The account I have given by no means exhausts the ways in which the relationship between psychosis and creativity has been explored.72 Suffice it to say that, overall, the research is surprisingly consistent, and the long-held association between madness and creativity seems to be a real one. One unresolved issue concerns whether creativity is related to any particular type of psychosis. Writers such as Nancy Andreasen and Kay Jamison have favoured a link between creativity and mania whereas others, notably John Karlsson, have argued for a link with schizophrenia.
This question was addressed directly by Gordon Claridge, who studied in depth ten authors who had written at length about their mental troubles. The writers were Margery Kempe, Thomas Hoccleve, Christopher Smart, William Cowper, John Clare, John Ruskin, Arthur Benson, Virginia Woolf, Antonia White and Sylvia Plath. When their self-reported symptoms were coded using the OPCRIT computer diagnostic program, many diagnoses fell in the schizophrenia spectrum, but some diagnoses of bipolar disorder were also made. Interestingly, several of the writers received both types of diagnosis, depending on the precise criteria employed. For example, William Cowper was diagnosed as suffering from depression according to Taylor and Abrams’ criteria, bipolar disorder according to DSM-III and DSM-III-R, schizoaffective disorder according to the RDC, and schizophrenia according to five less widely used diagnostic systems.73 Once again, it seems, we are confronted with the limitations of Kraepelin’s distinction between dementia praecox and manic depression.
A Matter of Perspective?
Everywhere we look, it seems that the boundaries between sanity and madness are indistinct and permeable. Contrary to the neoKraepelinian assumption that a clear line can be drawn between mental illness and normal functioning, it seems reasonable to assume, as a general principle, that abnormal behaviours and experiences exist on continua with normal behaviours and experiences. This principle of continuity might be formally stated as follows:
Abnormal behaviours and experiences are related to normal behaviours and experiences by continua of frequency (the same behaviours and experiences occur less frequently in non-psychiatric populations), severity (less severe forms of the behaviours and experiences can be identified in non-psychiatric populations), and phenomenology (non-clinical analogues of the behaviours and experiences can be identified as part of normal life).
Some of the evidence we have considered poses problems even for sophisticated accounts of madness. For example, Gordon Claridge’s revised biomedical model – in which madness is regarded as the dysfunctional manifestation of an extreme variant of normal personality – seems threatened by the apparent association between madness and genius. It might be argued that these observations undermine any approach that automatically assumes madness to be a medical condition.
Challenges to the medical approach to madness have a long history. Freud, for example, although a doctor by training, came to believe that medicine provides a poor framework for either understanding or treating mental disorders, and defended the right of ‘lay analysts’ to practise psychotherapy.74 Popular concerns about the value of the medical approach reached something of a crescendo during the 1960s and 1970s. At this time, those who opposed conventional psychiatry (mainly because they regarded it as dehumanizing) often styled themselves as ‘anti-psychiatrists’. Some historians of psychiatry have argued that the neoKraepelinians emerged as a group partly in reaction to the anti-psychiatry movement.75 Certainly, it can be no accident that anti-psychiatry was a popular intellectual position at the same time that Robert Spitzer and his colleagues were fashioning DSM-III.
Many of those who proposed anti-psychiatric arguments were psychiatrists themselves. In Britain, R. D. Laing became one of the most celebrated contributors to the anti-psychiatry debate following the publication of his books The Divided Self and The Self and Others.76 These built on Laing’s training in psychoanalysis and his experiences with a group of Scottish psychiatrists who had argued that schizophrenia patients should be treated with psychotherapy. Laing’s main claim was that psychotic symptoms are meaningful and therefore cannot be understood as medical phenomena. In his later books, Sanity, Madness and the Family and The Politics of Experience, he suggested, first, that schizophrenia patients were driven insane by persecutory family systems and, later, that madness could be seen as a creative, mystical experience.77 Although these ideas were passionately expressed and resonated well with the Zeitgeist (for me, reading Laing as an undergraduate psychology student who had not long escaped from the grip of parental authority was an almost intoxicating experience) it is probably fair to say that their expression was often muddled and inconsistent. This was partly because Laing flirted with various poorly thought out, New Age ideas, and partly because his own creative powers were unable to survive his almost legendary predilection for alcohol.78 This is a pity because his early work revealed an uncanny empathy with psychotic patients, and appeared to offer intriguing insights into the psychology of their experiences.
Other influential critics of conventional psychiatry have put forward different arguments against the medical approach to psychosis. In the United States, for example, the Hungarian-born psychiatrist Thomas Szasz (who has been highly critical of Laing, and who denies that he is an anti-psychiatrist) has claimed that schizophrenia cannot be an illness, because no evidence of pathology has ever been found in the brains of psychotic patients. Indeed, he has gone as far as to assert that mental illness is a myth.79 We will examine these arguments (which I will ultimately reject, although in a way that will offer little comfort to the neoKraepelinians) in a later chapter. For the moment, we need only note that the research on the continuum or continua between psychosis and normal functioning suggests a startling conclusion that is in some ways consistent with Laing’s loosely expressed philosophy. Perhaps the line between sanity and madness must be drawn relative to the place at which we stand. Perhaps it is possible to be, at the same time, mad when viewed from one perspective and sane when viewed from another.
6
Them and Us*
Father, Mother, and Me,
Sister and Auntie say
All the people like us are We,
And everyone else is They,
And They live over the sea,
While We live over the way,
But – would you believe it? – They look upon We
As only a sort of They.
Rudyard Kipling1
During my career, I have met mental health experts in many different parts of the world. Perhaps the most unusual meeting of this kind that I have so far experienced took place in a small village, high in the hills above the town of Mbarara in southern Uganda. I had travelled to the country in support of a British Council-sponsored link between my own university and the Psychology Department at Makarere University in Kampala, where plans were afoot to establish a clinical psychology training course. The trip southwards from the capital had been arranged by Joanna Teuton, a British clinical psychologist who was researching Ugandan attitudes towards psychosis for her Ph.D., and who thought it might be useful for me to see how mental health services were organized in remote areas.
On our arrival in Mbarara, we had met up with Marjolein van Duyl, a young Dutch psychiatrist, who ran a clinic in the small medical school that had recently been established by the Ugandan government. Accompanied by a couple of local nurses, the three of us left the town
in a pick-up truck and, after venturing along a dirt track for about three quarters of an hour, arrived at a small cluster of brick buildings, surrounded by a huge expanse of open grassland. At the sound of our engine, people began to filter out of doorways into the sunlight. Disembarking, we made our way along a small footpath into a field where the healers were gathering. There were about fifteen in total, men and women, young and old, some standing, some squatting on two old benches that had been dragged in to the sharply defined shade of a solitary tree. Some of those present, Marjolein explained, were traditional birth attendants, some were spi
ritual healers, some specialized in diseases of the gut and others in diseases of the mind. ‘Hello-how-are-you-I-am-well-thank-you’, spoken almost as one word, seemed to be the customary Ugandan greeting even among those who did not speak English and, as each of the traditional healers found it necessary to greet each of the visitors, it was some time before we were all settled.
The discussions that took place over the following hour were facilitated by one of the nurses, who proved to be a gifted translator. It was not the first time the healers had met Marjolein, who had worked hard to build a good relationship between them and the medical school. By fostering a climate of mutual respect, Marjolein hoped to help the healers give front-line medical care, while she provided European-style psychiatric treatment to those who failed to benefit from the traditional methods.
We began by exploring the healers’ ideas about psychiatric problems. The most severe disorder that they recognized, called irraro in Runyankole (the local language), made people aggressive and violent. People who suffered from this disorder typically threw stones, ran about naked and refused to eat food. Addiction to alcohol was also seen as a serious problem. Surprisingly, the healers regarded hallucinations and delusions as much less worrying. As the afternoon wore on, we shuffled around to stay in the shade and discussed treatment methods. Some of those who specialized in psychiatric problems said that they would use herbs, grown especially for the purpose. Others said that they would use spiritual methods. For example, when asked how he would treat a patient who was suffering from voices, one man said that he would summon his spirits and ask them to speak with the spirits who were tormenting the afflicted person.
Throughout the discussions, the healers responded politely to the questions that Joanna and I put to them. The healers also asked questions about the kinds of treatment that would be offered to emotionally distressed people in Britain. I found myself trying to explain my role to an audience that had never before encountered a psychologist and began by attempting to outline, in simple terms, how I might set about helping a patient who suffered from auditory halucinations.
The healers listened thoughtfully. They did not seem to find my ideas ridiculous, or necessarily incompatible with their own. In their efforts to compare the two approaches, they asked intelligent questions about the effectiveness of my techniques. Although the conversation was conducted via a translator, and despite the unusual circumstances, it seemed fairly typical of the kinds of discussions that take place whenever clinicians gather to discuss their cases.
Is Madness Universal?
In the middle of the nineteenth century, Samuel Butler, the rebellious son of an English rector, left his homeland to rear sheep in New Zealand. At the time, large areas of that country were still unmapped. Butler’s experiences gave him a distant perspective on his own society, which he affectionately mocked in his utopian fiction Erewhon (Nowhere), which was published in 1872.2. In the novel, he described a civilization in an undiscovered corner of the world, chanced upon by an explorer, where many of the values of Victorian society were inverted. Attitudes towards crime and health were prominent among the topsy-turvy features of Erewhonian culture. In Erewhon, ill health was considered a crime and was severely punished, whereas immoral behaviour was regarded as a cause for pity and professional treatment. Butler’s satire raises an important question about the nature of mental health and illness: Are psychiatric disorders universal phenomena, or are they culturally determined?
This question needs some unpacking. Horacio Fabrega, Professor of Psychiatry and Anthropology at the University of Pittsburgh, has argued that all cultures, past and present, have recognized human behavioural breakdowns – anomalous behaviours that are sustained and judged negatively, and which are regarded as disruptive to organized
social life.3 However, this does not mean that madness, as defined within the Kraepelinian paradigm, is a universal phenomenon. Perhaps different societies single out different kinds of behaviours and experiences as evidence of madness? We must therefore divide our question about the universality of psychiatric disorders into two separate questions. First, do psychotic experiences and behaviours, as defined by neoKraepelinian criteria, appear everywhere we look? Second, do different cultures draw the boundaries between sanity and madness in the same or in different places?
My encounter with the traditional healers illustrates some of the difficulties involved in answering these questions. It seemed to me that irraro did not obviously correspond to any category of illness recognized by psychiatrists from the developed world, but it was possible that closer study of the disorder would have shown me to be mistaken. John Orley, a psychiatrist who spent some time with the Baganda (the largest tribe in Uganda), documented, in addition to this kind of madness (known as eddalu to the Bagandans), other locally recognized disorders, some of which, like obusiru (foolishness), are regarded as diseases of the head whereas others, for example emmeme etyemuka (fright), are regarded as diseases of the heart. Some, such as ensimbu (fits), seem to correspond very closely to Western medical concepts (in this case, epilepsy) whereas others, for example emmeme egwa (a general weakening of the body and failure to eat), do not.4
In practice, cross-cultural studies of madness have been pursued by two different groups of researchers, who have started out with different assumptions. Psychiatrists, for the most part, have tried to use Western medical concepts to explain the behaviour of people in developing countries. Orley, for example, argued that many cases of eddalu are in fact people suffering from schizophrenia. Social anthropologists, in contrast, have been interested in exploring concepts of normality and abnormality in different cultures.*
Are Psychotic Symptoms Found in All Societies?
As we have already seen, Kraepelin was one of the first people to investigate whether psychotic symptoms could be found in non-Western cultures. Although he concluded that both dementia praecox and manic depression occurred in Java, he qualified this observation by suggesting that delusions and hallucinations were less common among the Javanese than among Europeans, and that states of mania and depression in the Far East seemed to be milder and more fleeting. Speculating about the likely causes of these differences, he argued that:
It is, of course, an open question whether the underlying processes there are basically the same as those which produce similar clinical pictures in our hospitalsat home. Perhaps it will be possible to settle the matter by anatomical studies, but from the clinical point of view, based on a comparison between the phenomena of disease which I found there and those with which I was familiar at home, the overall similarity far outweighed the deviant features… The relative absence of delusions among the Javanese might be related to the lower stage of intellectual development attained, and the rarity of auditory hallucinations might reflect the fact that speech counts far less than it does with us and that thoughts tend to be governed more by sensory images.5
Studies conducted by anthropologists and doctors working for colonial administrations during the first half of the twentieth century reported low rates of psychosis in non-Western countries, leading some observers to doubt whether schizophrenia could occur in societies that were close to a ‘state of nature’. C. G. Seligman, for example, in a report published in 1929, commented of the people of Papua New Guinea: ‘There is no evidence of the occurrence of mental derangement, other than brief outbursts of maniacal excitement, among natives who have not been associated with White Civilisation.’6 Foremost among those who elaborated on this theme was John Carothers, a young physician who, in 1938, was appointed senior medical officer in charge of Mathari Mental Hospital in Nairobi, following the dismissal of James Cobb from the same position.7 (Cobb, who unlike Carothers, had received a formal training in psychiatry, had scandalized Nairobi society by his drinking, his open homosexuality and his bizarre
attachment to two pet lion cubs, with whom he was rumoured to have enjoyed sexual relations.)
Believing his appointment to be a temporary one, and m
indful of his lack of experience in psychiatry, Carothers was at first reluctant to record any scientific observations about his patients. However, after working alongside a group of British army psychiatrists who passed through Kenya during the Second World War, and following a short period of training in London afterwards, he began to see parallels between European schizophrenia patients and ordinary African citizens. Both seemed self-absorbed, morally lazy, preferred to live in a world of fantasy and projected their own qualities and emotions on to the world around them. Because ‘the step from the primitive attitude to schizophrenia is but a short and easy one’, he believed that ordinary Africans would remain psychologically healthy in the simple and unstructured environment of the rural village but that, on coming into contact with European rule in the urban centres, ran the risk of becoming psychotic.
Such was Carothers’ reputation that, in 1952, he was commissioned by the World Health Organization to write a report on the African mind, and, in 1954, by the British government to write a psychological analysis of the Mau Mau rebellion. The former, in which he attributed the African personality to poorly developed frontal lobes, was surprisingly well received by anthropologists. The latter attempted to pathologize the motives of a revolutionary movement and failed to mention the land disputes that had triggered the insurrection. Looking back from our vantage point at the beginning of the twenty-first century, it is easy to see that Carothers’ ideas were taken seriously because they were consistent with the assumed inferiority of Africans, rather than because of the quality of his research. Not surprisingly, a rather different picture became apparent when the first systematic cross-cultural research on psychosis was conducted several decades later.
Madness Explained Page 15