The mentally troubled and the mentally ill turned back into people in the nineteenth century. Having spent the previous hundred years like animals, they were now to be imitators of middle-class propriety—whether they wished it or not. Philippe Pinel was among the earliest reformers of treatment for the mentally ill, publishing his Treatise in 1806. He introduced the notion of “the moral treatment of insanity,” which, given that “the anatomy and pathology of the brain are yet involved in extreme obscurity,” seemed to him the only way forward. Pinel set up his hospital to conform to high standards. He persuaded his chief of staff to “exercise towards all that were placed under his protection, the vigilance of a kind and affectionate parent. He never lost sight of the principles of a most genuine philanthropy. He paid great attention to the diet of the house, and left no opportunity for murmur or discontent on the part of the most fastidious. He exercised a strict discipline over the conduct of the domestics, and punished, with severity, every instance of ill treatment, and every act of violence, of which they were guilty towards those whom it was merely their duty to serve.”
The chief achievement of the nineteenth century was the establishment of the asylum system for residential care of the mentally ill. Samuel Tuke, who managed one such institution, said, “In regard to melancholiacs, conversation on the subject of their despondency is found to be highly injudicious. The very opposite method is pursued. Every means is taken to seduce the mind from its favorite but unhappy musings, by bodily exercise, walks, conversation, reading, and other innocent recreations.” The effect of this kind of program (as opposed to the punishing shackles and bizarre “taming” techniques of the previous century) was, according to the master of another asylum, that “melancholia, not deepened by the want of all ordinary consolations, loses the exaggerated character in which it was formerly beheld.”
Asylums pullulated like toadstools after a rainstorm. In 1807, 2.26 persons in every ten thousand of England’s general population were judged to be insane (a category that would have included the severely depressed); in 1844, the number was 12.66, and by 1890, it was 29.63. That there were thirteen times as many nutters in the late Victorian period as there were at the dawn of the century can be explained only in small part by the actual increase of mental illness; in fact, in the sixteen years between Parliament’s two Lunatics Acts (of 1845 and 1862), the number of identified poor mentally ill people doubled. This was occasioned in part by the increasing willingness of people to identify their relatives as crazy, in part by more rigorous standards of sanity, and in part by the depredations of Victorian industrialism. The same depressive, not sufficiently ill for Bedlam, who would once have skulked silently around the kitchen was now removed from the jolly family circle of Dickensian Britain and placed out of reach, where he did not interrupt social interaction. The asylum gave him a community in which to operate, but it also cut him off from the company of those who had any natural cause to love him. The growth of the asylum was also intimately connected to the growth in rates of “cure”—if some people’s illness could actually be ameliorated through time in an asylum, then it was very nearly a duty to place anyone who might be at the brink of a lifetime of misery somewhere where he might be saved.
The principle of the asylum was to go through a long sequence of refinements. It was already a topic of debate in parliamentary select committees in 1807. The first Lunatics Act passed by Parliament required that every county provide asylum for the poor insane, including the severely depressed; and the 1862 Act to Amend the Law Relating to Lunatics opened up the possibility of voluntary confinement, so that those experiencing symptoms might, with the approval of medical authorities, put themselves into asylums. This provision demonstrates quite clearly how far the asylum had come; you would have had to be far more than crazy to check yourself into one of the eighteenth century’s hospitals for the insane. By this time, county asylums were being run with public funds; private asylums run for profit; and registered hospitals (such as Bedlam, which in 1850 housed some four hundred patients) for the more acutely ill supported with a mix of public funds and private charitable contributions.
The nineteenth century was a time of classifications. Everyone debated the nature of illness and its parameters, and everyone redefined what had previously been simply identified as melancholy into categories and subcategories. Great theoreticians of classification and cure succeeded one another rapidly, each determined that some minor adjustment of his predecessor’s theory would improve treatment by leaps and bounds. Thomas Beddoes wondered already in the first year of the century “whether it be not necessary either to confine insanity to one species, or to divide it into almost as many as there are cases.”
Benjamin Rush, in America, believed that all insanity was a fever that had become chronic. This condition, however, was subject to external influence. “Certain occupations predispose to madness more than others. Poets, painters, sculptors, and musicians, are most subject to it. The studies of the former exercise the imagination, and the passions.” Delusional depression was strong among Rush’s patients. One, for example, was a sea captain who believed absolutely that he had a wolf in his liver. Another believed himself to be a plant. The plant man was persuaded that he needed to be watered, and one of his friends, a bit of a prankster, took to urinating on his head, so enraging the patient as to effect a cure. Though Rush, unlike others, did not rise to Pinel’s level of sympathy for patients, he did, unlike his predecessors, believe in listening to them. “However erroneous a patient’s opinion of his case may be, his disease is a real one. It will be necessary, therefore, for a physician to listen with attention to his tedious and uninteresting details of its symptoms and causes.”
W. Griesinger, working in Germany, reached back to Hippocrates and declared once and for all that “mental diseases are brain diseases.” Though he was not able to identify the origin of these brain diseases, he firmly insisted that there was one; and that the fault in the brain should be located and then treated, either preventatively or curatively. He accepted the movement of one mental illness into another, what we might call dual diagnosis, as part of Einheitspsychose—the principle that all mental illness is a single disease and that once your brain goes wonky, anything can happen in it. This principle led to the acceptance of manic-depression, the understanding that patients who fluctuated between extreme states might have a single disease rather than two in fateful alternation. On the basis of this work, brain autopsies became common, especially in instances of suicide.
Griesinger was the first to present the idea that some mental disease is only treatable, while other mental illness is curable, and on the basis of his work most asylums began to divide their patients, separating those who stood a chance of recovery and of return to functional life from the more desperate cases. Though the lives of the truly insane remained horrible, the lives of the other patients began to take on a greater semblance of normality. Treating depressed people once more as people kept them from descending into total dependence Meanwhile, research along the lines of Griesinger’s began to usurp religion; the change in social standards that began in the late Victorian period may in some ways be linked to the rise of the medical model of the brain.
In Griesinger’s hands, depression came to be fully medicalized. In the twentieth century’s most influential history of mental illness, Michel Foucault has suggested that this was part of a grand scheme of social control related to colonialism and the entrenchment of ruling wealth over a trampled underclass. By classing those who found life too difficult as “ill” and by removing them from society, the ruling class could impose levels of genuine social strain and difficulty that were in fact inhuman, and against which a less contained class of miserable people might have rebelled. If the proletariat of the industrial revolution were to be effectively oppressed, those among their number who were truly at the brink of self-destruction had to be removed, lest they serve as warnings to those around them and foment revolution.
Fo
ucault makes good reading, but the influence he has had is much crazier than the people who are his subject. Depressed people cannot lead a revolution because depressed people can barely manage to get out of bed and put on their shoes and socks. I could no more have joined a revolutionary movement during my own depression than I could have had myself crowned king of Spain. The truly depressed were not made invisible by asylums; they had always been largely invisible because their very disease causes them to sever human contacts and allegiances. The general reaction of other members of the proletariat (or, indeed, of any other class) to people who are severely depressed is revulsion and discomfort. Those who are not themselves afflicted with the complaint dislike seeing it because the sight fills them with insecurity and provokes anxiety. To say that the severely ill were “taken away” from their natural context is to deny the reality, which is that the natural context rejected them, as it had always done insofar as it could. No conservative parliamentarians came into the streets of the cities soliciting patients for the asylums; the asylums overflowed with people being checked in by their own families. The attempt to define the social conspirators continues like an interminable Agatha Christie novel in which everyone has actually died of natural causes.
Busy asylums were in part a consequence of the general alienation of late Victorianism, which was articulated in one form or another by everyone from the pillars of the social order (Alfred Lord Tennyson, for example, or Thomas Carlyle), to the ardent reformists (Charles Dickens or Victor Hugo), to those at the decadent fringe of society (Oscar Wilde or Joris-Karl Huysmans). Carlyle’s Sartor Resartus chronicles alienation from an overcrowded world, a kind of universal depression, foreshadowing Brecht and Camus. “To me the Universe was all voice of Life, of Purpose, of Volition, even of Hostility: it was one huge, dead, immeasurable Steam-engine, rolling on, in its dead indifference, to grind me limb from limb.” And later, “I lived in a continual, indefinite, pining fear; tremulous, pusillanimous, apprehensive of I knew not what: it seemed as if all things in the Heavens above and the Earth beneath would hurt me; as if the Heavens and the Earth were but boundless jaws of a devouring monster, wherein I, palpitating, waited to be devoured.”
How to endure life, itself so burdensome in this sorrowful time? The American philosopher William James most directly addressed these problems and correctly identified the apparent source of early modernist alienation as the breakdown of unquestioning faith in a supreme God benevolently disposed toward his creation. Though James himself ardently believed in a personal creed, he was also a sharp reader of the process of disbelief. “We of the nineteenth century,” he wrote, “with our evolutionary theories and our mechanical philosophies, already know nature too impartially and too well to worship unreservedly any God of whose character she can be an adequate expression. To such a harlot, we owe no allegiance.” Addressing a group of Harvard students, he said, “Many of you are students of philosophy and have already felt in your own persons the skepticism and unreality that too much grubbing in the abstract roots of things will breed.” And of the triumph of science, he wrote, “The physical order of nature, taken simply as science knows it, cannot be held to reveal any one harmonious spiritual intent. It is mere weather.” This is the essence of Victorian melancholy. Periods of greater and lesser faith had alternated through human history, but this relinquishing of the notion of God and of meaning opened the way to agonies that have endured since, far more plangent than the sorrow of those who thought that an omnipotent God had forsaken them. To believe oneself to be the object of intense hatred is painful, but to find oneself the object of indifference from a great nothingness is to be alone in a way that was in some sense inconceivable to the imagination of earlier eras. Matthew Arnold gave voice to this despair:
The world, which seems
To lie before us like a land of dreams,
So various, so beautiful, so new,
Hath really neither joy, nor love, nor light,
Nor certitude, nor peace, nor help for pain;
And we are here as on a darkling plain
Swept with confused alarms of struggle and flight,
Where ignorant armies clash by night.
This is the form that modern depression takes; the crisis of losing God is far more common than the crisis of being cursed by Him.
If William James defined the philosophical gap between what had been thought to be true and what philosophy had revealed, then the eminent doctor Henry Maudsley defined the consequent medical gap. It was Maudsley who first described a melancholy that recognizes but cannot resolve itself. “It is not unnatural to weep,” Maudsley commented, “but it is not natural to burst into tears because a fly settles on the forehead, as I have known a melancholic man to do. [It is] as if a veil were let down between him and [objects]. And truly no thicker veil could well be interposed between him and them than that of paralyzed interest. His state is to himself bewildering and inexplicable. The promises of religion and the consolations of philosophy, so inspiring when not needed and so helpless to help when their help is most needed, are no better than meaningless words to him. There is no real derangement of the mind; there is only a profound pain of mind paralyzing its functions. Nevertheless, they are attended with worse suffering than actual madness is, because the mind being whole enough to feel and perceive its abject state, they are more likely to end in suicide.”
George H. Savage, who wrote about insanity and neurosis, spoke of the need, at last, to bridge definitively the gap between philosophy and medicine. “It may be convenient,” he wrote, “but it is not philosophical to treat the body apart from the mind, and the physical symptoms separately from the mental. Melancholia is a state of mental depression, in which misery is unreasonable either in relation to its apparent cause, or in the peculiar form it assumes, the mental pain depending on physical and bodily changes and not directly on the environment. A saturated solution of grief,” he wrote, “causes a delusion to crystallize and take a definite form.”
The twentieth century saw two major movements in the treatment and understanding of depression. One was the psychoanalytic, which has in recent years spawned all kinds of social science theories of mind. The other, the psychobiological, has been the basis for more absolutist categorizations. Each has at times seemed to have a more convincing claim on truth; each has at times seemed positively ludicrous. Each has taken a certain quantity of real insight and extrapolated absurdities from it; and each has undertaken an almost para-religious self-mystification that, had it occurred in anthropology or cardiology or paleontology, would have been laughed out of town. The reality doubtless incorporates elements from both schools of thought, though the combination of the two is hardly the sum total of the truth; but it is the competitive gleam with which each school has viewed the other that has been the basis for excessive statements that are in many instances less accurate than Robert Burton’s seventeenth-century Anatomy.
The modern period for thought about depression really began with Freud’s publication, in 1895, of the “Fliess Papers.” The unconscious, as formulated by Freud, replaced the common notion of a soul and established a new locus and cause of melancholia. At the same time, Emil Kraepelin published his classifications of mental illness, which defined the category of depression as we now know it. These two men, representing the psychological and biochemical explanations of illness, established the rift that the field of mental health is now trying to close. While the separation between these two versions of depression has been damaging to modern thinking about depression, the independent ideas themselves have considerable significance, and without their parallel development we could not have begun to pursue a synthetic wisdom.
The imaginative framework for psychoanalysis had been in place for years, albeit in a distorted form. Psychoanalysis has much in common with the bloodletting that had been popular some time before. In each instance, there is the assumption that something within is preventing the normal functioning of mind. Bloodletting was to re
move malign humors by drawing them physically from the body; psychodynamic therapies are to disempower forgotten or repressed traumas by drawing them from the unconscious. Freud stated that melancholy is a form of mourning and that it rises from a feeling of loss of libido, of desire for food, or for sex. “Whereas potent individuals easily acquire anxiety neuroses,” Freud wrote, “impotent ones incline to melancholia.” He called depression “the effect of suction on the adjoining excitation,” which creates “an internal hemorrhage,” “a wound.”
The first coherent psychoanalytic description of melancholy came not from Freud but from Karl Abraham, whose 1911 essay on the subject remains authoritative. Abraham began by stating categorically that anxiety and depression were “related to each other in the same way as are fear and grief. We fear a coming evil; we grieve over one that has occurred.” So anxiety is distress over what will happen, and melancholy is distress over what has happened. For Abraham, one condition entailed the other; to locate neurotic distress exclusively in the past or future was impossible. Abraham said that anxiety occurs when you want something you know you shouldn’t have and therefore don’t attempt to get, while depression occurs if you want something and try to get it and fail. Depression, Abraham says, occurs when hate interferes with the individual’s capacity to love. People whose love is rejected perceive, paranoiacally, that the world has turned against them and so they hate the world. Not wishing to acknowledge such hatred to themselves, they develop an “imperfectly repressed sadism.”
“Where there is a great deal of repressed sadism,” according to Abraham, “there will be a corresponding severity in the depressive affect.” The patient, often without realizing it, gets a certain pleasure from his depression as a result of his sadistic attitudes. Abraham undertook the psychoanalysis of a number of depressed patients and reported substantial improvements in them, though whether these patients were redeemed by true insight or comforted by the idea of knowledge is unclear. In the end, Abraham admitted that the kind of trauma that leads to depression can also lead to other symptoms, and “we have not the least idea why at this point one group of individuals should take one path and the other group another.” This, in his words, is “the impasse of therapeutic nihilism.”
The Noonday Demon Page 46