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THE MORAL AND THE MOLECULAR IN THE FUTURE OF PSYCHIATRY

by Robert M. Young

Summary: I want to ask what ’moral treatment’ should mean in the next century. As Kathleen Jones has shown in her Preface to Tuke’s account of the York Retreat (Tuke, 1813), there is an ambiguity about this phrase. It connotes common sense morality in English and the world of emotions in French. I want to ponder both meanings. In particular, I want to reflect upon what it means for a person who would formerly have been in an asylum or retreat to be treated morally (Eng.) in the community, taking full account of his or her moral (Fr.) vicissitudes. This involves philosophical and political questions about being a person, citizen, member, while, as the same time being selectively ’disabled’ in the sense of recent debates on that concept. Whatever else these terms mean, they do not mean ’de-mented’. A second strand of my reflections concerns the relationship between the experiential, on the one hand, and the psychopharmacological and biological aspects of our humanity, on the other. The problems associated with dividing the person into mind and body, i.e., into moral and mechanical, are likely to increase in the next hundred years, and this process is likely to make the moral issues raised above even more urgent.

I begin with some recent images from the mass media. The first is Mohammed Ali lighting the Olympic Flame in Atlanta. The second is Christopher Reeve addressing the Academy Award ceremony and the Democratic Convention. A third is the publicity given to the Para-Olympics. A fourth is a news item: Margot Kidder was found wandering and distraught in Hollywood.

What these images say to me is that disability is becoming re-located in world culture. I want to suggest that it may be helpful to think of mental illness in terms of the concept of disability and recent developments in our thinking about it. Several things strike me about the images I have mentioned. First, the huge split between the able-bodied and the disabled is closing. The connection between the two ends of the split is being acknowledged, although I would not claim that we have moved from a paranoid-schizoid to a depressive way of thinking about them. By that I mean that there is, as yet, no integration, only a juxtaposition, but that’s a start. One way the disability movement refers to this is to say that we are all only temporarily ’abled’. The chances are that we will almost all become disabled at some stage — feeble, hard of hearing, seriously forgetful. These images say to me that Superman can meet with profound misfortune and become permanently paralysed and confined to a wheelchair, something no fall from a horse could have done to him when I was a boy. Only kryptonite could do it and then only temporarily. Similarly, the man known as ‘The Greatest’, the world’s best known athlete, a man who could ’dance like a butterfly and sting like a bee’ and compose witty doggerel all the while, could fall prey to Parkinsonism and be hesitant of gait, of speech of gesture — this, too was until recently unthinkable or at least something to keep hidden.

Even more important than acknowledging their vulnerability to human frailty, it seems to me, is this fact that such people are no longer hidden away. Their humanity, their dignity, their struggles are bought before a world audience with sympathy, respect and admiration for their fortitude. It is no longer thought that they have ’lost it’ like pugilists portrayed in sports movies of my childhood, when punch-drink fighters were portrayed in bit parts on the fringes of sports movies. Something similar can be said about prowess in the Olympics. The Olympic ideal meant perfect physique, perfect fitness, when I was a boy. I happened to know an Olympic diving and gymnastics champion. He was perfect. The whole idea of the Para-Olympics says that fitness and prowess are relative. There are a number of categories and criteria for disability. People are encouraged to compete against comparably disabled people. There was even an advert last summer stressing that the athletes in the wheel chair marathon moved a great deal faster than the runners.

I grant that there are contradictions in all this and that the motives for displaying Christopher Reeve and Mohammed Ali are complex and mixed and that there is awful sentimentality and, arguably, some serious poor taste involved. But never mind. I am sure this is, on balance and all things considered,. progress.

But what about Margot Kidder, who, you may or may not recall, played Lois Lane in the Superman movies? The fate which has befallen her has not been displayed with the same public respect and sympathy. That news item came across to me more pruriently, voyeuristically, with a sick irony. Becoming mentally ill is in no way viewed with the same compassion; one’s dignity is not retained. It is sordid, tawdry. Something similar can be said about the stories surrounding the death of Margaux Hemingway. How the mighty are fallen... A sad end, reminding one of Marilyn Monroe’s death.

One of the things I want to suggest today is that we begin to think about the mentally ill in ways analogous to how we seem to be thinking about the disabled. It is not a simple analogy, if only because the mentally ill are often experienced as Other in a way that those otherwise disabled are usually not or not to the same degree. It has been said that the modern disability movement can be traced, to a significant degree, to the militancy of returning Viet Nam veterans in wheelchairs as a result of spinal injuries. They fought for access to public transport, sports events, public buildings. They said to the rest of us, in effect, ’Just because I am disabled and in this chair, I’ll be damned if you are going to deprive me of my rights of access and other dimensions of dignity’. We also have subtitles and signing of some speeches on the television, hearing loops in various public places, large print and audio cassette books.

I could go on in this vein at length, but I think you see the positive side of the analogy. The physically disabled have insisted that we not add insult to injury, and their campaigns are making a great deal of headway, even though they have a long way to go. The same cannot be said about the mentally ill or disabled. Why not? Well, to put is crudely and obviously, to have a sound mind in a damaged body is not the same as having a sound body with a damaged mind. We have to find a way of retaining the dignity, personhood, membership, citizenship and rights of the mentally ill — issues which, on the whole, simply do not arise for the physically disabled (though, of course, they also have mental damage and recalcitrant administrations to contend with). The part of the person which is okay with the physically disabled and makes their campaigns work - their insistence that their personhood is intact — is just what’s damaged with the mentally ill. But that’s no reason not to pursue the analogy. Indeed, I have recently seen the following self- description of a mental patient:

If you believe in the inner man and the outer man, if you understand something about the inner man... Well, that’s what breaks and that’s why it makes you less confident, and more difficult and hard to form relationships and the rest of it. That’s the only way I can describe it.... That’s the thing that happens. So that’s why I just regard it as an internal disability, if you see what I mean (Barham and Hayward, 1991, p. 10).

This brings me to ‘moral treatment’, a helpfully multivalent phrase which was used to characterize the novel regime at the York Retreat. First and most obviously and relevant to our presence here today, it meant treating people kindly, in contrast to the treatment Tuke deplored and set out to improve upon in a way which constituted a revolution in the care of the insane. Gentle, dignified, retaining contact with the inner light Quakerism postulates is in every human being. It is deeply ironic that the history of much of the asylum movement which had its roots in the inspiration of Tuke and Pinel came to be seen in recent decades as inhuman — not usually, of course inhuman in the use of chains and physical cruelties, but inhuman nonetheless in the sundering of human dignity. We should not forget, however, that there was a heyday of the country asylum. It was believed during much of the nineteenth century that these castles were indeed havens from the degradations of urban, industrial capitalism. People were thought to be cured by the very act of going to such places, which were thought of as something like the twentieth-century health spas came to be regarded, veritable Wellvilles, and they came to have equally arcane modes of treatment. But that was later. I well remember being told as a medical student that the statistics for cures in nineteenth-century asylums went up and up until, at last a Doctor Awl was able to announce a one hundred per cent cure rate. He was thenceforward known as ’Dr Cure-Awl’. Somehow, during the ensuing decades, these large institutions changed from being ‘instruments of regeneration’ to ‘dustbins for the incurable’ (Roy Porter, quoted in Barham, 1992, p. 68). A century later I worked in such an institution in Arizona (as part of a Quaker project in Arizona) at a crucial turning point in the mid-1950s when the back wards had become places without hope, while the admission ward was about to open its doors, and the highest hopes were attached to the new tranquillisers, hopes which we did not yet know were exaggerated.

As we all know, the writings of subtle and courageous people from the Author of The Mentally Ill in America (Deutsch, 1948, 1948a; Wright, 1947) to The Snake Pit (Ward, 1946) and on to One Flew Over the Cuckoo’s Nest (Kesey, 1973) (both made into films which had huge impacts - see Shortland, 1987), coupled with the critiques of Goffman (1961, 1971), Schiff (1966, 1971) and other theoreticians of labelling and deviance (Pearson, 1975) and others, e.g., Ronald Laing, 1960; Laing and Esterson, 1964), led to a discrediting of the old, large custodial mental hospitals which, with hindsight, we are coming to see was only partly appropriate when compared to what has been put in their place. I am thinking now of places like Fulbourn Hospital, near Cambridge, which under the leadership of David Clark (1996), re-established and embodied many of the ideals of the York Retreat. It was not unique. Other therapeutic communities could make similar claims, for example, The Henderson Hospital, the Cassel; you will have your own nominees.

We all know that the next step was pretty awful, and people like Andrew Scull (1979, 1984, 1989) and Peter Barham have provided us with insightful accounts of the unholy alliance between the critics of the old asylums and the misguided and opportunistic cost-cutters who used ‘care in the community’ as a slogan for closing the institutions without putting anything approaching adequate facilities in their place.

This brings me to the second meaning of ‘moral’, the French sense of moral as the realm of the emotions. The truth is that the mentally ill are not in- sane, any more than they are de-mented.

They are something in between. No, that’s not it. There is no simple way of expressing what I mean. Their difficulties are highly-textured. Their personalities have complex coastlines, sometimes with fissures which go deep, sometimes almost all the way across, rather like the one extending from the Moray Firth to the Firth of Lorn and includes Loch Ness (where there may be a monster) and nearly cuts Scotland in two. While people were in custodial settings, a terrible enforcement of uniformity was imposed. I vividly recall being instructed not to help a slow person feed himself, since it took too much time. Simpler to shovel it in. On a ward of severely mentally handicapped people, it was deemed easiest to let them eat any way they liked and hose down the lot at the end of each meal. All dignity sacrificed on the alter of staff shortages.

When the mentally ill were turfed out into the community it was not properly realised that a certain minimal cosseting would be lost which occurred in spite of that inhuman blunting . My view is that the task for the future is to find ways of catering for the profoundly craggy and individual and highly-textured and changing (sometimes dramatically changing) coastlines of the individuals who have been, are and may again become mentally ill. This is a tall order, given the way our family patterns have developed. How can we care for the mentally ill when we are so uncaring about our other fellow humans?

You may recall that one of the way Foucault (1967) characterised the people who ended up in asylums was that they were not reliable employees. He referred to them as ‘those who will not work’. This phrase can stand for all sorts of aspects of the idiosyncrasies of the recovering and intermittent mental patient. Peter Barham and Robert Hayward have made a special study of this issue in their fine book, From the Mental Patient to the Person (1992) recently re-issued as Relocating Madness. I want to say here that Barham’s work strikes me as the best single guide through the labyrinth I am trying to thread today. His Schizophrenia and Human Value (1984) posed the problem of the humanity of the mentally ill, while his Closing of the Asylums: The Mental Patient in Modern Society (1992) is the best short account of the history of the present policy and the problems it poses. I have said before and repeat here that Schizophrenia and Human Value is one of the best books I have ever read. Not just best in this field. Best full stop. The reason is that it poses in terms of philosophical reflections and political and cultural theory the problem of what it means to be a person in a society and a culture and how hard it is to place the mentally ill person in this framework as a fully human being or, as he puts it, as a person and a citizen. That, I suggest, is our task for the future. But it is posed in the face of a community which is in many ways uncaring of all of us and in the face of a fashion in psychiatry which is, in the main, turning its face away from the humanistic and toward the biochemical. As Barham says, ‘Deinstitutionalization implicates rather more than the administrative substitution of one locus of care for another, and invites also a drastic reshaping of the ways we think about, describe and, in particular, relate to people with a history of Mental Illness’ (Barham, 1992, p. 151).

The task of a proper policy of care in the community is not one which we approach de novo. Positive models of care in the community was a theme in this year’s biennial conference on ’Psychosis’ at the University of Essex, optimistically subtitled this time ‘Integrating the Inner and Outer Worlds’. We heard about the dramatically improved statistics obtained by Dr Lawrence Ratna and his team with an attentive and meticulous crisis intervention team which has been in existence for over a quarter of a century. An equally carefully worked out approach has been developing for the past eight years under the rubric of ‘Psychosicial Intervention’, which has so far involved more than thirty NHS trusts and which can be studied as a postgraduate course at the Centre for Psychotherapeutic Studies of the University of Sheffield, where I work. Moving further back, there is the inspiring story of Trieste, generalised into Law 180, passed in 1978, which led to the closing of the Italian psychiatric hospitals, and the development of a careful scheme of community care, story which Dr Tim Kendall (1996) brought up to date at the Psychosis conference. But there are even more venerable ways of accommodating the mentally ill in communities. There has been a scheme in Ainay le Château since 1900 (Jodelet, 1991) and a system of boarding out in Scotland for even longer. The longest-established programme is in Geel, Belgium, which has been operating since the eleventh century. People came to the shrine of St Dymphna, the patron saint of the mad, and then hung about in the community and were integrated into it. There has been a scheme operating there ever since. There are now about 800 patients in a community of 30,000. When the BBC (1992) filmed there recently, what was most striking was the sheer tolerance of the host families, who treated the patients symptoms and preoccupations as eccentricities and made emotional space for them. This latitude for the expression of symptoms seems to me to be of the essence of what is needed. It is the emotional equivalent of the achievement on behalf of the physically disabled of special toilets with access for wheelchairs which we see in more and more public places or the special rails or chair lifts at swimming pools and in community centres. It allows people to move about without being in constant fear of being blocked or caught short. It is the opposite of what Foucault observed. Instead of hiding away ’those who will not work’, we need to revamp the community and the interfaces between the mentally ill and the rest of us in whatever ways turn out to be necessary to make them user-friendly for those who are periodically in mental distress.

I am not suggesting that ’the loonies should take over the asylum’, as the reactionaries might put it. Even in Geel, patients were quite clearly told, in a way some viewers of the BBC documentary found patronising, that if they went beyond certain limits with their behaviour, as a punishment they would have to spend a period back in the custodial mental hospital which remains open in the city. When they learn to behave acceptably, they can return to their adoptive families. Pure anarchists might not like this, but I found it reasonable in a rough and ready way. As St Paul reminded us, it is not the letter but the spirit of the law that matters, and the families I saw seemed to me to be admirably commonsensical about the boundaries which had to be drawn and enforced from time to time with the help of hospital liaison nurses.

I am not suggesting that London or York should just adopt the Geel, Ainay or some similar scheme wholesale. I am suggesting that we put our imaginations to work in creating spaces in which those of intermittent disability of mind and spirit can remain as fully human and participant in culture and society and the polity as they can manage at any given time — once again, personhood and citizenship. As I said earlier, Peter Barham and Robert Hayward have in their fieldwork carefully delineated how complex and subtle a problem this poses. Their quotations from discussions with a goodly number of mental patients in remission and in the grip of current difficulties make it painfully clear that negotiating life on the streets and conducting relations with the health and welfare authorities is a daunting labyrinth, full of snakes and precious few ladders. My point is that it should be addressed in as commonsensical a way as the problems of other disabled people. One group which strikes me as pointing part of the way is the Hearing Voices group, which seeks to make this symptom seem less extraordinary and not to be denied or suppressed. Indeed, it turns out that a majority of people in Holland who hear voices never come in contact with the psychiatric services at all. I’m not saying that it’s fun or ordinary; I am just saying that it can be borne and tolerated, like many other forms of behaviour which strikes one as odd, eccentric or even mad.

As I have implied, I believe that these are philosophical issues as well as social, cultural and political ones. We have to be clear about what it means to be a person, member, citizen, even while being limited and very unusual at times and in certain ways. I’d like to share some of Barham and Hayward’s findings, since they are so evocative of what I am trying to convey. They suggest that for a mentally ill person ‘personhood in not a tenured accomplishment’ (p.71); it is ‘constantly on probation’ (p.14). Mental patients often no longer feel themselves to be ’agents with a life to live’ (p. 92). After a breakdown, the task was ’nothing less than to start "establishing" herself "as a person" all over again’ (p. 97). Mental patients have to ’learn from hard experience to become active strategists in the reconstitution and negotiation of their lives ...a severe schizophrenic breakdown typically wreaks havoc upon the agent’s sense of his own biographical continuity and telos, upon the narrative coherence of his life’ (p. 91).

The task of achieving some kind of biographical reconstruction is fraught and full of pitfalls. A word which recurs again and again in Barham and Hayward’s account is ‘demoralised’.

Not infrequently, the person finds himself in a field of forces in which he is made to feel demoralised about his own prospects, about what he can realistically hope for, and his demoralisation may then impact upon his ability to care for himself, which in its turn, may demoralise him still further. For the person to ask for help in this situation — even to admit to himself that he is in need of help — may seem to confirm the feelings of incompetence and humiliation that have already been borne upon him’ (p. 53).

Barham says in Closing the Asylum, ‘...if we are not to fuel the demoralization of people with mental illness, and stigmatize them still further, we... stand badly in need of psychiatric theories that try to grapple with what users of mental health services themselves want’ (p. 62).

The social and the diagnostic location of such people are mutually reinforcing. Here are some remarks about two interviewees. Sally’s statement,

"I feel I’m a psychiatric patient" functions here not as a description of what she actually is, or of a role to which she has been assigned, but as a negative definition of what she feels about herself as a person and of the life prospects that she judges to be available to her.

‘In Henry’s usage "schizophrenia" is not so much the name for an illness as for a social predicament to which the experience of illness has given rise. For Henry coming to "accept" the illness and coming to "accept" an impoverished conception of what he can reasonably do and hope for — of his significance and value — have been brought to merge in a painful experience of exclusion and worthlessness. In what they say about themselves Henry and Sally illustrate not the natural consequences of mental illness, but the social consequences of becoming mentally ill in society as they enter into the person’s most intimate sense of who he or she now is (p. 77).

Another challenging philosophical problem about personhood brings us to my closing point. With the rise of more and more drugs and the likely addition of intracranial electronic and surgical manipulations of increasing complexity and precision, it is becoming more and more difficult to speak of a clear split between natural and artificial or mind and body. Indeed, the relationship between speaking of ourselves as persons and doing so in terms of minds and bodies has been an unresolved issue at the heart of the modern world view at last since René Descartes’ Discourse on Method, published in 1637. (cf. Strawson, 1959 and Young, 1990 and 1994). I am not going to waste our time making dire predictions, but I am sure that developments are in train which will profoundly challenge our concept of personhood from genetic, psychopharmacological and neurophysiological points of view. The likelihood that more and more of us will be cyborgs — part organism, part cybernetic systems — is very great (Harway, 1990). I am not at all sure I welcome these developments in our present socio-economic order, since I hold he view that the profit motive will be likely grossly to distort their development. In this daunting future, I believe that something else which Peter Barham said should be our guiding principle. Whatever may turn out to be the biochemical or genetic causes or other aspects of mental illnesses, the subjective experiences and the civil rights and the dignity of the mentally ill — the meaningfulness of their experience — should be respected and nurtured, cultivated and protected, according to political and cultural values which must not be in any way reified (Ingleby, 1970) down to the pseudo-neutrality and falsely conscious value free stance of reductionist science. The values of humanity — moral in focus and moral in the full appreciation of the emotional gamut of our humanity — must be husbanded.

I began by following Kathleen Jones in pointing to two senses of the moral — moral treatment as civilised and humane and the moral as the vicissitudes of emotions. I end with two senses of the molecular. The first is the focus on genetics and molecular interactions, for example, involving the metabolism of substances like the enzyme monamine oxidase in relation to serotonin, dopamine and noradrenalin. I have simply said that the moral should never be superseded by the molecular. Where are the Professors of Care in the Community? Their numbers and resources should be on a par with Professors of Psychopharmacology and Molecular Biology in our psychiatry departments. The second meaning of molecular, however, takes me back to the complexities of care in the community: the need to create facilities and user-friendly interfaces which can fit or accommodate all the inlets and outlets of the textured idiosyncrasies of the mentally ill person. In politics, this careful mode of alteration of bad practices is called ’molecular change’, change which suits the tiny individual features of individuals, in contrast to the conformity-requiring changes which have been too characteristic of recent policies of care in the community, where defensively devoting scarce resources to compiling lists or people at risk of being violent seems to be a higher priority than individual consideration in, for example, living accommodation. I shall never forget a television image in a recent BBC television week on mental health in which a patient was told he could have a bus pass if he would just sign here that he was permanently incapacitated. These are the ways of thinking of people in the mass, without regard for their sensibilities and hopes, which rightly led to the downfall of nominally socialist regimes in Eastern Europe.

If we can develop a truly molecular policy of care in the community, making full allowance for the emotional range of mentally distressed people, which never ceases to treat them as moral beings, the tradition of ‘moral treatment’ begun exactly two centuries ago in this building will remain unbroken. I want to close on a note about Margot Kidder who you’ll recall was found wandering around, dishevelled in the California capital of idealised personhood, just as the Olympics (both able-bodied and para) represent the ideal of athletic prowess and marriage to Lois Lane’s hero — which occurs this month in Superman comics and on television — represents idealisations of personal relations. Perhaps one day it will be appropriate, dignified and respectful for us to see Margot Kidder lighting some care in the community equivalent of the Olympic Flame. I hope so. She seemed such a nice woman in the Superman movies.

I wish to acknowledge with thanks the influence on my thinking about disability of ongoing discussions with Dr Deborah Marks. She has developed the MA in Disability Studies at the Centre for Psychotherapeutic Studies at the University of Sheffield.

REFERENCES

(Place of publication is London unless otherwise specified.)

robert@rmy1.demon.co.uk