The Quest for Mental Health: A Tale of Science, Medicine, Scandal, Sorrow and Mass Society

Has insanity increased or is the concept all in the mind? David Healy welcomes an insightful debate

August 18, 2011

Really good history can challenge us in many different ways. There is the shock, for example, of finding that in 1939 Hitler was nominated along with Gandhi for a Nobel Peace Prize. Arresting details such as this can liberate us from the presumptions of the present and enable us to ask new questions about our times.

Good history also asks us about ourselves. Where once our identities were shaped by wars and politics and events spaced years or decades or even centuries apart, now we are increasingly defined by breakthroughs in health. Medicines such as Valium, Prozac and Viagra are serving to define events that happen at ever-closer intervals, sometimes no more than months apart. Health, like economics, has become a domain in which political processes play out, and no branch of health more so than mental health.

Ian Dowbiggin writes excellent history on both scores. Time and again he stops readers in their tracks. For instance, almost everyone who picks up this book will start with the impression that general medicine and its specialities were flourishing long before psychiatry, that hospitals antedated asylums, and that where medicine has eliminated many scourges, psychiatry has cured nothing. Dowbiggin shows that the record was very different. Society invested in asylums before hospitals; psychiatrists were the first medical speciality to form, and they had academic forums and journals long before others. And a century ago psychiatry had seen off diseases such as dementia paralytica (tertiary syphilis) and pellagra psychosis, and more recently catatonia and possibly puerperal psychosis.

The fact that mental disorders continue to multiply confounds this picture. Oddly, this confounding doesn't happen in response to the increasing number of physical disorders for which we are now being treated. What's going on?

Before spilling the beans, it's worth telling the reader more about the genre of history that Dowbiggin is approaching. After the fall of psychoanalysis, a hole opened in our collective history. There had been a steady stream of books on the origins of and disputes within dynamic psychology - some of which, like Henri Ellenberger's The Discovery of the Unconscious (1970), are classics. But with the demise of Freudianism, this market dried up and, for a while, there was little or nothing. The gap was filled in part by general histories of health, such as those written by Roy Porter and Ned Shorter, that also touched on nervousness. In the past five years, there has been a flood of books on the rise of biological psychiatry and psychopharmacology - histories of the tranquilisers, the antidepressants, the stimulants and others. But for the most part, and with the exception of Andrew Scull, scholars did not attempt to tackle the bigger picture.

It is relatively straightforward to write a history of a commodity, but a lot harder to connect that commodity to a bigger picture. This is where Dowbiggin's background comes into play. He comes to our 21st-century issues from an interestingly different hinterland to others writing about psychotropic drugs. He cut his teeth on questions such as degeneration in 19th-century European thought, followed by studies of the hope and despair linked to asylums.

The spectre of degeneration was close to the mirror image of our current quest for well-being, and it is a spectre we have turned away from. One of its incarnations could be seen in Cesare Lombroso's L'Uomo Delinquente (1876) - the born criminal, whose image underpins fictional creations from Dracula to Hannibal Lecter; the person who cannot be redeemed or reformed. That such people existed challenged both religion and the emerging structures of liberal republicanism.

It is this background that prepares Dowbiggin to ask questions few others ask. He points up the paradoxes of liberalism, examining how, in the new world of democratic tolerance inaugurated by the French Revolution, we have shaped psychiatry into an arm of government, between the legislature and the army and police. And he considers how our embrace of diversity has led to increasingly severe restrictions on "normality", so that few if any of us are normal any more - we all, it seems, have depression, social phobia, ADHD (attention deficit hyperactivity disorder), autistic spectrum disorder - and how, newly liberated from authoritarianism, we have increasingly turned to experts to tell us what to do.

The asylums were built as part of this new morality. At first they posed little threat, in that only those with severe psychotic disorders were incarcerated, although the increasing rates of incarceration caused much soul-searching. Was insanity truly increasing? Were the conditions of modern life creating it? Were we contravening the natural order and paying the price?

The failure of asylums to "work" led to despair and created the conditions for a further set of problems - radical treatments such as insulin coma, prefrontal leucotomy and the fever therapies of the 20th century. Paradoxically, this institutional failure acted as a brake neither on the growth of therapeutic culture nor on radical biological solutions. The dynamic psychotherapies emerged to minister in a semi-spiritual fashion to our malaise, while psychopharmacology has since commandeered the physical ground of our being and is busily converting the vicissitudes of daily life in everyone from infants to centenarians into deviations that can be corrected, provided we take an ever-greater number of medications.

These therapies bring our spiritual malaise to a focus. That there is a "spiritual" component, as Dowbiggin points out, is also attested to by the growth of seances and spiritualism at the end of the 19th century, which spoke vividly of widespread efforts to escape from materialism, just as did the psychedelic counter-culture of the 1960s.

The problem is that with the death of God, we do not seem happy simply to let people be - we now have an apparatus in place that insists on conformity. It is as though having replaced God, to paraphrase Bruno Schulz, we have reached down to feel our creation and have retreated in bewilderment at how strange it is.

There are profound mysteries here that Dowbiggin's book raises rather than closes. Has insanity increased? Is it possible that disorders such as schizophrenia were linked to factors such as changed obstetrical care or lead poisoning, and might some day vanish and leave our therapeutic culture in their wake like the grin of the Cheshire Cat? Is it the collapse of authority or the emergence of markets that is the primary driver of therapy? Does it make a difference what lies beneath the burkas of women in shopping malls in Dubai? Are those concealing Western fashions beneath their burkas more or less likely to have a "coincident" mental disorder than those wearing traditional clothing only?

There are urgent questions here that need answering. The failure of the asylum as an institution has been profound, and anticipates our current lack of trust in government and institutions in general. The problem for those who have lost faith in institutions is that the alternative, community care, seems as bad, if not worse. We are now caught in a wasteland between bio-babble and psychobabble, ever more prey to manias such as the recovered-memory craze of the late 1980s and early 1990s and more recent crazes for ADHD, autistic spectrum disorder, juvenile bipolar disorder and Tea Parties.

The only quibble I have with this book is that towards the end Dowbiggin refers to magnificent discoveries in brain science and drug therapies. My hunch is that he feels that a historian cannot readily dispute today's propaganda from the biosciences. But this concession to "progress" lets a little steam out of the pressure cooker.

The Author

Ian Dowbiggin has been professor of history since 1991 at the University of Prince Edward Island in Canada's smallest province, the setting for the children's classic Anne of Green Gables.

While studying for his undergraduate degree at McMaster University in Ontario, Dowbiggin became fascinated by the history of science and medicine. By the time he graduated in 1975, his chief interest was the writings of Sigmund Freud, and his master's thesis at the University of Toronto was on Freud's short-lived collaboration with Carl Jung. On learning that the renowned Freud scholar William J. McGrath taught at the University of Rochester in New York state, Dowbiggin transferred to Rochester for his doctorate, which he completed in 1986.

Aside from youthful dreams of becoming a professional athlete, Dowbiggin says he always envisioned being a teacher and writer of history. He is on the editorial board of the peer-reviewed journal History of Psychiatry and regularly commentates on public affairs for the CBC radio programme Island Morning. In his spare time he enjoys playing golf, as well as making "amateurish attempts to the play the piano".

The Quest for Mental Health: A Tale of Science, Medicine, Scandal, Sorrow and Mass Society

By Ian Dowbiggin

Cambridge University Press

220pp, £55.00 and £16.99

ISBN 9780521868679 and 688680

Published 25 August 2011

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