Till now, madness has been thought a small island in an ocean of sanity. I am beginning to suspect that it is not an island at all but a continent.
The history of mental illness is a fickle one. Like the patients in its asylums’ small cells, it tosses and turns between the external and internal and constantly changes definitions. The problem has largely been that, in order to define madness, one has to first define what a healthy human being is. Obviously, people are going to have different interpretations of that.
In 1882, Joaquim Maria Machado de Assis, arguably Brazil’s greatest writer, published a novella called O Alienista: The Alienist. In it, he chronicles the fate of a small town going through a small-town revolution: the founding of an asylum. Its protagonist, Simao Bacamarte, a man of extreme reason, is granted the power to decide who should be interned, and to try to cure those who are deemed to be mentally ill. He starts out with a sensibly vague definition of madness:
We must determine the nature and boundaries of reason. Madness is simply all that lies beyond those limits. But what is reason if not the equilibrium of the mental faculties? An individual, therefore, who lacks this equilibrium in any particular is, to that extent, insane.
Machado de Assis, as any devoted writer would, takes this idea and runs with it. Bacamarte soon becomes a kind of tyrant – or God, if you will – whose will shall be done, and whose sole judgement decides the fate of the poor townsfolk. He stalks the town in search of signs of irrational behavior. Slowly but certainly, he applies his definition – lack of equilibrium – more strictly, up until the point where the people of the town realize “the alienist’s concept of madness included practically everybody.”
From that day on, the population of the asylum increased even more rapidly than before. A person could not utter the most commonplace lie, even a lie that clearly benefited him, without being immediately committed to the Green House. Scandal-mongers, dandies, people who spent hours at puzzles, people who habitually inquired into the private lives of others, officials puffed up with authority – the alienist’s agents brought them all in.
Indeed, as Bacamarte walks around and observes, he confirms his theory that “the number of persons suffering from insanity was far greater than commonly supposed.” His ideas are reminiscent of those expounded by Sherwood Anderson in the first story of his seminal work Winesburg, Ohio. In “The Book of the Grotesque,” an old writer dreams and reminisces about the people he met throughout his days in the small town of Winesburg. The tale sets the stage for the rest of the collection’s loosely connected stories wherein, as Woody Guthrie so wonderfully summarized it, “people laugh and love and dream, they fight, they hate to die.”
At his desk the writer worked for an hour. In the end he wrote a book which he called “The Book of the Grotesque.” It was never published, but I saw it once and it made an indelible impression on my mind. The book had one central thought that is very strange and has always remained with me. By remembering it I have been able to understand many people and things that I was never able to understand before. The thought was involved but a simple statement of it would be something like this:
That in the beginning when the world was young there were a great many thoughts but no such thing as a truth. Man made the truths himself and each truth was a composite of a great many vague thoughts. All about in the world were the truths and they were all beautiful.
The old man had listed hundreds of the truths in his book. I will not try to tell you of all of them. There was the truth of virginity and the truth of passion, the truth of wealth and of poverty, of thrift and of profligacy, of carelessness and abandon. Hundreds and hundreds were the truths and they were all beautiful.
And then the people came along. Each as he appeared snatched up one of the truths and some who were quite strong snatched up a dozen of them.
It was the truths that made the people grotesques. The old man had quite an elaborate theory concerning the matter. It was his notion that the moment one of the people took one of the truths to himself, called it his truth, and tried to live his life by it, he became a grotesque and the truth he embraced became a falsehood.
This is what the fictional Bacamarte did. He presupposed man as a rational being, he presupposed man as a machine. And this is exactly what real scientists started doing approximately during the Cold War. They developed game theory, which stated that every human being was a conspirator, a calculating, scheming egotist out to one-up everyone that interfered. This is the idea of man-as-machine, driven by “selfish genes.” In this analogy, unexpected output came to be the shibboleth of mental illness. Thus, aberrant behavior in and of itself, no matter what the consequence, turned man-machines into grotesques.
Reading The Alienist, with its light-hearted, mocking tone, you cannot escape the feeling that Machado de Assis was simply poking fun at what he considered to be a silly occupation. I cannot imagine he meant the story as a cautionary warning to the future, to the dangers of one person judging the sanity of another. In hindsight, however, it is remarkably prescient. During the century after the book’s release, psychiatry evolved under the wing of biological and psychoanalytical factions, and grew to accommodate more and more people. From merely the external – madmen shouting in the street, people who heard voices – psychiatry started to adopt everyone who came to knock on their door. Never was this better shown than in the infamous Rosenhan experiment.
In 1973, David Rosenhan, a Stanford professor of psychology, along with several volunteers, presented themselves at twelve different mental hospitals across the US, claiming they heard voices in their head (which they didn’t). Rosenhan was trying to show that doctors were not at all capable of discerning the mental health of patients. With startling success, all but one of the volunteers were admitted and diagnosed with schizophrenia. Moreover, after they had entered the hospital, their claim that, actually, they were healthy, was ignored. The only way for them to get acquitted was to first agree with the doctors’ diagnoses and then pretend to get better.
“Talk sense to a fool, and he will call you foolish,” Euripides had already concluded roughly twenty-four hundred years ago. What all this goes to clearly show, as most all psychological research confirms, is that strong prejudices come in when any one person attempts an estimation of another. Or, as a dissenter of Bacamarte has it in The Alienist, “If so many men whom we considered sane are locked up as madmen, how do we know that the real madman is not the alienist himself?”
Partly in response to the influential Rosenhan experiment, psychiatrists tried to devise a more objective way to diagnose patients. They started to focus only on symptoms and turned diagnosis into a list of yes/no questions, the results of which could be computed “objectively.” When these lists were sent out across the United States, the results were shocking: over 50% of the diagnosed were found to be mentally ill. Almost a century after Bacamarte posed his theory, it had finally been confirmed.
But what does it mean to consider more than half the population, or in The Alienist‘s case, four-fifths of the population, mentally ill? Of course, the 50% should have been enough of a warning. Should not normality be with the majority, after all? Bacamarte started to think so, with radical consequences:
He had concluded not only that his theory was unsound but also that the exactly contrary doctrine was true – that is, that normality lay in a lack of equilibrium and that the abnormal, the really sick, were the well-balanced, the thoroughly rational.
Perhaps this is what Carl Jung was thinking of when he quipped: “Show me a sane man, and I will cure him for you.” Within this new definition, Bacamarte had a much harder time admitting people to his asylum. While for evidence of lack of equilibrium one aberrance is enough, the opposite is not so easily confirmed. A long period of stability was necessary before the diagnosis could safely be made.
Robert Spitzer, one of the architects of the diagnostic revolution in psychiatry, later admitted to Adam Curtis – in the documentary series The Trap – that he partly regretted the move, pointing out that it had “medicalized” a part of the population that had never needed medication in the first place. In creating these disorder checklists, the psychiatrists had inadvertently created a standard that people could compare themselves to. The public was finally presented a firm handle to hold on to in order to be(come) normal.
What was needed to cure the insane, according to Bacamarte, seems closely related to Anderson’s aforementioned idea of the grotesque, of a single truth (ideology?) getting out of hand and deforming people:
Having divided the patients into classes according to their predominant moral qualities, the doctor now proceeded to break down those qualities. He applied a remedy in each case to inculcate exactly the opposite characteristic, selecting the specific medicine and dose best suited to the patient’s age, personality, and social position.
For example, to cure a modest poet, Bacamarte lauds him, comparing him to the great Camoes. In this way, he balances out the modesty. This is closely related to the earlier idea of the man-as-machine and the mentally-ill-man-as-malfunctioning-machine. The mentally ill have to be nudged back into place. Nudging is indeed the proper word here, as it is now more and more used in what has been termed liberal paternalism, or even – with the rise of Silicon Valley – algorithmic regulation.
However, when behavioral economists started to actually test the ideas of game theory and started to look for the homo economicus they supposed, their results revealed nothing. Indeed, as Adam Curtis has it in The Trap:
It has been found that the only people who really fit the simplified mathematical model of self-interested rational behaviour at all times are economists and psychopaths.
Would you believe that Machado de Assis had foreseen even this unlikely outcome? After he has cured everyone, he comes to the conclusion that he has not really changed these patients, but that they were simply inherently “unbalanced” all the time. The alienist can then affirm the ultimate truth, that “there never were and never would be any madmen in Itaguai or anywhere else.” (Incidentally, herein, too, he was remarkably prescient; see The Myth of Mental Illness) However, he immediately realises such a theory that includes everyone is not worth all that much. “If he could just find one undeniably well balanced, virtuous, insane man, the new theory will be acceptable – not as an absolute, exceptionless principle, which was inadmissable, but as a general rule applicable to all but the most extraordinary cases.” You might guess where this is heading. It takes one to know one: like the economists who found in themselves the prime specimen for their theory, Bacamarte’s theory, too, is saved by himself:
He had found in himself the perfect, undeniable case of insanity. He possessed wisdom, patience, tolerance, truthfulness, loyalty, and moral fortitude – all the qualities that go to make an utter madman.
Jeroen van Honk is a writer living in Leiden, Netherlands. He has published stories in the Quotable, Sassafrass Magazine and Paper Tape Magazine. Links to his published works can be found at jeroenvanhonk.com/.