In Search of Madness: A Psychiatrist's Travels Through the History of Mental Illness

By Brendan Kelly

Who is 'Mad'? Who is Not? And Who Decides?
In this fascinating new exploration of mental illness, Professor Brendan Kelly examines 'madness' in history and how we have responded to it over the centuries.
We travel from the psychiatric institutions of modern India to scientific studies of the brain in Victorian England. We discover the beginnings of formal asylum care and witness the experimental therapies of the cavernous psychiatric hospitals of the nineteenth and early twentieth centuries in Ireland, England, Belgium, Italy, Germany and the United States.
Covering lobotomy and the Nazis' Aktion T4 campaign, as well as Freud, psychoanalysis, cognitive behavioural therapy and neuroscience, In Search of Madness examines the shift in recent times from 'psychobabble' to 'neurobabble'.
This is an all encompassing history of one of the most basic fears to haunt the human psyche – madness – and it concludes with a passionate manifesto for change: four proposals to make mental health services more effective, accessible and just.

• Language: English
• Publisher: Gill Books
• Release date: Apr 14, 2022
• ISBN: 9780717193790

Brendan Kelly

Professor Brendan Kelly is a professor of psychiatry at Trinity College Dublin and a consultant psychiatrist at Tallaght University Hospital in Dublin. In addition to his medical degree, he has master’s degrees in epidemiology, healthcare management, and Buddhist studies, and doctorates in medicine, history, governance, and law. He has published two previous books with Gill, The Doctor Who Sat for a Year and The Science of Happiness.

Book preview

A Note on Language

Throughout this book, original language and terminology from the past and from various archives, reports and publications have been maintained, except where explicitly indicated otherwise. This reflects an attempt to optimise fidelity to historical sources and does not reflect an endorsement of the broader use of such terminology in contemporary settings. The term ‘madness’, in particular, is used in a solely historical sense, as in the titles of leading books such as Roy Porter’s Madness: A Brief History (Oxford: Oxford University Press, 2002), Andrew Scull’s Madness in Civilization: A Cultural History of Insanity from the Bible to Freud, from the Madhouse to Modern Medicine (London: Thames & Hudson Ltd, 2015) and Mike Jay’s This Way Madness Lies: The Asylum and Beyond (London: Thames & Hudson Ltd, Wellcome Collection, 2016).

Content Warning

This book discusses issues such as depression, suicide, self-harm, mental illness and related matters in direct terms, in order to demystify them and to delineate and understand them better. For this reason, certain readers might find certain sections distressing.

Introduction

What Is Mental Illness?

In 1684, Nathaniel Lee, an exuberant Restoration playwright, was committed to Bethlem lunatic asylum in London (widely known as Bedlam). Lee objected vociferously: ‘They called me mad, and I called them mad, and damn them, they outvoted me.’¹

Lee was discharged, ‘recovered’, after five years in Bedlam. He died in a drunken fit three years later, but his comments about ‘madness’ retain their resonance today, over three centuries later. Who is ‘mad’ and who is not? Who decides?

There are two key reasons why Lee’s words echo today. In the first place, the fear of serious mental illness remains one of the most basic fears to haunt the human psyche. Most of us secretly worry about our sanity, at least from time to time. All of us dread the prospect of mental illness, holding, as we do, our rationality and autonomy at the core of our identity. If we lose those, what is left? Lee saw his rationality impaired and autonomy taken away, emerging from the asylum after five years in a quieter state, but far from cured. Soon, he died. His story is a terrifying one. Could this happen to me?

The second reason we fear mental illness is that its borderlines have never been clearly defined. In Lee’s case, his fate was decided by a consensus of ‘experts’. Today, psychiatric diagnoses and their implications are decided by a complex mixture of doctors, psychologists, other mental health professionals and, occasionally, judges in courtrooms. Formal criteria for diagnosing mental illness, in handbooks published by the World Health Organization and the American Psychiatric Association, have never been so detailed, but have also – paradoxically – never been more negotiable.

On paper at least, many diagnostic decisions depend on the severity of such common feelings as anxiety and depression, with the result that the demarcation between the mentally well and the mentally ill is sometimes unclear. When does unhappiness become depression? At what point does a tendency to check the locks and windows shade into obsessive-compulsive disorder? What differentiates a general mistrust of other humans from paranoia, delusions and psychosis, indicating a significant break from reality?

In other words, how can we know who is mentally ill and who is not? Which am I today? Which will I be tomorrow?

As a psychiatrist – a medical doctor who specialises in the treatment of mental illness – I am only too familiar with these problems and dilemmas. They are not without basis. Much is uncertain in this field. Everything is contested.

But neither is the situation quite as unfocussed or arbitrary as is often feared. No one can deny the reality of psychological suffering. Few can ignore the impulse to help a person whose mental distress is both obvious and solvable. These things are real.

Against this background, the practice of psychiatry remains a very human endeavour that is largely understandable if we look carefully at the broader landscape in which it developed. It is essential that we take this wide view, examining psychiatry from a range of perspectives, not just a scientific one. People with mental illness deserve no less.

While recent decades have seen increased research into the human brain, our restricted understanding of the science of the mind greatly limits the benefits from recent advances in brain sciences. As a result, and despite the best efforts of generations of researchers, recent ‘neuroscience’ does not shape the experiences of most people with mental illness to any significant degree. We have treatments that work very well, but social conditions and cultural attitudes still loom large. Brain science is certainly an increasing part of the story, but it is not the full story, nor even the greater part of the story, even today.

For a better and deeper understanding of mental illness, then, we need to look not only at scientific studies of the brain from the 1800s to today, but also at the social history: evolving social expectations of psychiatry over this time; the contested history of this most contested of disciplines; the evolving roles of culture and geography; and a range of other factors that have always determined social responses to mental illness. That is what this book is about.

In one sense, this is a travel book. In the course of my story, I visit Ireland, England, Belgium, Italy, Germany, India and the United States. There are lessons everywhere.

This is also a history book, looking at the past as much as the present, and using both to outline prospects for the future. Most of all, this is a book about mental illness and what we can do to help, illustrated by case histories and my experiences as a doctor and psychiatrist.

I conclude with a manifesto for change. Drawing on the travels, thoughts and explorations in preceding chapters, I outline ways to improve the experiences of people with mental illness and their families.

This matters to everyone, not just people with mental illness or problems with mental health. We suffer, heal and help each other in families, communities and societies.

We must do better. Together, we can.

Chapter 1

Psychiatry: Haunted by Institutions

I first meet John in a psychiatry outpatient clinic in Ireland. I am the new psychiatrist and John is a long-standing patient of the mental health service. John is in his sixties when I meet him. Four decades earlier, he spent 22 years in the local ‘mental hospital’, diagnosed with schizophrenia. John’s old case notes strongly support this diagnosis. He was clearly very mentally ill at the outset: hearing voices, believing his food was poisoned and insisting that the radio was talking about him.

John was discharged from the hospital 18 years ago when a community residence operated by the mental health service opened on a nearby street. He has lived there ever since. At the community residence, John is free to come and go as he pleases. Mental health staff call in three times a week to check how the residents are getting on and help solve any problems they might have. The staff know John and the other residents very well.

John is receiving long-term treatment with antipsychotic medication administered by injection once every four weeks. He has not required hospital admission at any point following his discharge to the community residence. None of the residents have been admitted. Neighbours comment that theirs is the quietest house on the street.

When I first meet John, I ask what he thinks about the monthly injection. He says: ‘I’ve been on it for 30 years. It’s part of my life. Is that all, doctor? Can I go now?’ And off he goes, out of the clinic – until next month.

I discuss John with the community mental health nurse on our team. She tells me that, despite great efforts by the social worker and occupational therapist, all that John wants to do is to walk around the local neighbourhood during the day and visit the hospital in the evenings. There, he has tea with long-stay patients and long-term staff members whom he knows, before returning to the community residence where he lives. He sometimes says he wishes he was still in hospital.

John does not seem unhappy, but his life seems rather limited to me, shaped in part by mental illness, but also by prolonged institutionalisation as a young man. While John might have initially required hospitalisation all those years ago, surely his 22-year hospital stay dampened his personality and limited his horizons in the longer term? While he certainly has a diagnosis of schizophrenia, did his early institutional treatment prove worse than his illness? And why was he kept in hospital for so long? Were there no alternatives?

The boy is happy. He looks at me with big dark eyes and an enormous smile. He cannot be more than four years of age and he has no idea who I am, what I want, or why I am standing here. But he is enormously happy to see me. He is seated on a dilapidated motorcycle, eating a tiny banana and watching the world go past. This is the perfect place for people-watching – possibly the best place in the world.

The boy and his family are camped outside the gate of the Mahabodhi Temple in Bodh Gaya in northern India. This is where Buddha attained enlightenment during a night of meditation under the Bodhi tree, two-and-a-half thousand years ago.

They still have the tree. As a result, the tiny town of Bodh Gaya is crammed with pilgrims, spiritual tourists and curious travellers, all filing past the boy, his family and countless other street-traders, on their way to the temple to see if they, too, can be enlightened under the sacred tree. There are stray dogs in the middle of the road, sacred cows ambling about, camels conveying travellers from afar, and even cages of birds to buy and release moments later, as an offering to the gods – ‘good karma’. The entire scene is loud, dusty and oddly intoxicating. I love it.

I stop beside the boy because his father is selling carved wooden Buddhas unlike any I have seen before. Buddha is in a skeletal state during an ascetic phase prior to his enlightenment, when he virtually starved himself to death in search of wisdom. You can see Buddha’s ribs jutting through his skin, his face gaunt, his eyes haunted. Despite his best efforts, Buddha remains unfulfilled at this early stage on his spiritual journey. I buy the carving for a tiny sum, smile at the boy and move on. Enlightenment awaits, just beyond the security barrier and the seething crowd.

To tell the truth, I have not come to India in search of spiritual enlightenment, although I’ll take that willingly if I find it. No, I’ve come in search of ‘madness’.

Mine is a peculiar quest. As a psychiatrist, I often use the term ‘mental illness’ when I see someone who is distressed and disturbed and needs to seek help outside their own personal resources, beyond their circle of family and friends. I’ve seen thousands, maybe tens of thousands, of such people over the past 25 years and, even so, I still do not know fully what ‘mental illness’ really means to many people.

But I do know that while the terminology changes over time – ‘madness’, ‘insanity’, ‘mental disorder’ – the fact of psychological suffering remains remarkably constant. It is real. My goal in this book is to dig more deeply into this psychological suffering, to see how our understanding of it changes with time and geography, and – hopefully – to figure out how we can better help people with mental illness.

But, for now, I sit here under the Bodhi tree in Bodh Gaya and wait to be enlightened. Nothing happens.

Gods, Demons and Supernatural Forces: The Prehistory of Mental Illness

The prehistory of ‘madness’ takes us back to earliest times.¹ Mental illness has always been with us. Every spiritual tradition has, at one time or other, blamed human ‘madness’ on the work of gods or devils, or the result of supernatural forces that sought to disturb the affairs of man, wreak havoc or exert revenge for unspecified infringements. Sometimes ‘madness’ was the result of obvious wrong-doing, sometimes the vagaries of the deities, sometimes just bad luck. Responses were often harsh: while some who ‘heard voices’ were hailed as saints or mystics, most were dismissed as mad, persecuted, confined, ostracised or constrained to lives of wandering, loneliness, destitution and early death.

Attitudes changed over time but did not necessarily improve. In Greek tradition, soldiers were occasionally seized with the ‘madness’ of war, and illnesses such as mania, melancholia and epilepsy began to appear in the literature. A shift occurred in medical texts written in the tradition of Hippocrates (c.460–c.370 BCE), a Greek physician, when his followers spoke of ‘hysteria’ as a form of mental illness in women. They linked this to the womb rather than to the gods or the uncontrollable forces of fate.

Hippocrates and his followers developed the idea of the four ‘humours’: black bile, yellow bile, phlegm and blood. Health resulted when the humours were in balance, and disease resulted when the balance was disturbed.

Hippocrates placed particular emphasis on the role of the brain in generating emotions, knowledge, perceptions and our responses to the world:

Men ought to know that from nothing else but thence [the brain] come joys, despondency and lamentations. And by this, in an especial manner, we acquire wisdom, and knowledge, and see and hear, and know what are foul and what are fair, what are bad and what are good, what are sweet, and what unsavoury; some we discriminate by habit, and some we perceive by their utility. By this we distinguish objects of relish and disrelish, according to the seasons; and the same things do not always please us.

But, according to Hippocrates, the brain was also responsible for ‘madness’:

And by the same organ we become mad and delirious, and fears and terrors assail us, some by night and some by day; and dreams and untimely wanderings, and cares that are not suitable, and ignorance of present circumstances, desuetude and unskilfulness. All these things we endure from the brain when it is not healthy, but is more hot, more cold, more moist, or more dry, than natural, or when it suffers any other preternatural and unusual affection.

And we become mad from humidity [of the brain]. For when it is more moist than natural, it is necessarily put into motion, and the affected part being moved, neither the sight nor hearing can be at rest, and the tongue speaks in accordance with the sight and hearing.

The key, according to Hippocrates, lay in maintaining a balance between ‘rest’ and activity of the brain, and the balance of the humours:

As long as the brain is at rest the man enjoys his reason; but the depravement of the brain arises from phlegm and bile, either of which you may recognise in this manner: those who are mad from phlegm are quiet, and do not cry out or make a noise; but those from bile are vociferous, malignant, and will not be quiet, but are always doing something improper.

If the madness be constant, these are the causes thereof. But if terrors and fears assail, they are connected with derangement of the brain, and derangement is owing to its being heated. And it is heated by bile when it is determined to the brain along the blood vessels running from the trunk, and fear is present until it return again to the veins and trunk, when it ceases. He is grieved and troubled when the brain is unseasonably cooled, and contracted beyond its wont. It suffers this from phlegm; and from the same affection the patient becomes oblivious.

From this point on, mental illness was increasingly located in the body and the brain, and in the humours, rather than in the heavens.

But where did this medicalisation of ‘madness’ leave religious explanations, folk traditions and local cures, such as spells, charms and incantations? Cultural beliefs, once evolved, are notoriously difficult to abandon. Moreover, there were now flourishing markets in cures for ‘madness’, with significant vested interests.

Tensions between folkloric and medical explanations of ‘madness’ in the Greek and Roman worlds were echoed in other civilisations. In China, demonic possession and disturbances to cosmic forces were commonly invoked to explain ‘madness’, but existed alongside physical causes such as cold, damp and wind. In Islamic tradition, folkloric tales and supernatural therapies abounded in popular culture, but the extensive Islamic hospitals of the eighth century also made specific ‘medical’ provision for the ‘insane’. The first mental hospital was reputedly built in Baghdad in 705.² Early treatments included baths, music and occupational therapy.³ In many places, blood-letting, vomiting, purging, opium and herbs were also used to expel noxious ‘humours’ causing mental illness, along with physical restraint and beating, aimed at quelling furious ‘insanity’.

This composite picture – folk remedies mingling with ‘scientific’ advances, medical treatments coupled with unflinching social control – was to persist for many centuries, even through the asylum era of the nineteenth century and the reformation of the ‘mental hospitals’ in the twentieth. Today, similar controversies still rage about treatment, responsibility and exploitation of the mentally ill, reflecting continued tension between medical and social dimensions of ‘madness’. All of this weighs heavily on my mind during my travels in India in search of the story of psychiatry.

Back in my hotel near Bodh Gaya, the Times of India reports that a Mumbai schoolboy died by suicide after he was suspended from school for allegedly beating up a classmate. The boy’s parents blame the school principal and teachers, but the High Court concludes that they are not responsible. The Court says that while the suicide was deeply tragic, there is no evidence that school staff abetted or instigated it.

The challenges presented by mental illness have always been common, complex and costly in both human and economic terms. I console myself today with other distracting news in the Indian press: enthusiastic reports about economic successes, endless accounts of social initiatives, and articles on health and lifestyle. But psychological concerns are rarely far from the surface: even the serious-sounding Economic Times has a column called ‘The Speaking Tree’ with psychological advice for readers.

I turn to other sections of the newspapers in search of lighter fare. The Times of India breezily advises readers to switch to natural gas: ‘If you care, change the air’. This enhanced awareness of the environment might not be quite the enlightenment of which the Buddha spoke, but it’s plenty for me this evening – along with some tongue-tingling Indian food and a restless night’s sleep, punctuated by dreams about the cavernous asylums of the nineteenth century, a calmly starving Buddha, and a camel dozing gently under the sacred Bodhi tree.

Institutions, Innovations and Forgetting

The Central Institute of Psychiatry in Ranchi in northern India is an impressive place and an excellent starting point for my exploration of psychiatric institutions. I don’t know quite what I am searching for, but I hope I’ll know when I find it. Maybe it’s here, in Ranchi.

Prior to the nineteenth century, care for the mentally ill in most countries was patchy and uneven, if it existed at all. The development of this field in India reflects many aspects of the broader history of psychiatry around the world. That is why I am here.

In India, ancient traditions linked disease with diet, and Unani medicine included Ilaj-I-Nafsani as a form of psychotherapy.⁴ Other practices offered variable degrees of support in certain parts of the country, and there were early hospitals for people with mental illness during the reign of King Asoka (268–232 BCE). Later, British colonisation resulted in the creation of asylums to cater primarily for European people who became mentally ill. This system of Indian asylums developed considerably over time and soon became a complex but integral part of the colonial enterprise.

Ranchi European Lunatic Asylum, as it was then named, was established by the British on 17 May 1918 when they realised that the mental asylums at Bhowanipore and Berhampore in Bengal were in very poor condition and increasingly crowded with European patients. In 1919, Lieutenant Colonel Owen Berkeley-Hill, a psychiatrist in the British Army, became medical superintendent here and, in 1924, wrote:

The Ranchi European Mental Hospital is the only mental hospital in India which is intended solely for the treatment of persons of either European or American parentage. Natives of Asia or Africa are not eligible for admission. The term European includes persons of mixed parentage, i.e., Anglo-Indian or Anglo-African, and to the former the largest percentage of patients belongs.

The hospital at Ranchi was part of an extraordinary wave of asylum-building that swept across much of the world in the late nineteenth and early twentieth centuries, fuelled by genuine concern about the mentally ill, philanthropic impulses to help the dispossessed, and growing belief in the power of science and medicine to heal the afflicted.⁵ The emergence of psychiatry as a profession within medicine both reflected and fuelled these developments. Such enthusiasm seems elegiac in retrospect, but it was well meant at the time and sought to correct a clear injustice against the mentally ill, especially those who were homeless, destitute and wandering the streets and villages.

The early 1900s saw the hospital in Ranchi expand greatly in line with this global trend: new treatments such as hydrotherapy (i.e. water treatments) were introduced, dances and social events were held in the hospital, and – in a notably progressive move – discharged patients were followed up with a ‘welfare inquiry letter’ to check how they were getting on after they returned home.⁶ In 1920, an early form of psychological therapy was introduced using a ‘Habit Formation Chart’. In 1922, the Institute established India’s first department of occupational therapy for mental illness. Seven years later, cottages were built just outside the hospital gates for patients’ families to stay in so that they could take part in family therapy. Berkeley-Hill was also an enthusiast for psychoanalysis, Sigmund Freud’s great vision for understanding and shaping the workings of the human mind.

When Berkeley-Hill left Ranchi in 1934 he wrote: ‘The miserable bear-garden I had taken charge of in October, 1919, [has] become the finest mental hospital in Asia, and a great deal finer than many mental hospitals in Europe.’⁷ This spirit of innovation continued after Berkeley-Hill’s departure and a succession of new treatments for mental illness were introduced at Ranchi as they were developed during the remainder of the twentieth century. India achieved independence in 1947. The following year, the hospital’s name was changed to Inter-Provincial Mental Hospital and it was opened to all Indians.

Today, the hospital in Ranchi integrates patient care with teaching and research across a range of clinical and neuroscientific disciplines. It is a government institution, run by the Indian Ministry of Health and Family Welfare. The vast campus is set on 211 acres and comprises 17 wards: seven for male patients, six for females, one for children and adolescents, one for people with addiction problems, one for emergencies, and a family unit – an enduring testament to the family-oriented legacy of Berkeley-Hill.

While the hospital remains relatively large by European standards, this accurately reflects the position of the mentally ill in many parts of India and elsewhere. In India, a significant proportion of people with mental illness experience difficult conditions in their home villages. Some are neglected, chained and even beaten. In this sense, psychiatry and its institutions have always been shaped by broader social forces. This is clearly reflected in psychiatry’s history and I notice that many of the wards in Ranchi are named after famous figures in psychiatry, including one especially prominent nineteenth-century English asylum doctor: John Conolly.

John Conolly: ‘Indications of Insanity’

John Conolly was born in Market Rasen, Lincolnshire, England, in 1794 and grew up at a time when concern about the mentally ill was reaching a peak in England and elsewhere. The eighteenth century had seen a considerable change in attitudes and a growing belief that mental illness was a problem for society to solve. While there is no real evidence that rates of mental illness actually increased during this period, industrialisation and changes to family structures made the mentally ill more visible in the towns and on the city streets of many countries.⁸ Clearly, something had to be done.

Large public asylums were quickly established in the early nineteenth century to deal with this issue and, while the treatment of ‘insanity’ remained peripheral to medical education for some time further, it could not be ignored indefinitely. Against this background, Conolly graduated as a doctor from the University of Edinburgh in 1821 and was appointed professor of medicine at University College, London, seven years later. In 1830, he published a career-making book on what was still an unusual topic for a medic: mental illness.

Conolly’s text was titled An Inquiry Concerning the Indications of Insanity with Suggestions for the Better Protection and Care of the Insane.⁹ Two years after publication, Conolly co-founded the influential medical organisation that would later become the British Medical Association. In 1839, he was appointed resident physician to the Middlesex County Asylum at Hanwell, west London, where he pioneered the principle of ‘non-restraint’ in the treatment of the ‘insane’. This was one of the earliest moves towards the more humane management of mental illness.

Conolly died in 1866, but is remembered for both his 1830 book and his belief in ‘non-restraint’ – achievements still recognised with a ward named after him here in Ranchi.