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EXCHANGE PROGRAM FOR HUMAN SERVICE WORKERS |
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ROME CONFERENCE 2001 |
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Rome Conference Menu |
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DIVERSITY OR
MADNESS |
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Roberto
Ghirardelli Psychiatrist doctor. The Mental Health
Department of Genoa Director. He is the president of "The Acanto" a
C.O.I.R.A.G. (Confederation of Italian Organisations for Analytical
Research on Group) association for the study of group dynamics from a
psychoanalytic point of view. This association organise:
DIVERSITY OR
MADNESS Much Madness is divinest Sense To a discerning Eye Much Sense… the starkest Madness. ‘Tis the Majority In this, as All, prevail Assent… and you are sane, Demur… you’re straightway dangerous And handled with a Chain.
(Emily Dickinson, 1830-1886) I
open the discussion about this difficult and tricky topic with a quotation
from a poem by a nineteenth century American woman that sums up, in a few
words, a subject that, in our century, and especially in the last fifty
years, has produced ponderous philosophical essays and passionate shifts
in opinion. Goodness knows
what the townsmen of Amherst (Ma) had thought of the aristocratic old maid
who dressed only in white, had refused to leave her house for twenty years,
her paternal home, so loved and so hated and, better still, would hardly
leave her room. But she was also sensitive, intelligent, refined; she was an
artist and with her poems she conveyed to us some truths that her townsmen,
in spite of all their steady common sense, could not find. We
too, doctors, social workers, educators, should perhaps bring our poetic
side to light, besides rationality and science, to tell the difference
between diversity and madness. The difference between reason and not
reason, madness and sanity, acceptable and disturbed behaviour is not only
an academic or philosophical question to us, but a necessity our job and
our wages are based on. And every day we are faced with difficult choices. We
meet people who astonish us, who don’t reason and don’t behave
suitably, as they should, and for official reasons we must make a decision
on another person, whose freedom will often be restricted by our judgement.
A report, a certification will open or close a door, give access to
social benefits or admission to hospital.
A diagnosis of mental illness is a medical, scientific act, but
also the way to catalogue a person, to deprive him of his freedom of
judgement, to stick a label on him and show him in a different, harsher
light. I
selected this topic, diversity or madness, when I was invited to this
lecture and I thank you for this honour, since whenever Italians attend
international meetings, we are very often questioned about an initiative
taken twenty years ago, i.e. closing Mental Hospitals, known in our jargon
as Law 180. A brave or a rash
legislative act? A scientific
reform or a romantic, idealistic choice? How do you handle people who are
unsound of mind or socially dangerous? Law
180 was actually the result of different forces, some of them scientific
and organisational, others less noble.
But, owing to its ideality, it came to stand for a concept of
psychiatry that regards mental illness not as a loss, but as a diversity
that should not be hidden and feared. Coming
back to our question, I ask your permission to begin with mental hospitals
and see together, through history, in the course of centuries and among
different cultures, how madmen were handled and how the mental hospitals
we chose to abolish in Italy were born. As
you certainly know, up to modern times in Western society madmen had been
roaming the streets, more or less free and neglected, together with a
large number of poor people and beggars who were the main feature, and the
danger, of the large cities. King
Louis XIV, le Roi-Soleil, the inventor of the modern State, centralising
and ubiquitous, issued an order to intern all beggars and “loafers”,
as they were called, who crowded the city of Paris causing trouble in the
orderly society of the capital. Grand buildings were erected, called
Albergo dei Poveri or Hotel Dieu or Workhouse; their inmates were dressed
and fed at public expense and given a training. The most dangerous among
them, the “raving madmen”, as they were called, were just shut up in
prison and fettered. The King’s idea had a moral purpose: ‘the Devil
finds work for idle hands’, and abnormal or deviant behaviours, as we
call them now, are the consequence of a free choice of the individual for
the evil. Begging, crime, prostitution, madness were confined in a single
Institution whose aim was not only the punishment and isolation of those
who caused trouble or shocked the other citizens, but also their
redemption and the correction of their mistakes through work and strict
rules. The
following step was taken in the Age of Enlightenment, where the social
behaviour, the life of the States and the Ideology of the eighteenth
century common sense were subjected to the analysis of Reason and Logic.
It was then discovered that most of the people interned into Institutions
could be classified in different ways, according to their defects or
faults. What we now call
mental illness was also discovered. The brain could be working normally or
abnormally, causing not only neurological diseases but also mind
disturbances. Amoral or disturbing behaviours should not be regarded as
the products of vice or heresy, but simply as the products of an unsound
mind. The most glaring example, according to Enlightenment philosophers,
was the witch hunt, that had been very popular since Medieval times. It
wasn’t a question of the Devil’s savage concubines, but only of poor
madwomen. Voltaire
went so far as to mock the Catholic Church and its Saints who often had
visions and heard voices: Saint Joan of Arc was not a woman in touch with
God but an exalted and cunning peasant woman, in love with her King and a
victim of her heart’s passions. At
this point I hope you will forgive my digression and try to answer a
question: in you opinion was Saint Joan of Arc, this nineteen-year-old
ignorant peasant woman who believed she had been chosen by God to save
France, heard the voices of the Saints who advised her, managed to lead an
army to victory winning the respect of generals and rough soldiers alike
and was finally burnt at the stake as a heretic and a witch, was she a
schizophrenic, a hysteric person or a person gifted with different powers
and sensitivity? Was she a madwoman or was she gifted with a superior
personality, different from the ordinary mortals? If she turned up at our
surgery, would we prescribe psychodrugs or would we listen to her with
admiration? And
now let’s proceed with our history of mental hospitals.
The Enlightenment saw the birth of the mental hospital, i.e. a
facility to separate madmen from criminals and beggars.
It was a moment of deep emotion: civil and human progress was
taking a giant step forward when madmen were freed from the chains and the
cells they had been confined into. I like to mention that among other
prisoners, a madman was freed from the Bastille, whose attack was the
starting-point for the French Revolution. The
mental hospital’s function was not only to isolate the disturbers and
avoid social danger but also to treat them. Isolation
and social segregation, still maintained in the mental hospital as in the
previous institutions, were not regarded as a means of punishment but as a
therapy. The ‘moral therapy’ was the scientific basis of the
institution: a place isolated from contemporary society, far from the
social causes and moral deviations leading to the illness. Order, moderate
work and hygiene were taught under simple, humanitarian rules. The
nineteenth century scientist had discovered chemistry laws, electricity,
engines. He was proud of democracy, replacing the whims of a few with the
reason of many. He believed
that, soon, also the spirit would no longer be the subject of metaphysics,
religion and philosophy, but
would show all its reasonableness and clarity through the new human
sciences, sociology, psychology, medicine. Madness,
now called mental illness, lost its character of oddity or diversity, to
be feared or condemned and was approached, observed and studied, precisely
in the mental hospital, and finally classified and described in medical
treatises. Depression,
Schizophrenia, Psychopathic Personalities were born. We
too, psychiatrists, educators, social workers, were born at that time.
The State created a staff of employees in order to diagnose and
treat the mentally ill, separating them from the others.
As you see, the question I ask, diversity or madness, is closely
connected with the birth of our profession and the role we play in
society. But
let’s proceed with the history of mental hospitals, that is now our
history. In
the previous centuries madness was punished with prison.
Now, instead, it is regarded as an illness of the brain and treated
by doctors. But that is not all. Also criminality is considered
scientifically an illness. The Italian Lombroso went so far as to theorize
that you could diagnose the criminal behaviour of a person by his somatic
traits, the conformation of the skull, of the ears etc…
Kraepelin believed all tramps and prostitutes to be affected by
dementia praecox, while Kraft Ebing listed minutely all the sexual
behaviours falling outside the average behaviour of a Viennese citizen in
the late nineteenth century and declared them pathological. In
short, any behaviour that fell outside the measured, tolerant and sober
common sense of an average Western citizen, that was statistically a
minority, was subjected to study and research from a pathological point of
view to find a cerebral anomaly. On this subject I wish to remind you
that,
as late as 1945, the Americans performed an autopsy on Mussolini’s body
and took his brain out to have it studied, as if his being an arrogant and
braggart dictator were good reasons to consider him a madman. But a hope faded at the beginning of the twentieth century: the development of mankind founded on a science that brought progress, on a State that guaranteed the regular development of society, on the good reasons of Reason. The disorderly point of view of the artists (surrealism, abstractionism, jazz, Proust, etc.) held a greater vitality and truth than the tired calls to realism and harmony of the pretty or grand compositions. Freud’s unconscious passions proved less false and sick than the conscious reasons leading to neurosis and to a daily unhappiness. Then
two World Wars, extermination wars, Auschwitz, the atomic bomb: we
discovered the violence of reason, the cruelty of common sense. We
discovered the peace crimes, the places of affliction hidden behind good
intentions. After
the experience of concentration camps, mental hospitals are regarded
differently. The mentally ill
are put on the same footing as the Jews, the blacks, the persecuted.
The Soviets, during the cold war, showed us how to use psychiatry
for political reasons against dissidents (Sacharov). But
the postwar period also led to the economic development of the Western
countries and to a new culture based on freedom and on the protest against
the previous values. Make
love, not war, was the catchword. Free yourself of stereotypes,
conventions, definite and reasonable rules.
Take imagination to power. And
that was the beginning of new psychiatry, or better, antipsychiatry. A
psychotic is not only a psychotic, but a person trying to assert his
identity in the overwhelming world
around him (The English Ronald Laing).
Mental illness is a myth made up to divert our attention from our
independence (The American T. Satz).
The inmate of a mental hospital is a proletarian interned by the
power because he refuses to conform to the laws of profit (The Italian
Franco Basaglia). You
may remember the film “One flew over the cuckoo’s nest” that was
very popular in the ‘70s. The
main character, Jack Nicholson, a mental hospital patient, is persecuted
by a perfect and cruel nurse and since he doesn’t conform to the
hospital rules, he is lobotomized. The psychiatrist, born to fight illness
and suffering, turns into a persecutor who doesn’t understand and
inflicts suffering. As
you see after this roundup of a few centuries, at the beginning the
“mentally ill” were regarded as a social disturbance to correct and
hide; after many swings we have come to the present times, to the most
advanced reformist experiences, to the concept of “madness” as a
diversity to protect and support. Here
we pause and wonder how we can tell
the difference between madness and diversity when History, Science and
Philosophy have found, in the course of centuries, so many different
answers. To
sum up the debate, we could place our trust in medicine and consider all
behaviors and thoughts not conforming to the scientifically tested codes,
to common sense and to reasonableness as the outcome of mental illness. Or,
on the contrary, we can make a different choice and deny the existence of
madness; we will ascribe an abnormal behavior to the conditions imposed by
circumstances or society. On
an academic level, in this Convention, for instance, we might calmly
debate about which theory is more convincing, we might extend our talk to
philosophical themes; how we consider human nature, whether we believe
that knowledge and communication are possible… But
we are doctors and social workers and, as you know, we don’t have this
freedom of thought. Every day
we are faced with the need to settle the question on a diagnostic level
and decide on the action to take: is this man before me an ill person to
assist and treat, or a different and misjudged person to defend? What
can we do? Three roads are
open before us: 1.
Look for signs and symptoms of a biological or social pathology,
defined as such by the scientific treatises of the disciplines we were
trained into. For instance,
ascertain whether the patient is suffering from hallucinations or is
making use of alcohol or is showing suicidal impulses. According to this
operational choice, the reasons of the patient are insignificant; we give
up any possibility to communicate and to sense the patient’s feelings.
We need not understand a patient psychologically to make a diagnosis and
prescribe drugs, to ascertain whether he may gain access to a certain
social service: on the contrary, it is often misleading.
We are concerned with the biological datum, the symptom, the type
of behavior that drove him to our observation and on which we have to
operate. 2.
Accept as norm the average social behaviors of a given environment
in a given historical period. Hashish
consumption may have been pathological fifty years ago, but no longer now,
homosexuality was regarded as a sexual perversion, no longer now. The tramp sleeping in railway stations was not tolerated
before, but now he is.
Suicide is forbidden by some religions but not in modern states; on the
contrary, in a few cases euthanasia has been regulated by law.
Pedophilia is condemned today, maybe no longer in the future.
That is, we accept the behavior of the patients who are brought to
our attention, we try to understand them, to describe them but we don’t
presume to modify or correct them, since each of us has good reason for
his behavior. We don’t
presume to decide what is right and what is wrong and, in particular, what
is sane and what is ill.
This attitude is more respectful towards the patient’s freedom,
but we are running a risk. Common sense and the triviality of everyday
life may hide the need, the call for help hidden behind provocative or
anomalous behaviors. 3.
Make use of our clinical sensitivity, our sixth sense. The words
employed by a patient, his behavior before me can help me feel his
suffering, his psychic pain, his conflicts.
I identify with him, I put myself in his shoes and I exercise my
judgement. I worry and intervene only if I feel a tingling at the back of
my neck, only if my unconscious thermometer for what is normal and what is
pathologic gets going. In
this case the obvious risk is to mistake my problems for his problems, to
justify in him what I justify in myself and to condemn what I fear.
Therefore I’ll choose to belittle a violent behavior towards
one’s parents if I, for first, have a difficult relationship with mine;
or I will prescribe a treatment with psychodrugs to a woman tired of her
family life if my married life is not at its best. As
you see, snares and possibilities of mistakes lie hidden behind every
point of view. I
did not find any ultimate solution and I will just tell you that the truth
lies in the middle, i.e. only using all the three criteria can I get a
wider and deeper picture that allows me to take a final decision and carry
out a project of intervention. For
this reason now, at the end of my lecture, I invite you to join me in a
consultation I had recently, just before writing this text, when I tried
to verify, as far as I could, consciously, the decisional processes I
developed. It
is not a difficult or extreme case. I
am submitting a simple experience to you, an everyday case, a case we
often treat automatically in our surgeries, without thinking much about
it. A
common friend introduces me to a mother who is worried because she
recently found out that her son smokes joints in excess.
She is a perfect mother, I am told; devoted to her children and her
husband, who, by the way, is an established colleague of mine. The
first feelings I have to resist are competition and envy for my colleague;
I want to show that, yes, he is well-known, but he has family problems.
His wife may well be admired and efficient, but she isn’t such a good
mother after all. And then
the narcissistic answer I would like to give my friend who submitted this
case to me: don’t worry, I’ll settle everything, I am the best. My
judgement is in danger of being overwhelmed by unconscious feelings and
forbidden affections even before being put to test: jealousy, envy,
aggressiveness, vanity. Luckily
I employ the scientific criteria: clinical examination, objective findings,
assessment of the cultural background. Then
this mother arrives and I start the clinical talk employing the scientific
criteria I have been taught: case history, clinical observation of the
behavior, analysis of the reasons leading to the talk. The mother tells me
his behavioral data which I turn into clinical evaluations, i.e. her
son’s neurological diseases during his childhood, enuresis, fits of
convulsions. Then she updates
me on his son’s alleged use of hashish that frightens her so deeply, his
being behind with his studies, his association with hard rock groups and
his nocturnal, disorderly life. While answering my questions she is
anxious and upset and keeps comparing her children’s life to the
difficulties she encountered in her family of origin, with her own
parents.
My
first feeling, that I try to keep in check, is the comparison between this
mother and myself, since my son, too, is the same age and I, too, am
sometimes worried about his behavior and his choices. But I must keep
aloof and consider the situation objectively, scientifically, following
the handbooks. And
so I can understand that on one hand her son smokes more hashish than the
average of his peers, and on the other, that this mother is overwhelmed by
her personal anxieties dating back to her sad childhood and by her wish of
redemption, of raising perfect children in a perfect family.
Everything seems to be collapsing because of her son’s
provocative and moderately antisocial behavior. I
wonder whether I must take under treatment the mother, because of the
excessive anxiety she is
aware of, or the son, because his mother claims he is different from her
expectations and the usual behavior of balanced young men.
Is there a pathology in the son or in the mother?
Or, more simply, is there a pathology at all? Aren’t we dealing with those generation conflicts that
everyone has to solve by himself, without involving the psychiatrist? And
can I only prescribe some tranquilizers to the mother, since she is so
agitated, is aware of it and asks for a treatment? In
the end the son, the appointed patient, arrives. Our talk begins with a
misunderstanding: he refers he has been deceitfully taken to me by his
mother. He states he is feeling well and has no psychological problem.
He denies any alcohol or hashish abuse
and accuses his mother of being overanxious. However,
the way he speaks, breathless and logorrhoic, in order to show me that the
patient has no symptoms, without even listening to what I’m telling him,
leads me to suspect that the patient is cheating, that he has something to
conceal. I understand by the
clinical signs, half-closed eyes, half-open mouth, dysarthic speech, that
the patient has just been smoking, i.e. has made use of those very drugs
his words so insistently deny. All the same, a pathological relationship
with his mother, too close and persecutory, appears: ten-year-old boys
often have such relationships, but our young man is twenty-two. Here
ends my example. As you will notice, at the end of the talks I am still
feeling various doubts about the pathology shown by the young patient.
In fact, the criteria required by the psychiatric treatises to
assess a psychological pathology were not present, since the patient did
not show any disturbance of thought or of affectivity.
Neither did a comparison with the average of his peers show any
obvious difference, since the use of psychotropic substances,
microconflicts at home and school curriculum were within the statistical
norm, although at the lowest levels. But the tingling at the back of my
neck had started, triggered by the suffering I could feel behind his words
and confusedly expressed in the suffering shown by his mother, who I
considered a good person, and in the indirect, frightened and indifferent
attitude shown by the young man during our talk. My task was to put all
these elements together and make a decision and a judgement.
And so I did: I decided to take the young man under treatment,
making a diagnosis of a personality disorder.
But I am certain that
if you and I had to make a joint decision, we would hardly reach an
agreement, since each of you would feel and lay the stress on a different
aspects of this case. At
the end of this journey through history and through our mind, we are back
to the starting point. Is
there a normal thought, a right personality?
Is it possible to tell the difference between madness and sanity in
a person’s life? Is it right to treat and modify a person’s behavior?
Can we trust medicine, sociology, psychoanalysis? Perhaps
there is no answer to these questions, but we keep asking them, driven by
the anxiety we feel when we are dealing with psychic pain.
We wish we could drive it away but at the same time we are
intrigued and attracted by it. A part of us is solidly behind our
patients’ psychic sufferings, and especially understanding about the
defenses, at times quite odd, employed by our patients to check them.
We too, maybe, are carefully hiding some crazy thought and often
forget about it. Perhaps,
deep down, we sense that mental health is not something fixed, we were
born with, but a result we painfully achieve, day after day. The
struggle, the dilemma between sanity and madness does not concern our
patients only, but ourselves, our inner world; we know that this battle
was not won once and for all. My
conclusion is that medicine and sociology help us understand the universal
natural laws and the social conditionings. But it is not enough; every man
has his freedom and his thought and his life-style: in short, his soul. We must respect them, share them and be curious, too, about
them, since we are doing this job. Therefore,
when Joan of Arc turns up at our surgery, my advice is, before prescribing
haloperidol or a nice social benefit, let us listen to her.
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