Today, I finished reading Andrew Scull’s Madness in Civilization: a cultural history of insanity, which has prompted a few posts here and here. The book ends with a series of falls from grace of modern ways of thinking about madness; psychoanalysis becomes stranded with its limitation to a small elite, only to find itself as defined as irrelevant to the great suffering of the most severely mentally ill; then the great disappointments of the evacuation of the asylum, seen as the great enemies of freedom, the great bankrupting social shames, but without any conscientious attention to the community care of the most unwell; and finally, the descent into confusion and denial of the Diagnostic and Statistical Manual itself, which in its fifth edition, was abjured by Robert Spitzer and Allen Frances, the architects of its earlier editions.
Out of the collapse of the great encyclopaedia of the disordered mind, there emerged a new project – to fix all mental illness to single biological causes. Led by the Institute of Mental Health in the USA the new scientists of the brain disavowed the DSM’s study of symptoms to search for a more fundamental biological mechanism. Thomas Insel said “As long as the research community takes the DSM to be a bible, we’ll never make progress. People think everything has to match DSM criteria, but you know what? Biology never read that book” (quoted Scull, p 408).
Rather than a descriptive symptomatology, the new neuroscience believed they could build a diagnostic system on firm biological foundations. But they were to be disappointed. Despite the flashy images of the brain in action, they came no closer to really understanding the mysteries of the disordered mind or much beyond the routines of the ordered mind. And the reason is in part at least that the human mind, and madness as among the most potent expressions of that mind, is one part biology, two parts culture.
So Scull notes that the metaphysical wager that madness is an illness explicable by the body alone has not paid off. Our cures can be neither solely mental nor merely medical. They must embrace the cultures that temper, limit and excite the voices of madness within us. It is not that the pills or biological explanations will not play some role. “But will madness, that most solitary of afflictions and social of maladies, be reducible at last to biology and nothing but biology?” (p 411)
No, Scull replies:
The social and cultural dimensions of mental disorders, so indispensable a part of the story of madness in civilization over the centuries, are unlikely to melt away, or prove to be nothing more than epiphenomenal features of so universal a feature of human existence. Madness indeed has its meanings, elusive and evanescent as our attempts to capture them have been. It remains a fundamental puzzle, a reproach to reason, inescapably part and parcel of civilization itself. (Scull, p 411)