Instituto de Historia, CCHS – CSIC, Madrid, Spain
e-mail: rafael.huertas@cchs.csic.es
SUMMARYThis article aims to summarise, in the first instance, some of the historiographical trends which have built a “critical” history of psychiatry from the 1960s onwards. Thereafter, it will demonstrate, with suitably significant examples, how methods and discourses were being refined and updated, before reaching a proposal for a new cultural history of psychiatry and subjectivity. In our analysis, special emphasis is placed on the “patient's view”. This renders necessary the task of identifying little consulted sources, such as the writings of the mad, and the incorporation of interdisciplinary hermeneutic tools, including, most notably, those taken from cultural studies and, in particular, written culture. Finally, it will offer a reflection on the epistemic role that this historiographical approach could play in the construction of new ways of understanding mental health, such as that represented by so-called post-psychiatry. |
RESUMENOtra historia para otra psiquiatría. La perspectiva del paciente.- Este artículo pretende revisar, en primer lugar, algunas de las tendencias historiográficas que han configurado una historia “crítica” de la psiquiatría a partir de los años sesenta del siglo XX. Se muestra a continuación, con algunos ejemplos suficientemente significativos, de qué manera los métodos y los discursos se fueron afinando y actualizando hasta llegar a la propuesta de una novedosa historia cultural de la psiquiatría y de la subjetividad. Especial importancia se concede, en nuestro análisis, al “punto de vista del paciente”. Esto obliga a una labor de identificación de fuentes escasamente trabajadas -como los escritos de los locos-, y a la incorporación de herramientas hermenéuticas de características interdisciplinares, entre las que destacan las procedentes de los estudios culturales y, de manera particular, de la cultura escrita. Finalmente, se ofrece una reflexión sobre el papel epistemológico que este enfoque historiográfico puede tener en la construcción de nuevas formas de entender la salud mental, como la representada por la llamada post-psiquiatría. |
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Received: 7 January 2013; Accepted: 19 February 2013 Citation / Cómo citar este artículo: Huertas, Rafael (2013) “Another History for Another Psychiatry. The Patient's View”. Culture & History Digital Journal 2(1): e021. doi: http://dx.doi.org/10.3989/chdj.2013.021 KEY WORDS: historiography; cultural history; psychiatry; madness; subjectivity; cultural studies; PALABRAS CLAVE: historiografía; historia cultural; psiquiatría; locura; subjetividad; estudios culturales Copyright: © 2013 CSIC. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial (by-nc) Spain 3.0 License. |
CONTENTTHE POINT OF VIEW OF THE PATIENT: MADNESS AND CULTURE IN WRITING |
The mind is, without a doubt, one of the most discussed frontiers in modern science, a territory in which very different disciplines maintain an interest -from the most clinical (psychiatry, psychology, neurology) to the most experimental (basic neurosciences), not forgetting philosophy and other fields related to thought and culture (pedagogy, linguistics, religion, art, etc.). All of this within a framework in which cultural and biological trends often come face to face and in which reductionisms are as frequent as they are dangerous.
But whether it is catecholamine synapses or evolutionary psychology à la mode, the truth is that the “scientific” tackling of the mind has been present since the first rationalisations about the world and nature. Since Alcmaeon of Croton and the Pre-Socratic thinkers up to the 1990s, known by the more biological branch of psychiatry as the “decade of the brain”, this organ of the Central Nervous System has been considered the hub of sensory and psychic life in human beings. However, discussions about the healthy and “ill” mind have been subject to dramatic variations, precisely because of this hybrid condition of “diseases of the soul” -a platonic concept which unites medical tradition (diseases) and philosophy (soul), almost in equal parts (Pigeaud, 1981).
Specifically, this hybrid condition is what can explain the epistemic differences which arise in psychic disciplines: body and soul; brain and mind; matter and thought; neurotransmitter and signifier. These represent antithetical models from which approaches to the mind have traditionally been made. Not all mental health professionals do or say the same thing. The same goes for historians (Levin, 2012). Corresponding to the variety of psychiatric-psychological epistemes is a range of historiographical approaches, and as such the history of psychiatry is not limited to a sterile and objective narration of the formation of theories and concepts, the discrepancies between paradigms or different ways of dealing with the treatment and care of mental patients, but rather has become a vehicle for legitimisation and critique of the different epistemic and care options in the psychological field. As such, by way of example, there are works on the history of psychiatry which are principally medical and neuro-biological (Parker et al., 1996; Shorter, 1997) which highlight the importance of somatic (Shorter and Healy, 2008) or psychopharmacological treatment (Lehmann and Ban, 1997; López-Muñoz et al., 2002), whereas others offer historical reflections on the context of dynamic psychiatry and psychoanalysis (Ellenberger, 1970; Bercherie, 1980; Álvarez, 2008).
There is, thus, a reciprocal and dynamic interrelation between history and theory, or between history and psychiatric practice, which could have very important consequences. As the German psychiatrist and historian Otto Marx warned “Psychiatrists doing history must meet the standards of contemporary historiography and must know the realities of psychiatric practice and of mental illness today” (Marx, 1992: 297). Likewise, in the prologue to the first edition of José M. Álvarez's work, La invencion de la enfermedades mentales, Fernando Colina indicates “there are many parallels between history and clinical practice. Their interaction is so close that, whether it is known or not, deep down they are inseparable. Any historian of psychiatry researches with a clinical model in mind and any clinician acts not only according to insuperable historical coordinates but also to historical criteria” (Colina, 1999: 16). Thus put, the history of psychiatry could come to play an essential epistemic role in explaining why mental health professionals do what they do in their everyday practice and say what they say when creating conceptual constructs which are more or less solid, more or less polished. But the psychopathological dimension cannot ever make us forget about the sociological and cultural aspects of madness, which delve into the social reaction towards the latter, evolving both psychiatric theory and practice, as well as the position of the mad, isolated or mentally ill person (depending on the terminology used at any given historical moment) in the social, political and cultural context we are considering. Over the following pages, I will briefly analyse the paths, as well as their most significant developments, which this “other history” has followed, which has based its critical analyses on knowledge-power relations, on social regulation and subjectivity of the standard strategies, but which has also focused on the ways in which madness is represented and, in particular, on the patient's perspective. “Another history” engaged with “another psychiatry”, which deems necessary profound epistemic changes in the nature of mental illness, and the role of the expert (psychiatrist, psychologist, social worker, etc.) and the patients themselves in the handling of madness.
Often, two very different types of approach tend to be identified (in a slightly schematic way which is, however, useful for an initial historiographical approximation) which have allowed the definition of a “traditional” and a “revisionist” or “critical” historiography (Scull, 1991; Huertas, 2001a). The first is said to be characterised by a panegyrist view of the “greats” and by an effort to show, in a positive light, the achievements (scientific and philanthropic) of early psychiatry -the medicalization and humanisation of madness, the legendary “liberation of the mad”, the application of the scientific-rational principles to the understanding of mental illness and, ultimately, how a learned mentality overcame the opposition and superstition which existed with regard to madness. The most notable contributions to this traditional historiography, made in general by practising psychiatrists, took place between the thirties and fifties (Semelaigne, 1930–32; Deutsch, 1937; Jones, 1955; Zilboorg, 1941; Alexander and Selesnick, 1967) and offer a comfortable and, in a way, “heroic” view of the past, the goal of which was, principally, scientific and social legitimisation of mental health and its professionals.
There are works which may fall into what, in other historiographical areas, has been dubbed “Whig history” (Butterfield, 1931, 1950). If we accept that current psychiatric thinking is “most advanced” and that we have arrived at it thanks to the lineal and progressive development of “psychiatric science” in itself and from its roots, we are making an anachronic interpretation of history, in the same way that we consider the proving or failure of a certain theory, a diagnostic category or a psychiatrist more or less distinguished based on how close or how far they got to the scientific “truth”, according to the generally accepted criteria at present. In their defence, certain authors (Marx, 1992: 299; Porter and Micale, 1994: 13) have highlighted the importance of these contributions for their pioneering qualities, insisting that they should be defined and judged “according to the models for historical method of their time”. However, this “traditional” approach (although it can be considered to be a “first step” in psychiatric historiography) has continued to produce contributions of greater or lesser interest and more or less anachronic, which continue to strive for the professional and social legitimisation of psychiatry and the psychiatrist. These are histories which aim to show this “lineal” evolution of psychiatry, from a few initial fledglings to the present of “maximum progress”, which tend to assimilate with the advances of bio-medicine (Shorter, 1997; Shorter and Healy, 2008) and which are not exempt from contradictions, as on occasions, as José Luis Peset (1983, 1993) explained, sciences produces wounds which it is difficult to heal.
A second historiographical pole to take into account is that represented by a critical history of psychiatry, which, having emerged in the sixties and seventies, aimed to “revise” and expand the traditional perspective and approaches. Madness and psychiatric practice began to be analysed from social and cultural assumptions. On occasions, the term “history of madness” is preferred to “history of psychiatry” and will be emphasised in various aspects -madness as a myth and social construction, social responses to madness, the role of psychiatric institutions as instruments of social regulation, etc.
In 1961, Histoire de la folie à l’âge classique by Michel Foucault, Asylums by sociologist Erwing Goffman and The Myth of Mental Illness by psychiatrist Thomas Szasz appeared almost simultaneously. These are three fundamental works because they represented a veritable intellectual catalyst, introducing critical and discursive aspects which had been previously unthinkable, and because they incorporated new elements of analysis for traditional historiography and sociology. Madness and the mad, as well as other forms of illness and deviations, are now analysed not so much as problems which act as obstacles to harmonious social integration, but rather as intellectual constructions which express a relationship of power and justify the existence of a space (institutional space) in which this power is applied. As is logical and reasonably well known, the anti-psychiatry movement received these works very favourably (Dain, 1994; Postel and Allen, 1994). It is worth remembering that Franco Basaglia also arrived in Gorizia in 1961, ready to “deny the institution” (Basaglia, 1968) and putting in place a healthcare reform which led to an entire historical-psychiatric tradition in Italy, which is directly related to the “democratic psychiatry” movement and deals with the history of the asylum from the point of view of social regulation, but with an emphasis on political analysis of its content (Bernardi, 1982).
In direct opposition to “traditional historiography”, the discussion about madness and psychiatry took a one hundred and eighty degree turn and had serious problems with acceptance in the most conservative psychiatric environments. It is true that the vision offered by the most radical “revisionist” authors, particularly initially, was, at times, a bit Manichean and could stumble into similar errors to those committed by the historiographical trend that it aimed to improve upon (although its conclusions were diametrically opposite). In this respect, Andrew Scull indicated: “Where one tradition saw the asylum as a beacon of Enlightenment and hope, the iconoclastic challenger to the general feeling portrayed it as a fatally mistaken and profoundly repressive institution. Where psychiatrists liked to think of their ancestors (and themselves) as decent, humane, honourable scientists, they now found themselves faced with portraits of the profession in which they were only a little better than concentration camp guards” (Scull, 1991: 240).
It is no less accurate to say that the reaction, sometimes furious, against critical history can lead to a new and updated panegyric, in which revised justifications of psychiatry and psychiatrists once more play a legitimising role for the current “psychiatric process”. Edward Shorter, in the “Preface” to his A History of Psychiatry (an interesting book, on the other hand) rails against “the history of psychiatry of the sectarians who have made this subject into a sandcastle which fits with their ideas (…) fanatic historians have taken over the history of psychiatry to show how their favourite personal demons -whether it be capitalism, patriarchy or psychiatry itself- have turned those who protest into ill people, shutting up those who challenge the established order in asylums (…) The children of the sixties insist that psychiatrists and their imprisoning institutions do not lead us to ‘progress’” (Shorter, 1997: VIII).
In general, this accusation is directed at a critical historiography which, we are assured, is not based on historical truths but on ideological convictions. A paradoxical argument as nowadays we know that any historical analysis has an indisputable ideological aspect. The use of the history of psychiatry, whether to reduce the latter to a bio-medical speciality (which in Shorter's work is very clear) or to analyse its role in the broader context of social defence or to place madness, and its attempts at regulation, in a given social and cultural context implies the taking of a stance, which in the latter instance was ideological. This circumstance, in itself, does not necessarily undermine either approach. A historical source can have many different interpretations, probably almost all of them fair, but it is necessary, as Otto Marx (1992: 301) recommended, to make the objectives of all research clear and be honest enough, in the event that the previous hypotheses are not proven, to explain it in the best way possible.
In the years following the early sixties, an important series of studies broadened the historical view of this entire process, shaping its objectives and offering a social history of psychiatry (not necessarily Foucaldian) (Dörner, 1969) which continued to focus on the contradictions of moral treatment and on the dynamic and operation of the asylum (Rothman, 1971; Castel, 1977; Swain, 1977; Scull, 1979a, 1979b). Other academic traditions collaborated on the consolidation of a critical history of psychiatry. In the work Madness in Society (1968) by the historian of Medicine and Public Health George Rosen (collection of works published in various fields in the early sixties), mental illness is also incorporated into social and cultural history, leaving medical discourse and professional attitudes in the background. Rosen's contribution has, in my opinion, special significance because it introduces a new dimension to historical reflection on madness (that of the history of madness and the mad); because it takes into account super-structural factors which bring to mind, on occasions, the Gramscian concept of social hegemony; because throughout its pages, we can identify ideas and categories which, shortly afterwards, would be extremely valid such as the famous “great confinement”, the close relationship between “social order” and “mental health”, the relationships between the model of society (or mode of production) and mental healthcare, etc. (Rosen, 1970). The connection points with schools of thought with greater or lesser degrees of Foucaldian inspiration are clear. However, it is still curious that Rosen's work, and the historiographical tradition that it represents, has been considered very little by psychiatric historians, with a few exceptions (Mora, 1980; Morman, 1994).
The interrelation between social history and the history of psychiatry offers, however, other possibilities. The psychiatrist and semiologist Georges Lantéri-Laura, author of important works on the history of clinical psychiatry (Lantéri-Laura, 1979, 1991, 1998) published an influential work on chronicity in psychiatry in the pages of the prestigious journal Annales (Lantéri-Laura, 1972). This French author introduced elements of analysis which had not been taken into consideration by the more traditional historiographical approaches. With no need to profess Foucaldian faith, he offers institutional (the failure of moral treatment and the asylum as a therapeutic institution) and professional reasons (the appearance of new and vigorous specialities like neurology) to explain both the phenomenon of chronicity and the process of somatisation which mental illness underwent in the second half of the 19th century. Subsequently, our own group, taking this work as a point of reference, tried to complete this analysis, incorporating scientific and technical reasons (the influences of anatomical-clinical thinking and pathological anatomy thinking on the study of mental illnesses, the impact of the theory of degeneration, the development of forensic psychiatry, etc.) (Álvarez et al., 1993).
We can see, therefore, how criticism, revision and/or improvement of traditional historiography cannot be identified, at least exclusively, by the work of Foucault and his followers. Nor is there a single school of thought on critical history of psychiatry, or the historiographical trends which emerged in the sixties and seventies, which comes from one common root. In any case, it is a spectrum of approaches and trends which laid the foundations for the impressive development which the history of psychiatry has seen in recent years.
Throughout the eighties and, in particular, in the nineties and the first decade of the 21st century, methods were being refined and discourses updated. The work of Michel Foucault is revisited time and time again and works which are strictly inspired thereby, sometimes brilliant in their approaches, spark different methodological criticisms. The model of “psychiatric order” (Castel, 1977) involved, amongst other things, defining the asylum not so much as a space for clinical observation and production of knowledge but rather as an essential tool in a broad strategy of social disciplining and regulation. Thus, a shift from knowledge to power is proposed. Otherwise put, Castel, and naturally Foucault, deny the “scientific” nature of the institution to define it and analyse it as a space for supervision, discipline and social regulation. Due to its huge importance and influence (Álvarez-Uría, 1983), the model of “psychiatric order” (basically too narrow) was not able to give satisfactory answers to the various questions which were gradually being formed. The alienist movement did not constitute a monolithic block, nor did the results obtained correspond point by point to a perfectly designed strategy, executed by political power. The identification of the asylum as a kind of “social laboratory” in which to try out techniques which, later, could be transferred to the outside and be used to discipline the popular classes was put under consideration by subsequent works which focused on the inability of alienism to achieve said objectives (Jaeger, 1981). In the same context, it is worth pointing out the danger of transferring interpretative schemes, possibly valid in certain geo-historical contexts, but useless in others with very different social and political realities (Huertas, 2008: 51 and subsequent; Campos and Huertas, 2008).
All in all, I think that we cannot deny that in history of psychiatry, there is a pre- and post-Foucault and his contemporaries. Amongst other things, this is because his thinking highlights contradictions, takes into consideration the lineal, ascendant and “benefactory” vision offered (past and present) by traditional historiography, introduces doubts and forces us to reconsider “epistemic truths”. In order to do so, it is necessary to adapt, clarify and enrich discussion, aiming for methodological solidity and the incorporation of hermeneutic elements deriving from other historiographical and sociological traditions into thinking. Two good examples of the influence and modernisation of the critical thinking of the sixties are the works of American historian Jan Goldstein and the Canadian philosopher of science Ian Hacking. Both offer us very interesting aspects for a cultural history of psychiatry which we will only outline here.
In Console and Classify, Jan Goldstein (1987) painstakingly reconstructs the emergence and professional consolidation of French alienism, offering important interpretative keys and new categories of analysis which had a great influence on subsequent works (Dowbigging, 1991; Huertas, 2002). However, in The Post-Revolutionary Self, Goldstein (2005) covers the theoretical and institutional development of psychological knowledge in transition to Modernity and in the context of what we have called the “culture of subjectivity” (Novella, 2009). In both works, the debt to Foucault is clear. In the former, the concept of “disciplinary power” becomes once more one of the theoretical cornerstones of the discussion but, on this occasion, extensive handling of primary sources and thorough archive work documentally endorse and support Foucauldian theses on the role of early French alienism as a knowledge-power structure in the framework of establishment of the liberal state (Goldstein, 1984, 1987). In the latter, the author has recourse more to later Foucault and the “technologies of the self”, but disagrees with him by placing special importance on the philosophical theories of the mind and the importance of psychological spiritualism among the French elite in the 19th century (Goldstein, 1994; 2005).
But it is not only Foucault who is an unquestionable author of reference in Goldstein's work. Other theoretical resources, ranging from the classics like Weber, Durkheim and Habermas to the most modern sociology of the professions, give the work of this University of Chicago professor, a theoretical sophistication which does not prevent it from acknowledging the importance of previous contributions, such as those already mentioned by Robert Castel, Marcel Gauchet and Gladys Swain (Goldstein, 1987: 2 and subsequent).
For his part, Ian Hacking (1995, 1998) considers the cultural elaboration of mental illness (Moscoso, 2001) through a series of categories of analysis, among which the process of “making up people” stands out, characterised by the confluence of two vectors -on one hand, the (diagnostic) “classification” imposed by experts creates a reality which some people make their own; on the other, the independent experience of the classified person tends to recreate circumstances which, in turn, the specialist must face (Hacking, 1986). It is clear that the normalising aim of medicine (and, of course, of psychiatry), duly assisted by statistics, facilitated the creation of new spaces in which to list and classify people. New categories attracted new types of people. It is not so much that a certain class of subjects (the mentally ill, for example) already exists and begins to be recognised by administrators or scientists who are experts in human nature, but that this class of individuals “comes to be” (is invented, is constructed) at the same time as the class (of people) itself is formulated. “Natural” classes, species or varieties (from electrons to the different taxonomic ranks of the animal, plant or mineral world) are indifferent -they do not change depending on how they are named and they are not affected by cultural practices but human classes are interactive- their manner of being and acting, their subjectivity and their actions are not independent of how they are described and classified. This is what Hacking calls the looping effect of the human classes -interrelations between people and the ways in which they are classified. People tend to conform to, to stay and even to grow in the classified field in which they have been described or diagnosed (Hacking, 1994). It is not difficult to sense the application of this concept in the analysis of psychiatric classifications (Tsou, 2007).
The influence of the sociological school of Chicago, and its formulation of the labelling theory is more than evident. Hacking follows the example of Goffman (1968) and his Stigma, when he warns that certain categories of individuals are created, they only exist from the moment they are defined and studied by psychiatrists, criminologists or psychologists.
In short, Ian Hacking's proposal on mental illness contributes elements for consideration of great interest to the history of psychiatry because it updates (and complicates) the debate on social construction/cultural elaboration of madness. Some of his conclusions may be wrong or debatable from a historiographical point of view (Huertas, 2011) but we must keep in mind that at no point does Hacking aim to do history of psychiatry but rather to deepen, from the perspective of philosophy of science, our understanding of aspects such as causality, nominalism, classifications and the elaboration of concepts, the way in which they are named and their consequences for people. In this respect, the connection with Foucault (1966) in Les mots et les choses and, as I have highlighted, with Goffman, two fundamental and already classic authors in the critical historiography of psychiatry, whose importance and influence has been acknowledged by Hacking (2004) himself, is clear.
This process of “inventing people”, closely related to the force of the diagnosis and stigmatisation of the mad, in a way introduces us to an individual and social reality of people with a psychiatric diagnosis. Their experiences and values, etc., their context and subjectivity, must necessarily complete a critical historiographical project in which it is necessary to have recourse to specific theoretical and interpretative frameworks, as well as to access sources which transcend the discourse of specialists and which allow us to create a history “from below” which shows us the patient's point of view.
The British historian Roy Porter published, in 1985, an influential article entitled “The Patient's View: Doing Medical History from below” (Porter, 1985), in which he advocates creating a history of medicine based on the experiences and points of view of the patients. It was not an isolated proposal, as in the same year, Homo patients, by Heinrich Schipperges (1985), appeared, starting a tradition in the German academic field which continued until recent times (Stolberg, 2003). This “history from below” which Porter proposes has, however, a tradition which dates back to the Marxist historian George Lefebvre, and his pioneering works on the point of view of peasant during the French Revolution (Lefebvre, 1924) and, in particular, to British Marxist historians in the sixties, committed to highlighting the “victims of history” (the working class) and to make “current people” into history (Thompson, 1963; Hobsbawm, 1971).
From this original idea, in recent times, variants of great interest have developed, deriving, in general, from so-called cultural studies. The importance given to subordinate classes and groups as a historical subject has introduced fundamental elements of consideration, such as those which take into account the level of adhesion, negotiation or resistance of said sectors in hegemonic discourse and practices (Guha and Spivak, 1988; Mignolo 2003). It is made necessary “to shift the place of enunciation” (Harding, 1998) of the expert (who forms part of the hegemonic groups), considering other places of enunciation, in this case of the subordinates of official knowledge, that of the non-experts: women, workers, the colonised, and, naturally, the ill and the mad.
But how to access sources which inform us about the point of view of the mental patient? Roy Porter himself stated: “The writings of the mad can be read not just as symptoms of diseases or syndromes, but as coherent communications in their own right” (Porter, 1987: 12). The British historian thus drew attention to the need to undertake the study of various sources as yet little consulted by the history of medicine and psychiatry, from a socio-cultural perspective which takes into account the subjectivity of the patient and not just their use in the context of expert studies. Recent works have followed in his wake, updating Porter's work and stressing the importance of patient's writings for the history of medicine and psychiatry (Davis, 2001; Condrau, 2007).
The writings of the mad cannot, however, be considered in the context of two different scenarios: one psychopathological, in which the “dialogue with the mad”, as Gladys Swain (1994) put it, takes on a rare importance in the practice of alienism. Indubitably, Juan Rigolí (2001) is the person who has most clearly explained the ambition with which the alienists of the first half of the 19th century founded a psychic semiology based on knowledge of the word and the writings of the alienated. It deals, at least in part, with a certain re-interpretation of alienism (Tardits, 2002), which offers us key points of interest which help us understand not only the importance of “discourse” on madness but also the need for new experts to have recourse to a non-medical knowledge and culture: philosophy, aesthetics, linguistics, rhetoric, etc. which are, without doubt, of use in the construction and diffusion of a semiology of subjectivity. The idea is not a new one, as Marcel Gauchet indicates: “often we tend to forget that behind a certain clinical positivism, behind the medicalization of passions and the unreasonableness which alienism claims, there exists an attempt to explore the subjective field” (Gauchet, 1994: XXXII).
The consideration of the self of Modernity has facilitated, without a doubt, the cultural constitution of psychiatry and mental illnesses (Sass, 1992), which would have had difficulty establishing itself without the backdrop provided by a culture where the self has tended to be commonly perceived, as I have indicated, as problematic and precarious and where sources of unrest have ended up being located and processed in the field of subjectivity, an inner world assigned to the individual (Staeuble, 1991). To a certain extent, the little attention which psychiatric historiography has paid to the process of constitution of mental medicine from its development and diffusion into modern culture around the self and subjectivity is surprising. Despite the suggestions made in some already classic works, such as those of Michel Foucault (1961), Klaus Dörner (1969) or, in particular, Gladys Swain (1977) -an author whose work is being re-read and revived from various perspectives (Weymans, 2009; Moyn, 2009; Huertas, 2010)- it is not until the nineties that we can identify contributions which take up this epistemic framework once more. In the German context, historian Doris Kaufmann (1995) has shown how the new perception of the individual promoted in the transition from the 18th to the 19th century by romanticism, idealism and spiritualism -with an emphasis on cultivation of the inner being and the resulting confrontation with irrationality- led to a new view of madness which, in turn, played a decisive role in the creation of new institutions for the mad, in the consolidation of a medico-scientific discourse on mental illnesses. In Spain, the contributions of Enric Novella (2010, 2011) are pioneering in this field and, largely, they are opening up an important and hugely promising path.
Faced with consideration of writing in a psychopathological context, understanding this from the perspective of the symptom or from the metaphor of the interpretation, as a self-reparative effort, as part of the therapeutic process or as the essence of psychosis itself (Colina, 2007), the writings of the mad can also be presented to us as proof of the experience of committal. I am not referring, at this point, to the Memoirs of famous and learned madmen, such as John Perceval, founder of the Alleged Lunatic's Friend Society (Hunter and Macalpine, 1961; Hervey, 1986) or Clifford Beers, who inspired the pro-mental hygiene movement (Dain, 1980), who were capable of writing and publishing their experiences both with regard to their own madness and the healthcare mechanism to which they were subjected. It is interesting to look at the notes and writings of anonymous madmen who never had the primary aim of being published. These are diaries, letters, etc. but especially letters written by patients who, for various reasons, never reached their recipients and remained in their clinical file. There are some narratives which contrast with others, those of the psychiatrists who label and diagnose with alleged “scientific” objectivity but who aren't free from their own emotions either when it comes to handling madness and the suffering of other human beings. In conclusion, a “polyphony of clinical files” (Ríos, 2004: 23) which must be taken into account when handling this kind of source (Huertas, 2001b: 25; Huertas, 2012: 149 and subsequent). This epistolary literature can give us information on the functioning and everyday life of psychiatric establishments from the perspective of the confined, on their worries, their anguishes and fears, and, ultimately, on the experience of illness from the perspective of the patient. In recent years, research has been carried out in various geographical contexts which shows the growing interest which the writings of the mad are arousing among psychiatric historians (Barfoot and Beveridge, 1990; Beveridge, 1998; Reaume, 2009). Among these studies, it is worth highlighting the developments from a general approach, which have taken as their sources the writings of women confined in psychiatric institutions (Molinari, 2005; Wadi, 2009; García Díaz and Jiménez Lucena, 2010).
Another possible approach to these types of sources can be done from the perspective of so-called “written culture” (Lyons, 2012). The writings of patients, if they were used as legal evidence (Artières, 2000; Campos, 2010), were also considered deeds, exercises in which, sometimes simultaneously, both the expression of madness and its therapy were produced, managing to identify correlations between the uses of lexicon, specific rhetoric, the spelling of letters, etc. and certain forms of mental illness (Artières, 1998). On occasions, the writing done within the asylum has been compared to that identified in other spaces of confinement (prisons, concentration camps, etc.) (Castillo and Sierra, 2005) but which bear the unmistakeable mark of psychopathological disturbance or suspicion thereof. In any case, we can conclude, with regard to the study of this type of document, the existence of an unequal “pact” between doctor and patient, between he who reads and he who writes. He who writes does so, in most cases, to express his “truth” and he who reads does so to confirm his diagnosis or as an “archivist” who identifies and classifies writings on mental illness. And it is this “pact” -certainly unequal, as it is based on the ever-changing elements of authority, submission and resistance- which allows us to explain and explore the different textual modalities, like a petition or bureaucratic certification, addressed to the authority, forming part of a certain ritual of subordination (Molinari, 2005: 395).
The history of psychiatry from the perspective of the patient allows us, ultimately, to access levels of interpretation which would not be possible from other historiographical approaches. If “history from below” gives a voice to those “without a voice”, if that of the madman can occupy a far from negligible space in the field of cultural studies, in particular those dedicated to subordinate groups or to otherness, there is no doubt that it also offers fundamental aspects to consider madness and how to act upon it. The point of view of the patient gives us key points to assess that the bio in mental health is not only biological, but also biographical; it also allows us to consider the importance of the experience of madness and the subjectivity of the mad, to understand the violence of diagnosis and the stigma, and to appreciate the negotiation and resistance processes which are established between patients, professionals and society. At the moment, the so-called post-psychiatry has proposed a new direction for mental health (Bracken and Thomas, 2001). Post-psychiatry places great importance on the social, political, economic and cultural context at the root of mental illnesses, aims to de-medicalize madness, supporting initiatives such as the “hearing voices network” (Romme and Escher, 1993, 2000) and the movement for ex-patients and survivors of psychiatry (Morrison, 2005) with a view to promoting the “empowerment” of people diagnosed with mental illness, fighting the stigma surrounding madness and vindicating the “other side of reason” as a situation which is not necessarily susceptible to technical intervention (and much less coercive) (Bracken and Thomas, 2005). Obviously, this is not the most common discourse, and much less hegemonic, in mental health, but it is still enlightening that both Michel Foucault and Roy Porter appear as intellectual references in works which support part of the arguments of post-psychiatry (Bracken and Thomas, 2001: 725) whose formation in history and philosophy is far from negligible. In summary, post-psychiatry does not propose new theories on mental illness, nor the abandonment or denigration of “psychiatric science”. It proposes opening up spaces in which new perspectives can be heard, both from the point of view of professionals -who must recognise how their own values can influence their decisions and relationships with patients- and from that of people with a psychiatric diagnosis, who must “own” the clinical experience (Matusevich and Pieczanski, 2012: 93).
The perspective of the patient, analysed by history, sociology or psychiatry/psychology itself, thus appears to be a crucial element in the research-action process (Lewin, 1946) applied to health problems. At present, an ever more powerful health activism is proposing fundamental elements for debate -social and economic inequalities in health, health and social movements, associationism and the capacity for organisation and participation of the population, etc. (Laverack, 2013)- which affect mental health, and of which there is already a certain historiography (Berridge, 2007) which reminds us, once more, that the economic, social, political and cultural context is central to understanding of health problems (and of mental health).
In conclusion, I think that updating discourse on the critical history of psychiatry is providing a theoretical and overall solidity to this field of knowledge, which is moving towards a cultural history of subjectivity as a historiographical option. A proposal in which an intellectual history is constantly “put across”, which would explore the evolution of certain scientific discourse in the context of the process of secularisation and rationalisation of knowledge, characteristic of modernity, understanding psychiatric concepts as cultural objects; a social history which would deal with professional strategies and cultures in the framework of a society characterised by specialisation and the division of work; and a political history which would deal with disentangling the relationship between psychiatric knowledge and practice in the interests of political power and hegemonic culture (or its resistance). All of this, without forgetting the importance of the patient's perspective, their experiences and subjectivity. A way of doing history of psychiatry which relates directly, as we warned at the beginning of this essay, with a way of thinking about madness. The essentialist and non-essentialist conceptions on the nature of mental illness, the debate on which reached its climax in the late nineties (Wakefield, 1999; Lilienfeld and Marino, 1999) have largely shaped the way in which psychopathology is understood, but also its history. To a psychiatrist who understands mental illness from an essentialist perspective, as a natural entity, as a concrete and fragmented reality which is “installed” in the individual and corresponds to somatic and permanent variables (Novella, 2007) would correspond a history which puts the emphasis on the “neurobiological signals” of the symptoms, although the most reliable contributions from this kind of approach do not necessarily dismiss philosophical or social aspects (Berrios, 1996; 2011). On the contrary, “other psychiatry”, from non-essentialist perspectives, would interpret the symptom, or disturbance, beyond its concrete reality (which may or may not have a biological root) as a cultural entity which is fully integrated into the individual, taking into account not only the phenomenon itself, but its variable contextual circumstance which refers us to symbols and myths, values and relationships, to individual and collective mentalities and experiences and subjectivities. This “other psychiatry” would require “another history” which, as we have just seen, takes into account all the indicated variables and provides reflections on the spectrum of hermeneutic possibilities, not always recognised, of madness and mental health.
Financial support from the Ministerio de Ciencia e Innovación (MICINN), Spain, project HAR2009-13389-C03-02.
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