MENTAL ILLNESS IN ANCIENT MEDICINE FROM CELSUS TO PAUL OF AEGINA

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The topic of this volume is located in the larger area of history of ideas and history of the representation of mental health and disorder, with two specifics that make it unique:

First of all, the particular focus is on ancient medical texts, as well as on philosophical texts to the extent that they respond specifically to medical texts and concepts; this contrasts with the larger, cultural-literary approach that underlies several recent studies of mental life and disorder in the ancient world, with their tradition, conventions and internal dialogues. 

Secondly, there is a clear delimitation of our chronological period of interest to the post-Hellenistic Graeco-Roman world. The reasons for this delimitation are not a mere matter of scholarly convenience or determined by the evident scarcity of studies on authors of this later period by comparison to earlier ones, but are intellectually motivated. In the tradition available to us it is in fact only after Cornelius Celsus’ discussion of mental illness in his De Medicina (3.18) that we are able to observe a conceptualization of mental disturbance as (variously) deserving description in its own terms and dedicated therapy. If much of Hellenistic medicine is unfortunately lost to us, it is evident, when one reads the medical texts of the fifth and early fourth century BC, that they are typified by the absence of such conceptualization: in the earlier sources mental life is organically inserted within the representation of the individual as a whole, with scarcely any hint to the existence of ‘mental disease’.

In the writings of the first centuries of our era a shift is noticeable, in two important senses: we observe both 

(1) the emergence of such a conceptualization, corresponding in some way to the modern notion of 'mental illness', and, simultaneously, 

(2) a complex interrelation between this conceptualization and the philosophical discourse on the soul and the mental (especially in Galen, but also elsewhere). 

 

This volume, which stems from a discussion initiated on the occasion of a Workshop held in Berlin, at the Humboldt University, in October 2014, sets out to address precisely this shift, and aims to contribute to the history of the category ‘mental’ in the developments of ancient medicine. The title of the workshop, ‘Mental diseases in Ancient Medicine’, aimed to be programmatic (and perhaps provocative) in this sense: not, of course, to propose a history of pathological entities, ‘diseases’, as ontologically substantial and as such traceable in different cultures across time, but to interrogate the developments towards a recognition of the independent category of ‘illness of the soul’, or ‘mental disease’ in our medical tradition, and to probe the debates and specific formulations surrounding this in a period whose authors are both neglected and of considerable later historical influence. 

MUSEUM DR. GUISLAIN (GENT, BELGIUM) : A review through pictures

Dr. Jozef Guislain (1797-1860) is an important figure in the history of the modern clinic. Together with P. J. Triest and other among the Brothers of Charity he is to be credited with initiating the liberation of the mentally ill left to languish in the madhouse of Ghent, the crypt of the infamous Gerard the Devil's Castle, one of the first such asylums in Europe and the first in Western Europe, in use from as early as the 16th century. In 1828 Guislain and his colleagues decided to transfer the patients imprisoned in the madhouse to the Alexian convent of the brothers of charity, marking the beginning of a new chapter in the history of the modern clinic.

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 Jozef Guislain

Jozef Guislain

 A recent publication authored by the current director of the museum, R. Stockman ( 200 Years of Breaking the Chains,  2015) offers an illustration of this history to celebrate the second centenary of the 'liberation' of mental patients.

A recent publication authored by the current director of the museum, R. Stockman (200 Years of Breaking the Chains, 2015) offers an illustration of this history to celebrate the second centenary of the 'liberation' of mental patients.

The museum that takes its name from Dr. Guislain is situated in the old Guislain Hospice, the first Belgian mental hospital. The collection originated in the early 1980s, when René Stockman, still today the museum’s curator and Superior General of the Brothers of Charity, worked as general director of the Dr. Guislain Psychiatric Centre. It was his decision to valorise the site of the Guislain Hospital and the old objects pertinent to the care of the mentally ill by organising a display open to the public. The resulting permanent exhibition is  one of the biggest and richest in Europe, comprising objects belonging to the genre of patient history, items illustrating methods, doctrines and practices of psychiatric care (from pharmacology to various technology, to instruments of coercion); pictures and photos; literature and propaganda illustrating various phases in history of psychiatry, from those of advancement to its many dark periods; art objects (including a great art brut collection); items of hospital furniture and machinery.

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Reconstruction of psychiatric ward

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Tools and instruments from the history of the psychiatric clinic

 Insuline coma induced as possible cure for mental disorders, following the studies of the Austrian physician Manfred Sakel (1922)

Insuline coma induced as possible cure for mental disorders, following the studies of the Austrian physician Manfred Sakel (1922)

 Lobotomy consists in the cutting of the connections between both halves of the brain. The image shows the technique developed in 1946 Walter Freeman, a surgical method practiced via the eye socket. 

Lobotomy consists in the cutting of the connections between both halves of the brain. The image shows the technique developed in 1946 Walter Freeman, a surgical method practiced via the eye socket. 

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 Electro shock: practice and theory

Electro shock: practice and theory

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 Breath, life and soul? Artistic assemblage of different animals' bronchial tubes (A. Williams Wynn, 2017, Resin corrosion casts)

Breath, life and soul? Artistic assemblage of different animals' bronchial tubes (A. Williams Wynn, 2017, Resin corrosion casts)

 From the installation by A. Williams Wynn, 2017, Resin corrosion casts

From the installation by A. Williams Wynn, 2017, Resin corrosion casts

 From the installation by A. Williams Wynn, 2017, Resin corrosion casts

From the installation by A. Williams Wynn, 2017, Resin corrosion casts

 Dementia and loss of memory. Photographic work by Evy Raes, 'Alzheimer Code Project', to illustrate the struggle with everyday reality experienced by people with early dementia.

Dementia and loss of memory. Photographic work by Evy Raes, 'Alzheimer Code Project', to illustrate the struggle with everyday reality experienced by people with early dementia.

 Darkest chapter in the history of modern psychiatry.  A propaganda poster about euthanasia of the 'mentally ill' or 'mentally disabled' during the third reich

Darkest chapter in the history of modern psychiatry.  A propaganda poster about euthanasia of the 'mentally ill' or 'mentally disabled' during the third reich

 Coercion

Coercion

 Images from the ward

Images from the ward

 Board for bathing therapy

Board for bathing therapy

Deterministic approaches to human mental life and the evaluation of mental capacities: phrenology (the allocation of faculties to different areas of the brain and regions of the skull); physiognomy (the ethical interpretation of bodily features, especially facial); anthropometry (the measurement and interpretation of bodily features and proportions):

 Phrenology

Phrenology

 Phrenology

Phrenology

 Phrenology

Phrenology

 'Anthropometry'

'Anthropometry'

 Coercive soothing - the padded bed-cage

Coercive soothing - the padded bed-cage

 Swinging as soothing method

Swinging as soothing method

 Means of coercion

Means of coercion

 Coercion: shackles and chains used before 1815 at the Gerard the Devil's Castle (Ghent)to restrain the mentally ill

Coercion: shackles and chains used before 1815 at the Gerard the Devil's Castle (Ghent)to restrain the mentally ill

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New book out! On ancient ideas about mental health:

The Hippocratic texts and other contemporary medical sources have often been overlooked in discussions of ancient psychology. They have been considered to be more mechanical and less detailed than poetic and philosophical representations, as well as later medical texts such as those of Galen. This book does justice to these early medical accounts by demonstrating their richness and sophistication, their many connections with other contemporary cultural products and the indebtedness of later medicine to their observations. In addition, it reads these sources not only as archaeological documents but also in the light of methodological discussions that are fundamental to the histories of psychiatry and psychology. As a result of this approach, the book will be important for scholars of these disciplines as well as those of Greek literature and philosophy, strongly advocating the relevance of ancient ideas to modern debates.

'OTHER PSYCHOTHERAPIES' (Glasgow, 3-4 April 2017). A conference report

The idea itself that there should be a kind of healing practice specifically devoted to mental well-being, or the health of the soul – a ‘psychotherapy’ – is a historical and cultural product, as such subject to all the variations the ideas of ‘mind’, ‘soul’ and medical cure undergo from context to context and from a historical period to the other. On 3-4 April 2017 I was very lucky to be part of a meeting at Glasgow University devoted to mapping some of the transformations, as well as the aspects of permanence that can be found in human culture in this respect: ‘Other Psychotherapies', organised by a combination of scholars in history of science, psychiatry, and ancient medicine: Sofia Xenofontos, Gavin Miller, Cheryl McGeachan, and Ross White.

The conference explored different psychotherapeutic models, contexts and concepts of the curability and pathology of mental suffering. The organisers put together 27 papers from a great range of topics and cultural environments, managing to raise a discussion much wider that the individual academic specialism, and touching on the key methodological challenges faced by the anthropologist, literary scholar, or historian trying to describe forms of healing of mental disturbances in different cultures. This breadth of the material analysed and the richness of examples and perspectives in this conference was a rare treat, as was the shared discussion reaching beyond the surface interest, or the curiosity that unfamiliar cultural systems may arouse in an audience. There was much to learn from every panel.

 

One could divide the topics and approaches discussed as follows – with, of course, overlap and crossing in most cases:

1.     papers addressing the particularities of specific geographical and cultural contexts

2.     methodologically focused interventions

3.     talks cutting through the surface to explore the complexity and variety necessarily co-present in a society at a given time

4.     presentations on particular mental syndromes and mental experiences, variously located in the spectrum between health and disease

5.     specific therapeutic cultures and modalities

6.    psychotherapeutic theories and practices of the ancient world

 

The anthropologist Claudia Lang gave the opening talk on ‘Theory and practice in Ayurvedic psychotherapy’, reporting on her own field experience in a clinic in India and sketching an introduction to the principles of Ayurvedic medicine and psychotherapy. Under the label of ‘local adaptation’ of a given paradigm of care for one’s mental health other geographical contexts were analysed: China (with Hsuan-Ying Huang, ‘Setting Psychotherapy Fees amid China’s Psycho-Boom: A Case of Unintended Localization’; Boon-Ooi Lee and Laurence J. Kirmayer, ‘Dang-Ki Healing: An Embodied Relational Healing’, and Xiaojiao Wu, ‘A study of the interaction between Western psychotherapy and psychotherapy of Traditional Chinese Medicine in China’); South-Africa, through the first person experience of an initiate in indigenous rituals among South African tribes (Lila Lieberman, ‘The Alchemy of Ceremony: Initiation as the gatekeeper of perception’), and the healing powers she acquired through it; as well as European phases closer to our official medical context, or other individual examples: Vasia Lekka on ‘The first steps of Psychoanalysis in the Greek society: the first Psychoanalytic Group (1946- 1951)’; Katerina Liskova on ‘Sex at a different time and place. Sexual therapies in 1970s Czechoslovakia’; Sarah Phelan, ‘Deciphering the Dream Books: Avenues to the Psychosocial in 1930s Glasgow Psychiatry’; David Freis, ‘Journey to the Centre of the Soul: Fischl Schneersohn’s Psycho-Expeditions between Modern Psychology and Jewish Mysticism’; Sarah Phelan, ‘Deciphering the Dream Books: Avenues to the Psychosocial in 1930s Glasgow Psychiatry’; Hazel Morrison ‘Changing landscape of therapeutic health care, Henderson, dynamic psychiatry, early twentieth century Scotland’; Irene Delodovici, ‘Body, gaze, alienation. Franco Basaglia’s phenomenological psychiatry’.

The exploration of different cultures of mental health and therapy is a delicate and potentially risky task, involving more than competent information about each specific environment, if one wants to avoid reducing the otherness of diverse approaches to mental health to ethnic curiosity. All speakers in the event were aware of the pitfalls in this research area: in particular, Jonathan Coope discussed ‘Exploring nature-connectedness as a “frame” for our dialogues between Western expertise and traditions from other spatially or historically distant cultures’ and Laurence J. Kirmayer, with his ‘Culture as Healing in Indigenous Mental Health’ brought the example of his own experience with clinic psychotherapy among indigenous communities in Canada, a great illustration of the necessary practices, and the challenges posed by patients who share an ethnic identification other than the dominant one.

Part of this methodological discussion was yet a further sense in which ‘other’ can be understood: not only geographical, historical or cultural variation but also stratification and sub-grouping within the same society. Some of the most useful talks were those exposing this complexity, one inherent to any culture and society at a given time - although accessible only with great difficulty when it comes to ancient worlds. In this sense, Robert Young discussed the ‘communities’ of self-harming young individuals, probing the concept of ‘subculture’ for this phenomenon (‘Is subcultural psychiatry a useful concept and can subcultural identity be useful in reducing harm?’); Sue Smith spoke on yet another circumscribed social category, war veterans suffering from PSTD (‘Rehabilitating the Mind: Avatar (2009) and Inception (2010) and the science fiction imagining of lucid dreaming in the psychotherapeutic treatment of Post Traumatic Stress Disorder (PTSD) in the American military’), and Elizabeth Roxburgh explored for us a variety of anomalous experiences (‘Anomalous experiences and mental health’) including within the category forms such as paranormal perceptions and experiences, and variations in one’s sense of identity (such as identification with animals).

Most of these interventions implicitely argued for a continuist view of the range between ‘healthy’ and ‘ill’ when it comes to mental life, proposing to reframe the often dominant clinical, but also lay evaluation of non-conforming human experiences as simply pathological. Another group of papers discussed individual experiences and therapeutic possibilities precisely in a non-dichotomic perspective: Louise Boyle, ‘“I’ve just got to keep myself together …”: The psycho-social geographies of living and coping with Social Anxiety Disorder’; Candela Sanchez-Rodilla Espeso, ‘Other psychotherapies: Therapeutic relationships to landscapes for panic disorder sufferers’. A speaker also shared his personal experience, Michel Syrett (‘Other Psychotherapies: A Service-User’s Experience’), offering remarkable insights into the role played by familial narratives in his understanding of his own mental history. A focus on a specific therapeutical method was offered by Jennifer Lea, who discussed meditation and mindfulness in theory and practice (‘Building “A Mindful Nation”? The use of mindfulness meditation in educational, health and criminal justice settings’).

An ‘otherness’ twice removed from us as audience is that of ancient Graeco-Roman cultures; although their psychologies contributed fundamentally to the vocabulary and categories of modern Western approaches to mental health, they remain opaque to us vis-à-vis the real human subjectivities they appear to refer to. Six speakers explored ancient ideas, from the philosophical contexts (Bernhard Kaiser, ‘Handling negative emotions – the role of Socrates in Plato’s Gorgias’; Anastasia-Stavroula Valtadorou, ‘Platonic Philosophy as a Form of Psychotherapy: The Case of Plato’s Symposium’; and Georgia Mouroutsou, ‘Marcus Aurelius’ Meditations: The Transformation of the Present Moment in Moral Progress’), to medicine (Peter Singer, ‘Ancient psychotherapies: Galen on physical disease and philosophical intervention’; Chiara Thumiger: ‘Therapies of the word in ancient medicine’) to tragedy (Sophie Mills, ‘“Look upon it closely and learn more clearly”: Tragedy and the “Talking Cure”’).

As one of the participants put it, this meeting was one of these rare cases in which a conference becomes more of the sum of its parts; ideas, questions and corrections to one’s views were offered by the discussion and by the dialogue between one paper and the next; especially, it came out very clearly that including as much as possible of the widely human variations and commonalities into any approach to the mind increases the power of cultural-historical analysis, as well as improves operative efficacy and even the understanding of one’s own ‘mental health’.

ANCIENT HOLISMS

 poster image by Christoph Geiger www.christophgeiger.com

poster image by Christoph Geiger www.christophgeiger.com

In Graeco-Roman medicine and its cultural context localisation has always been one of the key modalities, if not the central modality by which we read ancient accounts of human fundamental bodily experiences such as pathology, emotions and mental alteration. The firm identification of a locus affectus, an organ (or a set of organs) involved, or a suffering area of the body is indeed very visible in medical discussions of diseases and disorders, whether strictly physiological or also mental, as well as poetic representations of biological or mental experiences. The debate about the bodily seat of the soul and the development of anatomo-pathology in history of science has received attention, in modern history but also with reference to the medicines of the ancient world.

The complementary question, however, has not received as much attention: the alternative modality, that of de-localisation and more generally of an attention to human experiences of the body as diffuse, dynamic and explicitly disjointed from a firm location has received instead much less attention.

A forthcoming conference in London (11-12 September 2017I aims to redress this balance, by focussing on the following questions:

- What are the prominent examples of disputes on localisation in ancient science? What epistemological purposes are served by these disputes, aside from the advocacy of different medical doctrines?

- How did the ancient physicians explicitly engage with, and challenge questions of localisation, and why?

- What alternative ‘de-localising’ models were proposed? (e.g., bodily fluids and circulation models; the transit of substances in and out of the body through bodily vessels and channels; models of sympatheia between organs or areas of the body; attention to signs and symptoms affecting the body as a whole; and so on)

- What contributions can poetic representations give to this topic? In which way do representations of mental life and the emotions in epic, tragedy, lyric poetry - for example - compare to the localised model that appears dominant?

- Conversely, to what extent do medical authors refer to, criticise, adopt or distort poetic images of holism to make their theories conspicuous?

- Are there ancient roots, ancestors, or precursors of modern (medical and folk) concepts such as the ‘systemic’ level of bodily functioning, or the living animal as ‘organism’? Or are these completely anachronistic associations?

- Relatedly: what are the contemporary uses (and abuses) of ancient medical traditions in the elaboration of folk bio-medical systems and ‘holistic’ therapeutical ideals? Obvious examples of relevant material can be found as early as the Hippocratics. The famous image of the circle is used by the Hippocratic author of the treatise Places in Man, for instance, pointing precisely at a diffuse conceptualisation of vitality; some later medical schools are especially suitable to this enquiry, notably the Methodist and their challenge to the dogmatic search for precise localised causes of disease; waves of localisation and delocalisation, more broadly, characterise much of the discussion on mental disorder through the history of ancient medicine.

BEDLAM: THE PEOPLE AND THE ASYLUM

‘Psychiatric collections, while they comprise evidence of past practices, are really ... as much about constructing the present and the future of psychiatry’ (Dolly MacKinnon and Catharine Coleborne, ‘Seeing and Not Seeing Psychiatry,’ in Exhibiting Madness in Museums: Remembering Psychiatry through Collections and Display, 2011, 5). If all museums are mirror to the community that hosts them as much as of the past they want to document, this is the case all the more for museums of psychiatry, which are expression of the projects, the objections, and the conflicts of current psychiatric practices, as well as reflect the expectations and assumption of society at large.

 

 From The Bethlem Museum of the Mind

From The Bethlem Museum of the Mind

 From The Bethlem Museum of the Mind

From The Bethlem Museum of the Mind

It is then for obvious reasons that the history of mental health in Europe has been long equated with the history of the Asylum, the psychiatric hospital as place of confinement, symbol of exclusion, and actual, concrete institution with its reality of bricks and fences, its organisation, its rules. These important accounts have however one lacuna: they disregard - indeed they often erase from our perception as onlookers the subjectivity, personal history, and individuality of the inmates, the patients with their experience of illness and possibly recovery. They turn them into objects – inert receivers of care, wearers of the strict-jackets we can still look at through the glass, consumers of medications, prisoners of those laces and straps we can physically see.

 Elise Warriner,  Welcome to my world.  1993. From The Bethlem Museum of the Mind.

Elise Warriner, Welcome to my world. 1993. From The Bethlem Museum of the Mind.

At the same time, they make us, the observer, the positive of that image in turn, the healthy and wholesome possessors of rightness and understanding.

In history of medicine, as well as in reflections on medical practice, for sometimes now the claim for the ‚voice of the patient’ to be heard, and the ideal of a medicine made of patients rather than doctors, or primarily doctors, is being powerfully made. As the celebrated historian of medicine Roy Porter first spelled out clearly, a history of medicine 'from below’ is a needed project, and one that can potentially change the way we view medicine as historical product but also as social and personal activity. It is obvious that museal culture can also be deeply influenced by this shift in perspective.

One of the most famous names among psychiatric institutions in European history, ‚Bedlam’, has become proverbial and even symbolic, the 'madhouse' par excellence: the Bethlem Royal Hospital in London whose name became synonymous for chaos and madness through the centuries of its activity (from its foundation in 1247, on the land where now is Liverpool Street station in London, to its current practice as a hospital in Monks Orchard Road, Beckenham, Kent, in a green area outside the city).

   
  
 
 
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    Men’s Wards, St. George’s Fields, 1860 (Ink on paper, Frank Vizetelly)   From The Bethlem Museum of the Mind

Men’s Wards, St. George’s Fields, 1860 (Ink on paper, Frank Vizetelly)

From The Bethlem Museum of the Mind

In 2016 two exhibitions in London offered a great occasion to take both journeys: on the one hand, to learn about the developments of this key institution whose life spans eight centuries of European history, and on the other to stop and think about the multitude of people who made Bedlam beyond its concrete existence as institution: the countelss patients who passed through its halls and rooms, the irreplaceable individuals without whom Bedlam would not have existed. This complex history has its disturbing aspects – the confinement, the abandonment and the abuse - but also, finally, the positive ones: the healing and life one can find in the hospital now and in its more recent history. 

   
  
 
 
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    C.G.Cibber ‘Raving and Melancholy Madness’, Figures from the gates of Bethlem Hospital, c. 1676. Now at the Bethlem Museum of the Mind.

C.G.Cibber ‘Raving and Melancholy Madness’, Figures from the gates of Bethlem Hospital, c. 1676. Now at the Bethlem Museum of the Mind.

First, there is the permanent exhibit of the Bethlem Museum of the Mind, located on the current site of the Bethlem Hospital. What strikes the visitor, once passed the entrance  guarded by Cibber’s ‚Melancholy and raving Madness’, is precisely the intention to narrate the asylum through the words, minds, and eyes of patients as much as through their bodies as sufferers and receivers of medications.

 C.G.Cibber ‘Raving and Melancholy Madness’, Figures from the gates of Bethlem Hospital, c. 1676. Now at the Bethlem Museum of the Mind.

C.G.Cibber ‘Raving and Melancholy Madness’, Figures from the gates of Bethlem Hospital, c. 1676. Now at the Bethlem Museum of the Mind.

The first thing one sees walking into the main space is a sequence of pictures with short comments projected to the wall, some episodic, some longer, offering testimony to the experience of various people involved with the asylum or touched by it: the patients, their families, even people who worked in the museum or the hospital, or occasional visitors. These short stories nicely allow the psychiatric hospital to appear as part of the life of many, and in a sense open destination, temporary solution, and place to leave behind. The voices of patients who return to visit after a time, sometimes after decades, recall their experience and measure their new self against the old, becoming in turn spectators and external judges. 

 From the Bethlem Museum of the Mind.

From the Bethlem Museum of the Mind.

The space in the main room is filled with works of art of various kind produced by patients, especially paintings. Some of them are truly impressive, none is banal and the effect is to multiply once again the viewpoint behind the narration, to present a crowded humanity that cannot be reduced to any unifying label. Not only does this museum force you to think with the patient, but also to think of yourself as a patient, or as a physician, a nurse, a husband or child of an inmate; and, to ask yourself what in your life would be changed, what would remain, what different choices you would make, and so on.

In the opposite corner, another installation presents a filmed exemplary case, an anorexic patient: you can listen to her view and that of her family and doctors, as the option is posed between compulsory sectioning vs. respecting the patient’s will to be left in peace, and cast your vote by pressing a button. After listening to the short interviews the decision is much less easy than one would have thought at the start, and varies hugely from one onlooker to the other - a quick and effective lesson on the difficulty of operative psychiatry, as well as living with a mental disorder.

 From the Bethlem Museum of the Mind.

From the Bethlem Museum of the Mind.

Another piece makes you think in yet another direction: you can enter your own recollection of ‘words and phrases used over the centuries to describe, label or even stigmatise those with mental ill-health or disability’, which are collected in a database: crazy, idiot, fool, mad, lunatic, erratic, retard, psycho, and so on and so on, some of which are out of fashion, some other most of us have probably used in various ways; while the results run non-stop on a screen.

 

 

 

 

In a section at the centre of the space famous steps in the history of Western attempts to understand mental health are on display, such as frenology, the interpretation of mental functions and 'qualities' as corresponding to precise sections of the skull.

In another space there are the old instruments of supposed care and control, such as straps, straight jackets and drugs; an illustration recounts the far away origins of the concept of temperament, rooted in Greek medical theories about the bodily humours and their balance (or unbalance)… Throughout, however, the drawings and paintings with the thoughts and emotions of their authors remain the heaviest presence and somehow triumphs over history. The figurative art always manages to tip the balance against the narrower medicalised, institutionalised perspective - not only as museal style, but as real practice: in the recent history of Bethlem Royal Hospital patients have been encouraged to produce works of art, pieces which are then on display in the Bethlem Gallery, with this invitation to the onlooker: ‘The pieces displayed…are physical traces of a range of therapeutic, or not so therapeutic, relationships. Make your own judgement about how the artworks reveal these relatonships’.

In this spirit, even the more traditional pieces of evidence appear in a new light, such as Henry Hering’s pictures of patients (c. 1857-1859), photographies originally taken with a physiognomic purpose, but here reproposed as testimonies of real life, real people and actual, precise moments, resisting the reduction to nameless asylum inmates, remembered and catalogued for the mere sake of their psychiatric state.

   
  
 
 
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  Henry Hering, Acute Melancholia. From the Bethlem Museum of the Mind.

Henry Hering, Acute Melancholia. From the Bethlem Museum of the Mind.

The second opportunity in London to reflect about the Asylum and Bedlam is the temporary exhibition at the Wellcome Museum: Bedlam – the Asylum and beyond. There are many points of contact with the experience in the Museum of the Mind; in the exhibition space on the ground floor of the Wellcome Trust building in Euston visitors find however a denser, less structured display, mostly disconnected from any purpose to offer an historical frame. Art dominates also here; and here too, art is not the comfortable trope that casts the ‘mad’ as gifted outsiders (to see in this respect in the exhibition is the film ‘Abandoned Goods’, 2014, by P. Borg and E. Lawrenson, about art and mental patients in a psychiatric hospital). Beautiful and soothing paintings are placed next to challenging sculptures and installations that evoke constraint, imprisonment and even disembodiment, whose primary effect - for some at least - was to challenge the viewer's privilege as external, objective observer embodying the 'norm', and to expose how rapidly, sometimes unrecognisably can an object be altered by a slight change in the angle of observation.

There are individual stories and documents too: one of the strongest, most fascinating and instructive items here is a film reporting in details the process of receiving an ECT (electroconvulsive therapy) treatment, through the experience of a consentient patient - from the explanatory talk between doctors and patient to the actual preparation for the sessions, a glimpse into the routine and materiality that are the core stuff of illness and care, and yet the most difficult parts to grasp from the outside.

An important part of the collection, finally, documents various strands in the history of the ‘anti-psychiatric’ challenge – the questioning, sometimes almost the denial of any objectivity to 'mental disorder' as biomedical entity in the thought of influential sociologists and psychiatries in the last decades of the twentieth centry. 'Madness' is exposed as socially, culturally and politically constructed, partly in the spirit of Foucault’s broader critique: Szasz’s ‘The Myth of Mental Illness’ and Laing’s ‘The Divided Self’ are there, as well as the important turn initiated by the Italian psychiatrist Franco Basaglia, whose call to end psychiatric hospitalisation was made law in Italy in 1978.

In both exhibitions each visitor can find his own point of empathy, interest, understanding; or estrangement and even fear and repulsion. Rather than primarily an historical information on Bedlam the hospital, or the clinical enterprise, both explicitely aim at ‘changing assumptions about mental health’, that of others as well as one’s own and as such they reflect a wider project of inclusion and destigmatisation key in current psychiatry and social activities (examples in this sense, in the UK only, can be found even by a quick look to the websites of the association ‘Mind’, and of the foundation HeadsTogether: the fight against stigma, and the promotion of self-confidence and empathy are the priority).

 

   
  
 
 
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    Jodine Williams, ‘My mental health does not define me’ (from the ‘Museum of the Mind’)

Jodine Williams, ‘My mental health does not define me’ (from the ‘Museum of the Mind’)

At the end of the Bedlam exhibition at the Wellcome visitors are invited to take a card and note one's thoughts on how to possibly help, or approach in the future a person in one's life who is mentally suffering. And to fold it and take it away in one's purse. This element of awareness, listening and inner questioning, and of suspended judgement are probably quite the opposite of what mental health patients are used to finding in others, and not a small gain to take away from both visits.

Seishin - MENTAL by Kazuhiro Soda (2008)

“To make a diamond shine, you need an even stronger diamond” says one of the patients of the Chorale Okayama Clinic, a Japanese centre for psychiatric care. He is referring to the actions and healing powers of a good doctor – of his doctor - on a suffering patient. The good doctor is Dr. Yamamoto Masatomo, not an ordinary professional or a typical psychiatrist; and the patient speaking, Sugano, with his poetry, his sensibility and his profound insights is no ordinary individual either.

That of Sugano is just one of the human stories narrated by the film "Seishin" ("Mental"), by Kazuhiro Soda, an unforgettable documentary (if often hard to watch) about mental health and mental suffering in the context of a small clinical community, with its efforts and hard work, its struggles with the bureaucracy and with budgeting, and its daily routine. It is also a documentary on what it means to offer care to patients who suffer mentally, and to be a doctor; most of all, it is a touching collection of scattered pieces of human life, seen through the lenses of a handful of particular individuals. Their stories and emotions, but also their bodies, faces, expressions and physical presence – talking, working, laughing, smoking - are the real centre of the account; their individual viewpoints represent more clearly than any theoretical discussion the infinite possible meanings of ‘mentally ill’ and ‘mentally sound’ across different situations and worlds, and from one individual to the other.

The words of Sugano, the extraordinarily patient I have mentioned, appear in the second half of the film; still, for their clarity they stand out as a guide into the subtleties of mental health and illness. Through his words one can rethink many of the stories and lives that populate the documentary, and place the suffering and therapeutics of Chorale Okayama under a different light – one that brings them much closer to universal human vulnerability. 

In the clinic patients regularly receive a consultation with Dr. Yamamoto. During these meetings they are free to speak about their state and their struggles; the dialogue, however, does not resemble a psychoanalytical session by any means. Patients speak briefly and in a focused way, addressing only what is explicitly relevant, without digression; the respectful replies of the doctor, both succinct and gently prescriptive, are also different from an idea of conversational psychology. For example, he advises a patient who feels lonely to go and ‘ask the friends what is the problem they are having with you’; to another he assigns the task to ‘come up with a short-term objective’, something to be accomplished in a week; to a third he suggests a possible solution to find economic stability - to become a farmer. The advices, and their wording seem to be very carefully chosen in their apparent simplicity; and yet there is no emphasis, no pathos, and no visible dramatic empathy of the kind a Western viewer might instinctively expect in the face of such depth of suffering and misfortune. This blend of distance and true care makes the meetings extremely meaningful and charged, in an almost spiritual sense. 

As a consequence, to be in the position of offering care to others is seen as an immense power and responsibility, that can have two sides. ‘When you are as great as mother Theresa’, explains Sugano, ‘some pretty evil thoughts surface in your head’. As written in the bible, ‘when I want to do what is good, evil is right there with me’; in order to fight evil ‘you need to be somewhat evil you too’. Psychiatric medicine is a double-edged activity; there is an ethical force to it, one that is not always entirely pure or innocent.

Sugano is the more philosophical voice in the group of patients: he writes beautiful poems, and speaks of his past with exceptional clarity and details. In his youth he was an extremely hardworking and diligent student – too hardworking, studying eighteen hours a day. Unable to handle pressure, he chained himself to an impossible routine of excruciating study until one day he finally collapsed. His breaking point showed on the occasion of his final school exams: after having prepared meticulously for months, once finally seated in front of the exam papers he did not answer a single one of the questions. Rather, he gave each teacher a grade and submitted it. Because of this, teachers began to think he was mad, and he began to receive psychiatric care.

Life histories are central in the movie because they are also so important in the therapeutic process – no cure is administered without personal attention and existential intensity, it seems, although biomedicine is also there and pills play an important role in the daily life, emotions and balance of these individuals. Many other patients have a voice in the film, if less eloquent than Sugano, and their stories and relationship with the world outside are equally prominent. Two men discuss the nerves needed to be part of an activity with people who are healthy, as ‘healthy people have no mercy sometimes’: the possibility to join a music band turn out to be a challenge that requires an extreme courage. ‘For healthy people, the world of mental illness is hidden behind a curtain’, one created by the ‘healthy’, but sometimes by the patients too’, explains another: shame and self-closure can cause even more pain than the illness itself. There is a woman who always felt ‘there was a balloon inside me, growing little by little’, until this feeling exploded into illness when someone commented that her legs were fat. Again, there is the sense of shame and taboo, a continuous background presence: the stigma for the mother whose child has refused to visit her for years because of her condition; the sense of rejection from one’s friends felt by the first patient, a woman who says that people around her ‘don’t want to have anything to do with her anymore’; the abused daughter grown into a helpless, depressed mother, finally responsible for the death of her own child.

Communication is a central element of therapy; this is made clear by Dr. Yamamoto in one of his lectures to students in psychiatric nursing, in which he explains that the pain of mental patients lies for a good part in their feeling of worthlessness, because ‘they are ignored by everybody’. To be asked and listened to not only brings dignity and warmth to patients, but also shapes the best response that has to come to each of them, as opposed to a fit-for-all, one-way communication. For instance, when a man tells Dr. Yamamoto about his experience of anxiety and loneliness, his sense of emptiness and fear, he suggests to him that ‘a destination to go and a place to be are a reason to live’: the patient needs to find a goal, a plan, however small at the beginning. Often he takes a piece of paper to sketch out the advice. In another case he draws two alternatives, two possible ways of thinking of life as ‘a destination to go’, made of stages from childhood to death, to choose from: a ‘Western’ one – an arrow pointing towards the upper right, as trail of progress and achievement – and a more ‘Eastern’ one – a circle, where beginning and end give sense to one another. The patient prefers the second, as it agrees with his own Buddhist beliefs: ‘I want to believe in this circular one’.

The telling and comforting that sometimes goes on between these patients does not, of course, erase the sadness of mental illness. Sharing, acknowledging and accepting pain, however, can bring relief. ‘My heart is like a broken glass’ - says Sugano pointing at a cracked glass door; and for this reason it emits a different light from the others. ‘It emits kindness. The Japanese character for kindness is a combination of man and grief. The more grief you have, the kinder you become’. Kindness to others is also a way to look after oneself, and by helping healing the wounds of others one looks after his own.

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Many of the experiences presented in Seishin may sound familiar to a viewer who is accustomed to average Western care for the mentally ill, and with anecdotal experience with stories of mental suffering in this part of the world; many may strike personal chords. On the other hand, some aspects stand out more for a non-Japanese audience – especially, the weight of shame and the topic of social acceptance, and the presence of death as solution, or returning desire, so strongly and in so many of these voices.

It is impossible to say if these are more typical to the Japanese context than to Western societies. Although Japan is often described as a particularly traditional culture where dignity and shame play a far greater role than for many of us, the stereotypes should never be taken to the extreme; many European or American people who have suffered from mental illness might recognize these feelings too. What is clear, however, in the way these stories are presented (which perhaps reflects the characteristic style of the clinic as much as a cultural aspect) is that in the experience of illness and therapy a radical existential anguish comes to the foreground which is greater than the personal disappointments and problems. This is why to find an occupation, the possibility of entertainment and a chance to communicate with others is so important in this clinic which, as one of the operators explains, has much more staff than any other similar home, despite the costs: precisely to be able to afford that kind of help. This mission creates a moral and even philosophical level that gives the patients’ struggle a universal value, and casts Dr. Yamamoto as a figure of wisdom and an example of goodness before being a professional doctor – ‘he’s truly divine’, as Sugano says.