In Madness: A History, Pietikainen sets out to present a comprehensive yet accessible account of madness from antiquity to modern times. It is a formidable challenge, but Pietikainen succeeds in delivering a fascinating and beautifully written account, which is completely enthralling and at times quite horrifying. The structure of the book is similar to a guided tour in an art gallery: the reader is taken on ‘a walk through the history of madness’ (4), and at certain points along this walk the author stops to examine in more detail significant events, discoveries and key individuals who have played a major part in the development of this rich subject matter.
The author begins by suggesting there is ambiguity regarding the definition of madness, and this suggestion recurs throughout the entire book. Pietikainen argues that in the course of history, many different social, medical, judicial and religious meanings have been attached to madness and that definitions of, and criteria for, madness change temporally and locally (7). The difference between the sane and the insane, he argues, is a matter of scale, and in madness we see the same traits that can be found in sanity. Despite this, Pietikainen is also quite clear that mental illness is not a social construction which can be eradicated if the values and norms of society are changed. Rather, he argues, there is a biological reality to the nature of madness (9).
The book is broken down into four major parts. In Part I, Pietikainen looks at madness from the Age of Antiquity to the Age of Enlightenment and explores how madness was defined and treated in this era. The earliest explanations of madness begin with myths and religious stories, with people being possessed by gods and evil spirits. From this, Hippocratic medicine emerges, where madness comes to be described in naturalist terms of ill health and disease. During medieval times, the classical medicine of late antiquity gives way, once again, to largely religious explanations and remedies, reflecting the decline in the social prestige of physicians and the growing importance of the clergy. This is only reversed around the Age of Enlightenment, and the intellectual turn towards the veneration of reason, scepticism and secularism, when, amongst others, English political philosopher Thomas Hobbes describes madness as a ‘principal defect of the mind’. Following this ‘Hobbesian turn’, madness finally becomes defined as mental illness, a medical condition to be explained and treated materialistically and naturalistically (69).
Part II looks at the management of madness in the nineteenth century, the period labelled by Foucault as ‘The Great Confinement’. Although Pietikainen is critical of Foucault’s thesis, he charts the rise and ultimate decline of asylums, noting that whilst they were launched with great therapeutic expectations, they ultimately failed to live up to the unrealistic ideals of their supporters. This is perhaps one of the most fascinating, yet equally disturbing sections of the book. Pietikainen describes the institutional ill treatment of mental patients, the use of restraints, chains and isolation techniques. He also reviews the assorted ‘treatments’ devised to bring relief to patients, including cold water baths, temporary drowning and spinning chairs. Although Pietikainen acknowledges that many of the ‘treatments’ appear cruel by today’s standards, the idea behind many of them were well intentioned. Similarly, ‘the law and order approach’ that existed within many asylums was justified by the assumption that a patient’s path to recovery required them to be conscious of the need to be in control of themselves (137). However, as more and more patients entered publically funded asylums in the last decades of the nineteenth century, the use of restraints became more a practical matter of patient management in an increasingly under-resourced environment (140). Despite cataloguing the many examples of institutional abuse, however, Pietikainen argues we should not be too critical of asylums, for many offered patients care at crucial times, providing food, clothing and respite at a time when there were few attractive alternatives.
Part II also charts the rise of the psychiatry profession, and the growing dominance of the medical expert in diagnosing madness. Pietikainen looks at key figures in psychiatry including Pinel, Esquirol, Reil, Heinroth and Griesinger, and suggests that by 1900 psychiatrists had more or less attained a monopoly in the management of madness (106). The categorisation of madness and the rise of psychiatric theories such as physiognomy, phrenology, craniology, evolution and heredity also leads to the development of more disturbing theories such as Morel’s theory of ‘human degeneration’, which found a receptive audience in many parts of Europe where attitudes towards the mentally ill and disabled people were hardening. The rise of eugenics and theories of ‘racial hygiene’ which gained ground in the early twentieth century is also covered and represents, without doubt, one of the darkest periods in the history of madness.
Part III of the book looks at the naming and management of madness and looks at the rise of schizophrenia as it becomes the most common and widespread diagnosis of mental illness in the twentieth century. What is interesting to see in this section is how mental illness becomes ‘politicised’ and racialised, and how people with anti-establishment views are locked up and deemed schizophrenic. As an example of this, Pietikainen points to the civil rights era of the 1960s and 1970s, when the diagnosis of schizophrenia was overwhelmingly applied to African American protesters (193). Pietikainen also looks at twentieth-century treatments for madness – this time it is insulin and electroconvulsive therapy that provides the ‘shock’ to patients in an effort to re-order their mind. Reading this section, one is left with a feeling that many of these treatments, particularly lobotomy, were questionable, and many doctors appeared to operate on a purely trial and error basis, exaggerating successes and concealing failures to enhance their own personal professional standing.
The final section of the book, Part IV looks at madness from the Cold War period to the present day, outlining in Chapter 13 the frankly bizarre CIA ‘mind control’ programmes and in Chapters 14 and 15 charting the rise of psychopharmacological drugs to treat mental illness and the de-institutionalisation of mental health care. Perhaps the most startling observation in this section is the World Health Organization finding that there is a strong negative correlation between medication and schizophrenic patient outcomes, and yet, despite this, psychiatry has been largely drug based since the 1950s with large pharmaceutical companies continuing to make huge profits.
Madness: A History concludes with a discussion on the difficulties of diagnosing madness and looks at the work of Szasz and Rosenham who argued respectively that there really is no such thing as mental illness, publishing research which showed how it was almost impossible to distinguish the sane from the insane in psychiatric hospitals (320). Pietikainen also charts the ever-increasing number of diagnoses for mental illness as measured by the American Psychiatric Associations Diagnostic and Statistical Manual and wonders whether the increase in diagnoses is explained by the employment of more accurate diagnostic tools or is simply a product of a massive pathologisation of deviant or unusual behaviour.
Pietikainen has written a stunning, empathetic historical account of madness, which is easy to read and poses some interesting questions about how we diagnose and help people with mental illness. As a newcomer to the subject of mental illness, I found this book left with me with the desire to read and learn more.
Centre for Disability Research, Lancaster University, Lancaster, UK
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© 2017 Chris Spooner
https://doi.org/10.1080/09687599.2017.1372949