Review symposium on Liah Greenfeld, Mind, Modernity, Madness: The Impact of Culture on Human Experience. Cambridge, MA: Harvard University Press, 2013, x + 670 pp. Open Access

Over the past century and a half, mainstream psychiatry has been marked by two articles of faith, the idea that the cause of mental suffering is to be found in the brain and that mental diseases exist in nature just as other diseases do. In this lengthy, and finely wrought, work Liah Greenfeld challenges these assumptions and ventures the astonishing claim that the two major mental disorders of our period, schizophrenia and manic-depressive psychosis, which had been identified in the late nineteenth century by Emil Kraepelin, are caused not, as contemporary psychiatric wisdom would have it, by disturbances of brain function but rather by upheavals in the cultural and social order of things in the western world that are the consequences of modernity. Modernity, it turns out, is uniquely deranging. Normal brains in abnormal circumstances. One's incredulity in the face of such a claim is, in part, a measure of the extent to which, in recent decades, the assumptions of biological psychiatry have bamboozled us all and established a foothold in popular culture as a kind of common sense, though there are recent signs, not least because the quest for the neuro-grail remains elusive, that bio-triumphalism has, at the very least, been restrained and that approaches that evince an interest in, and respect for, meaning can once again receive a hearing.

For a considerable period, of course, in the USA especially, psychoanalysis was the standard-bearer of meaning against the reductionism of bio-medicine, but what interests Greenfeld is not the inner world in the style of psychoanalysis but mind-in-culture or culture-through-mind. The historic plot-lines in which to locate her discussion are contentions about the perverse impact of civilization on the incidence of insanity that run from Esquirol and Edward Jarvis in the nineteenth century through to Karl Menninger in middle of the last. To the resumption of this debate Liah Greenfeld brings not only formidable scholarship but an additional edge in the claim that the history of modernity can account very specifically for the origins, and unfolding, of the two major psychoses. And it is here that I return to another dimension of my incredulity. I write as one who has a background in the social history of mental health and in abnormal psychology and who has worked closely with people with a schizophrenia diagnosis over several decades. I am under no illusions about the seriousness of these conditions and the toll they frequently take over people afflicted with them. The onus is on Greenfeld to demonstrate the paths through which we can identify convincing links between an extended historical and cultural action and the disturbances of the sorts of people with psychosis I have encountered over the years. Can she do so?

Briefly, her argument is this. Madness as we know it today is a distinctly English home-brew that first makes its appearance towards the end of the sixteenth century. Only two centuries later does it become rampant in other parts of Europe, first in France and Ireland, and then beyond, for ‘until the very last years of the eighteenth century mental disease of the kind was as yet observed nowhere on the European continent’ (410). In the new world that was being propelled into being in England in the sixteenth century, a humanistic outlook, later to be dubbed nationalism, came to hold sway over Holy Scripture. Nationalism is to be understood as an essentially secular view of reality, a form of consciousness whose socio-political component rests on the principle of fundamental equality of membership in a popular sovereignty. The sixteenth century in England was the ‘first century of the world as we know it’ and it was only then that happiness became possible, and the only place in which, for some time, happiness was possible was in England (338). Nationalism did more, however, than provide the conditions for happiness, for by vastly increasing the opportunities for choice and self-realization it also made the formation of individual identity much more confusing and stressful, thus also stimulating the new form of modern unhappiness that Durkheim was to style anomie. By the end of the sixteenth century, madness as a form of human suffering was noticeably spreading in England, indeed by Shakespeare's time it had become the characteristic form of human suffering that, in Shakespeare's belief, was related to the current state of society. Malformations of the mind of this sort were to become a mark of nations. The sooner a society embraces the values of nationalism, and defines itself as a nation, the sooner diseases of the mind appear in it. Though madness only reaches a clinical level in a minority of cases, the pervasive anomie of modern national societies affects very large numbers of people, making them socially maladjusted and deeply dissatisfied with themselves.

In claiming that ‘madness’ is a distinct condition, unlike any other known to history (with some minor exceptions) before the sixteenth century Greenfeld is, in effect, presenting herself as the one who has discovered, or unearthed, this overlooked condition, and can now detect it in all sorts of historical recesses. Kraepelin was mistaken, she believes, to apportion the psychotic spoils between two distinct disease categories and we should, instead, identify the English Malady as a unitary form of psychosis that is the source of our modern ills. These are formidable proposals by any measure, not least from an outsider who has no previous association with, or background in, psychiatry and mental health. If Greenfeld can attract a significant groundswell of opinion in support of her arguments, then perhaps the designation of Greenfeld Syndrome (or some such) may eventually come to supplant the outmoded Kraepelinian schemata that still define the field. It must be said that her chosen standpoint is rather unfashionable in the contemporary history of psychiatry, for though she is profoundly critical of the biological assumptions that underpin psychiatric nosology, to a considerable extent she takes on board the categories of psychiatry, viewing the historical landscape through a psychiatric lens and taking it for granted that the mental illnesses she is discussing are real entities, thus eschewing the recommendation of a historian of psychiatry such as Mikkel Borch-Jacobsen that we ‘avoid unduly objectivizing mental illness, as if it existed independently of the psychiatrist and surrounding culture’. Within her scheme of things Greenfeld understandably gives short shrift to social constructionism, though the notion of social constructionism she deploys is a rather caricatured one, and one wishes she had engaged with the more nuanced, and challenging, arguments of the Canadian philosopher Ian Hacking to the effect that a phenomenon can be both real and socially constructed.

But how convincing is her account? I can only touch on a few methodological issues here. Schizophrenia, she proposes, is a cultural problem, so we must look for circumstantial evidence in the anomic conditions of modern society which makes the formation of identity hugely problematic. But how are we to identify this circumstantial evidence? To illustrate her thesis she discusses at some length the story of John Nash, the mathematician, who suffered 34 years of paranoid schizophrenia. Anomie, and resulting problems with identity, were ‘patently evident at every stage in his tortured life’, we learn, indeed

Anyone familiar with the history of schizophrenia will experience a distinct sense of deja vu in reading this account, for it is decidedly reminiscent of long-discarded theories of the schizophrenogenic mother, or of the double bind, with all the same methodological difficulties that attach to criteria that are only very loosely specified.

On Greenfeld's reading of it, signs of madness (or more exactly schizophrenia) are omnipresent in the historical field, and in the fabric of modern life, so much so that schizophrenia seems at points to provide the answer to the riddle of modern history. Thus ‘madness was the inspiration for Marxism’, she has discovered, since the concept of alienation in Marx's 1844 manuscripts turns out to bear ‘striking resemblances to symptoms of schizophrenia (and its spectrum disorders) as we see it today’. Balzac, she believes, was interested in madness because it was all around him, a central experience in the life of his time. ‘Schizophrenics whom one knew before outbreak of the disease as brilliant and enthusiastic, if somewhat desultory, intellectuals must have becomes as familiar a phenomenon in mid-nineteenth century France as Toms O’Bedlam were in late sixteenth century England’ (447). Remarking on the madness of poets in the eighteenth century, she comments that ‘poets writing in English have continued to go mad ever since: it is hard to find one among those who have achieved fame who has had no brush with one or another variety of schizophrenia’ (403) (well, here are a few: W.H. Auden, Ted Hughes, Philip Larkin, Wallace Stevens and Seamus Heaney). Literary Romanticism, ‘an extremely important phase in the development of Western modern literature, was, fundamentally, an expression of madness’ (425) and English language modern poetry, it now appears to her ‘undeniable’, has been ‘a creation of madness’ (616). Louis Sass famously explored similarities between schizophrenic forms of expression and the cultural forms of modernity but Greenfeld gives a much stronger twist to this association, proposing that the ‘(usually formless) form’ of modern poetry is ‘a function, a creation, of mental disease. It is, at its root, a symptom, an expression of madness, a desperate “I am” sign’ (404). Moreover, schizophrenic delusions also ‘explain the centrality of two themes in violent ideological politics of the last two centuries in the West: the evil rich (capitalism) versus the good poor; and Jews (now Israel) against the world’ (624). Lots of things are resoundingly ‘obvious’ or ‘undeniable’ to Greenfeld that may seem questionable at the least to many of us, and she does not really do the plausibility of her case any favours, I believe, by ratcheting it up to such a pitch. Other considerations aside (and I can think of several), my main concern here is that there is a good deal of slippage in the way that the term ‘schizophrenia’ is being used. Frequently it is to be taken rather loosely to refer not so much to a specific condition as to a general malaise of modernity. It is, for the most part, a cultural rather than a clinical diagnosis.

Of importance also in Greenfeld's historical analysis is the role of social class. What matters to Greenfeld is less the psychology of John Nash's mother, for example, than her class position for ‘the causal explanation of the psychotic illnesses under discussion here … boils down to the nature of experiences of the upper classes of modern societies and is to be sought in the cultural history of these classes’ (272). Greenfeld allows, of course, that ‘as the values of nationalism penetrated deeper into the masses of the population, insanity too became proportionately far-reaching’, but she claims that ‘the rates of insanity increased … as more choices became available to more people’, so linking the experiences of groups variably situated on the social class spectrum (4). The crises of identity experienced by a broad swathe of the population in industrial Britain were certainly very real. Thus James Dawson Burn in the Autobiography of a Beggar Boy (1855) recounted how ‘amid the universal transformation of things in the moral and physical world … I have been so tossed in the rough blanket of fate, that my identity, if at any time a reality, must have been one which few could venture to swear to’. However, it seems far-fetched to claim that the inmates of an asylum such as Colney Hatch near London, for example, documented by Richard Hunter and Ida Macalpine in their classic text Psychiatry for the Poor (1974), the vast majority of whom were pauper lunatics, were the beneficiaries of increased ‘choices’ or that there is necessarily any affinity between whatever may have precipitated their mental suffering and the experiences of the upper classes. If we are to look for circumstantial evidence to explain their suffering, we surely need to engage more directly with the substantive life-experience of the disadvantaged classes in this period, wage-labourers most of them, who were subject to the rapid and unpredictable fluctuations of the market. Actually, help may be at hand in the theories of social defeat – involving a profound subjective experience of failure that may include (though it is not the same as) Durkheim's anomie – that have been used to account for the experience of severe mental illness among ethnic minorities in contemporary Britain, but in other to embrace these, and introduce them into her framework, Greenfeld would have to be willing to relinquish her fixation on the experiences of upper classes as providing the model for the experiences of other classes.

‘Modern society is exceedingly complex’, writes Greenfeld in conclusion, ‘and our inability to cope with this complexity makes us mad’ (628). The identity problems of modern society may indeed be troubling and incommoding for increasing numbers of people but they do not necessarily make the people we label ‘schizophrenic’ schizophrenic, even though they may certainly aggravate their suffering. Maybe Liah Greenfeld can strengthen her case but right now I am not convinced that Greenfeld Syndrome can carry the day in supplanting the legacy of Emil Kraepelin. She makes that word ‘complexity’, with its link to Durkheim's theory of anomie, do a lot of work in her argument, and I am not persuaded that it can bear the load that it is required to. As I have suggested, in venturing a new culturalist interpretation of schizophrenia and other psychoses, theories of social defeat seem to me more promising. As to the remedies for the madness of the modern age, the ones that Greenfeld proposes are mainly educational and preventative. She appears to want to usher in a new era of moral therapy, but one is inevitably left to wonder if it would not suffer the same fate as its historical predecessor, optimistic hopes eventually crushed by the sheer weight and scale of suffering and demand. None of these qualifications should be taken to detract from Liah Greenfeld's achievement in this hugely stimulating and remarkable work which resists any casual classification and poses enormous challenges to a historical sociology of madness and to a programme for a history of psychiatry grounded in an historical anthropology of ‘mind-in-culture’. Hunter and Macalpine are dismissive of the abnormal mental states of the mad poor at Colney Hatch asylum, reflecting their belief that patients were ‘victims of their brain rather than their mind’ (1974, 184). But the mind, as Greenfeld adroitly points out, is not a product of the brain. ‘Rather, it is produced in the brain by culture’ (84). Surely, this is now an invitation to revisit the historical inmates of this and other asylums and to restore them to their proper context in an exploration of mind in history.

Peter Barham is a psychologist & a social historian. His books include Schizophrenia & Human Value (1986), Closing the Asylum (1997) and Forgotten Lunatics of the Great War (2004). Currently, he is an Associate Member of the History Faculty at the University of Oxford.

Email: [email protected].