Peter Sedgwick has given us an informative, penetrating, witty and critical account of anti-psychiatry as represented by Laing, Szasz, Goffman and Foucault. The central ambition of anti-psychiatry has been to replace the so-called medical model of mental illness by a ‘labelling’ one, according to which the behaviours which provoked diagnoses of psychopathology were not manifestations of some underlying pathology but merely conduct found obnoxious by the labellers. Sedgwick counters anti-psychiatry’s startling claim that mental illness is just deviancy with the apparently paradoxical one that illness of any kind is deviancy: ‘The attribution of illness always proceeds from the computation of a gap between presented behaviour (or feeling) and some norm.’
Granted that a preference, on the one hand, for personalities capable of self-control and remorse, without marked propensities for delusion or hallucination, whose sexual inclinations are directed towards persons of the opposite sex and the same species, and a preference for blood-sugar levels compatible with consciousness, on the other, are equally preferences – are there no differences between them such as might support the anti-psychiatrist’s case? Might it not still be possible to distinguish between these ‘norms’ on grounds of universality, culture-neutrality and adaptiveness? Even an Eastern bloc country which ran out of Vitamin D would be unlikely to declare: ‘Straight legs good, bandy legs better.’ If the argument is to work, it must not depend merely on the occurrence of physical conditions which are only culturally dysgenic and are treated by the same personnel as treat incapacitating physical conditions but on the analogy of mental illness with these incapacitating conditions themselves. For example, J.K. Wing has pointed out that under-arm odour is rare among the Japanese and was once felt by them to justify exemption from military service and referral to hospitals for treatment. But the fact that some medical norms are less universal than some psychiatric ones is not sufficient to justify psychiatry. On the other hand, it is relevant that there are no societies in which unprovoked random attacks on people are not seen as symptomatic. The concepts of ‘amok’ and ‘latah’ are not manifestations of psychiatrisation.
In the literature of anti-psychiatry a libertarian thesis was persistently and gratuitously confronted with its ontological one. Although if mental illness were indeed a myth intervention would be unjustifiable, the reverse is not the case. It does not follow from the fact that someone can be justifiably described as mentally disordered that this automatically confers on the community the right of custody or intervention. There is no a priori reason why someone convinced he is Jesus Christ or Napoleon should not be left at large. The abolition of involuntary mental hospitalisation does not require as a premise the mythical status of mental illness. Too many have found this claim sound because they found its policy implications welcome, and were so half-hearted in their libertarianism that they could see no other way of arriving at them. It is as if they feared that unless we declared baldness a myth we would be on the slippery slope which leads to the compulsory wearing of hair pieces. Mental illness can be de-stigmatised without being mythologised, i.e. defined into non-existence. Szasz himself has argued that the disabilities traditionally imposed on epileptics are unjustifiable without concluding that epilepsy is a myth. The apprehensions about Clause 38 (iii) of the Mental Health (Amendment) Bill, which is intended to place obstacles between a patient and treatment to which he has not consented, have a more cogent rationale than simply the sense that mental illness is a reality. Sedgwick is also concerned with what he sees as the baleful social consequences of anti-psychiatry. ‘It is in the battle on the wrong side; the side of those who want to close down intensive psychiatric units and throw the victims of mental illness onto the streets.’ There is an example of the kind of thing Sedgwick is up against in The Voice of Experience. One of Laing’s new atrocity stories involves a young woman with a history of schizophrenia being kept under observation while ‘three first-rank psychiatrists’ monitor her symptoms. If Laing wants to put a stop to this state of affairs he should call it to the attention of the right Conservative MP, who would see to it that she was not long permitted to hog such persecutors. What the mentally afflicted and disabled have now to fear is not wanton intervention but neglect.
‘Some say he’s mad; others, that lesser hate him, do call it valiant fury’ – it would be a mistake to see in Caithness’s account of Macbeth evidence of the irredeemably subjective character of psychiatric diagnosis. Hard cases make bad psychopathology – i.e. they make anti-psychiatry. This tradition is continued in Laing’s new book. Laing thinks that in medicine diagnostic judgments refer to objective biological processes, whereas in psychiatry ‘it is because we regard some experiences as worthless and destructive per se that we feel that the biological processes that accompany them must be pathological ... Should biologists be happy about this?’ Szasz is invoked in support. Laing makes it sound as if the standards employed in psychiatric diagnosis were either completely discretionary or confined to a psychiatric sub-culture. ‘Psychiatrists of this persuasion cultivate ways to ... restrict or stop whatever we think, feel, imagine or remember which, in their judgment, requires to be curtailed or cancelled.’ John Wing is taken to task for remarking that a young woman’s grief-stricken response to the death of her husband is a ‘typical depressive reaction’: ‘Her grief and mourning are looked upon as a pathological syndrome. The basic decisions are of a medico-political order. For how long shall we allow it to go on?’ Calling the decisions medico-political makes it sound as if they were made by dubious characters in smoke-filled rooms. Sedgwick states the truth of the matter: ‘The line of division between a bereavement and a psychiatric illness following bereavement would seem to depend on our culturally-derived expectations about how to mourn properly.’ Our standards, not just the psychiatrist’s. Does Laing think that when Gertrude and Claudius remonstrate with Hamlet they are evincing their indoctrination at the Elsinore Institute of Psychiatry?
In 1894 Freud wrote to his friend Fliess: ‘It is painful for a medical man who spends the day struggling to gain an understanding of the neuroses, not to know whether he himself is suffering from a reasonable or hypochondriac depression.’ At about the same time, Pater’s Sebastian Von Storck found himself in the same predicament: ‘ “Is it only the result of disease,” he would ask himself with a sudden suspicion of his intellectual cogency, “this unkind melancholy?” ’ Mark Rutherford (in The Revolution in Tanner’s Lane), the Professor in Chekhov’s ‘A Trivial Story’, Antonio in Scene One of The Merchant of Venice (where it is Antonio’s friends who attempt to persuade him that his melancholy is justified by his circumstances and he who is perplexed as to its source), are further examples of this familiar dilemma, and this dilemma is not due to the importation of esoteric psychiatric standards but to the ambiguity of our lives.
In any case, the problems posed by suspicions of abnormal affectivity do not infect the diagnostic enterprise as a whole. Both Laing and Szasz misconstrue the nature of these problems and their sources. When the Trojan delegation commiserated with Tiberius on the recent death of his son, he ironically offered them his condolences for the death of their ancestor Hector. Charting what William James called ‘the proper bounds of lachry-mosity’ is an enterprise which is unlikely to generate unanimity. The same is true of apprehension. At one end of the continuum we have the Grimm Brothers’ Clever Else overwhelmed by the thought of a domestic mishap which might overtake her unconceived child, Gulliver’s Laputans’ agitated anticipation of the Sun’s ultimate extinction, Mill’s panic at the thought of the exhaustibility of musical combinations and Hans Christian Andersen’s practice of carrying a rope ladder about with him on his travels so that he could escape from his hotel should it catch fire; and at the other, someone with a critical but possibly operable illness who decides to anticipate the likely event and take his own life. Though it is difficult to see how disputes about where to draw the line between these mind-states could be settled if they arose, it is even more difficult to see what bearing further knowledge of obscure happenings in their neural substrates could have on the matter. Gibbon took issue with Buffon for remarking that no rational man would be apprehensive about a possibility which rose above 5000 to 1. Is it sensible to expect that Laing’s ‘biologists’ will one day settle this?
Szasz tells us that ‘strictly speaking an illness is a biological or physiochemical abnormality of the human body or its functioning,’ and that had Bleuler and Kraepelin been honest men, they would have been compelled to discharge most of their patients because a medical examination would have revealed nothing ‘demonstrably wrong with the anatomical structure or physiological functioning of their bodies, and thus they would have had to conclude that their “patients” were not sick.’ Szasz does not stop to ask what leads us to call physiochemical functioning ‘abnormal’. What makes the conditions of the auditory apparatus that cause deafness, say, abnormal is the fact that it is deafness which they cause and not any microstructural anomalies which would reveal themselves to inspection in ignorance of the disablement brought about. Laing thinks there is something anomalous in this state of affairs and that the ‘biologist’ should be worried by the fact that there are processes which he can only identify as abnormal when the psychiatrist has told him what dysfunctions they occasion. But what does he think happens in the case of blood-sugar levels? Does he think they come signposted as ‘biologically abnormal’?
If I can’t think straight, don’t take pleasure in anything and am afraid of everyone – must confirmation that I am ill wait on the postmortem? The notion of illness is wider than that of disease. A broken leg is not a disease but this doesn’t make it merely a label which we apply to people who annoy us by limping. First we diagnosed, say, near-sightedness, and only much later were we in a position to spin a story as to the flaccidity of the ciliary muscle and consequent blurring of vision. And nearsightedness will not have been a myth in the interim, nor spectacles a conspiracy to impose uniformity of vision on deviants. There is no redundancy in the notion of a disease theory of illness. Deprivation dwarfism seems to be Sedgwick’s paradigm; and it is certainly a striking – and contentious – one. But suppose the facts are as Sedgwick reports them: children adequately fed but insufficiently loved suffer retardation of physical and mental growth, both conditions disappearing with the replacement of the missing love? What are its prophylactic, remedial and therapeutic implications? Since the lack of affection is not pathogenic without some predisposing constitutional factor it does not necessarily follow that this is the feature which must be attended to. We might prefer to manipulate one of the other necessary conditions, or, if they are not manipulable, to strive to make them so. To single out lack of affection as the cause is to make what might be called a programmatic use of the term ‘cause’: change this! In this particular case, it is a natural choice to make. Love is something of which we approve, conditions in orphanages something we can change. But can we treat the whole of society like a badly-run orphanage? Sedgwick hopes so.
In Sedgwick’s judgment contemporary psychiatry is ‘over-biologised’. If this means no more than that medication is sometimes too readily resorted to, it is acceptable. But Sedgwick seems to mean more than this: that it is over-biologised in its aspirations, that the problems of psychiatry ‘should be met in preventive terms implicating the wider social and political system’. ‘If the psychological illness of depression is closely bound up in its origins with the onset of early traumatic life-events, or with the poor level of intimacy in the patient’s personal relationships,’ he writes, ‘then the demand for improved treatments – whether psychotherapeutic or pharmacological – for this condition makes as little sense as a programme for treating purely through individual medication ... illnesses such as asbestosis or silicosis which arise from ... unsafe but profitable industrial processes.’ Just how does Sedgwick think ‘implicating the wider social and political system’ is going to supply potential depressives with satisfying personal relationships and childhoods free from trauma? In any case, the right medical analogy for depression may not be asbestosis but rather diabetes, and the appropriate treatment something like maintenance medication on insulin. Though Sedgwick does not go as far as his fellow Marxist, Sebastiano Timpinaro, in holding that the best prophylaxis against mental illness is the abolition of capitalism, he does seem to overrate the relevance of social factors. ‘The solitude of the adolescent waiting on the tenth-floor ledge to jump, or the crazed exile in the backroom with a calculated overdose, of the lovesick, the melancholic, the intensely weary – each solitude radiates a social order.’
Sedgwick’s unrealistic assessment of the role of social arrangements emerges in his remarks on Goffman’s Stigma: ‘The stigma documented by Goffman are inflicted by a neurotically competitive and mercenary society.’ We need only remind ourselves of the range of disabilities with which Goffman deals for the unlikelihood of this to become manifest – a war veteran with hooks instead of hands, a girl with a wooden leg, a dwarf, people with startlingly hideous facial disfigurements, people who have to excrete through a fistula in their sides, stammerers. The predicament of these cannot be assuaged in the same way as that of homosexuals, bastards, mental patients, and members of stigmatised ethnic groups. ‘Do we have to have beauty, or even presentableness in facial and other physical characteristics? Could we construct another type of society in which the romantic projections and exaggerations that cluster round physique ... become at any rate much more muted?’ Perhaps what needs muting is the ‘romantic projection’ involved in the notion of ‘constructing’ societies.
By the waters of Babylon
I heard a public works official say
A culture that is truly philanthropic
Has been ordered for delivery today.
(Apologies to James McAuley.)
In placing such emphasis on matters of care and social prophylaxis Sedgwick understates the moral claims of basic research on our resources. We have good grounds for believing in an intimate and not unmanageably complex relation between bodily conditions and mental illness. There is a plethora of reports of radical changes in mental states produced by administration of, or insulation from, certain physical substances. We must either discredit the authenticity of these reports or incorporate their implications in any reasoned view of the nature of mental disorders.
‘Laing,’ Sedgwick says, ‘issued notice of his purpose to seek intelligibility and praxis in quite gross and grotesque forms of human behaviour.’ And if he had succeeded, what then? Hamlet’s behaviour in his mother’s bedroom would have become more intelligible to Gertrude if she had realised that he thought he was speaking to his father’s ghost, but making it more intelligible need not make it more rational. Nor does it necessarily resolve the aetiological question in favour of whatever content makes the symptoms understandable. The illness may be one thing, the symptomatic content another. This distinction was made as neatly as it has been since in Charles Lamb’s once well-known essay ‘Witches and Other Night Fears’. Although much work in the Laingian tradition consists of failed attempts to establish that ‘the symptoms of the author’s favourite nut are actually quite comprehensible and therefore not crazy at all,’ as Sedgwick once put it, even where it succeeds in conferring comprehensibility on psychotic symptoms this does not, on that account, undermine their pathological status. Even what Sedgwick refers to as Laing’s ‘stunning’ demonstration that what seemed to be the inconsequential ramblings of a patient of Kraepelin’s were comprehensibly related to the situation in which he was placed do nothing to show that he was not ill. To deride the invocation of somatic factors because of their explanatory nullity with respect to many aspects of the behaviour which characterises people diagnosed as mentally ill is like denying the causal relation between alcohol and drunkenness because it can shed no light on the spirit or content of a drunken monologue.
In The Voice of Experience Laing reveals that ‘in my adult life I have recalled and reenacted experiences long before birth.’ But science tells us that ‘ova and sperm, zygotes, blastulas, embryos, foetuses are too young to remember what happens to them.’ So Laing attempts to reduce the dissonance this conflict engenders by arguing that the same science which tells us that such experience ‘transgresses the bounds of scientific possibility’, denies the reality of daily life: ‘experience itself is a scientific scandal ... the ordinary everyday human world ... is consigned by science to its slop bucket.’ Having disposed of science, we are in a position to give its proper weight to the ‘correspondence between the foetal-umbilical-placental pattern and many mythologems and psychologems’:
The spirit enters matter. The Shining One enters Earth. Jonah is swallowed by the whale. We sink into sleep. The blastocyst enters the endometrium.
He also believes that our dealings with telephones may have been influenced by our experience of the severance of the umbilical cord (we speak of being ‘cut off’), and he protests at the arbitrariness of the psychoanalytic equation of the theme of entry with birth in reverse: ‘the correct analogue to entry may be implantation.’ Elongate objects need not be phallic allusions, as Freudians maintain, but may ‘resonate with’ the umbilical cord, ‘especially the umbilical vein’. The Freudians’ invocation of phallic and genital significances was obsessive and may be a manifestation of resistance to their umbilical complexes. Neither ‘placenta’ nor ‘umbilical cord’, Laing points out, occurs in the index of the Interpretation of Dreams.
Laing is amusingly tart about a distinguished analyst’s conclusion that the remarks of a schizophrenic patient showed that he believed himself to have eaten the analyst’s penis. ‘Honours for craziness are evenly divided.’ But his astringency does not extend to his own interpretative activities. A woman dreamt of a piece of gum going along an escalator into a garage: ‘The piece of gum is the blastocyst, the escalator is the oviduct, the garage the uterus.’ It might be said on Laing’s behalf that his interpretations are not more fanciful than the standard psychoanalytic ones, and that it is even refreshing to vary the orthodox Freudian menu of phallus-vagina-anus with some foetal-placental-umbilical fare. But the correct inference to be drawn from the fact that Laing’s pre and peri-natal parallels are no less eligible than the conventional Freudian ones may be that they are equally tendentious. Laing says of a picture of Kali, ‘the devouring mother’, eating a victim’s entrails: ‘What is she devouring? Not our penises! Our umbilical cords.’ Honours for craziness are indeed evenly divided.