Paperback(First Edition)
-
PICK UP IN STORECheck Availability at Nearby Stores
Available within 2 business hours
Related collections and offers
Overview
Product Details
| ISBN-13: | 9780520383135 |
|---|---|
| Publisher: | University of California Press |
| Publication date: | 06/08/2021 |
| Edition description: | First Edition |
| Pages: | 376 |
| Product dimensions: | 6.00(w) x 9.00(h) x 1.10(d) |
About the Author
Read an Excerpt
CHAPTER 1
Introduction
THE TRAVAILS OF PSYCHIATRY
I must be a masochist. Almost a half century ago, I embarked on a study of lunacy reform in Victorian England. I have remained obsessed with madness ever since — as unsavory as many find the subject, and as stigmatized and marginalized as those who suffer from mental disturbances almost universally seem to be. Or perhaps I am simply one of Isaiah Berlin's hedgehogs, fascinated by one big thing. If so, it is a thing that haunts all of our imaginations, one that all our efforts at repression cannot succeed in entirely dismissing from consciousness. Madness reminds us of how tenuous our own hold over reality may prove to be. It challenges our very sense of what it means to be human. Madness continues to tease and bewilder us, to frighten and fascinate, to challenge us to probe its ambiguities and depredations. Reason and unreason coexist uneasily in our everyday lives, their boundaries fraught and contested. And, like every society before it, twenty-first-century America finds its efforts to confront and solve the problems posed by serious forms of mental disturbance largely unavailing and frequently counterproductive.
This volume is a collection of some reflections on various aspects of the psychiatric enterprise that I have written over the past decade or so, many of which I revised extensively as I set about bringing them together for this publication. The essays reflect a lifetime of thinking and writing about mental illness and about those who have made it their professional business to attempt to understand and perhaps ameliorate the sufferings that flow from disturbances of this sort. It is not a history, I'm afraid, of very much in the way of progress, but nor is it one that revels in that sad situation or claims that no advances have been made over the past two centuries.
Madness remains, in my judgment, an enigma. The etiology of the various disturbances psychiatrists have claimed jurisdiction over remains obscure, and the best the profession has been able to offer are palliative measures. For some patients, those interventions have mitigated suffering, and that is something we should not lose sight of and ought to be grateful for. But for many, the weapons at psychiatry's disposal remain ineffective, and sometimes harmful. At times, exceedingly harmful. So, mine is a critical and skeptical view of the psychiatric enterprise. But it is not one that minimizes or denies the reality of mental disturbance and the immense suffering it often brings in its train — not just for its victims but also for those around them. Serious forms of mental illness remain, as they have always been, the most solitary of afflictions and the most social of maladies.
I have made my career in sociology departments, save for a year spent in Princeton's excellent history department, and in an odd way, that has served me well. Historians tend to be hired to plough down a narrower furrow than I would ever be comfortable with, sticking to a particular period and a particular national historiography. The sociology departments I have been fortunate to work in, however, were willing to tolerate someone who spent a good deal of his time working on the distant past and imposed no limits on my scholarship — the University of Pennsylvania, to be sure, because its senior faculty paid little mind to the junior faculty so long as they carried the teaching load; and the University of California at San Diego because its founding figures deliberately distanced themselves from the disciplinary mainstream, and during my time on the faculty, the department has continued to take seriously the idea that sociology can be a historical and comparative discipline.
My first book, as it happens, dealt with the pressing contemporary issue of deinstitutionalization. Its genesis was my experience during my first time on the job market, seeking to persuade North American sociologists that they should hire someone with a bizarre interest in social reform in Victorian England. I did so in a handful of departments by persuading them that I had something original to say about the origins of the total institutions Goffman had written about just a few years before and by drawing attention to the medicalization of madness that had taken place in the nineteenth century.
Wherever I spoke, however, in those peculiar hiring rituals scholars undergo where they present a canned version of their research, my audience wanted to know what I thought about contemporary developments, and more specifically the abandonment of the asylum. It seemed an odd development to one aware of how much capital, physical and intellectual, Western societies had invested in the institutional solution to mental illness. But it also seemed well worth investigating and trying to understand. So I gave it a shot.
"Community care" was the slogan of the moment, and the consensus appeared to be that abandoning the asylum was a grand reform that would usher the mad back into our welcoming midst, or so the ideologues of the movement would have it. The drugs made it all possible, so the psychiatrists assured us, on the basis of no more than temporal coincidence and their own overweening confidence in chemical cures. It was in part the product of the critical "anti[psychiatry" of people like Goffman and Szasz, claimed their followers. My book rejected or was sharply critical of all these claims, pointing to the limits of antipsychotics and to their many adverse effects, the nonexistence of community care, and the hostility and neglect that were the fate of discharged patients. It argued that deinstitutionalization was driven in great measure by fiscal concerns, and in the United States by the ability to transfer costs between levels of government. And it suggested that the rhetoric of reform masked what was an emerging policy of malign neglect. I think those criticisms have held up rather well, though some of my attempts to link all this to the then-fashionable arguments about the fiscal crisis of the state now strike me as jejune.
Dividing most of my time between two cities in California, I am reminded daily of the consequences of deinstitutionalization as I walk their streets. Visits to New York or London demonstrate that the challenge of the sidewalk psychotic is not uniquely a problem of La-La Land. Though not solely the product of our abandonment of the mentally ill to their fate, the homelessness crisis is most assuredly exacerbated by that decision, made by our political masters. And it is only one dimension of a problem that extends, of course, to the reinstitutionalization of those who would once have been confined in asylums in our massively overcrowded prisons and jails — the very policy asylums were supposed to supplant.
It didn't take much to justify that line of research to my sociological colleagues, which was fortunate for me in my untenured state, but I swiftly returned to my doctoral researches on lunacy reform and spent much of the next two decades on nineteenth-century matters (though I worked on American as well as European themes). Unlike many who claim to produce historical sociology, I do not shy away from the archives — indeed, I love playing historical detective and am continually seduced by the pleasures of encountering the raw materials that any historical analysis and narrative worth its salt must depend on.
Tenure gave me the freedom to follow my intellectual interests wherever I chose to take them, and I have subsequently ranged across an ever-wider historical canvass. I extended my researches on the emergence of psychiatry as a profession. I worked on the mad trade in eighteenth-century England and on the complex relations between doctors, patients, and families in eighteenth-century London. In the mid-1980s, I was one of the first scholars to engage with the history of psychiatric therapeutics, and that led in turn to a detailed examination of experimentation on vulnerable mental patients in twentieth-century America. Then Oxford University Press invited me to write a book on the protean disorder of hysteria, forcing me to pay attention to the longue durée.
On finishing this project on the history of hysteria, I decided that before I declined into my dotage I might indulge in a larger fit of scholarly chutzpah. So, I wrote a book I had long fantasized about producing: an extended examination of madness in civilization that started by ranging from ancient Greece and Palestine to China and the Islamic world before focusing on the history of madness in the West from what we used to call the Dark Ages to what purports to be the enlightened present. What is more, I sought to attack this subject as broadly as possible, moving beyond the relations of madness and medicine and madness and confinement to examine insanity's place in religion and in popular and high culture: in music, in the plastic arts, in literature, on the stage, and even in movies.
Over the course of my career, American psychiatry has undergone a transformation as dramatic and fundamental as can readily be imagined. When I began to explore its past, psychiatry, at least in its American guise, was dominated by psychoanalysis. The Freudian movement had first risen to prominence during World War II with the treatment of "war neurosis." Through the 1960s, its hold over the profession and the public imagination steadily grew. With scarcely an exception, the departments of psychiatry at the major medical schools were headed by psychoanalysts or psychoanalytic fellow travelers. The "refrigerator mother" was blamed for the seeming epidemic of schizophrenia. Although Freud himself had questioned the relevance of psychoanalysis in the treatment of psychosis, his more optimistic American epigones were undeterred. Those who reluctantly began to use the first generation of antipsychotic drugs saw them merely as useful therapeutic adjuncts to calm down florid symptomatology so that the "real" work of psychotherapy could proceed. Hollywood dramatized the miracles of the talk cure in movies like Suddenly, Last Summer (1959) and I Never Promised You a Rose Garden (1977). Anxious American parents turned to Dr. Benjamin Spock for enlightenment and were rewarded with a bowdlerized version of Freud's theory of child development. Bestseller lists saw the appearance of potboilers such as Robert Lindner's The Fifty-Minute Hour (1955), titillating the masses with tales of the secrets of the couch. Psychoanalysis ruled the roost.
And then it didn't. More swiftly and silently than the Cheshire cat, psychoanalytic hegemony vanished, leaving behind not a smile but a fractious group of Freudians and neo-Freudians who squabbled among themselves. Professors of literature and anthropology tried feverishly to fend off the notion that Freud had turned into an intellectual corpse, but cruel realities suggested otherwise. Psychoanalysts were rapidly defenestrated, lost their hold over academic departments of psychiatry, and were replaced by laboratory-based neuroscientists and psychopharmacologists. Psychoanalytic institutes found themselves bereft of recruits and forced to abandon their policy of admitting only the medically qualified. The very term "neurosis" was expunged from the official nomenclature of mental disorder, along with the hypothetical Freudian etiologies for various mental disorders. The "surface" manifestations of mental diseases that psychoanalysts had long dismissed as merely symptoms of underlying psychodynamic disorders of the personality became instead scientific markers, the very elements that defined different forms of mental disorder. And the control of such symptoms, preferably by chemical means, became the new Holy Grail of the profession. For a historian of psychiatry, living through such revolutionary times has been remarkable indeed.
This rapidly shifting landscape was the context within which my own scholarship has been conducted, and a number of the essays in the third and fourth parts of this book reflect my efforts to grapple with and come to terms with these emergent realities. But our contemporary travails form part of a much larger history that also deserves our attention, and it is those earlier aspects of our encounter with madness on which the first chapters in this book are focused. As a now infamous social theorist once remarked, "The tradition of all dead generations weighs like a nightmare on the brains of the living." We may be experiencing our own nightmares to add to the ones our cultural inheritance brings in its train. But interpreting the dreams of earlier generations may help us to cope with and comprehend a bit better the novel ones we have since conjured up. Or so the historian must hope.
Much of my work on the history of psychiatry has appeared in book form, including the various studies I have mentioned here. But I have also written many essays, which have appeared in a wide range of journals and periodicals. Academically speaking, these span a great number of disciplines, from law to literature, and from a variety of subfields in history (social history, cultural history, and medical history) to general medical and psychiatric and neurological journals. I have also been invited on a number of occasions to review the contributions of other scholars working on psychiatry (which increasingly extends to the territory of the neurosciences), and to do so for a broad audience of general readers.
The chapters that follow constitute my attempt to grapple with the psychiatric enterprise from a variety of perspectives, and in the remainder of this introduction, I suggest that this kaleidoscopic line of attack can provide a valuable portrait of the complexities and contradictions that mark the Western encounter with madness. That portrait is, of course, refracted through a single sensibility, and I hope this gives some semblance of unity to what is otherwise a deliberately fragmentary approach to the protean history of madness.
I have chosen to divide this book into four separate sections that largely follow chronological lines. However, this has proved possible only to a degree, for some of the issues I have sought to address refuse to confine themselves neatly to a single historical epoch, demanding instead a less chronologically constrained approach. Still, the basic principle applies and informs my organization of the chapters that follow.
Part 1 thus deals from a variety of perspectives with the rise of the asylum era, which was essentially a nineteenth-century phenomenon. Those who have grown up in the past four decades can have little notion of the immense sway the idea of confining the mentally ill once enjoyed. In this opening section, I look at where this idea came from and discuss how we are to understand the near-universal embrace of a segregative response to madness in the Western world two centuries ago. It was on these nineteenth-century museums of madness (and their immediate antecedents) that social historians of psychiatry first concentrated their attention when they sought to provide a more critical and nuanced history of psychiatry than superannuated psychiatrists had previously offered in their own reconstructions of their past.
The mentally ill were not always willingly shut up, in the many senses of that term. Protests about their confinement, accusations that alienists (and family members) had corrupt motives for confining them and that asylums were a form of imprisonment or even a kind of living death — all these objections emerged very quickly once madhouses appeared on the scene. The culture of complaint (which allows us a glimpse of mental illness from the perspective of some of those defined and confined as such) is virtually coextensive with the asylum era. It thus forms a vital part of any sustained attempt to come to terms with the meaning and impact of the Victorian asylum. Likewise, as the utopian expectations that accompanied the discovery of the asylum foundered on the recalcitrant realities of unreason, so too some sufferers looked beyond the newly consolidating psychiatric profession for solutions to the problems posed by mental troubles.
Part 2 looks in turn at how this nineteenth-century legacy played out in the first half of the twentieth century. Freud and psychoanalysis provided a challenge to the understandings and practices of institutional psychiatry and helped to broaden the territory within which the profession of psychiatry began to move. Despite Freud's disdain (to put it mildly) for the United States, his ideas would later enjoy greater resonance there than anywhere else besides Buenos Aires. But that popularity has now waned, save in some humanities departments in academia. For more than a quarter of a century, these lingering traces of psychoanalysis have provoked wrath among a group of critics, who have launched a war on Freud's ideas and reputation. Paradoxically, I suggest, the very vehemence of Freud's detractors has had the perverse effect of keeping his ideas alive. And perhaps that is not entirely a bad thing.
(Continues…)
Excerpted from "Psychiatry and Its Discontents"
by .
Copyright © 2019 Andrew Scull.
Excerpted by permission of UNIVERSITY OF CALIFORNIA PRESS.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.