Madness Is Civilization: When the Diagnosis Was Social, 1948-1980

by Michael E. Staub

In the 1960s and 1970s, a popular diagnosis for America’s problems was that society was becoming a madhouse. In this intellectual and cultural history, Michael E. Staub examines a time when many believed insanity was a sane reaction to obscene social conditions, psychiatrists were agents of repression, asylums were gulags for society’s undesirables, and mental illness was a concept with no medical basis.

Madness Is Civilization explores the general consensus that societal ills—from dysfunctional marriage and family dynamics to the Vietnam War, racism, and sexism—were at the root of mental illness. Staub chronicles the surge in influence of socially attuned psychodynamic theories along with the rise of radical therapy and psychiatric survivors movements. He shows how the theories of antipsychiatry held unprecedented sway over an enormous range of medical, social, and political debates until a bruising backlash against these theories—part of the reaction to the perceived excesses and self-absorptions of the 1960s—effectively distorted them into caricatures. Throughout, Staub reveals that at stake in these debates of psychiatry and politics was nothing less than how to think about the institution of the family, the nature of the self, and the prospects for, and limits of, social change.

 The first study to describe how social diagnostic thinking emerged, Madness Is Civilization casts new light on the politics of the postwar era.

Genres: Psychology, Politics, Philosophy, Nonfiction, Sociology, Activism, Mental Illness

264 pages, Hardcover

First published January 1, 2011

Reviews

[Linus Williams · Rating 4 out of 5]

Psychiatry is unlike many other medical disciplines in that there really isn't (yet?) a biological test for many psychiatric illnesses, yet psychiatric illnesses clearly have just as much effect on the well-being of the affected individuals as any physical ailments do. The challenge, and occasional over-reach, of modern psychiatry is deciding how to wield the power of institutionalization and medication such that people who are truly sick get some level of help while not making the diagnosis of mental illness omnipresent and meaningless. This discussion must be set in the social context of psychiatric development, especially during the 1960s "hippie" era and the conservative backlash that followed. Staub does an excellent, well-researched and sourced, job of laying the groundwork for understanding the debates that raged in psychiatry in these times, while staying relatively impartial. I learned a lot from this book, and I felt the book got stronger as it went on, which is always nice. Overall an excellent read about an interesting field. I wonder where psychiatry will go in the 21st century....

[LuisJ · Rating 2 out of 5]

I wanted to like this book as I think that in Laing's The Divided Self there are seeds of fruitful discussion and discovery. The problem is that this book is rather too biased and, as such, makes it hard to take it seriously as a reliable source of historical information. There are hints early on but once he starts talking about Szaz and how he didn't believe that mental illness really existed and keeps referring back to him then you know it's a rigged game. By the time you get to the chapter on Feminism and the Epilogue it just becomes a mess, logically speaking. I'll include some examples below shortly.
But I came away from this book feeling like there wasn't enough ownership on the side of antipsychiatry for their own downfall. It's clear, according to the author, that Laing and others said some pretty bat-shit crazy and unsupported stuff but that's just hand-waved away as if it's an interesting thing to note; but it's not a small thing when people start talking like mystics or madmen, it's a big part of what makes them attractive in the moment and then dooms them later when the tides turn. Taking the stance of wilful ignorance doesn't help the credibility of their views but perpetuates the damage.


Here are some issues I picked up on that were worth commenting upon. I've not overly pedantic about this stuff but I didn't want to leave a review that didn't have some specifics to get a feel for what I'm talking about:

As Kittrie argued forcefully in 1971: Surely the right to live one's life free from bodily and psychological alteration is basic to the scheme of our society. The ability to remain as you are is clearly a right suggested by the general pattern of the Bill of Rights.

Except that this quote simply asserts what the author of Madness Is Civilization wants us to agree to, it doesn't itself offer any argument but instead offers only an echo of repetition.
In the first place the claim that living one's life free in this narrow sense isn't at all common-sense or "basic". After all, we lock up people who knowingly break the law and harm others. And we think that things like the state of mind and attitudes of the prisoner should weight significantly on whether they are granted things like parole; as such, the purpose of prison and even of criminal punishment in general is to alter the behaviour of the person. That itself is both a modification of behaviour and attitudes (even if those modified attitudes might sometimes be more a case of not wanting to commit crime rather than believing it is genuinely wrong). Even normal human-relationships contain this sort of dynamic. If you have a negative experience with a person you may object to their words or behaviour; the purpose here is to modify their behaviour (and often express your offence) and the thought that originated the action.
Naturally, there is a lot of room for nuance in these sketches I've presented and they are not intended to be complete or knock-down arguments in any sense, but, they are enough to show that the first claim is far from obviously true as the author presents it.

The second sentence is just crap; lots of things suggest other things but the Bill of Rights is to be taken in terms of what it says and what that implies; anyone can take something (The Bill of Rights, for example) to suggest something else (that it needs updating, for example).

This view not only obscured the fact that feminism's goal had never been self-indulgence for women but rather self-respect. It also actively and aggressively buried the fact that the rise of a wider culture of narcissism had little to do with either antipsychiatry or feminism, but rather with the efflorence of pop psych-- and efflorence that had far more to do with soothing the self-doubts and fears of men than it ever had to do with either political radicalism in general or feminism in particular.

Except that the author has just spent a while talking about the feminist therapies and how they ended up being seen as worthless by the practioners themselves. There is a not-unreasonable intuition that if you want your cake and get to eat it then if it turns out bad then that's on you. The idea that, according to the author, extreme feminist practioners actively rejected more mainstream methods and then wound up with methods that really didn't work at least explains the prima facie intuition that the author claims to not understand. That's not to say that I agree that this is a reasonable conclusion about the most extreme feminist psychotherapy of the period but the author just seems to want to act like a reaction to the movement somehow magically came about by denying any sort of connection between the group's practices and the reactionary attitudes. It doesn't explain anything either for or against the reactionary position but just nudges you to react on the basis of some ham-fisted rhetoric. Better would have been an account of what this reactionary view was and why people held it with a view to then assessing its merits or, as they may well be, demerits.

Secondly, a lot of effort has been expended by the author to draw other groups into the discussion such as women, black people in the USA and children. The idea being to acknowledge that if the/some causes of mental illness are social (which is view the author leans towards) then there are many groups who will be acutely affected even if they are not in the severe categories of the full-blown mental ill (such as Schizophrenics, for example). I think that's a good idea and it works well until he just dismisses the claims that some men of the same period were also struggling with issues that today's societies are looking to address (male depression, toxic-masculinity, poor male role-models, antiquated notions of male roles and behaviour in society). So the question is why does the author consider that to be nothing more than the "soothing the self-doubts and fears of men"?

I could reconstruct the likely chain of reasoning but perhaps (in short) it's because the author considers males, especially white ones, to be the perpetrators whose dominance of the system results in women and minority groups' suffering in the first place (through patriarchal views of correct behaviour for women and racist mentalities, respectively).

That may or may not be the case but it's not really the issue here. Just as the author points out that not all women found having female (as opposed to male) therapists more effective (or even at all helpful) it is the case that not all men benefit in the same way from other men being in charge. By analogy, as anyone who's had a crappy boss knows, being a white-male isn't any remedy against a crappy white-male boss. Some men will benefit in such a situation (and that's likely part of the reason why the boss is a crappy boss) but other men won't and may, indeed, suffer for it. The idea that there is that sort of benefit is clearly as sexist and racistly naïve as the idea that a women with a female boss will always be in a better situation or a black employee under a black boss.
Whether they enjoy any benefits or disadvantages depends on the person, their boss and the situation that they find themselves in- it will vary. What's hideously offensive is the idea that whether you do or do not sit in a, for want of a better phrase, homogenous relation with your employer determines whether you are experiencing genuine suffering. The counter-example would be refusing to acknowledge a female employee's claims of difficulties at work because her boss is female and so everything must be fine. It's offensive because it reduces a person to their relation to others and, specifically, others of their own 'kind'.

Spitzer transformed Rosenhan's experiment into a teachable moment, taking its evidence seriously while reversing its analysis in order to push his own agenda, namely, an urgent need for more accurate and reliable nosology- which for him meant the revitalization of a medical model for mental illness. In short, Spitzer used antipsychiatry's exposure of numerous weaknesses in the prior medical model in order to lay the groundwork for a thoroughly reconceived biochemical paradigm.

The use of the word "agenda" here is highly loaded, especially given he does not refer to antipsychiatrists as having an agenda. The alternative interpretation provided by Spitzer isn't prima facie unreasonable; the requirement that an expert can identify things in his field of expertise always assumes that someone is not trying to deceive them. We don't think that art-authenticators practice bunk just because some people create convincing fakes. In fact, the opposite conclusion is the case: if we didn't think that telling the difference between a real-item and forgery was possible or even made sense then we'd not have any interest in authentication of art in general. But we do think that my copy of a Van Gogh is less valuable because it's a copy and because someone can tell the difference. Making mistakes in judgment explains the value of experts not the other way around; indeed, the fact that an expert can be wrong is exactly why some experts are more highly sought after than others. After all, if the whole enterprise of art authentication was a theoretically impossible task then there would be no reason to prefer a world-class art expert over the guy down the pub. As such, it's hardly surprising that Spritzer interprets this as being a reinforcement of the diagnostic project and a good reason to improve the tools and rules by which experts operate in their diagnoses.

In short, psychiatry has been in the process (again) of changing its mind.

To quote the philosopher Hilary Putnam: "I've never thought it a virtue to adopt a position and try to get famous as a person who defends that position,[...]"like a purveyor of a brand name, like you're selling corn flakes."
The idea that psychiatry is willing and able to change is surely a good thing.
I'm actually far more disappointed to see that the antipsychiatrists that he talks about tended to become more extreme and polarising rather than adapting to the medical progress of the time; and perhaps that has more to do with why (according to the author) the door to such viewpoints is now closed.

"There has also been pioneering research on the impact of hazardous environments on epigenetic transgenerational inheritance. As clinical psychiatrist Mindy Thompson Fullilove commented on in the American Journal of Psychiatry in 2009: "Massive harms, of the kind caused by neighbourhood collapse, can cause heritable phenotypic alterations. Although such physiological changes are not changes to the DNA sequence itself, the epigenetic alterations can pass along the injury for one or more generations."

The problem I have is that the paper the author references is actually referencing another paper:
Jablonka E: Epigenetic epidemiology. Int J Epidemiology 2004
find it here:
https://academic.oup.com/ije/article/...

And I've read the paper and it makes no mention of that sort of conclusion.
Perhaps elsewhere the work of Mindy Thompson Fullilove supports her assertion and the author's but the provided references don't support it.

In the mean-time, that blurry line between pychosis and sanity that proved so useful to postwar psychiatrists as they worked to expand the national agenda for mental health has found new confirmation

This is pretty much Dr. Evil levels of paranoia; I can almost imagine the psychiatrists looking at patients and potential patients as a sort of duck-hunt game where each person scrolls along in front of the psychiatrist while they use their lethal psychiatry skills to bag as many of the ducks as patients as they pass.

Medical researchers now identify risk factors associated as symptomatic of psychotic disorders as also not uncommon in the general population. Adults who acknowledge having had hallucinations have been estimated at between 10 and 25 percent. A study of children age seven and eight revealed a prevalence rate for vocal hallucinations at nearly one in ten [...]. Such results have led to proposals that psychosis should be placed on a continuum with normality, and to inquiries as to whether "it is possible to consider psychosis as a dimension of human experience".

To borrow an analogy that the author himself borrows, a significant percentage of the population have probably coughed, spat, vomited some blood at some stage of their life but someone who either threw-up copious quantities of blood one one occasion or smaller amounts regularly would rightly be considered abnormal and in need of treatment.
There may well be a continuum between aspects of the mental states of the mentally ill on the one hand and so-called normal states on the other; and, indeed, I think that anyone coming to a book on this particular topic will be likely to give such a possibility a favourable hearing. However, having hallucinations under very specific conditions doesn't really make that argument.

Consider that during certain stages of growing up children are often clumsy and accident prone due to their rapid growth; then there are people who as adults may experience for a variety of reasons issues with coordination. In the case of the child it is not appropriate to send the child for medical help to cure their clumsiness because it is expected within certain circumstances that are easily explained and necessarily unavoidable; whereas in the case of the adult we see no prima facie reason for such issues and would see it as abnormal and likely requiring diagnosis and intervention.

The author finishes up with...

Abandoned and banished, perhaps forever, has been not only the idea that states of madness ever were-- or might have been-- the consequences of civilization, but also the ability to argue persuasively that what might pass for normal all too often may be insane.

The latter point is one that the author makes but really doesn't make enough of in this book insofar that many researchers and theoreticians failed to have that leap during the period in which antipsychiatry and social-models of mental illness were in ascendancy. As such, while it does seem to be a stone left un-turned, the idea that the backlash against the hippie, self-indulgent sixties is a blocker to persuasive arguments of that sort coming about seems to be somewhat muddled. Sure, it may now be difficult since the whole-sale rejection of those movements and time-periods, but those sorts of arguments didn't really get advanced with any sort of rigour or clinical efficacy (at least according to the book) and so it's unhelpful to throw the baby out with the bath-water in this circumstance pointing to lack of fertile grounds for proposing such arguments without also identifying why those arguments about the nature of mental abnormality never made the transition to questions of normality.


Apologies if this seems overly critical but I found it hard to connect with a book that I was looking forward to connecting with and it would have been unfair to be vague about why. Writing a book like this takes a lot of work and effort and the author deserves praise and respect for that. I just wish these sorts of things hadn't been the case and it had been a book I could have liked more.

[Craig Werner · Rating 5 out of 5]

The core argument of this book will be familiar (at second or third hand) for anyone who's read (or seen) Catch 22, One Flew Over the Cuckoo's Nest, The Manchurian Candidate, The Bell Jar, Go Ask Alice (and who knows how many other books focusing on the question of "who gets to decide who's sane (and insane)"? But Staub performs an invaluable service in grounding that socio-existential question in the practices of psychology and psychiatry in the 1950s, 1960s, and 1970s. The central story is the shift in an understanding of madness as familial, to a broader understanding of madness as social (and to some extent political) to the retrenchment asserting that madness is individual and biological. In an era when we diagnose and medicate more or less everybody, it's absolutely crucial to remember that the underlying issues aren't closed. Staub provides lengthy discussions of the psychological approaches of R.D. Laing, Thomas Szasz, and Erving Goffman (a sociologist who wrote the influential book Asylums), all of whom exerted immense influence on the debates around mental health in the 1960s. I was fascinated by his discussion--entirely convincing--of the way the fear of brainwashing shifted from a right wing political issue in the 1940s and (especially after the Korean War) 1950s to a left wing issue (fear of a totalitarian government demonizing and institutionalizing blacks, hippies, unruly women) in the 1960s. There's an excellent chapter on the feminist implications of psychiatric practice.

I learned a great deal from the book and highly recommended to anyone interested in psychology, the social construction of knowledge, the sixties.

[Liam · Rating 4 out of 5]

Narratives of psychosis: interpersonal dynamics/family relations (Laing); institutional setting (asylums, Goffman); social construct (Szasz); political phenomenon. (7)

"'More precisely, according to the common-sense definition, mental health is the ability to play whatever the game of social living might consist of and to play it well. Conversely, to refuse to play, or to play badly, means that the person is mentally ill.'" (quoting Goffman, 102)

"At times the argument was that true sanity meant resistance to the war and institutional racism and poverty. At other times the point was that what counted as sanity was evil, and craziness was the only appropriate moral response. Or, in yet a third variation, the contention was that society was making people crazy." (120)

"Thus, and however counterintuitively, the antipsychiatric critique that claimed the psychiatric profession had too much indiscriminate power to label people and enforce norms came to propel -- not impede -- the medical model proponents' reformation of psychiatric nosology and nomenclature. What psychiatry required, according to these proponents, was more science, even (or especially) in the absence of new science." (181)