psychiatric writing worth reading suicide in the middle...

Suicide in the Middle Agesalexander murray

“Suicide in the Middle Ages” sounds strange. Did anyone really commit suicide then?Didn’t they all believe suicides would go to Hell if they did it? And how can we know,

anyway? Let me start with the last question. Treating the “Middle Ages” as running from 500 to

1500, it is almost true to say that records on this topic are non-existent until around theyear 1000. But only “almost”; and from the year 1000 records gradually multiply, with up-ward step-changes around 1100 and 1300. The records divide into three categories, eachwith its own perspective. One is chronicles, and other supposedly factual narratives. Thesedo begin before 1000, and say just enough to show that suicide was not wholly unknowneven in those obscure centuries. The second category is that of legal records. These growsteadily in England and France after around 1200, and in Germany slightly later. (Italy isan exception, to be explained later.) The third category consists of religious narratives likesaints’ Lives and miracle stories, which run fairly steadily throughout the Middle Ages.Because their aim is “PR” for a saint, they are particularly informative about suicide at-tempts, where a saint steps in to save a suicide – though a few go theother way with a “Judas-type” suicide, when stubborn opposition tothe saint earns this grim reward.

All three types of source need careful interpretation. Suicide is no-toriously elusive to records even in modern times, and more so for theMiddle Ages. Once due allowances have been made for each genre,however, it is some reassurance that they agree on certain basics, andthat these, in turn, agree with estimates from better-recorded centuries– suggesting that from this particular angle, at least, the very notion ofa “Middle Ages” may be partly a myth. One basic is the male-female ratio for completedsuicide. This comes out at roughly 2.5: 1. The ratio is all but reversed for attempted suicide,to the extent that we can overcome the inveterate difficulty of distinguishing the attemptas a different kind of act. Both ratios tally broadly with those from post-medieval estimates.Again unsurprisingly, female suicides tend to happen in or near home, male out in thefields or in the woods. Methods, too, confirm the same broad medieval-modern continuity.A graph based on a fourfold distinction of methods – as between hanging, drowning, ahand-held weapon, and “other” – will be almost identical for the Middle Ages and for thelate nineteenth century. Hanging is nearly twice as common as the next method down,drowning (slightly commoner in the Middle Ages). Blades come in the medieval thirdplace, most of their role taken in modern times by firearms. “Other methods” come fourthin each survey, if by a smaller margin in the modern one, perhaps because there are nowmore high buildings and pharmaceuticals.

Where we can divine the circumstances and motives of suicide, these again hold noth-ing surprising. The age of a suicide is seldom indicated. But where it is, ages suggest a

editor’s note 2

assessing the asylum 6

the art of medicine 10

on the use and abuse 13of Psychohistory

inside

volume 18 • number 5 • fall/Winter 2012

P s y c h i at r i c W r i t i n g W o r t h r e a d i n g

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“Hanging is nearly twice as common as the nextmethod down, drowning. Blades come in themedieval third place, most of their role taken inmodern times by firearms.”

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Welcome to the Fall/Winter 2012edition of Synergy.

This edition’s theme is History and Psychiatry. A psychiatrist’s clinic days are spentpeering – or sometimes, unfortunately, rifling – through the past events and

motives of an individual life. In this issue, we examine aspects of the history of ourprofession itself.

Our cover essay is by one of the world’s foremost medieval historians who haswritten two volumes so far in a trilogy on suicide in the Middle Ages. An emeritusfellow of University College, Oxford, Alexander Murray here condenses the vast re-search of his work thus far into an extended essay – no mean feat. We have not in-cluded footnotes, as further reading and references can be easily found in his volumesthemselves.

Our second essay focuses on Canada, but on a topic not unique to Canada. ACanada Research Chair in Medical History, Erika Dyck discusses the legacy of ourimposing – physically and culturally – government asylums, a topic still very relevantfor mental health policy despite the demolition of some of the hospitals themselves.

Our third essay examines the contributions of a 19th-century psychiatric pioneerwhose legacy has been largely misunderstood or forgotten. Ian Dowbiggin, an histo-rian and Fellow of the Royal Society of Canada, explains the contributions ofBenedict-Augustin Morel.

Finally, our back pages go to a book review, which discusses a topic (a question,really) relevant to history and psychiatry: Can psychohistory be accurate, and shouldpsychiatrists analyze or diagnose the well-known dead?

We hope you enjoy the prose and, as always, welcome your comments.

EDITORIAL BOARD

eric Prost, md, frcPc.editor,assistant Professor,department of Psychiatry,Queen’s university.

Karen gagnon, mlis.assistant editor,director of library services,Providence care.

alan mathany, msW, rsW, cPrP.director of clinical services,frontenac communitymental health services.

Katherine buell, Phd, c. Psych.Psychologist, ongwanada &Kingston internship consortium.

sandra lawn, mPa.community representative.

roumen milev, md, Phd,frcPsych(uK), frcPc.Professor & head of Psychiatry,Queen’s university,Providence care, Kingston generalhospital & hotel dieu hospital.

heather stuart, Phd.Professor, departments of community health &epidemiology and Psychiatry,Queen’s university.

REVIEWERS

duncan day, Phd.Psychologist, Private Practice.

stephen yates, md, ccfP, fcfP.family Physician.

SYNERGY SUBMISSION GUIDELINES

Synergy invites submissions from members of themental health community in southeastern ontarioand beyond. We encourage articles on current topics in psychiatry. our essays are scholarly in outlook but not number of footnotes. We strive to publish good prose and ideas presented withvigour. articles range from 500 – 1000 words.longer articles may be accepted.

copyright of all material submitted for publicationin Synergy rests with the creator of the work. for inquiries regarding the use of any material pub-lished in Synergy, please contact ms. Kristarobertson – [email protected]

articles may be submitted in the form of amicrosoft Word document as an email attachment.

Queen’s universityhotel dieu hospitalProvidence careKingston general hospitalfrontenac community mental health servicesongwanada

PSYCHIATRIC WRITING WOR TH READING 3

“bell-curve,” with middle age the most dan-gerous time, but also with extremes, suchas a “mad” Frenchman of “a hundred,” or –this is among attempts for she was saved bya miracle – one of a child. As to days anddates, Monday seems to have been a badday, and April the cruelest month, as for T.S. Eliot (at least for women; July was worsefor men). All socio-economic classes arerepresented – poor, middle-class, and rich– though their proportions are especiallyhard to gauge because courts had an eye onconfiscations. They took little or no interestin the destitute, and an absorbing interestin a super-rich man, if his unexplaineddeath could be construed as suicide. (Theunder-representation of nobles, as such, isalmost certainly due to their regular partic-ipation in war, which gave abundant op-portunities for death to anyone whowished for it.)

In the matter of motives for suicide wehave to include attempts, since the reli-gious sources that tell of them are conspic-uously strong on the lead-up. The motivesare again comprehensible from a modernpoint-of-view. Bereavement, poverty, andsudden disgrace or dismissal from a highpost – this last one conspicuous in thechronicles – all play a part. One somewhatmodern-looking case, from a religioussource, is that of a girl whose body someGerman monks came across one day: shehad been seduced by a young man, thenabandoned, and had apparently drownedherself.

A smaller number of suicides have noobvious external motive. They seem to re-flect mere “sickness of the soul,” to useWilliam James’ expression. They appear tohave been a specialism of monks and nuns,and this invites a word of comment, espe-cially since clerics and the religious have anoticeably high profile in the data as awhole. Most of this high profile is almostcertainly due to “over-determination” in thesources. “Cleric” was a broad term, claimed

by anyone who thought he could gain legaladvantage from it without his otherwisekeeping the rules (look at all the “Clarks,”etc. in modern surnames). Clerical statuswould also infallibly be recorded, unlikethat of peasants or merchants. One cate-gory of source, furthermore, the saints’Lives and miracles, was written in religiousconvents with disproportionate knowledgeof tragedies in their own milieu.

After all these allowances have beenmade, however, suicides without obviousexternal motive do seem to have presenteda special danger for the cloistered religious.Monastic teachers became expert on it andon the moods that might lead to it. St JohnCassian (d. 435), one of the most widely in-fluential teachers, had spoken of acedia, adepressive mood which he thought endan-gered his monks, especially after their earlylunch. He identified it as the psalmist’s“demon that stalketh at noon-day” (Psalm91: 6). I think of it as an equivalent to themood to which Durkheim gave the nameanomie, the motiveless misery of a loner ina “bed-sit,” with no moral compass; and Irelate it to one of the big changes broughtabout by the medieval-modern transition,a dispersion of the small monastic societyinto a big non-monastic one. The disper-sion appears to have brought the demon ofnoon-day with it, but without the advan-tage, for sufferers, that most medievalnovice-masters knew about it and kept itwell in check – some having gone throughit themselves, and knowing they had comeout all the better for the experience. (Theautobiography of John Busch (d. 1479/80),of the Dutch Devotio Moderna, has good re-marks on the subject, but he was far fromthe only one.)

The starkest difference between me-dieval and modern suicide is in the rate per100,000 of population. Modern rates areusually judged this way, and run betweenapproximately 3 and, say, 25 (the latter fig-ure is from Paris in the 1870s). I can wran-

gle no medieval source into suggesting ahigher rate than around one, and of courseeven that involves much speculation.Subjective impressions by contemporariesare more informative and a few suggesttrends. Dante wrote his Divine Comedy soonafter 1300 and had a canto specially for sui-cides. Commentators soon after then sayhe did so because there were a lot of sui-cides in his time and region, in and aroundhis native Florence. (Giotto’s picture ofDisperatio as a self-hanged woman, inPadua’s Arena chapel, reflects Giotto’s sim-ilar Tuscan background.) This place andtime just happens to be when the city wasbecoming Europe’s great financial power-house, and there may be a lesson here. It isas if Adam Smith’s otherwise salutary doc-trines had this dark underside: the capital-ist free market may make us collectivelyricher (and did for the Florentines), but atdreadful cost for some individuals. Thistheory would fit with another, later, cir-cumstance. Post-medieval England had acontinental reputation for being the prom-ised land of suicide (the French thoughtEnglish people might do it between lunchand tea, so to speak). But I find no tracewhatever of that reputation in the MiddleAges, even the opposite (the English dranktoo much and boasted, but there is neverany word of melancholy). The first trace Iknow of was in 1562, when a Venetian vis-iting London’s “Square Mile,” in its firstmighty stirrings, remarked on the numberof people who seemed to throw them-selves down wells.

As to rates just before and after 1500,business-centres apart, a lot suggests theywere edging steadily upwards anyway.Some sixteenth-century suicides were inpalpable response to the religious up-heavals (“apostates,” and double “apos-tates,” throwing themselves off towers, etc).Although legal records are one sign of thisgeneral rise in the suicide rate, they are dif-ficult to read because we can never be sure

SUICIDE IN THE MIDDLE AGES continued from page 1

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whether it is a case of more suicides ormore active courts. The answer is probablya bit of both. The interest in suicide shownby Renaissance writers Spenser, Burton,and Shakespeare has this background.

I have said nothing about public atti-tudes to suicide, or of the reasons why itwas condemned. Over history – of whichthe European Middle Ages are just onephase – there have been three main “ratio-nales” for the condemnation of suicide.They touch at their corners like sides of atriangle. One rationale dominant in theMiddle Ages was the idea of lordship.Everyone “belonged” to someone else. Tokill yourself was to rob your lord of yourservice, so the lord could “punish” you. Thegrowth in legal records after c.1200 reflectsthe growth of monarchies, when themonarch established himself as “lord oflords” and treated suicide as an offenceagainst the Crown – whence those reveal-ing court records. I said earlier that Italywas an exception in not “punishing” sui-cide. One reason for this was almost cer-tainly that the Italian communes haddeliberately rejected lordship as an idea,and preferred to take their cue from Romanlaw, whose main drift was against treatingsuicide as an offence.

A second rationale, distinct from lord-ship, draws from the community, arguingthat a suicide offends his fellow human be-ings. The socially-minded Aristotle saidthis was why the feet of suicides were cutoff before burial in his contemporaryAthens as a sign of public disapproval.Aristotle was here probably rationalizing amore instinctive taboo, present all overearly Mediterranean society and certainlywidespread in the European Middle Ages.The taboo element is clear from some me-dieval “punishments” for suicide, like thepulling-down of a suicide’s house, or theextraction of a suicide’s body from a houseotherwise than over the threshold. Thesehave clear anthropological reference andresemble rites traceable in Africa and other

non-European societies. If a modern ration-alization were required for the taboo, wemight point to the evidence, well-known tosociologists since Durkheim, that suicide iscontagious. If I do it, you are more likely to(though I hope you have wholesomeenough defences to resist the idea). On thisargument, sheer biological necessity woulddictate that a species must discourage sui-cide or damage its chances of survival.

This brings us thirdly to religion. Itslink-up with the social argument is clear inthe case of that passage in Aristotle. WhenAristotle’s Ethics, where it appears, becameavailable in Latin translation around 1250,theologians leapt on it like hungry men ona sandwich. Earlier theologians had nothad much to appeal to. Until then, they hadusually treated suicide as so unmention-able that they rarely mentioned it. To killoneself was just a very bad sin indeed(some said the worst), but when it came toexplaining why, they could only quotesnippets from a very long passage on thesubject by St Augustine (d. 430), provokedby the suicides of some Roman womenwho had thrown themselves into the Tiberrather than be raped by Goths during thesack of Rome in 410. Augustine had basedhis case mainly on the commandment“thou shalt not kill,” and the example ofJudas. This latter was especially importantbecause pagan Romans had their own“saint” in Lucretia, who according to legendhad killed herself after being raped, declar-ing that she preferred death to “dishonour”.Augustine said that being raped was notdishonourable. It was just a case of extremesuffering, and there was a difference between pollution and guilt. BecauseLucretia’s rapist had been the son of KingTarquin, it had triggered off the risingagainst the monarchy (all this allegedly in509 BC), which established the Roman re-public, of which Lucretia had thus becomea kind of patron saint.

Putting Judas in her place thereforemade Augustine’s point, though on histor-

ical grounds hardly less shaky. According toSt Matthew, Judas had hanged himself. TheActs of the Apostles gave a different ver-sion, saying Judas had died when his gutsburst out. But the vulgate translation of StJerome (d. 420) had given the operativeword as suspensus. So medieval readers hadno reason to doubt Judas’ suicide. Nor didthey. Artists portrayed Judas as both self-hanged and with his guts hanging out, andthis image, added to accounts of Judas’ tor-tures in Hell, different each day (withSundays off), exercised medieval imagina-tions to their exotic limits. The reasons forthis did not have much to do with history,or even theology, but with the fact that me-dieval society was largely held together bythe idea of lordship. Judas was the arch-traitor. It was only when the lordship ideadeclined in importance that anyone couldtry to understand his motives or even sym-pathize with him. Meanwhile, it was dan-gerous to do so: St Vincent Ferrer (d. 1419)once narrowly escaped a charge of heresyfor trying to excuse him. Judas thus re-mained a potent symbol and proof of justhow bad suicide was.

Christianity, as such, had in fact onlystrengthened ancient religious misgivingsabout suicide. Before Aristotle, the more re-ligiously-minded Plato had given a differ-ent rationalization to the suicide taboo,approving a doctrine he ascribed toPythagoras, which said that we mortals aresoldiers on sentry-duty, and must not aban-don our posts without divine permission.The Roman Empire had tried to concrete-over these ideas by decriminalizing mostsuicide. The Empire, after all, had been cre-ated by outstanding soldiers, and was coun-seled by outstanding philosophers; andboth categories have their own “take” onsuicide. Soldiers have generally had above-average suicide rates, for reasons not toodifficult to suggest – honour, and the prox-imity of weapons and death. Philosophersfor their part follow reason, as distinct, thatis, from instinct, custom, or public opinion;

SUICIDE IN THE MIDDLE AGES continued from page 3


and reason may well recommend that if lifebecomes intolerable we should end it. Afavourite Epicurean way of putting thatpoint was that if a room gets too smoky youshould leave it. Seneca, who was his ownkind of Stoic, went so far as to say that tostop a man committing suicide was worsethan to kill him, because it deprived him ofthe ultimate human freedom. The philoso-phers’ exculpation of suicide became aprinciple of Roman law, which took painsto remove any sanctions specific to the act,assiduously distinguishing it from anybreaches of social obligation some suicidesmight entail. The main obligation theythought about – because it affected theEmperor’s wealth – was that of a criminalsentenced to death, who might try to savehis estates from confiscation by committingsuicide before execution. Careful study ofsuccessive stages of the law reveals howthese obligations kept pushing through, sothat by the late Empire, when the tide ofpublic opinion was changing anyway, thelaw had given up trying to excuse suicideper se and was condemning it.

There is no sign that the change in pub-lic opinion was a result specifically ofChristian influence, though the Empirewas by then officially Christian. Even be-fore Augustine’s utterances on the subject,Neoplatonist philosophers like Porphyry(d. 303) were condemning suicide as an actof “passion,” conceivably in reaction, partly,to currents associated with Indian religion– currents which actually recommended akind of suicide, teaching that if you hadconquered all bodily passion it was posi-tively virtuous to complete your escapefrom passion by (for instance) starvingyourself to death. Porphyry objected that tokill yourself was itself an act of passion, sowas wrong, and this (he said) was why sui-cides could not “get away,” but instead be-came ghosts, lingering round their homesor places where they had done the act.Semitic religions, including Islam when itcame, only strengthened all these misgiv-

ings. To the Semitic God, all-powerful andall-knowing, but simultaneously knowingintimately and loving every individual, sui-cide could only be an act of defiance, as ifone were saying to God: “You may havecreated me, but I don’t care, and I’m going”.This argument was peculiarly strong in thecase of Christianity, whose man-god hadsuffered extremes of loss and pain withoutdisobedience.

But Christianity was also meant to bekind and understanding. As in so manyother respects, Christianity had to pull bothways, and the Middle Ages inherited thisapparent contradiction. Thus we often findparish priests trying to hide or excuse sui-cide, helping families conceal it, and them-selves getting into trouble for doing so – allthis despite the Church’s official condem-nation of the act. We find the same contra-diction in religious literature. Some saints’Lives record “miracles” which implicitlynegate the official doctrine. A touching ex-ample is that of St Hugh, abbot of Cluny (d.1109), who happens anyway to have beenone of the most conspicuously humaneand eirenic of medieval saints. (He oncetold an attempted suicide not to be such asilly boy, but to go home and look after hisageing mother.) The miracle in questionconcerns a monk called “Stephan” who hadhanged himself in a wood. Soon afterwards,one of the monks in choir said he had re-ceived a supernatural message that BrotherStephan could not be admitted among theCluniacs in Heaven, because of the way hehad died. St Hugh prayed, and prayed, andprayed, and prayed. Several nights later, the“wireless-operator” monk got another mes-sage. As a result of the saint’s prayers,Brother Stephan had been admitted intoHeaven after all.

alexander murray, fba, is an emeritus fellow of university college, oxford. his writings on medieval life andreligion include the first two volumes of a planned trilogy on suicide in the middle ages: The Violent AgainstThemselves (1998) and The Curse on Self-Murder (2001), both published by oxford university Press. he hopesto complete the third, The Mapping of Mental Desolation, by 2016.

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Recently I was approached by a provincial government agency to provide informationabout the historic value of mental hospitals. Saskatchewan was looking to close its

last asylum-styled but active mental health facility and members from the local commu-nity had convinced the government to do a historical assessment before demolishing thebuilding altogether. Assigning a particular cultural value to the legacy of the long-stay,custodial mental hospital proved to be a difficult and challenging task.

Historically, Saskatchewan had been home to two large-scale mental health facilitiesor asylums, alongside a series of smaller or adjoining clinics. The first, and remaining,one had been built in the 1910s in North Battleford, while the second hospital opened in1921 in Weyburn and has been hailed as the last and largest asylum built in the BritishCommonwealth. The Weyburn facility closed in 2007 after retreating from providing men-tal health services over the latter half of the twentieth century under a wave of deinstitu-tionalization and decentralization of mental health services. The once grand, evenpalatial, asylum was eventually closed entirely and boarded up – and then literally begancrumbling apart. It finally reached a point where the bulldozers finished the job and lev-eled the building, its outposts, and any remaining signs that thousands of people hadever lived and worked there. This story has repeated itself across the continent as long-stay asylums have disappeared from the landscape or been repurposed and erased frompublic memory. How could one begin assigning heritage value to this relic of psychiatry’spast?

In an effort to undertake this challenge, I started by considering some of the historicalconditions surrounding the rise and fall of the asylum. Asylum-styled mental health ac-commodations arose in the late 19th century in Canada as elsewhere as a logical, pro-gressive solution to the perceived growing problem of mental disease. The rise of theasylum occurred amid state building campaigns, rapid industrialization, andurbanization.1 Some historians have argued that the asylum provided a progressive al-ternative to family-based care, while at the same time created space for the emerging psy-chiatric discipline to observe, study, classify, and ultimately treat individuals sufferingfrom problems that were increasingly understood as medical in nature. The grand facilitiesalso reminded visitors, staff, and patients that the nation-state had the capacity and fi-nancial strength to provide large-scale facilities for its citizens. Put more cynically, thetowering and sprawling buildings dwarfed the flow of individuals moving in and out ofthe asylum and reinforced a sense of state power over individual autonomy, particularlyfor the institutionalized residents.

The dismantling of asylum-based care was similarly shaped by concerns for nationaldevelopment. After the Second World War, Canadians entered a period of reconstructionand the development of what some have called the “welfare state”.2 Mental health care ex-panded as the welfare state blossomed at mid-century and acquired additional social serv-ices and associated elements of care in the community. By the latter half of the century,and certainly by the 1970s, national goals had shifted once again, and an era ofReaganomics took over in the United States, while Britain faced Thatcher-style reforms,and Canada, though a few years later, succumbed to a similar economic mantra as BrianMulroney opened the Canadian border to freer trade and weakened the social servicesinfrastructure that previous governments had established. The changing economic frame-works that supported or reduced support for mental health care had corresponding im-plications in public policy on areas of child welfare, disability supports, and provincialprograms for social services, health care, housing, and education more broadly.3

Assessing the Asylum eriKa dycK


The asylum had also emerged in the 19th century as a bi-product of industrialization,which introduced new valuations on labour and output. A growing but persistent empha-sis on one’s contributions in the workforce has continued to frame discourses on abilityand disability. The asylum, in some ways, functioned as an integral part of the labour econ-omy, not only by providing employment for medical, nursing, administrative, and socialwork staff, but also for capturing individuals who fell within the framework of disability,or an inability to work in a new industrialized economy. Within the institution, rehabili-tative treatments often focused on work therapy as a path for reintegration into the com-munity with a newly acquired set of useful skills. Patient labour simultaneouslycontributed to the functioning of the large institution as residents contributed to the laun-dry, cleaning, gardening, sewing, and other areas of the institution’s maintenance. Somescholars have critiqued this situation by pointing to the folly of assigning value to workbut not providing remuneration for work conducted by institutionalized individuals, whenit could be written off as therapeutic. Geoffrey Reaume’s pioneering work in this field notonly reminds us that the labels of ability and disability were often too simplistic, but heshows how the social and economic context of the asylum influenced ideas about mean-ingful versus rehabilitative work.4

Over the course of the first half of the twentieth century psychiatric approaches alsochanged. Moral and occupational therapy gave way to more aggressive attempts to curbthe incidence of serious mental illnesses. Institutions began showing their age as resi-dents grew increasingly accustomed to the rhythms of asylum life but showed few signsof progress towards rehabilitation or reintegration into mainstream society. Stories of over-crowded asylums repeated across the continent and mental hygiene surveys routinely re-ported on the unsavoury conditions faced by patients and staff alike in an under-fundedand overcrowded mental health system where the asylum appeared to warehouse the de-tritus of society. This period bore the stigma of a languishing discipline that had failed tosupport a struggling segment of the population.

During and immediately after the Second World War, psychiatrists began experiment-ing with asylum populations in a manner that appeared both desperate and humane.Somatic or bodily therapies, including lobotomies, promised to restore health to psychi-atric patients and to the profession. Although perhaps these seem barbaric in hindsight,the gross overcrowding and problematic conditions experienced in asylums requireddrastic measures, and even lobotomies offered some positive testimonials. In the UnitedStates, lobotomies attracted sufficient praise to encourage the Kennedys to arrange for alobotomy for Rosemary, sister to both Bobby and John Fitzgerald who had been diagnosedwith intellectual disabilities. Rosemary’s lobotomy ended badly, leaving her permanentlyincapacitated, and the public attention cast the therapy in a negative light. The temporaryembrace of such interventions, nonetheless, indicated that the asylum had played an im-portant part in producing conditions that led to an experimental phase within psychiatryas it continued to wrestle with its professional and scientific orientation.

After the Second World War, the widespread development of psychotropic medicationshelped to launch what some scholars have called a psychopharmacological revolution.5

The same year that the first anti-psychotic medication became commercially available inEurope and in Canada, 1952, the American Psychiatric Association released its first versionof the Diagnostic and Statistical Manual of Mental Disorders. These professional and struc-tural developments in psychiatry coincided with new research directions within the dis-cipline which, as historian Edward Shorter has argued, resurrected biological psychiatry continued

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Photographs of the Weyburn mental hospital, Weyburn,saskatchewan. used by permission.

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and forged a renewed connection withneuroscience after the distractions of theSecond World War and a fascination withpsychoanalytic, psychodynamic, andFreudian-based theories of behaviour.6 Theasylum functioned as an important testingground for psychopharmaceuticals, andsome advocates even claimed that thepharmacological revolution would trans-form mental health care and alleviate thereliance on long-stay custodial institutionsby controlling psychiatric symptoms and al-lowing patients to live in regular communi-ties.

The nature of mental illness, however,was also undergoing changes. Asylums hadbeen home to a wide variety of individualswith different diagnostic pictures, but asdrug therapy gained traction, some diag-nostic categories seemed fixed in the asy-lum. Psychotic disorders, and typicallyschizophrenia, responded inconsistently tothe much-celebrated anti-psychotic med-ication chlorpromazine. Patients exhibitedside effects and returning to a somewhat in-hospitable community no longer seemedfeasible for many patients. Pharmaceuticalcompanies also recognized that the drugmarket extended well beyond asylum pop-ulations.

North American communities were also undergoing dramatic changes duringthis period. Urbanization by the secondhalf of the twentieth century included sub-urbanization and led to the creation ofnew, often gendered, discourses on mentalhealth, behaviour, and illness, includingthat which Betty Freidan called “the prob-lem that has no name,”7 while psychiatristsnow armed with newly approved medico-scientific labels from the AmericanPsychiatric Association offered medical ex-planations and pharmaceutical remedies.8

Some of these pharmacotherapies replacedinstitutional care in an asylum setting, butdid not fundamentally replace the need forcare and attention to disordered, undesir-able, or unwanted behaviours – whetherfrom the individual’s or the physician’s per-spective. The gendering of mental disor-

ders, for example, has a long history.Asylum wards had reflected a structural di-vision of genders, but in the post-asylumera many of the gendered distinctions re-mained in place, even as the walls of the in-stitutions dissolved from the picture.9

Acceptable displays of masculinity andfemininity, often characteristics infusedwith ideals of sexuality, continued to shapethe way that mental disorders were under-stood and addressed.10 In that way, at least,the presence of the asylum made very littleimpact on the gendered experience ofmental illness.

Drugs, however, did not cause deinstitu-tionalization. The process of closing asy-lums was multi-faceted and had acombination of economic, political, cul-tural, and medical triggers. American histo-rian Gerald Grob, one of the leadingscholars on the history of mental healthcare policy in the United States, argued thatthere were several distinct factors that cul-minated in what became a transnationalphenomenon called ‘deinstitutionaliza-tion’.11 He suggested that psychotropicmedications and changes within the pro-fessional landscape of psychiatry, includinga shift towards more private practice and anincreased reliance on general practitioners;more federal funding for intensive researchprograms into mental disorders; a changingpolitico-economic climate that coincidedwith the dismantling of the welfare state;and the rise of human rights and humani-tarian campaigns, including those levelingcritiques at the plight of institutionalizedindividuals, were critical ingredients in thehistory of deinstitutionalization.

On the social horizon, for example,amid the momentum of civil rights, femi-nism, and gay and lesbian rights move-ments, patients’ rights began campaigningfor their place in the human rights dis-course. Disability rights activists engagedin aggressive campaigns for better access toservices,12 while psychiatric patients andtheir families began lobbying for anti-stigma campaigns, alongside demands foradequate housing, basic health services,

voting rights, and access to safe employ-ment. Some of these campaigns were bothfuelled by, and gave inspiration to, a set ofintellectual critiques that questioned theway that mental disorders were understoodand treated, many of which leveled theircriticisms at the asylum itself.

Some critics, including Thomas Szasz,pronounced that “mental illness was amyth,” which had no basis in scientific ormedical reasoning.13 Michel Foucault wentwell beyond blaming the psychiatric profes-sion, but began his career with a trenchantcritique of a modern world where psychia-trists wielded significant and illegitimatepower to determine what was and what wasnot acceptable behaviour.14 In a world wherefree will was leached away by modern aspi-rations of productivity, capital accumulation,and moral authority, Foucault lamented theopportunities that the modern world cre-ated for individuals to police normalcy andto discipline members of society, includingthrough the use of institutions. The evolu-tion of an “anti-psychiatry” perspective,which sometimes cross-fertilized with post-modernism, provided fodder for critiques ofasylums. One contemporary scholar ofFoucault and Szasz, Erving Goffman, fo-cused his doctoral work specifically on theway in which the institution itself producedabnormal behaviours, due to the disciplinedexistence within its walls, the rhythms of in-stitutional life, and the reinforced labels thatone was forced to adopt while “playing arole” in the institution. Goffman introducedthe term “total institution” to describe thedamaging effects that life in an asylum had,not only for the patients, for whom this fatewas the worst, but also for the staff at all lev-els, whose versions of the outside world be-came perverted over time as they becamemore and more accustomed to the routinesof the asylum.15

Deinstitutionalization, with its myriadbeginnings and endings, nonetheless sig-naled the end of the age of the asylum andthe dawn of a new kind of mental health ac-commodation. The new face of mentalhealth included a precipitous decline in

ASSESSING THE ASYLUM continued from page 7


long-stay patient populations, the gradualclosure of separate mental hospitals as psy-chiatric wards were folded into general hos-pitals, and the rise of an entirely newsystem for mental health, one that increas-ingly relied on emergency wards and familyphysicians to sift through psychiatric casesbefore they might ever reach a psychiatrist.Where the asylum had ostensibly provideda set of services under one roof, problem-atic though they may have been, the post-asylum world involved a complicated matrixof services that did not even belong to asingle governmental or medical depart-ment, nor did it necessarily fit neatly into aconstitutional federalist framework. Medicalservices alongside housing and employ-ment needs in combination with financialand family support services often involveda delicate degree of bureaucratic coordina-tion in a Kafkaesque world of red tape.

For many people, deinstitutionalizationwas not an event, but instead a process. In2004, psychiatrists Sealy and Whiteheadpublished a report in the Canadian Journalof Psychiatry, suggesting not only that dein-stitutionalization was still underway, butthat its greatest variability came in a provinceby province comparison. Moreover, theyconcluded that the term deinstitutionaliza-tion was misleading; “transinstitutionaliza-tion” better suited the reality faced bypatients who left long-stay hospitals only tobe later admitted, albeit in shorter stints, toa variety of hospital-based facilities, includ-ing nursing homes, emergency rooms, andfor some, penitentiaries.16 According totheir study, centralized mental health serv-ices in the form of an asylum had merelybecome decentralized in the latter part ofthe twentieth century. The asylum thenhad not disappeared, but had transformedinto a new era of service delivery that reliedon a more individualized and client-ori-ented series of services. The onus hadshifted from the state and medical authori-ties to consumers, patients, and familieswho needed to navigate the contours of apatchwork of services, supports, and gapsin a modern mental health system.

Deinstitutionalization represented aculmination of ideological and culturalchanges in the latter half of the last century.As that process hollowed out the old asy-lums, and forced communities across thecountry to respond either by demolishingor refurbishing these antiquated mau-soleums of a by-gone era, I am left wonder-ing whether destroying asylums has a

positive effect on our mental health sys-tems, or whether it serves simply to help usforget the indelible mark that mental ill-ness has left on our communities. Exchanginginstitutions for golf courses will not fix ourmental health system, while perhaps main-taining a few buildings will serve as a reminder of the intransigence of mental ill-ness in our society.

erika dyck, Phd, is a canada research chair in medical history and an associate Professor at the university ofsaskatchewan. she is the author of Psychedelic Psychiatry: LSD from Clinic to Campus (2008), published by Johnshopkins university Press.

references

1 For a thorough historical examination, see: David Rothman, The Discovery of the Asylum: Social Order and Disorderin the New Republic. Boston: Little Brown; 1971; Andrew Scull, Museums of Madness: The Social Organization ofInsanity in Nineteenth-Century England. New York: St. Martin’s Press; 1979; James Moran, Committed to the StateAsylum: Insanity and Society in Nineteenth-Century Quebec and Ontario. Montreal: McGill-Queen’sUniversity Press;2000.

2 See for example, Jim Struthers, The Limits of Affluence: Welfare in Ontario, 1920-1970. Toronto: University of TorontoPress; 1994.

3 See for example, Raymond Blake, From Rights to Needs: A History of Family Allowances in Canada, 1929-1992.Vancouver: University of British Columbia Press; 2009.

4 Geoffrey Reaume, “Patients at Work: Insane Asylum Inmates’ Labour in Ontario, 1841-1900” in James E. Moranand David Wright (eds), Mental Health and Canadian Society: Historical Perspectives. Montreal: McGill-Queen’sUniversity Press; 2006, pp. 69-116.

5 See for example, David Healy, The Anti-Depressant Era. Cambridge: Harvard University Press; 1997.

6 Edward Shorter, A History of Psychiatry: From the Era of the Asylum to the Age of Prozac. New York: John Wiley &Sons Inc.; 1997.

7 Betty Friedan, The Feminine Mystique. New York: Norton; 1963, chapter 1.

8 For historical studies of the cultural and gendered implications of the psychopharmaceutical approach to ‘mod-ern’ mental health, see: David Herzberg, Happy Pills in America: From Miltown to Prozac. Baltimore: Johns HopkinsUniversity Press; 2008; Jonathan Metzl, Prozac on the Couch: Prescribing Gender in the Era of Wonder Drugs. Durham:Duke University Press; 2003; Andrea Tone and Elizabeth Siegel Watkins, Medicating Modern America: PrescriptionDrugs in History. New York: New York University Press; 2007; Andrea Tone, The Age of Anxiety: A History ofAmerica’s Turbulent Affair with Tranquilizers. New York: Basic Books; 2009; and Erika Dyck, Psychedelic Psychiatry:LSD from Clinic to Campus. Baltimore: Johns Hopkins University Press; 2008.

9 See Elaine Showalter, The Female Malady: Women, Madness and English Culture, 1830-1980. New York: Virago Press;1987; Wendy Mitchinson, The Nature of their Bodies: Women and Their Doctors in Victorian Canada. Toronto:University of Toronto Press; 1991, especially chapter 10; and Elizabeth Lunbeck, The Psychiatric Persuasion:Knowledge, Gender, and Power in Modern America. Princeton, NJ: Princeton University Press; 1994.

10 Elise Chenier, Strangers in Our Midst: Sexual Deviancy in Postwar Ontario. Toronto: University of Toronto Press;2008; and David Herzberg, Happy Pills in America: From Miltown to Prozac. Baltimore: Johns Hopkins UniversityPress; 2008.

11 Gerald Grob, “American Psychiatry: From Hospital to Community in Modern America,” Caduceus (1996) 12(3):49-54; see also: Grob, “Deinstitutionalization: the Illusion of Policy,” Journal of Policy History (1997) 9(1): 48-73;Grob, “The National Institute of Mental Health and Mental Health Policy, 1949-1965” in Caroline Hannaway(ed), Biomedicine in the Twentieth Century: Practices, Policies and Politics. Amersterdam, IOM Press; 2008, pp. 59-94; Grob, The Mad Among Us: A History of the Care of America’s Mentally Ill. New York: The Free Press; 1994; andGrob, From Asylum to Community: Mental Health Policy in Modern America. Princeton, NJ: Princeton UniversityPress; 1991.

12 Geoffrey Hudson, “Regions and Disability Politics in Ontario, 1975-1985,” paper presented at “Region Matters:Health and Place Conference,” University of Alberta, Edmonton, 2007.

13 Thomas Szasz, The Myth of Mental Illness: Foundations of a Theory of Personal Conduct. New York: HarperCollins;1974, first published in 1960.

14 Michel Foucault, Madness and Civilization: A History of Insanity in the Age of Reason. New York: Vintage Books;1965.

15 Erving Goffman, Asylums: Essays on the social situation of mental patients and other inmates. Garden City, New York:Anchor Books; 1961.

16 Goffman.

10

The Art of Medicine:Clinic and Compassion in 19th-Century Psychiatry ian doWbiggin

Like a scene from La Bohème, two med-ical students huddle in a cold, run-

down Paris garret. They are so poor theyhave only one suit between the two ofthem. When one dons the suit, the othercurls up in bed shivering under threadbareblankets in a desperate effort to keep warm.

One of the medical students is ClaudeBernard, who will achieve fame as perhapsthe greatest physiologist of all time.

The other student is Bénédict-AugustinMorel (1809-1873). Today, unlike ClaudeBernard, Morel is hardly remembered. Yetfew individuals better embodied the ad-venturesome nature of nineteenth-centurymedicine. Morel’s day was a time of bril-liant, larger-than-life characters who oftensacrificed their own health in the quest toexpand the frontiers of medical science andimprove the fortunes of humanity. Peoplelike Morel and Bernard believed that clini-cal and experimental science could solvethe mysteries that had plagued humanhealth for centuries. If from our vantagepoint one hundred and fifty years later wefind it difficult to share fully their optimism,we still must admire the courage of theirconvictions and their soaring intellectualbravado.

Morel, a pioneer in psychiatry and pub-lic health, also possessed a rare clinical bril-liance and a deep learning. Combiningthese traits with true compassion for hispatients, he devised a sweeping theoryabout humankind’s place in the natural andsocial order – a combination akin to meld-ing William Osler with Charles Darwin.

If Morel has never received his duerecognition, it is mainly due to his 700-pageTreatise on Degeneracy, in which he arguedthat the families of many people plaguedby mental and physical disabilities weredoomed to extinction because of their badheredity. Morel described how the poor inEurope’s burgeoning cities were exposed toa variety of poisonous agents, including to-bacco, lead, ergot, and alcohol, all of which

caused fearsome health effects. These fac-tors, Morel argued, afflicted countless fam-ilies whose members passed on theirdiseases to offspring through inheritance.

Morel’s theory of degeneration rapidlypassed from the realm of biology and med-icine into popular language. By the end ofthe century, there arose countless opinion-makers, ranging from Dracula author BramStoker to sociologist Emile Durkheim andsexologist Havelock Ellis, who used theterm “degeneracy”. Meanwhile, Morel’soriginal definition of the word was forgot-ten. Instead, degeneration had become apejorative term referring to people withdisabilities as a whole. When in the twen-tieth century psychiatrists ceased using“degenerate” to describe patients, Morel’sgreat contributions to clinical psychiatrylargely vanished from memory. Only re-cently have historians begun to restoreMorel to his rightful place in the history ofmedicine.

Morel’s fluctuating reputation began theday of his birth on November 22, 1809, inwar-torn Vienna. Aside from Morel’s father, a supplier of military equipment toNapoleon’s armies, little is known about hisparents or his upbringing. In 1831 Morel arrived in Paris where he dabbled in jour-nalism before entering medical school.There he met Bernard and his medical career accelerated.

Three key nineteenth-century currentsshaped Morel’s approach to medicine ingeneral and psychiatry in particular. Thefirst was a movement, led by Henri Saint-Simon and Auguste Comte (who coinedthe term “sociology”), which held that theprogress of science had reached a point inhistory when researchers could talk realis-tically about a science of humanity. Comte’sown theory of positivism best captured thissentiment and bolstered the view that sci-entists were on the verge of discovering thenatural laws governing society. Such knowl-edge, it was felt, would enable scientists to


end the illnesses, disabilities, injustice, andconflict which had afflicted human history.

The second trend that influenced Morelwas the growth of psychiatry as one of thefirst specialties to carve out a separate pro-fessional identity in medicine. Largely ledby French physicians trained in the hospi-tals of revolutionary Paris, psychiatry beganas an institutional specialty headquarteredin the asylums that western governmentsstarted to build in the nineteenth centuryto house the countless poor with mentaldisabilities at public expense. Psychiatrists– or “alienists” as they called themselvesthen – argued that people with mental dis-abilities were all too often jailed, whipped,neglected, or drugged. The mentally ill, sowent the argument, were best off in mod-ern hospitals headed by licensed physicianswhose benevolent care provided inmatesthe opportunity to recover their senses andrejoin society. Alongside their self-avowedcompassion, psychiatrists were motivatedby the belief that mental diseases were realorganic illnesses whose causes anatomistsand physiologists would soon discover.Studying people with mental disabilities inasylums enabled psychiatrists to begin thetime-consuming task of classifying diseasesof the mind on a scientific basis, each withits own symptoms and outcome.

The third influence on Morel was theturmoil within early nineteenth-centuryRoman Catholicism. Faced with the ap-palling costs to human health and dignityinflicted on the poor by industrializationand urbanization, more and more Catholicthinkers called on the Church to take an ac-tive role in social reform. Catholic intellec-tuals with a social conscience advocatedtrade unions under Church auspices andlegislation to improve work conditions infactories. The views of these Catholics haveoften been described as “Christian social-ism” and were designed to counter-actwhat was perceived to be the rampant in-dividualism of the day. Between the fall of

Napoleon I in 1815 and the failed Europeanrevolutions of 1848, in the words of onehistorian, “virtually everyone who consid-ered himself a socialist claimed to be in-spired by Christianity or even by Catholicismitself. The Gospels were everywhere, andJesus, it seemed, was the founding father ofrevolutionary change.”1 Reared as a devoutCatholic, Morel viewed psychiatry as ameans of the putting the social gospel intopractice.

Meanwhile, Morel had begun his ownmedical career. Jean-Paul Falret, a leadingFrench psychiatrist of the day, took Morelon as a resident at the well-known Salpêtrièrehospital, and soon Morel was engaged inefforts to establish a professional identityfor the fledgling specialty. Morel traveledextensively across Europe in the 1840s tosee how people with mental disabilitieswere treated in other countries. After a stintat the Maréville asylum, Morel became headpsychiatrist at the St. Yon asylum near Rouen.

Morel’s travels and clinical experiencetaught him that Europe’s masses endured ahost of crippling diseases, including cre-tinism and ergotism. Shocked by the inci-dence of these and other diseases amongthe poor, Morel turned the theory of progresson its head. His theory of degeneration saidthat the very growth of civilization couldimpede the progress of human history ifthe necessary public health measures werenot taken.

With his emphasis on heredity, Morelhas been accused of helping to launch thetheory of eugenics, which in the twentiethcentury culminated in the enactment in nu-merous industrialized countries of involun-tary sterilization laws targeting the mentallyhandicapped. However, those who blameMorel for eugenics ignore the fact that herejected the idea, popular among later eu-genicists, that people with mental disabili-ties were highly fertile. On the contrary, hewrote that such people and their familiestended to have few offspring. Far from the continued

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THE ART OF MEDICINE continued from page 11

infamous Jukes and Kallikak families of eu-genic lore, which supposedly kept breedingprofusely, patients who suffered from de-generacy were mostly infertile.

If Morel’s only contribution to medicinehad been his theory of degeneration, hislack of notoriety might be understandable.But Morel deeply cared for his patients, re-moving restraints, encouraging early dis-charge, and boarding out patients in thecommunity. He worked assiduously to pre-vent the warehousing of his patients.

Next to his compassion for his patients,perhaps Morel’s most striking talent was hiskeen clinical eye, which empowered him tomake one of the outstanding discoveries inthe history of medicine. Typically asylumphysicians of his day first encountered pa-tients when they were admitted to hospital,well after the onset of sickness. It was diffi-cult to discern at that point the full courseof the illness; so nineteenth-century psy-chiatrists normally based their diagnosison the state of the patient when he or shewas admitted. A psychiatric diagnosis wasoften just a “snapshot” of the underlying ill-ness, and thus incomplete.

In some respects, Morel was susceptibleto the fashions of his time, but like theother greats of the history of medicine healso had a talent for “thinking outside thebox.” During the 1850s he devoted moreand more attention to disease outcome, no-tably dementia, what he called the “termi-nal state” for most asylum inmates. Thenone day a distraught father brought hisfourteen-year-old son to see Morel. Once abright student, this teenager had lost all hisearlier intelligence and was rapidly becom-ing dull and lethargic. When Morel saw theboy later in adolescence, he wrote that itwas obvious that the patient suffered froma kind of “démence précoce,” a prematuredementia. “This desperate diagnosis is or-dinarily far from the minds of parents andeven of the physicians who care for thesechildren,” Morel added.2 Families living

with schizophrenia today can poignantlyrelate to these words.

With this case history Morel became the first psychiatrist to use the term “de-mentia praecox,” later popularized byGerman psychiatrist Emil Kraepelin. In 1911,Swiss psychiatrist Eugen Bleuler renameddementia praecox “schizophrenia”. By then,Morel had been written out of the history ofschizophrenia as a disease concept, an un-deserving casualty of the widespread cele-bration of all things German in medicine.

Morel’s discovery of a form of schizo-phrenia with early onset and poor progno-sis was not the only breakthrough thatmade the period a revolutionary time inthe history of psychiatry. In 1851 his formerpatron Jean-Paul Falret had discoveredbipolar disorder, the concept that maniaand melancholy were not two separate dis-orders but just distinct phases of the samedisease. Considering the many obstaclesMorel and Falret faced due to the condi-tions of asylum psychiatry in their day,their discoveries stand out as stunningachievements in the art of medicine.

Morel died of diabetes in 1873. By thenover-crowding and rising rates of chronicdisease were steadily transforming mentalhospitals into the “snake pits” muckrakersof later generations would denounce. Inthe coming years, the profession Morel haddone so much to establish would beginsplintering into recondite conflicts betweenbiologically-oriented and psychodynami-cally-oriented psychiatrists.

But for a brief time in the mid-nine-teenth century the field of mental healthcare had pulsed with the energy and visionof physicians such as Morel who brought acompassionate and unwavering commit-ment to their challenging clinical tasks.Later generations might match their dedi-cation, but they would have trouble equal-ing their selfless resolve to help those lessfortunate. We may never see the likes ofMorel and his generation again.

ian dowbiggin, Phd, is a professor of history at theuniversity of Prince edward island. he is the authorof several books in the history of psychiatry, includ-ing The Quest for Mental health: A Tale of Science,Medicine, Scandal, Sorrow, and Mass Society (2012),published by cambridge university Press. a fellowof the royal society of canada, he blogs forPsychology Today.

references

1 Edward Berenson, “A New Religion of the Left:Christianity and Social Radicalism in France, 1815-1848” in Francois Furet and Mona Ozouf (eds), TheFrench Revolution and the Creation of Modern PoliticalCulture. 3 vols. London: Belnap Press; 1989. Vol. 3,p. 543. Cited in Michael Burleigh, Earthly Powers: TheClash of Religion and Politics in Europe from the FrenchRevolution to the Great War. London: HarperCollins;2005.

2 Edward Shorter, A Historical Dictionary of Psychiatry.New York: Oxford University Press; 2005, p. 268.


On the Use and Abuse ofPsychohistory eric Prost

Ghaemi, Nassir. A First-Rate Madness: Uncovering the Links Between Leadership and Mental Illness (Penguin, 2011); 340 pages; CAD$17.00 paperback.

If a psychiatrist is wise – possesses knowledge and discernment beyond his narrow field– it is neither because of his profession nor in spite of it. Rather, it probably has little to

do with his day job at all and much more to do with upbringing, interests pre-dating psy-chiatric training, or the influence of friends and lovers. The practice of psychiatry itself,while honourable and full of satisfactions for the intellectually curious, equips no one toventure beyond its boundaries and to tread with confidence in other fields. And yet, asPaul McHugh, the former and long-time psychiatrist-in-chief at Johns Hopkins, writes, “abelief persists that psychiatrists are entitled to special privileges – that they know the se-cret of human nature – and thus can venture beyond their clinic-based competencies toinstruct on non-medical matters: interpreting literature, counseling the electorate, pre-scribing for the millennium.”1 If a psychiatrist “counsels the electorate” as other than apsychiatrist, that is one thing – as Charles Krauthammer (MD, Harvard, 1975) does dailyon PBS and Fox News as a political pundit – but if a psychiatrist feels qualified to lectureon various topics of interest because he is a psychiatrist, then the whole profession looks bad.

Many disciplines ostracize the member who escapes the academy and publishes inthe popular press, often making a name and money in the process – the professional his-torian who writes for the Sunday papers and debates on TV for example, or the amateurhistorian who writes bestselling works of history for the general public. And yet the publicdeserves to be presented with knowledge that is well-packaged and neither dry norpedantic; no one can expect the non-specialist to digest academic journals on the onehand, or to be simply satisfied with sound-bites devoid of content on the other.

To explain psychiatry (how does it differ from psychology, anyway?), or to present thefascinating but confusing symptoms of mental illness in good prose (what is “psychosis”?),or to outline the various theories of child development (why is my child so obsessed withrules and fairness right now?) is a useful task for any psychiatrist wishing to leap the con-fines of routine clinical work or randomized controlled trials and go public. But to diag-nose the dead with psychiatric disorders in an attempt to prove a tenuous thesis basedon incomplete and sometimes shoddy sources is this tendency at its worst.

Nassir Ghaemi is a well-respected and published academic psychiatrist at TuftsUniversity in Boston, and an expert in mood disorders. In his book, A First-Rate Madness,he argues the following thesis: “The best crisis leaders are either mentally ill or mentally abnor-mal; the worst crisis leaders are mentally healthy” (italics, unfortunately, are ubiquitous in theoriginal).2 His text is divided into four main parts, each a supposed attribute more commonin the mentally ill than the majority of people: creativity, realism, empathy, and resilience.He admirably takes some time to discuss definitions of each and then attempts to provehow these qualities were present in our great leaders and, indeed, made them great, andthat all this was simply and only because they were “mentally abnormal”. General Sherman,Ted Turner, Winston Churchill, Abraham Lincoln, Gandhi, Martin Luther King, FranklinRoosevelt, and John F. Kennedy are presented as the main examples of the MentallyAbnormal Leader who successfully handles crises because he is ill. Mentally Normal Leadersare fine during good times, even preferable as they place a steady hand on the peaceful na-tion and its flourishing economy, but in a crisis it is the mentally abnormal who are neces-sary. In such circumstances the calm, the measured, and the bland will always fail.

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Dr. Ghaemi follows all readable historians by having a point-of-view and marshalinghis evidence to support it while mostly ignoring contradictory information. After all,Edward Gibbon and A.J.P. Taylor were great because of their novel and opinionated ideason the Roman Empire and the origins of the Second World War, not because they wroteeminently balanced history textbooks. Unfortunately, Ghaemi’s work does not deserveto rest on the shelf beside Gibbon’s Decline and Fall (although alphabetically it may dojust that). While it has a clear thesis, it has many faults.

First, the thesis is so bald and the evidence displayed so one-sided that the historian’scraft is ultimately abused. There are few armchair neurosurgeons in the world, some arm-chair psychiatrists, but many armchair historians. Pontificating about the past seems opento all, regardless of qualifications; many do not understand that more than one’s personalcommon sense is needed to write history, and that training, as in any profession, mightadd something. Without this, Ghaemi presents history as simplistic with all the depth ofa cardboard prop. For example, he reduces the 20th century to a paragraph that would fitwell if delivered in jest and spoken rapidly from a drawing room in a George BernardShaw play: “Soon he [Hitler] began to abuse those treatments [amphetamines] by receiv-ing daily intravenous injections – a practice that continued every day throughout theSecond World War, worsening his bipolar disorder, with more and more severe manicand depressive episodes, while he literally destroyed the world”.3 In a sentence, Ghaemihas reduced the world’s bloodiest century to one man’s abnormal mental state. Not onlyis this the simplistic “Great Man” theory of history where key individual actors make allthe difference, but it is the “Abnormal Great Man” theory where the course of history ischanged by an individual mood swing or an injection.

Ghaemi makes a good point when he writes that historians must not ignore true men-tal illness when it exists in historical figures: if mental illness affects the life courses of ourindividual patients, it likely also has affected the course of the lives of prominent figuresof the past. Historians, he writes, already engage in psychological history when they at-tempt to understand why past leaders behaved in certain ways. Why then not label one’shistorical research for what it is – a psychological assessment of past figures and their mo-tives – and then attempt to judge accurately by incorporating real evidence from the sci-ences of psychiatry and psychology? Where Ghaemi errs even in this argument, however,is that his criticism of how history is practiced does not apply to most current historicalwriting, but rather just to biography – only a sub-genre of historical writing.

But Ghaemi has more to say on writing history. “History,” he writes, “involves the in-terpretation of people’s motives and intentions. Psychiatry also entails interpreting peo-ple’s motives and intentions. The only difference between history and psychiatry, in thissense, is mortality – psychiatrists examine the living, historians the dead, but both in thesame manner”.4 When this is coupled with a comment earlier in the book that“Psychiatrically speaking, living people are more difficult to examine than the dead”,5 wehave a portrait of the author as fully equipped, nay better equipped, than the historian toilluminate the personalities of the past. Compare this stance to the position taken by an-other practitioner of psychological biography, the psychiatrist Anthony Storr (1920-2001).Right at the beginning of his essay “Churchill: The Man,” before a lengthy psychoanalytictreatment of the British prime minister, Storr writes this:

The psychiatrist who takes it upon himself to attempt a character study of an individual whom he has never met is engaged upon a project which is full of risk.In the exercise of his profession, the psychiatrist has an unrivaled opportunityfor the appraisal of character, and may justly claim that he knows more personsdeeply and intimately than most of his fellows. But, when considering someonewho has died, he is deprived of those special insights which can only be attainedin the consulting room, and is, like the historian, obliged to rely upon what writtenevidence happens to be available.6

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Hubris is missing. Just the necessary reverence for the awesome task of presuming to understand the dead remains, a task best approached with humility by the historian, andcertainly by the psychiatrist.

When Dr. Ghaemi presents a positive argument – one that attempts to prove the exis-tence of something, in this case mental illness in certain leaders – he makes some ques-tionable points. He argues that General Sherman had Bipolar Disorder and PresidentLincoln depression, and he is probably right. However, his case for depression in MartinLuther King is more tenuous. Less convincing yet is his treatment of Presidents FranklinRoosevelt and Kennedy, for in these last two cases the label of mental illness is down-graded to “mentally abnormal,” a nebulous label if there ever was one. Ghaemi thinksthat both men had “hyperthymia,” a collection of personality traits for which Ghaemiseems to claim reliability and validity as a diagnosis. These include being “high in energy,extremely talkative, outgoing, extraverted – in short, very good company”7 (this last state-ment of preference alone seems highly questionable to this introverted reader).Hyperthymia also explains Kennedy’s sexual peccadilloes (the trait is dubbed “libidinous”in Ghaemi’s words). The collection of traits is less extreme for Kennedy than for Roosevelt,Ghaemi admits, but he nevertheless surges forward with his thesis that Kennedy’s lead-ership abilities were because of mental abnormality. He concludes this section with thesupposedly novel insight that there is a Kennedy gene for “hyperthymia” and that thepresence of certain personality traits in successive Kennedy generations is somehow sur-prising.8

With both Roosevelt and Kennedy, Ghaemi stresses the influence of each man’s phys-ical illness on his mental resilience. Again, this is no doubt true: surely FDR’s sudden polioand lasting paralysis from his 30s onward, and JFK’s Addison’s Disease and chronic painshaped their personalities and likely contributed to resilience and drive. But this hardlyproves Ghaemi’s central thesis about the best crisis leaders being mentally ill or abnormal.The only possible (and non-original) conclusion to this section is this: FDR and JFK wereextraverted high-energy aristocrats who suffered physical illnesses which, in turn, re-shaped them to be resilient and manage their respective crises when in power. This Ilearned in textbooks years ago.

Where A First-Rate Madness really falters though is when Dr. Ghaemi attempts to provea negative – the absence of something, in this case that all unsuccessful crisis leaderswere “mentally normal”. Even to attempt this shows a sensibility at odds with the writingof serious history. It is difficult not to suspect that evidence of unsuccessful leadershipduring a crisis came first and then evidence for the normality of the leader was sought atall costs.

All unsuccessful crisis leaders are, for Ghaemi, “homoclites”. Again, this term is pre-sented as a robust diagnosis. It comes from a 1962 study in the Archives of General Psychiatrywhere young men from the American Midwest, students at a YMCA-run college, were ad-ministered a battery of psychological tests; a group who scored in the middle “healthyrange” were then selected to be interviewed over two years. The resulting cohort does in-deed sound bland and was described in the study as having “practically no trouble withthose in authority” and men who would “abide by rules”. Whether these “homoclites” canthen be assumed to comprise the bulk of humanity, or the vast denizens of the mentallynormal, across time and cultures, is a big leap. Young men from 1960s Chicago might bemore different than similar to most members of the officer class in the Union Army ormost of the 20th-century U.S. presidents or Prime Minister Neville Chamberlain, even ifthey all would score middling results on psychological tests. All these people, however,are just homoclites to Dr. Ghaemi, men too mentally healthy to possess the attributes tolead in a crisis, men who couldn’t hack it like their insane counterparts General Sherman,John F. Kennedy, and Winston Churchill.

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ON THE USE AND ABUSE OF PSYCHOHISTORY continued from page 15

The historical record is stretched almost beyond belief in the chapters attempting todismiss as normal successive world leaders. Tony Blair is “curious but not a risk-taker”and, therefore, a homoclite. “Even his earnest attitude to religion is consistent with ho-moclite psychology,” writes Ghaemi.9 This intriguing statement is not explained further.George W. Bush, too, is the quintessential homoclite who got Cs at Yale and married a li-brarian. Ghaemi sketches Bush’s pre-presidential life in a few pages, highlighting the ev-idence for homoclite status while sprinkling the paragraphs with stand-alonesentence-paragraphs suitable for quoting, such as “A homoclite makes a good friend, buta risky leader”. Bush’s alcoholism is simply explained away. It is odd for a 21st-century psy-chiatrist to treat a substance use problem so lightly and categorically refuse to call it amental illness. It is true, if Bush is an alcoholic in sustained remission, this would spoil aperfectly good thesis. Better to use Bush’s success at abstinence to say patronizingly thathis alcohol problem “was mild and easily solved,” thus rendering him again mentally nor-mal, as all who do not meet crises satisfactorily must be.10 President Eisenhower is dubbeda homoclite even though he was “relatively successful,” because his presidency did notentail “handling major crises”; in fact, although he “briefly intervened in Little Rock” re-garding civil rights, he “otherwise avoided conflict”.11 Planning and commanding the in-vasion of Normandy – deemed a conflict by some – while Supreme Allied Commanderin Europe has never before earned this personality description.

If 20 percent of the population will experience a mental illness over their lifespan, then80 percent will not. They are the homoclites. 80 percent of the population, therefore, isdescribed by Dr. Ghaemi’s universal statement: “The homoclite does not fail often, andwhen he does, he learns little”.12 Is it not possible that some men and women who willnever suffer from mental illnesses may yet learn from mistakes? Is it not possible that in-troverts, rule-followers, middle westerners, the calm and the measured, might gain insightwhen they suffer? A psychiatrist with a clinical practice sees many patterns in a day’s work:he sees patients whose symptoms fall into common clusters again and again, across gen-erations and cultures; he sees childhood insults presenting in similar ways in patientslater in life. But he also sees infinite variety. Ghaemi is right in saying that Lincoln’s melan-choly enhanced his leadership performance, as did Churchill’s moods. But Roosevelt’sparalysis likely accomplished this too, for it made him become more than a lightweightaristocrat from New York State with a jaunty manner. We do not have to prove he wasalso mentally ill or abnormally “hyperthymic” to understand this. There are routes to insight that do not pass through mental illness. Hemingway’s sentiment in A Farewell To Arms potentially applies to 100 percent of humanity: “The world breaks every one andafterward many are strong at the broken places”.

eric Prost, md, frcPc, is a staff psychiatrist at Queen’s university, Kingston, ontario, and the editor of Synergy.

references

1 Paul R. McHugh, “Psychiatric Misadventures” in TheMind Has Mountains: Reflections on Society andPsychiatry. Baltimore: The Johns Hopkins UniversityPress; 2006, p. 3.

2 Nassir Ghaemi, A First-Rate Madness: Uncovering theLinks Between Leadership and Mental Illness. New York:Penguin; 2011, p. 17.

3 Ghaemi, 170.

4 Ghaemi, 272.

5 Ghaemi, 153.

6 Anthony Storr, Churchill’s Black Dog and otherPhenomena of the Human Mind. London: HarperCollins;1989, p. 3.

7 Ghaemi, 131.

8 Ghaemi, 157.

9 Ghaemi, 245.

10 Ghaemi, 236.

11 Ghaemi, 223.

12 Ghaemi, 238.

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