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  • Sasha Durakov Warren

Approaching the question "What was madness before psychiatry?"

This text will be the first in a new series on pre-psychiatric care for the mad, or more precisely (since these didn’t always appear as a system of care) on the different defined social meanings and roles created for the mad. In the simplest terms, I am looking to answer the question “how were the mad defined and integrated into [this or that community, this or that economy, this or that social institution] before the appearance of psychiatry?”

Though this may seem to some like a diversionary historical curiosity, it’s a question of some contemporary relevance insofar as the alternative social responses to madness throughout history constitute the primary ammunition for all those who want to make cracks in the edifice of psychiatric hegemony and the apparent fate of the mad. The basic argument is: If the mad were once somewhere integrated as soothsayers or normalized as village oddities, then their consignment to a lifetime of chronic suffering and social marginalization is not organically ordained.

Although I certainly agree that past examples can help denaturalize the kinds of truth claims made by psychiatric researchers and disturb their teleological compulsions (where they are always the most humane and most correct, of course), the problem is that critics and apologists of psychiatry alike broadly rely on optimistic and pessimistic stereotypes about the past. This war of representations between images of edenic community where the mad woman was consulted as an expert or hellish basements with the madman in chains is really about the present and the future, not the past. My wager is that we can only benefit from learning about what those forms of integration looked like in practice, what manner of social life sustained them, and what caused them to disappear. I believe such a project can help us 1. Learn to tell the difference between what from the past is practicable (or adaptable) and what is too tied to material or psychic structures that belong to another time and place to apply today, 2. What is specific to psychiatry relative to these other forms of care or integration, and 3. What these former systems and their transformation processes might tell us about the present and the future of mental health care. An added benefit is that it may aid us in dispensing with Rousseauistic simplifications about some past golden age where madness was accepted by all and consider people in the past in their real conditions and not according to an ideal of a character role we want them to play.

Some possible examples of what I’ll look at include: the Gheel colony in Belgium; the Iwakara family boarding system in Japan; various systems of confinement; medieval and Renaissance medical knowledge and treatment throughout the Mediterranean (Arabic-language physicians are the most important, but I’ll also look at medieval physicians in France, Germany, and England); the Bimaristan in Baghdad, Damascus, Egypt, and Turkey; monastic care; and whatever else I find that seems fitting. Along the way, I intend to take brief stopovers on topics of interest like the obsession with melancholy in 16th-17th century England or the figure of the holy fool around the world. The primary condition to warrant consideration (no one’s asking me to do this, so I should add: besides my own personal interest!) is that the model of care or integration considers the people in question mad (or whatever term was in use or in vogue: lunatic, delirious, of unsound mind, etc) and treats them differently on that account.

William Blake. "Nebuchadnezzar," 1795. The bliblical story of Nebuchadnezzar was the foundational piece of the popular etiological theory connecting sin to lunacy throughout medieval Christendom

I don’t think it’s possible to verify whether all those called mad in 16th century England would qualify as mad now or vice-versa, and it’s a moot point. What counts as mad for the purposes of this project is the following: to be considered in contrast to “sane” or “rational” to such a degree as to be singled out and treated as such by a social group, institution, or community with the power to make such a distinction. I will not play the game of subsuming other ways of distributing responsibility or difference in a social group into contemporary ones by imposing psychiatric terms over on top of them. An egregious example of this occurs in Vanished in Hiawatha: The Story of the Canton Asylum for Insane Indians where the author, Carla Joinson, says that “Native Americans” (a uselessly broad term in the context of a huge range of understandings of deviance, difference, or illness contained under that appellation) simply understood depression or other mental disorders under the culturally specific rubric of spiritual alienation or soul sickness. Such an approach implies that depression as psychiatric knowledge frames it is the universal, underlying truth and the “others” just use their own weird little names for it. Other cosmologies and structures of consciousness are at best in search of a rigorous vocabulary, or at worst simply wrong. For the purposes of my exploration, I will even exclude examples of things like hearing voices or seeing visions if they aren’t considered exceptional and somehow differentiated from another group called normal, rare though that may be (but not unheard of in times and places of extreme religious fervor, for instance). My approach is therefore not at all neutral. In Recovery From Schizophrenia, Richard Warner makes the distinction between “social recovery” and “symptom suppression” in models for the treatment of schizophrenia. Such a distinction (even if you balk at the trite uses of “recovery” currently in the market) is a useful general rubric. Most forms of integration historically have aimed at “social recovery;” the domination of medicine and the goal of “symptom suppression” are quite new and historically minor tendencies in the long arc of the history of madness. I am assuming that even “symptom suppression” as a goal “in itself” is a confused concept (the result of forgetting and professional consolidation in moments of crisis) in the history of social integration/recovery and will therefore make up a very small portion of the examples.

I make a conceptual distinction between expulsion, which includes things like forced exile or elimination/murder; integration, which I will use in an uncommonly non-valued way in the broadest sense of “bringing in and making a place for” (putting lepers in a colony is also a way of “integrating” since it still finds a place for them that is part of the representational, conceptual, administrative, political, and economic universe of the community); and absorption where things we might consider madness are so thoroughly included that they cease to exhibit clear boundary lines between other experiences. Madness effectively does not exist where it is successfully absorbed, and that marks the limit point of all integrative projects. The history of negative eugenics in Vichy France teaches us that some forms of “integration” are slow forms of elimination. These distinctions are therefore not always easy to tell apart, and are only very generic placeholders. My hope is that, in looking at particular examples, how they play out in reality will become clear enough.

A similarly thorny problem I will continually face is that the question of when psychiatry begins is not at all simple or decided. When I first decided to undertake this little research project, I framed it as an investigation of “pre-capitalist” systems of care, since the rise of psychiatric care is tied so closely to the dependence on wages, the technical adaptations of labor to industrial discipline, and especially the weakening and gradual elimination of subsistence economies characteristic of capitalist development. Because these processes don’t occur overnight, because there are often lags between those developments and changes in mental health care, and finally because eclectic treatment regimes mixed pre-psychiatric models with more modern ones, tracing “pre-capitalist” mental health care proved too complicated a framing.

Defining the break between “pre-psychiatric” and “psychiatric” is a little clearer, but still presents difficulties, the first of which being that there is no consensus about what the psychiatric revolution was or when it happened. Most would say it commences with Phillipe Pinel at the Bicêtre hospital in Paris when he (or Pussin, really) unlocked a group of madmen from their chains in 1793; Edward Shorter locates it a little earlier with William Battie’s privileging of “moral management” at St. Lukes in London in the 1750s; but Gregory Zilboorg places the first psychiatric revolution hundreds of years earlier with the medical psychology of ​​Juan Luis Vives in the early 16th century (188). These divergent starting points correspond to different assumptions about what psychiatry is, each of which seem to present more questions and exceptions than clarity. In service of establishing some dividing lines between “psychiatric” and “pre-psychiatric” for the project, I’ve settled on the following criteria: psychiatry is a dynamic system that rationalizes the organization and management of a group socially designated as mad connecting purpose-built segregated spaces to transitional spaces of variable degrees of integration into public life. What makes psychiatry special is that these two functions (institutionalization and rationalization) exist in tandem in a productive circuit. This distinguishes it from earlier, broader forms of incarceration and from the chaotic, eclectic nosologies of madness in the Renaissance, for example. This system can only properly function when two conditions are met, neither of which are exclusively about medicine or treatments: 1. it must either align its knowledge about madness or its taxonomic categories (e.g. ADHD or schizophrenia) to a lay perception of madness, secure a sufficient amount of public trust in its expertise, or strive to attain monopoly over the representations of madness. If and when they fail to do so, people don’t seek out their aid nor institutionalize loved ones to a sufficient degree for the project to be viable on a mass scale; 2. It requires the law sufficiently differentiate its object, madness, from other forms of social deviance (crime, delinquency, perversion, etc) and define a course of action for courts, officers of the law, corporate bodies, families, etc in processing the mad and ensuring they end up in the correct space (historically the asylum is most prevalent, but the community mental health center or outpatient clinic are others). To make a final point clear: psychiatry is not the appearance of the asylum or other segregated space, of the medical rationalization of insanity, nor of civil codes pertaining to madness, since each has on occasion appeared prior to psychiatry proper, but rather the formation of a dense network of connections between these that form a productive circuit.

This description doesn’t exactly roll off the tongue, but pithiness is not possible with such an ambiguous theme. By my definition, we can date the rise of psychiatry to specific localities with a higher degree of specificity, because psychiatry did not arise all at once and immediately subsume all other modes of integrating the mad. With a definition based on its conditions for existence, its dynamic totality, and its functions, it’s possible to denationalize our understanding of the project and see how, even in a more centralized country like France with a strong historical dividing line like the law of 1838, it may have become increasingly dominant in Paris in the 1810s or 20s, while non-psychiatric care practices could still be dominant or at least mixed with more modern psychiatric care in a place like the Vendée region until well after the law. My hope is that, in addition to clarifying questions about the usefulness of past examples for current alternatives to the contemporary mental health system, examining the rise of psychiatric hegemony in places where other forms of integration were dominant might also help us better see how and why psychiatry becomes dominant. The goal as always should be to avoid any conspiratorial explanations that make psychiatrists as a group out to be organized political Machiavellis or savvy backroom insider traders (they’re not).

Two texts will loom large over the whole venture: Robert Burton’s Anatomy of Melancholy and Michel Foucault’s History of Madness. The first for uncomplicated reasons: it’s a massive compendium of knowledge about melancholy and madness from the 17th century with quotations from what feels like anyone who ever said anything about either up to that point. The shadow Foucault’s towering book has cast over the history of madness and proto-psychiatry is more troubling and inextricably bound up with a deeply ambivalent history of interpretations for and against his supposed claims. The next post will be on what’s actually in the History of Madness about madness before psychiatry, on its history of translation, and how the history of its interpretation has shaped the dominant optimistic and pessimistic concepts of pre-psychiatric care up to today.


Joinson, Carla. Vanished in Hiawatha: The Story of the Canton Asylum for Insane Indians. Lincoln: University of Nebraska Press, 2016.

Shorter, Edward. A History of Psychiatry From the Era of the Asylum to the Age of Prozac. New York: John Wiley & Sons, 1997.

Warner, Richard. Recovery From Schizophrenia: Psychiatry and Political Economy. Hove: Brunner-Routledge, 1997.

Zilboorg, Gregory. A History of Medical Psychology. New York: W.W. Norton & Co, 1941.

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