreover, interviewees often remarked that individuals with mental illness ‘cannot
be left without supervision’ because they can cause danger to themselves or others,
for example, ‘…can leave gas open…,’’If not supervised, they can set home on fire
… .’
Furthermore, the focus group participants expressed strong hesitance to
approach mental health professionals for help when encountering mental problems.
For the general public, this hesitance is based on fear of being classified as
abnormal, mentally ill or mad, and to be excluded and stigmatised. Mental illness
and visits to mental health care professionals were associated with shame, stigma
and fears of being excluded from society. Thus ‘a visit to a doctor is shameful,
better to try to solve this problem on my own,’ ‘like going to a sex-shop, it is
shameful to go to see a psychiatrist.’ Being perceived as ‘abnormal’ mental illness
is identified with shame (‘it is shame because others do not have such an illness’).
In addition to shame, people are afraid to get stigmatised (‘once you have been in
__________________________________________________________________________
psychiatric hospital, you are lost,’ ‘ you are going to be labelled for all your life’).
As the result of stigma, people are afraid to be excluded from society and to lose
friends and their job (‘They [friends] will not ask you out anymore and won’t be
friends anymore,’ ‘people will avoid me,’ ‘you are going to get fired from the
job… they will find an excuse why,’ ‘you won’t be able to find a job’).
Moreover, it seems that the knowledge about non-biomedical forms of
treatment of mental problems has not yet fully reached laypersons, as the focus
group participants expressed strong concerns about the methods of treatment used
in mental health care, meaning mainly treatment with medicines. ‘I am afraid of
the psychiatrist because I don’t know what he will do to me.’ Treatment with
medicines is perceived as being more harmful than helpful: ‘The medicines are
going to make it worse and worse.’ Moreover, general public expressed strong
fears of being isolated into hospital (‘I am afraid that I will get locked into a home
for crazy people’) and being included in a r egister of mental health care patients
(‘people are afraid to be included in the register’) in case of approaching mental
health professionals.
Fears associated with the ways of treatment for mental health problems also
indicated that general public still understood mental illness in terms of ‘major
psychiatry.’ This understanding was echoed in mass media in Latvia. In 2004 a
content analysis of a representative sample of magazines and newspapers published
in Latvia in May/June 2004 was conducted. For the content analysis all issues of
fifteen newspapers and magazines for one randomly chosen month (6th May to 6th
June) were collected. Then all issues were searched for analytical units: any
publications (i.e. news, reports, ads, anecdotes, interviews etc.) that were related to
mental health or illness. All units for analysis were coded qualitatively using the
‘grounded theory’ approach, e.g. identifying themes that appeared in texts without
prior assumptions. The results of the content analysis indicated that the vast
majority of publications on mental health/illness were related to mental disorders
that fall into the category of ‘major psychiatry,’ e.g. psychoses and schizophrenia.
Moreover, in mass media people with mental disorders were represented as mad,
inadequate, aggressive and dangerous to others. It is noteworthy that only
externally observable criteria for defining them as crazy/mad and ill were used.
However, the situation us likely to change and both laypersons’ and
professionals’ representations of mental illness might soon converge. In 2008, a
repeated content analysis of mass media indicated that the number of publications
devoted to the mental health issues related to ‘minor psychiatry’ had substantially
grown, mainly due to the increased number of publications by mental health care
professionals. The focus group interviews in 2004 revealed that mass media was
the principal source of information on mental health issues that general public was
consulting. Taking that into account it is likely that soon the professionals’
representations of mental disorders are going to penetrate laypersons’
understanding of them. Laypersons’ definition of mental illness might broaden
__________________________________________________________________________
over time and the rejection and negative stereotypes associated with it might
decline.
The discrepancies between professional and lay notions of mental illness may
have important consequences, as public conceptions of mental disorders are
strongly related to the help-seeking behaviour and attitudes towards the mentally
ill.15
4. Conclusions and Discussion

To summarise, the findings from the literature review of Soviet-times’
publications on psychiatry, focus group interviews and two mass media content
analyses reveal that redrawing boundaries of psychiatry (and mental illness) in
Latvia is characterised by expanding the borders and development of discrepancy
between lay and professional understanding of these borders.
The expansion of the field of psychiatry in Latvia by including in it relatively
less severe mental problems remind the findings from the Rose’s study on the
professional expansion of British psychiatry after the WWI and even more, after
the WWII.16 Like other doctors, also psychiatrists in United Kingdom increasingly
responded to the needs of political regulation of population, its quality as well as
its military, industrial and social efficiency.17 Psychiatry moved from the mental
institution to community and became, alongside a number of paramedical sectors,
an agent of social management and normalization. As a result of joint efforts of
mental health professions a h ost of new techniques came into existence aimed at
normalizing ‘maladjusted selves.’ The move away from the asylum broadened the
range of social ills seen to be flowing from psychiatric disturbance and, for that
matter, medicalised and psychiatrised new populations. As a major factor behind
that move Rose saw the psychiatrists’ aspiration to new careers and a higher status
within medical profession. Similarly, since the late 1970s and even more so since
the 1990s, psychiatrists in Latvia have expanded their notion of borders of
psychiatry including within them ‘minor’ psychiatric problems, such as neurosis.
A literature review also reveals that not only expansion of psychiatry but also
discrepancies between professional and laypersons’ perception of mental illness
have been identified outside of the ex-Soviet block. Thus, similarities in public
notion of mental illness in Eastern and Western European countries have also been
highlighted by Shorter: ‘Much of the population of central and eastern Europe still
fears the notion of psychiatric illness, preferring to think of mental afflictions as
affections of the ‘nerves.’ They prefer, in other words, the ‘N’ word to the ‘P’
word.’ 18 The population of the United Kingdom and western Europe is scarcely
more enlightened, although several generations of exposure to the concept of
mental health have, in fact, borne some fruit.19 Also Angermeyer and Matschinger
found discrepancies between the lay and professional understanding of mental
illness, in general, and schizophrenia, in particular, in the 1990s in the former
__________________________________________________________________________
Federal Republic of Germany. 20 They also observed that the gap between lay and
professional perception of mental illnesses has narrowed from 1990s to 2001.21
There similarities between Latvia and Western European countries in redrawing
boundaries of psychiatry and mental illness are not surprising. Similarly to ex-
soviet counties, for many years institutional mental health care was the only choice
in many Western European countries.22 The institutional model was strongly
supported by the stigma attached to mental suffering and the corresponding wish of
the general public to distance themselves from the mentally ill. Even after
community-based mental health care was introduced, the institutional mental
health care model still for a l ong time was determining lay perceptions of the
mentally ill.
The findings presented in this chapter suggest that even though Eastern
European countries might be behind in time in introducing community-based
mental health care, the process they are undergoing in definition of mental
abnormality/illness might be very similar to what in many Western European
countries has taken place from the 1950s on (when moving towards community
based mental health care started) and still is going on. However, this hypothesis
requires further investigation.
Notes
1
T. Tomov, R. Van Voren, R. Keukens & D. Puras, ‘Mental Health Policy in
Former Eastern Block Countries’, in Mental health Policy and Practise across
Europe: The Future Direction of Mental Health Care, M. Knapp, D. McDaid, E.
Mossialos & G. Thornicroft (eds), McGraw Hill & Open University Press,
Maidenhead, 2007, pp. 397-425.
2
M. Knapp, D. McDaid, E. Mossialos & G .Thornicroft, ‘Mental Health Policy and
Practise across Europe: An Overview’, in Ibid.
3
S. Rausing, ‘Re-Constructing the ‘Normal’: Identity and the Consumption of
Western Goods in Estonia’, Consumption and Household Economy in the Baltic
States: Microlevel Approaches, Stockholm School of Economics in Riga, Riga,
1998; D. Stukuls Eglitis, Imaging the Nation: History, Modernity, and Revolution
in Latvia, the Pennsylvania University Press, Pennsylvania, 2002.
4
V. Skultans, ‘Varieties of Deception and Distrust: Moral Dilemmas in the
Ethnography of Psychiatry’, Health, 2005, pp. 491-512.
5
I. Eglītis, Par cilvēka psihi [On human psyche, in Latvian], Zvaigzne, Rīga, 1979.
6
P.B. Gannushkin, Izbranniye trudi [Selected Papers, in Russian], Medicina,
Moskva, 1964.
7
Y.V. Shirin & V.T. Malahov, ‘Opit raboti v psihogigiyen'icheskom klube
[Experiences of work in a club of psychohygiene, in Russian]’, Aktual'niye voprosi
n'evrologii, psihiatrii i n'eirohirurgii. II syezd n'evropatologov, psihiatrov i
n'eirohirurgov Latviiskoi SSR’; Z.G. Sochneva & Y.K. Liepinsh, ‘Sostoyan’iye i
__________________________________________________________________________
perspekt’ivi razvit’iya psihitriachicheskoi pomoshchi v Latviiskoi SSR in
Aktual’niye voprosi nevrologii, psihiatrii i neirohirurgii. II syezd nevropatologov,
psihiatrov I n’eirohirurgov Latviiskoi SSR.
8
L.S. Mehilane, ‘Aktual’n’iye voprosi d'iagnost'iki i l'echen'iya psihogennih
zabol'evan'ii’[Current Issues in diagnosis and treatment of mental illnesses, in
Russian]’, in Aktual'niye voprosi n'evrologii, psihiatrii i n'eirohirurgii. II syezd
n'evropatologov, psihiatrov i n'eirohirurgov Latviiskoi SSR [Current Issues in
Neurology, Psyhiatry and Neurosurgery’. 2nd Congress of Neuropatologists,
Psyhiatrists and Neurosurgeons in the SSR of Latvia]’, Riga, 1985; A A Severniy,
‘Principi d'emaskirovan'iya maskirovannih vegetat'ivnih sindromov’ [The
Principles of uncovering of symptoms of latent vegetative syndroms, in Russian]’,
in Aktual'niye voprosi n'evrologii, psihiatrii i n'eirohirurgii. II syezd
n'evropatologov, psihiatrov i n'eirohirurgov Latviiskoi SSR' [Current Issues in
Neurology, Psyhiatry and Neurosurgery’. 2nd Congress of Neuropatologists,
Psyhiatrists and Neurosurgeons in the SSR of Latvia], Riga, 1985.
9
L.S. Mehilane, op.cit.
10
Ibid.
11
I.R. Eglitis & Z.G. Sochn’eva, ‘Opit podgotovki vrachei obshchel'echebnoi set'i
po probl'eme psihosomat'icheskih otnoshen'iy [Experiences of training of general
practitioners on of psychosomatic issues, in Russian]’, in Aktual'niye voprosi
n'evrologii, psihiatrii i n'eirohirurgii. I syezd n'evropatologov, psihiatrov i
n'eirohirurgov Latviiskoi SSR [Current Issues in Neurology, Psyhiatry and
Neurosurgery’. 1st Congress of Neuropatologists, Psyhiatrists and Neurosurgeons
in the SSR of Latvia], Riga, 1979, pp. 13-14.
12
I. Eglītis, Par cilvēka psihi [On human psyche, in Latvian], Zvaigzne, Rīga,
1979, p. 79.
13
Association of Private Psychiatrists, Viewed on 01 A ugust 2008,
http://www.privatpsihiatrija.lv/public/.
14
B.G. Glaser & A.L. Strauss, The Discovery of Grounded Theory: Strategies for
Qualitative Research, Aldine Publishing, New York, 1967.
15
A.F. Jorm, ‘Mental Health Literacy: Public Knowledge and Beliefs about Mental
Disorders’, British Journal of Psychiatry, Vol. 177, 2000, pp.396-401.
16
N. Rose, ‘Psychiatry: The Discipline of Mental Health’, The Power of
Psychiatry, P. Miller & N. Rose (eds), Polity Press, Cambridge, 1986, pp. 43-84.
17
Ibid, pp. 45-47.
18
E. Shorter, ‘The Historical Development of Mental Health Services in Europe’,
in Knapp, et al., p. 28
19
Ibid.
20
M.C. Angermeyer & H. Matschinger, ’Causal Beliefs and Attitudes to People
with Schizophrenia’, The British Journal of Psyhiatry, Vol. 186, 2005, pp. 331-
335.
__________________________________________________________________________
21
M.C. Angermeyer & H. Matschinger, ‘The Stigma of Mental Illness in
Germany: A Trend Analysis’, International Journal of Social Psychiatry, Vol.
51(3), 2005, pp. 276-284.
22
E. Shorter, op. cit., pp. 15-34.
Bibliography
Angermeyer, M.C. & Matschinger, H., ‘Causal Beliefs and Attitudes to People
with Schizophrenia’. The British Journal of Psyhiatry. Vol.186, 2005, pp. 331-335.
–––, ‘The Stigma of Mental Illness in Germany: A Trend Analysis’. International

Journal of Social Psychiatry. Vol. 51(3), 2005, pp. 276-284.
Eglītis, I., Par cilvēka psihi. Zvaigzne, Rīga, 1979.
Eglitis, I.R. & Sochn'eva, Z.G., ‘Opit podgotovki vrachei obshchel'echebnoi set'i
po probl'eme psihosomat'icheskih otnoshen'iy’. Aktual'niye voprosi n'evrologii,
psihiatrii i n'eirohirurgii. I syezd n'evropatologov, psihiatrov i n'eirohirurgov
Latviiskoi SSR. Riga, 1979.
Gannushkin, P.B., Izbranniye trudi. Medicina, Moskva, 1964.
Glaser, B.G. and Strauss, A.L., The Discovery of Grounded Theory: Strategies for
Qualitative Research. Aldine Publishing, New York, 1967.
Jorm, A.F., ‘Mental Health Literacy: Public Knowledge and Beliefs about Mental
Disorders’. British Journal of Psychiatry. Vol. 177, 2000, pp. 396-401.
Knapp, M., McDaid, D., Mossialos, E. and Thornicroft, G. (eds), Mental Health
Policy and Practise across Europe: The Future Direction of Mental Health Care.
McGraw Hill & Open University Press, Maidenhead, 2007.
Mehilane, L.S., ‘Aktual'n'iye voprosi d'iagnost'iki i l'echen'iya psihogennih

zabol'evan'ii’. Aktual'niye voprosi n'evrologii, psihiatrii i n'eirohirurgii. II syezd
n'evropatologov, psihiatrov i n'eirohirurgov Latviiskoi. Riga, 1985.
Rausing, S., ‘Re-Constructing the ‘Normal’: Identity and the Consumption of

Western Goods in Estonia’. Consumption and Household Economy in the Baltic
States: Microlevel Approaches. Stockholm School of Economics in Riga, Riga,
1998.
__________________________________________________________________________
Rose, N., ’Psychiatry: The Discipline of Mental Health’. The Power of Psychiatry.
Miller P. & Rose N. (eds), Polity Press, Cambridge, 1986, pp. 43-84.
Severniy, A.A., ‘Principi d'emaskirovan'iya maskirovannih vegetat'ivnih

sindromov’. Aktual'niye voprosi n'evrologii, psihiatrii i n'eirohirurgii. II syezd
n'evropatologov, psihiatrov i n'eirohirurgov Latviiskoi SSR. Riga, 1985.
Shirin, Y.V. and Malahov, V.T., ’Opit raboti v psihogigiyen'icheskom klube.

Aktual'niye voprosi n'evrologii, psihiatrii i n'eirohirurgii. II syezd n'evropatologov,
psihiatrov i n'eirohirurgov Latviiskoi SSR. Riga, 1985.
Skultans, V., ‘Varieties of Deception and Distrust: Moral Dilemmas in the

Ethnography of Psychiatry’. Health. Vol. 9 (4), 2005, pp. 491-512.
‘Sostoyan'iye i perspekt'ivi razvit'iya psihitriachicheskoi pomoshchi vLatviiskoi

SSR. Aktual'niye voprosi n'evrologii, psihiatrii i n'eirohirurgii. II syezd
n'evropatologov, psihiatrov I n'eirohirurgov Latviiskoi SSR. Riga, 1985.
Strauss, A.L. and Corbin, J.M.. Grounded Theory in Practice. Sage, London, 1997.
–––, Basics of Qualitative Research: Techniques and Procedures for Developing

Grounded Theory (3rd ed). Sage, New York, 2008.
Stukuls Eglitis, D., Imaging the Nation: History, Modernity, and Revolution in
Latvia. The Pennsylvania University Press, Pennsylvania, 2002.
Daiga Kamerāde is a Lecturer in Organisational Behaviour and HRM at Salford

Business School, University of Salford.
E-mail: D.Kamerade@salford.ac.uk
Agita Lūse is a Lecturer in Social Anthropology at Riga Stradiņš University. E-

mail: agita_luse@apollo.lv
Acknowledgements
The studies presented in this chapter were financially supported by Latvian
Council of Science and International Policy Fellowship from Open Society
Institute, Soros Foundation.
Intimacy and Control, Reciprocity and Paternalism: Madness
and the Ambivalence of Caring Relationships in a
Post-Soviet Country
Agita Lūse and Lelde Kāpiņa

Abstract
A characteristic feature of Soviet psychiatric care was paternalism. Neither the role
of lay care nor patients’ mutual care was articulated in Soviet mental health care
discourses. Presence or lack of loving, intimate, and/or confiding relationships was
viewed as having a marginal importance for persons diagnosed as ‘mentally ill.’
Notwithstanding the general paternalistic model of care, in Soviet Latvia one could
often observe a degree of solidarity and reciprocity in doctor-patient relationships,
especially for such widespread forms of mental distress as neurasthenia and
vegetative dystonia. The post-Soviet reforms in psychiatry brought with them
novel ideologies of care and have lead to prioritising cure over care thus widening
the status difference between doctors and most patients. In Latvia, also the
emotional distance between them has grown. At the same time, the new mental
health discourses have facilitated somewhat greater attention to the patients’
emotional needs, both in professional and voluntary sectors of care. The question
as to what degree mental health service users need, desire or are capable of
intimate and loving relationships nonetheless still elicits ambivalent reactions in
today’s Latvia. This chapter examines various ways in which psychiatric patients
and their carers in Latvia address such dilemmas as care and reciprocity, treatment
and control, intimacy and vulnerability. The presenters will base their discussion
on the data that stem from interviews with psychiatric service providers, users and
their relatives conducted in 2007 and participant observation/ listening in two
Latvian service users’ organisations in 2007-2008.
Key Words: Doctor-patient relationships, mental health care, peer support,

professional care, psychiatry service users, reforms in post-Soviet psychiatry,
Soviet psychiatry.
*****
1. Introduction
Intimacy can be define as an intersubjective mode of being in the world which
stems from the human being’s need to feel accepted and form meaningful
relationships. Intimacy acquires a particular significance for sufferers from mental
disorders. Psychiatrists often regard a p erson’s failure to maintain close, intimate
relationships and build a s ocial support network as characteristic features of
schizophrenia. 1 On the other hand, hardly anyone will deny that distress caused by
a failed relationship may trigger or exacerbate a mental disorder. 2 Does it m ean
68 Intimacy and Control, Reciprocity and Paternalism
__________________________________________________________________
that trustful patient-carer relationships can, at least to some degree, reverse these
adverse effects?
In spite of a number of studies confirming the importance of social support for
reducing mental distress, there is no unanimity among psychiatrists as to the
relative importance of supportive relationships vis-à-vis the conventional forms of
psychiatric treatment. 3 Moreover, the question has not been resolved who is likely
to provide the needed support most successfully: kin, peer carers or professionals?
A recent study on the link between social integration and health suggests that
intimacy and attachment have meaning not only for relationships that are
traditionally thought of as intimate (such as between partners and family members)
but also for more extended ties. 4 Thoits, in turn, has argued that the perception or
belief that emotional support (love and caring, sympathy and understanding, and/or
esteem and value) are available from significant others appears to be a much
stronger influence on mental health than the actual receipt of such support. 5 Now,
sufferers are very likely to perceive their carers as significant others, whether the
latter appear emotionally supportive or not. The corollary is that confiding, trustful
relationships with their psychiatrists, therapists, counsellors or peers play a
decisive role in the patients’ recovery and sustaining their mental health. That has
been demonstrated by a number of psychosocial rehabilitation programs elaborated
from the 1950s on, for instance, by Dr. Brooks in Vermont, 6 Dr. Bettelheim in
Chicago, 7 Dr. Bullard in Chesnut Lodge in Maryland, USA, 8 and Dr. Foudraine in
‘Rose Cottage,’ 9 not to mention Dr. Laing’s efforts in Glasgow’s Gartnavel Royal
Mental Hospital. 10 Slater, a counsellor, describes how through ‘finding herself in
the patient and the patient’s self in herself’ and building a shared language she
succeeded in treating a group of chronic schizophrenics in East Boston. 11 Users
and ex-users of psychiatric services have recently discussed their positive
experiences with various alternatives to psychiatry, such as user-controlled houses
and peer-run crisis groups. 12
In this chapter we hypothesize that the effectiveness of care depends on the
historically specific configuration of sources of care available to particular socio-
economic groups of sufferers from mental disorders rather than solely on the
specific mode of a dyadic relationship between the patient and the carer. Focussing
on the particular context of Soviet Latvia we sketch the ways in which various
agents of care - the state administration, mental health practitioners, relatives and
peers in state-socialist countries have interacted with patients since the mid-20th
century. We explore historically successive notions of care and discuss our data
from a field research that we conducted among psychiatric service providers, users
and their relatives in 2007.
2. ‘The Caring State’

Neither the role of lay care nor patients’ mutual care was articulated in Soviet
mental health discourses. Presence or lack of intimate relationships was viewed as
Agita Lūse & Lelde Kāpiņa 69
__________________________________________________________________
having marginal importance for persons diagnosed as ‘mentally ill.’ For instance,
in a textbook on psychiatry used in nurses’ training in the 1960s such topics as
patients’ social needs, mutual care, or importance of familial relationships were
never mentioned. 13 One should keep in mind that a c haracteristic feature of
psychiatric care in state-socialist countries was paternalism. The socialist health
care system has been described as techne, a ‘rational and rationalizing form of state
knowledge and planning.’ 14 Citizens appeared as passive recipients of state care
embodied by medical practitioners. Additionally, they were targeted by
ideologically framed expert advice on how to lead physically and mentally healthy
and socially useful lives. Within this general paternalistic framework there were,
nevertheless, local variations in day-to-day practices. For instance, in Soviet Latvia
one could observe a degree of solidarity and reciprocity in doctor-patient
relationships, especially for such a widespread form of mental distress as
neurasthenia from which also Latvian psychiatrists suffered at times. 15
3. Nursing as Care
Historically changing definitions of nursing care in general and psychiatric
nursing in particular, illustrate the ways in which carer-patient interaction reflects
changes in relationships between the state and its citizens. In Czechoslovakia, for
instance, nursing care during the socialist period was focussed on managing
patients’ physical problems and symptoms. Addressing their social and emotional
needs was left to relatives and friends. Nursing care was not only spatially but also
morally distinct from care offered by kin. 16 From this perspective, the omission of
any discussion of patients’ relational patterns and needs in nurses’ psychiatric
training is only too understandable. According to the above-quoted Soviet
textbook, nurses working in psychiatric hospitals were to perform the following
functions vis-à-vis inpatients: physical care (uhod), surveillance (nadzor), and
servicing. 17 They were expected to be ‘serious, polite, affable, and sympathetic’
towards patients, ensure there is order and silence in the ward and avoid chatting in
patients’ presence. 18 Namely, nurses were expected to observe emotional distance
vis-à-vis patients and act primarily as agents of treatment routines, hygiene, and
social control.
The outline of how nursing care was understood in state socialist societies
suggests a parallel to the notion of care in the 19th century Anglo-Saxon
philanthropic thought. Namely, care in that context was ‘the means by which the
conditions likely to produce danger [were] constantly monitored and kept under
control.’ 19 In the private domain (in Western societies), in contrast, ‘care’ was
linked to ‘love’ through middle-class female socialization patterns. It was the latter
meaning of care that informed the ethos of nursing as a new profession. For
instance, Florence Nightingale in Notes on Nursing (1860) demanded of a carer an
effort to place herself imaginatively in the other’s situation, a quality that is
nowadays called empathy. 20 From the mid-19th century on, the private domain
__________________________________________________________________
notion of care gradually permeated carers’ practices in the public domain of
healthcare institutions in the West. Dunlop, however, remarks that this
transformation of meaning of professional care made the carer-patient relationship
inherently ambivalent. For instance, by the 1980s North American nurses had
become wary of identifying themselves with their patients’ family to a degree that
also involved coercion and domination over patients. Such an excessive
involvement was regarded as ‘distortion of caring.’ 21 Paradoxically, one hundred
years later, control had again become carers’ concern, although this time not as a
rationally planned and necessary measure but rather as an unwanted emotional side
effect of an attitude modelled upon the parent-child relationship.
4. The Changing Relationships with Professional Caregivers in Latvia

The post-socialist health care reforms brought with them a considerable change
in how such notions as care and control were understood. Various mental health
care specialists revised their areas of expertise. Due to far-reaching structural
changes also patterns of interpersonal relationships transformed. For instance, in
the course of the first post-socialist decade in Latvia the status difference between
psychiatrists and most of their patients widened. Compared with their situation in
the much more egalitarian Soviet society, the liberal economic reforms of the
1990s disadvantaged sufferers from mental and emotional disorders both socially
and economically to an unprecedented degree. Psychiatrists’ standing, at the same
time, considerably rose due to the expansion of their sphere of expertise (discussed
in the other chapter co-authored by Luse for this conference), their intensive
retraining in psychotherapy, and the increased promises of psycho-
pharmacological treatment. In the mid-1990s new professional codes began to
shape the therapeutic encounter prompting doctors to observe greater emotional
distance towards patients, a stance that was less common among psycho-
neurologists of Soviet Latvia. 22 The dynamics of relationships between patients
and psychiatric nurses, however, has taken a different turn.
In the countries of East and Central Europe and the former Soviet Union the
notion of nursing care has evolved under a considerable influence of contemporary
Western ideologies of care, namely, there have been attempts to redefine nursing as
not only incorporating physical care but also meeting patients’ social and
emotional needs. 23 A review of four recent ethnographic studies conducted in
diverse ex-socialist settings (in East Germany, the Czech Republic, Western
Siberia) established that the caring practices that have emerged in various contexts
outside kin relations ‘invoke notions of ‘privateness’ and intimacy, which are
conventionally associated with kinship in the feminist literature on care.’ 24 The
new mental health discourses have facilitated greater attention to patients’
emotional needs in the professional as well as voluntary sector of care. Research
evidence from post-socialist Latvia suggests that psychiatric nurses appear to
patients emotionally more responsive than before. A person with a 30-year career
__________________________________________________________________
as a mental health patient recently shared with Luse her observation of changes in
the nurses’ attitudes in a hospital in Riga, the capital of Latvia:
Well, after all, a p sychiatric nurse - here the main thing is her
experience and maybe also a s ort of keen perception and
empathy, and composure. Qualities like that. For instance, I can
recall that some ten and more years ago there used to be one or
two [nurses] who behaved in an extremely domineering manner.
[...] The situation has been steadily improving. [...] Well, at least
in the ward X one can approach majority of nurses with any kind
of question. [...] Well, if they have time - then they readily talk
[to a patient]… [I mean] if something is troubling one’s heart. 25
Since the 1990s psychiatric nurses in Latvia have had ample opportunities to
acquire new qualifications. Some of them have undergone training in Social Work
while others studied towards a university degree in Nursing (neither existed in
Soviet times). The most dedicated of their craft have formed a p rofessional
association. For our study we interviewed a r eform-minded psychiatric nurse (let
us call her Daina) who has been committed to building respectful relationships
with patients. She has observed that in most cases patients appreciate such an
attitude:
Patients very much like that they are treated as equal rather than
kind of: ‘I’m a s pecialist whereas you are somewhere much
lower, you are an ill person. [...] Well, to me it seems to come
naturally that one should reply politely rather than brusquely,
with abrupt phrases. I smile and keep eye contact while I talk. 26
Nevertheless after a recent incident with a former client from a day centre that
she ran two years previously Daina has begun to doubt if she has chosen the right
approach to her patients. For his misbehaviour the client had been suspended from
the centre. He had seemed deeply offended and one day approached Daina on the
street and began slapping her. We guess that the patient’s anger hardly was caused
by the particular fact of his suspension: it rather signalled his feeling excluded
from a rare opportunity to be accepted, respected and treated as equal - for it is
very unlikely that he would have come across another representative of egalitarian
nursing ideology so soon. The new ideology still often clashes with routine care
patterns. Moreover, the question as to what degree mental health service users
need, desire or are capable of trustful and loving relationships still elicits
ambivalent reactions from carers.
__________________________________________________________________
5. Self-Care and Mutual Care
The idea that users of psychiatry could draw on their own community as a
resource of social and emotional support is quite novel in Latvia. It has only been
promoted by a number of reform-minded psychiatrists and nurses since the mid-
1990s. Some doctors have inspired their patients living in the same vicinity to meet
in their own midst. Nurses have helped inpatients of a long-stay psychiatric
hospital to organise themselves and articulate their interests vis-à-vis the
administration. A Life Skills re-training course has been elaborated for those
inpatients whose health allows them to resume life outside the asylum walls.
Among other things, during the course patients are being retrained in self-care
patterns. Such training programmes have been praised by the participants but being
pilot projects and depending mostly on foreign funding have only been open to a
tiny proportion of patients.
In 2005 a recent high school graduate (then aged 30), joined by a dozen other
psychiatric patients, created the first psychiatry service users’ association in Latvia.
Subsequently there have been attempts to create community-based mental health
patients’ associations in three different towns. None, however, has managed to
recruit more than half-a-dozen members and only one group currently has a legal
status as a voluntary society (that, among other things) makes it e ligible to apply
for funding for its projects). Thus the question remains open as to how to account
for Latvian mental health patients’ hesitance to form mutual care structures? The
first, most obvious explanation is the stigma that in Latvia still accompanies any
kind of psychiatrically defined problem. Another factor could be a relatively lower
educational level of chronic sufferers from mental disorders. In our study we
established that especially education in social sciences and humanities has proved
an empowering resource for the most reform-minded among service users. The
meagre income of most chronic sufferers has been significant too. Beside these
factors, however, also subjective attitudes play a s ignificant role. One of central
concerns to both service users’ relatives and leaders of patients’ organisations has
been withdrawal, a common pattern among the mentally disturbed.
Corin et al in their recent studies, however, argue that in case of psychotic
patients, withdrawal can have a p rotective value. 27 In a study conducted in
Montréal, Canada, it was established that for patients diagnosed with
schizophrenia, ‘the ability to construct a personal protected space at the margins of
the ordinary ‘normal’ world was of central importance.’ 28 In particular, patients not
re-hospitalized within four years prior to the study, tended to accept or even attach
a positive meaning to their subjective sense of being outside society (Corin has
qualified this attitude as ‘positive withdrawal’). Corin found that another group of
patients of the Montréal study, namely, those frequently hospitalized, did feel
excluded and desired more social contacts and support. Thus we have to take into
account the meaning that each sufferer attaches to her/his particular ‘mode of
feeling’ in the social world. Addressing the diverse of meanings of ‘being outside,’
__________________________________________________________________
however, demands a g reat deal of shared experience and intersubjective
understanding, resources that may more readily be available to peers rather than
social workers or relatives.
6. Family Members as Caregivers

The family members of chronic sufferers from schizophrenia, in particular,
often find themselves in a highly strenuous situation. In 2007 members of a support
group (the only one of its kind in Latvia) for psychotic patients’ relatives shared
with one of us, researchers, their most pressing concerns, namely:
- They find it hard to cope with the patient’s (apparent) lack of

meaningful occupation, social isolation and emotional
withdrawal, say, when a son or a daughter never goes out and
even has meals in solitude.
- They often feel desperate when the sufferer comes forward with
what appear to be delusions, becomes verbally aggressive, or
behaves in a destructive way.
- They feel they would need a psychiatrist’s advice on how to react
to the patient when she/he is troubled but usually get none.
- Those relatives who have initiated hospitalization of their family
member against his or her will (and involving municipal police)
feel remorse about their decision.
- They often feel sorry seeing their family member being ‘doped’
while in a hospital ward.
- They rarely know precisely, however, what medication their ill
family member has received while at hospital.
- They try but often fail to administer medication without the
patient noticing it, e.g., adding it to the patient’s food.
- Trying to spare the sufferer they feel obliged to conceal many
things from her/him, for instance, for how long the prescribed
medication has to be taken.
- Most of them believe that schizophrenia is likely to be inherited
and that a person diagnosed with it should avoid ever building a
family.
- They attempt to conceal the fact of their family member’s
psychiatric treatment from colleagues, neighbours and
acquaintances but at times realise that their sense of shame only
exasperates pain that the patient is coping with.
- They regret that neither the sufferer nor they have had access no
‘talk therapy.’
- Many of them also struggle to make ends meet since the
allowance which a patient is entitled to in the case of formally
__________________________________________________________________
acknowledged disability only suffices to cover the cost of
medication and hardly anything more.
Our interviews demonstrated that family members, notably mothers, sisters,

wives and daughters, have a number of unresolved questions: for instance, what
kind of care does the sufferer actually need? Are they skilled enough to provide
such? Is their caring and sparing attitude likely to heal the sufferers’ traumas? To
what degree should care involve controlling the patient, manipulating information,
or applying force in case of their ‘mad behaviour’? May their motherly/sisterly
love or sense of duty be enough to sustain their caring efforts and prevent them,
carers, from falling into despair and escaping into illness themselves? Finally, do
sufferers from schizophrenia always need and desire so much attention as their
relatives at times feel obliged to provide? May it be that sufferers would sometimes
prefer to cope on their own and/or to receive support and assistance from their own
midst? It seems, however, that only a tiny minority of patients’ family members in
Latvia have tried to address such questions in a constructive way. The majority of
them have hardly questioned the notion (a legacy of the post-WWII Moscow
school of psychiatry) that schizophrenia is a primarily biologically based,
endogenous and incurable disease. Such a notion of psychotic disturbances
presupposes that psychiatrists are the only competent carers and
psychopharmacology the only reliable remedy.
7. Conclusion
In this chapter we attempted to sketch ambivalences, tensions and
contradictions involved in caring for sufferers from mental disorders. Some of
these ambivalences seem to be rooted in the very foundations of human existence.
Say, children up to a cer tain age are dependent on their parents and other kin. In
this sense they also are vulnerable to their early carers’ mental and emotional
influences. Most parents do love and care for their offspring but at times this love
and care are conditional, and parental power may be used even with the most
magnanimous purpose in mind. Alternatively, one or both parents may be missing.
Family members may also have other priorities than listening and talking to their
children, at times because in their own childhood they themselves have not been
listened to. In such cases intimacy may be threatened and reciprocity precluded
from the child’s subsequent relationship patterns in family as well as beyond it.
Other ambivalences of caring relationships stem from the historically particular
meanings that a society or a community attach to the concept of care. In industrial,
literate societies these meanings are very much shaped by ideologies, political as
well as clinical ones. Our outline of the transition from paternalism to more
egalitarian forms of care (be it peer support groups or partnerships between
patients and carers) in Latvia has demonstrated how slowly the institutional care
__________________________________________________________________
patterns change even though the range of meanings attached to them have
undergone a radical transformation.
Paradoxically, in a society ruled by neo-liberal values the notion,
conventionally associated with kinship, of care as a loving attitude has been
gradually transferred to the caring professions, such as nurses, social workers as
well as activists of voluntary organizations. Emotional care in a post-socialist
society is once more being seen as morally distinct from physical care. In contrast
to the patterns of care and control in state socialist societies, however, this time
diversification of the forms of care takes place because of different reasons. First,
faced with the pressures of free-market economy and expectations of
competitiveness, family members seem to be too preoccupied by their own
economic and social survival, especially in the face of stigma. Secondly, the new
discourses of the ‘therapy culture’ 29 that posit as a central point of reference the
ego psychology and individual self-mastery rather than shared moral values and
societal interests, lets many of them, especially people in their middle age and
older, feel ever more powerless when faced with interpersonal tensions. Without
many opportunities to learn how to master their moods and how to better
understand feelings of a mentally disturbed family member, at times they feel
incompetent to provide the ‘right kind’ of care. These people are only too willing
to delegate their caring responsibility to ‘experts’ - each according to their social
standing: the well-off may opt for a specialist in the private health care sector, the
middle class rely on occasional hospitalizations and nurses and psychiatrists’
‘emotional labour’, while the most realistic option for the poorer families is to rely
on the specialized public sector residential facilities - even if instead of receiving
‘specialist’ care the sufferer there is more likely to serve a life-sentence.
Notes
1
M. Albert, T. Becker, P. McCrone & G. Thornicroft, ‘Social Networks and
Mental Health Service Utilisation: A Literature Review’. International Journal of
Social Psychiatry. Vol. 4, 1998, pp. 248-66. L. Wetterberg, Psihiatrija.
Rokasgrāmata. [Unknown publisher], Latvija, 1993, p. 42.
2
L. Johnstone, Users and Abusers of Psychiatry: A Critical Look at Psychiatric
Practice, 2nd edition, Routledge, London & Philadelphia, 2000, pp. 71-77.
3
See, for instance, F. Baker, D. Jodrey & J. Intagliata, ‘Social Support and Quality
of Life of Community Support Clients’, Community Mental Health Journal, Vol.
5, 1992, pp. 397-411; J. Leff, The Unbalanced Mind, Phoenix, London, 2002; E.
Rozier, ‘Institution Defining Madness: A Place for the Individual’, 1st Global
Conference – Madness: Probing the Boundaries, Interdisciplinary Net, Mansfield
College, Oxford, 2008.
__________________________________________________________________
4
L.F. Berkman, T. Glass, I. Brissette & T.E. Seeman, ‘From Social Integration to
Health: Durkheim in the New Millennium’, Social Science & Medicine, Vol. 2000,
p. 848.
5
P.A. Thoits, ‘Stress, Coping, and Social Support Processes: Where Are We?
What Next?’, Journal of Health and Social Behavior, Extra Issue, 1995, p. 64.
6
C.M. Harding, ‘Beautiful Minds can be Recovered’, New York Times, 10 March
2002.
7
B. Bettelheim, A Home for the Heart, Bantam Books, New York, 1974.
8
Rozier, op.cit.
9
L. Johnstone, Users and Abusers of Psychiatry: A Critical Look at Psychiatric
Practice, 2nd edition, Routledge, London & Philadelphia, 2000, pp. 202-215.
10
R.D. Laing, Wisdom, Madness and Folly: The Making of a Psychiatrist 1927-
1957, Macmillan, London & Basingstoke, 1985.
11
L. Slater, Welcome to my country. Harmondsworth: Penguin. 1997.
12
P. Stastny & P. Lehmann (eds), Alternatives Beyond Psychiatry, Peter Lehmann
Publishing, Berlin, 2007.
13
G.V. Morozov & V.A. Romanenko, Nevropatologiya i psihiatriya, Medgiz,
Moskva, 1962.
14
Scott 1998, quoted in R. Read, ‘Labour and Love: Competing Constructions of
‘Care’ in a Czech Nursing Home’, Critique of Anthropology, Vol. 27, 2007, p. 206.
15
V. Skultans, ‘Neurasthenia and Political Resistance in Latvia’, Anthropology
Today, Vol.11, 1995, pp. 14-18.
16
Read, pp. 204-206.
17
Morozov & Romanenko, p. 243.
18
Ibid., p. 243.
19
Dean & Bolton, 1980, quoted from M.J. Dunlop, ‘Is a Science of Caring
Possible?’, Interpretative Phenomenology: Embodiment, Caring, and Ethics in
Health and Illness, P. Benner (ed), SAGE Publications, Thousand Oaks, London,
New Delhi, 1994, p. 30
20
Ibid., p. 30.
21
Ibid., p. 31.
22
V. Skultans, ‘From Damaged Nerves to Masked Depression: Inevitability and
Hope in Latvian Psychiatric Narratives’, Social Science & Medicine, Vol. 56,
2003, pp. 2421-2431. V. Skultans, ‘The Politics of Normality and the
‘Democratisation’ of the Self’, Memory and History, Aberdeen, 2005. A. Luse,
Changing Discourses of Distress and Powerlessness in Post-Soviet Latvia, PhD
Thesis, University of Bristol, 2006, pp. 207-209.
23
Read, pp.203-222.
24
R. Read & T. Thelen, ‘Introduction: Social Security and Care after Socialism:
Reconfigurations of Public and Private’, Focaal: European Journal of
Anthropology, Vol. 50, 2007, p. 11.
__________________________________________________________________
25
An excerpt from an interview conducted in June 2007.
26
An excerpt from an interview conducted in April 2007.
27
E. Corin, R. Thara & R. Padmavati, ‘Shadows of Culture in Psychosis in South
India: A Methodological Exploration and Illustration’. International Review of
Psychiatry, Vol. 17, 2005, pp.75-81.
28
E. Corin, ‘The “Other” of Culture in Psychosis: The Ex-Centricity of the
Subject’, Subjectivity: Ethnographic Investigations, J. Biehl, B. Good & A.
Kleinman (eds), University of California Press, Berkeley, Los Angeles, London,
2007, p. 280.
29
F. Furedi, Therapy Culture: Cultivating Vulnerability in an Uncertain Age,
Routledge, London, New York, 2004.
Bibliography
Albert, M., Becker, T., McCrone, P. and Thornicroft, G., ‘Social Networks and
Mental Health Service Utilisation: A Literature Review’. International Journal of
Social Psychiatry. Vol. 4, 1998, pp. 248-66.
Baker F., Jodrey, D. and Intagliata, J., ‘Social Support and Quality of Life of
Community Support Clients’. Community Mental Health Journal. Vol. 5, 1992, pp.
397-411.
Berkman L.F., Glass, T., Brissette, I. and Seeman, T.E., ‘From Social Integration
to Health: Durkheim in the New Millennium’. Social Science & Medicine. Vol.
2000, pp. 843-57.
Bettelheim, B., A Home for the Heart. Bantam Books, New York, 1974.
Biehl, J., Good, B. & Kleinman, A. (eds), Subjectivity: Ethnographic

Investigations. University of California Press, Berkeley, Los Angeles, London,
2007.
Corin, E., Thara, R. and Padmavati, R., ‘Shadows of Culture in Psychosis in South
India: A Methodological Exploration and Illustration’. International Review of
Psychiatry. Vol. 17, 2005, pp. 75-81.
Das, V. and Addlakha, R., ‘Disability and Domestic Citizenship: Voice, Gender,
and the Making of the Subject’. Public Culture. Vol. 13, 2001, pp. 511-531.
__________________________________________________________________
Dunlop, M.J., ‘Is a Science of Caring Possible?’. Interpretative Phenomenology:

Embodiment, Caring, and Ethics in Health and Illness, Benner, P. (ed), SAGE
Publications, Thousand Oaks, London, New Delhi, 1994.
Furedi, F., Therapy Culture: Cultivating Vulnerability in an Uncertain Age.

Routledge, London, New York, 2004.
Grāvere, L., Kamenska, A., Leimane-Veldmeijere, I., Pūce, I. and Veits, U.,
Monitoringa ziņojums par slēgtajām iestādēm Latvijā. Latvijas Cilvēktiesību un
etnisko studiju centrs, 2006.
Harding, C.M., ‘Beautiful Minds can be Recovered’. New York Times. 10 March
2002.
Johnstone, L., Users and Abusers of Psychiatry: A Critical Look at Psychiatric

Practice. 2nd edition. Routledge, London & Philadelphia, 2000.
Laing, R.D., Wisdom, Madness and Folly: The Making of a Psychiatrist 1927-
1957. Macmillan, London & Basingstoke, 1985.
Leff, J., The Unbalanced Mind. Phoenix, London, 2002.
Leimane-Veldmeijere, I. and Veits, U., Psihiatrijas pakalpojumu lietotāju

vajadzību izvērtējums. Latvijas Cilvēktiesību centrs, 2006.
Leimane-Veldmeijere, I. and Šulce, L., Key Developments in Mental Disability

Advocacy in 2007 a nd the First Six Months of 2008. Newsletter Zelda. Vol. ½,
2008, pp. 1-6.
Leimane-Veldmeijere, I., ‘Diskusija’. Vai Latvijai ir vajadzīga ANO Konvencija

par personu ar invaliditāti tiesībām? Rīga, 2008.
Luse, A., Changing Discourses of Distress and Powerlessness in Post-Soviet

Latvia. PhD thesis, University of Bristol, 2006.
Morozov, G.V. and Romanenko, V.A. Nevropatologiya i psihiatriya. Medgiz,

Moskva, 1962.
Read, R., ‘Labour and Love: Competing Constructions of “Care” in a C zech

Nursing Home’. Critique of Anthropology. Vol. 27, 2007, pp. 203-222.
__________________________________________________________________
Read, R. and Thelen, T., ‘Introduction: Social Security and Care after Socialism:
Reconfigurations of Public and Private’. Focaal: European Journal of
Anthropology. Vol. 50, 2007, pp. 3-18.
Rozier, E., ‘Institution Defining Madness: A Place for the Individual’. 1st Global
Conference – Madness: Probing the Boundaries. Inter-Disciplinary.Net, Mansfield
College, Oxford, 2008.
Skultans, V., ‘Neurasthenia and Political Resistance in Latvia’. Anthropology

Today. Vol. 11, 1995, pp.14-18.
—, ‘From Damaged Nerves to Masked Depression: Inevitability and Hope in

Latvian Psychiatric Narratives. Social Science & Medicine. Vol. 56, 2003, pp.
2421-2431.
—, ‘The Politics of Normality and the “Democratisation” of the Self’. Memory and
History. Aberdeen, 2005.
Slater, L., Welcome to My Country. Penguin, Harmondsworth, 1997.
Stastny, P. and Lehmann, P. (eds), Alternatives beyond Psychiatry. Peter Lehmann

Publishing, Berlin, 2007.
Thoits, P.A., ‘Stress, Coping, and Social Support Processes: Where Are We? What
Next?’. Journal of Health and Social Behavior. Extra Issue,1995.
Wetterberg, L., Psihiatrija: Rokasgrāmata. [Unknown publisher], Latvija, 1993.
Agita Lūse is a Lecturer at Riga Stradiņš University. She obtained a PhD from
Bristol University (2006), for the thesis Changing discourses of distress and
powerlessness in post-Soviet Latvia and has authored a number of articles in the
field of medical anthropology and anthropology of religion. Currently she is
researching the situation of psychiatry service users in Latvia and their efforts to
form mutual support and advocacy groups.
Lelde Kāpiņa, MSc, is a Consultant in Qualitative Research Methods for

FACTUM Research Studio (Riga). She has about 15 years experience in
qualitative research and is interested in destigmatisation of psychiatric service
users as well as different ways in which social studies and social researchers may
contribute to solving problems related to mental health and improve the quality of
life of psychiatric patients.
Determining Insanity in New Zealand Courtrooms
Katey Thom
Abstract
In New Zealand a person who has committed a serious offence may be found not
guilty by reason of insanity if when committing the act, they were labouring under
a ‘disease of the mind.’ In such cases, the defence has to demonstrate that the
accused was affected to such an extent by this disease of the mind as to render
them incapable of knowing that the act was morally wrong in regard to commonly
accepted standards of right or wrong. As part of this process, the defence and
prosecution each employ a psychiatrist to act as an expert witness who will give
opinion as to whether the defendant meets this criteria. The term ‘disease of the
mind’ is a legal term; the psychiatric expert witnesses may offer opinion as to what
constitutes a disease of the mind but the final decision is a matter for the judge to
decide. Common law stipulates that a disease of the mind must be lengthy in
duration and an effect of internal rather than external causes. It must also be so
severe in nature as to render the accused incapable of knowing the moral
wrongfulness of their actions. Drawing on information generated from qualitative
research, this chapter considers the implications of illicit drug use for determining
diseases of mind and moral wrongfulness. Specifically it considers the implications
of the rise in the use of pure methamphetamine in New Zealand and the problems
the use of this drug have created for determinations of insanity. Using a s pecific
criminal trial to illustrate, the chapter will explore the difficulties psychiatric expert
witnesses and the court face with regards to delineating transitory from permanent
disorders and internal from external causes in light of personal choice and
responsibility.
Key Words: Forensic psychiatry, expert witnesses, insanity defence.
*****
1. Introduction
Dr. Fletcher: Kathryn, you know he can’t possibly know that.

You’re a rational person. You’re a trained psychiatrist. You
know the difference between what’s real and what’s not.
Kathryn Railly: … and what we believe is what’s accepted as

‘truth’ now, isn’t it, Owen? Psychiatry – it’s the latest religion.
And we’re the priests – we decide what’s right and what’s wrong
– we decide who’s crazy and who isn’t. ... I’m in trouble, Owen.
I’m losing my faith. 1
82 Determining Insanity in New Zealand Courtrooms
__________________________________________________________________
In coming to terms with the idea that her patient and friend - James Cole - may
be telling the truth about being from the future and not delusional, the character in
12 Monkeys, Kathyrn Railly, describes the possible power psychiatry holds in
deciding who may be considered ‘mad’, ‘crazy’ or ‘insane’ and what behaviour
should be deemed right or wrong. On another level, the dialogue illustrates that
idea that knowledge, fact and truth may not be ‘out there’ waiting to be discovered
but rather they are actively produced, contingent and continually negotiated. The
central tenet within the legal setting that facts can be divorced from values can
become challenged when viewed in this way; a proposition a group of sociologists
studying law-science relations have sought to explore. 2
This is at the heart of what my PhD research over the last couple of years has
broadly sought to explore: What is the role of psychiatric expert witnesses in
constructing a defence of insanity in New Zealand courtrooms? Part of my
fascination with this area is how psychiatric expert witnesses grapple with cases
that are particularly difficult to delineate mad from bad, often showing up exactly
why this dichotomy is somewhat unhelpful and how legal constructs, which
emphasise such black and white decision making, are very different from those
utilised by psychiatrists in their everyday clinical settings. With all this potential
complexity in mind, my research has aimed to investigate how lawyers and
psychiatrists interact together to formulate (or not) a defence of insanity.
More often than not the role of psychiatric experts in New Zealand courtrooms
is less contentious. In the past cases of insanity have frequently been put to the jury
with agreement from the prosecution and defence. In these cases the defence offers
psychiatric expert opinion supporting insanity without the prosecution providing
opposing evidence in rebuttal. Recent changes in legislation have also introduced a
new procedure whereby a verdict of insanity may be found by a judge alone in a
hearing characterised by an inquisitorial rather than adversarial approach. These
hearings arise where, based on the evidence of two psychiatric experts, the
prosecution and defence agree that a finding of not guilty by reason of insanity is
the only possible verdict.
However, the boundary between demarcating the ‘sane’ and ‘insane’ can still
become tested and a recent murder trial in New Zealand proved this. This chapter
discusses one area where the determination of insanity in the courtroom can
become contested. This involves the use of methamphetamine and its relationship
to psychosis and insanity. Using this trial to illustrate, this chapter will consider the
key question the courtroom and public at large want answered: are you mad or bad
when you chose to ingest a substance that has the power to make you psychotically
unwell or which may exacerbate your existing mental illness?
The case involved the use of pure methamphetamine and differing psychiatric
diagnoses that were complicated by the concept of severe personality disorder and
the accused’s supposed malingering or feigning of symptoms. Due to the
restrictions of time this chapter only considers the implications of pure
Katey Thom 83
__________________________________________________________________
methamphetamine use for determining insanity drawing on what I observed while
attending this trial for six weeks and information I collected from interviews with
lawyers and forensic psychiatrists throughout New Zealand.
2. The Law in New Zealand

I will turn firstly to what the law stipulates in New Zealand regarding insanity.
Section 23 of the Crimes Act (1961) specifies that a person who has committed a
serious offence may be found not guilty by reason of insanity if when committing
the act, they were labouring under a ‘disease of the mind.’ In such cases, the onus
is on the defence (rather than the prosecution) to prove that the accused was
affected by this disease of the mind, on t he balance of probabilities, to such an
extent as to render them incapable of knowing that the act was morally wrong in
regard to commonly accepted standards of right or wrong.
In order to construct a d efence of insanity or not, as the case may be, the
defence and prosecution will each employ a psychiatrist to act as an expert witness
who will give opinion as to whether the defendant meets this criteria. The term
‘disease of the mind’ is a legal term and this is emphasised in the way case law
stipulates that the psychiatric expert witnesses may offer opinion as to what
constitutes a ‘disease of the mind’ and whether this affected the accused’s
knowledge of moral wrongfulness, but the final decision is always a matter for the
‘fact finders’ (i.e. judge or jury) to decide.
As this chapter is focused on the legal construct of disease of the mind its
relationship to drug use (with particular reference to pure methamphetamine) it is
important to discuss current case law in order to show how the New Zealand courts
currently view this topic. Firstly, it is important to note there is no precise
definition of ‘disease of the mind’ given by the court. Instead the term has
purposively been left open by the court for interpretation, as suggested by Justice
Gresson in R v Cottle it is ‘a term which defies precise definition and which can
comprehend mental derangement in the widest sense.’ 3
Although disease of the mind may be described as a vague legal term, case law
has provided examples of psychiatric diagnoses that could correspond and be
accepted as a d isease of the mind. The major mental disorders accepted by the
court are those defined by the medical profession as ‘psychoses’ which are
characterised by loss of appreciation of reality, delusions and hallucinations.
Apart from the broad descriptions of what mental disorders may or may not be
considered a disease of the mind, there are additional criteria that should be met
according to common law. One criteria is that a d isease of the mind should be a
disorder which is the result of an ‘internal’ and not an ‘external’ causes. External
causes can include such things as a blow on the head, the absorption of drugs or
alcohol. 4 In this way the mental disorders that amount to ‘disease of the mind need
to be a process in the brain,’ 5 something that is inherent or internal to the person,
and this internal process must not be transient but persistent. Psychosis, for
__________________________________________________________________
example, is generally accepted as an internal and non-transient process and is
therefore, generally accepted by the court.
Following on from this it is generally accepted in case law that a disease of the
mind caused by the ingestion of drugs or alcohol – an external factor – will not be
accepted in the consideration of insanity. This seems simple enough to delineate, if
someone has chosen to take a drug that brought about a state of mind – external in
origin – but that could be characterised as a disease of the mind, they cannot be
excused of any crimes they committed while in this state of mind. This is because
the state of mind brought about by the drug did not originate from within; it was
not inherent to the person.
3. In the Case of X
The case is well known to most New Zealanders and involved the accused
travelling from one city to the next over a 12 hour period leaving a trail of death
and destruction in his wake. His actions culminated in eight charges: wounding
two women with intent to cause grievous bodily harm, one count of murder,
discharging a firearm with intent to cause grievous bodily harm, two counts of
using a f irearm against police, kidnapping and aggravated robbery. The
proceedings at which I was present were a retrial due to various legal reasons to do
with the judge’s summation in the first trial that took place four years earlier. I
observed the retrial over six weeks beginning the week of Monday 23 June and
ending 31 J uly 2008. The defence put forth several defences one of which was
insanity.
In short, the prosecution’s narrative was that the accused was in control of his
actions the day of the incidents from start to finish. He may have been affected by
his use of pure methamphetamine, or ‘P’ as it is colloquially known, but he still
knew what he was doing and therefore had knowledge of the moral wrongfulness
of his actions. They also accepted that while he may have a severely disordered
personality with symptoms that may have been exacerbated by his use of P, this
was not considered a mental illness and did not affect his ability to reason morally
nor can it be considered a disease of the mind.
The defence, on the other hand, argued that the accused suffered from the
serious mental illness that could be considered a d isease of the mind on top of a
severe personality disorder. The accused’s use of P was also argued to have
seriously affected his ability to form intent and realise the moral wrongfulness of
the situations he faced. His lack of personal responsibility was attributed to the fact
that he was not in control of his actions but rather driven by delusions, severe
paranoia and suspicion. His childhood, which involved physical and sexual abuse
coupled with intense religious coaching, ‘never gave him a chance.’ 6 The jury was
asked the day of the defence’s closing to give him that chance.
As suggested earlier an overriding theme was the idea that the accused was
feigning his symptoms in order to receive a verdict of not guilty by reason of
Katey Thom 85
__________________________________________________________________
insanity. From the first psychiatric report shortly after the incidents the idea of
possible malingering of symptoms had been indicated. This was intensified by the
fact that the accused did not allow for the prosecution’s psychiatric experts to
interview him for the purposes of their evaluative report; a rare occurrence, indeed
none of the experts who testified had ever come across this situation before. Even
rarer was the fact that the accused testified in the retrial allowing for an insight into
his understandings of events which culminated in the charges laid before him. This
added to the view that some of the psychiatric experts held - and the public at large
- that he was acting or feigning his symptoms. So on top of the methamphetamine
use, personality disorder and malingering, and their relationship to constructions of
mad or bad, were additional issues that added to the complex picture but which I
cannot go into here.
4. The ‘Experts’
The case involved five psychiatric experts giving evidence. The defence
employed a general psychiatrist who worked in acute mental health services and
two other well experienced and respected forensic psychiatrists (although one of
these did not give an opinion as to whether X met the criteria for insanity). The
prosecution employed two well renowned forensic psychiatrists, something that
may have been of great influence to the outcome of the juries’ decision but which
cannot be considered in great length at this time.
In short the two prosecution experts explained that their opinion was that the
accused had a severely disordered personality that made him prone to violence and
aggression, paranoia, grandiosity, narcissism and neediness. They argued that this
was not a mental illness and therefore not a d isease of the mind (while using the
DSM-IV in court to explain these traits that comprise a personality disorder). His
personality, however, made him vulnerable to the effects of P - that affect the
central nervous system and create a sense of euphoria, heightened sense of energy
and hyperactivity - which the prosecution argued was no different to an angry and
violent man who ‘perhaps after a few drinks, gets paranoid and angry that his wife
may be unfaithful and attacks her and beats her up.’ 7 In this way, P exacerbated
that which characterised X’s severely disordered personality making him
increasingly paranoid, self centred and violent. They gave examples where the
accused believed that he had bugs under his skin, that everyone driving a
Commodore, a F alcon or wearing a moustache was a p oliceman. One of the
forensic psychiatrists described how the methamphetamine acted as a dis-inhibitor
that took the brakes off the accused’s ability to maintain self control. So although
what he did and said leading up to and throughout the incidents seemed to be
attributed to some sort of ‘madness’, the prosecution argued that this sort of
behaviour is exactly what the Police and psychiatrists routinely see in heavy
methamphetamine users.
__________________________________________________________________
The first defence psychiatrist opined that accused had a mental illness that
involved psychotic symptoms and mood symptoms which predated his use of
methamphetamine. His conclusion was that the accused was ‘suffering from
harmful use of methamphetamine, rather than methamphetamine induced
intoxication’ that ‘aggravated or precipitated’ his mental disorder called ‘schizo-
effective disorder’: a combination of mood, emotions and schizophrenia-like
symptoms source. 8 He accepted that the accused also had a s evere personality
disorder that involved a propensity towards violence and aggression, paranoia, low
temper threshold, grandiosity associated with narcissism, impulsivity, and possible
religious delusions. It was this psychiatrist’s opinion that the accused suffered from
a disease of the mind. T he second defence psychiatrist argued that the accused
suffered from a p aranoid psychotic illness independent of his severe personality
disorder. Further he explained that the accused’s use of methamphetamine may
have contributed to aggravating his psychotic symptoms but his opinion was that
methamphetamine cannot be the primary explanation. This paranoid psychotic
illness, the psychiatrist concluded, represents a disease of the mind.
Overall, this case illustrates some of the difficult decisions facing New Zealand
courts with the advent in the rise of use of ‘P’ regarding particular states of mind -
psychosis - brought about by the use of this drug. One of the questions central to
these debates is whether, psychosis arising from ‘P’ alone would amount to a
disease of the mind? Some of the lawyers I interviewed were of the view that those
who have ingested ‘P’ do s uffer from a disease of the mind and this should be
considered in the courts: ‘I would have to say that I’m a believer that someone, I’m
in the minority, but if someone does take ‘P’ and like Jones, he had to be off the
planet doing what he was doing, but the juries don’t like that sort of defence. No
one likes that sort of defence.’ 9 While other lawyers were against the idea of
alcohol, drugs or other external causes being considered: ‘The reality is alcohol is
the same… Together with increasingly ‘P’, but I there is a tendency to make
criminals say ‘well, it’s all ‘P’s’ fault’ [and] they’ll grab it.’ 10
The forensic psychiatrists I interviewed explained that states of mind induced
by drugs (or what they define as ‘drug induced psychosis’), although more likely to
result in people carrying out dangerous acts, are not considered to result in a
finding of insanity: ‘… amphetamines, speed and P… can induce such states and
can make it more likely for people to do dangerous things. In general these people
are not deemed by the court to be insane even though they may have some of the
symptoms because it was a self induced state… .’ 11
As discussed above, this notion appears to have been confirmed in the trial I
observed. The judge’s summing up to the jury emphasised that disease of the mind
does not include a ‘temporary mental disorder caused by some factor external to
the accused such as the taking of drugs.’ 12 However, what was more accepted by
the court was the idea that someone who had been recognised by a psychiatrist to
have a mental illness that predated the use of drugs and with this use of drugs may
Katey Thom 87
__________________________________________________________________
have exacerbated the symptoms of this illness may be considered to have a disease
of the mind. The psychiatric expert witnesses in the case of X all agreed with this
proposition but differed in their opinion as to whether X had a mental illness or
whether he only had a severe personality disorder (which they all agreed would not
constitute a disease of the mind).
5. Some Conclusions
What resulted in the trial of X was a classic case involving conflicting expert
evidence around what constitutes a d isease of mind when the internal/external
distinction become murky. The psychiatric expert witness on the one hand, must
give evidence regarding the accused’s mental state within the constraints of the
legal system using legal language which often emphasises dualisms over
multiplicity, as one forensic psychiatrist explained:
... so someone might have mental illness and drug misuse, but
one, or the other, or neither might be related to their offending
behaviour ... [In these cases] The issue of mutual exclusivity
comes up and I have been involved in situations where it is
almost as if it was either ‘this’ or ‘that’. Things can become over
distorted into a simplified, for instance, a dichotomy – is it is this
or this? So these are the sorts of issues come up. 13
Unlike other experts, however, they may give opinion on matters which may
appear to be in the vicinity of law and the jury. Various commentators have
critiqued this aspect of psychiatric testimony arguing that legal rules are applied
inconsistently by the courts when it c omes to insanity defence cases allowing
psychiatrists to give expert opinion as to the ultimate issue of the case. This was
also discussed in my interviews with forensic psychiatrists who discussed their
experiences or trying to refrain from matters they thought were for the jury to
decide:
If there are psychiatrists on both sides ... then I think that is

unfortunate and it usually results in this issue of stepping outside
of the science into the realm of the law. Where experts stick to
the science they are almost always in complete agreement. You
will find … I think this subtle distinction as to whether the person
may have a drug induced psychosis or an exacerbation of a
mental illness … usually psychiatrists will agree about those
things where they will tend to disagree is whether this is a disease
of the mind, which is a legal test and not one which they learnt
about at medical school. Hence it is not surprising, perhaps, that
they disagree. 14
__________________________________________________________________
In practice however, psychiatric expert witnesses almost always talk to the
ultimate issue, even if in a round bout way. The legal professionals I interviewed
seemed to acknowledge this:
In the case of insanity, yes they do [give opinion as to the

ultimate issues] and the courts have long allowed experts to do
that… The ultimate issue… It’s artificial to prevent the
psychiatrist addressing the ultimate issue when he can’t really
give that opinion without addressing the ultimate issue. 15
This may reflect the fact that while I was conducting the interviews with
lawyers the Evidence Act 2006 was enacted which stipulates that the expert
evidence is not necessarily excluded simply because it expresses an opinion on an
ultimate issue. 16 The new Act abolished the ultimate issue rule and replaced it with
the ‘substantial help test’ meaning that to be admissible, expert opinion must
substantially assist the jury or judge in determining material facts.
But what his quote also illustrates is what researchers on law-science relations
have been arguing for years that law demands facts to be separated from values,
with experts being used to maintain this divide by offering evidence based on
scientific facts. In cases involving contested psychiatric evidence, the impossibility
of the distinction is made explicit offering an invaluable space to investigate the
messy and impossible practice of separating facts from values when deciding who
is insane or not insane, mad or bad; discussions over the internal/external ‘causes’
when methamphetamine is involved is one illustration of this point. As Wynne has
suggested, critics have always
... wrestled with the unacknowledged problem that any factual

statement about mental states always embodies interpretation,
which inevitably implies evaluation of responsibility. It has
proved impossible to make statements about mental condition
which do not imply something about moral responsibility. 17
The question of insanity, to conclude, is a moral and legal one – not a matter of
‘discovering the facts’ of the case: legal constructions of insanity cannot operate
outside of a moral framework.
Notes
1
D. Peoples & J. Peoples, 12 Monkeys, Original Screenplay, 1995.
2
S. Jasanoff, Science at the Bar: Law, Science, and Technology in America,
Harvard University Press, Cambridge, MA, 1995; R. Smith, ‘Forensic Pathology,
Katey Thom 89
__________________________________________________________________
Scientific Expertise, and the Criminal Law’, Expert Evidence: Interpreting Science
in the Law, R. Smith and B. Wynne (eds), Routledge, London and New York,
1989; S.M. Solomon, and E.J. Hackett, ‘Setting Boundaries between Science and
Law: Lessons from Daubert v. Merrell Dow Pharmaceuticals, Inc.’, Science,
Technology, & Human Values, Vol. 21 (2), 1996, pp. 131-56.
3
‘R v Cottle’, NZLR, 1958, p. 1011.
4
F.B. Adams, Adams on Criminal Law, [online text accessed 7 O ctober 2008],
Thomson Brookers, Wellington, New Zealand, 2008.
5
Interview with forensic psychiatrist #8, 2006.
6
Case of ‘X’, Notes of evidence, July 2008.
7
Ibid.
8
Ibid.
9
Interview with defence lawyer #11, 2007.
10
Interview with defence lawyer #12, 2007.
11
12
Case of ‘X’, notes of evidence, July 2008.
13
14
15
Interview with prosecution lawyer #8, 2007.
16
Cross on Evidence (NZ), Evidence Act 2006 [online text accessed 7 October
2007], Lexis Nexis Ltd, Wellington, New Zealand, 2007.
17
B. Wynne, ‘Establishing the Rules of Law: Constructing Expert Authority’,
Smith and Wynne (eds), op. cit.
Bibliography
Adams, F.B., Adams on Criminal Law [online text], Thomson Brookers,
Wellington, New Zealand, 2008.
Crimes Act of 1961.
Cross on Evidence, Evidence Act 2006 [online text], Lexis Nexis Ltd, Wellington,
New Zealand, 2007.
Edmond, G., ‘Azaria’s Accessories: The Social (Legal Scientific) Construction of

the Chamberlains’ Guilt and Innocence’. Melbourne University Law Review. Vol.
22, 1998, pp. 396-441.
__________________________________________________________________
—, ‘Science in Court: Negotiating the Meaning of a “Scientific” Experiment

during a Murder Trial and Some Limits to Legal Deconstruction for the Public
Understanding of Law and Science’. Sydney Law Review. Vol. 20, 1998, pp. 361-
401.
—, ‘The Law-Set: The Legal-Scientific Production of Medical Propriety’. Science,

Technology, and Human Values. Vol. 26, 2001, pp. 191-226.
—, ‘After Objectivity: Expert Evidence and Procedural Reform’. Sydney Law

Review. Vol. 25, 2003, pp. 131-163.
Jasanoff, S., Science at the Bar: Law, Science, and Technology in America.
Harvard University Press, Cambridge, MA, 1995.
Lynch, M., ‘The Discursive Production of Uncertainty: The OJ Simpson “Dream

Team” and the Sociology of Knowledge Machine’. Social Studies of Science. Vol.
28(5-6), 1998, pp. 829-868.
Lynch, M. and Jasanoff, S., ‘Contested Identities: Science, Law and Forensic
Practice’. Social Studies of Science. Vol. 28 (5-6), 1998, pp. 675-686.
Nader, L., ‘Anthropological Inquiry into Boundaries, Power and Knowledge’.

Naked Science: Anthropological Inquiry into Boundaries, Power, and Knowledge.
Nader, L. (ed), Routledge, New York and London, 1996.
R v Cottle., NZLR (999: CA), 1958, p. 1000.
Smith, R., ‘The Trials of Forensic Science’. Science as Culture. Vol. 4, 1988, pp.
71-94.
—, ‘Forensic Pathology, Scientific Expertise, and the Criminal Law’. Expert

Evidence: Interpreting Science in the Law, Routledge, London and New York,
1989.
Smith, R. & Wynne, B., ‘Introduction’. Expert Evidence: Interpreting Science in

the Law. Smith, R. & Wynne, B. (eds), Routledge, London and New York, 1989.
Solomon, S.M. and Hackett, E.J., ‘Setting Boundaries between Science and Law:
Lessons from Daubert v. Merrell Dow Pharmaceuticals, Inc.’. Science,
Technology, & Human Values. Vol. 21, 1996, pp. 131-56.
Katey Thom 91
__________________________________________________________________
Wynne, B., ‘Establishing the Rules of Law: Constructing Expert Authority’. Expert
Evidence: Intepreting Science in Law. Routledge, London and New York, 1989.
Katey Thom is a PhD candidate and assistant research fellow at the University of
Auckland. Her research and writing is focused on issues relating to mental health
law and mental health services in New Zealand.
State-Made Madness: Official Knowledge, (Anti)Stigma and the
Work of the Mental Health Commission of Canada
Kimberley White
Abstract
In this chapter I interrogate both the nature and broader social/cultural effects of
state knowledges of ‘mental illness’ through an analysis of the objectives and
organization of the Mental Health Commission of Canada (MHCC). In particular, I
examine the form, content and meaning of a national anti-stigma/discrimination
campaign recently launched by the MHCC to ‘correct’ public misperceptions about
‘those living with mental illness.’ This interdisciplinary study of the MHCC
highlights the very powerful ways in which official knowledges shape, and are
shaped by, broader cultural and historical representations of madness, insanity,
mental disorder and/or mental illness. The political rhetoric of the MHCC clearly
seeks to promote a social justice mandate - to bring those living with mental illness
‘out of the shadows’ and into full citizenship. I argue, however, that in adopting a
strict corporate governance model to identify specific problem sites, involve
stakeholders and create targeted cost/time/resource efficient solutions, initiatives
such as the anti-stigma campaign are more likely to affirm than destabilize the
dominant representation of madness as a disease, and of mental illness as a national
(social, political and economic) problem.
Key Words: Anti-discrimination, anti-stigma, knowledge, madness, mental

illness/health, narrative, representation.
*****
1. Introduction
The creation of a permanent Mental Health Commission of Canada was first
proposed by the Standing Senate Committee in November 2005, and was
reaffirmed in May 2006, when the Committee tabled its final report titled, Out of
the Shadows at Last - Transforming Mental Health, Mental Illness and Addiction
Services in Canada, also known as The Kirby Report. 1 The current Conservative
Government announced funding for the MHCC in its March 2007 budget, setting a
10-year mandate. The organization and working model of the MHCC is in keeping
with a strict corporate/economic model. It is registered as a corporation and draws
heavily on marketing frameworks designed to identify specific targeted
objectives/goals, to develop and initiate specific plans to meet those goals, and to
establish success indicators in order to effectively measure and evaluate the
impact/outcome of targeted projects and initiatives.
In this chapter I interrogate both the nature and broader social/cultural effects
of state knowledges of ‘mental illness’ through an analysis of the objectives and
94 State-Made Madness
__________________________________________________________________
organization of the Mental Health Commission of Canada (MHCC). In particular, I
examine the form, content and meaning of a national anti-stigma/discrimination
campaign recently launched by the MHCC to ‘correct’ public misperceptions about
‘those living with mental illness.’ This interdisciplinary study of the MHCC
highlights the very powerful ways in which official knowledges shape, and are
shaped by, broader cultural and historical representations of madness, insanity,
mental disorder and/or mental illness.
The well-publicized agenda of the MHCC clearly seeks to inspire and promote
a grass-roots, social justice movement - to bring those living with mental illness
‘out of the shadows’ and into full citizenship. However, in adopting a strict
corporate governance model to identify specific problem sites, involve
stakeholders and create ‘targeted’ cost/time/resource efficient solutions, initiatives
such as the anti-stigma campaign are more likely to affirm than destabilize the
dominant representation of mental illness as a d angerous and pervasive social
problem in Canada. For instance, in a plan to target discrimination in schools and
the workplace, the anti-stigma campaign brings together dominant scientific and
social scientific knowledges about the cause/nature of mental illness with political
and economic concerns of national health, productivity, citizenship and work. As
several scholarly accounts of the history of madness have shown (Menzies,
Reaume, Foucault), these alignments produce a certain moral knowledge about the
potential social and economic dangers of ‘unmanaged’ mad people. Here I will
demonstrate some of the ways in which the corporate model forces a particular set
of administrative structures that strictly manage the production of mental
health/illness knowledge within, and beyond, the MHCC.
2. Mandate of the MHCC

From the evidence gathered by the Standing Senate Committee, and
summarized in the Kirby Report, three ‘key initiatives’ were established in the
terms of reference as priorities for the new MHCC:
1. A National Service Strategy. This national strategy aims

to develop a unifying vision, and to encourage the adoption of
Canadian and international best practices. The Commission will
work with provincial governments to ensure a national mental
health strategy that is practical and useful and that will benefit
people living with mental illness throughout the country.
2. A Knowledge Exchange Centre. The Commission will

create an internet-based, pan-Canadian knowledge exchange
centre to allow governments, service providers, researchers and
the general public to access evidence-based information about
mental health and mental illness.
Kimberley White 95
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3. Anti-Stigma Campaign. This national 10-year campaign is
aimed at eliminating stigma, reducing discrimination, and
changing public attitudes toward mental illness. All goals are
‘recovery’ focused and messages are intended to inspire hope
and promote wellness. The approach is to develop a carefully
targeted, outcomes-oriented strategic plan based on the best
available research that can be evaluated over time to measure its
effectiveness.
So from the start, the official discourse of mental illness, reified through the
mandate of the MHCC, is constituted in such a way as to privilege particular
representations of madness as illness, and of mental illness as a social problem. In
order to identify and ameliorate the problems associated with mental illness, the
Commission is thus charged with the task of prioritizing and laying claim to certain
knowledges (regarding causes, effects and solutions) as best knowledges.
This seemingly tidy, focused, linear model, the business model, when applied
to the profoundly complex issue of mental illness, is especially perplexing. Not
only does it simply not ‘fit’ somehow with the remarkably untidy, non-linear
socio-legal history of madness (broadly defined), or mental illness (more
specifically) as a cultural phenomenon, but it may also in fact serve to set back,
rather than move forward, many of the more ideological transformations intended
by the MHCC to create an unstoppable grass-roots social movement that will
positively change the lives of those living with mental illness. My point here is
simply that the well-intended (if not very deep or creative), liberal social justice
mandate of the MHCC is significantly undone by its remarkably conservative
corporatization, and in particular by its adamant reliance on social marketing
strategies to get the work done. This is especially evident in the emerging plans for
the national anti-stigma campaign.
While there is much unpacking to be done of the work of the MHCC in general,
and of the anti-stigma campaign in particular, I am developing several converging
lines of analysis that will explore the anti-stigma project as and expressed
empirical project (working toward practical, evidence-based, demonstrable
solutions), and at its base, a colonial exercise (privileging dominant notions of
universality/standardization, progress, science, reason, order, economics and
citizenship/identity). In the remainder of this chapter, I would like to at least begin
to explore the processes and implications of these early stages of gathering,
organizing, producing and disseminating state-sanctioned knowledges on mental
illness in and though a corporate structure. Focusing on the anti-stigma campaign,
I highlight some of the discursive, symbolic and performative aspects of the target
- as a marketing concept, as a s ocial practice, and as a lived experience. In
particular I would like to demonstrate how the MHCC’s commitment to social
marketing technologies, prescribed through a co rporate administrative structure,
__________________________________________________________________
pushes into the spotlight several ongoing socio-legal and historical tensions related
to representations of citizenship, identity and humanness of those identified as
mad/mentally ill. In other words, in adopted a largely ahistorical - and arguably
apolitical - approach (not recognizing or reconciling past/present role of the state
and state institutions in the subjugation, oppression and violence against mad
peoples) the MHCC will be limited in its ability to affect deep social change.
3. Target Practice: Marks of Citizenship and the Marketing of Anti-Stigma

Mad peoples have endured a l ong history as ‘marked’ individuals: targets of
discrimination, attack, exclusion, violence and oppression. Identified as a blemish
on society, a diseased population and subject to numerous social, medical and
institutional regimes intended to help, hide and fix those afflicted. The symbolic,
discursive and performative function of the target in the anti-stigma work of the
MHCC can be seen operating on several different levels and has the effect of
reinforcing, rather than destabilize, dominant representations of madness as a
social problem in Canada and mad peoples as non-citizens. I argue here that the
social marketing model that has been fully and firmly embraced by the MHCC
may, in effect, prevent more progressive and inclusive models of citizenship and
social justice that the Commission claims to be moving toward, and that watchers
and critics of the MHCC are hoping for.
The anti-stigma campaign is spearheaded by the Commission’s Director of
Information Services and communications specialist. 2 In his role as Director of
Information Services, he is responsible for all official communications from the
MHCC to the public. This includes unifying, synthesizing and projecting the
Commission’s profile, as well for helping to formulate and focus the key messages
of the Commission to targeted populations and stakeholder communities.
In September 2007, a research consultant hired by the MHCC produced a report
titled ‘A Time for Action: Tackling Stigma and Discrimination.’ 3 The centre of the
cover of the report displays an image of a bull’s-eye, or target, with three arrows
(perhaps representing the three key initiatives) stuck into the highest-scoring
middle ring indicating a succession of well-played, precision shots. This is a
winning sign - the confluence of accurate measure, honed skill, and focused
attention directed toward hitting a central, clearly marked, target. The target has
become (at least temporarily) the emblem (mark) of the anti-stigma project. It is
reproduced in the bottom right corner of every page of the report, as well as on the
executive summary report and ‘Strategic Business Plan’ released in March 2007.
There is some (not much) social science evidence that calls into question the
social impact and economic justification of anti-stigma campaigns - and in
particular campaigns focused on education and awareness. There has also been
some sharp criticism from media/communications scholars regarding theoretical
and methodological gaps in anti-stigma research. At best, it seems, we don’t know
4
for certain if anti-stigma campaigns work. We also don’t seem to know how to
Kimberley White 97
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effectively measure whether or not they work. And there is a d ecided lack of
consensus on precisely what work it is that we expect anti-stigma campaigns to do.
Nevertheless, a r eview was made of the social science literature in conjunction
with consultations with key expert informants and a summary of findings and
recommendations was provided to the Commission.
The overarching theme of recommendations to come out of the report - which
seems in part to be a cautionary way to move the Commission’s anti-stigma agenda
forward in relative empirical darkness around the impact and effectiveness of anti-
stigma campaigns - is that the MHCC will need to narrow its focus, establish clear
measurable goals, and target efforts toward particular group deemed most likely to
ensure ‘successes.’ As the author of the report put it: ‘The more targeted the
intervention the more likely the success.’ 5 To further help fill the knowledge void,
the Commission is advised to design the general work and specific projects of the
anti-stigma campaign in such a way as to produce the very knowledge that is
missing, but is also seen as necessary to justify the Commission’s expenditure and
to legitimize its profile as a ‘social movement.’ We need to evidence the nature and
direction of the ‘movement.’ Here I draw on a few of the 10 recommendations
made to the Commission in the ‘A Time for Action’ report as a way to flag some
of the concerns I have about ideological and practical implications of this work as
it is designed and articulated through specific organizational knowledges and a
marketing framework, paying particular attention to potential meanings and effects
of the various practices of targeting. 6
Based on the knowledge brought to the Board of Directors in the background
report, the Commission is currently working on how to best deliver its ‘key anti-
stigma messages’ to the public. They are advised to:
1. Create (amongst themselves) and communicate (to the public) a cl ear,

unified vision and to establish clear goals as the priority of the Commission:
Messages need to convey a s imple and enduring vision, which positions
consumers/service users (not survivors) as leaders; which encourages contact with
individuals living with mental illness as the best proven method to eliminate fear
associated with stigma; which promotes wellness and recovery and prevention as
the unifying goals; and which inspires hope and empathy in all communities.
2. The Commission is also advised to encourage and ‘convey a shared

understanding amongst mental health leaders’: Conveying a shared understanding
and a shared message is necessary from a marketing perspective. While there is
wide agreement within the Commissions that stigma is a problem, as I have already
indicated, there is lack of agreement about how it o ught to be tackled. In the
context of this campaign, the unifying goal and message (that which is currently
understood to unite consumers, families, service providers and policy makers) is
‘recovery’ - although, as the report indicates, there is ‘no universal understanding
__________________________________________________________________
of what that means, how it is accomplished and measured.’ (A new research
project and lit r eview is now underway to inform the Commission on what
recovery means, and how it is best measured.)
These ambiguities create a r eal problem from a marketing perspective, and
needs to be addresses - quickly - by ‘creating’ a shared understanding of these
important elements; by developing key messages regarding stigma, discrimination,
wellness and recovery; and by communicating this decided ‘shared’ understanding
broadly. Drawing on simple critical mass theory, the Executive is thus ‘encouraged
to work closely with those who are [already] in alignment with its vision and goals,
build momentum and bring others along by demonstrating an early record of
success.
3. To ensure an early record of success, the MHCC is advised to ‘build a

culture of research’ and to ‘create benchmarks and success indicators at the front
end to align with the Commission’s vision and stated goals.’ (This is the kind of
research most of us have been taught not to do….) ‘Make your benchmarks and
success indicators action oriented. Make what you measure matter.’ The
Commission is told to ‘make measures media worthy by sharing survey findings
with the public’ in order to foster interest, support and legitimacy for the
organization.
4. The Commission is advised to position and ‘engage consumer/users in a

leadership role.’ The general use of ‘consume/user’ in official discourse, rather
than ‘survivor/consumer’ here is very important- politically and symbolically. The
language around what to call the peoples being ‘helped’ by the commission has
been a little contentious, but primarily just around the use of ‘consumer’ and even
then only quietly. The Commission has, in its official capacity, rejected the more
political identities of ‘mad’ and ‘survivor.’ This tension forces to the surface
several unsettled and unsettling issues around the cultural identity and citizenship
of individuals identified as ‘mentally ill’ - arguably the most widely accepted and
most stigmatizing identity out there.
This indicates an official rejection on the part of the MHCC to the anti-colonial
resistance of mad peoples and survivors to be recognized as self-determined, to
locate themselves in culture, to reclaim their histories and assert a p olitics of
identity that reflect their experiences, as mad or as survivor/consumers. The
identity of survivor, as I’m sure most reading this will understand, reflects one’s
experiences of systemic, institutional, and psychiatric survival, not one who has
survived the suffering of a mental illness. And consumer is intended to reflect a
self-directed choice to actively engage the system, not simply as a
recipient/customer of services. The Commission, thus far, refuses to acknowledge
the explicitly political identity of survivor, and has recast the ‘consumer’ identity
to fit its marketing model: as customers of services.
Kimberley White 99
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5. One of the key marketing goals of the anti-stigma campaign is to promote the
Commission as a catalyst for change. The Commission is encouraged to use the
‘skill and expertise of social marketing to develop the profile of the Commission to
the community and [key] stakeholders.’ ‘Use the power of personal contact and
story telling to put a human face on mental illness and communicate the shared
goals and challenges the Commission will take on. Bring together the brightest,
most creative and best minds to help us catch the attention of the community and
engage them as partners in change. Convene an expert panel… to guide the
MHCC’s message development.’ Dare I say it will likely be experts on madness
and not mad experts who will be engaged here.
The focus on humanness comes up at several points throughout the report. 7
There is a suggestion to promote human stories and shared experiences with
messages of help, recovery, wellness, and hope. The aim here is to dispel myths of
difference, danger, incompetence and impulsivity, by portraying those with mental
illness as normal, as human. There has been some debate about the particular
effectiveness of using celebrity faces vs. the faces of ordinary mentally ill people,
but generally they seem to want recognizable faces. Faces that reflect a cer tain
measure of success and citizenship – the recovered, employed, educated, well-
managed, well-groomed, well-behaved, socially/legally-responsible citizen.
The strategy is in large to establish certain degrees of sameness/universality,
predictability, rationality, order and control, in order to abate fear and stigma. To
transform public perceptions not by moving it toward inclusion and respect for
difference, but by showing that ‘they’ are just like ‘us’ and so there is nothing to
fear. It is not clear how this exemplification of mad (or formerly mad) people who
appear and behave ‘normal’- possessing all the key marks, not of madness, but of
full citizenship - will dispel the myths and negative attitudes reinforced through
extreme representations of mad peoples in pop culture, or through the realities of
those mad peoples who do not present - by choice or by circumstance - the marks
of full citizenship.
The recommendations of the consultant have now been adopted into the
working Business Plan of the MHCC under the project title: ‘Stigma and
Discrimination Reduction: Communications and Marketing Perspectives.’ At the
January 2008 Board meeting, The Director of the National Mental Health Strategy
for the MHCC delivered a presentation on the goals to move ‘From Planning to
Action.’ (The PowerPoint document from this presentation is posted on the MHCC
website). The plan is for a ‘multi-faceted, targeted approach’ where interventions
and messages are specifically tailored to each audience. The focus will be on
educational activities, promoting contact with people with a l ived experience of
mental health problems, and challenging discriminatory policies and practices.
Based on the research, the Commission will utilize contact opportunities to
‘target’ the hearts and minds of the public, to normalize, to inspire hope, to
challenge myths, and to change behaviour. These (for now) are the dominant
__________________________________________________________________
messages of the MHCC to be translated into series of strategic projects. Currently,
eight advisory committees are working on 24 di fferent projects to support the
Commission’s key initiatives. The targeted areas include children and youth, the
workforce, service systems, mental health and the law, seniors, science, and First
Nations, Inuit and Métis communities.
Simon Cross and others have done a good job of problematising the tendency
of anti-stigma initiatives to focus on ‘normalizing’ through deconstructing the ‘us-
them’ binary as a way to understand and address stigma/discrimination, as well as
initiatives set up to dispel ‘myths’ about mental illness trough positive, ‘accurate’
messaging. Most notably absent from the plan is an explicit anti-discrimination
program, which would help establish the campaign not as a marketing initiative,
but as a human rights initiative. Perhaps a shift in official discourse away from the
rather dated concepts of deviance and stigma, toward the more progressive
concepts of human rights and discrimination, would send a more meaningful
message to the Canadian public. But of course, this first requires a full recognition
of humanness.
4. Concluding Thoughts
Inquiries into the nature, meaning and problematics of madness and the mad,
broadly defined, can be traced through the writing, research and work of
philosophers, artists, historians, lawyers and legal scholars, medical experts,
humanists, social scientists, politicians, mad people and social reformers, dating
back centuries. More recently, however, public knowledge of issues related to
‘mental illness’ and ‘mental health’ in Canada has been in large part constituted
and organized through the mandates and administrative structures of state-
sanctioned public inquiries, special committees and commissions.
The MHCC is fiscally accountable to the Canadian Government, and thus its
value and legitimacy, as a corporation, is determined through evidence of sound
business planning, economic frugality and indications of ‘success.’ The
Commission is thus required to provide clear and justifiable rationale regarding
how its objectives are identified and prioritized; how those objectives and priorities
can be operationalised as a strategic business plan; how evaluative measures, such
as benchmarks and success indicators are to be established; and ultimately how
outcomes are measured and interpreted. This way of organizing knowledge and
identifying problems related to mental illness - through political structures and
official discourses of mental health/illness - necessarily requires the negotiation of
certain kinds of knowledge as more legitimate than others. We ought to be
concerned here about the meaning and effects of the Commission’s targeted
initiatives, and we ought to be theorizing the larger cultural effects of these
processes. What, if any, will be the effects the MHCC on the lives and lived
experiences of mad people? Or, perhaps more profoundly, on how we will come to
see (imagine, represent, resist, express and experience) and not see madness.
Kimberley White 101
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Notes
1
By permanent, I mean that the MHCC is not intended to be an ad hoc special
committee or a royal commission of inquiry, both of which would have a more
limited mandate and usually a single organized working committee. Board and
committee members of MHCC are expected to complete a three-year term before
being replaced or renewed. Background information on the appointment of the
MHCC and its Board of Directors can be found at: http://www.mentalhealthcom
mission.ca/.
2
Michael Pietrus’ biographical information from the MHCC website includes the
following:
• Michael is a highly skilled communications professional with more than 20
years of leadership experience in planning, strategy, project development and
implementation, and team building.
• Michael has been a t rusted advisor to senior executives and has earned a
reputation for producing innovative projects and solutions.
• Most recently, he helped develop and launch the world’s first daily broadband
television internet news service for the energy industry.
• As Director of Communications for the Alberta Mental Health Board
(AMHB), he generated communications plans and strategies, which raised the
public profile of the AMHB and its programs.
• At the same time, Michael was instrumental in cultivating relationships with
community groups, government agencies and the media, which helped the
Board achieve its goals. He also worked in a similar role for the Government
of Ontario.
See http://www.mentalhealthcommission.ca/executive.html, for brief biographical
information on other MHCC Board members.
3
M. Neasa & V. Johnston, ‘A Time for Action: Tackling Stigma and
Discrimination’, Report to the Mental Health Commission of Canada, Sept, 2007.
Retrieved from http://www.mentalhealthcommission.ca/keyinitiatives.html.
4
H. Stephen, ‘Media, Madness and Misrepresentation: Critical Reflections on
Anti-Stigma Discourse’, European Journal of Communication, 2005, pp. 460-483;
and C. Simon, ‘Visualizing Madness: Mental Illness and Public Representation’,
Television & New Media, Vol. 5(3), 2004, pp. 197-216.
5
‘A Time for Action’, p. 18.
6
Ibid., pp. 36-39.
7
Our long history of imagining mad people as non-human and non-citizens
(Foucault, Szasz…) is reflected in the report through some of the suggestions
coming from an online survey set up by the consultants, and from consultation with
key ‘expert informants’ who suggest that the Commission, in its multi-media anti-
__________________________________________________________________
stigma campaign, needs to work hard to put a ‘human’ face on mental illness. Ibid.,
p. 21.
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460-483.
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Clinic. University of Toronto Press, Toronto, 1989.
–––, ‘The Making of Criminal Insanity in British Columbia: Granby Farrant and
the Provincial Mental Home, Colquitz, 1919-1933’. Essays in the History of
Criminal Law Volume 6. University of Toronto Press, Toronto, 1999.
Standing Senate Committee on Social Affairs, Science and Technology, Out of the
Shadows at Last: Transforming Mental Health, Mental Illness and Addiction
Services in Canada. May 2006, Viewed on 24 June 2009, http://www.parl.gc.ca/
39/1/parlbus/commbus/senate/com-e/soci-e/rep-e/rep02may06-e.htm.
Kimberley White is Associate Professor of Law and Society at York University,

Toronto, Canada. Her current research is focused on narratives of legal
responsibility, cultural representations of madness and the production of
knowledge.
PART III
Madness, Philosophy, History and Language

Madness-Group Feelings in the Presocratics’ Fragments
Robert Zaborowski
Abstract
The remaining fragments of the presocratic philosophers contain several words
related to particular feelings. In general twelve groups can be distinguished, among
them the group of various nouns and verbs denoting madness in its different
aspects. They are: kakophradmosune, enthousiadzein, aluein, apoplexie,
aphrosune, mania, moria. In the light of this vocabulary, madness can be
considered as a complex phenomenon, stratified on different both bodily and
psychic levels. On the basic level madness means the lack of coordination,
incapacity for distinction, and is understood as an opposition to wisdom. On the
contrary, madness on the highest level is related to philosophy and designates the
inspired wisdom. Its character is universal and definitive. Taking all these elements
together one can distinguish: excitment, passion, frenzy, insanity, obsession,
inspiration, enthusiasm. The chapter also discusses the causes, effects and objects
of madness as presented in the fragments of the Presocratics, its relation to values
and to other feelings and psychic phenomena, its dynamics and, finally, its essence.
The main feature of madness, common to all these levels seems to be the strenght
or, more exactly the intensification of what is felt.
Key Words: Different psychic levels, enthusiasm, folly, inspiration, madness,

passion, Presocratics.
*****
1. Introduction
Madness is among about 12 m ajor groups of particular feelings I had
discriminated in the remaining fragments of Presocratic philosophers. Others are:
joy, sadness, fear, depression, desire, anger, worry (concern), shame, courage,
hatred, friendship.
This is a study based on the vocabulary of philosophers, however it is quite
possible to speak about madness without using the word denoting madness. But
this is rather the case of non-philosophical authors, for example, of poets. They
describe human behaviour including feelings in terms of several images, mainly, of
bodily changes such as screaming, weeping, contraction, groaning, laments,
palpitation, pallor, etc.
In the presented chapter I will consider only these contexts in which madness is
mentioned verbatim. Secondly, in order to present these data mainly fragments B
from Diels-Kranz edition (DK) will be taken into consideration.
All in all we find 7 words (or families), which are: mania, aphrosune,
enthousiadzein, moria, plus three hapax legomena: aluein, apoplexie and
106 Madness-Group Feelings in the Presocratics’ Fragments
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kakophradmosune. In sum there are 27 occurrences. That means that madness is
more frequently attested in Presocratics than, for example, depression and shame
but less than for example joy and courage.
2. Mania
The most frequent, and perhaps the best known from the cultural point of view,
is: μαίνεσθαι, μανία, μανικός. (LSJ for μανία: ‘madness [...] enthusiasm, inspired
frenzy, but for μαίνεσθαι: rage, be furious.’)
From the very first Presocratic mania is associated with divinity, like in two
fragments of Heraclitus:
εἰ μὴ γὰρ Διονύσωι πομπὴν ἐποιοῦντο καὶ ὕμνεον ἆισμα

αἰδοίοισιν, ἀναιδέστατα εἴργαστ’ ἄν· ὡυτὸς δὲ Ἀίδης καὶ Διόνυσος,
ὅτεωι μαίνονται καὶ ληναΐζουσιν. (DK 22 B 15, transl. Burnet: For
if it were not to Dionysos that they made a procession and sang the
shameful phallic hymn, they would be acting most shamelessly. But
Hades is the same as Dionysos in whose honour they go mad and
keep the feast of the winevat.)
and:
Σίβυλλα δὲ μαινομένωι στόματι καθ’ Ἡράκλειτον ἀγέλαστα

καὶ ἀκαλλώπιστα καὶ ἀμύριστα φθεγγομένη χιλίων ἐτῶν
ἐξικνεῖται τῆι φωνῆι διὰ τὸν θεόν. (DK 22 B 92, transl. Burnet:
And the Sibyl, with raving lips uttering things solemn,
unadorned, and unembellished, reaches over a t housand years
with her voice because of the god in her.)
In the passage which seems to be of orphic inspiration but which we find in

Plato, madness is akin to a philosopher:
πάντες γὰρ κεκοινωνήκατε τῆς φιλοσόφου [Sokrates] μανίας

τε καὶ βακχείας· διὸ πάντες ἀκούσεσθε ... οἱ δὲ οἰκέται, καὶ εἴ
τις ἄλλος ἐστὶν βέβηλός τε καὶ ἄγροικος, πύλας πάνυ μεγάλας
τοῖς ὠσὶν ἐπίθεσθε. (DK 1 B 7 = Plat. Symp. 218 b, transl.
Jowett: [...] all of you, and I need not say Socrates himself, have
had experience of the same madness and passion in your longing
after wisdom.).
Different background is presented when mania appears as opposite to wisdom.

Robert Zaborowski 107
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Man is not able to experience both simultaneously. Then madness is described as
producing in man the intention of undertaking what is impossible, unlucky,
shameful, an act hurting his friends and helping his enemies. In case of Palamedes
it would lead to betrayal of Greece:
κατηγόρησας δέ μου διὰ τῶν εἰρημένων λόγων δύο τὰ

ἐναντιώτατα, σοφίαν καὶ μανίαν, ὥπερ οὐχ οἷον τε τὸν αὐτὸν
ἄνθρωπον ἔχειν. ὅπου μὲν γάρ με φὴις εἶναι τεχνήεντά τε καὶ
δεινὸν καὶ πόριμον, σοφίαν μου κατηγορεῖς, ὅπου δὲ λέγεις ὡς
προὐδίδουν τὴν Ἑλλάδα, μανίαν· μανία γάρ ἐστιν ἔργοις
ἐπιχειρεῖν ἀδυνάτοις, ἀσυμφόροις, αἰσχροῖς, ἀφ’ ὧν τοὺς μὲν
φίλους βλάψει, τοὺς δ’ ἐχθροὺς ὠφελήσει, τὸν δὲ αὑτοῦ βίον
ἐπονείδιστον καὶ σφαλερὸν καταστήσει. (DK 82 B 11 a , 25,
transl. Freeman: You are accusing me of two opposites, wisdom
and madness: wisdom in that I am crafty, clever, resourceful;
madness in that I wished to betray Greece. It is madness to
attempt what is impossible, disadvantegeous, disgraceful,
injurious to friends and helpful to enemies, and likely to make
one’s life intolerable).
But according to another Sophist, Prodicus, madness becomes love when

redoubled, which, in turn, is a doubled form of desire: ἐπιθυμίαν μὲν
διπλασιασθεῖσαν ἔρωτα εἶναι, ἔρωτα δὲ διπλασιασθέντα μανίαν γίγνεσθαι.
(DK 84 B 7, transl. Freeman: ‘Desire when doubled is love, love when doubled is
madness.’).
There are several fragments in which Presocratic philosophers focus on the
reasons of madness. According to Cleobulus, one of Seven Sages, madness results
from an excess of affectivity displayed to a woman in presence of other people: 16.
γυναικὶ μὴ μάχεσθαι μηδὲ ἄγαν φρονεῖν ἀλλοτρίων παρόντων· τὸ μὲν γὰρ
ἄνοιαν, τὸ δὲ μανίαν δύναται παρέχειν.
In Pythagoreans’ opinion mania, which concerns the movement of the soul,
comes from diversity of man’s food:
ἔτι δὲ σαρκοφαγίαι παντοδαπῆι χρῆσθαι, καὶ ἔργον εἶναι

εὑρεῖν, τίνος οὐ γεύεται τῶν χερσαίων καὶ τῶν πτηνῶν καὶ
τῶν ἐνύδρων ζώιων. καὶ δὴ σκευασίας παντοδαπὰς περὶ ταῦτα
μεμηχανῆσθαι καὶ χυμῶν παντοίας μίξεις· ὅθεν εἰκότως
μανικόν τε καὶ πολύμορφον εἶναι κατὰ τὴν τῆς ψυχῆς κίνησιν
τὸ ἀνθρώπινον φῦλον. (DK 58 D 8, 207)
and the same is said about drinking too much wine first bringing hilarity and after
__________________________________________________________________
that making man mad and ugly:
ἀλλὰ τοὺς ἀνθρώπους τὰ μὲν παραχρῆμα μεγάλης

ἀλλοιώσεως αἴτια γενόμενα συνορᾶν, οἷον καὶ τὸν οἶνον, ὅτι
πλείων προσενεχθεὶς μέχρι μέν τινος ἱλαρωτέρους ποιεῖ,
ἔπειτα μανικωτέρους καὶ ἀσχημονεστέρους· (58 D 8, 208).
According to Gorgias madness (mania) has a t raumatic cause: when one sees
the terrible images, he is affected with incurable madness:
οὕτως ἀπέσβεσε καὶ ἐξήλασεν ὁ φόβος τὸ νόημα. πολλοὶ δὲ

ματαίοις πόνοις καὶ δειναῖς νόσοις καὶ δυσιάτοις μανίαις
περιέπεσον· οὕτως εἰκόνας τῶν ὁρωμένων πραγμάτων ἡ ὄψις
ἐνέγραψεν ἐν τῶι φρονήματι. (DK 82 B 11, 17, transl. Freeman:
People who have seen a frightful sight have been driven out of
their minds, so great is the power of fear; while many have fallen
victims to useless toils, dreadful diseases and incurable insanity,
so vivid are the images of the things seen which vision engraves
on the mind.).
Finally, Thrasymachus speaks generally about madness of some people

produced in situation of evil (however other people’s reasoning is improved by
such an evil):
[...] ἀντὶ δ’ ὁμονοίας εἰς ἔχθραν καὶ ταραχὰς πρὸς ἀλλήλους

ἀφικέσθαι. καὶ τοὺς μὲν ἄλλους τὸ πλῆθος τῶν ἀγαθῶν
ὑβρίζειν τε ποιεῖ καὶ στασιάζειν, ἡμεῖς δὲ μετὰ μὲν τῶν
ἀγαθῶν ἐσωφρονοῦμεν, ἐν δὲ τοῖς κακοῖς ἐμάνημεν, ἃ τοὺς
ἄλλους σωφρονίζειν εἴωθεν. (DK 85 B 1, transl. Freeman: [...]
and that we have sacrified concord for enmity and internal
disturbance. Others are driven to excesses and civil strife through
a surfeit of prosperity; but we behaved soberly in our prosperity.
We were seized with madness at a time of adversity, which
usually makes others act soberly.).
We find also two descriptions of the way madness shows itself. According to
Chilon shaking one’s hand means madness: 18. μηδὲ τὴν χεῖρα κινεῖν· μανικὸν
γάρ.
The other one is a v ery specific description given by Heraclitus: madness
manifests in following behaviour:
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καθαίρονται δ’ ἄλλωι αἵματι μιαινόμενοι οἷον εἴ τις εἰς πηλὸν
ἐμβὰς πηλῶι ἀπονίζοιτο. μαίνεσθαι δ’ ἂν δοκοίη, εἴ τις αὐτὸν
ἀνθρώπων ἐπιφράσαιτο οὕτω ποιέοντα. καὶ τοῖς ἀγάλμασι δὲ
τουτέοισιν εὔχονται, ὁκοῖον εἴ τις δόμοισι λεσχηνεύοιτο, οὔ τι
γινώσκων θεοὺς οὐδ’ ἥρωας οἵτινές εἰσι. (DK 22 B 5, transl.
Freeman: They purify themselves by staining themselves with
other blood, as if one were to step into mud in order to wash off
mud. But a man would be thought mad if any of his fellow-men
should perceive him acting thus.).
Madness may concern the tongue, that is the faculty of speech: ἀλλὰ θεοὶ
τῶν μὲν μανίην ἀποτρέψατε γλώσσης (DK 31 B 3, 1, transl. Burnet: ‘But, O ye
gods, turn aside from my tongue the madness of those men.’).
Among tones some are signs of madness:
καὶ μετὰ Δάμωνος βουλευσόμεθα, τίνες τε ἀνελευθερίας καὶ

ὕβρεως ἢ μανίας καὶ ἄλλης κακίας πρέπουσαι βάσεις, καὶ
τίνας τοῖς ἐναντίοις λειπτέον ῥυθμούς. (DK 37 B 9 = Plato,
Rep. 400, transl. Jowett: Then, I said, we must take Damon into
our counsels; and he will tell us what rhythms are expressive of
meanness, or insolence, or fury [RZ: madness], or other
unworthiness, and what are to be reserved for the expression of
opposite feelings.).
According to Empedocles madness is attributed to hatred: τῶν καὶ ἐγὼ νῦν

εἰμι, φυγὰς θεόθεν καὶ ἀλήτης, νείκεϊ μαινομένωι πίσυνος. (DK B 115, 13-14:
transl. Burnet: ‘One of these I now am, an exile and a wanderer from the gods, for
that I put my trust in insensate [RZ: mad] strife.’) and in a r hetoric passage of
‘Dissoi logoi’ madness is identified with the sane mind (σωφρονοῦντες): ‘ταὐτὰ
τοὶ μαινόμενοι καὶ τοὶ σωφρονοῦντες καὶ τοὶ σοφοὶ καὶ τοὶ ἀμαθεῖς καὶ λέγοντι
καὶ πράσσοντι. (5, 1, cf. also 5, 6; 5, 7; 5, 9).
3. Aphrosune
Besides mania we have another notion: ἀφροσύνη, ἄφρονω, the word being
the negation based on φρήν, a very complex term (root for schizo-phrenia; to take
it etymologically: schizophrenia = ‘divided self’ vs. aphrosyne = ‘lack of self’).
The meaning of aphron is (LSJ): ‘senseless [...] crazed, frantic [...] silly, foolish’
and that of aphrosune: ‘folly, thoughtlessness.’
In an orphic fragment madness is related to unhappiness and is described as the
limitation of human power to recognize the oncoming good and evil:
__________________________________________________________________
ἄφρονες ἄνθρωποι δυστλήμονες <οὔτε κακοῖο ὔμμιν
ἐπ>ερ<χομένου πρ>ογνώμονες οὔτ' ἀγαθοῖο. (DK 1 B 15 a =
Papyr. Berol., col. 6, transl. Freeman: ‘Foolish and wretched
mortals, having foreknowledge neither of the evil nor of the good
in prospect for you!’).
The example mentioned by Epicharmus shows that madness must be something

related to inappropriateness as for instance when a mad man enjoys a good fortune
- it is ridiculous:
ἄφρονος ἀνθρώπου τυχόντα καταγέλαστα γίνεται. (DK 23 B

44 a, transl. Freeman: [...] if they [property, a house, absolute
rule, wealth, strength, beauty] fall to a man of no intelligence
[RZ: a mad man], become ridiculous.).
Its character must be univocal as results from the advice given by Bias to avoid
madness: 6. ἀφροσύνην μὴ προσδέχου. and more precisely from Gorgias’ saying
according to which it can be overcome by force of reason: τῶι φρονίμωι τῆς
γνώμης παύοντες τὸ ἄφρον <τῆς ῥώμης> [...] (DK 82 B 6, transl. Freeman:
‘checking with the prudence of the mind the imprudence of the body [RZ: the
madness] [...]’).
In similar vein, according to Democritus, when bad people receive honours that
they do not deserve, they become insolent and mad:
οἱ κακοὶ ἰόντες ἐς τὰς τιμὰς ὁκόσωι ἂν μᾶλλον ἀνάξιοι ἐόντες

ἴωσι, τοσούτωι μᾶλλον ἀνακηδέες γίγνονται καὶ ἀφροσύνης
καὶ θράσεος πίμπλανται. (DK 68 B 254, transl. Freeman: When
base men enter upon office, the more unworthy they are, the
more neglectful, and they are filled with folly and recklessness.).
In Theagenes’ fragment aphrosune is associated with Ares:
[...] διονομάζοντα τὸ μὲν πῦρ Ἀπόλλωνα καὶ Ἥλιον καὶ

Ἥφαιστον, τὸ δὲ ὕδωρ Ποσειδῶνα καὶ Σκάμανδρον, τὴν δ’ αὖ
σελήνην Ἄρτεμιν, τὸν ἀέρα δὲ Ἥραν καὶ τὰ λοιπά. ὁμοίως
ἔσθ’ ὅτε καὶ ταῖς διαθέσεσιν ὀνόματα θεῶν τιθέναι, τῆι μὲν
φρονήσει τὴν Ἀθηνᾶν, τῆι δ’ ἀφροσύνηι τὸν Ἄρεα, τῆι δ’
ἐπιθυμίαι τὴν Ἀφροδίτην, τῶι λόγωι δὲ τὸν Ἑρμῆν, καὶ
προσοικειοῦσι τούτοις· (DK 8, 2).
__________________________________________________________________
4. Enthousiasmos
The third term denoting madness in Presocratics is: ἔνθεος, ἐνθουσιασμός
(LSJ: ‘full of the god, inspired, possessed’).
Its main feature is well seen in Gorgias where it is an attribute of moral
excellence:
οὗτοι γὰρ ἐκέκτηντο ἔνθεον μὲν τὴν ἀρετήν, ἀνθρώπινον δὲ τὸ

θνητόν [...] (DK 82 B 6, transl. Freeman: For the courage [RZ:
the excellence] these men possessed was divine [RZ: inspired,
mad], and the mortal part (alone) was human.).
Here we may observe the opposition between mortality and excellence,

between what is human and what is mad, that is inspired by god.
It relates also to incantations: αἱ γὰρ ἔνθεοι διὰ λόγων ἐπωιδαὶ ἐπαγωγοὶ
ἡδονῆς, ἀπαγωγοὶ λύπης γίνονται· (DK 82 B 11, 10, transl. Freeman: ‘The
inspired incantations of words can induce pleasure and avert grief [...]’).
It is striking that entheos is, first, a well known term, copied in other languages,
similarly as mania, and, second, also as mania, the value of which is (at least
partly) positive. Thus, two of the terms pertaining to madness used by the
Presocratics more frequently stress its positive feature: that some of types of
madness are divine and creative.
Elsewhere we may observe its association with divinity and enthousiasmos is a
productive madness. For instance, Orpheus inspired by Apollo was able to write
hymns:
ὁ δὲ Μους>ῶν βασιλεὺς Ἀπόλλων τού<τωι ἐπέπνευσεν, ὅθεν>

ἔνθεος γενόμενος <ἐποίησεν τοὺς ὕμνους,> οὓς ὀλίγα
Μουσαῖος ἐπα<νορθώσας κατέγρ>αψεν· (DK 1 B 15 a = 2 B 19
a, Colli (= 4 B 21 = Kern F 49 K) = Papyr. Berol., col. 1, transl.
Freeman: and the Lord of the Muses, Apollo, nodded towards
him so that he became inspired and wrote his Hymns, which to
slight extent Musaeus corrected and wrote down).
And according to Democritus what is ever written by a poet in a state of

enthousiasmos is beautiful:
καὶ ὁ Δ. ὁμοίως ‘ποιητὴς δὲ ἅσσα μὲν ἂν γράφηι μετ’

ἐνθουσιασμοῦ καὶ ἱεροῦ πνεύματος, καλὰ κάρτα ἐστίν ...’ (DK
68 B 18, transl. Freeman: What a poet writes with enthusiasm
and divine inspiration is most beautiful.).
__________________________________________________________________
5. Moria
The last major term is μωρία (LSJ: folly). In Anaxarchus’ fragment it is
opposed to wisdom and associated with the act of speaking in wrong time:
οἳ δὲ ἔξω καιροῦ ῥῆσιν ἀείδουσιν, κἢν πεπνυμένην ἀείδωσιν,

οὐ τιθέμενοι ἐν σοφίηι γνώμην αἰτίην ἔχουσι μωρίης. (DK 72
B 1, transl. Freeman: Those who recite a saying outside the right
time, even if their saying is wise, are reproached with folly,
because they do not mix intelligence with wisdom.).
Similarly in Aristocles’ fragment madness pertains to the act of speaking and

means a false talk (because in fact Lycon, who declares to be a Pythagorician, is
not considered by Aristocles as a P ythagorician): πάντα δ’ ὑπερπαίει μωρίαι τὰ
ὑπὸ Λύκωνος εἰρημένα τοῦ λέγοντος εἶναι Πυθαγορικὸν ἑαυτόν. (DK 57, 4).
In Gorgias madness moria relates to giving credence that someone would make
a wrong choice, for instance chooising slavery instead of authority and the worst
instead of the best: ἀλλά γε ταῦτα πολλῆς μωρίας καὶ πιστεῦσαι καὶ δέξασθαι·
τίς γὰρ ἂν ἕλοιτο δουλείαν ἀντὶ βασιλείας, ἀντὶ τοῦ κρατίστου τὸ κάκιστον;
(DK 82 B 11 a, 14, Freeman omits this passage is her translation).
6. Hapaxes
Three hapaxes remain. The first one is ἀλύειν (LSJ: ‘to be deeply stirred,
excited’). In Empedocles its cause is tormenting evil:
τοιγάρτοι χαλεπῆισιν ἀλύοντες κακότησιν οὔποτε δειλαίων

ἀχέων λωφήσετε θυμόν. (DK 31 B 145, transl. Freeman:
Therefore you are distraught [RZ: in madness (?)] with dire sins,
and shall never ease your heart of your grievous sorrows!).
The second one is ἀποπληξίη (LSJ: ‘madness [...] apoplexy’). The sexual act is
qualified as a mild apoplexy. As Democritus says: ξυνουσίη ἀποπληξίη σμικρή·
(DK 68 B 32, transl. Freeman: ‘Coition is a slight attack of apoplexy.’).
Finally, κακοφραδμοσύνη (LSJ: ‘= κακοφραδία [...] folly’) is madness akin
rather to women than to men: γυνὴ πολλὰ ἀνδρὸς ὀξυτέρη πρὸς
κακοφραδμοσύνην. (DK 68 B 273, transl. Freeman: ‘A woman is far sharper than a
man in malign thoughts [RZ: madness].’)
7. Conclusion
Now, to conclude my chapter, I will offer some general observations.
The first, the most important and the most obvious is that since the very first
Greek philosophers two, quite different types of madness were recognized - the
__________________________________________________________________
distinction that will be carried on by Plato and explicitly stated by him in his
Phaedrus. As Plato says there:
διότι δὴ ὁ μὲν μαίνεται, ὁ δὲ σωφρονεῖ. εἰ μὲν γὰρ ἦν ἁπλοῦν

τὸ μανίαν κακὸν εἶναι, καλῶς ἂν ἐλέγετο· νῦν δὲ τὰ μέγιστα
τῶν ἀγαθῶν ἡμῖν γίγνεται διὰ μανίας, θείᾳ μέντοι δόσει
διδομένης. (244 a 5, transl. Fowler: [...] because the lover is
insane, and the other sane. For if it were a s imple fact that
insanity is an evil, the saying would be true; but in reality the
greatest of blessings come to us through madness, when it is sent
as a gift of the gods.)
Of course, this is to be taken literally. That is: the greatest of blessings come to
us through madness, but it d oes not mean that: every madness does produce a
great blessing. This is the right point. And we must not forget the second
condition: it happens only when madness is sent by gods.
Thus this twofold character of madness or rather two kind of madness, hence
two madnesses, taken in term of their definitions, are following: the first one is
more than wisdom or a short-way, shortcut to wisdom, while the second one seems
to be less than ignorance or stupidity. While the ignorance is lack of knowledge,
madness is a negative knowledge - some construction relying on or even refering
to contradiction: to deny what is evident, to belief what is impossible, to engage
what is obviously false, to behave in a contradicted way.
The fragments of the Presocratics confirm that on the one hand madness is to
be identified with wisdom and moral excellence, but on the other it is contrary to
them. It could be said perhaps that if ignorance is opposite to knowledge, madness
is its negative (as in photography). That’s why madness as such is a paradox: it is
more profound than wisdom, and more profound than stupidity. In order to solve
this paradox we have to distinguish two facets of madness.
On a more detailed plan it is worth underlining the following aspects of the
issue:
- some 10 authors out of 90 in DK edition are involved and it

should be stressed that among them there are the first as well
the last Presocratics, so the conclusions are valid for the whole
historical period,
- the reasons of madness are: physiological (mania),
constitutional (kakophradmosune: rather woman’s than man’s
madness), behavioural (apoplexy), psychological (mania) or
spiritual (mania, enthousiasmos),
- its effects are: wrong or excellent choice, shameful or perfect
act,
__________________________________________________________________
- which objects does it embrace? the most general it is what
seems impossible, rare or difficult, inappropriate: in bad sense
(inappropriateness of place, time, purpose, behaviour,
circumstances, merit) or in good sense (novelty of wisdom and
of moral excellence), madness is what is out of the ordinary,
madness both takes sense away from what is sensible and gives
sense to what seems senseless,
- madness manifests itself strongly, in speaking (false or inspired
talk) and in acting, in all cases it exteriorizes,
- the behaviour or attitude recommanded is to be avoided or to be
hoped,
- concerning its value, it c an be positive (enthousiasmos),
negative (aphrosune, moria, aluein, kakophradmosune), or
both (e. g. mania), thus we have two poles and the middle
which links them,
- different deities are involved: Sibyl and Dionysos (mania),
Ares (aphrosune) and Apollo (enthousiasmos),
- madness is related to both hatred and love.
It appears that if madness has to be analyzed as such, it is necessary to take it

into account as a dynamic phenomena and to distinguish its different levels,
namely:
- craziness (mania): betrayal, opposition of wisdom (moria) or

lack of wisdom (aphrosune),
- religious madness,
- poetical madness (enthousiasmos) - inspiration,
- philosophical madness (mania) - passion.
This being so, madness seems to be a border-feeling because it covers the

extremities of human conduct and human condition. It not only reaches the
boundaries but obviously goes beyond them.
Bibliography
Burnet, J., Early Greek Philosophy. 2nd ed., Adam and Charles Black, London,
1908, 4th ed., 1930.
Colli, G., La sapienza greca. Vol. 1, Adelphi Edizioni, Milano, 1977.
Diels, H. & Kranz, W., Die Fragmente der Vorsokratiker. Vols. 1–3, Weidmann,
Berlin, 1951 (quoted as DK).
__________________________________________________________________
Freeman, K., Ancilla to the Pre–Socratic Philosophers. Basil Blackwell, Oxford,

1948.
Liddell, H.G., Scott, R. & Jones, H.S., A Greek–English Lexicon with a

Supplement. Clarendon Press, Oxford, 9th ed., 1940 (quoted as LSJ).
Plato, Phaedrus. transl. Fowler, H.N., Harvard University Press/William Heinemann

Ltd, Cambridge MA / London, 1925.
Plato, The Dialogues of Plato. 4th ed., transl. Jowett, B., Clarendon Press, Oxford,
1953.
Zaborowski, R., Sur le sentiment chez les Présocratiques. Contribution

psychologique à la philosophie des sentiments. STAKROOS, Warszawa, 2008.
Robert Zaborowski is professor of Ancient Greek philosophy at University of

Warmia and Mazury, Olsztyn. His interest is in philosophy and psychology of
feelings.
Religious Insanity and the Limits of Religious Tolerance in
Nineteenth-Century America
Loren A. Broc
Abstract
Excessive zeal or obsessive spiritual introspection in matters of religion were
commonly thought to be causes of insanity in the United States during much of the
nineteenth century, and cases of mental derangement attributed to those causes
were labelled ‘religious insanity.’ In the antebellum era the small group of
physicians in charge of insane asylums shared a set of values concerning personal
responsibility and behavior which they used as criteria to evaluate what they
considered to be acceptable religious belief and practice. They publicly condemned
religious movements that did not meet their criteria, especially ‘new measures’
revivals and Millerism. As the psychiatric profession matured in the United States
during the latter half of the century, it played down the importance of religion as a
cause of insanity, but nonetheless continued to judge and condemn religious
movements such as spiritualism and Christian Science according to criteria based
on the ideology of scientific positivism.
Key Words: Asylum physicians, Christian Science, Millerism, new measures

revivals, spiritualism, religious insanity.
*****
1. Religious Insanity
Throughout the nineteenth century a sizeable number of individuals in the
United States were committed to insane asylums for a kind of mental disorder
known as ‘religious insanity.’ The term refers to a d iagnostic category used by
asylum physicians based on the assumption that certain religious beliefs or
practices, when carried to extremes, could trigger attacks of insanity in persons
already predisposed to mental illness because of heredity, disease, or poor
childhood upbringing. An analysis of the patient records and annual reports of
American asylums shows that increases in religious insanity admissions were
coincident with the rise of certain movements in American religious history; in
particular, the new measures revivals of the Second Great Awakening, the
millenarian Millerite movement, spiritualism, and Christian Science. These
movements troubled the emerging psychiatric profession because they threatened
some of its core values and assumptions and appeared to endanger the mental
health and moral character of the population. Asylum physicians responded to
these perceived threats by wielding their system of values as a s tandard to
distinguish between genuine and spurious religious experience. By doing so they in
118 Religious Insanity and the Limits of Religious Tolerance
__________________________________________________________________
effect tried to limit the kinds of religious experimentation and innovation they
believed were appropriate for American society.1
The notion that some religious beliefs and practices might lead to insanity was
rooted in early nineteenth-century psychiatric theory, an amalgam of the
associationism of John Locke, the faculty psychology of the Scottish Common
Sense school of moral philosophy, and certain tenets of Protestant theology.2 Early
psychiatrists conceived of the human personality as being made up of various
physiological and mental capacities or ‘faculties’ arranged in a hierarchy: the
‘mechanical’ faculties of involuntary reflex actions, the ‘animal’ faculties of the
emotions and desires, and the ‘rational’ faculties of reason and conscience. They
regarded human beings as having both spiritual and material natures, and equated
the mind with the immortal soul of Christian theology. The rational faculties of the
mind were a divine endowment bestowed on human beings alone, which enabled
them to master themselves and their environment and to discern the divinely
ordained moral and spiritual truths which governed the natural world. Insanity was
therefore an especially grievous disorder because it subverted the rational faculties,
obscured the essential human qualities of individuals, and rendered them incapable
of fulfilling their roles and duties in society. According to early psychiatric theory
insanity was a physical disease in which either an excessive flow of blood or an
irritation of the nervous system injured the brain and thereby disrupted the proper
functioning of the mind. Asylum physicians recognized a wide variety of physical
causes that could produce this outcome, such as acute and chronic diseases, injuries
to the head, exposure to noxious chemicals, congenital deformations, and the
infirmities of old age. But they also placed equal weight on what they called
‘moral’ or psychological factors that could affect the brain adversely. In general,
they believed that any event or practice that provoked acute and prolonged
emotional stress in individuals was a potential danger to their mental health. So,
for example, physicians regarded events such as business failures, the death of
relatives, abusive family relationships, disappointment in love, and such practices
as novel reading, excessive study, and sexual immorality as potential causes of
insanity. Indeed, an article in the American Journal of Insanity in 1852 l isted 93
physical and 88 moral causes of insanity ‘reported in the several hospitals of the
United States and Great Britain.’3
Asylum physicians recognized two different kinds of religious insanity, each
with distinct symptoms. ‘Religious anxiety’ referred to insanity caused by spiritual
introspection carried to an obsessive and morbid extreme. I ndividuals who
suffered from this disorder were convinced they were inveterate sinners unworthy
of divine grace and feared they would be consigned to eternal punishment after
death. In extreme cases such spiritual despair and fear could drive individuals to
suicide. ‘Religious excitement,’ on the other hand, referred to a state of spiritual
euphoria in which individuals were convinced they had received special divine
communications and powers. Such individuals were commonly distracted by
Loren A. Broc 119
__________________________________________________________________
supernatural visions and esoteric knowledge received in trance states, and often
insisted they were charged with divine missions to proclaim the spiritual truths
vouchsafed to them.
Asylum physicians of the early nineteenth century were in an especially
influential position, for they were first American medical practitioners to organize
a professional group, the Association of Medical Superintendents of American
Asylums for the Insane, and to establish a p rofessional journal, the American
Journal of Insanity, both founded in 1844. They were therefore able to establish
themselves as the only reputable experts on the subject of mental health, and
dominated the development of American psychiatric theory and practice for much
of the nineteenth century. They used their authority and their institutional resources
not only to educate the public about the causes, treatment, and prevention of
insanity but also to promote a system of values which they considered essential to
the preservation of American society. In the first place, they constantly urged the
necessity for the rational faculties to be always in control over the lower animal
passions of the individual. Asylum physicians had a great distrust, even fear, of any
emotion or desire that was allowed unchecked and prolonged expression, for such
excesses in individuals could threaten the integrity of their personalities and, in
groups, could undermine the order and stability of society. It followed, therefore,
as a second value that men and women had a responsibility to themselves and to
society to maintain their emotional self-control; that is, to use their rational
faculties not necessarily to suppress their emotions and desires but to maintain a
judicious balance among them and thereby enable themselves to function
effectively in their environments. Finally, asylum physicians proclaimed the
constant moral improvement of individuals and society. They were convinced that,
given a favorable environment, human character could be changed and improved,
and therefore it was necessary to inculcate and strengthen the ideals of self-control
and moral responsibility in all members of society, and especially in its weaker
members, such as children, criminals, the insane, and the destitute.4 Dr. Samuel
White, superintendent of a private asylum in New York, summarized this
prescriptive attitude in an address to the New York State Medical Society in 1844:
Education, based upon moral discipline restraining violent

emotions and passions, bringing the will under due
subordination; placing suitable guards on the extremes of hope
and disappointment, will go far to lessen the moral, and physical
causes of Insanity.5
By aggressively promoting these values in their professional writings asylum

physicians presented themselves not only as medical experts but also as social
critics. They applied their system of values as a standard to judge whether events
and trends in American society promoted sound mental health and moral character,
__________________________________________________________________
and often found that society did not measure up to their standard. They warned
against injurious aspects of American society such as indulgent child rearing
practices, the feverish pace of everyday life, and the national competitive striving
for financial gain and social advancement, all of which they regarded as symptoms
of a dangerous lack of character and self-discipline in the population.
2. ‘New Measures’ Revivals and Millerism

Asylum physicians were especially concerned about the condition of religion in
the United States, for they regarded Protestant Christianity as the primary
institution for promoting moral character and social stability. They had much to be
worried about on this matter, for the early period of asylum building in the United
States during the first half of the nineteenth century coincided with a period of
intense religious revivalism and experimentation throughout the country known as
the Second Great Awakening. During this period the traditional leadership role and
high social standing of the learned Protestant clergy were challenged by self-
appointed religious leaders who arose from among the laity, and a wide variety of
new denominations, sects, and interdenominational religious and benevolent
movements were founded.6
Two of the most controversial of these religious movements were the so-called
‘new measures’ revivalism and the Millerite movement. New measures religious
revivals involved the use of a v ariety of techniques for the immediate mass
conversion of large numbers of individuals at a single event. Those techniques
were deliberately designed to stir up the fears of eternal punishment in revival
audiences and to put intense psychological pressure on them to surrender
themselves without delay to the regenerating influence of the divine spirit.7 The
Millerite movement, based on the interpretation of biblical prophesies by the
Baptist preacher William Miller, used new measures techniques in its own
proselytizing campaigns and added a new spiritual fear of its own, for it
proclaimed that the final judgment of humanity would occur on a specific date in
October of 1843. New measures and Millerite revival meetings produced
uninhibited and often startling behavior among their participants, such as
uncontrollable sobbing, shouting, and convulsive fits, or falling prostrate in trance-
like states. Such behavior shocked and outraged many, but proponents of the
revivals claimed that it was evidence of the divine spirit sanctifying the souls of
those affected, and insisted that their measures were necessary to shock people out
of their spiritual complacency.8
Asylum physicians condemned these movements on both psychological and
religious grounds. They charged, first, that the emotional stress of such revivals
could cause insanity, and that any religious movement that produced such an effect
could not be authentic Christianity. Secondly, they put forward their own standard
of ‘pure’ Christianity, which they insisted prevented rather than incited insanity. In
essence, early American psychiatrists established criteria for valid religious
Loren A. Broc 121
__________________________________________________________________
experience, and, by condemning any form of religious expression that failed to
meet their criteria, tried to set a limit on religious innovation in American society.
To demonstrate that revivals could cause insanity asylum physicians pointed to
the statistics in their annual reports, which showed that during the 1830s and 1840s
between 5% and 10% of new asylum admissions each year were attributed to
religious insanity triggered by attendance at new measures or Millerite revivals.
They also published illustrative cases of religious insanity among their patients, as
a warning against the consequences of participating in those movements.9 On the
other hand, asylum physicians maintained that the Christian religion, when
properly taught and understood, strengthened the rational faculties and improved
the moral character of individuals. ‘The genuine principles of Christianity have no
tendency to distract the mind;’ wrote Samuel Woodward of the Worcester State
Asylum in his annual report for 1836, ‘on the contrary, they are directly calculated
to calm and allay the feelings when excited, and to encourage and give hope to the
depressed and desponding.’10 Genuine Christianity was therefore the best
preventive against insanity and the best means of human improvement, as
Woodward wrote in a later report:
Christianity is a rational system of religion ... it commends itself

to the higher and nobler faculties of man. Whatever animal
feeling is exhibited in connection with it, is but the dross which is
to be separated as useless and debasing ...11
During the middle decades of the nineteenth century changes in the intellectual
and religious climate in the United States brought about changes in the
philosophical foundations of asylum psychiatry and a re-examination of the
supposed causal relationship between religion and insanity. The psychiatric
profession was influenced by advances in the knowledge of human anatomy and
physiology, the spread of the theory of evolution as an explanation for biological
change, and the failure of the early psychological therapies to effect permanent
cures of insanity. These developments led a new generation of asylum physicians
to recognize the intractability of mental illness and to place more emphasis on its
presumed somatic causes, and especially on the role of heredity in transmitting
insanity across generations. At the same time religious worship in the United States
was influenced by Victorian ideals of decorum, propriety, and sentimentality.
Revivals in general became more routinised and orderly; the emotionalism of new
measures revivals was toned down in the major denominations and survived
mainly among small holiness sects in rural areas.12
These developments are reflected in changes of emphasis and subject matter in
the professional writings of asylum physicians in the latter half of the nineteenth
century. The influence of Protestant theology on psychiatric theory diminished and
was replaced by the ideology of scientific positivism. Some asylum physicians
__________________________________________________________________
came to regard religious anxiety and excitement as symptoms of more general and
deep-seated psychological dysfunctions, rather than as causes of mental illness in
their own right. The psychiatric profession in general began to concentrate more of
its attention on purely medical matters and less on larger social issues, and asylum
physicians devoted more time and effort to their role as medical practitioners and
less to their former role as critics of the moral character of American society.
3. Spiritualism and Christian Science

Yet these changes in the psychiatric profession were introduced only gradually,
and coexisted with vestiges of earlier thought and practice. This is especially
evident in the matter of religious insanity, for even as the profession as a whole
was beginning to doubt its validity as a diagnostic category of mental illness many
asylum physicians still continued to list it in their annual reports as an immediate
cause of insanity. Because of the changes in psychiatric thought and revival
practices mentioned above, the number of new cases attributed to religious insanity
declined in the latter half of the nineteenth century, but never vanished entirely
(Figure 1 illustrates this trend in the admission statistics of the Worcester State
Hospital in Massachusetts). Furthermore, asylum physicians did not abandon their
evaluation of the validity of certain religious beliefs and practices, but rather
changed the basis of their evaluation. They continued to define limits to acceptable
religious innovation, as shown by their criticism of two movements that became
prominent in the latter half of the nineteenth century, spiritualism and Christian
Science.
Figure 1: New Cases of Religious Insanity and Spiritualism
Worcester State Hospital, Massachusetts, 1833-1900
30
25
20
15
10
0
1833 '43 '53 '63 '73 '83 '93
Religious Insanity includes cases of "anxiety," "excitement," and "Millerism"
new cases religious insanity new cases spiritualism
Spiritualism arose and spread quickly in the United States in the 1850s. The
core of its belief was the existence of a supernatural world populated by the spirits
of the dead. Spiritualists believed that this world could be accessed by individuals,
known as mediums, who had a special capacity while in a trance state to enable
spirits to communicate knowledge of the afterlife through physical means, such as
knocking sounds, the movement of material objects, and the production of writings
and drawings. In an age when the medical profession had no effective cure for
most diseases and the death of family members and friends at an early age was a
common experience, the messages communicated at spiritualist séances brought
Loren A. Broc 123
__________________________________________________________________
comfort to many persons and seemed to confirm the reality of the Christian
doctrine of life after death. Opponents of spiritualism, however, denigrated it as a
fraud perpetrated on the credulous and condemned it as heretical to orthodox
Christian belief.
Asylum physicians unanimously opposed spiritualism and regarded it as a
separate category of religious insanity. They reported it separately in their annual
reports (see Figure 1) and in their professional writings questioned its validity as a
genuine religious movement. Their criticism, however, was not based on the failure
of spiritualism to meet some ideal standard of Christian belief and practice, as was
their opposition to earlier revivals. Instead, they objected to spiritualism because it
denied the major assumption of their positivistic ideology that scientific
explanations based on empirical investigation alone were sufficient to account for
all objects and events in the natural world. They treated spiritualism as a popular
delusion and rejected its claims of supernatural knowledge. In their public writings
asylum physicians seldom compared spiritualism to Christianity directly, but
implicit in their criticism of spiritualism was the argument that it tr ivialized the
divine aspect of the supernatural. Spiritualism made the divine appear to be subject
to purely human manipulation and to produce effects that contradicted the laws of
the natural world established by empirical science. Hence, they asserted that any
movement claiming to produce supernatural phenomena that could also be
produced by naturalistic means could not be a g enuine religious movement. A
lengthy article on spiritualism in the American Journal of Insanity in 1861
concluded that the supposed supernatural manifestations at séances were the result
of ‘hypnotism, fraud, and delusion,’ that the communications received through
mediums contained ‘nothing that might not emanate from the brain of the
medium,’ and that the ‘lofty pretensions’ of spiritualist leaders ‘cannot for a
moment be sustained in the face of criticism.’13
The psychiatric profession responded to the rise of Christian Science in the last
two decades of the nineteenth century in the same way as it had to spiritualism. In
1875 Mary Baker Eddy published Science and Health with Key to the Scriptures,
which became the doctrinal foundation of the Christian Science church, and as it
gained adherents the church became controversial because of its teachings
concerning the nature of reality and healing. Professing an extreme form of
philosophical idealism, the church maintained that all reality consisted of divine
spirit, that the reality of physical matter was an illusion, and that disease could be
healed by ridding the mind of its mistaken belief in material existence and
contemplating the true spiritual nature of reality. Only a handful of new insanity
cases in the late nineteenth century were attributed to Christian Science, but
asylum physicians were called upon as witnesses in civil litigation cases to
evaluate the beliefs and practices of the church.14 In their testimony in such cases
they did not evaluate Christian Science in comparison to Christianity, but rather in
comparison to their professional ideology of scientific positivism. They considered
__________________________________________________________________
the new church’s idealism to be a false understanding of reality which could easily
promote delusional thinking and endanger the mental and physical health of its
adherents. The court cases involving Christian Science illustrate an important
distinction that must be made to achieve an accurate understanding of how the
concept of religious insanity was used as a diagnostic category. An examination of
nineteenth century medical records and professional literature shows that
individuals were not placed in asylums simply because they were adherents of
unconventional religious movements. Rather, patients who were diagnosed with
religious insanity were committed to asylums because their families, friends, and
physicians determined that the patients’ religious beliefs and practices inhibited
their ability to manage their personal affairs (as, for example, in the Christian
Science cases the disposition of their estates) to their own advantage, and to
function effectively as responsible autonomous individuals in a society that valued
initiative and competitive enterprise in its members. In making that determination
the American psychiatric profession in nineteenth century used its institutional
authority to declare invalid any religious experience that did not accord with its
own value system.
Notes
1
The concept of religious insanity was well established in the United States in the
early nineteenth century, having been current in both Anglo-American medical
opinion and popular belief since the seventeenth century, when the English
physician Robert Burton first identified religious melancholy in his book The
Anatomy of Melancholy (1621) as a malady common among Puritan ‘precisians.’
The concept was reinforced in the British colonies of North America during the
emotional religious revivals of the First Great Awakening in the mid eighteenth
century.
2
For a full presentation of early American psychiatric through see N. Dain,
Concepts of Insanity in the United States, 1789-1865, Rutgers University Press,
New Brunswick, NJ, 1964.
3
J.P. Gray, ‘On the Supposed Increase in Insanity,’ American Journal of Insanity,
Vol. 8, April 1852, pp. 351-352.
4
This system of values was not exclusive to asylum physicians, but rather was
consistent with the conservative political and social ideology of the Whig party in
antebellum America. See, for example, D.W. Howe, The Political Culture of the
American Whigs, The University of Chicago Press, Chicago, IL, 1979, pp. 23-42.
5
S. White, ‘Annual Address Delivered before the Medical Society of the State of
New York, Feb. 7, 1844,’ Transactions of the New York State Medical Society,
Vol. VI, p. 9.
6
N.O. Hatch, The Democratization of American Christianity, Yale University
Press, New Haven, CT, 1989, pp. 3-46.
Loren A. Broc 125
__________________________________________________________________
7
The new measures techniques included the careful organization of prolonged
outdoor and indoor gatherings filled with fiery sermons and feverish prayer
sessions and hymn singing. Some techniques offended the norms of public
propriety, such as allowing women to pray aloud and testify in mixed company,
praying for the conversion of specific individuals by name, giving free rein to
emotional expression, and moving doubters and waverers to specially placed
‘anxious benches’ where the entire assembly could identify, exhort, and pray over
them. Descriptions of new measures revivals are contained in A. Brigham,
Observations on the Influence of Religion upon the Health and Physical Welfare of
Mankind, Marsh, Capen & Lyon, 1835, pp. 228-236, and A. Taves, Fits, Trances,
and Visions: Experiencing Religion and Explaining Experience from Wesley to
James, Princeton University Press, Princeton, NJ, 1999, pp. 76-155.
8
C.G. Finney, Lectures on Revivals of Religion, W.G. McLoughlin (ed), The
Belknap Press of Harvard University Press, Cambridge, MA, 1960, pp. 9-10.
9
See, for example, American Journal of Insanity, Vol. 1, January 1845, p. 248;
State Lunatic Hospital at Worcester, Tenth Annual Report, 1842, p. 68.
10
State Lunatic Hospital at Worcester, Fourth Annual Report, 1836, p. 160.
11
State Lunatic Hospital at Worcester, Eleventh Annual Report, 1843, p. 53.
12
For nineteenth-century developments in the American psychiatric profession, see
G.N. Grob, The State and the Mentally Ill: A History of the Worcester State
Hospital in Massachusetts, 1830-1920, University of North Carolina Press, Chapel
Hill, NC, 1966; Mental Institutions in America: Social Policy to 1875, The Free
Press, New York, 1973; and The Mad Among Us: A History of the Care of
America’s Mentally Ill, The Free Press, New York, 1994. F or developments in
American revival practices, see W.G. McLoughlin, Jr., Modern Revivalism:
Charles Grandison Finney to Billy Graham, Ronald Press, New York, 1959.
13
‘The Marvellous,’ American Journal of Insanity, Vol. 18, July 1861, pp. 17-29
& 30-42.
14
For example, between 1880 and 1900 three asylums in Massachusetts, the state
mental hospitals at Worcester and Taunton and the private McLean Asylum near
Boston, each recorded only one new case of insanity attributed to belief in
Christian Science. For contemporary accounts of psychiatrists testifying as expert
witnesses against Christian Science, see ‘Christian Science an Insane Delusion,’
New York Times, February 19, 1901, and ‘Christian Science a Cause of Insanity,’
New York Times, January 2, 1912.
Bibliography
Brigham, A., Observations on the Influence of Religion upon the Health and
Physical Welfare of Mankind. Marsh, Capen & Lyon, 1835.
__________________________________________________________________
‘Christian Science an Insane Delusion.’ New York Times. February 19, 1901.
‘Christian Science a Cause of Insanity.’ New York Times. January 2, 1912.
Dain, N., Concepts of Insanity in the United States, 1789-1865. Rutgers University
Press, New Brunswick, NJ, 1964.
Finney, C.G., Lectures on Revivals of Religion. McLoughlin, W.G. Jr., (ed), The
Belknap Press of Harvard University Press, Cambridge, MA, 1960.
Gray, J.P., ‘On the Supposed Increase in Insanity.’ American Journal of Insanity.
Vol. 8, April 1852, pp. 351-352.
Grob, G.N., The State and the Mentally Ill: A History of the Worcester State
Hospital in Massachusetts, 1830-1920. University of North Carolina Press, Chapel
Hill, NC, 1966.
–––, Mental Institutions in America: Social Policy to 1875. The Free Press, New
York, 1973.
–––, The Mad Among Us: A History of the Care of America’s Mentally Ill. The
Free Press, 1994.
Hatch, N.O., The Democratization of American Christianity. Yale University

Press, New Haven, CT, 1989.
Howe, D.W., The Political Culture of the American Whigs. The University of
Chicago Press, Chicago, IL, 1979.
‘The Marvellous.’ American Journal of Insanity. Vol. 18, July 1861, pp. 1-42.
McLoughlin, W.G., Jr., Modern Revivalism: Charles Grandison Finney to Billy

Graham. Ronald Press, New York, 1959.
Taves, A., Fits, Trances, and Visions: Experiencing Religion and Explaining
Experience from Wesley to James. Princeton University Press, NJ, 1999.
State Lunatic Hospital at Worcester, Massachusetts. Fourth Annual Report, 1836.
–––, Tenth Annual Report, 1842.

Loren A. Broc 127
__________________________________________________________________
–––, Eleventh Annual Report, 1843.
White, S., ‘Annual Address Delivered before the Medical Society of the State of
New York, Feb. 7, 1844.’ Transaction of the New York State Medical Society. Vol.
VI, pp. 1-21.
Loren A. Broc is an instructor in American history at the University of Rochester,

New York.
From Jameson to Badiou: Madness and Critical Theory
Alexander Dunst
Abstract
Cultural appropriations of madness play a central role in reformulating individual
agency after World War II and react to a p erceived inadequacy of modern
conceptions of subjectivity. Phrased as the ‘death of the author’ or the ‘end of
man,’ these deconstructions of the subject find their perhaps most radical
expression in discourses of psychopathology. Why did the vocabulary of madness
prove so popular for imagining a subject in crisis? What did psychiatric and
psychoanalytic concepts contribute to the critique of modern subjectivity? What
role, finally, does madness play for thinking about the subject today, considering
widespread announcements of its return? After pointing to the developments that
played a part in the constitution of this discourse in the 1960s and 1970s - from
economic changes to the failure of institutional psychiatry and a renewal of
critiques of Enlightenment rationality - this chapter will read the work of Fredric
Jameson, frequently called today’s most important cultural critic, as representative
of a wider discourse of symptomatology in the humanities and culture at large.
Building on Lacan and Deleuze and Guattari, Jameson from the 1970s to the 1990s
identifies the contemporary subject as constitutively schizophrenic - and thus
places madness at the heart of the human condition. The analysis of his influential
writing on subjectivity will highlight some of the motivations behind cultural
appropriations of psychopathology: from the pessimism of the left after 1968, to
conceptualising the increasing heterogeneity of contemporary society, and, more
specifically, to the expression, on the level of the subject, of what Alain Badiou has
called the ‘20th century’s passion for the real.’ Finally, Jameson’s work of the new
millennium will be read as a contribution to recent debates about a ‘return of the
subject,’ rethinking a politically viable subject that incorporates rather than
dismisses the challenge posed to it by madness.
Key Words: 1960s, Alain Badiou, Critical Theory, Fredric Jameson, Gilles
Deleuze, Jacques Lacan, politics, subjectivity.
*****
If the 1960s were the decade of the so called ‘death of the subject’ in the
humanities, then the last two decades would seem to have seen its return in various
guises: from the turn to biographical fiction, to Foucault and Derrida’s re-
engagement with a subject they had once deconstructed, to interpellations of the
consumer via the I-Pod and MySpace - the subject once more seems at the centre of
contemporary lives, narratives, and philosophical thought. 1
130 From Jameson to Badiou
__________________________________________________________________
But what does all of this have to with madness, you might ask? When we go
back to the declarations of ‘the death of the subject,’ most famously in Foucault’s
prophesy of the imminent disappearance of the transcendental subject of
modernity, what he famously called the ‘death of man,’ and Roland Barthes’ ‘death
of the author,’ we find, in close proximity to these statements, the beginnings of a
certain discourse of madness. 2 After all, it was with a doctoral thesis on paranoia
that Jacques Lacan began his career; with the History of Madness that Foucault
initiated his archaeologies of modernity, and with their celebration of the
schizophrenic subject of capitalism that Gilles Deleuze and Félix Guattari reacted
to the political defeats of 1968. 3
The work of these authors, along with that of Derrida and many others, has
sometimes been grouped under the heading of poststructuralism, itself taken as part
of the broader cultural and economic formation of postmodernism. More to the
point, perhaps, the thought of Lacan, Foucault and Deleuze, in its highly
contextualised reaction against the post-war philosophical establishment in France,
participated in a cultural shift that began after World War II with sociological
theories that posited a loss of individuality in a mass society of giant corporations
and bureaucracy. 4
But why did the vocabulary of madness prove so popular for imagining this
loss of individual agency, this modern subject in crisis? And what, if any role, does
madness play in thinking about the subject today? Let me start by looking at the
first of these two questions in more detail. I will return to the relationship between
the discourse of madness and contemporary theories of subjectivity in my
conclusion.
Perhaps we can separate our initial enquiry about the ‘death of the subject’ and
its formulation in terms of madness into two more precise questions. First, what
were the historical conditions that made these cultural metaphors, these
popularisations of originally medical terminology, possible? Secondly, once these
historical conditions of possibility were in place, what did the imagination of an
experience of madness contribute to the critique of modern subjectivity?
I will start by trying to provide brief, necessarily incomplete and tentative
answers to the first question. It seems possible to point to at least four coordinates
that play a part in this emerging discourse.
(1) First, as a somewhat earlier discursive pre-condition, the widespread
influence of psychoanalysis on mid-century thought and the establishment of a
psychoanalytically influenced popular psychology in the 1940s and 1950s as an
explanatory model for human behaviour.
This, in turn, provides the groundwork for the convergence of three distinct
developments in the 1960s and 1970s:
(2) The economic shift in the West from Fordism to Post-Fordism, and thus the
emergence of what is variously, and with differing connotations, called
postmodernism, globalisation, or neoliberalism.
Alexander Dunst 131
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(3) The failures and reforms of institutional psychiatry, expressed and
popularized in the anti-psychiatry movement and the counterculture of the time.
(4) Finally, the re-evaluation and renewal of a critique of Enlightenment
rationality emerging in certain strands of European philosophy.
Yet, each taken on its own, these historical developments are simply pre-
conditions and might not be able to sufficiently explain the broad and consistent
appeal of a discourse of madness for explorations of post-World War II
subjectivity. One clue as to a p ossible answer might, then, lie in the relation
between the discourse of the death of man, and a discourse of madness.
At a first glance, this discourse of madness could be understood as a less radical
version of diagnoses of the death of the subject. The subject might have fallen ill,
and its capacity to act may have been reduced in the process, but it has not, at least
not yet, ceased to exist. In Lacan’s early theory of psychosis, for instance, the
psychotic lacks control over linguistic structure: he is adrift, without any quilting
points, as Lacan calls them, that would connect the web of signifiers to meaning. 5
But the problem with defining this mad subject as an earlier, or less radical,
version of the subject’s demise is that no direct line runs from the pronouncements
of illness to death. The mad of Foucault’s History of Madness are not identical
with the figure of man soon to be erased, like ‘a face drawn in sand at the edge of
the sea’ in The Order of Things. 6 Lacan, first and foremost a practising
psychoanalyst, will know better than to declare the ‘death’ of his patients, or even
to deny their capacity to change and to act. Deleuze, for his part, abandoned the
metaphor of transindividual schizophrenia in the 1970s after witnessing the havoc
wreaked by those years on the mental health of some of his students. 7
Perhaps it is thus better to say that the mad subject allowed French philosophy
of the 1960s and 1970s to continue speaking about a subject after it had dethroned
it. No longer the origin of knowledge and centre of perception, the subject hangs
on, much diminished in ability and importance, as a by-product of discourse. But
something elementary is missing here. No doubt the mad subject as imagined by
Foucault and Deleuze, was one whose ascribed characteristics of illness and
reduced agency could be ideologically reversed in their work. But another
character trait, as it were, was common to their work: the mad were positioned at a
remove from society, the loss of social bonds meant they inhabited a shadowy
outside.
The German critic Peter Bürger has suggestively described the literary
imagination of this outside as a ‘miming’ of madness. For Bürger, however, this
outside necessarily remains inaccessible. Its literary representation invents, he
writes, ‘equivalents of this other experience.’ 8 But why would the imagination of
something that remains inaccessible so vehemently capture not only these writers’
but also our attention? Why does Foucault rewrite the history of mental illness to
insist on the opening to another world that a medieval imagination detected in the
ravings of the mad? 9 Why does Lacan speak of psychosis as the edge of man’s
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freedom, and Deleuze and Guattari place their political hopes on the
schizophrenic? 10
Of course, we can hold that what Bürger sees as the inaccessible experience of
madness simply provides a space for the projection for any number of concepts and
ideals favoured by today’s philosophers: transgression, intensity, freedom, truth.
But while such an explanation holds some interpretative value, it also accords no
role to the experience of madness as such, nor does it explain why it has been this
outside that has proven so popular for imagining the crisis of the modern subject.
A more suggestive answer can be found in Alain Badiou’s recent lectures
collected as The Century. Badiou here attempts to rescue what is meaningful for us
today from the twentieth century. That century, both in the grandeur and the
horrors of its most radical scientific, artistic and political expression - Einstein,
Malevich, and Lenin are some of Badiou’s preferred examples here - was
characterised above all, Badiou holds, by what he calls the ‘passion for the real.’ 11
But while this Lacanian real remains an outside in that it is not a positive space,
not a space man can inhabit, it also constitutes the kernel of our subjective reality.
In fact, as both Lacan and Badiou insist, man only becomes subject in his relation
to this real - in those moments when the coordinates of our reality, of meaning and
understanding, shatter. It is in search of these radical experiences - re-directing us
towards a personal truth that for Badiou evades the traps of discursive knowledge -
that the writers I have spoken about here would seem to have taken recourse to the
experience of madness throughout the century.
We will briefly return to Badiou’s thought in the conclusion, but I would now
like to focus on a critic and theorist who perhaps more than anyone else can
provide a perspective on the development of a cultural discourse of madness from
the 1960s to the present. This will lead us, therefore, from the ‘death of the subject’
to its gradual reconstruction in recent thought.
This critic, Fredric Jameson, is perhaps most famous for his description of
postmodernism as the cultural logic of late capitalism. 12 What is less often
remarked upon is that Jameson’s theory of the postmodern present centrally
revolves around an account of the contemporary subject. 13 For Jameson, political
agency in late capitalism is severely weakened, and politics therefore defunct in its
truly radical sense. In the absence of a clearly discernable social base - a feature of
Jameson’s work throughout most of his career - this results in an understanding of
the subject, as the locus of that agency, as equally incapacitated.
So far, this is a s tandard left account of contemporary politics. The reason
Jameson is of interest here is that he consistently expresses this disablement of the
subject in the vocabulary of psychopathology. Jameson names two sources for this
account: Lacan’s early essay ‘On a Question Prior to Any Treatment of Psychosis,’
and, for his work of the 1970s, Deleuze and Guattari’s Anti-Oedipus. 14 In fact,
from the mid-1970s to the mid-1990s - and thus longer than any of the authors
Alexander Dunst 133
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mentioned above - schizophrenia becomes Jameson’s central metaphor for the
status of the contemporary subject.
It is best to understand Jameson as a populariser here. He is less interested in
the subtleties of Lacan’s account of psychosis or in following the route suggested
by the Deleuzian schizophrenic than to diagnose a cultural and political situation.
This is not to say that he misreads Lacan or Deleuze, but rather that his aim is
different: what counts for Jameson is the construction of an emancipatory cultural
politics, and his theory of the postmodern present will from the beginning work
towards the restoration of such a political perspective.
In the title chapter of his Postmodernism, or, the Cultural Logic of Late
Capitalism, Jameson, referring to Lacan’s concept of the signifying chain,
describes a ‘shift in the dynamics of cultural pathology’ that ‘can be characterized
as one in which the alienation of the subject is displaced by the latter’s
fragmentation.’ 15 In Lacan’s early work, the signifying chain as the metonymic
sequence of signs structures experience, and in psychosis the signifying chain
breaks apart. 16 Jameson, in turn, takes this to imply that schizophrenia amounts to
the ‘fragmentation’ of an earlier centred subject - the same subject deconstructed in
French philosophy of the 1960s and 1970s.
Based on this notion of the increasing fragmentation of the subject - a notion
perhaps more in line with popular understandings of schizophrenia than with
Lacan’s elaborate theory of psychosis - he extends that diagnosis in an interview to
describe postmodernism as a situation in which ‘subjects and objects have been
dissolved, hyperspace is the ultimate of the object-pole, intensity the ultimate of
the subject-pole, though we no longer have subjects and objects.’ 17
The extreme pessimism of such a t heoretical position is undeniable. It is a
position, however, that has proven extremely influential and acted as an
intermediary between French philosophy and Anglo-American academia.
Jameson’s work thus helps us to track the historical development of the discourse
of madness. What was, in the France of the 1960s, a highly contextualised attack
on their philosophical predecessors, from Husserlian phenomenology to Sartre’s
existentialism, has, by the 1980s, become a general diagnosis of the times. Where,
in the 1970s, the slogans of the subject’s liberation from its bourgeois straight-
jacket, the hopes invested in Foucault’s and anti-psychiatry’s heroic madman, and
the euphoria of a schizophrenic counter-culture had lived on, these trajectories of
madness had come to a d efinite end by the time of Jameson’s work on
postmodernism.
It is against the background of the violently anti-collective ethos of
Thatcherism and Reaganomics that Jameson imagines the subject at its most
marginalized and most incapable of offering resistance to the powers that be. In his
understanding of the term, the mad subject has finally become one with its death.
This pessimistic portrayal of the subject’s fragmentation and dissolution lies at
the heart of Jameson’s canonical theory of postmodernism. However, this theory
__________________________________________________________________
largely stems from the early and mid-1980s. Much has changed since, not only in
academia, but in the world at large: the fall of communism has allowed capitalism
to become truly global, but it perhaps also allows, slowly and tentatively, for the
construction of new alternatives.
If Jameson accepted so called poststructuralist diagnoses of the demise of the
subject in his work of the 1980s and incorporated them into his Marxist
framework, he at times also suggested that the schizophrenic subject held a
possible promise. Beyond the unified ego of modernity, and the celebration of a
weak postmodern subject lay a third strategy, what he called ‘the reinvention of the
collective.’ 18
It is this, so far largely submerged, aspect of Jameson’s theory of the present
that has come to the fore in his newest work. In a r ecent essay written for a
symposium on the future of criticism, Jameson ventures to predict developments in
theory. Following on from the moments of structuralism and poststructuralism, he
describes a third stage of politics as presently ‘new and imperfectly explored.’ The
fourth moment, ‘as yet on the other side of the horizon,’ as he writes, will entail
‘the theorizing of collective subjectivities’ – and Jameson returns to Deleuze and
Lacan here as early contributions to this new field of inquiry. 19 In another essay
Jameson speaks of the ‘correction of the earlier […] doxa of the ‘death of the
subject’’ and new forms of ‘collective subjectivity.’ 20 What he had once, in the
postmodern 1980s, largely understood as schizophrenia has turned into its
dialectical opposite, the ‘depersonalization of the subject’ and the revival of
collective forms of agency. 21
Jameson here participates in a trend within contemporary thought and culture
that was tentatively termed, at the beginning of this chapter, the ‘return of the
subject.’ It will be necessary to examine this return in some more detail now. It
would seem that this resurgent interest takes at least two forms. The first is the re-
construction of the subject in contemporary culture, an affirmation of the bourgeois
individual as creator and social actor. The second, introduced here by Jameson’s
newest work, rather than thinking the subject as individual, pits it against the later
and reworks an alternative, if now largely forgotten, subject of modernity,
initiating from the Marxist conception of class.
We will come back to this de-personalisation of the subject in recent theory in
our conclusion, but I will now try to describe the first version of its return, the
reconstruction of the subject in a number of works of contemporary theory. To
speak of an affirmation of the individual creator and actor is not to say that subject
positions in these studies are not problematised. But the slogan of the subject’s
return would seem warranted since what is propagated are notions of pluralised or
heterogeneous subject positions that ultimately still find their identity in the
singularity of the individual. Summarising, we could say that the return in question
here is to a modern conception of the subject, or, more precisely, its late bourgeois
version, into which contemporary notions of heterogeneity and multiplicity are
Alexander Dunst 135
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integrated. Three brief examples from the realm of philosophy and cultural
criticism shall support this claim. 22
In his recent Das Verschwinden des Subjekts (‘The Disappearance of the
Subject’) Peter Bürger reconstructs an intellectual field of modern subjectivity
from the writings of Montaigne, Descartes, and Pascal. This move, explicitly
directed against reductions of the modern subject to its canonical Cartesian
formulation, also allows Bürger, his emphasis on French thinkers notwithstanding,
to defuse the threat of contemporary philosophy to the individual subject. Radical
deconstructions of this subject, from proclamations of its death to diagnoses of
schizophrenia, are integrated – and Bürger’s curious elision of Lacan, Derrida and
Deleuze is symptomatic – into such a field of modern subjectivity with reference to
Pascal’s formulation of an existential nothingness of the subject. 23
What Bürger offers in exchange, as a simultaneously highlighted and excluded
heterotopian space (especially in his comments on Diderot and French women
writers of the eighteenth century) is a conception of subjectivity that could be read
as simultaneously endorsing a number postmodern themes while subordinating
them to a continuation of the bourgeois project of the individual subject. 24
This theoretical compromise is shared by two other recent studies: Peter Zima’s
Theorie des Subjekts (‘Theory of the Subject), appropriately sub-titled
‘Subjectivity and Identity between Modernity and Postmodernity,’ and Axel
Honneth’s notes towards a theory of intersubjectivity, collected in the volume
Unsichtbarkeit (‘Invisibility’). 25 Zima, and his text can be taken as broadly
representative of Honneth’s position as well, given their shared allegiance to the
Frankfurt School and the emphasis upon the integration of diverse subject positions
into the individual’s identity, conceives of a dialogical subjectivity that constitutes
itself in constant interaction with, what is here as elsewhere called, ‘the other.’ 26
This is, as Zima acknowledges, a project that once more holds on to an
‘autonomous individual subject.’ 27 Instead of drawing the consequences from its
crisis, the return to the subject is here to be taken literally: going back rather than
going beyond.
At this point, it seems important to briefly draw attention to a political impasse
at the core of such a dialogical subjectivity. This can be found in its constitutive
and, no doubt, laudable emphasis on dialogue. As Zima concedes, one could ask
what happens in situations too heterogeneous for dialogue, in which
communication breaks down or is refused by the other? At this point, Zima can
only dismiss his own rhetorical question as too extreme and restrict his conception
of subjectivity to the safe havens of literature and culture. 28 What a t heory of
dialogical subjectivity is unable to supply is thus a politics of the subject that goes
beyond consensus, beyond dialogue, and supplies the basis for a radical political
project.
Jameson’s writing, but also Badiou’s philosophy, would have to be
distinguished from this. So far we have spoken of Badiou with respect to what he
__________________________________________________________________
described as the twentieth century’s ‘passion for the real,’ a ch aracterisation we
applied to the century’s discourse of madness in particular. More importantly,
Badiou’s thought can be described as a new philosophy of the subject. Like
Jameson’s, Badiou’s political subject - with which it o therwise shares little - is
collective by definition and, if less explicitly than Jameson’s, shows remarkable
parallels with the Lacanian psychotic. 29
It is the treatment of madness in the authors discussed here that will allow us -
and I will have to end this chapter here - to perceive the central differences
separating them. The contemporary imagination of pluralistic subjects vacillates
between the integration and subsumption of madness and its continued abjection.
In contrast Jameson and Badiou utilise the discourse of madness for a
radicalisation, or the attempt at a Neo-Marxist Aufhebung, of modernity that re-
writes the decentring of the subject performed by French philosophy in the 1960s
and 1970s as its collectivisation. 30 Both Jameson and Badiou, in their own ways,
appropriate madness, once part of a discourse that had declared the death of the
subject, to think its future.
Notes
1
A number of recent studies have sought to complicate diagnoses of both the
subject’s death and return, arguing that neither Barthes nor Foucault ever followed
up on their own proclamations of the author’s and man’s disappearance, and speak
of an essential persistence of the subject throughout (Cf. S. Burke, The Death and
Return of the Author: Criticism and Subjectivity in Barthes, Foucault and Derrida,
Edinburgh University Press, Edinburgh, 1998; and C. Williams, Contemporary
French Philosophy: Modernity and the Persistence of the Subject, Athlone,
London, 2001, p. 9). I wholeheartedly agree with both studies, but also think that
they make a mistake in taking the slogan of the ‘death of the subject’ both too
seriously and not seriously enough: too seriously because they imagine an
academic slogan to mean the end of subjectivity per se, not seriously enough
because they tend to downplay the changes in conceptions of subjectivity in the
last half century. It is with regard to these conceptual changes and the renewed
interest in subjective political agency that it seems, at least initially, to be justified
to speak of a - not the first, only, or last - return of the subject.
2
M. Foucault, The Order of Things: An Archaeology of the Human Sciences,
Routledge, London, 2002, p. 373; and Cf. R. Barthes, ‘The Death of the Author’,
Image Music Text, Fontana, London, 1977, pp. 142-148.
3
Cf. J. Lacan, Über die paranoische Psychose in ihren Beziehungen zur
Persönlichkeit und Frühe Schriften über die Paranoia, P. Engelmann (ed),
Passagen, Vienna, 2002; M. Foucault, History of Madness, J. Khalfa (ed),
Routledge, London, 2006; and G. Deleuze & F. Guattari, Anti-Oedipus: Capitalism
and Schizophrenia, Continuum, London, 2004.
Alexander Dunst 137
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4
Cf. C.W. Mills, The Sociological Imagination, Oxford University Press, Oxford,
2001, pp. 165-176; and W. Whyte, The Organization Man, University of
Pennsylvania Press, Philadelphia, 2002.
5
J. Lacan, The Seminar of Jacques Lacan, Book III: The Psychoses 1955-1956,
J.A. Miller (ed), Norton, New York, 1997 pp . 258-270; and J. Lacan, ‘On a
Question Prior to Any Possible Treatment of Psychosis’, Écrits: The First
Complete Edition in English, Norton, New York, pp. 445-488.
6
M. Foucault, The Order of Things: An Archaeology of the Human Sciences,
Routledge, London, 2002, p. 422.
7
Deleuze speaks of his increasing distance from the concept of schizophrenia in
Pierre-André Boutang’s documentary L'Abécédaire de Gilles Deleuze (P.A.
Boutang, L'Abécédaire de Gilles Deleuze, Collection Regards. Paris, 1996.
Available at http://video.google.fr/videoplay?docid=438091653681675611, Last
accessed 3.1.2009.
8
P. Bürger, Das Verschwinden des Subjekts. Eine Geschichte der Subjektivität von
Montaigne bis Barthes, Suhrkamp, Frankfurt 2001, p. 253.
9
See especially Foucault’s preface to the first edition of the History of Madness
(Cf. Foucault 2006, xxvii-xxxvi). As Gary Gutting notes, Foucault did not include
this preface in later French editions, reflecting his increasing distance from such
idealisations of mental illness (Cf. G. Gutting, ‘Foucault and the History of
Madness’, The Cambridge Companion to Michel Foucault, G. Gutting (ed),
Cambridge University Press, New York, p. 68).
10
Cf. Lacan, 2006, p. 479. Lacan here refers to his earlier ‘Presentation on
Psychical Causality’ (Cf. J. Lacan, ‘Presentation on Psychical Causality’, Écrits:
The First Complete Edition in English, Norton, New York, 2006, pp. 123-158.)
11
A. Badiou, The Century, Polity, Cambridge, 2007, p. 32.
12
F. Jameson, ‘Postmodernism, or the Cultural Logic of Late Capitalism’, New
Left Review, Vol. 146, July-August 1984, pp. 53-92.
13
Also see my ‘Late Jameson, or, after the eternity of the present’, in which I
develop the comments to follow below at greater length (Cf. A. Dunst, ‘Late
Jameson, or after the Eternity of the Present’, New Formations, Vol. 65, October
2008, pp. 105-118).
14
F. Jameson, Postmodernism, or the Cultural Logic of Late Capitalism, Duke
University Press, Durham, 2001, p. 420.
15
Jameson, 2001, p. 14.
16
J. Lacan, ‘On a Question Prior to Any Possible Treatment of Psychosis’, Écrits:
The First Complete Edition in English, New York, 2006, p. 479.
17
A. Stephanson, ‘Regarding Postmodernism: A Conversation with Fredric
Jameson’, Postmodernism/Jameson/Critique, D. Kellner (ed), Maisonneuve Press,
Washington, 1989, p. 47.
__________________________________________________________________
18
F. Jameson, The Political Unconscious: Narrative as a Socially Symbolic Act,
Methuen, London, 1981, p. 125.
19
F. Jameson, ‘Symptoms of Theory or Symptoms for Theory’, Critical Inquiry,
Vol. 30, 2004, pp. 405-408.
20
F. Jameson, ‘Transformations of the Image in Postmodernity’, The Cultural
Turn: Selected Writings on the Postmodern, 1983-1998, Verso, London, 1998, p.
95.
21
F. Jameson, A Singular Modernity: Essay on the Ontology of the Present, Verso,
London, 2002, p. 134.
22
Why all of the following examples should have been written by German-
speaking authors remains unclear to me at this point. A simple dichotomy between
a French emphasis on collective subjectivity versus a G ermanic tradition of the
individual subject is clearly unsatisfactory, as Jameson’s recourse to Lukács
demonstrates - see, once more, my ‘Late Jameson’ (Dunst, 2008, pp. 106-112).
What is evident in all three studies is the decisive influence of Adorno. One
possible indication as to the shared insistence on the individual subject in the
German authors under consideration here, who all pay homage to the Frankfurt
School’s critical theory, can then be found in Bürger’s reminder that Adorno in the
1930s reversed his views on what he had earlier seen as the revolutionary potential
of a dissolution of the bourgeois subject (Cf. Bürger, 2001, 241).
23
Cf. Bürger, 2001, pp. 35-57 and pp. 223-254.
24
Cf. Bürger, 2001, pp. 77-103.
25
P.V. Zima, Theorie des Subjekts: Subjektivität und Identität zwischen Moderne
und Postmoderne, Francke, Tübingen, 2000; and A. Honneth, Unsichtbarkeit:
Stationen einer Theorie der Intersubjektivität, Suhrkamp, Frankfurt, 2003.
26
Zima, 2007, p. xii.
27
Zima, 2007, p. 408.
28
Cf. Zima, 2007, p. 388.
29
A. Badiou, Being and Event, Continuum, London, 2007, pp. 394-400.
30
This does not mean, of course, that Badiou and Jameson’s work can therefore be
called postmodern. Rather than speaking of a liberal postmodernism for the first
‘return of the subject’ discussed here, that of Bürger and contemporary culture, and
a radical post-modern of Jameson and Badiou, it would perhaps be more useful to
note how such a critical constellation exposes, as Andreas Huyssen has argued, the
increasingly obvious limitations and constrictions of the concept of postmodernism
as such (Cf. A. Huyssen, ‘Geographies of Modernism in a Globalizing World’,
Geographies of Modernism: Literatures, Cultures, Spaces, P. Brooker & A.
Thacker (eds), Routledge, London, 2005, pp. 6-18). One of the many differences
between Jameson and Badiou's take on madness should also be noted here. Where
Jameson adopts Lacan’s notion of the splintering of the signifying chain to imply
the collectivisation of the contemporary subject, Badiou draws on the psychotic’s
Alexander Dunst 139
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lack of social ties in the Lacanian theory of psychosis, his inability to form
relationships with others, to illustrate a non-relational truth of the subject that
separates itself from existing knowledge in its encounter with the real. Thus, as has
been the case so frequently in contemporary theory, the discourse of madness is
appropriated for diverse, if in this case politically congenial, uses.
Bibliography
Badiou, A., The Century. Polity, Cambridge, 2007.
–––, Being and Event. Continuum, London, 2007.
Boutang, P.-A., L'Abécédaire de Gilles Deleuze. Collection Regards, Paris, 1996.

Available at: http://video.google.fr/videoplay?docid=438091653681675611.
Bürger, P., Das Verschwinden des Subjekts. Eine Geschichte der Subjektivität von
Montaigne bis Barthes. Suhrkamp, Frankfurt, 2001.
Burke, S., The Death and Return of the Author: Criticism and Subjectivity in
Barthes, Foucault and Derrida. Edinburgh University Press, Edinburgh, 1998.
Deleuze, G. & Guattari, F., Anti-Oedipus: Capitalism and Schizophrenia.

Continuum, London, 2004.
Dunst, A., ‘Late Jameson, or after the Eternity of the Present’. New Formations.
Vol. 65, October 2008, pp. 105-118.
Foucault, M., The Order of Things: An Archaeology of the Human Sciences.

–––, History of Madness. Khalfa, J. (ed), Routledge, London, 2006.
Gutting, G., ‘Foucault and the History of Madness’. The Cambridge Companion to
Michel Foucault. Gutting, G. (ed), Cambridge University Press, New York, 2003.
Honneth, A., Unsichtbarkeit: Stationen einer Theorie der Intersubjektivität.

Suhrkamp, Frankfurt, 2003.
Huyssen, A., ‘Geographies of Modernism in a Globalizing World’. Geographies of

Modernism: Literatures, Cultures, Spaces. Brooker, P. & Thacker, A. (eds),
__________________________________________________________________
Jameson, F., The Political Unconscious: Narrative as a Socially Symbolic Act.

Methuen, London, 1981.
–––, ‘Postmodernism, or The Cultural Logic of Late Capitalism’. New Left Review.
Vol. 146, 1984, pp. 53-92.
–––, Postmodernism, or the Cultural Logic of Late Capitalism. Duke University

Press, Durham, 2001.
–––, ‘Transformations of the Image in Postmodernity’. The Cultural Turn: Selected

Writings on the Postmodern, 1983-1998. Verso, London.
–––, A Singular Modernity: Essay on the Ontology of the Present. Verso, London,
2002.
–––, ‘Symptoms of Theory or Symptoms for Theory’. Critical Inquiry. Vol. 30/2,
pp. 403-408.
Lacan, J., The Seminar of Jacques Lacan. Book III: The Psychoses, 1955-1956.
J.A. Miller (ed), Norton, New York, 1997.
–––, Über die paranoische Psychose in ihren Beziehungen zur Persönlichkeit und
Frühe Schriften über die Paranoia. P. Engelmann (ed), Passagen, Vienna, 2002.
–––, ‘On a Question Prior to Any Possible Treatment of Psychosis’. Écrits: The
First Complete Edition in English. Norton, New York, 2006.
–––, ‘Presentation on Psychical Causality’. Écrits: The First Complete Edition in

English. Norton, New York, 2006.
Mills, C.W., The Sociological Imagination. Oxford University Press, Oxford,

2001.
Stephanson, A., ‘Regarding Postmodernism: A Conversation with Fredric

Jameson’. Postmodernism/Jameson/Critique. Washington, 1989.
Whyte, W., The Organization Man. University of Pennsylvania Press,

Philadelphia, 2002.
Williams, C., Contemporary French Philosophy: Modernity and the Persistence of

the Subject. Athlone, London, 2001.
Alexander Dunst 141
__________________________________________________________________
Zima, P.V., Theorie des Subjekts: Subjektivität und Identität zwischen Moderne
und Postmoderne. Francke, Tübingen, 2000.
Alexander Dunst is a PhD candidate and teaching assistant in the Department of

Cultural Studies at the University of Nottingham, where he is currently completing
his thesis on ‘The Politics of Madness: Psychosis as Social Crisis in the United
States, 1950-2000’. He has published in New Formations and Textual Practice, and
regularly contributes to the Annotated Bibliography of English Studies (ABES).
History of the Present Illness: Is Foucault Still Relevant to the
Understanding of Mental Disorder?
Johnathan Sunley
Abstract
With the publication in 2006 of History of Madness, Foucault’s celebrated
magnum opus historicizing the concepts ‘reason’ and ‘unreason’ finally became
available in an unabridged English translation. Its impact, however, had been felt
much earlier. Already in the 1970’s, partly in response to the criticisms made by
the anti-psychiatry movement (itself greatly inspired by this work), Western
governments embarked on a policy of deinstitutionalization that would lead to the
numbers of psychiatric inpatients falling by three-quarters. After some 300 years,
what Foucault had termed the ‘great confinement’ appeared to be over. How, then,
might his views be applied to the understanding of mental illness in an era of
community care and evidence-based medicine? This chapter argues that it is his
concept of ‘biopower’, understood as a source of ‘subjectification’ rather than
domination that holds most potential for illuminating the ways in which madness is
perceived today. For one thing, thanks to the proliferation of diagnostic categories
and lowering in the stigma associated with most of them, we are all free – if not
actively encouraged – to find the disorder that suits us. In the jargon of current
mental health policy, we are (nearly) all ‘service-users’ now. Second, in an age
characterized not so much by conformity as restless relativism, the numerous forms
of ‘talking therapy’ offered to the mentally ill (and pursued enthusiastically by the
worried well) have become an essential medium for framing what Foucault
referred to as the ‘relationship between man and his own truth’. A third instance of
biopower is the demand increasingly pressed by psychiatrists and clinical
psychologists to be seen as ‘scientist-practitioners’: the prestige of biomedicine
may seem to legitimize this claim, but the supposedly non-evaluative statistical
norms that are their stock-in-trade are internalized by patients and so become
normalizing after all.
Key Words: Antipsychiatry, biopower, Foucault, history, madness, mental

disorder.
*****
1. From the Great Confinement to Care in the Community

There are several problems with Michel Foucault’s provocative yet extremely
influential history of madness. Not the least of these is that an unabridged English-
language edition of this monumental work has only become available in the last
couple of years. 1 That aside, the book has consistently come under attack from two
144 History of the Present Illness
__________________________________________________________________
types of critic – those in whose eyes it is itself mad and those for whom it is merely
maddening.
The first stance has been taken mainly by philosophers. Historians have
preferred to reproach Foucault for twisting or neglecting facts to suit his highly-
charged argument. 2 Was the Renaissance really so benign and inclusive in its
attitudes towards the mad? Did this period really come to such an abrupt end in
1657 with the founding of the Hôpital Général in Paris marking the start of what
Foucault calls the ‘great confinement’?
One response to objections of the second sort has been to claim that while
wrong in terms of much of his evidence, Foucault was nonetheless right in his
overall thesis. Porter, for example, takes issue with him over a range of facts and
figures related to the gradual establishing of English as opposed to French
psychiatry. Yet even he allows that while in 1800 there may have been only a few
thousand lunatics confined in English institutions, ‘by 1900 t he total had
skyrocketed to about 100,000’. 3
Another kind of comeback has been to contend that getting embroiled in a
debate over facts is to miss the point, since Foucault’s major commitment was not
to revisionist history so much as anti-history. He also liked to characterize his
books as ‘histories of the present’, as though challenging himself and his readers to
draw the obvious conclusion from them for the times in which they lived: that is, if
they didn’t like what they saw, to do something about it.
Of all his writings, History of Madness had the greatest effect of this kind. For,
although its impact may be difficult to isolate from that produced by other
charismatic contributors to the ‘anti-psychiatry movement’ of the 1960’s (primarily
Szasz, Laing and Goffman), what cannot be denied is that around this time the
concept of madness underwent another epistemic shift in the way it was
constructed. Following on from this, a policy of deinstitutionalization led to the
closure of many asylums such that whereas in the 1950’s there had been around
500,000 psychiatric in-patients in the USA and 160,000 in the UK, by the 1980’s
these numbers had fallen by eighty per cent. 4 After two or three hundred years, the
great confinement was finally over.
Where does this leave Foucault? To be sure, though mental hospitals are largely
a thing of the past, not all ‘care in the community’ takes place in people’s homes or
out-patient departments: many mentally ill patients are treated in specialized
psychiatric units based either in or alongside general hospitals. Moreover,
psychiatry remains a unique branch of medicine in possessing the legal powers to
treat people against their will.
It would be difficult, nonetheless, to argue that modern-day psychiatry is
fundamentally corrective or coercive in the way that Foucault claimed it was even
after the humanitarian reformers had in the early nineteenth century released the
mad from their chains. Yet, in his later work, Foucault himself came to take a more
nuanced view of the ways in which power is manifested. From having been
Johnathan Sunley 145
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concerned primarily with the processes of ‘objectification’ that, as he saw it,
underlay both disciplinary institutions and certain modes of enquiry (science
generally but particularly the social sciences), he came now to focus on the forms
of ‘subjectification’ in which individuals are themselves active.
If, in the post-asylum era, Foucault still has something to say to us about the
concept of mental disorder, then I would argue that it is as much on the insights of
this phase of his career as the earlier one that we may need to draw.
2. Who’s Silent Now?

For one thing, if part of the paradoxical purpose of History of Madness was – in
Foucault’s words – to ‘draw up an archaeology of that silence’ 5 occasioned by the
monologue of reason, then such an aim would surely be superfluous today. This is
because (as Foucault might have put it) having been freed from their confinement,
the mad have done the very thing the popular fear of which (as Foucault does
actually put it) led to their incarceration in purpose-built asylums in the first place:
they have infected the rest of us.
The ‘global burden of mental disorders’, as the World Health Organization
(WHO) terms it, is huge and growing. By 2020 they will account for 15 percent of
disability-adjusted life-years lost to illness, with depression alone becoming the
second biggest cause of disability in the world. 6 Of course, the reasons for this shift
have nothing to do with infection in the literal sense. It might be more appropriate
to see it as another of the legacies of anti-psychiatry: the madder we are as a
society, the less chance there will be of some self-declared sane majority
marginalizing an unfortunate few for not fitting in. It may well be true, therefore,
that mental illness is a great burden, especially in industrialized nations. But with
more and more people either acknowledging it in themselves or aware of its impact
on the lives of others, it would be naïve to pretend that this is not by now a well-
established issue on the social and political agenda
For Foucault, nonetheless, what would be far more naïve is to suggest that the
state has not long been interested in our welfare. For centuries, now, governments
have taken a keen interest in the birth and mortality rates of the populations under
their authority. The term Foucault uses to capture the relations that this concern
(along with the battery of administrative and regulatory techniques accompanying
it) gives rise to is ‘bio-power’.
Foucault introduces this concept in the first volume of The History of
Sexuality. 7 Here, with characteristic aplomb, he makes the argument that far from
not being talked about in the Victorian era, sexuality was actually discussed at
great length – only in new ways (medical, juridical and psychological) that
changed the way in which people saw themselves. Whether this change was for the
better or not is beside the point. What matters is that people have new forms of
subjectivity available to them that then partly constitute what they become. As one
commentator has written of bio-power in this context: ‘it has been positive and
__________________________________________________________________
productive rather than negative, and has ensured a proliferation of pleasures and a
multiplication of sexualities’. 8
Could it not be argued that something similar has taken place with mental
illness since it moved out of asylums and into the community and afforded people
a diversification of identities around it? Whereas in the past, for example, one
person might have been shy, another inclined to drink too much coffee and a third
given to outbursts of irascibility, nowadays all three can think of themselves as
‘ill’. For, applying the categories of the main diagnostic manual in use among
psychiatrists today, they can be regarded as suffering from ‘social anxiety
disorder’, ‘caffeine-related disorder’ and ‘intermittent explosive disorder’
respectively. 9
3. Getting the Most Out of Us

Bio-power is productive, then, in the sense already discussed. But it is also
concerned with productivity. From the perspective of the modern state driven by
the demands of economic growth, this is too important to be left to chance. So it
has no choice but to busy itself with the very bodies of its citizens, in an attempt to
optimize their performance. Although Foucault was mainly concerned with the
implications of what he called ‘anatomo-politics’ for our sexuality, the argument
he is advancing can also be applied to some of the terms of discourse around
mental health.
Often these are spelt out quite explicitly. According again to the WHO: ‘The
burden of mental disorders is maximal in young adults, the most productive section
of the population.’ 10 While it is obviously appropriate to bear in mind what might
be called the opportunity costs of mental illness as well as the far from negligible
matter of the cost of treatment, fixing productivity both as the benchmark and
ultimate aim of mental well-being might appear more questionable. Yet this is part
of the rationale behind the recently-launched initiative within the NHS to train
thousands of extra therapists to treat sufferers of depression and anxiety – not so
much to alleviate their distress as to get them back to effective work at a time when
mental illness is said to have overtaken unemployment as the greatest drain on the
country’s economy. 11
Of course, being and feeling productive are essential to a person’s self-esteem.
But having observed in History of Madness that the psychiatric reformers who ran
the asylums of the early Victorian era did so not by virtue of any medical expertise
so much as the moral authority they exerted over their charges, Foucault would
surely have seized upon the fact that the main advocate of this policy is neither a
doctor nor a psychologist but an economist. Then again, he might also have
suggested that this was a pass sold from the other side some twenty or thirty years
ago when, in order to free themselves once and for all from the medical model,
those who had formerly been mental health patients incorporated the language of
_______________________________________________________
the market into their subjectivities and began calling themselves ‘clients’, ‘service-
users’ and even ‘consumers’.
4. The Truth Behind the Talking Therapies

Even if the considerable investment in Cognitive Behavioural Therapy that this
initiative requires is justified in cost-benefit terms as being cheap at the price, there
are other reasons why the ‘talking therapies’ more generally occupy such a
prominent place in the current episteme. For Foucault writing in History of
Madness, the key difference between the treatment of the mad in the eighteenth
and nineteenth centuries was that only in the asylums were psychological methods
brought to bear on their condition.
Previously, madness had been perceived simply as unreason, and whether it
was attributed to a sickness of the brain or simply the ‘vapours’ was secondary to
the state of non-being to which the sufferer was reduced and which demanded his
exclusion from the rest of society. Now, by contrast, the mad were seen as partly
responsible for their fate: ‘what had been error became fault’. 12 By the same token,
they were also now expected to take some responsibility for their cure, by
accepting the moral condemnation and exhortations that could deliver them from
their alienation.
It would be impossible here to do justice to the massive range of principles and
techniques represented in the various forms of counselling and psychotherapy
offered to the mentally ill to day. 13 But whether personal change is seen as being
made possible by the modification of maladaptive schemata or by becoming
capable of introjecting positive transference interpretations, the need of the
patient/client to find ‘his own truth’ (as Foucault puts it) might be regarded as the
one belief all talking therapies are agreed on.
Then there is another side to contemporary therapy that might have intrigued
the later Foucault. This is its confessional aspect. In The History of Sexuality, he
argues that what had been one of the main rituals of truth-production in the
medieval period was later co-opted by secular authorities determined to extend and
perhaps improve their subjects’ lives by instilling in them habits of self-scrutiny.
As he puts it: ‘Western man has become a confessing animal.’ 14
If, as might be argued, ‘Western man’ today is more likely to be living alone
and is increasingly distrustful of the state-sanctioned experts charged with
improving his quality of life, to whom can he turn for confession? From a
Foucauldian perspective, it might be that the therapist to whom we bring examples
of the closely-monitored negative thoughts that have arisen since the last session, is
one of the few figures still capable of fulfilling such a role.
5. It’s Not Me, It’s My Neurotransmitters

At the same time, however, one of the most striking characteristics of the other
main type of treatment offered to sufferers of mental illness today is its non-
__________________________________________________________________
judgmental nature. T his was certainly not the case, according to Foucault, in the
nineteenth century when general paralysis of the insane (most likely to be the result
of sex with prostitutes) and something called ‘moral insanity’ were two of the
commonest types of diagnosis. In that era ‘A purely psychological medicine was
only made possible when madness was alienated into guilt’. 15
The fact that we no longer have to feel guilty about our disorders (even
runaway lust is now simply sexual addiction) may be related to what might be
termed the progressive de-psychologization of mental illness over the second half
of the twentieth century. Psychiatry has come full circle to Griesinger’s celebrated
pronouncement of 1845 t hat ‘mental diseases are brain diseases’ – the difference
being that it is now equipped with the molecular biology, the
psychopharmacological feedback and the neuroimaging techniques to demonstrate
why this is so.
In response, a sizable literature has built up that seeks to account for the
attraction of the chemical-imbalance-in-the-brain theory through the financial
power of pharmaceutical companies all too willing to fund the kinds of research
that will increase demand for their products. 16 From a F oucauldian perspective,
however, it would be neither ‘big pharma’ nor cost-cutting departments of health
that are mainly responsible for taking the guilt out of mental illness. Rather, this
would be the achievement of psychiatrists and perhaps other clinicians, who as the
twentieth century progressed came to see themselves more and more as scientists.
This is a story with many strands to it. And again anti-psychiatry must be
accorded a significant role in shaping its outcome, as it was largely in response to
the charge coming from this movement that what was meant by ‘mental illness’
was really social deviance, that psychiatry subsequently tried to distance itself from
evaluative norms as much as possible: by developing a n aturalized concept of
‘disorder’ on a theoretical level that could then be put to work diagnostically on the
basis of descriptive rather than prescriptive criteria. Of course norms haven’t
disappeared entirely. But the belief among most psychiatrists or clinical
psychologists is that the norm in question is now a statistical one and hence
capable of being objectively measured – thereby also becoming a proper starting-
point for scientific research. 17
Foucault’s response to this would be to note that standard deviations and social
deviance have more in common than might appear. Statistics may be the
foundation of randomised control trials and evidence-based medicine more
broadly. But in themselves they are not as innocent as those who have such ready
recourse to them like to think: the term itself, he would point out, means ‘science
of the state’ and is an excellent example of bio-power. Thirty or forty years ago,
Foucault’s critique of psychiatry was widely regarded as persuasive if somewhat
excessive. Today his no less radical views on other topics such as literature and
homosexuality have become part of the cultural mainstream, while the
conceptualization and treatment of mental disorder have – it is argued – undergone
_______________________________________________________
so much change as to have put themselves beyond the reproaches he levelled at
them. 18 Certainly the ‘techniques of domination’ he devoted the early part of his
career to exposing, seem to hold little relevance to the study of this subject as it is
now. As for the ‘techniques of the self’, that may be another matter.
Notes
1
M. Foucault, History of Madness, Routledge, London, 2006. In his foreword to
this book, Ian Hacking usefully traces the various transformations undergone by
the text in both French- and English-language editions since its first publication in
France in 1961.
2
See, for example, the collection A. Still & I. Velody (eds), Rewriting the History
of Madness: Studies in Foucault’s Histoire de la folie, Routledge, London, 1992.
3
R. Porter, Mind Forg’d Manacles: A History of Madness in England from
Restoration to Regency, Athlone, London, p. 2.
4
T. Burns, Psychiatry: A Very Short Introduction, Oxford University Press,
Oxford, 2006, p. 51.
5
Foucault, 2006, op. cit., p. xxviii.
6
World Health Organization, The Mental Health Context, World Health
Organization, Geneva, 2003.
7
M. Foucault, The History of Sexuality, Vol. 1, Penguin, Harmondsworth, 1976.
8
B. Smart, Michel Foucault, Routledge, London, p. 97.
9
Disorders, Fourth Edition – Text Revision (DSM-IV-TR), American Psychiatric
Association, Washington DC, 2000.
10
World Health Organization, op. cit., p. 17. Italics mine.
11
This government initiative, known now as the Improving Access to
Psychological Therapies (IAPT) programme, owes its existence to
recommendations made by the economist Lord Layard. See R. Layard, The
Depression Report: A New Deal for Depression and Anxiety Disorders, London
School of Economics, London, 2006.
12
Foucault, 2006, op. cit., p. 296.
13
Sixteen different kinds of psychotherapy, all of them mainstream, are described
in the latest edition of W Dryden (ed), Dryden’s Handbook of Individual Therapy,
Sage, London, 2007.
14
15
16
See, for example, D. Healy, The Antidepressant Era, Harvard University Press,
Boston, 2000.
17
Philosophers have also attempted to naturalize mental illness – for example, by
grounding it in the supposedly hard facts of species-typical performance. See C.
__________________________________________________________________
Boorse, ‘What a theory of mental health should be’, Journal of the Theory of
Social Behaviour, Vol. 6, 1976, pp. 61-84.
18
This argument is made in E. Matthews, ‘Moralist or Therapist? Foucault and the
Critique of Psychiatry’, Philosophy, Psychology and Psychiatry, Vol. 2, 1995, pp.
19-30.
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Bentall, R.P., Madness Explained: Psychosis and Human Nature. Penguin,

London, 2004.
Bolton, D., What is Mental Disorder? An Essay in Philosophy, Science and Values.
Oxford University Press, Oxford, 2008.
Boorse, C., ‘What a Theory of Mental Health Should Be’. Journal of the Theory of
Social Behaviour. Vol. 6, 1976, pp. 61-84.
Burns, T., Psychiatry: A Very Short Introduction. Oxford University Press, Oxford,
2006.
Double, D., ‘The Limits of Psychiatry’. British Medical Journal. Vol. 324, April
2002, pp. 900-904.
Dryden, W. (ed), Dryden’s Handbook of Individual Therapy. Sage, London, 2007.
Foucault, M., History of Madness. Routledge, London, 2006.
Foucault, M., The History of Sexuality. Vol. 1, Penguin, Harmondsworth, 1976.
Foucault, M., The History of Sexuality. The Use of Pleasure. Vol. 2, Penguin,
Harmondsworth, 1984.
Foucault, M. & Sennett, R., ‘Sexuality and Solitude’. London Review of Books.
June 1981.
Hansen, S., McHoul, A. & Rapley, M., Beyond Help: A Consumer’s Guide to
Psychology. PCCS Books, Ross-on-Wye, 2003.
_______________________________________________________
Healy, D., The Antidepressant Era. Harvard University Press, Boston, 2000.
Kendell, R., ‘The Next 25 Years’. British Journal of Psychiatry. Vol. 176, 2000,
pp. 6-9.
Kutchins, H. & Kirk, S.A., Making Us Crazy: DSM – The Psychiatric Bible and
the Creation of Mental Disorders. Free Press, New York, 1997.
Layard, R., The Depression Report: A New Deal for Depression and Anxiety
Disorders. London School of Economics, London, 2006.
Luhrmann, T., Of Two Minds: The Growing Disorder in American Psychiatry.

Alfred A. Knopf, New York, 2000.
Matthews, E., ‘Moralist or Therapist? Foucault and the Critique of Psychiatry’.

Philosophy, Psychology and Psychiatry. Vol. 2, 1995, pp. 19-30.
Nasser, M., ‘The Rise and Fall of Anti-Psychiatry’. Psychiatric Bulletin. Vol. 19,
1995, pp. 743-746,
Oksala, J., How to Read Foucault. Granta, London, 2007.
Porter, R., Mind Forg’d Manacles: A History of Madness in England from

Restoration to Regency. Athlone, London, 1987.
Porter, R., Madness: A Brief History. Oxford University Press, Oxford, 2002.
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Organization, Geneva, 2003
Johnathan Sunley is studying for an MSc in the Philosophy of Mental Disorder at

King’s College London. He is also a trainee psychotherapist.
‘Madness’ and ‘Brain Disorders’: Stigma and Language
Christian Perring
Abstract
Modern psychiatry has moved away from the language of madness, referring to
particular disorders such as schizophrenia, and general types of disorders such as
psychoses. The justification for this move is that it is both more scientific and less
stigmatizing. Furthermore, groups such as NAMI and other official bodies
representing the mentally ill also discourage the use of terms such as ‘madness’.
Indeed, NAMI and many other groups want to move away from all talk of ‘mental
illness,’ and replace it with talk of brain disorders. Yet the general public continues
to use terms such as ‘mad,’ ‘crazy,’ and ‘loony,’ in disparaging ways. Of particular
importance has been the ‘Mad Pride’ movement which, echoing the tactics of the
Black Power movement, the Feminist movement and the Gay Rights movement of
earlier decades, has tried to reclaim the old language of madness, attempting to
reverse the stigma of the formerly pejorative words. I compare these two
approaches to fight the stigma attached to madness, evaluating their success, and
discussing the advantages and disadvantages of the different approaches. The
sanitized language of ‘mental’ or ‘brain’ disorder is more socially acceptable and is
less confrontational. It also fits well with the aims of the ‘Big Pharma’ and the
corporate world. ‘Mad Pride’ is more subversive with respect to the social
structure, challenging assumptions of normality and appropriate behaviour. I assess
the ethical issues connected with using the language of madness and make some
suggestions in favour of retaining it.
Key Words: Brain disorders, disability, Mad Pride, madness, mental illness,
stigma.
*****
As a philosopher, my work in the philosophy of psychiatry concerns the

meanings of words, the coherence of concepts, the viability of reductionist views
such as saying that the mind is just the brain, and the foundation for ethical
judgments about people’s actions. Yet I am also deeply interested in
interdisciplinary work and I want to explore the ways in which different
philosophical positions gain general acceptance in modern society and are
exemplified in our practices. I also hold that much philosophy, in order to be done
well, must involve understanding of other disciplines. This is a chapter about
language and ethics.
A few years ago, when a colleague and I proposed teaching an interdisciplinary
course on ‘The Culture of Madness’ at our college, it was suggested that we should
not use the word ‘madness’ because it carried pejorative connotations. We were
154 ‘Madness’ and ‘Brain Disorders’
__________________________________________________________________
reluctant to change the name, because we both felt that ‘madness’ is a useful word
that conveys more than phrases such as ‘mental illness’ or ‘mental disorder.’
However, this incident reflects the prevalent trend these days to use more sanitary
language when talking to people with mental illnesses. Now psychiatrists refer to
their patients’ delusions and psychoses, but they do not say that their patients are
crazy and they do not call themselves ‘mad doctors.’ Most patient groups also
argue against old fashioned terms like ‘mad,’ ‘lunatic,’ and ‘hysteric.’
Those who want a science of abnormal psychology have their own reasons for
wanting to dissociate themselves from what I shall refer to as ‘the language of
madness.’ 1 They believe that science must use well-defined terms, and so rather
than use the vague and morally-laden terms that come from our ordinary language,
we should use more precisely-definable and morally neutral terms. The movement
to create a scientific psychology has existed since the 19th century, and has been
applied to mental illness and mental deficits since the latter half of the nineteenth
century. Some parts of the emerging discipline of psychology were more
successful than others at gaining scientific respectability. The German science of
psychophysics exemplified by the work of Fechner and Helmholtz was probably
the premiere approach. Other approaches, such as the notorious phrenology, the
‘science’ of determining people’s characters and capabilities from the shape of
their brains and heads, made very dubious claims and also imported in many
problematic racist and sexist assumptions. The history of different approaches to
the scientific study of the mentally ill is fairly well known, and does not need to be
repeated here. However, it is clear that the recent trend in scientific psychiatry has
been to focus on genetics and the brain, and words like ‘crazy’ and ‘mad’ have no
place there. It is arguable that the new terminology of science has not completely
avoided morally loaded connotations, but even if we grant this it is clear that the
moral component of the scientific approach is far more subtle than it was before.
The other main motivation for changing the way we refer to people with mental
illness is the problem of stigma. There has been a great deal of work on stigma in
the last several decades, starting with Goffman’s classic work, and which has
helped show how beliefs about the inferiority and moral unworthiness of people
can be conveyed through linguistic and other depictions. People with mental illness
are often considered less than human, worth less than others, and not deserving of
as much help or care as people with other illnesses. There are countless ways that
mentally ill people have been denigrated in film, TV, literature, and of course in
ordinary life.
The National Association for the Mentally Ill, which is the biggest US
advocacy group of people with mental disorders and their families, has taken
strong stands on stigma. Currently, their website describes mental illnesses as
‘medical conditions.’ In the past, they have described mental illnesses as ‘brain
disorders.’ On their dual diagnosis fact sheet, they still equate mental illness with a
brain disorder. 2 In both cases, the move is to identify mental illness as not just a
Christian Perring 155
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‘psychological condition,’ nor a moral condition. The pros and cons of identifying
mental disorder with brain disorder have been discussed by Patrick Corrigan and
Amy Watson in a r ecent chapter. 3 They point out that thinking of someone as
having a b rain disease can lead to their being treated as more different.
Furthermore, one can add, other research has indicated that there is comparable
stigma towards people with brain injuries. 4 Corrigan and Watson argue in favour
of psychosocial explanations of mental disorder, on the grounds that it does not
have the same problems. Exactly what they mean by a ‘psychosocial approach’ is
not spelled out, but the general idea is fairly clear. The psychosocial approach does
not identify mental disorder as a brain disease, but rather explains it as a
psychological problem and as a response to difficult circumstances.
Among the general public, there is little sign of a dramatic change in language
when referring to the mentally ill in recent decades, although one might make a
plausible case that people are less scared of people with serious mental illnesses
now and are more ready to disclose their own mental illnesses to others. Yet both
in the USA and in the UK, there is still considerable suspicion of the mentally ill,
and certainly both moderate and serious mental illnesses still carry stigma. The
media is full of portrayals of crazy people as dangerous and malevolent, while
sympathetic depictions of serious mental illness are rare. Presumably, this reflects
the public’s tolerance for such depictions.
The proper ethical stance of the views considered so far seems to be to find the
educational program and public activism that will be most effective at reducing
stigma against mentally ill people, by eliminating stigmatizing representations and
morally-loaded language from general use. However, I want to raise some
concerns about this approach and to explore alternatives.
In the last decade, the Mad Pride movement has gained some attention,
especially in the UK. According to one of the Mad Pride websites 5 the idea came
from the 1997 Gay Pride Festival in London. The website draws a parallel with
Black Pride, and explains what the name is about.
So the committee at their October 99 meeting has agreed to

model the word more closely along the lines of the Black struggle
and to encourage the use of the word ‘mad’ but to capitalise
it!!!!!! It therefore is always to be written Mad to distinguish it
as a d eadly serious political word - a constant reminder of how
we were treated by others, how we are treated by others, but
sending out a message that the day has now arrived when we are
not going to be treated like this any more. 6
This is not a movement with any great organizational structure. It consists

mainly of websites that seem to have short lives and do not work well. There is
also a M ad Pride book that contains accounts of people’s experience of mental
__________________________________________________________________
illness. 7 It is worth noting that in the last year, the Mad Pride movement, in various
forms, has started to take off. In London this year there was Bonkerfest with
comedians and musicians entertaining a crowd. 8 There was another event in May
of this year with Vic Goddard and the Subway Sect, promoting Mad Pride UK. 9
The New York Times covered some of these events and groups in a May 2008
article, ‘Mad Pride’ Fights a Stigma, by Gabrielle Glaser. 10 This article spurred a
fair amount of other discussion on the Internet. For example, there was a piece in
the Furious Seasons blog, 11 The New York Times On ‘Mad Pride’, and another in
the Writhe Safely blog. 12
One of the central ideas of Mad Pride is to work against stigma, and in some
ways to celebrate madness. There is indeed a good deal of creativity in the work of
people with mental disorders, and some argue that the creativity can be caused by
the mental illness. This has been claimed especially for people with manic
depression, and one can find on the Internet long lists of artists who have been
diagnosed with or suspected of having bipolar disorder.
Yet many people with serious mental illness do not take pride in having what
they see as a d isabling disease, and they want to be rid of their condition. Some
have objected to the Mad Pride movement on these grounds. So the movement
raises questions of whether it makes sense to make an analogy with Black Pride,
Gay Pride, or pride in being a woman, since being black, gay, or a woman are not
conditions that are inherently disabling, even if in our society, they can put one at a
disadvantage. The predominant view is that mental illness is inherently an
impairment or disease. By comparison, it would be bizarre for someone to propose
a Cancer Pride movement. One can take pride in one’s fight against the disease or
one’s dealing with the associated suffering, but not in having the disease itself. To
take the Mad Pride movement seriously, it s eems that it h as to propose an
alternative view of what we call mental illnesses.
More generally, the Mad Pride movement fits well with the C/S/X movement:
C/S/X standing for consumer, survivor, ex-patient. The C/S/X movement places
emphasis on asserting the rights of mentally ill people, and often takes a somewhat
antagonistic attitude towards mainstream psychiatry, while also showing some
ambivalence about seeing mental illness as a disorder. I should note that it is very
difficult to give a complete description of the C/S/X movement since it is so
diverse and changeable, and there are few surveys of it. 13 Yet this ambivalent
attitude toward psychiatry and the reality of mental illness does not seem to split
the movement into different factions, because its primary concern is with helping
people who have been labelled as mentally ill, and thus is closely related to the
rehabilitation movement, which has some support from the medical and
governmental establishment, and thus gets at least some funding.
The C/S/X movement is itself closely related, at least in spirit if not in
interaction, to that of the disability rights movement. This movement has been
highly critical of the medical establishment and the medicalising of disability. They
__________________________________________________________________
have argued that conditions such as being deaf, blind, or wheelchair bound are not
medical conditions, but rather are different states of existence for which society
should make accommodation. Theorists argue that while people classified as
disabled do have an impairment, they are not intrinsically disabled but instead are
disabled by society. By placing expectations on people that they should have
certain abilities, and refusing to make adequate allowances for the differences of
people, those who lack some abilities are thus excluded from society. One of the
central debates for policy makers and the disability studies movement is which
deficits and differences are relevant and which are not. That is to say, it is up for
debate, even among those in disabilities studies, when accommodations should be
made, and what sorts of accommodations should be made for people who are
different. This is in obvious conflict with the medical view that people with
conditions such as deafness and blindness simply have deficits, departing from
biological normality, and are simply not able to participate in what is socially
normal, since the socially normal is and should be based on the biologically
normal.
So we have two main approaches to formulating the language with which to
describe mentally ill p eople: the medical reductionist approach and the ‘language
of madness’ approach. I have outlined some of the political motivations behind the
language of madness, and so I should do the same for the medical approach. Here,
the role of the drug companies is of preeminent importance, since they favour the
medical reductionist language in their advertising both to physicians and to the
general public. This is especially apparent in their promotion of antidepressants.
For example, Pfizer on their Zoloft website say
Today, it’s widely understood that depression is a serious

medical condition. Scientists believe that it could be linked with
an imbalance of a c hemical in the brain called serotonin. If this
imbalance happens, it can affect the way people feel. 14
They also use imagery of humanized neurotransmitters that were involved in

their early advertising campaigns showing the depletion of serotonin in the brains
of depressed people.
GlaxoSmithKline spell out the connection with brain chemistry in a little more
detail on their Paxil website:
Paxil CR helps balance your brain’s chemistry. (See Important

Safety Information about Paxil CR.) Just as a cake recipe requires
you to use flour, sugar, and baking powder in the right amounts,
your brain needs a f ine chemical balance in order to perform at
its best. Normally, a chemical neurotransmitter in your brain,
called serotonin, helps send messages from one brain cell to
__________________________________________________________________
another. This is how the cells in your brain communicate.
Serotonin works to keep the messages moving smoothly.
However, if serotonin levels become unbalanced, communication
may become disrupted and lead to depression, anxiety, and
PMDD. Paxil CR helps maintain a b alance of serotonin levels,
which may help cell-to-cell communication return to normal.
Paxil CR is with you throughout the day to help you manage and
treat your condition. 15
We can note that the claims here are vague and are hedged, and while they are
not obviously false (despite some dispute from psychiatric experts 16), they can
leave an impression that science has established more causal claims about the
direction of causation between mental disorders and transmitter imbalances than is
actually the case.
The motivation for the pharmaceutical companies to pursue this sort of
description of mental illness and their causes is rather obviously that if they
promote a ch emical and neuroscientific account, their products appear to be the
most appropriate treatment for mental illness. A non-stigmatizing description also
encourages people to seek treatment, and thus increases the likelihood of the use of
medications. It is not cynical to say that commercial companies aim to make a
profit, and so this helps to explain how they frame the promotion of their products.
The question about the drug companies is whether the profit motive overrides all
other motives. It is relatively clear that the pharmaceutical industry has been
closely allied with the psychiatric profession, and there is considerable overlap in
the description of mental illness by both. Without resorting to any conspiracy
theories, it is easy to see how the motivations of both groups would work well
together. Of course, there are conspiracy theories that the psychiatric profession,
and especially the American Psychiatric Association, has colluded with Big
Pharma in the creation of the categories of mental disorder such as Social Anxiety
Disorder, Pre-Menstrual Dysphoric Disorder, childhood depression, and Attention
Deficit Hyperactivity Disorder.
Given the situation I have outlined so far, the question remains how to view the
language of madness. We can now see that this is a far more complex decision that
it might have first seemed. Each approach has allegiances with different camps,
different stances toward difference, toward medicine, and toward social change. It
is not just a matter of being stigmatizing or non-stigmatizing. We must
acknowledge that the best language to use will depend on one’s position in the
debate, and also possibly one’s personal relation to mental illness: as someone with
it, as a scientific observer of it, as a clinician wanting to help those with mental
illness, or as a political activist. It is much more acceptable for mentally ill people
to refer to themselves as ‘mad’ than for others to call them mad, just as physically
disabled people can call themselves ‘cripples’ when it would be outrageous for
__________________________________________________________________
others to describe them with such words. It makes little sense to insist on a
universal use. Nevertheless, I do want to urge that there is much to recommend
retaining the language of madness. Rather than aiming to make our language more
bland and ‘scientific,’ we retain a richness of expression by using the language of
madness. If possible, we will do better to retain this richness and strip the language
of madness of its pejorative connotations. There are positive political connotations
in using the language of madness, and of course, there is no guarantee that by
switching to more supposedly neutral language, we will reduce stigma. The history
of terminology in special education helps to illustrate that: the word ‘moron’ was
introduced by Henry Goddard in 1910 as scientific terminology to describe people
with a mental age between 8 and 10. It soon acquired a strongly stigmatizing use.
Furthermore, the use of formerly stigmatized terms in anti-stigmatizing ways can
be more effective, because of their shock value, than attempting to use neutral
terms. Of course, any such use of language cannot occur in isolation, but needs to
be part of a larger effort to reduce stigma.
A final comment. While I have mentioned the idea that the language of
madness carries rich connotations that are lost when moving to a more sanitized
scientific language, and I have argued that the scientific language can itself be
problematic, I have not spelled out what those rich connotations consist in. To do
so will require a more historical survey of how the language of madness has
evolved over the centuries, what varieties of words it uses, and an account of what
makes any language rich rather than impoverished. I hope to grapple with these
issues in future work.
Notes
1
Note that, with this expression, I am not referring to David Cooper’s book The
Language of Madness.
2
NAMI, ‘Dual Diagnosis: Adolescents with Co-occurring Brain Disorders &
Substance Abuse Disorders,’ http://www.nami.org/Content/ContentGroups/Illnes
ses/Dual_Diagnosis_Fact_Sheet.htm, Viewed on August 27, 2008.
3
P. Corrigan & A. Watson. ‘At Issue: Stop the Stigma: Call Mental Illness a Brain
Disease’, Schizophrenia Bulletin, Vol. 30(3), 2004, pp. 477-479.
4
See the discussion in P. Zachar, Psychological Concepts and Biological
Psychiatry, John Benjamins Publishing, Philadelphia, 2000.
5
Mad Pride, About Mad Pride, Viewed on August 24, 2008,
http://www.ctono.freeserve.co.uk/id17.htm.
6
Mad Pride, That Mad Pride Name Again, Viewed on August 24, 2008,
http://www.ctono.freeserve.co.uk/mpname.htm.
7
T. Curtis, R. Dellar, E. Leslie & B. Watson (eds), Mad Pride, Spare Change
Press/Chipmunkapublishing, 2000.
__________________________________________________________________
8
G. Hopkins, Festival Preview: Bonkerfest!, Viewed on August 24, 2008,
http://www.communitycare.co.uk/Articles/2008/08/13/104653/festival-preview-
bonkerfest.html.
9
Mad Pride UK 2008, May 17th Subway Sect and Angel Racing Food, Viewed on
September 24, 2008, http://madpride.org.uk/events/eventsubwaysect.php.
10
G. Glaser, ‘Mad Pride Fights a Stigma’, New York Times, Viewed on August 24,
2008, http://www.nytimes.com/2008/05/11/fashion/11madpride.html.
11
P. Dawdy, ‘Furious Seasons’, The New York Times On ‘Mad Pride’, May 10,
2008, Viewed on August 24, 2008, http://www.furiousseasons.com/archives/
2008/05/the_new_york_times_on_mad_pride.html.
12
Flawedplan, Writhe Safely, About Sunday’s NY Times Piece on MAD PRIDE,
May 12, 2008, Viewed on August 24, 2008, http://writhesafely.wordpress.com/
2008/05/12/about-sundays-ny-times-piece-on-mad-pride/.
13
One of the best available descriptions is on Wikipedia. Wikipedia Contributors,
Consumer/Survivor/Ex-Patient Movement, Viewed on August 24, 2008, http://en.
wikipedia.org/wiki/Consumer/survivor_movement.
14
Pfizer, Causes of Depression, Viewed on September 6, 2008, http://www.
zoloft.com/content/depr_causes.jsp?setShowOn=../content/learning_about_depress
ion.jsp&setShowHighlightOn=../content/depr_causes.jsp .
15
GlaxoSmithKline, SSRIs like Paxil CR Help to Balance Serotonin, Viewed on
September 6, 2008, http://www.paxilcr.com/how_paxilcr_works/how_paxilcr_
works.html.
16
J.R. Lacasse & J. Leo, Serotonin and Depression: A Disconnect between the
Advertisements and the Scientific Literature, Vol. 2, No. 12, PLoS Medicine,
Viewed on September 23, 2008, http://medicine.plosjournals.org/perlserv/?req
uest=get-document&doi=10.1371/journal.pmed.0020392.
Bibliography
Cooper, D., The Language of Madness. London, Allen Lane, 1978.
Curtis, T., Dellar, R., Leslie, E. & Watson, B. (eds), Mad Pride. Spare Change
Press/Chipmunkapublishing, 2000.
Dawdy, P., ‘Furious Seasons’. The New York Times On ‘Mad Pride’. May 10,
2008, Viewed on August 24, 2008, http://www.furiousseasons.com/archives/
2008/05/the_new_york_times_on_mad_pride.html.
__________________________________________________________________
Flawedplan, ‘Writhe Safely’. About Sunday’s NY Times Piece on MAD PRIDE.

May 12, 2008, Viewed on August 24, 2008, http://writhesafely.wordpress.com/
2008/05/12/about-sundays-ny-times-piece-on-mad-pride/.
Glaser, G., ‘Mad Pride Fights a Stigma’. New York Times. Viewed on August 24,
2008, http://www.nytimes.com/2008/05/11/fashion/11madpride.html.
GlaxoSmithKline, SSRIs like Paxil CR Help to Balance Serotonin. Viewed on

September 6, 2008, http://www.paxilcr.com/how_paxilcr_works/how_paxilcr_wo
rks.html.
Goffman, E., Stigma: Notes on the Management of Spoiled Identity. London,

Penguin, 1968.
Hopkins, G., Festival Preview: Bonkerfest! Viewed on August 24, 2008,

http://www.communitycare.co.uk/Articles/2008/08/13/104653/festival-preview-
bonkerfest.html.
Lacasse J.R. and Leo, J., Serotonin and Depression: A Disconnect between the
Advertisements and the Scientific Literature. Vol. 2, No. 12, PLoS Medicine.
Viewed on September 23, 2008, http://medicine.plosjournals.org/perlserv/?req
uest=get-document&doi=10.1371/journal.pmed.0020392.
Mad Pride, About Mad Pride. Viewed on August 24, 2008, http://www.ctono.
freeserve.co.uk/id17.htm.
Mad Pride, That Mad Pride Name Again. Viewed on August 24, 2008,
http://www.ctono.freeserve.co.uk/mpname.htm.
Mad Pride UK 2008, May 17th Subway Sect and Angel Racing Food. Viewed on
September 24, 2008, http://madpride.org.uk/events/eventsubwaysect.php.
NAMI, ‘Dual Diagnosis: Adolescents with Co-occurring Brain Disorders &

Substance Abuse Disorders’. Viewed on August 27, 2008, http://www.nami.org/
Content/ContentGroups/Illnes ses/Dual_Diagnosis_Fact_Sheet.htm.
Pfizer, Causes of Depression. Viewed on September 6, 2008, http://www.zoloft.

com/content/depr_causes.jsp?setShowOn=../content/learning_about_depression.jsp
&setShowHighlightOn=../content/depr_causes.jsp .
__________________________________________________________________
Zachar, P., Psychological Concepts and Biological Psychiatry. John Benjamins

Publishing, Philadelphia, 2000.
Christian Perring is an Associate Professor of Philosophy at Dowling College,

New York, USA and is Editor of Metapsychology Online Reviews. His main
research interests are in philosophy of psychiatry, moral psychology and personal
identity.
PART IV
Cultural Representations of Madness

They Wouldn’t Make Good Ophelias: Reality of Experience in
Women’s Madness Narratives
Katarzyna Szmigiero
Abstract
20th century human sciences criticized bio-medical psychiatry for its reductionist
attitudes as psychiatric diagnosing is based on culturally and historically dependant
factors. It is also guilty of gender bias. Moreover, diagnostic criteria and
procedures used worldwide vary, which suggests the inability of contemporary
medicine to pinpoint the legitimate psychiatric complaint. That is why anti-
psychiatry thinkers have denied the existence of mental illness, regarding it as a
social construct, an attempt to stigmatize unorthodox members of the society. They
frequently idealised madness. Ironically, such an attitude was more often expressed
by scholars than the patients themselves. Those who suffer from a mental disorder
might reject pharmacological treatment or patronizing medical establishment; yet,
they would seldom go as far as to question the existence of the illness itself or view
it as beneficial. Mental disorder, for the sufferer, is a painful, desolating reality,
threatening one’s sense of integrity. This chapter analyses the experience of mental
illness and its consequences as expressed in women’s madness narratives. Contrary
to anti-psychiatrists’ beliefs, the characters in these texts do not perceive
themselves as scapegoats punished by psychiatric machinery for various
transgressions but as individuals who, due to their mental agony, are unable to
cope with everyday life.
Key Words: Anti-psychiatry, gender, madness, narrative, women.
*****
1. Introduction
20th century human sciences often criticised bio-medical psychiatry for its
reductionist attitudes. Undoubtedly, psychiatric diagnosing is based on subjective,
culturally and historically dependant factors. Within the last hundred years some
illnesses have completely disappeared like, for instance, neurasthenia; others have
transformed beyond recognition since the symptoms of hysteria as described by
Jean-Martin Charcot have been now replaced by a myriad of complaints, among
others, by multiple personality and chronic fatigue syndrome. They all appear to be
caused by the same subconscious processes to convert mental discomfort into
physical symptoms, yet their manifestations are unbelievably distant. Some
tendencies little known in the previous centuries have grown into epidemic
proportions - few ‘fasting girls’ are now an army of anorectics and bulimics. Many
new conditions have been recognized and labelled - premenstrual tension
syndrome, borderline personality or attention deficit disorder. Simultaneously,
166 They Wouldn’t Make Good Ophelias
__________________________________________________________________
some behaviours, notably homosexuality, have been de-medicalised and taken off
official registers. Moreover, ethno-psychiatry has proved that what is perceived as
pathological in one culture can be seen an entirely normal, or even desirable, in
another. All this suggests that it i s rather our perception of what is a legitimate
illness that constitutes a separate entry in a psychiatric textbook, not unchanging,
objective, external reality.
Modern psychiatry is also guilty of gender bias as it m ore willingly
pathologises irregular female behaviour than male deviancy. It is partly due to the
fact that the norms of healthy adult personality correspond to norms of masculinity,
from which expectations towards femininity differ, as the famous experiment by
Inge Broverman proved. 1 Women, in order to fit their gender role, are to be
emotional, submissive, passive and dependant on others. Yet, such a personality is
undesirable in a grown-up and might be diagnosed as an illness. On the other hand,
if women exhibit such features as professional ambition, rationality, ability to
control their emotions and simultaneously express lack of interest in activities
perceived as ‘feminine,’ they may be seen as psychologically weird, thus,
unhealthy. No matter if a woman conforms to or transgresses from social
expectations she is likely to be perceived as pathological. On the other hand,
psychiatry seldom looks at undesirable male behaviour as a mental disorder.
Substance abuse, alcoholism, violence, especially within the family, tends to
interest policemen, not doctors. They are interpreted as personal faults which are a
consequence of individual’s inappropriate moral choices, not as an illness. Thus,
women are mad and unable to control themselves, men are bad yet potentially they
could become good if they would be bothered to make an effort and the state
ensures they are forced to re-socialise, placing them in prisons.
Moreover, diagnostic criteria, procedures and verdicts used worldwide vary.
Morton Kramer in the 1960s presented a video-recording of a potential patient to a
group of American psychiatrists. They offered three contradictory diagnoses
(schizophrenia, personality disorder, neurosis) while the British doctors, viewing
the same patient, did not recognize any schizophrenic traits. 2 In an equally
disturbing experiment David Rosenhan proved that after lying during a hospital
admittance the staff was not able to realize they have sane people on their wards.
Later, ‘the staff at a r esearch and teaching hospital was falsely informed that at
least one pseudopatient would attempt to be admitted to the psychiatric ward. Of
193 patients, 41’ were recognised as malingerers while no false patient was ever
sent to that hospital! 3 Likewise, the some American doctors often diagnose
multiple personality while others never do that. Some claim the disorder does not
exist but is projected onto the patients by manipulative therapists.
Needless to say, this difficulty has wide ranging consequences as it determines,
for instance, who can receive disability pension, be legally incapacitated, forced to
undergo medical treatment or found not guilty after committing even a most
atrocious crime. Thus, it seems that achieving objectivity and uniformity in
Katarzyna Szmigiero 167
__________________________________________________________________
psychiatric diagnosing and treatment will never be entirely divorced from social
norms, expectations and moral judgements.
That is why some anti-psychiatry thinkers have denied the existence of mental
illness and questioned psychiatry as a b ranch of medical science. Thomas Szasz
and Michel Foucault regarded it as a social construct and an attempt to stigmatize
unorthodox members of the society rejecting the bourgeois status quo. For Erving
Goffman, asylum was an instrument of power, a total institution the aim of which
is to standardize inmates’ behaviour. That was, and in some cases still is,
undeniably true in many totalitarian regimes which lock up political dissidents.
Ronald David Laing, David Cooper and Joseph Berke claimed madness is not a
pathology but a comprehensible, ‘sane’ reaction to insane environment, such as
capitalism or unbearable family tensions. Most of them would use the words
mental illness in inverted commas, emphasising the arbitrary character of the label.
For instance, Berke refers to ‘something called schizophrenia’ 4 as if the term was
arbitrary. This tradition is not entirely extinct as many opponents of biomedical
psychiatry still adhere to this custom. Anti-psychiatrists frequently idealised
madness seeing it as rebellion, which liberates the self from everyday restrictions.
Ironically, such an attitude was more often expressed by scholars or even avant-
garde doctors than the patients themselves. Those who suffer from a mental
disorder might reject pharmacological treatment or patronising medical
establishment; yet, they would seldom go as far as to question the existence of the
illness itself or view it as beneficial. Mental disorder, for the sufferer, is a painful,
desolating reality, threatening one’s sense of integrity as well as quality of life,
personal happiness or employment opportunities. Undoubtedly, in cases of mild
mania, it might contribute to outbreaks of creativity, yet reasoning that the
imaginative activity could not have been achieved without madness is both
groundless and risky - after all, most productive individuals are sane. Moreover, art
frequently functions as therapy, helping to alleviate symptoms and to regain a
sense of self. Thus, seeing madness as a cause of creativity is incongruous with
perceiving creativity as a cure for madness.
2. Women’s Madness Narratives

I want to analyse the subjective experience of mental illness and its
consequences as expressed in women’s madness narratives. This genre, comprising
both autobiographic novels and non-fiction accounts of insanity and
hospitalisation, has a distinct literary tradition in woman’s writing in English which
can be traced back to the medieval Book of Margery Kempe, which is probably the
first autobiography written in English. Gradually, the started being published in
literary periodicals and attracted the interest of non-medical audiences. The
majority of madness narratives were written in the last two centuries. The 19th
century texts are mostly sensational in nature and focus on exposing abuses to
which psychiatric patients were subjected. 5 Their authors’ aim was to lead to
__________________________________________________________________
asylum reforms and changes in the legal status of women, who were incarcerated
by their male relatives, frequently before prior medical examination. The most
known asylum autobiography was authored by Elizabeth Packard, whose husband,
a clergyman, disapproved of her religious views. Sophie Olsen and Elizabeth Stone
claim they were removed to asylums for similar reasons. An objective modern
reader would easily notice that mania and paranoid delusions are present in many
of these stories, for example in Clarissa Lathrop’s narrative. These women hardly
ever describe the inner anguish caused by madness as they simply deny ever being
ill. Instead, they focus on h orrors of force feedings, mechanical restraints,
unscrupulous attendants and corrupted doctors. Ironically, mentioning other
inmates, expressions like ‘dangerous lunatics’ are unsparingly used while the
sanity of the author is repeatedly stressed.
A notable exception to this trend is provided by Charlotte Perkins Gilman’s
famous The Yellow Wallpaper (1892). It is a semi-biographical account on how
limited gender roles and isolation combined with well-meaning but unimaginative
carers can transform a nervous indisposition into a full-blown psychosis. Gilman
focuses on the inner life of her protagonist and analyses her descent into madness.
Her protagonist is a young upper-class mother who complains of vague
nervousness and oversensitivity. Her rational and conservative husband is also a
physician - an obvious embodiment of patriarchal and scientific control over
women. Following the famous Weir-Mitchell’s rest cure, the young woman is
deprived of intellectual stimuli and confined to a quiet bedroom. Boredom caused
by isolation and overprotective relatives breed paranoia and hallucinations.
Gilman’s story is surprisingly modern as it, on the one hand, blames the
incongruity of female social roles with their true ambitions as the cause of madness
but, on the other hand, describes the horrors of the deranged mind.
More recent works are, similarly to Gilman’s tale, more private in nature
although their feminist and political aspects cannot be neglected. Nevertheless,
since the legal status of women has changed, their option of life choices broadened
and general conditions of living dramatically altered, comparing psychiatric
complaints, their causes and cures, for 19th and 20th century women is rather
pointless. For the sake of coherence, this article focuses only on the 20th century
accounts.
Despite numerous differences, asylum narratives share several important
features. First of all, they are predominantly produced by women. It can be partly
explained by the fact that historically many more women then men fell victims to
psychiatric complaints due to their relative social and economic powerlessness.
Moreover, patriarchal communities encourage women to be selfless creatures,
sacrificing their own needs and ambitions for the sake of their loved ones.
Modesty, submission, self-denial are traditional female attributes. Yet, to quote
Sandra M. Gilbert and Susan Gubar ‘[t]o be trained in renunciation is almost
necessarily to be trained to ill health, since the human animal’s first and strongest
__________________________________________________________________
urge is to his/her own survival, pleasure, assertion.’ 6 On the other hand,
contemporary demands expect women to be competitive, outgoing and successful
in several fields at the same time. Trying to be an accomplished cook, perfect
hostess, great mother, seductive lover, and productive professional is, ironically,
equally debilitating as being told to abandon all ambitions. In a way, both
traditional and modern cultures contribute to female psychopathology by setting
impossible role-models.
Another explanation why madness narratives have been predominantly
produced by women can be provided by Estelle C. Jelinek. She observes that
women’s autobiographies tent to focus on personal matters and do not shun from
admitting to failures or succumbing to adversities while men write about their
professional careers - ‘touting their exploits in historical chronicles or res gestae.’ 7
Since being declared mad can hardly qualify as an achievement, it is no surprise
few men directly deal with this issue. Furthermore, male writers aim at projecting a
‘self-confident, one-dimensional self-image’ while their female counterparts
‘depict a multidimensional, fragmented self image colored by a s ense of
inadequacy and alienation, of being outsiders or other.’ 8 Women try to write an
apology of their life choices while men do not consider they need to vindicate or
apologize for anything. Thus, the experience of being pronounced insane appears
to be an ideal subject matter for a woman’s autobiography.
Furthermore, the great majority of these texts has been written in the United
States, with only few notable exceptions. Those include postcolonial writers such
as such as Janet Frame (New Zealand), Bessie Head (Botswana), Kate Grenville
and Alexis Wright (both from Australia) as well as English anti-psychiatry classic
co-authored by Mary Barnes and Joseph Berke, which offers an insight into the
philosophy of Kingsley Hall community. If British literature is concerned, major
madness narratives come from Antonia White’s novels, a thinly disguised
autobiography. Curiously enough, Virginia Woolf, a perfect candidate for the
genre both in terms of literary talent and profound mental difficulties seldom wrote
about her illness directly in fiction.
Finally, contrary to anti-psychiatrists’ beliefs, most characters in these texts do
not perceive themselves as scapegoats punished by psychiatric machinery but as
individuals who are unable to cope with everyday life. They desperately seek relief
from their misery as, sometimes, psychotherapy or drugs are able to provide it.
3. Unconvincing Accounts of Sanity

Ironically, the writers who created their narratives ‘to convince the sceptical
audience of [their] sanity’ 9 appear much less convincing than the ones who
acknowledge their experience of madness as an external threat to their integrity and
well-being. Two texts fall clearly into this category: Angel at my Table, which is
the second volume of Janet Frame’s autobiography and Kate Millett’s The Looney-
Bin Trip. After an adolescence marred by poverty, deaths of two sisters and unease
__________________________________________________________________
connected with menstruation, Frame describes how she found herself
mis/diagnosed as a schizophrenic. However, her growing shyness and
secretiveness combined with confabulation of picaresque symptoms in order to win
the attention of John Money, her university lecturer and therapist, suggest a highly
immature and withdrawn personality. Likewise, a melodramatic suicide attempt
and a f it of screaming at the sight of her mother coming to fetch her from the
psychiatric ward contribute to the impression of an unbalanced mind. After her
release from the asylum Frame voluntarily spent some time in a London hospital,
where her schizophrenic diagnosis was refuted. Tired with her label as a ‘mad
writer’ Frame asked her doctor to write an official letter explaining her mental
condition. The psychiatrist, admits that Frame was ‘under [his] care between 1958
and 1963’ and ‘she has never suffered from a mental illness in any formal sense.’ 10
One could wonder why an entirely sane person needs to visit a psychiatrist for five
years, though. Simultaneously, the Maudsley Hospital diagnosis at discharge was
that ‘of a p athological personality with schizoid and depressive features, and
difficulties on ordering perceptions and controlling behaviour.’ 11 It seems that
Frame, in an attempt to prove her sanity, plunges herself even deeper into
inconsistencies.
Yet, as her biographer Michael King observes, Frame willingly sought
psychiatric treatment in later life. A critical reading of her autobiography discloses
a rather disturbing image of a woman whose mental stability and emotions
frequently get out of her control, who seeks professional assistance yet refuses
admitting she has a mental disorder. Simultaneously, she confesses how her
behaviour frequently alienated her from other people, whose company and
approval she badly missed and forced her to seek menial employment much
beneath her abilities. In a similar manner, Kate Millett denies her diagnoses and
perceives her hospitalisations as a plot devised by her family and partners. Again,
reading about her swinging moods, sleeplessness and bouts of loquacity combined
with spending sprees one can reach a conclusion that Millet indeed became maniac
and was not able to judge her own behaviour. Especially her fascination with a stud
she bought is worrying. She feels sexually attracted to the animal as it … reminds
her own her father. 12 No wonder, her partner and family suggest hospitalisation.
One could hardly argue incest and zoophilia are synonymous with mental balance.
The two texts are classic examples of employing the strategy of denial as a
coping tool. Unable or unwilling to accept their diagnosis and suggested treatment,
both women fail to see their behaviour as dysfunctional and blame their
surroundings - family, friends, medical staff. Needless to say, Frame and Millett
end up hospitalised against their will, alienate their friends and are unable to pursue
their careers.
__________________________________________________________________
4. Admitting to Madness
Most asylum narratives, however, do not reject the reality of the illness.
Ironically, feminist critics often dismiss them because of it, claiming such women
‘testify against themselves by viewing themselves as mentally unhealthy.’ 13 Thus,
they commit the same mistake for which they have blamed the male doctors -
patriarchy used to know better what women should feel and how they should think,
now radical feminists know better how other women should interpret their life
experiences.
Nevertheless, books such as Sylvia Plath’s The Bell Jar (1963) Joanne
Greenberg’s (Hannah Green’s) I Never Promised You a Rose Garden (1964), Lori
Schiller’s The Quiet Room (1994) and Elizabeth Wurtzel’s The Prozac Nation
(1994) or Elyn R. Saks’s The Center Cannot Hold (2007) present the devastating
effects of a mental illness. Their brave depiction of the physical squalor of the
illness caused by indifference to even rudimentary personal hygiene
deromanticises madness. Traditionally, for instance the madness of Ophelia was
manifested in her incomplete clothing and loose hair. Although in the Elizabethan
fashion, the play’s stage directions are rather skimpy - ‘Enter Ophelia, distracted’,
many directors regarded them as an excuse to show her in disarrayed apparel or
even in negligee. Having a young aristocratic woman appear in public in lingerie
signified that insanity deprived her of feminine modesty. Nevertheless, her derange
mind ironically added to her charms - she was seductive and vulnerable at the same
time. Female autobiographic accounts of the illness, however, are much less
flattering. Plath’s heroine wears the same borrowed skirt and blouse for three
weeks, without washing them, Greenberg’s Deborah has ‘lank hair, dirty, flabby’ 14
while Lori’s ‘clothes seemed like she had slept in them. Her hair, once shiny and
bouncy, stuck together in oily strands, looking as if she hadn’t washed it in
weeks.’ 15 Mary Barnes experiments with her excrement, on one occasion
completely covering her whole body in it - literally from head to toes. Thus, with
their greasy hair and stained clothing stiff with dirt they make very bad Ophelias -
their behaviour is not elegant, appealing or even rebellious as they have hardly any
control over it. Moreover, many characters engage in acts of deliberate self-harm,
which further mars their skin with hideous burns, scars and bruises. Wurztel scars
her legs with razors or digs holes in them obsessively tweezing minute hairs, Saks
and Greenberg burn their own flesh, Kaysen bangs her wrists against a rocking
chair. Such a destructive behaviour becomes an irresistible compulsion. Yet,
physical ugliness is only an external manifestation of the internal chaos. As inner
suffering is impossible to convey in words, the characters resort to maiming or
disfiguring their bodies to render their despair. Before they learnt to understand
and express themselves well enough to put their stories on paper, self-mutilation
had provided the only available method of communication.
__________________________________________________________________
5. Loss of Selfhood and Agency
Another source of agony is a complete lack of control over one’s moods or
responses. It is especially visible in the case of schizophrenic patients, constantly
accompanied by threatening voices which humiliate them, urging them to commit
suicide - ‘You must die! You will die! (…) You whore bitch who isn’t worth a
piece of crap!’ 16 Saks and Schiller report obscenities and urges to commit suicide
while the Kingdom of Yr, invented by Greenberg as a s helter against unbearable
pressures she experiences in the real world, soon starts demanding self-mutilation
from the young woman.
Overwhelming misery makes Wurtzel take part in wild parties and casual sex.
Although she feels guilty afterwards, the momentary pleasure caused by the
physical warmth of another person makes her sleep around. She entitles chapter 12
‘The Accidental Blowjob’ expressing the involuntary character of the act. Wurtzel
is frank about her self-destructive behaviour:
[t]he thing is, there was never any pleasure, no element of

partying in any of the drug abuse I was involved with. It was all
so pathetic, so sad, so psychotic. I was loading myself with
whatever available medication I could find, doing whatever I
could do to get my head to shut off for a while. 17
Although other madness narratives have not been equally explicit, Frame
mentions her first (and only) proper love affair was a result of curiosity, not
affection while Plath’s Esther engages herself in heavy drinking and desperately
attempts to loose her virginity; neither women experience much pleasure from their
actions. Ironically, all of them used to have rather romantic expectations about
their future love life.
Wurtzel is also very honest that her behaviour estranged and hurt the people she
sincerely cared for - yet was unable to express it. She sleeps with her best friend’s
boyfriend to take him away from her, ignores her grandparents’ visit although they
travelled five hundred miles there only to see her, and makes her mother feel guilty
she must have contributed to her illness. Her most counter-productive behaviour,
though, is her treatment of her boyfriend. Although the man is truly involved and
protective he runs out of patience when Wurtzel calls him a dozen times a day,
visits him unexpectedly and cries all the time. She is so certain he would leave her
that she makes her greatest nightmare come true. Likewise, Lori Schiller offends
people telling them nasty things about their appearance or releasing confidential
information to her co-workers. Unsurprisingly, it makes her lose her friends and
her job in one evening. She also, like Wurtzel, resorts to street drugs as they make
her auditory hallucinations less pronounced:
__________________________________________________________________
[c]ocaine (…) helped me to ignore the Voices. For as long as it
lasted, cocaine made me feel alive. It made my senses feel sharp
and clear again. When I did a line I felt good, I felt real, I felt
vital in a way I hadn’t since the Voices entered my life. Cocaine
directed my attention outside of myself. 18
Promiscuity and/or substance abuse are extreme instances of loss of agency.

Nevertheless, characters are also exposed to more mundane lack of control of their
daily routines, which make living impossible. In More, Now, Again Wurtzel
describes how washing and dressing every morning or choosing which tea to have
for breakfast would regularly turn into sources of agony. Inability to make up her
mind would result in leaving most every-day tasks unaccomplished. Saks starts
stammering as she cannot remember the sentence she has started uttering. She also
does not wash, eat or sleep regularly as she forgets to do so - all the aspects of
living demand so much effort that there is hardly any energy left for proper self-
care. Similarly, Frame, who wants to submit her work to a students’ magazine, is
too self-conscious to enter the common room and leave it in a box provided for the
purpose. Sending it by post does not occur to her. These examples prove that
madness makes daily living impossible as things people take for granted, such as
getting up, washing, having breakfast and leaving turn into ordeals.
6. Conclusions
For all the women mental illness is an alien force that disturbs their daily lives,
breaks their hopes and plans for the future. It causes they are no longer in control
of their thoughts, memories, feelings and behaviour - their feel their usual sense of
self has been replaced by some malignant usurper. Although some try to find
explanations to their present state in childhood trauma, yet all are aware that these
events might have only partly contributed to the onset of the illness, which will
forever remain inexplicable. It is not the society that stigmatizes them for their
difference, or sadistic psychiatrist who want to maintain their jobs, inventing
diagnoses for non-existent symptoms. Quite the contrary, it is wise and patient
therapists as well as loving and supportive family members who help them to
master their illness. Their writing stimulates the healing process and gives a
testimony to their fight. Jane Ussher observes that ‘the deconstruction of madness
alone does not remove women’s unhappiness […] since no real working alternative
to the oppressive treatment of madness was ever mooted.’ 19 Likewise, the
observations of sociologists who ling the illness with economic powerlessness and
oppression does little to remedy the situation as it i s naïve to believe a u topian
society with no poverty, abuse or personal unhappiness will ever come into being.
Thus, the role of personal accounts of people who fell ill and managed to combat
the illness can never be overestimated.
__________________________________________________________________
Notes
1
See S. Hubert, Question of Power: The Politics of Women’s Madness Narratives,
University of Delawere Press, Newark, 2002, p. 62; D. Russell, Women, Madness
and Medicine, Polity Press, Cambridge, 1995, pp. 30-33.
2
R. Jaccard, Szaleństwo (org. La Folie), Wydawnictwo Siedmiogród, Wrocław,
1993, pp. 37-38.
3
Hubert, op. cit., pp. 87-88.
4
M. Barnes & J. Berke, Mary Barnes: Two Accounts of a Journey through
Madness, Harcourt Brace Jovanovich, New York, 1972, p. 78.
5
See J. Geller & M. Harris, Women of the Asylum: Voices From behind the Walls,
1840-1945, Anchor Books, New York, 1994 a nd M. Wood, The Writing on the
Wall: Women’s Autobiography and the Asylum, Anchor Books, New York, 1994.
6
S.M. Gilbert & S. Gubar, The Madwoman in the Attic: The Woman Writer and
the Nineteenth-Century Literary Imagination, Yale, Nota Bene, 2000, p. 54.
7
E. Jelinek, The Tradition of Women’s Autobiography: From Antiquity to the
Present, Twayne Publishers, Boston, 1986, p. 53.
8
Ibid., p. xiii.
9
M. Wood, op. cit., p. 1.
10
Quoted in M. King, Wrestling with the Angel: A Life of Janet Frame, Picador,
London, 2001, p. 388.
11
Ibid., p. 187.
12
K. Millett, The Loony-Bin Trip, Touchstone, New York, 1990, pp. 128-132.
13
Hubert, op. cit., p. 62.
14
J. Greenberg, I Never Promised You a Rose Garden, Signet, New York, 1989, p.
148.
15
L. Schiller & A. Bennet, The Quiet Room: A Journey Out of the Torment of
Madness, Warner Books, New York, 1996, p. 44.
16
Ibid., p. 6.
17
E. Wurtzel, Prozac Nation: Young And Depressed in America, Riverhead Books,
New York, 1995, p. 121.
18
L. Schiller & A. Bennet, op. cit., p. 104.
19
J. Ussher, Women’s Madness: Misogyny or Mental Illness? Harvester
Wheatsheaf, London, 1991, p. 214.
Bibliography
Barnes, M. & Berke, J., Mary Barnes: Two Accounts of a Journey through
Madness. Harcourt Brace Jovanovich, New York, 1972.
Fee, D. (ed), Pathology and the Postmodern: Mental Illness as Discourse and
Experience. Sage Publications, London, 2000.
__________________________________________________________________
Frame, J., An Autobiography. Vintage, Auckland, 2004.
Geller, J. & Harris, M., Women of the Asylum: Voices From behind the Walls,
1840-1945. Anchor Books, New York, 1994.
Gilbert, S. & Gubar, S., The Madwoman in the Attic: The Woman Writer and the
Nineteenth-Century Literary Imagination. Nota Bene, Yale, 2000.
Greenberg, J., I Never Promised You a Rose Garden. Signet, New York, 1989.
Hubert, S.J., Question of Power: The Politics of Women’s Madness Narratives.

University of Delawere Press, Newark, 2002.
Jaccard, R., Szaleństwo. Wydawnictwo Siedmiogród, Wrocław, 1993.
Jelinek, E., The Tradition of Women’s Autobiography: From Antiquity to the

Present. Twayne Publishers, Boston, 1986.
King, M., Wrestling with the Angel: The Life of Janet Frame. Picador, London,
2001.
Millet, K., The Loony-Bin Trip. Touchstone, New York, 1990.
Russell, D., Women, Madness and Medicine. Polity Press, Cambridge, 1995.
Schiller, L & Bennett, A., The Quiet Room: A Journey Out of the Torment of
Madness. Warner Books, New York, 1996.
Strong, M., A Bright Red Scream: Self-Mutilation and the Language of Pain.
Penguin Books, New York, 1999.
Ussher, J., Women’s Madness: Misogyny or Mental Illness? Harvester Wheatsheaf,

London, 1991.
Wood, M., The Writing on the Wall: Women’s Autobiography and the Asylum.
University of Illinois Press, Urbana, 1994.
Wurtzel, E., Prozac Nation: Young and Depressed in America. Riverhead Books,
New York, 1995.
__________________________________________________________________
Katarzyna Szmigiero is an Assistant Professor at the English Department of

University of Jan Kochanowski in Piotrków Trybunalski, Poland. Her research
interest concentrates on cultural representations of psychiatry and mental illness as
well as writing as a form of therapy.
Hanago in Distress: The World of Hanjo in the Noh Theatre
Keiko Kimura
Abstract
Hanjo is a play featuring a deranged woman, written and first staged by Zeami
Motokiyo in the fourteenth century in the Muromachi period Japan. In Hanjo, the
heroine Hanago’s endless waiting for her lover, a courtier Yoshida, takes her into a
state of derangement. Zeami established the genre of noh called ‘monogurui noh’
(frenzied noh). He writes that there are two kinds of ‘monogurui noh’ in which the
former deals with madness because of possession by spirits and the latter, because
of distress. The latter one is called ‘kyojo’mono’ (plays in the mad-woman style),
and Hanjo is one of the best known ‘kyojo’mono.’ From Hanago’s dialogue and
song, we understand that Hanago is preoccupied with the loss of her lover, and her
grief in losing him arises frequently. According to Kleinian hypothesis, the loss of
the present object in the external world brings with it the person’s unconscious
fantasies of having lost one’s internal good objects as well. Every time grief arises,
it undermines the feeling of secure possession of the loved internal objects. This
kind of mourning-like state makes Hanago feel ambivalently towards Yoshida. She
regresses to the infantile Kleinian paranoid-schizoid position, emotionally
oscillating between love and hatred towards him. That is why it i s difficult for
Hanago to promote separation from him and her self-integration. Hanago loses her
sanity because of her ambivalent feelings towards him. But in the last scene of the
play, Hanago is suddenly restored to sanity after reconciliation with her long-lost
lover, Yoshida. Different from the Western mad-woman plays, Zeami’s
‘kyojo’mono’ tends to have a happy ending. In medieval Japan, though shocked by
the mad women’s attitudes and actions in ‘kyojo’mono,’ the audience was relieved
by the plays’ happy-ending, and felt a kind of catharsis.
Key Words: Hanjo, mad woman, Melanie Klein, noh theatre, Tale of Genji,
Zeami.
*****
Hanjo is a play featuring a deranged woman, written and first staged by Zeami
Motokiyo in the fourteenth century in the Muromachi period Japan. With his father
Kan’ami, Zeami, a playwright, a dancer, and a director, refined and highly stylized
the noh theatre which previously had been a form of rustic entertainment. In
Hanjo, the heroine Hanago’s endless waiting for her lover, a courtier Yoshida,
takes her into a state of derangement.
Zeami established the genre of noh called ‘monogurui noh’ (frenzied noh). He
writes that there are two kinds of ‘monogurui noh’ in which the former deals with
madness because of possession by spirits and the latter, because of distress. The
178 Hanago in Distress
__________________________________________________________________
latter one is called ‘kyojo’mono’ (plays in the mad-woman style), and Hanjo is one
of the best known ‘kyojo’mono’ which includes Hyakuman and Sumidagawa
among others.
Hanjo is originally an historical figure, Pan Chieh-Yu from Han Dynasty
China. She had been the favourite of emperor Cheng-ti, but she was discarded as
the emperor became fixated with a s ensual femme-fatale-like beauty.
A mournful Pan compares herself to a round fan used in summertime and put away
in autumn in one of her famous poems, ‘A poem on regret.’ The fan Pan has is a
round, snowy, moon-like one whose shape and colour is like the full moon.
Without the light of the sun (the emperor), the moon (Pan) cannot shine. Pan is
passive in her fate. She laments her lost love in the poem:
A newly torn strip of fine white silk

As unsullied as frost and snow.
Cut into a shared-pleasure fan,
Carefully rounded like the full moon.
No matter where the lord goes, tucked into his sleeve,
When moved, it stirs him a light breeze.
Often feared, the arrival of the autumn season
The cool winds that carry off the fiery heat,
Causing it to be tossed into the bamboo hamper –
Favour and love out off before they run their course. 1
Pan Chieh-Yu (Hanjo) has been versed in the poetry and literature of China and
post-Heian period Japan.
The heroine of the play, Hanago is a ‘yujo’ or ‘asobime’ (‘geisha’ in the
relatively recent term), at an inn in Nogami, which was one of the main post-
stations on Nakasendo in Minonokuni in the Heian period. From the Heian period
to the Muromachi period, yujo’s main work was dancing and singing to
entertain inn guests or travellers.
One day in springtime, Hanago happens to meet Yoshida, one of her passing
guests on his way from Kyoto to Togoku. Their encounter is a fateful one for both
of them. Although their social status is different, they instantly fall in love, and he
promises to come back and marry her after he finishes his official mission to
Togoku.
As a pledge of their love, they exchange their fans. On Hanago’s fan, a yugao
(moonflower in English) is painted; on Yoshida’s, the moon at twilight.
The yugao has a white round flower which blooms on summer evenings and fades
before the dawn. The shape of its blossom is like the full moon. The name yugao
reminds us of the transient and fragile-natured woman, Yugao in Genji Monogatari
(The Tale of Genji), written by Murasaki Shikibu in the eleventh century.
Keiko Kimura 179
__________________________________________________________________
Prince Genji, the son of the emperor, happens to meet Yugao, a l ower class
woman. He has made love to her, and she is cursed to death by the ‘mononoke’
(the malevolent spirit) of Genji’s other lover, Rokujo-no-miyasudokoro on the next
day of the full moon. Rokujo is consumed by jealousy for Yugao, and her
unconscious spirit visits Yugao. The meaning of the Chinese characters ‘Yugao’ is
‘an evening face (the twilight beauty).’
The meaning of the Chinese characters of ‘Hanago’ is a ‘flower child.’ The
image of the flower is beautiful, but transitory. In Zeami’s Fushikaden (The
Flowering Spirit), analysis of the art of acting and dancing noh, ‘hana’ (flower) is
the most important word meaning the pageantry of performances which attracts
people.
The stage opens with a s peech by the female manager of the Nogami post-
station inn who complains about Hanago’s neglect of her job as a yujo and the
story behind it. She gets angry with the fact that Hanago is persistently preoccupied
with her love for Yoshida. The only thing Hanago does is to moon over the fan he
gave her, remembering the night with him. Hanago’s attitude is so vexing for the
manager that she decides to fire Hanago from her job. For hopeless Hanago, the
only way left is to go westwards to Kyoto where Yoshida is supposed to live. She
thinks that she might see him again there. But she does not know where he is.
Finally, her (mind) wanderings take her to the Tadasu Forest. For her, as a
homeless woman, the forest is a safe, enclosed place, protection against incursions
from the dangerous outside world.
The Tadasu Forest surrounds the Shimogamo Shrine. From ancient times, the
forest has been regarded as the sanctuary of the gods in Japan, and the original
shrine had been the forest itself which was respected and revered as a holy place
where the gods lived. That is why the Shimogamo Shrine was built in the forest.
The Tadasu Forest is located on the delta of the Kamo river and the Takano river,
where the two rivers meet and become the Kamo river– the pronunciation remains
the same but the Chinese characters change. This conjunction of rivers is why it is
believed that the god of marriage lives in the Tadasu Forest.
In the next scene, the season is autumn. After his mission in Togoku, the
courtier Yoshida visits the inn at the Nogami post-station in order to see Hanago
and take her to Kyoto. But it is after Hanago has left the inn. In vain, he goes back
to Kyoto and decides to go to the Shimogamo Shrine to pray to be reunited with
her.
The following scene is set in the Tadasu Forest. As the season changes from
summer to autumn, melancholic Hanago doubts whether Yoshida will keep his
promise to get married. She starts to feel some animosity towards him as she states:
‘The faithless man! O he is hateful, hateful!’ 2 We find a strong emotional tension
emerge within her.
From her dialogue and song, we understand that Hanago is preoccupied with
the loss of her lover, and her grief in losing him arises frequently. According
__________________________________________________________________
to Kleinian hypothesis, the loss of the present object in the external world brings
with it the person’s unconscious fantasies of having lost one’s internal good objects
as well. Every time grief arises, it undermines the feeling of secure possession of
the loved internal objects. This kind of mourning-like state makes Hanago feel
ambivalently towards Yoshida. She regresses to the infantile Kleinian paranoid-
schizoid position, emotionally oscillating between love and hatred towards him.
That is why it is difficult for Hanago to promote separation from him and her self-
integration. Hanago loses her sanity because of her ambivalent feelings towards
him. Hanago laments her situation while dancing the ‘kuse’ part (‘kuse’ is the most
dramatic scene of a noh play):
Hanago: Ah, but my own love promised me

he would return before autumn came,
and still the nights go by: so many nights
that prove he lied, he with his false heart!
I believed him, and he never comes.
Evenings I spend leaning on the railing,
gazing out towards far distant skies.
Autumn wind at twilight, rushing gales,
chill air from the heights, the late fall storms,
all come calling on that pine nearby.
When will I hear from him, for whom I pine?
At least I have his gift: the fan I hold,
that its breeze might whisper me some word.
Yet summer now is past, and through the cedar window
the autumn wind sinks, cold. Round Snow, my fan,
so frosty white, starts me shivering
merely to hear its name. O autumn wind,
I would quarrel with you.
Yet well I know, to meet means to part,
and loss follows from past happiness.
No, I should not blame him or the world.
But how can I forget my unloved state?
That is all that matters. He is gone,
and Hanjo’s poor room is desolate. 3
Her ambivalent feelings are described by her dance as well as her dialogue and
song. She repeatedly goes a few steps forwards and a few steps backwards, opens
her fan and closes it, and looks upwards and downwards, as if these attitudes and
actions reveal her ambivalent feelings.
In medieval Japanese, ‘kuruu’ (‘go insane’ in general meaning), has several
interpretations among which are: ‘go insane’; ‘go insane because of possession by
Keiko Kimura 181
__________________________________________________________________
spirits’; ‘run wild’; and ‘dance madly.’ It is believed that in Zeami’s thought the
meaning of ‘kuruu’ includes ‘dance madly’ as well. In Hanjo, one of the visitors to
the Shrine says to Hanago in the Tadasu Forest, ‘You, the mad girl! Why are you
not raving today? Come, rave and entertain us!’ 4 Hanago’s ‘aesthetic derangement’
offers a kind of entertainment for the visitors.
Hanago’s madness is symbolized mainly by two kinds of imagery: the forest
and the moon. The symbolism of the forest signifies the unconscious. Even during
the day the forest is dark inside. The sun there is limited, so the forest is opposed to
the sun which symbolically represents the conscious. In this darkened realm the
psychological state is released from the constraints of society. Another motif of the
symbol of madness is the moon. The moon shines at night, and night belongs to the
unconscious. The word ‘lunacy’ means ‘intermittent insanity once believed to be
related to phases of the moon.’ 5 The moon is represented by Hanago’s fan (‘ohgi’).
Because the time setting of the story is in the Heian period, the fan is a round one
which was used only in summer like Pan’s fan. On the face of Yoshida’s fan which
he gives Hanago, a picture of the moon is painted, and the shape of the fan is
like the moon. The part of ‘kiri’ (the ‘kiri’ part is the climax of dance which ends
plays) begins from Hanago’s words: ‘I slip beneath my robe, the moon I hold.’
Hanago: I slip beneath my robe,

the moon I hold.
my bright sleeve, make three–––
so pretty, too–––
his most earnest vow,
to return by fall. Yet suns and moons
in procession pass, while fall winds blow,
and still no word breathes to stir the reeds.
The belling of the stag, shrill insect cries
recede and lapse. So too his promise fades.
Better, then, if he had never made it!
His gift to me, this fan
his gift to me, this fan,
with its back and front, is less two-faced
than the giver’s heart. Oh yes, he lied.
As I can’t see him, my love will never die
As I can’t see him, my love will never die. 6
On the noh stage, using a folding fan, the phases of the moon are described by
how to open and close the fan. It symbolizes Hanago’s ambivalent mind which is
inconstant like waxing or waning moon.
In the last scene of the play, Hanago is suddenly restored to sanity after
reconciliation with her long-lost lover, Yoshida. On his way to the Shimogamo
__________________________________________________________________
Shrine in the Tadasu Forest, Yoshida finds the fan he gave to Hanago. Without the
reunion, it may be said that Hanago’s madness would have continued. In contrast
to the Western ‘mad-woman’ plays, Zeami’s ‘kyojo’mono’ series like this
Hanjo tend to have a happy ending. Zeami describes his reasoning in Fushikaden
(The Flowering Spirit):
With regard to secret matters, it is said that the origin of the art of
noh is to soothe the minds of the people, and to move the
sensibilities of both the high and the low equally. This is the very
basis for a long life, happiness, and prosperity, and is further the
means to extend one’s longevity. 7
In medieval Japan, though shocked by the mad women’s attitudes and actions
in ‘kyojo’mono’, the audience was relieved by the plays’ happy-ending, and felt a
kind of catharsis. The deranged women’s state of mind is actually a reflection
of that of real women in medieval Japan who experienced much sorrow and loss,
and that was one of the reasons why they were so enthusiastically received. Few
women in that period could have behaved like Hanago, but she indeed spoke for
the majority of women.
This story is brought up-to-date by Mishima Yukio (1925-1970) in a one-act
play ‘Hanjo’ in his Modern Noh Plays first staged in 1957. Mishima,
who understood modern European literature well, does not offer a happy-
ending.
In his adaptation of Hanjo, three characters appear: an ex-geisha Hanako for
Hanago; an artist, Jitsuko (‘fruit child’ in Chinese characters) for the female
manager of the inn; and Yoshio for Yoshida.
In contrast to the original noh Hanjo, in Mishima’s play, Jitsuko lives with
Hanako and she does not want Hanako to leave her–––this modernized version has
a lesbian undercurrent with Jitsuko’s jealousy of Yoshio (Jitsuko has been attracted
by ‘the beauty of [Hanako’s] innocent face, like the moon with a ring round it.’ 8)
But Jitsuko’s love is unrequited. For Hanako, her love for Yoshio is blind.
Hanako, however, remains insane and cannot recognize Yoshio even when he
appears in front of her, and she turns him away. She seems to be in an eternal state
of insanity, waiting for her own idealized ‘Yoshio’ forever.
Yoshio: What are you saying? Have you forgotten me?

Hanako: You look very much like him. Your face is exactly like
his, just as I’ve seen it in dreams. And yet you are different. The
faces of all the men in the world are dead, and only Yoshio’s face
was alive. You are not Yoshio. Your face is dead. 9
Keiko Kimura 183
__________________________________________________________________
In Hanjo there are Hanago’s words in which she says, ‘As I can’t see him, my
love will never die.’ 10 In the unconscious, Hanako might think that it is important
not to see him in order to continue her love for Yoshio. If he appears, her love for
him might disappear. The world of madness is where Hanako cherishes her
genuine love for him detached from the reality of the outside world. For that, it
seems that Hanako unconsciously does not want to leave the forest of her
madness.
Notes
1
A. Levy & W.H. Nienhauser, Jr., Chinese Literature, Ancient and Classical,
Indiana University Press, Bloomington, pp. 66-67.
2
M. Zeami, ‘Hanjo’, Japanese Noh Dramas, Penguin, London, p. 114.
3
Zeami, pp. 116-117.
4
Zeami, p. 115.
5
Definition from the Merriam-Webster Online Dictionary, http://www.merriam-
webster.com/.
6
Zeami, p. 117.
7
Zeami, Fushikaden (The Flowering Spirit), Kodansha International, Tokyo, p.
108.
8
Y. Mishima, ‘Hanjo’, Five Modern Noh Plays, Tuttle Publishing, Boston, p. 186.
9
Mishima, p. 195.
10
Zeami, ‘Hanjo’, p. 117.
Bibliography
Barfoot, C.C. & Bordewijk, C., Theatre Intercontinental: Forms, Functions,
Correspondences. Rodopi, Amsterdam, 1993.
Bargen, D.G., A Woman’s Weapon: Spirit Possession in the Tale of Genji.

University of Hawaii Press, Honolulu, 1997.
Birrell, A., ‘In the Voice of Women: Chinese Love Poetry in the Early Middle
Ages’. Women, the Book, and the Godly: Selected Proceedings of the St. Hilda’s
Conference. Smith, L.J. & Taylor, J.H.M. (eds), Boydell & Brewer, Rochester, NY,
1995.
Brazell, K., Traditional Japanese Theater: An Anthology of Plays. Columbia

University Press, New York, 1998.
__________________________________________________________________
Brown, S.T., Theatricalities of Power: The Cultural Politics of Noh. Stanford

University Press, Stanford, 2002.
Hare, T.B., Zeami’s Style: The Noh Plays of Zeami Motokiyo. Stanford University
Press, Stanford, 1986.
Harrison, R.P., Forests: The Shadow of Civilization. University of Chicago Press,

Chicago, 1993.
Hokenson, J., Japan, France, and East-West Aesthetics: French Literature, 1867-
2000. Fairleigh Dickinson University Press, Madison, 2004.
Keene, D., Noh and Bunraku: Two Forms of Japanese Theatre. New York,
Columbia University Press, 1966.
Mishima, Y., Five Modern Noh Plays. Tuttle Publishing, Boston, 1957.
Murasaki, S., A String of Flowers, Untied: Love Poems from the Tale of Genji.
Stone Bridge Press, Berkeley, 2001.
–––, ‘Yugao’. Anthology of Japanese Literature. Keene (ed), D., Grove Press,
New York, 1988.
Ohtani, S., Zeami no Chusei. Iwanami Shoten, Tokyo, 2008.
Zeami, M., Fushikaden [The Flowering Spirit]. Kodansha International, Tokyo,

2006.
–––, Japanese Noh Dramas. Penguin, London, 1992.
–––, On the Art of the Noh Drama: The Major Treatises of Zeami. Princeton
University Press, Princeton, 1984.
Keiko Kimura teaches English at Kobe Women’s University and is the author of
Sylvia Plath: The Father-Daughter and Mother-Daughter Relationships (in
Japanese).
Lunatics and the Asylum: Representations of ‘The Loner’
Patrick Bryson
Abstract
In 1966, a young Australian factory worker, Peter Kocan, became infamous after
attempting to assassinate his country’s then opposition leader, Arthur Calwell.
During his subsequent incarceration in the maximum security criminal ward of
Morisset Mental Hospital, and in his outside life post-hospitalisation, Kocan went
on - with much critical acclaim - to document institutional existence in both his
poetry and his prose. A study of his autobiographical prose works, Fresh Fields
and The Treatment and The Cure, reveals a heavy reliance on images of war to
explain the self as a loner. The enemy, whether it is the self or the institution, is
always seen as the embodiment of all evil. The undiagnosed, unnamed,
schizophrenic character of The Youth, in Fresh Fields, is portrayed as being under
the influence of a fictitious Nazi soldier, and it is this influence that spurs on The
Youth to carry out the assassination attempt. Conversely, after the completion of
the criminally insane act and the subsequent diagnosis, Len Tarbutt (the adult
version of The Youth from Fresh Fields) is rehabilitated in The Treatment and The
Cure and renounces his imaginary Nazi past by establishing yet another fantasy
relationship, this time with a British infantryman from a World War I novel. Thus,
in Kocan’s hands, madness is not caused by a chemical imbalance in the mind after
drug usage, a hereditary predisposition towards mental illness, or by years of post-
traumatic stress. Madness is instead all about political allegiances; sanity is on the
side of good and insanity on the side of evil. Such an ideology can only be
understood through decoding the war imagery used in the texts, as The Youth and
Len Tarbutt (while both being outsiders) are presented as logical, thoughtful
characters – with a clear idea of their life’s mission.
Key Words: Australia, institutions, literature, loner, madness, politics,

schizophrenia, war.
*****
The autobiographical fiction of Australian author Peter Kocan can, to date, be

divided into two categories: the institutional, and the pre-institutional.
The event that splits these two phases of Kocan’s fiction down the centre, an
event not covered in the prose itself, occurred on the night of June 21, 1966, when
the 19-year-old Kocan shot then Australian Federal Opposition Leader, Arthur
Calwell, with a sawn-off shot gun. After being presented to the court as a
‘borderline schizophrenic,’ Kocan was sentenced to life imprisonment and
subsequently released in 1976, following a full recovery. 1
186 Lunatics and the Asylum
__________________________________________________________________
While becoming a recognised poet during the years of his incarceration, Kocan
did not start documenting his life in prose until after his release. The first two
instalments of this trilogy came in the form of two novellas (later released together
as one novel) titled The Treatment and The Cure. These works are both heavily
informed by Kocan’s life in the Morisset Mental Hospital, after his diagnosis. They
narrate the story of a n ineteen-year-old Len Tarbutt, from his arrival at the
Maximum Security Criminal Ward of a psychiatric hospital - where he is to serve
his life sentence - to a point just before his release.
The second category, the pre-institutional fiction, comprises the prequel to
these works, titled Fresh Fields. It is in this work that the life of the loner is
explained from the point of view of an uneducated and mentally unstable youth,
prior to his diagnosis. Again, this work draws heavily on Kocan’s early life -
dealing with poverty, homelessness, and the hired hand’s bleak existence.
What is noteworthy is the way that Kocan has dealt with mental illness in his
fiction, and in particular the way in which he has turned sanity into a Manichaean
conflict between darkness and light, good and evil, us against them.
The main inspiration that he draws upon for his protagonist, in this context, is
the figure of a l oner - who is the survivor of a war. The protagonist’s frame of
mind and his intentions are revealed through the company that he keeps: his allies.
In both narratives the ally-familiars are soldiers. The character of the protagonist is
equally exposed through his enemies, their backgrounds, and his different ways of
responding to them.
The two most important relationships in these narratives are pure fantasy. In
The Treatment and The Cure, the protagonist’s counsellor, and main source of
inspiration, is a ch aracter from a W WI novel - an infantryman called David
Allison. 2 In Fresh Fields, the protagonist has a similarly intense relationship, this
time with Diestl, a Nazi soldier from a WWII film.
Following the development of the protagonist in a linear fashion, I will first
examine the partnership between the character of ‘the youth,’ in Fresh Fields, and
his exemplar and friend the German soldier.
It was a gun shop. There were racks of rifles in the window and
on the wall behind were medals and flags and badges and some
Nazi armbands and a German steel helmet. The youth looked at
the helmet and began to feel calmer, for it had reminded him of
Diestl ... 3
This is the first occasion that Diestl is mentioned, and it comes right after a
time of intense anxiety and mental activity for the protagonist. The youth has just
fled, along with his mother and brother, from the house of the violent Vladimir, the
youth’s stepfather.
Patrick Bryson 187
__________________________________________________________________
The psychological pattern is repeated through the novel. Left to his own
devices, the youth tries to think his way out of all the quandaries that he is in - only
to find that he flounders and does not possess the temperament to cope in the real
world. It is then that he retreats to a quiet place and summons up what he calls, the
‘Diestl mood.’ 4
The film that Diestl has come from is set towards the end of the war. T he
young German is a lone gunman - the sole survivor of his unit - who knows that he
is on the losing side, and everything he holds dear has been destroyed. In the mind
of the youth, ‘Diestl has had every feeling burnt out of him except for a sort of
grim pride that will make him determined and dangerous until the moment he goes
down.’ 5 So the youth tries to imitate the way that Diestl, the underdog, reacts to
any threat - with impassivity, ruthlessness and the determination to strike a blow
before he is defeated.
What the youth has not yet understood at this point, by creating Diestl as an
ally, is that he is drawing upon himself the same enemies as the German. Thus we
have the aforementioned Russian stepfather, Vladimir, an adversary recalled with
much fear and loathing, as well as the Jewish landlord and hotel manager Mr
Stavros. While Diestl is no more objective help than any other imaginary friend,
the enemies the youth makes are all too real.
As an undiagnosed schizophrenic, unaware of the significance of the choice
that he has made in following the Nazi Diestl, the youth must rely on his ‘enemies’
to notice the evil that possesses him; he himself is incapable of drawing the
conclusion.
There is a t elling incident early in the book, when a r esident of the hotel in
which the youth’s mother works accidentally sets herself on fire while in bed. With
the smell of burnt human flesh in his nostrils, the youth stands by and watches the
spectacle of the stretcher being brought out by the paramedics, with a smile on his
face. He is unconsciously excited by the burning, until he sees Mr Stavros - a
Jewish survivor of the concentration camps - looking at him with undisguised
contempt. Realising that he has been caught out, and that the appropriate reaction
was concern, the youth tries to cover his mouth, still stretched tight in a grin.
Soon after this episode the youth is again caught by Mr Stavros, this time using
his little brother’s crayons to draw a large picture of a Swastika. The landlord tells
the youth’s mother that the boy is no longer welcome, and he is sent out by himself
to work in the country - only fifteen years old, and quite alone. The irony of a
Jewish landlord evicting him, and sending the youth to something like a labour
camp, is lost on the boy. He knows little of history, and has no insight into the
darkness within him.
The youth knows that he is different, but he does not understand why. Self-
knowledge comes much later, during his recovery. All he has to get him through at
the start is Diestl:
__________________________________________________________________
He knew he was not like other people. When the time came to
board his train he put himself into the Diestl mood. He limped
along the platform, imagining the Schmeisser against his
shoulder, then got into the compartment by himself and sat
staring blankly ahead until the train began to move. Then he let
the mood slip off because he knew he would need it later and
didn’t want to use it all up. 6
It could be said that the youth puts on t he Diestl mood because he is

uncomfortable with his own company, without realising it. He never retreats to the
Diestl mood in company, even when afraid. Instead he waits until he is alone to re-
imagine what might have happened and to recover a callous insouciance. But in the
real world, without Diestl, he cares deeply. Diestl is the youth’s reaction to not
feeling in control, and not having a significant relationship with anyone else. His
isolation is exacerbated by retreating into the Diestl mood, because Diestl demands
that no one be let in, and warns that the only way to survive is to keep one’s own
counsel.
Other heroes the youth finds all feed back into his main obsession, of being the
lone wolf ready to strike. He cries about the story of Harry Dale - a tragic figure in
a Henry Lawson poem - and about King Harold in 1066: ‘They were the knights
and warriors and horseman who bear the brunt and face the odds. It was always the
same story.’ 7 No matter the circumstances of these characters, the youth clings to
the common denominators that link them to him, and to Diestl; they are alone and
doomed to failure.
Kocan’s use of the Nazi character to describe the condition of the youth works
on different levels. It allows him to focus in on the glamour of the violence, the
sadomasochistic pleasure that the youth derives from it, while providing a
justification and an outlet for the paranoia that the youth feels.
The youth sees and hears Diestl, first in his imagination, then in his actual life.
The hallucinations progress to a sort of physical possession, in which the youth
takes on the characteristics of Diestl, and hears his voice inside his head,
unprompted. Only following orders, he can then disclaim responsibility for the
evil.
Yet the evil of Diestl is all consuming, and ruins even the innocent fantasies of
the youth - when, for instance, he imagines having Grace Kelly as his
‘Sweetheart’: 8
He wondered what Diestl would advise, but knew the answer

already. Do anything, as long as you fundamentally don’t care. If
you start caring, you start wanting to survive for the wrong
reason - you start wanting to savour life, and then the world has
you where it wants you. You have surrendered then. The only
Patrick Bryson 189
__________________________________________________________________
good reason to survive a bit longer is to get closer to the point of
striking one good blow, of hitting the enemy hardest as you go
down. But now the youth was toying with hopefulness. 9
The battle being fought by the youth at this point is a strictly internal one.
While this Manichaean conflict might seem a simplification of objective political
and ethical problems, when the battle is internal, like the psychomachia that the
youth endures, it is much harder to distinguish between right and wrong.
The relationships that Diestl seeks to destroy are ‘hopeful’ imaginary ones that
the youth retreats to in moments of exhaustion and weakness. His relationships in
the physical world, with his mother, his work colleagues and various landlords,
never have a chance of developing.
His relationship problems have to do with his age; the youth is a borderline
schizophrenic male teenager. Socially awkward, he has personalised the conflict he
experiences, witnesses and reads about to an unreal extent. He also has no one in
his life that can help to correct these deficiencies. 10 His only comrade and
confidant is Diestl.
With the Nazi as his spiritual director, the youth prepares to set fire to the town
and blow up the bridges on h is way out. He moves towards the final act of
destruction that he believes is his destiny.
This is how Kocan described it in an article he wrote after his release:
For over three years my fantasy and anguish had been building
towards this terrible ‘solution.’ I had never once considered what
would happen to me afterwards. I was blinded by the potent
vision of my life ending in a welter of violence, with the shocked
eyes of the entire nation riveted for a brief moment on me. 11
Fortunately for Kocan, history shows that his failure became the catalyst for his
future success. A consideration to keep in mind is that he did not do t his by
changing his modus operandi, or by trying to fundamentally alter his identity. As I
will now show, he did it by changing exemplars, and adopting a new allegiance.
Continuing this quest to investigate the mental life of the youth, and its strong
connection with war, I will now focus on the protagonist in his adult form, as Len
Tarbutt, in The Treatment and The Cure.
In the opening of The Treatment Len Tarbutt is about to enter the psychiatric
hospital, just months after his trial and incarceration. He has not yet started to
understand the enormity of his decisions, as ‘the youth,’ and the evil that gripped
him in the form of Diestl. Interestingly, there is still a residue of this character with
him when he is checked into the hospital. When asked to give the colour of his
hair, along with his name and height, he says that his hair is blond, and that he is
five foot ten. 12
__________________________________________________________________
In his mind, he has pictured himself as the Nazi Diestl, the blond death bringer
and perfect Aryan specimen. 13 The young Tarbutt has to be corrected and told that
his hair is actually brown. And here is the turning point and great irony for the
character. The mentally ill Tarbutt, now officially labelled and transferred to the
psychiatric hospital, would have been deemed to be genetically unacceptable to his
former Nazi cohort. As a schizophrenic, Tarbutt would have been cleansed in the
very first stages of the ‘final solution.’
The striking fact is that Fresh Fields is a prequel to The Treatment and The
Cure, and was written over twenty-five years later. Yet, as I have shown, the image
of Diestl found its way into the opening of The Treatment, as if the Kocan had the
full vision for his future work in mind, as a young novelist.
This is not an accident, and quite explainable. The young Kocan charted out the
mature destiny of his protagonist and did not, as a novelist or poet, attempt to
glorify or explain his youthful criminal past; for the most part he focused on the
life of the adult psychiatric patient, the workings of mental hospital, and the subject
of survival; in his view the criminal story had already been sensationalised and
tainted by vulgar, stupid journalism.
But, as in a war, it’s the winner who gets to write the history. The youth of
Fresh Fields was robbed of his autonomy and had his story written for him,
whereas Len Tarbutt, as the recovering writer of The Treatment and The Cure,
could take on the job of documenting his own existence.
It was only as a senior writer and teacher, with his literary position secure, and
his dignity restored, that Kocan felt he could return to the story of the youth, and
his fascination with a violent end - in retrospect providing for the ‘lost adolescent’
a compassionate defence for his actions.
In The Treatment and The Cure it makes sense that Tarbutt’s new comrade, the
British infantryman David Allison, is from the opposing side to Diestl - the
comrade of the youth. The point to remember, however, is that the protagonist is
still in a war and the same psychomachia is taking place inside him.
But where Diestl is a friend who tries to help the youth become someone that
he is not, a man of action, David Allison helps Tarbutt by showing him a way of
coping as a thinking man, as himself. Kocan stated this in plain terms:
You’re always like this. That’s partly how you know you aren’t
the same as most people. Most people just see one meaning and
go ahead and it turns out okay. The only other person you know
of who thinks and thinks and worries and worries like you is
David Allison in The Survivor. That’s why you often feel that
David Allison is your only friend, almost the only real person
that you know. 14
Patrick Bryson 191
__________________________________________________________________
The youth and Tarbutt’s fellow internees in the maximum security ward have
enlisted on the wrong side. But Len Tarbutt, in his new mission on the side of the
good, sees it as his duty to honour those who have lost and had no voice to speak
for them.
Where Diestl only offered a violent end as the solution, his polar opposite,
David Allison, instead offers hope and a means of survival. Indeed, Diestl was
opposed to the very idea of hope and survival, whereas the new allegiance with the
Englishman demands it.
That is the shift in thinking that determines whether or not the character is sane
or insane, right or wrong, in the work of Kocan. The recovering Tarbutt recognises
that the situation is hopeless, and – with the help of David Allison - still tries to
maintain his honour, in the process regaining his mind and his power. In the same
way, the insane youth of Fresh Fields judged the situation to be hopeless but – at
the instigation of his Nazi exemplar - fought violently to keep it that way, and in
doing so gave up his liberty.
To illustrate how similar the relationships with these two different spiritual
directors are, consider two quotations. When the youth of Fresh Fields starts to
picture a life without pain, ‘I thought you were one of my kind,’ Diestl would say.
‘But it seems not. You want Strudel instead of steel.’ 15 When Len Tarbutt dreams
about parole, and being moved to an open ward, he fantasises:
If you had parole you could hang about at the canteen and drink
milkshakes and stuff. You suppose you must be getting soft.
What would David Allison think of you? Milkshakes? 16
The two figures are not just admired for their way of dealing with crises, or for
seeing out a bloody war. They are idolised by the youth, and Len Tarbutt, to the
point where they influence every major decision of the protagonist.
The political morality of the figures that each protagonist hero-worships is all
important to the life of the youth and Tarbutt. That the protagonist is in crisis does
not change; what changes is the role model – the voice from whom he takes
direction.
The decisions are no easy matter; Diestl and then David Allison, in turn, come
to inhabit their protégé:
This novel had become part of your life, or maybe part of your
life had entered the novel - it was hard to say which. Finding it
was like an act of fate ... He (another poet) told you that you
simply must read The Survivor ... It was about a p erson called
David Allison who has an unhappy childhood, then goes to the
trenches in Flanders, and afterwards tries to become a writer so
as to tell the truth of the war for the sake of the dead men. 17
__________________________________________________________________
War as a metaphor for a patient stuck in a mental institution is apt, in that in the
mental hospital there are no real winners; and it is a highly traumatic environment
both psychologically and physically. The patients and the staff are all seen to be in
the same boat, with little to differentiate them other than the choice they have made
in terms of their ‘side.’ A World War is a particularly appropriate analogy, as the
losses are so catastrophic for all participants that even the character of David
Allison, a soldier from the victor’s side, can be looked on as a victim.
In The Treatment and The Cure the new enemy for Len Tarbutt is a female
German doctor, assisted ably by a male nurse who has Nazi sympathies. The
asylum doubles as a POW concentration camp, and the nurses are demonised as
guards determined to degrade the patients: ‘If I was in control I’d have all you
faaarkin blokes put down Hitler had the right idea. Crims, pervs, poofters all into
the faaarkin oven.’ 18
Kocan’s protagonist is, to all intents and purposes, the same before and after the
criminally insane act. The thought processes and the way of coping, the fantasy
relationship with a soldier, and the unchanging depiction of the self as a lone
warrior, whose only community is with those lost in action, is the same whether the
protagonist is declared sane or insane, right or wrong.
In the first two acts of Kocan’s autobiographical fiction, we are given both
views of this Manichaean conflict; the youth who cannot cope with human
relationships, keen to go down in a hail of bullets as a protest against an unfair and
inhumane world; and the adult who works to understand the system: fighting to
survive and giving a voice to those who were less fortunate than himself.
Survival, and sanity, depended on the protagonist’s selection of a guide: in the
end, the only difference was in this alliance.
Notes
1
G. Freudenberg, ‘Calwell, Arthur Augustus (1896 - 1973)’, Australian Dictionary
of Biography, Vol. 13, Melbourne University Press, Melbourne, 1993, pp. 341-345.
2
Clearly ‘George Sherston’ from Siegfried Sassoon’s Memoirs of an Infantry
Officer.
3
P.R. Kocan, Fresh Fields, Europa Editions, 2007, p. 15.
4
Ibid., p. 16.
5
Ibid.
6
Ibid., p. 33.
7
Ibid., p. 108.
8
Ibid., p. 210.
9
Ibid., p. 232.
10
H.G.P. Colebatch, ‘Fresh Fields by Peter Kocan’, Quadrant Magazine, April
2005, Vol. XLIX, No. 4.
Patrick Bryson 193
__________________________________________________________________
11
Kocan, op. cit., p.13-18.
12
P.R. Kocan, The Treatment and The Cure, A&R Classics, 2002, p. 5.
13
Ibid., p. 27.
14
Ibid., p. 201
15
Kocan, Fresh Fields, From 1st Synopsis page.
16
Kocan, The Treatment and The Cure, pp. 102-03.
17
Kocan, Fresh Fields, p. 232.
18
Kocan, The Treatment and The Cure, p. 132.
19
Ibid., p. 99.
20
Ibid., p. 24.
Bibliography
Colebatch, H.G.P, ‘Fresh Fields by Peter Kocan’. Quadrant Magazine, Book
Review. April 2005, Vol. XLIX, No. 4.
Freudenberg, G., ‘Calwell, Arthur Augustus (1896 - 1973)’. Australian Dictionary

of Biography. Vol. 13, Melbourne University Press, Melbourne, 1993, pp. 341-345.
Kocan, P.R., ‘After I Shot Arthur Calwell’. Quadrant Magazine. August 1977,
Vol. XXI, No. 8, pp. 13-18.
–––, The Treatment and The Cure. Angus & Robertson Classicsn, Sydney, 2002.
–––, Fresh Fields. Europa Editions, New York, 2007.
–––, Fresh Fields: An Exercise in Autobiography. Master of Creative Arts Thesis,

University of Newcastle, 2003, Thesis no. 2620.
Patrick Bryson is a Lecturer in Creative Writing at the University of Newcastle,

Australia.
I Can’t Get Off the Stage: Public Space, Acting Out and
Delusions of Grandeur
Eddy Falconer
Abstract
First person narrative about a compulsive anarchic conceptual performer at odds
with consensus reality by virtue of profession, reaction to trauma, character defect,
and some kind of political hyper-awareness. Caught up in a world revolution-the
fall of the Berlin Wall - and choosing performance as an act of survival, the
narrator is faced at the end with the derailing of this social context and these
personal artistic responses into a mundane diagnosis of ‘bipolar.’ A dark and
humorous perspective on these past events as reflecting the inconvenience to the
larger society of someone being slightly ahead of the curve, or in the wrong place
at the wrong time, or knowing things most people have no official license to know.
Key Words: Audio hallucinations, Avant-garde, Berlin Wall, bipolar, borders and
frontiers, nation and identity, performance, premonition, Situationism.
*****
1. What Did I Know and When Did I know It?

I know about 9/11. I don’t know that I know, I don’t tell anyone. But I know. I
suspect. I’m guessing… something will happen. How? Because I see something
about theater and grand opera, how to make a real lasagna of a drama from scratch,
that it takes a long time. I’m watching that lasagna unfold in a Kreuzberg kitchen
in 1990. Southern and Northern, Italians are teaching me pacing, systems,
organization, extensions, geography, simply by making a lasagna.
I know there is hatred in Europe and inside America for the symbol of the
World Trade Center. It does not mean those who also know this are plotting. It
means we are in a state of panic, panic well hidden by irony and a critical point of
view. I know that a non-Middle-Eastern-based kibbutz where we are all pro-
Palestinian and only one or two of us Jewish is being promoted to me, across
several continents, as the only way out of the future revenge.
I took, sometime before the Wall fell, a photograph of the World Trade Center
through the tenement-like smashed window of a Lower East Side squat. It was the
only photo I submitted for my narrative, my application to film school. I applied,
and was rejected. Apparently, I did not establish that one photo could tell a story.
I had gone to West Berlin to try attending film school over there. Three days
later, the Wall came down. My atheistic German-Jewish green card marriage in
New York must have been the final straw. For the DFFB I then made a rotten
collage about Geld coming in from the Ausland and now I’ve met with the same
result as before. A big nein. So I have time on my hands, while the earth shatters
196 I Can’t Get Off The Stage
__________________________________________________________________
and the world changes after November 9, 1989; while, in the aspiring future center
of Europe, the Wall comes down around me and the Berlin front of the Italian
underground. It’s the world post-11.9.
In the Kreuzberg kitchen, I’m becoming the performance artist Franklin
Furnace Archive in New York encouraged me to be.
It’s pre-Desert Storm and there’s nowhere for me to sit down. I’m a Jew, an
American, the locals don’t care what I think about any of it, I’m a complete
inconvenience to the left. Symbolically they must beat me up. I’m learning to
perform out of fear, paranoia, delusion that will follow me for 20 years. My green
card partner, no leftist he, has turned out to be a rat, a false friend or worse, and has
dumped me. Other dykes are shutting the door in my face, retreating into
subgroups based on national affinity-the whole community of Berlin-based
foreigners is living in fear, and I am bouncing from one temporary shelter or
alliance to another. I have no game face, no sense of humility but instead a sense of
outrage, pain, actually of abject terror. I’m only 25. A will to stand up against this
landscape at all is the only strength I can muster, but this will take years and I’m
right at the beginning. The surging morbidity of soil turned up, a dead zone
encountered, the merging of the gone world of East with the new, this fleeing
upward of ghosts, is transforming me. Centuries of memory are bleeding into faces
and minds. Wherever I go, suddenly the Germans can see me.
One particular Italian sees in me a smugness about shared space. One fine
morning I sigh and roll my eyes when asked to switch rooms, and for eight months
afterwards she who is fed up with more than just me will methodically kick my ass.
She moves her allies into the house. M y original roommates, from Torino,
Amsterdam, Alphabet City, have flown to the States and I’m left, like an idiot, to
fend for myself. All around Berlin, people are grabby for Lebensraum, immer mehr
Quadratmetern, real estate or turf in the East, the best room in the squat, the top
two floors for their wardrobe alone….I don’t know how to fight. I’m closer to
pissing in my pants. Twenty-five going on twelve and the Bari connection has read
me the riot act.
Inside the Italian kitchen I am developing my inner voice, which persistently
now and suddenly constructs outer reality as always possibly mutable,
combustible, a set of expectations that can be tweaked, possibly in order to save the
world. At best, everything is a negotiation, in this home where my feet hardly live
on the ground just as outside, all around the island. A friendly painter from Venice,
also passing through as a tenant, at last lays it o ut on the table for me: ‘Two for
four. What’s he saying?’ ‘Drugs,’ he cryptically explains. I accept, but have no
idea about anything but the math. He himself is not a user.
Does he mean the others are doping me? This notion makes one friend laugh.
Six of what? Sixes and sevens. Days in the week, a calendrical mystery, the
slippage between Christian and Jewish Sabbaths, a cipher of the Tarot.
Eddy Falconer 197
__________________________________________________________________
A negotiation with reality itself, between multiple languages, spoken and
unspoken, common and invented, will be the ongoing premise of the household for
months and months to come. Objects, words, actions, postures, durations and
tempi, anagrams and puns, the entire commedia will be instilled in me as we turn
the world upside down. The painter from Venice models clowning for me,
unwittingly, pasting photos of the sink onto the sink, photos of the window onto
the window.
For better or for worse, the new gang from Bari will help out by seeming, at the
least, to train me by calling their dog. ‘Klaaaaaauuuuus,’ 1 hisses one of them,
repeatedly, staring at me. As I try hopelessly to sleep, she flips the light switch on
and off. Pavlov. Why? Not until Christmas will the torment let up: the worst of the
gang will be out of the house, replaced by incomprehensibly stoned Sicilians, and
one peer pressured girl will cautiously befriend me around our love for the same
rock band. By then, I’ll have walked the whole of Berlin by night.
I genti di Bari play Jane’s Addiction repeatedly as the Wall tumbles. I’m
bruised, humiliated. I am prideful, I am angry, I am frightened. I’ll be socked in the
head by a woman I’m obsessed with, whacked in the head by three police who
wrestle me into jail at the end of a p erformance I think everybody worldwide
knows I am doing. I feel obvious in this, it’s inspired by Keith Haring and indeed
they’ve arrested me in the subway for spray painting purple spots on things. I’m on
my way to the Henry Ford building in Dahlem to write ‘O-Zone’ in the snow, in
homage to Guillaume Appollinaire, when the guy from BVG calls the cops.
My mind which travels round the world inside an hour is in conflict with bodies
that are by contrast drastically, severely, brutally limited in their movement (my
own body, other people’s). Even a body that never leaves a ten block radius may
somehow be equipped with a flow of information that brings wars, foreign
histories, intrusive dream state snapshots of international celebrities, endless
consumer garbage, personal biography and myth and folklore, illnesses,
hallucinogens tried or untried, to bear on a simple local dynamic. Here and now,
the clash of global and local realities feels to be embodied in one person, myself.
Any assumptions I have of a common plane with others do not bear out as true
when tested. I must invent that plane.
It’s true the Germans are a step ahead, with their plan for a holiday on October
3rd that will celebrate this Reunification they’ve been planning since before the
Wall went up. Why October 3rd? It’s not a full moon. I’ve worked out a
Kabbalistic, tarot-based calendar that will possibly explain and synch up with
theirs, though even I myself cannot adhere to it. All I can do is play Gorbachev in
the evening in the kitchen and wake up the next day as a Turkish Gästarbeiter,
fully clothed for the part in my too-small sleep sack. Then I go out as Garbo and
Corto Maltese rolled into the same outfit and rearrange the books on the shelves of
a small bookseller up the road. I do a pantomime in her window using a cane to
__________________________________________________________________
suggest my ‘blind seer’ capacities, and people outside watch, applaud. ‘Two for
four.’ Six of what? I’ve nothing better to do.
At the end of another foot journey, my angry fist goes up in the direction of the
rotating Mercedes sign near the Ku’Damm, around which the whole nation seems
to revolve. ‘Es macht nichts,’ sighs a guy working by dark beside a bus. ‘Der
Wagen ist schon kaput.’
Why do any of this? Classically, because German television told me to. The
anchorwoman of a 3 a.m. broadcast has said quite clearly, if we all play our parts
very carefully, in the end he’ll get his Torah back. He? Whoever-the symbolic one.
Might as well be me. I’m here. No one else is here the way I, Eduardo, am here. I,
Eduardo Falcone, product of my own transgender photo project for which no other
German feminist will model; I, Auto Dix, Autonomer Ottoman and used car
salesman. I’ll figure it out through anagrams and targeted kleptomania, thefts that
are acts of alchemical transformation: I steal accessories for dart games, jars of
peanut butter, cans of cat food with meaningful names, and relocate them to make
visual puns around the town. I create stage sets out of junkyards at midnight in
back of the R.A.M.M. Theater. Of course I steal The Thieves’ Journal! By the time
I reach Paris I’ll be leaving all my secret translations in handwritten documents at
public monuments, shoving them inside books at the contemporary art museum.
I’ve been making mixed media pieces and leaving them in front of the doors of
Berlin galleries. Shoes designed by Eduardo, delivered by Polish Spy to the steps
of Martin Gropius-Bau. A piece titled ‘Unten-Oben-Links-Rechts,’ with arrows
indicating movement into opposites. As above, so below-when I drop it off on
Potsdamerstrasse, another ‘spy’ comes by and photographs it. Yeah, I know her,
but we have no appointment. She’s simply on the same plane, the network of literal
lunatics transforming the Berlin landscape. Sailing by in the opposite direction, she
calls out, ‘Ahoy!’ as she leaves. She’s been walking around with cracks painted on
her head, for her part. The Wall in the mind is crumbling; as for me, I’ve turned my
mirror to the wall of my bedroom.
German television, in cahoots with Hollywood, the Queen of England, and the
film academy, must have arranged with a lesbian video artist to pipe the
aforementioned television broadcast into the bedroom of a friend at the Hexenhaus
just in time for me to see it. Who the hell isn’t a witch here, or a warlock,
anymore? Only the worst people wouldn’t be. From Torino, I’ve brought a jacket
made of white paper with green lettering that says ‘Fata.’ The painter tells me, that
means ‘witch.’ E duardo thinks it’s good for riding scooters and being seen. Not
that he owns a scooter, but he can liberate one with a pun, for sure, and laying out a
fork and knife on the floor on e ither side of the dog’s dish even makes a skinny
little self-described fascist laugh at last. Art is supposed to change minds; he tells
me I’ve just changed his.
Outside, they’re sending actors from America to play my old friends for me, or
to play passersby. A morphing, melting version of a former college roommate
Eddy Falconer 199
__________________________________________________________________
walks past with a brand new beau on her arm. Warren Beatty, a magnificent twenty
years younger than himself, glides by Viktoriapark on a bicycle, standing on one
pedal. The whole world is watching. We all, on the ground, have been telling each
other this. And we’ve known since before eleven-nine that they’re listening. Il
nemico origlia, der Feind hört mit 2-they’ve never stopped tapping the phones in
Berlin. Especially, right now, mine. It’s because the CIA and the president of Yale,
whose last name is the same as that of my soon to be ex-husband, would very
much like to know what we’re all up to on the left, and they think they can twist
my arm.
In ’91 in Paris, the French are playing along. They’ve got the sign on the door
of the office turned upside down on the hotel staircase, they’re moving me from
room to room in order to telegraph the inverse numerology of doorways. Room 6
becomes Room 9, overnight. In Paris, there are books on Surrealism in the shop
windows. Not so much the case in Berlin. The hidden knowledge I’ve accessed is
quite public in the French Sprachraum. The end of the German sentence, France,
bears out the verb, the action, which is alchemy. It’s the final proof I’m right all
along. The game is played out more slowly, but the bain-marie for the work is
right there in the Luxemburg gardens, and so, and so….es muß so sein, es muß so
sein. The deeds must be carried out. Otherwise…annihilation. Nuclear genocide.
But still, I have to stop, because I can’t even hold onto my keys anymore. In
New York in ‘91, there is little in the air of this post-Berlin Wall frenzy. I realize,
strolling down Broadway, that the person I’ve always recognized to be a certain
celebrity in real life is not the person I twice mistook for her in cafes in Berlin. The
real celebrity has indeed stood up and is exiting a bank south of Houston Street.
Not surprising, I used to see her at the gym near there all the time, before the Wall
came down, only a year or two before. So something must in fact be wrong with
my brain. I’ll use the San Francisco leather scene to cobble my head back together,
and after a year in California will return to Berlin with a mind so brittle and fragile,
with a posture so studied and a wardrobe so martial….A scholarly friend will draw
an analogy to Balzac’s Montriveau. I’m dragging one heel in its armor, heavily
adorned green cowboy boots.
Berlin again,’92. The return of Prince Eduardo erupts into violence. Mania now
leads to property damage. Sooner or later, when drifting, dreaming, hypnotized,
tuned to the spheres, from now on I’ll end by nearly punching someone. I’m trying
to hit people back. I’m telling them, don’t get too close. Don’t ask me to
goddamned perform, because if I do it, the world will collapse. I feel the same way
about buying cans of beans. Pick the wrong one and disaster occurs. Pick the right
one, and…. Charmed and apparently charming, asked to perform at the HdK, I will
become fully unable to stop, to the point where I’m ejected from the stage design
program.
Incessantly walking and mentally reconfiguring, ‘Four, five, one!’ I shout at the
Hexenhaus video artist on the occasion of her screening of a p iece about, lo and
__________________________________________________________________
behold, interacting glances of local ‘witches.’ Eine Hexe, una strega, ‘una fata,’ I
don’t recall how I arrived at those numbers on that night in’94. I recall Charlotte
von Mahlsdorf literally propped up my back, gave me courage as I shivered.
Charla Drops, a cab aret actor, had once done the same, straightened me up and
dusted me off as I learned, repeatedly, how to fall off my chair, bounce right up
and laugh about it.
My parents come to visit me, in 1993, and we go to see Faust together at the
Deutsche Oper. The set, which contains twin towers constructed entirely of
hundreds of lightbulbs, is a clear parabolic reference to German economic
aggression operating in Frankfurt (represented in the costumes) but controlled by
Bavaria (Mephistopheles in his fabulous bright red lederhosen). I’m laughing to
myself, at intermission, and my parents think I’ve fully lost my mind. But by now I
have seen how theater transforms. I’ve been studying it with the masters. It’s as
simple as musical chairs, and masks that need not even be constructed. It’s looks,
gestures, body language. It’s moving a p ack of cigarettes across somebody else’s
table, for no reason, simply upon walking past them. This silent comedy, rooted in
anarchy, dangerous if done evilly, is fully in operation wherever I go on the earth.
On the one hand, dykes can throw me against bathroom walls and look as if to
punch me out for violating silent dance codes. (‘Du hast den Spiegel zerbrochen!!’
one hisses, accusatorily.) On the other, I’ve discovered I’m gifted at not being me
even when I am being me. Hamlet und nicht-Hamlet, as they say on the East Berlin
stage.
Compulsion to act out: If I hit just this spot with my toe beneath this table, the
tiny glass of sherry will bounce off-exactly how? Geometries, geographies, nothing
you see on a map, they’re common mental trajectories, associations we all have. Or
so I think, and cannot stop. The problem has become, I’m kicking up a table in a
café in Neukölln to experiment with this, while angry, and my friend who sits
across from me, indeed the entire restaurant, can have none of this, none of it,
anymore. Yes, it’s true I don’t care about them, but I also want to make the earth
spin on the corner of a cube. And I can’t stop to save myself, to save anyone else,
for that matter.
Gradually there will be voices. ‘Es wird geflüstert….’ 3 they’ll say at the theater
school, grinning in anticipation of premieres. I will hear the Germans asking,
‘Hörst du?’ as I pass. I will hear them, eyes lit up, respond to my very presence:
‘Wir hören…’ They’ll egg me on with ‘Trotzdem…’ and a smile: trotzdem, street-
level slogan of the losing nation in wartime, this thing is said to me. Even tourists
from Spain will utter these words, with Spanish accents, and when I furiously
inquire why, they will deny having said a thing at all. The one that gets me is
‘Leider nie….’ Over and over, leider nie. Unfortunately never, ever what? They
see I’m fighting, but I’m fighting because they’re saying these things. The
organized resistance, people who act sanely in groups to change things, has
retreated since the shattering of the rose-colored lens of Olympic glory, which was
Eddy Falconer 201
__________________________________________________________________
sought by the Mayor Diepgen for the year 2000. To host the games and relocate the
capital in the same year, that scared the hell out of everybody. To connect both
ends of Oberbaumbrücke, closing the traffic ring around the metropolis and
effectively inviting all of Germany to run Berlin, a catastrophe for the left. But
these initiatives are quiet and folks are going along with the capital plan now,
while only I smash rearview mirrors and twist up windshield wipers in a lone gun
attempt to slow the annihilation of the bicycle-driven economy. There’s a
consensus revolving stage now, Berlin Hauptstadt, and I’m not at all in the wings.
For my troubles, continual arrests. Rumour’s indeed out about me in this
Großstadt inhabited by villagers from the provinces; their sixth sense kicks in and
excludes me from group planning for magazines I’ve been illustrating, grabs work
tables away from me at design school, keeps asking me when I’m leaving. Indeed,
a conspiracy of voices and actions which seem totally to aggress me. Hardly the
celestial voices one associates with being a s aint, with belief that one is in tune
with the planets or the Paracelsian energies. If crossed, I destroy. I’m smashing
windows now with junk store scimitars and telling them Robert Wilson has nothing
on my Orlando. I’m kicking that Pentax in its carrying case all up and down
Charlottenburg and declaring it to be the head of Euripides’ tragic prince.
I’m losing housing repeatedly. Like clockwork, they’re kicking me out. People
steal my negatives out of my bike bag, lure me to move into rooms where, indeed,
I’ll have my politics interrogated each morning, or my willingness to clean floors.
I’m a terrible inconvenience: a J ew who won’t speak for other Jews, I refuse to
‘represent.’ This somehow puts me at odds with anti-racism. I’m also told by some
that I personally have suppressed the Holocaust stories of the whole entire non-
Jewish world, that my job is to shut up and serve, or simply to disappear.
Years later I introduce myself to a s quatter living near my parents in San
Francisco, because she’s got ‘Einstürtzende Neubauten’ painted on her jacket. Yes,
she, too, has been to Berlin, and finds the racial factionalism annoying, even
though, being Native American, her affiliation made her popular during her stay.
‘That was your green card,’ I say to her.
‘Yep,’ she smiles.
‘I couldn’t stand it,’ I respond, ‘this business of them wanting me to line up
with their message all the time, move in here, talk about this, be what they need or
else.’
‘You had other fish to fry,’ she nods. We laugh and go our separate ways.
In 1996, I’ll begin to go home. Back in New York, though, the voices will
continue. ‘Leider nie’ in Bronxville, spoken at Starbucks in American accents. In
Manhattan, distorted voices echo my given name as in a B -movie about
alcoholism. The mystery rumour has followed me to these shores. It’s driving me
to act like an American-style street person, and then I am one, unsuccessfully
dancing the Hustle for money on a Soho corner as if tossed out of Studio 54.
How has it gotten this far?4
__________________________________________________________________
Notes
1
Possibly they had named their new dog after Klaus Barbie. Or Hurricane Klaus.
2
The enemy is listening. Wartime civil propaganda slogan.
3
There’s a rumour going around.
4
The conclusion takes place in 2008 and contains critical reflections that must be
left out of an abridged version. The chapter has been made available to the reader
in its entirety at http://www.theicarusproject.net, in the future, look to
http://www.eddyfalconer.com, for another instance.
Eddy Falconer was a founding member of The Icarus Project, a mutual aid web
community and grassroots activist group for persons with bipolar diagnosis, and is
an independent film and theatre artist.

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Edited by

Dr Alejandro Cervantes-Carson Dr Peter Mario Kreuter

A Probing the Boundaries research and publications project.

The Making Sense Of: Hub

The Inter-Disciplinary Press is part of Inter-Disciplinary.Net – a global network for

Inter-Disciplinary Press, Priory House, 149B Wroslyn Road, Freeland, Oxfordshire.

PART 1 Diagnosis and Treatment

Mad Tourists: The ‘Vectors’ and Meanings of City Syndromes 3

Auditory Hallucinations in Schizophrenia: Collaborating with 15

Carving Dreams on Marbles Lost: The Transatlantic Research 25

Institution Defining Madness: A Place for the Individual 33

‘Your Drugs Take away the Love’: A Resident Psychiatrist’s 45

PART 2 Madness, State and Law

Redrawing the Boundaries of Psychiatry and Mental Illness 55

Intimacy and Control, Reciprocity and Paternalism: Madness 67

Determining Insanity in New Zealand Courtrooms 81

State-Made Madness: Official Knowledge, (Anti)Stigma and 93

Madness-Group Feelings in the Pre-Socratics’ Fragments 105

Religious Insanity and the Limits of Religious Tolerance 117

From Jameson to Badiou: Madness and Critical Theory 129

History of the Present Illness: Is Foucault still Relevant 143

‘Madness’ and ‘Brain Disorders’: Stigma and Language 153

PART 4 Cultural Representations of Madness

They Wouldn’t Make Good Ophelias: Reality of Experience 165

Hanago in Distress: The World of Hanjo in the Noh Theatre 177

Lunatics and the Asylum: Representations of ‘The Loner’ 185

Diagnosis and Treatment

Key Words: Acute psychological disorders, diagnosis, Florence, Jerusalem,

1. Overview of the Syndromes

2. City-Syndromes and Hacking’s Theory of Transient Mental Illnesses

In view of our accumulated data, Jerusalem should not be

Fastovsky, N., ‘Jerusalem Syndrome or Paranoid Schizophrenia?’ (letter).

Hacking, I., Mad Travelers: Reflections on the Reality of Transient Mental

Kalian, M. and Witztum, E., ‘Comments on Jerusalem Syndrome.’ Letter. British

–––, ‘Jerusalem Syndrome or Paranoid Schizophrenia?’ Letter. Psychiatric

–––, ‘Jerusalem Syndrome as Reflected in the Pilgrimage and Biographies of Four

Viala, A. et al., ‘Les Japonais en voyage pathologique à Paris: un modèle original

Nadia Halim is a Ph.D. candidate in Philosophy at York University in Toronto,

Key Words: Auditory hallucinations, meaning, recovery, research, schizophrenia.

2. Auditory Hallucinations in Schizophrenia

useful to the mentally healthy in really finding their minds,

One of the most prevailing paradigms of auditory hallucinations in

… psychiatrists and others who insist that such voices do not

3. Auditory Hallucinations in the Recovery Process of Schizophrenia

… there is no symptom which could be described as

What matters most to the contemporary clinician is the

… a deeply personal, unique process of changing one's attitudes,

… hearing voices has been considered solely as a s ymptom of

It appears that there is meaning in auditory hallucinations; meaning that cannot

It helped that somebody believed me. Somebody was taking me

Fadiman & Kewman note that decades of research on auditory hallucinations,

Bentall, R. and Slade, P., Sensory Deception: Towards a Scientific Analysis of

Fadiman, J. and Kewman, D., Exploring Madness: Experience, Theory and

Fromm-Reichmann, F., Psychoanalysis and Psychotherapy. The University of

Jaspers, K., General Psychopathology. Manchester University Press, Manchester,

Jung, C., On the Psychogenesis of Schizophrenia. Princeton University Press,

Laing, R., The Divided Self. Tavistock Publications, London, 1960.

Lelut, L., Du demon de Socrat. Trinquart, Paris, 1836.

Lockhart, R., ‘Voices of Psychosis’. Psychological Perspectives. Vol. 6, 1975, pp.