Psychopathology and human nature
Normality at the mirror of madness: historical considerations on a chimeric boundary
NORMALITY AT THE MIRROR OF MADNESS: HISTORICAL CONSIDERATIONS ON A CHIMERIC BOUNDARY1
Francesco Paolo Tocco
1 Preliminary warnings
It should be useful to start this chapter with some preliminary warnings. The first one - probably the most important one - is that the chapter is elaborated by a historian, which means that for the author, it is not only possible but also essential to analyse the arguments concerning medical and psychological aspects of mental diseases - or better, as it was mainly named until not so many years ago, mental insanity - not only from a psychiatric or a psychological or a philosophical perspective, but especially from cultural history perspective. Historical perspective could give a dynamic vision on items primarily studied through structuralist methodologies, from scholars that are often more interested about the recognition and classification of symptoms rather than their outset, evolution, and permutation or, sometimes, disappearance.
Another warning, which depends strictly on the historical point of view that I’ve just highlighted, must concern the fact that - opposite to an often not explicit but usually passively accepted hypothesis - conceptions and mentalities towards mental disease are not even the same all over the world: not only during the past centuries, but also in present times. It is a fact, this one, that has been recently efficaciously demonstrated among others by Alan Ehrenberg’s studies (Ehrenberg, 2010), that enforces our awareness of the differences existing between the American and the French approach to psychological problems, despite the cultural uniformity caused by globalization that leads us to erroneously think that the psychological dimension should be uniform all over the world.
The third, but not less important, warning consists in the fact that in comparison to an enormous number of scientific ponderings on mental insanity it is -apparently incredibly - less easy to find well-founded reflections about normality. So, we are almost compelled to try to reach normality moving necessarily from madness or, more generally, from the so-called (but today unmentionable - at least officially) abnormality.
2 Normality: a self-evident concept?
If we meditate on the evanescence of commonly accepted definitions of normality (especially in the psychological field), we have to admit that this is the basic problem of all the DSMs (Diagnostic and Statistical Manual of Mental Disorders). It is a problem getting more and more serious from the birth of the manual in the middle of the twentieth century until its most recent edition. Nikolas Rose summarizing the history of DSM writes:
The first Diagnostic and Statistical Manual of Mental Disorders, published in 1952, was prepared by a Committee on Nomenclature and Statistics of the American Psychiatric Association in the wake of psychiatry’s wartime experience and conceived mental disorders as reactions of the personality to psychological, social, and biological factors.... DSM II, published in 1968, was 134 pages and had 180 categories framed in the interpretative language of psychoanalysis. DSM III, published in 1980, ran to almost 500 pages and is often seen as a response to the crisis in legitimacy of psychiatry over the 1970s (American Psychiatric Association, 1980). The revised version of 1987 had 292 categories, each defined by a set of objective “visible” criteria. Ideally, each of these categories was a distinct disorder, with a unique aetiology' and prognosis, amenable to a specific kind of treatment. DSM IV, published in 1994, runs to 886 pages and classifies some 350 distinct disorders, from Acute Stress Disorder to Voyeurism. DSM IV cautions that individuals within any diagnostic group are heterogeneous: its categories are only intended as aids to clinical judgment. But it promotes an idea of specificity in diagnosis that is linked to a conception of specificity in underlying pathology'.
(Rose, 2007: 199)
In light of this concise summary, it should be evident that the reason why DSM-V avoids to define what exactly should be considered a mental disorder is strictly related to the problem that it is impossible to assert with absolute certainty' what constitutes normal behaviour. A problem which is well pointed out by' Wakefield in his reflections about the most appropriate terms to efficiently describe mental disease (Wakefield, 1992, 1999, 2006). Wakefield avoids, more or less consciously, to define normality' but he does not renounce to define “abnormality'” from a psychiatric point of view. Wakefield’s definition of abnormality' is well known, but it is important to mention it, because we will return on some of the terms used in this definition:
I argue that a disorder is a harmful dysfunction, wherein harmful is a value term based on social norms, and dysfunction is a scientific term referring to the failure of a mental mechanism to perform a natural function for which it was designed by evolution.
(Wakefield, 1992: 373)
This definition and the problem raised by the absence of a definition of normality has been debated by many scholars, and has been well highlighted by Massimiliano Aragona in his studies (Aragona, 2009, 2013) about mental disorder and the debate on its denomination during the elaboration of the DSM-V:
|I]t would be very difficult to find clear and consensual definition/description of what is exactly to be intended as normal reaction proportional and appropriate response and so on. . . . Who must decide what should be intended for disproportionate? When should a response to a living situation be considered exaggerated, and who decides what is exaggerated? Who knows when stimuli are appropriated? How many specific circumstances are known that in normal conditions invariably elicit has given response? Are rational decisions synonymous of normal decisions? . . . |T|he question that implicitly underlies the overinclusion problem, that is “what (who) is normal and what (who) is mentally disordered?” should be reconsidered, being significantly influenced by what is conceived as normal and what is thought to be a mental pathology' in our society and our era.
(Aragona, 2009: 8)
The majority of the insider beneficiaries of the recent DSM-V, whose purpose was to give an order to the knowledge, diagnosis, and potentially to the cure of mental diseases, admits that this ambitious volume has not clarified the problems that it wanted to resolve, making the status quaestionis more uncertain than before. Moreover, this latest version of the DSM has produced a sort of explosion of new pathologies, which can hardly be considered as an aid to the diagnosis.
Moreover, there is a minority of professionals who not only find the new DSM impractical, but who also criticize it strongly from a point of view which is, at least at a first glance, diametrically opposite to the authors of the manual.
Indeed, Lennard J. Davis, the author of The End of Normal. Identity in a Biocul-tural Era, a well-constructed hymn to the cultural integration of the diverse, writes in his book:
The Diagnostic and Statistical Manual- V (DSM- f) has elaborated a dizzying display of lifestyle illnesses that demand medical treatments to cure and normalize people. Sadness, shyness, obsession, sexual desire, anger, adolescent rebellion, and the like now fall under a bell curve whose extremes become pathologies. Surgical and pharmaceutical interventions are designed to return normalcy or the appearance of normalcy to aberrant bodies.
(Davis, 2014: 7-8)
And, as we will see up ahead, to aberrant minds.
On the other side, the current psychiatric perspective, that we can consider the most popular in the last 30 years, and that is well represented by the recent studies of many scholars like the psychiatrist Oleguer Plana Ripoll and the public health specialist Benjamin Lahey, criticizing the chaos generated by the DSM-V, supposes that behind this multiplicity of illnesses, there must be a unique biological - or better, genetic - cause of all mental diseases.
In a very recent article, Michael Marshall writes:
Some psychiatrists have put forward a radical hypothesis that they hope will allow them to make sense of the chaos. If disorders share symptoms, or cooccur, and if many genes are implicated in multiple disorders, then maybe there is a single factor that predisposes people to psychopathology'.
(Marshall, 2020: 21)
In both theories (of Davis and Lahey) normality comes into play, in a way that is explicit in Davis’ words and implicit in the recent researches of neuropsychiatry. At first glance, it seems we are in front of two different, and apparently, opposite kind of normalities.
According to Lahey, we can divide people into two distinct categories: the normal ones, and the ‘abnormal’ ones, genetically predisposed to mental illness, although on different levels. It is important to observe that the abnormal ones, if looked after, could belong to the world of normal people. But only if they recognize that their behaviour is constitutively damaged, which medical therapies and treatments aim to control or, better, eliminate.
The first theory is more sophisticated. Let Davis speak for himself:
We are all humans, diverse as we may be. In that sense, although our diversity is a sign of our difference, it is also a sign of our sameness, the sameness of being human. This is a proposition with which few will disagree. There is a built-in contradiction to the idea of diversity in neoliberal ideology; which holds first and foremost each person to be a unique individual. Individualism does not meld easily into the idea of group identity. And yet for neoliberalism it must be part of a “different” group - ethnic, gendered, raced, sexual. It is considered boring if not limiting, under the diversity aegis, to be part of the nondiverse (usually dominant) group. So diversity demands difference so it can claim sameness. In effect, the paradoxical logic is: we are all different; therefore we are all the same.
(Davis, 2014: 13)
Davies then highlights the dark side of the neoliberal ideology with a series of observations:
What is suppressed from the imaginary of diversity, a suppression that actually puts neoliberal diversity into play, are various forms of inequality, notably economic inequality. . . . But what is also suppressed ... is disability - particularly a notion of disability without cure. In this sense disability (along with poverty) represents that which must be suppressed for diversity to survive as a concept. . . . Thus “we are all different; therefore we are all the same” becomes “we are all the same because we aren’t that kind of different.” “that kind of different” would refer to that which cannot be chosen - the intractable, stubborn, resistant, and yet constitutive part of neoliberal capitalism - zoe, bare life, the ethnic order, the abject, the disabled - that which cannot be transmuted into the neoliberal subject of postmodernity.
(Davis, 2014: 13)
This cogent reflection ends with a very incisive sentence regarding the contemporary notion of normality that - let’s bear it in mind - is substantially accepted by Davis himself:
Disability is an identity that is unlike all the others in that it resists change and cure. It is not chosen, and therefore it is outside of the dominant ethic of choice. It is an atavism representing the remainder of normal at the end of normal. But such it isn’t an anomaly, but rather the capstone that upholds the arch of the neoliberal notions of diversity. It is the difference that creates the fantasy of a world in which we are all so diverse that we become the same. As such, paradoxically, it upholds meaning and significance because without difference there can be no meaning. Thus disability is the ultimate modifier of identity, holding identity to its original meaning of being one with oneself. Which after all is the foundation of difference.
- (Davis, 2014: 14)
- 3 Can the history of words help us?
At this point, it seems to be clear that scholars considerably debate about abnormality, difference, and mental disease, but at the same time and with the same determination they accurately avoid to explain what normality should be for them. Let us try to see if a historical analysis based on linguistic landmarks can help us to reach this elusive concept, starting from the basic question whether the couple ‘madness-normality’ has been characterized during the centuries by the same kind of relation, and even whether this pair has always existed.
First of all, it will be useful to debunk the myth of the scarceness of scientific researches about madness in Greek, Roman, and Medieval societies. Conversely, we have a very rich stream of high-level works, especially regarding the first two cultures. This myth has been promoted by some opening observations in the classic Foucaultian work about madness in Classical age - we must remember that ‘classic’ in Foucault means ‘Early Modern’, and that the American translation of the original locution is ‘Age of Reason’ - and this commonplace was acceptable at the time when Foucault wrote his book. But from the 1970s, scholars have abundantly provided for this lack in research.
So, we can affirm with a high degree of certainty that in the ancient Greek culture - from its beginning until the first centuries of the Christian Era - the disorder of the mind was a phenomenon which did not have a univocal definition. There were different words to indicate mental disease, each investing in different kinds of behaviour and emotions. To indicate the furious madness, the Greeks used the word peAay/okia - from which derives the word melancholy, which has however acquired a different semantic meaning. But the most probably used and known word to generically suggest madness was pavia, a term documented since fifth century B.C. and ascribable to irrationality and furious passion more than exclusively to pathology. Ancient Greeks believed that mental diseases were originated from the possession of the person by many Gods. Moreover, it is important to underline that lunacy and prophetic inspiration were strictly associated. Indeed, the words pavTtKf), meaning ‘prophetic art’, and pavtKf), meaning ‘madness’, are etymologically connected. In this culture, madness doesn’t represent uniquely the obnubilation or, worse, the vanishing of reason, but also a different and superior kind of knowledge. This higher knowledge could be reached by the ¿vOouotaopoq, inspiring energy that permits to earn a real awareness, supported by a God (Guidorizzi, 2010: 11; 94). For this reason, probably, crazy people had to be differentiated from other people by wearing headgear and it is quite certain that there did not exist any form of repression of people who suffered from mental illnesses. To the demented, it was only forbidden to bring weapons, to serve in the military, and to make a will.
The situation in the ancient Roman world was richer and more articulated than in the Greek one, but it was nonetheless homogeneous to the other one. The Latin vocabulary is more accurate than the Greek one, and it makes a distinction between insania and furor. Cicero wrote that this second term was more precise than the generic pekay/okia of the Greeks, because it showed better physical and moral causes of madness. Furor is a very severe form of mental disease and it is more dangerous than insania, but it is a kind of more noble madness (Diliberto, 1984: 27) that can strike the sapient too - differently from insania, which is nothing more than a kind of stultitia, that is to say foolishness. According to the philosophy of the Stoics, Cicero asserts that people in good health are those whose mind is not disturbed by passions: all the other people, the majority, suffer from that disease that can be named insania.
It is important to observe that to be furiosus does not imply the loss of role and dignity. These prerogatives must be maintained, as there is always the possibility to leave this condition. But if the condition persists, the furious cannot practice the office of judge, even if it will be in his power if he returns to normality. Moreover, the furious does not lose the patria potestas (Rizzelli, 2014: 157-158).
At this point, it should be clear that in classical Western cultures madness was a component of human life: an unfortunate, problematic, also painful one, like in our Western contemporary culture. However, differently from our beliefs, it was not a state directly related to the abnormality, at least in the sense we now give to this word, as we will see beyond. Also, it is important to observe that the terms used in these two ancient languages to indicate normality are in Greek KavovtKOi;, which has to do with the word that means ‘rule’; and in Latin rectus, iustus, solitus, medius. The Latin words enrich the Greek semantic field related to the rule, adding notions connected to the idea of normality as ‘most likely frequency’. What we must focus on is the linguistic component that suggests the concept of rule, or better, of the law (iustus), because we will find it again in the final paragraphs of this work.
4 An imperceptible but radical transition
During the Middle Ages, things imperceptibly start to change, especially during the last centuries of the period (Horn and Frohne, 2013). Concepts linked to mental illness - aside from the representation of literature, that we intentionally will not consider, as, after all, we have already done for Greek and Roman cultures -are analysed and reported almost uniquely in juridical environments (Metzler, 2010): with the flourishing of written texts starting from the thirteenth century, it emerges a certain number of very important juridical lexicographies, in which a specific space is dedicated to illness and madness (Mayali, 1987).
One of the first of this kind of lexicons was the one written by Alberico da Rosciate of Bergamo at the middle of fourteenth century entitled Alphabetum, trivially known as Dictionarium iuris tarn civilis quam canonicis (Dictionary of Civil and Canonic lau>) (Silanos, 2015: 31)
In Alberico da Rosciate’s Alphabetum, the headword infirmity is divided into three basic groups: physical debility (infirmitas corporis), mental disability (dementia), and spiritual weakness, which we could call sin (infirmitas animi). It is important to highlight that physical and mental disabilities, in substantial continuity with the Roman tradition, are considered conditions that exempt from penalties and exonerate from guilt. In the specific case of mental disease, there is a distinction between two kinds of illnesses: the actual madness, amentia, a condition in which the person is not imputable of a crime, and dementia, that is the inability to express self-will, which is contemplated only for issues pertinent to canonic law, like weddings or sacred orders (Silanos, 2015: 33-35). Regardless, we can affirm that late Medieval civil right is not particularly interested in any kind of invalidities, neither physical nor mental, as in ancient Rome. This is another fact that attests that mental disease in Medieval world was considered one of the multiple aspects of “normal” human life (Turner, 2010).
But there was a special case where madness put men out of humanity: the Furor Hereticorum, that is, the ‘madness’ of the heretics. This exception appeared very soon, at the beginning of the institutionalization of Christianity in the late Roman Empire (Zuccotti, 1992: 48-57). This kind of furor during the thirteenth century will be connected to the crime of lese-majesty against the Emperor and later the Kings, but - especially from the time of Pope Innocence IV - against the popes, the vertex of the social world of that time. Only in this case we can say that madness was a form of shocking damage of the social and consequently universal order, punishable with the death penalty.
Medieval civilization did not know any difference between invalidity (the physical/ mental problem in the strict sense) and handicap (that is to say, the sociocultural image regarding the subject affected by an invaliding sickness). All infirmed people, especially since the last centuries of the Middle Ages, were simply ‘useless’ (inutiles personae), even if terminology related to mental illnesses was a bit richer, with terms like furiosus, mentecaptus (stupid), non sanae mentis (insane). They are all pauperes and miserabiles (poor and miserable), because, as Mollat has efficaciously observed: “The poor is one who lived - permanently or temporarily - in a condition of weakness, reliance or humiliation, characterized by the lack of tools of power and of social respect” (Mollat, 2001: 7). Mollat identified morbidity as one of the causes that transformed a state of precariousness in a state of need.
During the end of the Middle Ages, the social aspects of the mental disease start to change compared to the past centuries and, in general, compared to nonChristian Mediterranean civilizations. We will return to this observation, but first of all, we must focus on the aspects of this change. We have to recognize that the behaviour that urban Italian legislators implemented to regulate the social problem of disabled can be efficaciously represented by the sociological couple inclusion/exclusion. The first one, inclusion, suggests the juridical protection of people affected by physical or psychical infirmity; the second one consists in the ‘social exclusion’ of particular sick persons whose presence in the town could be dangerous for the whole community. It is a process that starts during the thirteenth century and that at the beginning concerns only the leprous, with a degree of expulsion that will increase with time. With this notice about the marginalization of the leprous, we have reached the first chapter of Foucault’s masterpiece, Madness and Civilization: A History of Insanity in the Age of Reason (this is the American translation of the title), in which the French philosopher underlines the switch of marginalization from the leprous to those who suffered from mental diseases. We will return to examine several observations of Foucault’s book. However, before doing so we must focus on some other aspects of the Middle Ages’ culture and society.
First of all, it is essential to underline that the word ‘normal’ appears for the first time exactly during the Middle Ages. And that its semantic field is unequivocally tied to the dimension of rule and law. If we read the lemmas related to the word ‘normal’in the richest vocabulary of Medieval Latin (Du Cange, 1883—87), we can find many meanings of the word. The first meaning is enlightening, because it is Regula monastica (Monastic Rule) and it is quite old, tracing back to the year 770. The second one is the earliest word, from which all the other meanings develop: Norma, a Latin word of unknown origin that indicates “carpenter’s square, rule, pattern”. The derivatives of Norma are quite interesting too: Normatrix, that is abbess; Normales limites, a word used by the land surveyors to signify the line traced from the border of a land to another one; Normalis honor, that is the proper deference to religious authorities. To have a clear perspective of the evolution of this word from its birth to modernity, we will report the meanings of the voice ‘normal’ from the Oxford Online Dictionary, which gives us its first attestation in the English language:
c. 1500, “typical, common”; 1640s, in geometry, “standing at a right angle, perpendicular,” from Late Latin normalis “in conformity with rule, normal,” in classical Latin “made according to a carpenter’s square,” from norma “rule, pattern,” literally “carpenter’s square,” a word of unknown origin (see norm). Meaning “conforming to common standards or established order or usage, regular, usual” is attested from 1828 but probably is older than the record [Barnhart], Meaning “heterosexual” is by 1914. As a noun meaning “usual state or condition,” from 1890 (in geometry as “a perpendicular” from 1727). Sense of “a normal person or thing” is attested by 1894. Normal school “training college for teachers” (1835) is a translation of French école normale (1794), a creation of the French Republic; the notion is of “serving to set a standard”.
To end our reconstruction, we will report the adverb derived from normal, ‘normally’:
1590s, “regularly, according to general custom” (a sense now archaic or obsolete), from normal + ly. Meaning “under ordinary conditions” is by 1838.
Through the reading of this simple quotes from dictionaries - although it may be a bit boring - we can adequately understand how a word that formerly had to do with the establishment of rules and the administration of people, unambiguously -only a well-used carpenter’s square allows erecting flawless buildings - transformed itself in a word that should be meaning ‘being within certain limits that define the range of normal functioning’.
An equivalent process happens when analysing the linguistic history of ‘rationality’, whose loss is still considered by many people and a certain number of physicians as automatically associated with mental disorders. Recent studies, on the contrary, have abundantly demonstrated that people affected by mental disorders have more logical abilities as compared to the so-called normal people (Cardella, 2018). There is probably a historical reason behind this commonplace. If we read on the Du Cange the voice Ratio and all the correlated voices, we understand that they mainly concern the semantic field that has to do with juridical trials and accounts. The first item for Ratio gives Jus, causa, judicium (Law, trial); then we have Rationis Cónsules (Judges); Rationis exercere (to issue laws); Mittere/Ponere ad rationem (to summon); Rationator, Ratiocinator (attorney); Ratiocinate (Litigare, in jure agere, jus suum disceptare, ad rationem ponere, causant suant coram Judice rationibus probare, rem quampiam, rationibus ad id adductis, sibi asserere, crimen rationibus in judíelo a se amolirtj. The other items for Ratio are “goods”, “ration”, “descendants”, “measure”, and “straight line” according to the agricultural writers.
This long list of terms can be reconnected to the ancient Latin meanings of the word and to its etymological origin. The word ratio comes from ratus, the past participle of the verb rear, whose original meaning is sum, count, calculation. Ancient people knew very well that people with mental diseases usually had a working ratio, as it is demonstrated by the fact that the terms used to define crazy people very rarely concerns rationality. Insanity, in the Greek and Roman cultures, was principally to be furious, not to be irrational. Things started partially to change during the end of the Middle Ages (Murray, 1978), with an important semantic relocation in many vernaculars that facilitated the present misconception about the irrationality of people with mental diseases. Alexander Murray reminds us:
In this period [towards the end of the XII century] a wider audience had given the verb rationare the plain meaning “to talk” (the first known example of this usage in Italy dates back to 1228). This connotation, too, perhaps had its antecedent in ancient vulgar Latin, but in the Middle Ages it undoubtedly developed partially in symbiosis with the equivalence ratio “courthouse”, as rationare had taken on the meaning “to press charges”. However, the correlation “to reason/to talk” became so deeply rooted in vulgar languages that it gave birth to new acceptations. A French saying - paradoxical only on a surface level - that is around 1260 stated: “Keep your tongue or else resun [speaking] will make you feel embarrassed”.
- (Murray, 2011: 933)
- 5 From 'God-signed' to dangerous marginalized
So far, we have tried to show how, during the long centuries of the evolution of Greek, Latin and, for the most part, Medieval civilizations, the room of madness was a ‘piece’ of the social world. A certainly troubled and suffering piece (Pfau, 2010), that could be nevertheless become noble, a voice of God, able to force humanity to meditate on its meaningless ambitions. This conception received its most relevant celebration, thanks to Erasmus Roterodamus with his The Praise of Folly, ironically written at the turning point of the social conception of the mental disease: a panegyric which exactly behind its humanistic and highbrow weaving seems to hide the symptoms of a tragic change under the sign of the banishment of the lunatics from the humanity. Foucault’s work shows clearly how during Renaissance and until the beginning of the sixteenth century, insanity, in a way that is ironic and tragic at the same time, can help us to reflect about the sense of life and the real consistence of reason:
Finally, at the centre of all these serious games, the great humanist texts: the Moria rediviva of Flayder and Erasmus’s Praise of Folly. And confronting all these discussions, with their tireless dialectic, confronting these discourses constantly reworded and reworked, a long dynasty of images, from Hieronymus Bosch with The Cure of Madness and The Ship of Fools, down to Brueghel and his Dulle Griet; woodcuts and engravings transcribe what the theatre, what literature and art have already taken up: the intermingled themes of the Feast and the Dance of Fools. Indeed, from the fifteenth century on, the face of madness has haunted the imagination of Western man. A sequence of dates speaks for itself: the Dante of Death in the Cimetiere des Innocents doubtless dates from the first years of the fifteenth century, the one in the Chaise-Dieu was probably composed around 1460; and it was in 1485 that Guyot Marchant published his Danse macabre. These sixty years, certainly, were dominated by all this grinning imagery of Death. And it was in 1494 that Brant wrote the Narrenschiff; in 1497 it was translated into Latin. In the very last years of the century Hieronymus Bosch painted his Ship of Fools. The Praise of Folly dates from 1509. The order of succession is clear. Up to the second half of the fifteenth century, or even a little beyond, the theme of death reigns alone. The end of man, the end of time bears the face of pestilence and war. What overhangs human existence is this conclusion and this order from which nothing escapes. The presence that threatens even within this world is a fleshless one. Then in the last years of the century this enormous uneasiness turns on itself; the mockery of madness replaces death and its solemnity. From the discovery of that necessity which inevitably reduces man to nothing, we have shifted to the scornful contemplation of that nothing which is existence itself.
(Foucault, 1963: 15—16)
But with the seventeenth century, the destiny of the fouls is marked by the triumph of modern Rationalism: the insane must be closed, forever far from society. Insanity gives to us no more kind of benefit. Reason does not need the self-critical role of madness anymore:
Since delirium is the dream of waking persons, those who are delirious must be torn from this quasi-sleep, recalled from their waking dream and its images to an authentic awakening, where the dream disappears before the images of perception. Descartes sought this absolute awakening, which dismisses one by one all the forms of illusion, at the beginning of his Meditations, and found it, paradoxically, in the very awareness of the dream, in the consciousness of deluded consciousness. But in madmen, it is the medicine which must effect the awakening, transforming the solitude of Cartesian courage into an authoritarian intervention, by the man awake and certain of his wakefulness, into the illusion of the man who sleeps waking: a short cut that dogmatically reduces Descartes’s long road. What Descartes discovers at the end of his resolution and in the doubling of a consciousness that never separate from itself and does not split, medicine imposes from outside, and in the dissociation of doctor and patient. The physician, in relation to the madman, reproduces the moment of the Cogito in relation to the time of the dream, of illusion, and madness. A completely exterior Cogito, alien to cogitation itself, and which can be imposed upon it only in the form of an invasion.
(Foucault, 1963: 184-185)
With Descartes, with the triumph of a new Rationality, never seen in the past centuries, there is only a place for the insane ones and their reiterated dangerous uselessness: the hospital.
It is common knowledge that the seventeenth century created enormous houses of confinement; it is less commonly known that more than one out of every hundred inhabitants of the city of Paris found themselves confined there, within several months. It is common knowledge that absolute power made use of lettres de cachet and arbitrary measures of imprisonment; what is less familiar is the judicial conscience that could inspire such practices. Since Pinel, Tuke, Wagnitz, we know that madmen were subjected to the regime of this confinement for a century and a half, and that they would one day be discovered in the wards of the Hospital General, in the cells of prisons; they would be found mingled with the population of the workhouses or Zuchthäusern. But it has rarely been made clear what their status was there, what the meaning was of this proximity which seemed to assign the same homeland to the poor, to the unemployed, to prisoners, and the insane. It is within the walls of confinement that Pinel and nineteenth-century psychiatry would come upon madmen; it is there - let us remember - that they would leave them, not without boasting of having “delivered” them. From the middle of the seventeenth century, madness was linked with this country of confinement, and with the act which designated confinement as its natural abode. A date can serve as a landmark: 1656, the decree that founded, in Paris, the Hopital General.
- (Foucault, 1963: 38)
- 6 What Foucault has neglected
At this point we have to return to the end of the Middle Ages. There were some places in the South of Europe and in the Mediterranean area where the attitude towards illness and crazy people was characterized - even if based on the same social and cultural atmosphere of the fifteenth and sixteenth centuries - by care and inclusion, most probably, thanks to ideas and strategies originated in the Islamic culture.
On 24th February 1409, friar Joan Gilabert Jofre was headed to the cathedral of Valencia. As he was walking, he chanced upon a group of young people abusing and insulting a madman, as they believed the poor man to be possessed. After defending the insane man, the friar brought him into his convent and two days later, during his sermon at the Cathedral, he exhorted believers to put an end to the cruel persecution of innocent and powerless people like the mad ones. A few months later, a group of artisans and merchants gathered some funds to build a hospital for people with mental diseases. After an official authorization by the King of Aragon Martin the Humane and by Pope, Benedict XIII, on 1st June 1410, the hospital started its life under the protection of the ‘Holy innocent Martyrs’ - the children killed by King Herod - the only canonized saints that lacked reason. It was a clear sign that there was a place in heavens for lunatics, too.
Then, other hospitals aimed to recover all kind of innocent and troubled people (e.g., castaways, disabled, and prostitutes), which were built. The hospital of Valencia encouraged the spring of many other foundations of this kind, starting from the one founded in Zaragoza by Alfons V of Aragon ‘the Magnanimous’ in 1425. All these hospitals applied to insane people the treatment that many centuries later became known as ‘moral treatment’, a well-known practice in the history of psychiatry. The hospitalized spent their time doing physical exercise, group games, working, attending ludic performances, and following specific diets and hygiene programs. It is most important to highlight that the rules of the hospital of Valencia, which were authorized by King Martin, provided the Clavarias or Hospitaler (Hospital Manager) to gather the insane tramps wandering into the town and to bring them to the hospital willingly or unwillingly. There, the manager was responsible for them and with time he was vulgarly named ‘Father of Insanes’, a locution denoting a protective connection between him and the lunatics (López-Ibor, 2009).
Many scholars believe that the role model of the Hospital of Valencia was the Maristán of Granada, a hospital for insane people founded in the Islamic Emirate of Granada from emir Muhammad V during the years 1365-1367 (Fernández Vazquez and Maña Ares, 2016). This building had surely been created to put into practice Islamic beliefs on madness, which can be considered an evolution of the ancient Greek and Roman attitudes towards crazy people. Muslim society generally considered madness as the possession by spirits or magical creatures such as genies (djinn or jinn), intelligent beings with great knowledge, who control the actions of those innocents that they possess. The most used word to define lunatics is majnun, which is directly translatable as “possessed by a jinn”. The connection between madness and possession is the basis of a great number of beliefs and practices linked to religion and magic, and it was generally accepted by Medieval Islamic society. Together with this widespread belief, Islamic medicine - developed from the theories of Hippocrates and Galenus (Pérez et al., 2012) — supposes that mental illnesses can be treated with a certain degree of success and that, in any case, crazy people must be helped and respected: the mentally ill must not be excluded from society because they are proof of human diversity. This attitude was certainly driven and reinforced by religious prescriptions. Indeed, a verse of the Qur’an (IV, 4) delivers “And do not give the weak-minded your property, which Allah has made a means of sustenance for you, but provide for them with it and clothe them and speak to them words of appropriate kindness”. This attitude was different from that of Christian charity - that we have seen abundantly applied to the lunatics - and it can be considered an aspect of Islamic ihsan, that means “to do beautiful things”, one of the three basilar dimensions of the Islamic religion, which encourages social responsibility and a mutual exchange of good deeds.
For all of these reasons, bimaristans were scattered all over the Islamic world. These were both helpful centres, for people affected by mental or physical invalidity, and educational centres, for those who took up healthcare careers. Towards the end of the Middle Ages, the majority of bimaristanes received insane people almost exclusively. At the end of thirteenth century, bimaristanes were well attested in the oriental area of the Islamic world, in Damascus, Baghdad, Antioch, Aleppo, Jerusalem, and Cairo, whereas the diffusion in the West Islamic countries was tardive, starting from Morocco (Issa, 1928). It is very likely that the Maristdn of Granada was the first and probably the only one in Islamic Europe.
We must not emphasize the nobleness of Spanish catholic mental institutions, because insane were not always treated as their statutes prescribed. This is especially true over time as attested by the life and initiatives of Juan Ciudad Duarte, canonized as Saint John of God, who was sectioned for a short time exactly in the hospital of Granada where he saw the tortures inflicted to insane patients. For this reason, when he returned to free life in 1535, he founded another hospital in Granada: this one based on humanitarian practices whose success will be unquestionable, playing a crucial role in the foundation of the hospitaller order commonly known as ‘Brothers of Mercy’. This order supervises hundreds of hospitals all over the world still now.
7 From marginalization to declassification
Now we can return to the time of the decree of the foundation of the Hopital General in Paris, at the half of the seventeenth century, but not before having explained the purpose of the previous paragraph. It is not an erudite critique of Foucault’s quotes. The History of Insanity remains a masterpiece, and his silence on the Spanish hospitals and the Islamic concept of insanity has its reasons: the winning worlds are the French, the English, and later the German and the American one: the Western world. But it does not mean that there were no other contemporary approaches to the cure of lunatics and above all, contemporary conceptions of the social role of madness which differed drastically from the one described by Foucault. To give a further example, it is enough to remember that precisely during the ‘infamous’ seventeenth century, in many towns of the Ottoman Empire crazy people could walk freely along the streets without being confined or abused or ridiculed as it was observed by many astonished Western observers and by some grateful Islamic travellers. This last one was the case of Evliya Celebi: in 1648, while he was in Damascus, he was
invited by ten Turkish officers to join them for a night of revelry in a house of ill repute . . . . En route to the establishment, Evliya suddenly came face to face with a local majdhub (holy fool) by the name of Shaykh Bakkar.
(Scalenghe, 2014: 102)
Shaykh Bakkar acted foolishly and embarrassingly towards him. However, these are the words that Çelebi employs in recounting his experience:
I was on my way with these men to the den of vice. But because I am one of those who bear God’s holy word, having memorized the Koran, his holiness Shayk Bekkar received divine inspiration and seized me from the midst of those doomed men. He paraded me round about, crying: “One sinner!” and so rescued me - may his secret be sanctified. Owing to that saintly man I was saved from that abyss.
(Scalenghe, 2014: 103)
It cannot be denied that during those years in Europe, some people could ponder on the meaning of life after witnessing embarrassing behaviours of madmen. However, these attitudes towards madness became more and more an exception rather than the norm, which was, if anything, internment. Insane people were locked up together with syphilitics, lascivious men, homosexuals, and blasphemers, and in this way madness was inexorably enchained to the sin.
At the same time, the sign that during the seventeenth and eighteenth centuries will identify the madmen is the absence of reason. This fact is well explicated by Foucault:
We no longer understand unreason today, except in its epithetic form: the Unreasonable, a sign attached to conduct or speech, and betraying to the layman’s eyes the presence of madness and all its pathological train; for us the unreasonable is only one of the madness’s modes of appearance. On the contrary, unreason, for classicism, had a nominal value; it constituted a kind of substantial function. It was in relation to unreason and to it alone that madness could be understood. Unreason was its support; or let us say that unreason defined the locus of madness’s possibility. For classical man, madness was not the natural condition, the human and psychological root of unreason; it was only unreason’s empirical form; and the madman, tracing the course of human degradation to the frenzied nadir of animality, disclosed that underlying realm of unreason which threatens man and envelops - at a tremendous distance - all the forms of his natural existence.
(Foucault, 1963: 83)
So, we can say that also Shayk Bekkar, for the ‘classical man’, should be only a dangerous beast to chain up and enclose.
8 The last step: from degradation to abnormality
At the end of eighteenth century and the beginning of nineteenth century, things seem to change. A revolutionary swing appears to take place, thanks to Tuke, Pinel, Esquirol, and all the representants of the ‘moral treatment’. But it’s a short spring, which turns out to be unable to truly modify the tendency towards the degradation of insane people. And, after all, this change would have been unfeasible in the society of the industrial revolutions; a society which aspires to the reification of man, to the exploitation of the utilitas that we have seen mentioned for the first time in late Middle Ages in Italian towns. A society, therefore, which cannot give dignity or freedom to all kinds of inutiles personae, and which - thanks to the development of science and its application to technology, and in our case to medicine - classifies all deviants under a new mark (Knepper and Ystehede, 2013). The mark of mental insanity, the mark of an abnormal biological and chronic condition for some failed humans: the degenerates.
On the basis of the constitution of the degenerate, set in place in the tree of heredity and bearing a condition that is not a condition of illness but one of abnormality, we can see that the theory of degeneratio enables psychiatry, with its divergent power relation and object relation, to function. Even better, the degenerate gives a considerable boost to psychiatric power. In fact, you can see that when it became possible for psychiatry to link any deviance, difference, and backwardness whatsoever to a condition of degeneration, it thereby gained a possibility of indefinite intervention in human behaviour. However, by giving itself the power to dispense with illness, by giving itself the power with the ill or the pathological and to connect a deviation of conduct directly with a definitive and hereditary condition, psychiatry gave itself the power of dispensing with the need to find a cure. Certainly, at the beginning of the century mental medicine had made a great deal of incurability, but incurability was defined as such precisely in virtue of what was the necessary major role of mental medicine, namely, to cure. Moreover, incurability was only the current limit of the essential curability of madness.
As it is well known, Foucault identifies three historical characters who prepare the way to the creation of the ‘abnormal’ and his dangerous significance inside the institution: the ‘human monster’, the ‘man to correct’, and the ‘masturbating child’. The latter is the origin of all sickness according to certain successful nineteenthcentury medicine theories. This genealogy is effective in describing most of the prejudices that are even now ascribed to the abnormal.
To prevent the risk constituted by the abnormals, from the half of the nineteenth century, psychiatric power moves its first, incessant steps towards the control of all lives (Foucault, 2003) in perfect harmony with a society in which work and accumulation of wealth are, always more frequently, the only aim of human life. Foucault explains very efficaciously how psychiatry is first of all the watchdog of any dominant social system, even when it seems to be opposed to Capitalism. This is true also for the historical actualization of Communism, which has substantially resulted in a mere deviation from Capitalism instead of an overcoming of the latter.
Presently, the political embodiment of this assertion can be found in the Popular Republic of China.
As highlighted by Foucault:
Psychiatry no longer seeks to cure, or in its essence no longer seeks to cure. It can offer merely to protect society from being the victim of the definitive dangers represented by people in abnormal condition. . . . With the medi-calization of the abnormal and by dispensing with the ill and the therapeutic, psychiatry can claim for itself the simple function of protection and order. It claims the role of generalized social defence and, at the same time, through the notion of heredity, it claims the right to intervene in familial sexuality.
(Foucault, 1999: 316)
Consequently, the political, medical, and psychiatric control of sexuality and reproduction becomes one of the most efficacious ways of social regimentation: a man who is not part of the biological coordinate of this new, apparently scientific kind of normality is not only an abnormal but also a degenerate that can only reproduce other degenerates and that must be shut in, inspected, subdued, and in many cases erased, in the name of normality:
With this notion of degeneration and these analyses of heredity, you can see how psychiatry could plug into, or rather give rise to, a racism that was very different in this period from what could be called traditional, historical racism, from ethnic racism. The racism that psychiatry gave birth to in this period is racism against the abnormal, against individuals who, as carriers of a condition, a stigma, or any defect whatsoever, may more or less randomly transmit to their heirs the unpredictable consequences of the evil, or rather the non-normal, that they carry within them. ... It is internal racism that permits the screening of every individual within a given society.
- (Foucault, 1999:316-317)
- 9 Has abnormality been defeated at last?
To put an end to this chapter, let’s make a conceptual experiment. Let’s imagine a 16-year-old guy surviving a shipwreck in the Ocean. He reaches a desert island very far from other inhabited places where he is the only survivor. At the age of 25, he starts hearing voices and experiencing several delusions. Therefore, he experiences the symptoms of schizophrenia, a psychosis of which he has never heard a word of before the shipwreck. Would he consider himself sick - especially, insane? Anybody who has been reading the paper up to this point can imagine that my answer would be negative. That is, for the simple reason that there would be nobody to tell him that what he senses is not real. On the contrary, if he suffered from some other illness - even one never heard before his shipwreck - he most probably would be able to understand that he is sick, or more optimistically that he is feeling unwell. He would never guess to be insane for the simple reason that there would not be any society around him to govern his concept of normality and reality.
Through this conceptual experiment I have tried to explain, although in a quite trivial way, what Georges Canguilhem had already written several years ago, especially in his The Normal and the Pathological, published in 1943 and then enriched in 1966. Canguilhem’s theory can be immediately recognized behind these words of Foucault (1954):
[B]ut with that we came perhaps to one of the paradoxes of mental illness, which forces us to look for new analysis forms: if subjectivity of what is senseless is, at the same time, a plea and a way to lose oneself to the world, isn’t it perhaps to the world itself that we must ask for the secret of its enigmatic statute? Does not illness perhaps implicate a nucleus of meanings derived from the environment where it arose — and, in the first place, the plain fact of being defined by it for the reason of being an illness?2
(Foucault, 1954: 65)
After all, the pathological process is, as Binswanger puts it, a Venveltlichung, a “Mun-danization”, or “total affinity to the world” (Binswanger,  1968: 284). But in the case of mental illness, the world is split into two parts: while the first one defines a specific ordinance for mental illness, the second one creates a stigma against the mental illness through the creation of new significance and truths. These two components brilliantly outline how modern subjectivity is constantly forced between subjectification and subjugation and how individual self-determination and selfrecognition in the modern world is made possible precisely because of this strain. Foucault argues that analysing the history of psychiatry through an epistemological and political lens allows an understanding of a historical-genealogical mechanism whose functioning is essential in determining modern power relations and discursive regimes.
We are not only in front of a simple repressive attitude, but in front of something more complex and oppressive: the positive imposition of normality, the only one possible in our society. And this is true for our contemporary society too, despite the elaborate and cogent Foucault’s critical work. Furthermore, despite the enormous efforts of a homogeneous coalition of scholars active in several regions of the Western world, like Erich Fromm, the members of the school of Palo Alto, Franco Basaglia, and many others, are part, everybody with his specificity, of the so-called Antipsychiatry:
Foucault’s reflection has often been compared to the one of Antipsychiatry, although the French philosopher himself outlines the differences of method, especially on the issue of “political ontology”: anti-psychiatric readings -such as the one of Italian Franco Basaglia - were focused especially on a criticism of the repressive form acquired by institutions - in other words, power was interpreted as something which “deprives”, while the “psychiatrized” subject was considered an object of “deprivation”. In the same period Foucault was moving towards a different idea on how power relations operate in capitalistic western modernity: these relations may not be only “repressive” and, if anything, they may not produce “deprivation” dynamics. Rather, they might be “productive” in so far as the “psychiatrized subject” is found in the condition to have to cause a process of subjectification on himself. This process determines and shapes the subject through feedback from objective to subjective in a productive accent.
(Salottolo, 2015: 88)
It is the norm more than the law that operates in those new power devices associated with the bourgeois ascent. Law, which establishes what must not be done, is by nature a repressive force, whereas norm, which dictates what must be done, produces truth, institutions, and subjectivity. For this reason
[njormalization can be nearly total, in so far as any subject must adjust to it to feel “normal” and to be part of organized social life’s “normalcy”. The passage from the dimension of “law” and “taxation” to that of “norm” and “production” - a passage which complicates instead of excluding - sets forth the birth of the capitalistic social organization. In a few words, the question on normality and abnormality - together with how easily one can move from one to the other - is what defines the fundamental problem.
(Salottolo, 2015: 91)
As an operational reaction to psychiatric normalization, Antipsychiatry has undoubtedly been successful for two decades (the 1960s and the 1970s):
A certain number of professionals soon understands that psychiatric rehabilitation is filtered through society’s awareness. ... In other words, the concern is not with patients’ rehabilitation, as in orthopaedics, but with rehabilitating communities to welcome insane people. [But] nowadays, this democratic break is subject to alarming countertrends: classic coercive systems are reactivated in different shapes from the past. . . . When dominant psychiatry becomes aware of this mental revolution, it looks for shelter, finding it in an official present trend; that is to say, in the DSM.
(Barbetta, 2014: 115)
The relentlessly rising number of mental illnesses for each new DSM, and especially for the most recent version, gives us evidence of the permanence and paradoxical growth of the psychiatric power as denounced, even if against different targets, by Foucault (Still and Velody, 1992) and by Antipsychiatry at the same time. Most of the present psychiatry avoid accurately of speaking of abnormals, at least ostensibly, but always seems to be tempted to find exclusively biological causes of mental illnesses and, if possible, only one cause. In doing so, contemporary psychiatry rebirths the misconceptions of the recent past. At the moment, psychiatry is contented with the creation of new forms of mental diseases for which it offers to supposedly new patients two desired interdependent gifts: an official pathological label for what in the past would have simply been considered an oddity or a distress (e.g., premenstrual dysphoric disorder, caffeine withdrawal, rapid eye movement sleep behaviour disorder, restless legs syndrome, or apotemnophilia, an attraction to the idea of being an amputee) (Wieczner, 2013) and, at the same time - in the context of the same procedure - to remove the social stigma against these new mental pathologies, obviously by dosing these patients with an appropriate psychiatric drug.
All of that can be shown simply by reading Bruce A. Thyer’s cutting off of the nosological criteria of the most recent DSM. Firstly, however, let’s read the DSM-V definition of mental disorder:
A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation or behavior that reflects a dysfunction in the psychological, biological or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational or other important activities.
(АРА, 2013: 20)
Thyer rightly highlights that:
The beginning and the ending of this definitional sentence reads: “A mental disorder is a syndrome characterized by clinically significant disturbance in . . . processes underlying mental functioning.” By itself this is tautological, repeating the same sense in different words, and hence is unsatisfactory from a scientific standpoint. . . . [T]he DSM-V definition of mental disorder significantly expands beyond the definition found in the four previous versions of this manual. . . . The DSM-V greatly expands upon that of its predecessors by creating nine different pathways for mental disorder, with three potential sources of disturbance or aetiology (psychological processes, biological processes, and developmental processes) causing dysfunctions in three domains (cognition, emotional regulation, and behavior).
- (Thyer, 2015: 47)
- 10 Conclusions
To sketch a very synthetic conclusion to this chapter, I would like to remind the readers of a sentence which is very often repeated by Vittorino Andreoli, a well-known Italian psychiatrist: “Nowadays, if you want to be considered ‘normal’ you have to state that you are a bit ‘abnormal’” (2018, audio of a public lecture in Rovigo).
I believe that this paradoxical assertion can tell us much more than we can suppose at a first glance. To do it, we must return to Davis when he writes:
What is suppressed from the imaginary of diversity, a suppression that actually puts neoliberal diversity into play, are various forms of inequality, notably economic inequality. . . . But what is also suppressed ... is the disability -particularly a notion of disability without a cure. In this sense disability (along with poverty) represents that which must be suppressed for diversity to survive as a concept.
(Davis, 2014: 13)
Therefore, Andreoli’s aphorism shows efficaciously how - since capitalism has reinforced its cultural hegemony all over the world - by admitting and often asking for recognition of each diversity, everybody proves to be an efficient consumer. By demonstrating this, each one of us attests that he is not a poor, nor a fool unwilling to acknowledge his insanity or to ask for medications to cure illnesses whose number is ever more increasing, as is the case for depression, the most common mental disease of our times which increases more and more every day. This illness, as emphasized already in 1990 in a famous The Lancet article, could be erased simply by taking a pill: Take a pill and be happy! In this way, when everybody takes his ‘personal’ pill, we can all live in an enormous, coloured, happy asylum, even if in an uneasy society, as Alain Ehrenberg reminds us (Ehrenberg, 1998, 2010). Everybody, freely imprisoned and inevitably protected by institutions that ground their authority on scientific and algorithmic certainties (Medeghini, 2015), performs his desirably long biopolitical life and believes to be able to sustain the unsustainable effort to be at the same time always efficient and capable of continuously taking decisions and pragmatic actions, as the dominant ideology wants, although it is not explicitly imposed (Frances, 2013). In exchange, he receives an online echo chamber where he can meet the ‘different ones’ who all live in a state of identical diversity and who reinforce each other’s repetitive identity (Dardot - Laval, 2009). Quite a very efficaciously normed normality. Normality has died, long live normality!
- 1 I wish to thank my daughter Francesca Maria for her precious support, both linguistic and critical, during my composition of the chapter.
- 2 Text translated from the Italian edition.
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