Abstract
Andrew Scull, a sociologist from the University of California at San Diego, has written an impressive history of “madness”—a term specifically chosen over “mental illness” or “psychiatry” and a term which has had a much longer history and global significance than the more recent labels. The term madness is also more descriptive of how societies have viewed nonnormal, unexplainable (or unacceptable) behavior, in that those who are defined as “mad” have challenged the social order in every historical period and in every civilization that has documented their presence in medical treatises, government policy, art, literature, music, religious canon, or whatever contemporary commentary is available. The book is a welcome addition to the literature on the histories of psychiatry, psychotherapy, mental illness, asylums, and medicine, encompassing all of these within the context of their social meanings. The history spans the ancient world (both Western and Eastern civilizations) through pre- and post-Christian epochs, the Middle Ages, Enlightenment, and onward into the 20th and 21st centuries. A common thread throughout the presentation is that since ancient times, explanations for mental illnesses have alternated between internal (biological) and external (environmental and moral) etiological theories that are based on the society’s demarcations of exclusion. This is nothing new in sociological studies of mental illness. What’s new here is that the author succeeds in showing the continuity of specific etiological explanations that have led to various interventions which show a remarkable consistency over time, from herbal remedies of humoral disregulation to psychoactive medications and from the use of intense heat and other tortures to combat the mad effects of syphilis to the near present-day use of insulin shock therapy and lobotomy. In the absence of evidence, partial theories have led to ineffective and often dangerous cures. Of interest to scholars is the author’s critique of previous interpretations about the state of mental illness as shown in the arts, literature, and theater. He dismisses the insights of the philosopher Michel Foucault, for example, for taking too literally the artistic conceit of exaggerated images of ships carrying mad outcasts. Contemporary images served to reflect and reinforce the society’s fascination with nonnormal people (rather than accurately portraying their real experiences), although in some cases, they served as catalysts for social change. These archetypes continue to populate the arts even now. The rise and fall of asylums is shown to be in lock step with the 19th- to 20th-century urbanization of Europe and the United States, as the rise of urban upper classes led to fashionable neuroses (hysteria) requiring a lucrative profession of outpatient psychoanalytic psychiatrists who were finally freed from the low-esteem jobs administering asylums for the more seriously disturbed and oppressed poor. These massively populated asylums in Europe and the United States eventually collapsed under their own economic weight. Scull believes that the role of the use of psychoactive medications (such as Thorazine) is overstated in explanations about the deinstitutionalization of state hospitals in the United States. These institutions began discharging patients before the widespread use of antipsychotics. He also believes that the effectiveness of psychoactive medications has been overstated, citing recent studies that question earlier replications of clinical trials. Many studies’ null findings have been tamped down and not disseminated. He offers the idea that drug companies were directly responsible for creating a reductionist diagnostic system (versions of the Diagnostic and Statistical Manual of Mental Disorders) in order to simplify and smooth the way for successful drug trials. About his discussion of the present day, he could have made a stronger point about the social role of the current genetic and biological etiological theories and why they are so fascinating to us now. As he so competently presented throughout the book, what people say about the causes and cures of mental illnesses reflects deeply embedded social values, which makes the study of mental illness so difficult. Maybe our fascination with genes and neurology (and a reductionist approach to diagnosis) is the continuation of an unending struggle of societies to make sense of phenomena that so deftly elude understanding. Those of us in social work who value a comprehensive view about mental illness and our response to it may take this book as confirming evidence that no one explanation will ever be sufficient.