The new religion of madness
How the Christian concept of mental illness still infests psychiatric treatment.
Emerging from the subway in San Francisco, before the sight of the city strains into view, you are hit with the smell of it – a bit of marijuana, a bit of smog, and an unavoidable nasal punch of urine and feces. There are few places in the civilized world that smell so distinctly and regularly of human feces as the exit ramp of a San Francisco mass transit line.
And the explanation why is not long in coming – in every direction, wherever you care to cast your glance, you’ll see the city’s homeless, sleeping in doorways or huddled together in groups expansively relating tales of police brutality and the indifference of humanity.
Some are down on their luck but many, too many, are clearly not functioning at full mental capacity – wandering around in circles, having detailed conversations with nobody, beating their heads rhythmically against a nearby wall – people who, 40 years ago, had a governmental support system, and who now wander, lost and forgotten, victims of a new approach to mental health.
In the Christian era, madness was binary. Either your heart was full of God and you were sane, or the Devil had touched you, and rendered you insane. It was the continuation of that grand tradition of antiquity by which trembling humans were the victims of the whims of the gods, paper creatures liable to burst into tragic flame when caught in the crossfire of divine conflict.
Whereas for the Homeric Greeks, however, divine fate could be railed against but never overcome, the Christians founded themselves on a system of divine emergency services that could be called upon at any time, by any one. Exorcism and ritual, a high mass and the clang of a full donation box, all assured the proper intervention against the Devil’s machinations.
If a person remained insane even after the intercession of a priest, it was taken as a sign that they had not yet truly renounced the Devil. At that point, it was their problem, not the priest’s, and therefore they deserved their ultimate fate of familial scorn and societal cruelty.
Fortunately, this outlook had within it the germ of its own destruction, and with the religious excesses of the17th century, Europe finally started settling down to the idea that mental illness was organic, not divine, in origin. That idea, of a simple one-time cure-all that worked if you were a good person but failed if you were still somehow evil, gave way for the next three centuries to the notion of care and understanding.
At the same time as Europeans were philosophically prepared to entertain a biological portrait of mental disease, the continent was economically developing a service sector that specialized in taking over for the family unit its most intense tasks. Just as you no longer educated your child at home, but rather sent him off to a school if you had the money, so were you no longer expected to handle your unbalanced family members, but instead paid for their professional care at any of the private health asylums lurching unsteadily into existence.
Some were good, some were thoroughly awful, but governmental regulation throughout the 18th and 19th century was working towards curbing the worst excesses, and establishing public mental hospitals that had some notion of transparency.
Each nation had its own focus. While the Germans concentrated on the cellular and bacteriological origins of mental illness at the expense of recognizing the humanity of the person carrying the disease, the French developed a cacophony of therapeutic techniques seeking to either ease the patient back to normalcy, or shock him there, all at the expense of knowing what was actually underlying the phenomenon on a biochemical and anatomical level.
An amalgam of those two approaches, a mental hospital system that upheld a strong focus in fundamental research while still preserving and affirming the basic humanity of its patients, was on the horizon.
And then we out-clevered ourselves.
First through surgery (one doctor, armed with an ice pick placed in the eye socket, could bang out a hundred lobotomies a week) and then through medication (brain chemistry altering drugs are currently the most frequently prescribed of all medicines in the Western Hemisphere), the idea that mental illness was binary planted itself again in the imagination. A pill took the place of the priest, and the world celebrated.
Most of that celebration is, I think, justified. The slow and anguished unlocking of the brain’s plasticity and associative regions is one of the great triumphs of the 20th century, and a towering argument for our essentially chemical and mechanical nature as organisms. It has allowed us wholly new vistas from which to appreciate the complexity of mental illness, and provided new tools to manage our most debilitating of neural diseases.
The vocabulary of this new psychiatry, however, has had some disastrous consequences. Conservative politicians who had been aching with a desire to shut down the public mental health system seized upon their apparent efficacy, and declared the public mental hospitals dead. Under Thatcher and Reagan, funding was cut by 80 percent under the cavalier notion that people would be fixed on an outpatient basis using pharmaceuticals.
A health system that had been slowly learning how to do its job in fostering recovery was gutted to make way for a pharmaceutical system of huge promise but just in its infancy. It was the binary religious spirit reborn – here is a cure, if you take it and get better, you’ll rejoin society, and if you don’t get better, you’re irredeemable and so to the streets with you.
That vast intermediate zone, between those successfully cured by the wonder product and those untouched by it, was snatched away, and so likewise was the ability to treat anybody who fell on the wrong side of the pharmacy’s graces. And so they roam, intentionally lost by a society that had yearned to do away with them for centuries as the Devil’s Lot, and that only found the ability to do so when a new vocabulary arose to add a secular gloss to its medieval conceptions.
As Complicated Things go, the brain is the monarch of the natural realm. We gave public institutional care a mere century and a half, interspersed with World War and nuclear panic, to master handling the vicissitudes of that monarch before casting it away in favor of something that sounded comfortably like the exorcism that allows us to disregard continued sufferers as beyond the scope of our sympathy.
Someday, we shall understand that brain so well, and design medications to nurture its wendings so cheaply and effectively that, indeed, everyone who wants it might well have the level of cognitive functioning they desire regardless of their economic or social position. Someday, we might even be comfortable enough as a society to consider somebody who foregoes the option of “normal” neurochemistry as part of our fabric, and not some Other to be collectively acted upon.
For now, however, if we can at least check our impulse to religiously binarize the spectrum of mental illness, and to import that polarization into our personal judgments and governmental policies, then we shall be doing our small part in hastening the arrival of that day, and the richness of mutual comprehension it promises.
Editor’s note: The image above of a homeless man in San Francisco appeared in this late 2014 report that stated:
City officials estimate around 63 percent of the total counted homeless have a mental illness, addiction or debilitating physical condition as opposed to 55 percent two years ago.