DEMONS, BEASTS, BROKEN BRAINS and BAD BLOOD — A Brief History of the Understanding and Treatment of Psychosis

Jennifer Kanary in a case study 3 psychosis simulation labyrinth. Title: Intruder 2.0. Year: 2008. Technique: Installation. Materials: baking paper, book paper, mixed media. Size: 60m2. Location: Het Dolhuys Museum Haarlem— Image by Thomas Lenden

The past is our definition. We may strive, with good reason, to escape it, or to escape what is bad in it, but we will escape it only by adding something better to it. ~Wendell Berry

Life can only be understood backwards, but it must be lived forwards — Kierkegaard

INTRODUCTION

Due to the complexity of the history involved, the historical data in this article is limited to the general history of Western Europe, with an emphasis on England, Germany and France, distinguishing cultural time periods into:

  • ‘The Ancients’, in which magic is the dominant influence
  • ‘The Middle Ages’, in which religion is the dominant influence
  • ‘Renaissance, Enlightenment and Romanticism’, in which reason is the dominant influence
  • ‘Industrial Revolution, Late-Modernity and Post-Modernity’, in which medical psychiatry and psychology are the dominant influences.

It then takes a brief look at contemporary psychiatry and psychology, concluding with descriptions of madness from experiencers themselves. After each era, reflections are made, and points of which to be aware are collated, with emphasis placed upon those I feel a psychosis simulation practice should take into account when attempting to simulate the subjective experience of psychosis. Particular attention is drawn to these points when simulating for educational purposes.

To summarise the history of the understanding of psychosis, this article relies predominantly on three main bibliographical sources. The first is: The History of Psychiatry: An Evaluation of Psychiatric Thought and Practice from Prehistoric Times to the Present by Frans G. Alexander and Sheldon T. Selesnick (1995 [1966]); while the second is: Madness: A Brief History by Roy Porter (2003 [2002]). These two sources are often referenced in professional literature. In addition, this article also relies on the publication Van nar tot patient: Een geschiedenis van de zorg voor geesteszieken (2000) by René Stockman for the Dr. Guislain Museum in Ghent, Belgium, a museum dedicated to the history of psychiatric treatment. For legibility reasons, most references to these three books have been edited out. When referring to other sources than the above mentioned, I have left most of the reference’s in the text. For the complete overview of the original sources, please go to my thesis appendix 9, or the references chapter.

In order to be able to summarise the complex history of madness in a comprehensive overview, many potentially interesting details must, due to restrictions of space, remain unmentioned — for these the interested reader is advised to pursue further reading.

I hope this summary can help us better understand where we are coming from, so that we be can be more aware of our future.

A BRIEF HISTORY IN UNDERSTANDING PSYCHOSIS

Taking a closer look at the history of how societies have understood madness reveals a complex and diverse range of views on causes and treatments that, as such, challenge a psychosis simulation practice in its design choices on how to make sense of and incorporate the various notions in a respectful manner. Historian Rene Stockman describes that throughout history the ‘madman’ has been referred to as:

  • The deviatus (one who deviates from the normal)
  • The insensatus (one who has lost a medium to communicate)
  • The insipiens (one who has lost steering and reason)
  • The idiotus (the fool who does not understand what is being done or what is being said)
  • The garrulus (the talker)
  • The barburrus (the confused)
  • The solidus (the cheeky one)
  • The fatuus (the one who acts with shame and disgrace)
  • The rabienticus (one who embarks on extreme measures, one who knows no discipline or self-control)
  • The maniacus or furiosus (one who enters into ecstasy with the help of supernatural powers)
  • The fanaticus (one who is led by cosmic powers)
  • The lunaticus (whose madness is connected to the moon cycle)
  • The vesamus (who becomes mad from drink or food poisoning)
  • The melancholicus (whose body is riddled with evil fluids)
  • The obsessus (who is possessed by demons or the devil)
  • The insani (who received ‘nonsense’ through the womb’)

Let us take a closer look at history to understand how these views came to be.

1.1 THE ANCIENTS

In ancient Greece, madness was seen as a form of punishment for offending the gods; treatment was sought with priests at temples. Some treatments involved a form of ‘self-healing’. In the Aesculapius cult, treatment known as ‘incubation sleep’ was performed, in which a person was believed to receive dream inspirations that would reveal how he was to heal himself. Hippocrates (460–377 B.C.) is considered one of the first to seek a physical cause. He viewed the root of madness as the result of an unbalance of four bodily humours (blood, phlegm, yellow bile and black bile) affecting the brain:

Men ought to know that from the brain and from the brain only arise our pleasures, joys, laughters and jests […]. Those who are mad through phlegm are quiet, and neither shout nor make disturbance; those who are maddened through bile are noisy, evil-doers, and restless, always doing something inopportune.

People who were considered ‘sanguine’, i.e. in which blood was the dominant fluid, had a lively temperament. To diminish this overt liveliness the practice of bloodletting was applied. Asclepiades viewed (mental) illness as the result of inadequate motility in clogged pores. Themison (123–43 B.C), a student of Ascelepiades, focused on the control of pores — to open pores one needed to heat them, to close them they needed to be chilled. Treatments also involved soothing psychological well-being. Buddhist culture prescribed meditation for mental ailments; its goal was to reach nirvana, a tranquil state, which is devoid of strife and passion. The Greek physician Asclepiades (124–40 B.C.) regarded mental illness as a result of emotional disturbance. He treated the mad with baths, exercise and wine, along with music, massage and light airy rooms, emphasizing humane and dignified treatment. As early as 409 A.D., ancient Jerusalem had a hospital that provided for the mad. Rabbi Ami recommended diversion as a treatment for madness and advocated that a patient in trouble should speak freely about what ails him. Some treatments were quite disturbing. The Roman Aurelius Cornelius Celsus (25 B.C.-A.D. 50), a writer on medical subjects, conceptualised the application of scare tactics to drive spirits out of the possessed body. He would suggest isolation in darkness and administer cathartics (a substance that would induce explosive diarrhoea) to scare them back into health.

The methods used to treat madness in ancient times were diverse, sometimes bizarre, and sometimes cruel, while some appear surprisingly modern. What can one take from this history to a psychosis simulation practice?

1.1.1 VIEWS OF THE ANCIENTS AND WHAT THEY MEAN TO A PSYCHOSIS SIMULATION PRACTICE

When simulating the subjective experience of psychosis, it initially does not matter what causes the experience, or whether people from the outside world believe it is caused by emotional and / or physical disruption, by being possessed, tormented, and / or punished by benign or benevolent celestial forces. What is important is how it feels. By focusing on this, one takes the subjective experience of psychosis seriously. For instance, it is very easy to dismiss magical treatments as simply the methods of ‘primitive’ societies. However, when taking magical thinking seriously, it may be seen as a form of basic human communication:

Magic is a dialogue between humans and their surrounding reality by word, gesture or rite that may involve the use of herbs, objects or dances. […] It is an elusive tool to help deal with an elusive world. […] With magic, one does not necessarily aim to influence the outside world, but one aims to influence how one experiences the world and is plagued by it.

Meaning, magical gestures and rituals are methods to alter one’s own subjective experience of that world. Perhaps it is better to ask: why have people thought that psychosis is related to being possessed by demons, and why is this still thought as such today? Is this promulgated by religious beliefs, and by popular culture? Examples include the films Requiem by Hans-Christian Schmid (2006), and The Exorcism of Emily Rose by Scott Derrickson (2005), both of them based on the life story of Anneliese Michel (1952–1976), who was thought to be mentally ill, but who claimed she was possessed by demons. Although the influence of popular culture should not be taken lightly, a more fundamental answer may come from listening to descriptions of subjective experiences; one learns that it can actually feel like that:

When I was eating breakfast this morning I had the feeling that there was also a head of someone else and that they wanted to eat with me. I had the feeling as if other people wanted to put their head in my head. When I am chewing it seems as if another tongue comes to move the food. […] Just as if someone else has stepped into me. […] It seems as if they can place their head in your head, as if they are able to place their shoulders, their hands, their legs, in that of yours.

So, when one aims to design an artistic experience based on the subjective experience of psychotic phenomena, and one wants to use this in an educational context, what matters is that the experience is real for the person undergoing it, and, as such, should be taken into account in the design, because that is how it really feels. As a consequence, an psychosis simulation practice should, for instance, take experiences of possession or magical thinking into account, in particular, as it is a recurring phenomenon in the subjective experience of psychosis, so much so that magical thinking is often considered today to be a symptom of psychosis. As experiencer Anton Boisen describes: ‘The madman feel like they have been admitted into a scary and mysterious kingdom.’ A simulation should therefore aim to emulate that kingdom. So how does the history of understanding madness continue?

During the Middle Ages, views on madness as possession, and or punishment by evil, continued, its treatment as magical thinking, rituals and gestures were assimilated by religion.

1.2 THE MIDDLE AGES

1.2.1 VIEWS OF THE MIDDLE AGES AND WHAT THEY MEAN TO A PSYCHOSIS SIMULATION PRACTICE

The second aspect that comes from studying The Middle Ages is that, yet again, one may be inclined to think that the notion of psychosis being related to an almighty figure is a primitive consequence of culturally dominant ideas, but, as stated above, a psychosis simulation practice that takes the subjective experience as a starting point simply listens and accepts that that is how it feels even today: ‘I knew for sure that God existed, and nothing other than God’. This is not surprising: ‘Anyone familiar with the recurring themes of psychosis would recognise religious pre-occupations as commonplace’. The themes of these religious pre-occupations are often related to guilt and punishment. Rituals performed by religious representatives soothe suffering. Medical historian Henry Sigerist observes:

[…] The soul-searching of the patient who was convinced that he had suffered because he had sinned had a liberating effect; and the rites performed and the words spoken by the incantation priest had a profound suggestive power.

So, in a psychosis simulation practice that takes the subjective experience seriously, one should take into account themes of guilt and punishment, as feeling guilty is a common experience in psychosis. Often one feels guilty about worldly matters:

Please, Say Something! I silently beg Mrs. Rosen. Say everything is okay, say President Kennedy isn’t hurt, say he’ll be fine. I need to hear you say the magic words, No Pammy, it didn’t happen, it’s not the end of the world. […] and in that instant I understand that my life will never be the same. I will never be just a child anymore, protected, happy, oblivious. Dark bubbles flood my brain. I am drowning, unable to get enough air before I go under. Countless times I struggle to the surface, before being pulled back down. […] I’m shivering when I become aware-‘out of the corner of my ear’ — of muffled sounds, people whispering behind me, short snatches of music and conversation that echo in my head. (Spiro and Spiro, 2005, p.29)

Then I understand: the whispering people, the bits of music, the sound of footsteps, and President Kennedy, shot dead, dead, dead! It’s obvious isn’t it? I killed him! I’m to blame! Isn’t that what it’s all about? Isn’t that what they are saying, the whisperers? (Ibid, p.32)

One might begin to investigate what causes a person to have such revelations. One must try to understand what happens, that a person would have such certainties. In doing so, one is actually implementing a phenomenological method, as promulgated by Edmund Husserl, in which one does not make judgements about one’s experiences, which is an excellent method for understanding madness (Kusters, 2014, p.34). As we will now see, notions of what causes madness, and how it is treated, took a slight turn for the better in the following centuries.

1.3 RENAISSANCE, ENLIGHTENMENT AND ROMANTICISM

Unable to feed themselves, they sleep on the streets; they suffer from cold and hunger. They are taunted with insults and defamations, they are beaten and women are frequently assaulted. At the same time, they cause trouble and discomfort to those who live in the town.

Yet, as much as things took a step forward in the 15th century, such hospitals were not yet designed to care, but merely to detain.

In the 16th century people were convinced that horses could go mad when stung by a hornet, and so they believed that a hornet might be trapped in a person’s head. This later became a spider, a fly, a cockchafer beetle and even a rat that would turn to stone, so quacks either performed trepanations to let the insect out, or made small incisions on the forehead and behind the ear from where a stone would ‘magically’ drop into their hands. This provides an example of how one moved from initial ideas of spirits being trapped to a more ‘rational’ idea, while maintaining the same treatments. In the 17th century, materialist ideas again competed with religious notions.

Descartes was convinced that the mind or soul was connected to the body at the pineal gland, and mental disorder was speculated to be the result of disorder between mind and body. Thomas Hobbes believed that the universe was a material continuum devoid of spirit and considered all human action moved by external sense inputs. In this way, he dismissed religious beliefs in spirits and hence conceived of madness as a mere defect in the body’s machinery. From this perspective, madness could no longer be considered diabolical or threatening to the immortal soul. Nevertheless, in a violent response to the advancing materialist views and rise of Enlightenment ideas about psychology, demonology reached a new height of popularity in the Renaissance. There was again much turmoil. Feudalism was being undermined by the invention of gunpowder, the invention of the printing press created opportunities for self-education through the availability of books, misconduct in the Church was being exposed by precursors of the Reformation, and on top of that the Plague returned with a vengeance, killing off almost 50 per cent of the European population. A scapegoat needed to be found, and it was found in the guise of witches said to be possessed by the devil, and those deemed mentally ill were all too often among them. Many were burned at the stake, before public opinion shifted and governments created new laws against manslaughter.

As it was also called ‘the Age of Reason’, the Enlightenment brought about the view that the mad had lost their ability to reason; with the loss of rationality, the madman was to be ‘pitied’. Influenced by the writings of John Locke, Spinoza and Étienne Bonnot de Condillac, madness came to be attributed to faulty associations in the processes in which sensory data were transformed into ‘ideas’. New legislation considered the mentally ill not to be accountable for their actions. As a consequence those who died by suicide were allowed to have a normal burial. Previously, if a person who died by suicide was not deemed mentally ill, their properties would have been declared forfeit, their bodies impaled, and they would have been refused a church burial. The new legislation freed families from such disgrace. Family members could make a request for admission to a hospital, with city councils deciding whether a person was a danger to himself and/or others. Over the years, institutionalisation became more embedded in society; however, the general situation in such hospitals was still abominable. The cells had neither fresh air nor light nor, during the winter, heat. Coercion took place through the withholding of food and the use of straightjackets and chains. One of the most infamous hospitals was the Bethlem in London, also known as Bedlam, which was a family business for four generations. It was known to be very corrupt, and its ‘treatments’ very cruel. For many years, a patient called James Norris was detained at Bedlam, and his experience is described as follows:

A stout iron ring was riveted round his neck, from which a short chain passed through a ring made to slide upwards and downwards on an upright massive iron bar, more than six feet high, inserted into the wall. Round his body a strong iron bar about two inches wide was riveted; on each side of the bar was a circular projection; which being fashioned to and enclosing each of his arms, pinioned them close to his sides.

Winters could be particularly bad in the cells of the Salpêtrière, a mental hospital built in Paris in 1656. The already unhealthy circumstances became worse when water levels rose in the Seine and rats were driven to cell levels and gnawed at the residents, many of them dying from lethal bites.

Throughout the ages, many contrasting approaches continued to exist simultaneously in the same era. For instance, in the United Kingdom, Robert Burton recommended music therapy in 1621, as he had found a fitting reference in the Bible. He included the quote in his Anatomy of Melancholy, which was an encyclopaedic work, mapping the history of remedies:

‘And it came to pass, when the evil spirit from God was upon Saul, that David took the harp, and played with his hand: so Saul was refreshed, and was well, and the evil spirit departed from him’

Classical views were revived in the Renaissance; Greek mythology symbolised the mad as heroes punished by the gods. Plato spoke of a divine fury, and Aristotle depicted the profile of the mad as a melancholy genius. Humanist notions presented the madman as the only realist, who was allowed to unveil darker truths in the madness of the world without prosecution. So in the same period, the mad were often depicted in the theatre with the aforementioned stone growing out of their forehead, known as the ‘stone of folly’. Inhabitants of the infamous Bedlam were included in London shows, where the public went to watch the mad as a form of entertainment, while officially they were only allowed to visit and gaze upon the mad as a form of education, which functioned as a warning about sin and passion. At the same time, the folly of the mad became synonymous with the truth; to declare a poet mad was to provide him with a compliment.

It was not until the end of the 18th century that a movement emerged in Western Europe as well as the United States that aimed to improve care for the mad. William Cullen, famous for coining the term ‘neurosis’, held the notion that madness was an excessive irritation to the nerves, or acute cerebral activity. His treatments included a specific diet, physiotherapy, exercise, purging, blistering of the forehead, cold dousing, bloodletting as well as restraints, threats, and straightjackets. In 1758, William Battie, founder of Saint Luke’s Hospital in London, wrote the work Treatise On Madness, in which he argued for admission to hospital as a form of therapy to calm the nerves. He spoke of isolation as therapeutic and was the first to refer to moral management, which later grew into the term ‘moral treatment’, which involves methods of talk, (religious) discipline, and simple but honest work. He held the notion that madness was completely treatable, and that the mad did not deserve to be lumped with criminals and the unwanted of society, all held together for the sake of convenience.

When the priest Francis Willis was confronted with the responsibility of caring for King George III in 1791, he was successful in treating the king without using force. Inspired by a case of maltreatment, the tea merchant William Tuke founded a private clinic, The Retreat, in York, at which moral treatment was applied: ‘recovery was encouraged through praise and blame, rewards and punishment, the goal being restoration of self control’, which included the use of ‘soft restraints’, such as straightjackets and holding belts. The Retreat was situated in a rural location and there were windows that allowed for plenty of light and air. Tuke prescribed tea conversations, garden parties and walks. He also developed a form of occupational therapy. His generally ‘non-restraint’ work policy was one of the practices that had a substantial influence on the practice of psychiatry. When Philippe Pinel became director of the Salpêtrière, he, too, like Tuke, abolished chains and restraints. Slowly the professions of psychiatrist and psychologist grew.

In the 19th century, patients began to be categorised. The psychiatrist Johann Reil (1779–1813) argued for separation between those who could be cured and those who could not. He was known to take extreme measures for his patients, such as organising prostitutes for male patients, adding sex to a growing list of possible treatments for the mad. Reil also differentiated between illnesses of the nerves, like epilepsy, and illnesses of the mind, related to passions and desires. He was the first to coin the term ‘psychiatry’ in 1808. Thomas Arnold, a student of William Cullen, whom I mentioned earlier, distinguished between ‘ideal insanity’ (hallucinations) and ‘notional insanity’ (delusions). Rather than addressing the patient’s body, he believed that a doctor had to address the patient’s psyche, transforming the profession from ‘minding the insane’ into systemic psychological observation. The development of categorisations stimulated the publishing of papers and the creation of a more public discourse.

During the age of Romanticism, intellectual interest shifted from the external world to the internal world. After the fall of Napoleon, a strong police state emerged in France, intent on restoring absolutism, order and religion. The average individual retreated into the happiness of everyday life. As a result an exaggerated emphasis was placed on ‘love affairs, passionate involvements, friendships, and personal intrigues’. As a consequence, madness became romanticised. Jeanne Pierre Falret (1794–1870) held the idea that negative connotations of terminology had an influence on the place of the mad in society, and started to refer to the mad as the mentally alienated.

1.3.1 VIEWS OF RENAISSANCE, ENLIGHTENMENT AND ROMANTICISM AND WHAT THEY MEAN TO A PSYCHOSIS SIMULATION PRACTICE

Since a number of years I am ill; what is wrong with me I cannot say, but I am convinced that it is an illness. […] the symptoms are as follows; strong whizzing in the ear and in the head, as if there is a clock in it, continuous apparitions of various unpleasant things. These apparitions cause me much unrest, that I am not able to be mentally active for more than 5 minutes. […] Every sound associates within me a human voice, so that I often feel that lifeless things are talking to me.

Meanwhile, an excerpt from the diary of the 17th-century painter Christoph Haizmann still reports religious rituals as a functional method to be used against apparitions:

On January 13, as I was working on my painting, the Devil came and sat next to me at the table, after which I yelled to my sister, the Evil One was here. My sister came in with holy water and spread it around the room, after which everything at the table dispersed.

In this one might again consider the magical gesture as a way of altering one’s subjective experiences. By investigating Renaissance, Enlightenment, and Romanticism, one is again confronted with the history of cruelty towards the vulnerable, and one sees how a social and cultural mindset can influence both political and religious policies. The altering views of madness, its treatments, and its function in society, transforming throughout the Renaissance, Enlightenment, and Modern Era, have been described in depth by Foucault in his 1961 Madness and Civilization: A History of Insanity in the Age of Reason (Histoire de la folie à l’âge classique). But how does this relate to a psychosis simulation practice?

In spite of taking a stance that it does not matter how an experience is viewed from the outside, that it matters how it is felt from the inside, one now becomes aware of the tensions that may exist between outside views and inside views. For instance, a person convinced they are possessed might have to deal with a doctor who claims it is but an imbalance in their inner fluids, whilst a person claiming they are ill might have to deal with a religious representative claiming that they are being punished by God. So, when simulating psychosis, one may attempt to take into account the tension that exists between outside and inside views. Subsequently, if one takes this a step further, these tensions may be reflected in a single person’s individual experience. It could well be that one moment one may view one’s inner experience as being caused by an illness, and the next moment one may be convinced that one is tormented by demons. In that sense, a simulation practice that aims to simulate the subjective experience should think about how to simulate how such tensions are felt, in particular when they range from one perspective, being considered a genius, as having an illness, to another, being considered a criminal beast, or a witch with magical powers.

In the following ages, the treatment of madness slowly became an economic interest, initially improving healthcare, until taking a turn for the worse again before it suddenly became ‘big business’.

1.4 THE INDUSTRIAL REVOLUTION, LATE MODERNITY AND POSTMODERNITY

It was Charles Darwin who introduced the concept of natural selection by ‘survival of the fittest’, which provided a different view of the cause and/or purpose of human ailments. Together with the notion of stability (homeostasis) conceived by Theodor Fechner (1801–1887), Claude Bernard (1813–1878), and W. Cannon, (1871–1945), the theory was formed that an organism has ‘[…] a tendency to maintain within itself certain constant conditions necessary to perpetuate its life’. As in the 19th century, the notion returned that humans were rational beings influenced by the laws of nature, organic machines functioning in the context of biological determinants. Superstition, religious and magical systems began to lose influence once again. This is when the profession of psychiatry really took off.

Classification systems began to form to differentiate between different types of madness. The observational diagnostics provided by all the asylums allowed for the building of psychiatric profiles that distinguished, for instance, epileptics from the insane. Precise clinical descriptions were made for ‘hallucinations, cyclic insanity, monomania, idiocy, and hypnagogic and alcoholic hallucinations’. The German psychiatrist Karl Kahlbaum (1828–1899) believed that all symptoms could be organised. He introduced new descriptions such as ‘symptom complex’ and ‘catatonia’. Etienne Dominique Esquirol wrote Mental Maladies (1838), in which he delineated conditions that are used today such as ‘kleptomania’, ‘nymphomania’ and ‘pyromania’. In 1857, the French psychiatrist Bénédict-Augustin Morel developed the notion that madness was a hereditary disorder. He saw madness as a hereditary degenerative state and the madman as degenerative to the progress of society in general. He called the condition décomence précoce, a premature form of dementia. Wilhelm Griesinger, considered the father of biological psychiatry, published an article in 1867 arguing again that mental illness was not an illness of the mind, but an illness of the nerves and the brain. Griesinger’s position was shared by the neuro-pathologist Theodor Meynert. Followers of these two scientists were usually convinced that mental illness was not treatable, focusing mostly on lab work, investigating brains. A schism arose between clinical psychiatry and biological psychiatry, of which the latter developed more prominently. Influenced by Morel’s approach, the notion ‘degenerationism’ was born, spawning the concept that mad people were to be locked away and not allowed to procreate. This is the point at which things took a decided turn for the worse.

Emil Kraepelin continued the trend and need for classifying and labelling conditions. He put forth Morel’s view that young adults with hallucinations and delusions were suffering from décomence précoce, calling their condition ‘dementia praecox’. He would categorise catatonic dementia praecox, if a person was silent at times and violent at others. He would refer to ‘hebephrenic’ (symptoms being a loss of a train of thought, or spells of inexplicable laughter), when behavioural responses were inappropriate, and of ‘paranoia’, if a patient had delusions of persecution. Kraepelin differentiated between dementia praecox and psychosis — according to him, this came from manic-depressive illness, based on the prognosis of a patient. Receiving the diagnosis of dementia praecox meant that there was nothing to be done but to await complete deterioration. Kreapelin’s work was very influential. On the one hand, his medical approach put an emphasis on observation, description and organisation, paving the way for psychiatry to become a specialised clinical discipline in medicine. On the other hand, Kraepelin’s as well as Morel’s view of the mad as symptom-carriers influenced the eugenics movement that sought to improve human genetics, which in turn influenced political powers, leading to support for the sterilisation of the mad and the disabled, as well as homosexuals and Jews, under the Nazis. Being mad in World War Two eventually left one subject to experimentation and extermination. Eugenic ideas became an official policy of Nazi ideology. Between January 1940 and September 1942, 70,723 mental patients were gassed, selected from a list made by psychiatrists and physicians of lives that were ‘not worth living’. After the horrors of war, treatments refocused on psychological developments.

Towards the end of the 19th century, psychology became prominent once again, and, with this shift, treatments became correspondingly more docile. The philosopher-psychologist Johann Herbart was a key figure in developing psychology as a separate empirical discipline. He introduced a quantitative factor into mental processes with his visualisation of ‘a threshold of consciousness’ beneath which psychological processes are not perceived, but take place ‘unconsciously’. He described conscious mental content as ‘apperception’. Gustav Theodor Fechner is considered the first psychologist to investigate the complex relationship between external, physical stimulus and the resulting internal subjective sensations of seeing, hearing and feeling.

In the first half of the 20th century, the mad were still kept in mental health hospitals in which treatment would predominantly consist of prescribing (restrained) bed rest. It was thought that a horizontal position was the best position in which the body could heal. There was also a revival of hydrotherapy, in which patients would be placed in baths for two to three hours, and there was a revival of occupational therapy. This was the time when psychoanalysis developed.

Sigmund Freud’s psychoanalytic theory was probably one of the most important influences on how Western society deals with madness today. Freud held the idea that, in order to cure mental illness, one must understand the nature of the illness, by analysing phenomena through systematic observation. Although these ideas were not new, he was the first to develop a system that made the application of psychological causality operational, psychoanalysis being the valid method. Freud’s 1924 paper on ‘Neurosis and Psychosis’ makes a clear distinction between these two conditions: ‘Neurosis is the result of a conflict between the ego and its id, whereas psychosis is the analogous outcome of a similar disturbance in the relation between the ego and its environment (outer world)’. Freud held the notion that neurosis was caused by early sexual trauma, which he termed ‘seduction theory’, but he later retracted this theory, as he no longer considered neurosis to be caused by the perverse deeds of adults, but by the erotic wishes of the child. On the one hand, this altered the notion that the parent is responsible for the madness of the child, which brought much relief to families. Yet, on the other hand, it dismissed the experience of the patient as being just pure fantasy.

The Swiss psychiatrist Eugen Bleuler renamed dementia praecox as ‘schizophrenia’ (literally ‘split mind’) in 1908. Schizophrenia was accompanied by delusions, hallucinations and disordered thought. According to Bleuler, schizophrenics were ‘strange, puzzling, inconceivable, uncanny, incapable of empathy, sinister’ and ‘frightening’. Empathy is in essence a person’s ability to form a mental simulation of the experience of the other. In that sense it was actually Eugen Bleuler who was incapable of empathy.

Carl Jung developed, in contrast to Freud, a more idealistic rendering of the unconscious. Jung made clinical descriptions of hysteria, anorexia, amnesia and obsessional neuroses, for which he prescribed treatments such as hypnosis, suggestion, and other psychodynamic techniques. Jung saw emotional disorders as a result of conflict between what he calls the collective unconscious and the ego. His metaphysical and philosophical approach paved the way for phenomenological methods in psychiatry. Psychotherapy finds its roots in the use of hypnosis as a therapeutic device. With the rise of psychoanalysis, treatment of all sorts of mental illness moved into private practices, having a profound effect on the openness with which the general public began to speak about mental disorders (context). However Freud’s methods proved ineffective with the more severely disabled patients in mental hospitals diagnosed with schizophrenia.

In spite of the developments of these more compassionate approaches, treatments still took a turn for the worse. Stockman describes how the impotence of the existing treatments for madness sparked almost desperate experimentation. The Austrian physician and psychiatrist Julius Wagner-Jauregg (1857–1940) held the notion that insanity could be treated with fever. He discovered that if he injected patients with tuberculin, symptoms of neuro-syphilis would diminish. In 1917, he injected a patient with blood from a person suffering from malaria, and then treated them with quinine. This provided stabilisation for the patient, so much so that they were able to go home. In 1927, Wagner-Jauregg received the Nobel Prize for medicine. This inspired experimentations with chlorine, APO-morphine and potassium bromide that proved effective for patients suffering from epilepsy. Other experimentations took place with ‘sleep therapy’. Using barbiturates, a doctor would artificially put a patient to sleep for a long period. This was not without danger — when Somnifen was used, approximately 5 per cent would never regain consciousness and subsequently die. The Austrian neurophysicist and psychiatrist Manfred Sakel (1900–1957) published a paper in 1933, in which he suggested using insulin to treat schizophrenia. This involved injecting a patient with insulin, which would then put a patient to sleep and later into a coma. After 20 minutes, they would be injected with a sugar mixture after which they awoke. A neuropathologist from Budapest, Ladislas von Meduna (1896–1964), discovered that symptoms of schizophrenia could be relieved by cramping a patient’s body — this occurred when a patient was administered with cardiazol. This treatment is known as convulsion therapy. An account of the German psychiatrist Heinz Lehman (1911–1999), who fled to Montreal in 1937, is known for his experimentation with caffeine, sulphur, turpentine, and in particular chlorpromazine. In 1935, the Portuguese neurologist Egas Moniz (1874–1955) was curious to see if, by removing parts of the frontal lobes in humans, it would have an effect on symptoms. The neurosurgeon Almeida Lima (1903–1985) experimented on 20 patients between 1935 and 1936, by taking away parts of the frontal lobes. Seven were cured, seven showed some improvement and with six there was no change. In April 1938, the Italian neurologist Ugo Cerletti (1877 -1963) experimented on patients by briefly sending an electrical shock of 80–100 volts through the body. This diminished hallucinatory symptoms, and electroconvulsive therapy was born. In 1946, the American psychiatrist Walter Freeman (1895–1972) developed a method to operate via a patient’s eye socket, and the infamous lobotomy was born. In 1949, the Australian psychiatrist John Cade discovered that lithium was effective in treating manic depression. In 1951, the French neurosurgeon Henri Laborit (1914–1995) invented an artificial antihistamine, which developed into chlorpromazine. It was unclear how the treatment affected a patient, but the effects were significant; reports from Salpêtrière reveal quiet hospital wings in which no restraints or hydrotherapy were being used. Such results were considered a great success by society, yet were of course significantly detrimental to patients. However, further developments eventually began to change patient’s lives for the better.

The mainstream development of drugs, known as ‘the chemical revolution’, allowed for patients to begin a life outside of the asylum. Optimistic future scenarios stated that psychotropic drugs would eliminate madness by the year 2000. In spite of the relative success, political and ethical questions were raised when one began to discover the harmful long-term effects of drugs, and the re-shaping of personalities, as well as the fact that they were manufactured and marketed by monopolistic multinationals.

In 1956, the Gregory Bateson group published a series of papers called ‘Toward a Theory of Schizophrenia’, in which Bateson showcased his notion of the ‘double bind’ — he understood schizophrenia to be the reaction to a contradictory situation: If a person had no normal way to react he had to create an abnormal one, such as ‘withdrawal from communication, paranoid suspicion, an ability to take anything literally and mistaking inner voices for the outside world’ (Bateson et al. 1956 as referred to in Pickering, 2010, p.175). In the 1960s, a movement known as anti-psychiatry began to dominate public opinion, brought about by figures such as Ronald Laing, David Cooper, Franco Basaglia and Thomas Szasz. In his book The Myth of Mental Illness (1961), Szasz, professor of psychiatry at Syracuse University, New York, claimed that mental illness was a man-made myth:

[…] mental illness is not a disease, whose nature is being elucidated by science; it is rather a myth, fabricated by psychiatrists for reasons of professional advancement and endorsed by society because it sanctions easy solutions for problem people. Over the centuries, he alleges, medical men and their supporters have been involved in a self-serving ‘manufacture of madness’, by affixing psychiatric labels to people who are social pests, odd or challenging […] ‘mental illness’ and the ‘unconscious’ are but metaphors, and misleading ones at that.

Szasz’ work was a critique of ‘compulsory psychiatry’. As such, mental illness was no longer seen as an objective behavioural or biochemical reality, but as a strategy for the world to survive madness. Psychosis was seen as a healing process that should not be interfered with. Early anti-psychiatry of the 1960s presumed that the psychotic knew something or experienced something that was ‘more real’ than normal people experience, presuming that there is a more ‘real’ reality that hides behind our superficial reality, only reachable by a ‘happy few’ — be it artists, the mad or thinkers (Kusters pp. 18–19) It was, therefore, the way that society dealt with madness that was the true cause of the disease.

At the same time, Erving Goffman’s book Asylums (1961) provided a critical history of the psychiatric institution, in which a psychiatric patient loses their personal identity as a human being. In his opinion it is institutionalisation itself that is at the root of the degenerative and chronic nature of schizophrenia. And again, in 1961, Michel Foucault conveys, in Madness and Civilization: A History of Insanity in the Age of Reason (Histoire de la folie à l’âge classique), that mental illness must be understood as a cultural construct and not a natural fact. ‘Schizophrenia and recovery appear here as a sort of gymnastics of the soul, as Foucault might have said — a plunge beyond the modern self, precipitated by adaptations to double binds, with psychosis as a higher level of adaptation that returns to a transformed self’ (Pickering, 2010, p.179). The way that psychiatric practice developed was considered to be counterproductive: ‘hindering and even exacerbating circumstances during the progress of the psychosis’ (Bateson 1961, pp.xvi, as cited in Pickering, 2010). The influence that these debates had on political left- and right-wing strife about the ethics and costs brought on the demise of the oversized isolated mental health institutions. In the United Kingdom, between 1950 and 1980, the number of institutionalised patients fell by four-fifths. What does this mean to a psychosis simulation practice?

1.4.1 VIEWS OF THE INDUSTRIAL REVOLUTION, LATE MODERNITY AND POSTMODERNITY AND WHAT THEY MEAN TO A PSYCHOSIS SIMULATION PRACTICE

Another important aspect is that the way society deals with madness is politicised. Socrates, a well-known hearer of voices, was accused of listening to his daemon, which was not a recognised god (Leudar and Thomas, pp.17–18). Politics decided which voices, or which Gods, one was allowed to listen to. The early priestly physicians jealously guarded the secret knowledge of divination. With regards to a psychosis simulation practice, one could investigate the possible political or ethical implications of what one was attempting to achieve.

The exposure of this history reveals a need and urgency to be vigilant about modern-day understandings of psychosis. Is there madness hidden in modern-day treatments?

1.5 CONTEMPORARY PSYCHIATRY AND PSYCHOLOGY

The American Psychiatric Association regularly publishes a new version of The Diagnostic and Statistical Manual (DSM), considered by many as the ‘bible’ of psychiatric diagnosis. It was first published in 1952, followed by DSM-III and DSM-III, with the DSM-IV-TR published in 2000. Where the DSM-II only contained 134 pages, the DSM-IV-TR contained 943 pages. The additions to the DSM-V, published in 2013, inspired organisations like the British Psychological Society to create a petition that expressed concerns about labelling what they consider normal experiences of childhood and old age as mental disorders.The petition was endorsed by the International Society for Ethical Psychology and Psychiatry (ISEPP), in the following statement:

It is the position of the International Society for Ethical Psychology and Psychiatry (ISEPP) that the Diagnostic and Statistical Manual for Mental Disorders (DSM), a publication of the American Psychiatric Association, is a political rather than scientific document, one which damages human beings. Despite the position of its authors that it is primarily descriptive, the DSM supports the perpetuation of myths about mental, emotional, and behavioral disturbances in individuals which favor pseudoscientific, biological explanations and disregard their lived context. The evolving editions of the DSM have been remarkable in expanding psychiatric labels for alleged “mental illnesses” with no scientifically substantiated biological etiologies.

The forthcoming DSM-V edition continues this process while attempting to deepen indoctrination of mental health providers, consumers, and third-party payers into the fallacy that problems in the living result from problems in biology. Adherents of biopsychiatric explanations and pharmaceutical manufacturers are the primary benefactors of public acceptance of this myth. Beyond research and technical studies which repeatedly demonstrate the inherent lack of validity and reliability of the DSM as a nosological system, psychiatric labeling has real consequences in discriminating against and oppressing the disadvantaged, creating unnecessary obstacles to employment, housing, and social acceptance, lending false credibility to the concept of psychiatric disability, assaulting self-worth and self-efficacy, and undermining reestablishment of positive life-striving by inducing “behaviors to label” among people who have been so labeled.

More than 15,000 people have signed the petition. Psychiatry has always had two goals, to scientifically understand mental illness and to heal it, but in the frenzy to be respected as a scientific discipline, the healing seems to have lost priority. Descriptive psychiatry is highly criticised by psychologists such as Louis Sass (Sass, 1995, p.x):

A great weakness of twentieth-century psychiatry and clinical psychology, at least in the United States, has been the tendency to neglect careful description and analysis of abnormal psychological phenomena in favor of a too-quick and too-exclusive focus on etiology or causation. In practice this has meant that the nuances and complexities of psychopathological signs and symptoms tend to be ignored; too often we rely on the complacency and presumption of a misleading kind of “common sense,” an attitude that dismisses peculiar forms of action and experience as but inferior versions of the norm.

Along with other psychiatrists, professor and head of psychiatric service Manuel Gonzáles De Chávez addresses the practice of traditional descriptive psychiatry critically by asking what it has offered for the last 200 years. He describes this as:

A triple pirouette of ignorance, that initially considered these persons as alienated, then as brain damaged, and finally it stopped listening to them. It redefined voices on an exclusively pathological basis as auditory hallucinations, a symptomatic paradigm of diagnostic labels, such as schizophrenia or psychosis, with the unquestioning presumption of a (still undemonstrated) underlying brain disorder. And what is even worse, it condemned these persons to silence, because it maintained a priori that the voices had no meaning, that they were noises from a damaged brain machinery that were not worth listening to. Therefore, the professionals of the traditional descriptive psychiatry did not listen to them (Romme and Escher, 2012, p.xiv).

The differences of opinion between disciplines and experiencers lead to strong debates. An example of discussions surrounding today’s issues, such as forced medication, may be found in the dialogue between E. Fuller Torrey and Judi Chamberlin, which is published here. For an outsider attempting to understand psychosis, the discrepancies between the various models of understanding psychosis is confusing. In the Cambridge Medicine publication The Diagnosis Of Psychosis (2011) by Rudold N. Cardinal and Edward T. Bullmore, common causes of psychosis are listed, such as Delirium, Dementia, Alzheimer’s, Parkinson’s and Huntington’s disease, as well as Down’s Syndrome, Epilepsy and Migraine (eBook loc 537, 823, 842, 969, 1310 and 1417 of 14280). When one learns that dementia is seen as one of the biggest causes or risk factors of psychosis in the elderly, one begins to see the madness of today’s views.

1.6 BEING AWARE OF THE PAST AND WHAT IT MEANS TO A PSYCHOSIS SIMULATION PRACTICE

For an outsider, trying to understand psychosis, how it is viewed, how it is caused, and how it is treated today, is difficult, yet, being part of society, there is a responsibility to understand it (Geekie et al, 2012, pp.1–2):

While the kinds of experiences we are talking about are by and large, private in nature, in that they are immediately accessible only to the individual who actually has the experience, making sense of and deciding how to relate to these experiences commonly takes place in the interpersonal and social domain. […] We have a responsibility to search for truth, but at the same time we must be aware of the cost of that search as: ‘The sense we make can have major consequences in people’s lives’

It is important to realise that how one thinks about and understands psychosis influences how one deals with it, and thus how a person experiencing psychosis is treated. Any simulation of psychosis will contribute to this influence.

For those who attempt to understand psychosis, according to Kusters, reading modern-day psychiatric literature is not so interesting, as the majority of modern-day psychology and psychiatry, he says, are more focused on effectively destroying or subduing madness. He suggests that, by stating that psychosis is but a disruption in the brain’s dopamine levels, one still does not know anything about how that makes a person experience the world. He also says that even the psychologists attempt to reduce madness to deformities in a person’s personality, rather than opening themselves up to be challenged in their own assumptions about the nature of reality, which is, according to Kusters, understandable in a practical everyday context, but is a pity for the imagination (Kusters 2014, pp.27–28). For the imagination of an artist to be inspired, one needs to take a closer look at how madness is described by those who have been diagnosed with it.

1.6.1 VIEWS FROM WITHIN

One learns from it that the general idea, as described in the introduction chapter, is that psychosis is a reaction to life events; a type of escape from difficult and or traumatic situations. This may be puberty, moving house, the transition from being a student to entering professional life, an event related to a love relationship, the birth of a child, the loss of a loved one. One learns that psychosis is unique to each individual, and that madness can happen to anyone, but in particular to those who are described as being ‘thin-skinned’. One learns that psychosis is an altered form of processing reality, that it involves a particular ‘waywardness’ of body and mind, that the senses seem to ‘go their own way’, with images and voices developing that are no longer only influenced by the eye and the ear. One learns that this ‘thin-skinnedness’ relates to having one’s internal life forcing its way out, in the form of hallucinations, for instance, and external events reaching inside unfiltered, risking paranoid processing, or delusions. One learns that it is like ‘dreaming without the protection of sleep’ and that this form of dreaming can be dangerous: ‘dreaming that one is a bird is not dangerous but the same perception in psychosis can be risky’. One learns what it means to have access to unconscious experience, such as nightmares or wishful thinking. One learns that one’s perceptions can be compared to a return to childhood, in which one relates everything to oneself, causing one to feel guilty even if one has no influence over a situation, like a child feeling guilty over their parents’ divorce. One learns that madness can be like a desperate struggle for autonomy, a ‘retreat into a last stronghold of idiosyncrasy’, in which one feels that no one can follow. And one learns that madness can mean a loss of self-image, every action requires effort, nothing happens by itself, as everything is significant. As a consequence, questions arise about physical and existential limits, as well as one’s significance and responsibility towards others. Learning about what psychosis means is important to a psychosis simulation practice, but it is even more important to understand what madness feels like.

Madness can be an enticing siren, calling from many ragged shores with a promise of tranquillity hidden amongst the rocks; unfortunately, we are just as likely to find ourselves shattered and impaled on the rocks, as we are to find a safe and serene harbour. Once heard, though, those alluring siren calls are not easily forgotten and can be craved for, desired even, their duplicity forgotten amid the attraction of false rhapsody. I have succumbed to that charm many times, only later to witness my own demise fabricated in notions of grandeur, supremacy and bestowed mystical powers. It is hard to express the sensation of rising above the limitation of mortals to have within your grasp the intoxicating vigour of obtaining knowledge, all power, and all magic. This is the false rhapsody, this is the ‘drug’, this is the madness. (Lampshire, 2012, p.139 as found in experiencing psychosis).

Renee:

For me madness was definitely not a condition of illness; I did not believe that I was ill. It was rather a country, opposed to Reality, where reigned an implacable light, blinding, leaving no space for shadow; an immense space without boundary, limitless, flat; a mineral, lunar country, cold as the wastes of the North Pole. In this stretching emptiness, all is unchangeable, immobile, congealed, crystallized. Objects are stage trappings, placed here and there, geometric cubes without meaning. People turn weirdly about, they make gestures, movements without sense; they are phantoms whirling on an infinite plain, crushed by the pitiless electric light. And I — I am lost in it, isolated, cold, stripped, purposeless under the light. […] This was it; this was madness, the Enlightenment was the perception of Unreality. Madness was finding oneself permanently in an all-embracing Unreality. (Sechehaye [1950] 1994, p.1)

Kusters:

In madness one is actually, in a rogue, associative, wild manner, busy with solving the most fundamental questions of existence. One wants to know what it is about, what good and evil is, what is the point to existence, the point of life. Such questions should not be denied, but lived (Kusters, 2014, p. 20)

These are the stories that should inspire the artistic practice of psychosis simulation. This is where the artist, the philosopher and the ‘madman’ meet in the same mental landscape.

1.7 SUMMARY