A history of psychiatry in 1500 wordsBMJ 2021; 374 doi: https://doi.org/10.1136/bmj.n1443 (Published 09 August 2021) Cite this as: BMJ 2021;374:n1443
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Madness is an always exotic, always dangerous phenomenon. It is spread across the pages of those two not always easy and predictable pillars of literature, Shakespeare and the Bible.
With King Lear, or Lady Macbeth, or Orphelia, or Hamlet (was he just shamming, mind you?), Shakespeare, with typical gory consequences, liked to ham up insanity on the stage.
The Bible that assails our ears from the pulpit is full of people being possessed by demons.
Some of the more sly and skeptical bent would dare to condemn the whole of religion as merely irrational.
'Hearing voices' with Joan of Arc was seen by her followers who were under siege as God addressing France. They revered their apparently holy 'Maid of Orleans'. However, the callous English occupiers smirked at her 'voices' as evidence of witchcraft, to be punished on the pyre in Rouen.
'Hearing voices' is currently a 'medical' symptom of schizophrenia, to be managed through anti-psychotics and some sort of 'talking therapy'.
Not only the poor, but also the mad, will always be with us, to paraphrase Jesus.
I didn't like this BMJ piece. It seemed to be implying a 'Whig Interpretation' of psychiatric history. You know, the proclamation of progress, despite past mistakes.
I feel someone such as the anti-psychiatrist, Michel Foucault, could be described as more incisive in his own 'History of Madness' (1). He argues that madness was what replaced medieval leprosy in terms of 'a space of social and moral exclusion'. In our own less than blessed 2021, the mad are still the isolated, imprisoned ones.
It is such a terribly appropriate and frightening image -- of the mentally ill as lepers, loathed, locked up for life, stigmatized, shamed, and perpetually vulnerable.
Psychiatrists can often loom, for the patients, as dour and unsympathetic agents enforcing the way society in general hurts those who don't behave as others do.
That oppressive history of psychiatry!
How it echoes, even in 2021...
What about lobotomy, with Freeman wielding his sharp steel against the frontal lobes?
Or today's Community Treatment Orders (CTOs), which are being used 'en masse' by consultants, even though the underlying statistical evidence is far from solid?
To quote from the OCTET report in the Lancet (2):
'We found no support in terms of any reduction in overall hospital admission to justify the significant curtailment of patients' personal liberty.'
And then, what about the traditional overreliance on antipsychotics and antidepressants, despite the heaps and heaps of side effects (3)?
'Big Pharma' regards drugs such as Prozac as all too profitable.
There is just a huge reservoir of mental illness around us. It spills over, it floods. You put up CTOs as dykes against it, to try to tame it in the community, but you still can't stop the in-patient mental hospitals from being crammed.
Yes, the mentally ill are often difficult and infuriating.
But the albeit cliched answer would seem, to me, to be compassion.
We, the mad, are always going to be plaguing society, I'm afraid. And we're always going to be in need of psychiatrists. In the end, I'd ask that the patients' own perspective be allowed to shine forth. The BMJ essay in 1500 words gave us only the viewpoint of the psychiatrists. The problem has always been the imbalance between patients and psychiatrists. This ugly imbalance nowadays remains -- so very painfully.
We are the unclean, remaining on the far edges of a society that, like a machine, mangles those who can't or won't fit in.
(1) History of Madness. Michel Foucault. Edited by Jean Khalfa. Translated by Jonathan Murphy and Jean Khalfa. Routledge, 2006.
(2) Community Treatment Orders for patients with psychosis (OCTET): a randomised controlled trial. Tom Burns et al. Lancet 2013:31:1627-33.
(3) The Myth of the Chemical Cure. A Critique of Psychiatric Drug Treatment. Joanna Moncrieff. Palgrave Macmillan. 2008.
Competing interests: No competing interests
----Despite recent advances, neuroscience and psychology still cannot fully explain many disorders of mind, thought, and behaviour—the manifestations of which still engender fear and stigma, affecting patients and the people close to them.
Our prejudices manifest them in many ways, the pretense of "stigma" is among them. Hitler pretended it for Jews, generations pretended it for rape, we continue to be instructed to pretend it for the above. It is a comfortable position for those directing it, not so comfortable are the effects of so doing. Perhaps one of the most negative contributions psychiatry has made is to conform to that pretense.
Oncology, on the other hand, faced with a public belief in the stigma of breast cancer, did itself not. The public followed suit and does not. The women's movement told us to stop declaring rape stigma, and, without one single voice objecting, we stopped.
What would happen were psychiatry to provide that same kind of leadership is easy to imagine. I do not envision even one voice rising in objection.
We cannot criticise previous generations of physicians for their knowledge and well meaning interventions, although their unquestioning reverence for medical doctrine leaves me feeling uneasy.
We can, however, more scrupulousy examine present generations.
Harold A Maio, retired mental health editor
Competing interests: No competing interests