The Meaning of Mental Illness

THE ATLANTIC

by Donald Fleming

IT IS, as they say, a mad world; and we have the mad men to go with it. Mental illness, with cancer and heart disease, is now one of the handful of great health problems in the United States. The situation is accentuated by the fact that most of the famous contagious diseases have almost dwindled into insignificance, either from effective measures of prevention or known methods of cure, so that more people survive to fall afoul of the degenerative and functional diseases.

Important as the objective problem of mental illness is. it is more important still for the unprecedented role which it plays in shaping contemporary conceptions of human nature. It is a fair proposition that nothing is more diagnostic for the history of modern thought than the successive attitudes that have been taken toward mental illness. In the seventeenth century, it was habitually seen as a form of infestation by devils and evil spirits, a demoniac possession — a usage which corresponded to the biblical descriptions of epilepsy. This view of mental illness readily lent itself to the construction that demons were like any other visitors. They got inside because they were invited. In the most extreme form, this led to the execution of unbalanced persons as witches on the ground that they had deliberately laid themselves open to obscene incursions, leased their bodily premises to the devil.

As the eighteenth century terminated prosecutions for witchcraft, and benevolence became the great virtue of the age, there was an increasing tendency to acquit the mentally ill of any complicity in their predicament and see them as victims of a senseless affliction. The one marked exception to this trend was the relentless insistence down to the end of the nineteenth century that many vicious young men could and did bring insanity upon themselves by masturbation — a bugbear that was still being used by boarding schools in the twentieth century to keep their charges in line. Apart, however, from this brutal piece of fear-mongering, the basic trend in the eighteenth century was toward an increasingly enlightened view of mental illness as an affliction of the innocent. This development was accompanied by growing emphasis upon somatic derangements as the cause of mental disturbances. Fill the rise of psychosomatic medicine in the twentieth century, that was a definitive answer to any suggestion that the patient had willed his own plight.

Nineteenth-century physicians, particularly after 1860, converted the growing alertness to the physical basis of mental derangements into the doctrinaire theory that all mental illness without exception resulted from anatomical lesions of the brain or nervous system. One of the leading American alienists of the period, the superintendent of the State Hospital for the Insane at Utica, New York, Dr. John P. Gray, announced with ineffable complacency in 1870 that he had eliminated the old category of “mental and moral causes" from his statistics about the patients at Utica. “The mind,” he said, “cannot become diseased, only the body.”

This conception was brought to bear upon the assassination of two American Presidents — the moment when Americans have always been confronted most starkly with the aberrations of the spirit and moved to reflect as a people upon the meaning of insanity. When Charles Guiteau assassinated James A. Garfield in 1881 under instructions from God to “remove the President,” only one medical witness could be found to entertain the possibility that Guiteau was insane. Dr. John P. Gray said that, on the contrary, there was no indication of brain disease — a perfectly accurate statement borne out by the autopsy — and scoffed at old-fashioned people who thought that purely mental delusions could produce insanity without a diseased brain. At this point Guiteau could no longer contain himself and cried out, “There is no brainology in this case, but it is spiritology. Spirits get into a man and make him do this and that thing, and that is insanity.” He was convicted and hanged.

The same “brainology” that condemned a palpably unbalanced man was still riding high when Leon Czolgosz killed McKinley. The alienists who examined Czolgosz briskly over a weekend rightly surmised that he did not have a lesion of the brain. So he was perfectly sane, only an anarchist, and fit for the executioner. Later on it was discovered that he had had a major breakdown three years before, accompanied by severe paranoiac symptoms.

The upshot of this dogmatic “brainology” was to relieve people with a diseased brain from any responsibility for their actions, while sternly arraigning anybody who was functionally rather than anatomically deranged. The category of the genuinely ill had been severely narrowed, and those who did not qualify were as mercilessly held to blame for their actions as any witch had been in the seventeenth century.

THE great intellectual sponsors of nineteenthcentury brainology were the neurologists; and there is no doubt that Sigmund Freud began as one of them and wanted to perpetuate their commitment to the exclusively physical interpretation of mental illness. Yet Freud, after valiant efforts to keep the flag flying, had to admit before 1900 that neither he nor anybody else could yet correlate all mental disturbances with demonstrable physical processes in the brain or nervous system. The practical consequence was that he became, against the bent of his own spirit, the principal agent in rectifying the overextension of materialism that marked the dominant nineteenth-century conceptions of mental derangement. He had the courage to proclaim that the neuroses, at any rate, would have to be treated for the foreseeable future as purely functional maladjustments with no discernible anatomical basis. The psychiatrist would have to practice a science of the mind rather than of the brain.

By the same token. Freud re-expanded the category of genuine mental illness in a way that would have encompassed men like Guiteau and Czolgosz. In a still larger sense, Freud assimilated the gross neuroses to the strategies of concealment shown to be at work among normal people and given away by slips of the tongue, joking behavior, and the symbolic language of dreams. These were now portrayed as minor variants upon the severe organic displacements of intolerable mental stress as manifested in the worst hysterics. It did not follow by Freud’s lights that everybody was ill, but all life strategies were laid out along a continuous spectrum of deceptions great and small, signifying some degree of aversion from reality. “Every one of us,” he said, “behaves in some one respect like a paranoiac, corrects some aspect of the world which is unbearable to him by the construction of a wish and introduces this delusion into reality.” He added that “delusional remolding of reality” by a number of people in common was the essence of religion.

Freud, in short, was rubbing out any sharp line that might be thought to divide neurotics from “normal” people. In fact, it was he more than anyone else who put the quotation marks around normal and made people sheepish about saying it. In keeping with this, he consistently argued that he was expounding not merely a psychopathology but an absolutely catholic psychology applicable to all men. Abnormal psychology merely supplied an exaggerated delineation of processes that were universally at work. In this sense, the mentally ill became highly recognizable caricatures of their more smoothly functioning brethren, and the condition of the mentally disturbed a mirror held up to human nature at large.

Yet, important as this blending of psychology and psychopathology was, the really decisive step taken by Freud was to postulate the meaningfulness of every aspect of thought and conduct, the radically unfragmented and untrivial character of everything a man did — or didn’t do. All “incidental” aspects of behavior became no longer incidental but intensely meaningful revelations of the whole personality. All mental activity, waking or asleep, conscious or unconscious, normal or abnormal, was drenched in meaning, stamped with an indelible significance. The old discriminations between trivial and significant, accidental and meaningful, were destroyed. Everything started up into a uniform urgency and signification. In a way, it was like the old attitude toward the behavior of witches, who were seen as displaying a consistent pattern of diabolism that lent a sinister meaning to every detail of their existence. Freud, however, zealously strove to avoid any moral judgments upon the patterns that he discerned; and now it was no longer a special class of deviants whose life had achieved a unitary thrust but the entire human race.

To put the matter another way, Freud laid every man open to a definitive invasion of his psychological privacy, a relentless inquisition initially intended for therapeutic purposes by physicians but rapidly passing over into an insatiable roving inquiry by amateurs, by which all the facts of a man’s life were called in evidence and swept imperiously into an overriding interpretation in which precisely the data that people sought to withhold became the master clue. Every revelation told, and every act, but so did every attempt at concealment and every failure to act. To appreciate the difference this violation of psychological privacy made, one need only consider the lurid Freudian light that suddenly broke upon the great creators of children’s literature — upon Lewis Carroll’s affection for Alices and J. M. Barrie’s obsession with boys that wouldn’t grow up. An appalling meaningfulness has laid them, and ourselves, bare. Freud’s own retrospective psychoanalysis of Leonardo came a cropper upon an elementary mistake in translation. He thought that Leonardo was obsessively fixated upon vultures, but that was not the bird that Leonardo was talking about in the key passage. Yet the technique entrenched itself as a new kind of postmortem.

Classical Freudian discourse was a contradiction of nineteenth-century pathology but not an inversion. What turned pathology upside down was the rise of psychosomatic medicine, with its assumption that prolonged psychic disturbances, so far from being the result of anatomical lesions, could produce lesions. Freud himself had much experience of the hysterical conversion of psychic repressions into severe organic symptoms. It remained for others to draw the logical inference of psychosomatic illness in nonhysterics. The anxieties of functioning neurotics could be encoded into gastric ulcers and ulcerative colitis. Conversely, the code could be cracked to reveal the anxieties. In this way, a new dimension of Freudian meaningfulness was added to men’s lives, a new technique for penetrating their disguises.

The main historical contribution of Carl Jung was to confer comprehensive meaningfulness upon the lives of two classes of people whom Freud neglected. As a physician, Freud dealt chiefly with neurotics, who still had strong links with reality and some prospect of functioning successfully in the marketplace; and as both a physician and a theorist, he felt little confidence in grappling with the problems of people over fifty. He said, in fact, that psychoanalysis would do them no good. By contrast, Jung had a rich experience of institutionalized psychotics, more or less permanently cut off from reality; and a high proportion of his private patients were older people. He, with a new vocabulary of anima and animus, persona, and archetypes, lent the pitiless new dimension of inevitable meaningfulness to the latter end of life as Freud had done to the beginning. Seen in this context, the famous quarrel between Jung and Freud becomes insignificant by comparison with their common resolve to demonstrate meaningful relations among the apparently scattered fragments of psychic experience. It is a perspective in which the intellectual primacy of Freud over Jung is evident.

The other great lapsed disciple of Freud, Alfred Adler, also kept faith with the credo of compulsory meaningfulness. His special twist was to appropriate a brief exposition by Freud in 1909 of the “gain from illness.” Adler blew this up into a doctrine of neurotic “life styles” deliberately willed by weak or handicapped children to make the life of the family revolve about themselves in compensation for their feelings of inferiority. They made their illness pay. More generally, Adler saw the integral meaningfulness of men’s lives not as a retrospective discovery of the therapist but as a willful construct by the individual, a kind of prospective meaningfulness to be achieved as a goal.

Accordingly, Adler de-emphasized the role of the unconscious in favor of the conscious enactment of deliberate purposes. As applied to neurotic gains from illness, this doctrine lent to Freudian meaningfulness an emphasis that Freud had striven to avoid, upon the evil intent of neurotics. Adler spoke of a will to power, an instinct toward aggression-through-neurosis, which cast the same baleful light upon a neurotic that the seventeenth century had turned upon witches. Like witches, twentiethcentury neurotics of the Adlerian stamp were portrayed as putting spells upon their families, sucking other people’s lifeblood to feed their own craving for power.

If Freudian meaningful ness had purported to be merely a scientific fact, it would have left the patient naked to the eye of discerning observers; but it was far more than this, the ground of a new categorical imperative that the patient must acquiesce in the diagnosis of his own case. He must read himself as others read him, acknowledge the pattern they perceived, drain the bitter dose of reality to the dregs. He must be doubly full of his own meaning, as the experience that made him and the knowledge that would heal him. It was the sternest discipline that ever rang the changes upon the ancient command to know thyself.

IT IS no wonder that as the twentieth century wore on, there was a rising tide of resentment against the universal Freudian glare that lit up the dark places of the mind with obligatory meaning. The doctrine of pansexuality that originally gave offense has now become a commonplace. Dissent has come to focus, as it should, upon the more fundamental Freudian revolution of proclaiming universal meaningfulness. By 1960 the principal non-Freudian (frequently anti-Freudian) impulse among students of mental illness was to emphasize the meaningless components in mental life—the bad genes that are simply there, the brute conjunctions of experience that have no inner logic, the freestanding incidents that defy incorporation into an overall pattern.

On the genetic side, the great English physician Sir Archibald Garrod formulated as early as 1908 his now famous concept of “inborn errors of metabolism,” by which the normal metabolic pathways are blocked, often with the accumulation of biochemical “intermediates” that ought to have been converted into something else. It was not until 1934, however, that an inborn error of metabolism was shown to affect the mind — phenylketonuria, which produces severe mental deficiency ranging from idiocy to feeblemindedness.

Mental deficiency is different from mental illness, but the suspicion inevitably arises that some forms of the latter might also be genetically determined biochemical disorders. The hypothesis that schizophrenia results from some kind of biochemical mistake or imbalance has been repeatedly scotched and left for dead but never dies. Though still without confirmation, this stubborn conjecture illustrates the meaninglessness, by Freudian standards, that would invade the whole concept of mental illness if any major clinical entities were shown to be biochemical flukes, a kind of biochemical predestination to madness.

A more sweeping vindication of meaninglessness in mental life is the behaviorist psychiatry expounded by the psychologist H. J. Eysenck of the University of London. The origins of this can be traced back to the period before 1914. It was the joint offspring of the great Russian physiologist Ivan Pavlov and the firebrand of American academic psychology, J. B. Watson. Watson, as the founder of behaviorism, preached the doctrine that the psychologist ought to rule out any introspective report by the subject upon his own mental processes and substitute an objective account of the subject’s behavior as observed from without. The subject was no longer required to describe the flow of his own consciousness but treated as a mere object to whom externally observed sequences of behavior were attributed.

Watson was the great pioneer by world standards in the application to human psychology of Pavlov’s famous discovery of the conditioned reflex in animals— the repeated ringing of a bell before the presentation of food to a dog would eventually induce the dog to salivate at the mere sound of the bell. Watson undertook to apply this conditioning technique to human infants. He found that stimuli originally neutral or even attractive to an infant, such as pets, could be converted into lasting objects of distaste by repeated association with a loud noise. The fright induced by the noise got mixed up with the object and survived the conditioning period.

More generally, Watson emphasized that children had to learn associations and by luck or bad training might form the habit of linking things that had no intrinsic connection but happened to impinge upon them simultaneously. It followed that many accidental or conditioned associations could not possibly be understood by the individual as an expression of his own personality. They had been enforced upon him by external concatenations and remained as they began, arbitrary, irrational, and humanly meaningless. They could not become the legitimate object of an endeavor at Freudian understanding of one’s own plight. By the same token, the absence of meaningful connections in conditioned behavior constituted an argument for the basic Watsonian position that behavior is best described from without rather than rationally apprehended from within as a coherent unfolding of the personality.

Watson did not try to apply behaviorism to therapy, but this is the point of H. J. Eysenck’s endeavor to found a practical school of psychiatry on Watsonian principles. Eysenck’s premise is that if neurotic behavior can be regarded as the product of defective learning, perhaps it can be unlearned by deconditioning or reconditioning. Thus, alcoholism has been treated by “aversion therapy” — putting emetics in the patient’s drinks so that the pleasurable associations of alcohol are reversed.

The orthodox Freudian rejoinder is that alcoholism is a mere surface eruption of an underlying neurosis with wide ramifications in the entire personality, and if suppressed by behavior therapy, would be replaced by another symptom till the meaning of the neurosis was laid bare. Even as a form of symptomatic relief, behavior therapy, by the admission of its own practitioners, is of doubtful efficacy. They, however, would say the same of psychoanalysis. Whatever the value of behavior therapy may prove to be, it sketches a sharp alternative to Freudian psychiatry, by which the essence of the latter is illuminated.

Behavior therapy may seem remote from shock therapy by drugs or electricity and still more from lobotomies. Yet they all converge upon the irrelevance for therapy of the Freudian emphasis upon the meaningfulness of mental illness. They do not promise the patient any insight into himself — merely some kind of brute remission of his problems, to be cast out as a meaningless intrusion with no intrinsic roots in his own will. The illness is not regarded as a part of himself to be humbly accepted as the beginning of salvation but as an external invasion by a nonself to be repelled. It is, of course, true that neither Freud, Jung, nor Adler claimed that all forms of mental distress would yield to a draft of insight. Yet even to emphasize the boundaries of the Freudian universe of discourse already amounts to a profound reorientation in popular conceptions of mental illness. In the limiting case of the behavior therapists, the legitimate sphere of Freudian discourse is contracted to the vanishing point.

TO GRASP the full scope of the rising protest against Freudian meaningfulness, one must appreciate that the only new philosophy of life to commend itself in the last twenty-five years, existentialism, is precisely a reminder to men of the meaningless incursions that beset the effort to affirm their own being. By no accident, one of the best introductions to existentialism is the long-sustained critique of Freudian psychiatry by the trained psychiatrist turned philosopher, Karl Jaspers. Jaspers makes a fundamental distinction between “meaningful connections” and “causal connections.” Nothing, he says, animate or inanimate, can escape entanglement in the nexus of causal connections that constitute the theme of scientific research. But life continually confronts us with things that have no meaningful connection, sheer conjunctions that have no human meaning.

To have missed this distinction, says Jaspers, was Freud’s unconquerable blind spot. He “wanted to understand everything” as humanly meaningful. It was part of the existentialists’ indictment of Freud on this score that they had to reject his concept of the unconscious; for that was how he eked out the fragmented meaninglessness of conscious life and salvaged a coherent pattern from incoherent materials. In Jaspers’ view, Freud paid for this ingenious sleight of hand by missing the effect of the physical constitution upon mental illness and the reality of organic illnesses that signify nothing about the individual’s personality. Freud was too arrogant, too proud in his reason, to bow “before the elementary nature of these facts.”

Jaspers’ indictment of Freud is overdrawn. In fact, many efforts are currently under way to effect a synthesis between psychoanalysis and existentialism. The enterprise is not inherently absurd from the existentialist point of view. Though existentialism owes its distinctive place in twentieth-century thought to its insistence upon the meaningless side of life, it does not entail a refusal to acknowledge the meaningful whenever this can be salvaged from the causal flux. In principle, therefore, existentialism might accommodate some kind of thoroughly chastened psychoanalysis as an inclusion within itself. Orthodox Freudians, however, would have to resist the alliance — as they do — for the whole point of Freud’s endeavor was to expand the boundaries of the meaningful. To define the meaningless as anything other than a negative quantity of undeciphered meaning, and, still worse, to elevate the meaningless to parity with the meaningful as an object of deliberate acquiescence, would have been to Freud an obscene perversion.

Whatever the consequences for therapy of the encounter between psychoanalysis and existentialism, it is clear that some of the most fundamental issues of philosophy and conduct are brought to a burning focus for this generation in conflicting attitudes toward mental illness. Thus, the confrontation between Jaspers and Freud is the great contemporary re-enactment of the old conflict between religion and science, for meaninglessness is another name for the inscrutable will of God.

Yet, however significant the quarrel between the Freudians and the existentialists, the deepest historical insight always comes from excavating the unspoken premises that unite sworn enemies in debate because they live in the same age and participate in some underlying consensus. The existentialists are at one with Freud in dissolving the rigid boundaries between normal and abnormal, sane and insane. Existentialists speak of the “boundary situations” in which all men find themselves, the nightmare edge of existence, when the mind threatens to crack under the strain and sanity overlaps with madness. Cutting clean across the antithesis between Freudians and existentialists, one finds a common recognition that the mentally ill are no class of aliens to be fenced off from the remainder of humanity but emblems of the basic human situation to be scanned for clues to ourselves. This firm incorporation of mental illness within the sane man’s vision of his own potentialities marks off the twentieth century from any preceding age. When we talk about mental illness, we are talking about ourselves.