Madness: A Brief History (17 page)

Meanwhile, asylum superintendents and psychiatrists began to encourage patients to paint, less in expectation of finding Lombrosian evidence of pathography, than psychotherapeutically, in hopes that their creative artistic processes would shed light on the deep and dark recesses of the mind. In a private asylum near Bern, Dr Walter Morgenthaler encouraged the extraordinary patient-painter Adolf Wolfli, while the scholar Hans Prinzhorn and the painter Jean Dubuffet were active in establishing collections of the art of the insane, not as diagnostic but as rewarding in its own right.

Art as psychotherapy also became popular, though the danger lurked that—rather as with Charcot’s hand-picked hysterics—patients would end up being unconsciously coached to produce artworks according to psychiatric expectations. The decline of the asylum and today’s turn to drug therapies may toll the knell of the genre.

Maybe that would be no bad thing. Artistic and psychiatric conventions over the centuries stereotyped the mad, thereby perpetuating scapegoating prejudices. It is questionable whether the identification of a distinct genre served any useful diagnostic or therapeutic purpose. When Van Gogh painted himself, who can say whether he was painting madness?—all that is clear is that he was painting misery.

Science and psychiatry

Psychiatry has typically pursued twin goals: gaining a scientific grasp of mental illness, and healing the mentally ill. These have generally been seen as inseparable, but at times one has been emphasized more than another. In the late nineteenth century the priority lay, for many psychiatrists, upon establishing their discipline as a truly scientific enterprise, capable of taking its rightful place in the pantheon of the ‘hard’ biomedical sciences, alongside neurology and pathology, and utterly distinct from such quackish and fringy embarrassments as mesmerism and spiritualism. Providing psychiatry with a sound scientific basis was particularly important at that time, on account of its strong positivistic and Darwinian leanings. The great student of epilepsy, John Hughlings Jackson, for instance, drew on Herbert Spencer to make evolutionism the basis for his accounts of nervous dysfunction, while Henry Maudsley developed a psychiatric outlook grounded in Darwinian biology. Freud for his part was also a passionate admirer of Darwin and famously wanted to achieve a ‘Copernican’ revolution in his field. For the leading German Emil Kraepelin (18561926), it was essential to shed the unscientific dross which had gathered around psychiatry.

Following an early appointment at Dorpat University (in Estonia, then in Prussia), Kraepelin became professor at the university clinic at Heidelberg, a principal centre of German medicine. His career marks the culmination of a century of descriptive clinical psychiatry and psychiatric nosology. Downplaying the sufferer’s psychopathological state in favour of the ‘disease entity’, he approached his patients as symptom-carriers, and his case histories concentrated on the core signs of each disorder. The course of psychiatric illness, he insisted, offered the best clue to its nature, rather than, as in common practice, the raft of symptoms the patient showed at a particular moment.

On this basis, Kraepelin wrought a great innovation in disease concepts and classification. Amalgamating Morel’s
demence precoce
with the notion of
hebephrenia
(psychosis in the young, marked by regressive behaviour) developed by Karl Kahlbaum and his pupil Ewald Hecker, he launched the model of a degenerative condition which he named
dementia praecox,
to be decisively distinguished from manic-depressive psychoses (Falret’s ‘circular insanity’). The archetypal
dementia praecox
sufferer as pictured by Kraepelin on the basis of meticulous clinical experience might be astute and clever, but he seemed to have forsaken his humanity, abandoned all desire to participate in society, and withdrawn into a solipsistic world of his own, perhaps mute, violent, and paranoid. Kraepelin routinely used phrases like ‘atrophy of the emotions’ and ‘vitiation of the will’ to convey the sense that they were moral perverts, psychopaths, almost a species apart. As the precursor to schizophrenia, Kraepelin’s
dementia praecox
has left an indelible mark on modern psychiatry.

Kraepelin’s commitment to the natural history of mental disorders led him to track the entire life histories of his patients in a longitudinal perspective which privileged prognosis (likely outcome) as definitive of the disorder. An admirer of the experimental psychologist Wilhelm Wundt, he also pioneered psychological testing for psychiatric patients. Among Kraepelin’s colleagues was Alois Alzheimer (1864-1915), whose research into senile dementia led to the major specialty of psycho-geriatrics. Driven thus by a stern research ethos, his Munich clinic inspired similar establishments elsewhere, including the hospital which Henry Mauds-ley set up, by bequest, in South London, designed (uniquely in England) to be not an asylum but rather a research centre.

While heredity played a certain part in his conceptual apparatus, Kraepelin was critical of French degenerationist theory—a point he shared with Freud, though the two generally had little in common. Holding out slight expectations of successful treatment, Kraepelin, like the degenerationists, was gloomy about the outcome of major psychiatric disorders, especially
dementia praecox.
By 1900 Pinelian optimism had thus run into the sands: ‘we know a lot and can do little,’ commented one German asylum doctor. To many the psychiatrist seemed to have been reduced to acting as society’s policeman or gatekeeper, protecting it from the insane. Endorsed by eugenism and degenerationism, a psychiatric politics was emerging in which it could soon be decided that the very lives of the mentally ill were not ‘worth living’; in the 1930s, Nazi psychiatry deemed schizophrenics, no less than Jews, ripe for elimination. Between January 1940 and September 1942, in what might be seen as a trial run for the ‘final solution’, 70,723 mental patients were gassed, chosen from lists of those whose ‘lives were not worth living’ drawn up by nine leading professors of psychiatry and thirty-nine top physicians.

Psychodynamics

Partly in reaction against the pessimism of asylum psychiatry and the dogmatism of the somatists, new styles of dynamic psychiatry were launched and won support. Their historical roots include Franz Anton Mesmer’s therapeutic explorations, in Enlightenment Vienna and Paris, of ‘animal magnetism’. Bringing to light as it did multiple dissociations of personality and automatism of behaviour, such psychiatric recourse to hypnotism unearthed hitherto hidden strata of the self and raised issues about the will, the unconscious, and the unity of the person. All notion of a Cartesian cogito was now shattered; even before Freud, it was becoming clear that man was not master in his own house.

Drawing upon mesmeric techniques, the mysteries of the psyche were investigated in Nancy by A. A. Liébault and H. M. Bernheim, while in Paris the great Charcot made hypnotism a diagnostic device for exposing hysteria: only hysterics could be hypnotized, he believed (the Nancy school demurred). What he failed to notice —his critics were not so gullible—was that the hysterical behaviour of his ‘star’ hysterics, young working-class women, far from being objective phenomena ripe for scientific investigation, were artefacts produced within the supercharged theatrical atmosphere of the Salpêtrière. Charcot deceived himself into thinking his patients’ behaviours were natural rather than ‘performances’, the products of suggestion. The months Freud spent studying under Charcot in Paris in 1885 proved crucial to his development—which is one reason why psychoanalysis has never been able to shake off the charge that its ‘cures’, no less than Charcot’s, are largely products of suggestion.

The conquistador of the unconscious

Born to a middle-class Jewish family initially from Moravia (modern Czech Republic) and trained in Vienna in medicine and physiology, Sigmund Freud (1856-1939) initially specialized in clinical neurology. An enthusiastic Darwinist and a protégé of the hard-nosed neurophysiologist Ernst Brücke, he brought a materialist approach to the study of mankind, deeming mind reducible to brain and all his life disparaging religion as ‘an illusion ’. Working withJosef Breuer (184 2-1925), he became alerted to the affinities between hypnotic states,
hysteria, and the neuroses. Breuer told him about one of his patients, ‘Anna O.’, whose bizarre hysterical symptoms he had been treating by inducing hypnotic states and systematically leading her back, under hypnosis, to the onset of each symptom. On re-experiencing the precipitating traumas, the hysterical symptom in question vanished, so Breuer claimed.

The time he spent under Charcot in Paris gave Freud theoretical insights into Breuer’s experiences— not least a hint of the sexual origin of hysteria: ‘c’est toujours la chose génitale’, Charcot had whispered to him, privately (the public Charcot kept sex out of his explanations). Freud and Breuer began a close collaboration which resulted in 1895 in the publication of their
Studies on Hysteria,
but by then Freud was already going beyond his senior colleague and working on the idea that neurosis stemmed from early
sexual
traumas. His hysterical female patients, he concluded, had been subjected to pre-pubescent ‘seduction’—that is, in most cases, sexual abuse by the father; repressed memories of such assaults later surfaced, he concluded, in otherwise baffling hysterical symptoms. This ‘seduction theory’ was spelt out to his Berlin friend Wilhelm Fliess in May 1893, and during the next three years Freud’s enthusiasm for his shocking hypothesis grew until, on 21 April 1896, he finally went public
with it in a lecture in Vienna on the aetiology of hysteria.

The next year, however, on 21 September 1897, he confessed to Fliess: ‘I no longer believe in my
neurotica
’—that is, the seduction theory. By then Freud, deep in richly autobiographical dreams and selfanalysis, had convinced himself that his patients’ seduction stories were fantasies, originating not in the perverse deeds of adults but in the erotic wishes of infants. The collapse of the seduction theory ushered in the idea of infantile sexuality within the Oedipus complex, first disclosed to Fliess a month later:

I have found love of the mother and jealousy of the father in my own case too, and now believe it to be a general phenomenon of early childhood ... if that is the case, the gripping power of
Oedipus Rex,
in spite of all the rational objections to the inexorable fate that the story presupposes, becomes intelligible ... Every member of the audience was once a budding Oedipus in phantasy...

Throughout his career, Freud stood by the cardinal importance of this breakthrough: ‘if psychoanalysis could boast of no other achievement than the discovery of the repressed Oedipus complex, that alone would give a claim to be included among the precious new
acquisitions of mankind.’ The twin pillars of psychoanalysis—the workings of the unconscious and Oedipal sexuality—thus emerged from Freud’s volte-face: without the abandonment of the seduction theory, psychoanalysis as a theoretical edifice built upon unconscious libidinal desires and their repression could not exist.

How to explain this decisive switch remains hotly contested. Orthodox Freudians, notably Freud’s disciple and biographer Ernest Jones, have cast it as the ‘Eureka-moment’ in which he saw the light. Some critics allege, by contrast, a loss of nerve, and hold that it was the abandonment of the seduction theory that was the error, perhaps even a ‘betrayal’ both of psycho-sexual truth and of his patients. (If they had indeed been sexually abused, their stories were now discounted, as were those of future generations of patients on the couch.) This ‘betrayal’ has been associated with the cool reception of Freud’s Vienna lecture, and with the death of his father in October 1896. Thenceforth Papa Sigmund stood in father Jacob’s shoes, and psychoanalysis thus became a screen for the sins of the father. The most likely explanation is that Freud had become preoccupied with the role of fantasy in people’s lives, and especially in their neuroses.

Freud grew distanced from Breuer, who favoured the
use of hypnotic techniques, which Freud never mastered, and he also broke with Fliess, whose approach was more biological. In a string of profoundly original works beginning with his
magnum opus, The Interpretation of Dreams
(1900), Freud advanced the fundamental theoretical postulates of psychoanalysis: unconscious mental states, their repression, and the ensuing neurotic consequences; infantile sexuality, and the symbolic meaning of dreams and hysterical symptoms. He also outlined the investigative techniques of free association and dream interpretation—two methods for overcoming resistance and uncovering hidden unconscious wishes—and he elucidated what clinical practice had revealed to him: therapeutic transference. Much of this was summed up in his
Introductory Lectures
(1916-17).

During the Great War Freud applied his ideas about the psychogenesis of hysterical symptoms to shellshock and other war neuroses: soldiers displaying paralysis and loss of sight, speech, and hearing with no palpable organic basis were said to be suffering from conversion hysteria. Though he was still in principle committed to the scientific biology in which he had been trained, in actuality Freud’s psychodynamics proceeded without reference to neurological substrates.

In his later years, while continuing to elaborate his individual psychology—notably the notion of
developmental phases, the conflict between eros and the death instinct (thanatos), and the ego, superego, and id—Freud extended his speculations into the social, historical, cultural, and anthropological spheres, producing theories about the origins of the incest taboo, about patriarchy and monotheism, and about the neurotic springs of the religious and artistic impulses. His endlessly fertile, if obsessive, mind also shed light on many other mental manifestations, like jokes and ‘Freudian slips’.