Transformation and Healing After Trauma, Loss and Grief

My Mythic Garden

A blog by author and trauma expert Gary W. Reece, Ph.D.

Outcasts
By

Gary Reece

Men are so necessarily mad, that not to be mad would amount to another form of madness. Pascal
In the introduction to a book by Michel Foucault entitled “Madness and Civilization” there is a very nice synopsis of the area I want to write about in this blog. It begins,
Madness is really a manifestation of the “soul,” a variable concept which from antiquity to the twentieth century covers approximately what came to be known, after Freud as the unconscious part of the human mind. Only time will tell how much better students of the psyche can look at the future after reading this sobering recreation of yesteryear’s madness and the ineffective attempts of humanity to treat it by amputation, projections, prejudices, and segregation.” ( Introduction: Joel Barchilon, M.D.)

I was brought to this topic quite by accident, I was asked to moderate a panel discussion on the police and the homeless mentally ill. After I had made my introductory remarks and listened to the discussion I became aware of two things, 1) how little I knew about mental illness: even though I have a Ph.D. in clinical psychology and 40 years of practice. And 2) the thought came to me also, that if I knew so little, then the police who encounter the mentally ill must know even less than I do and I am sure, find themselves confronting a bewildering population of individuals with problems ranging the entire depth and breadth of mental illness. It is a very complex problem and the police as we have recently seen have often not responded well as they attempted to deal with particular individuals. I am thinking of recent examples in New York and Los Angeles where the individuals were killed after contact with the police. There are numerous graphic videos of police brutalizing individuals who were later described as having mental health issues.

Historically we have not been kind to individuals we do not understand or find behaving outside the “norms” of our society. We have stoned, crucified, burned at the stake, guillotined, incarcerated, shot and excluded them from our midst. These are our social outcasts.

Michel Foucault begins his very interesting treatise in “Madness and Civilization” this way:

At the end of the Middle Ages, leprosy disappeared from the Western world. In the margins of the community, at the gates of cities, there stretched wastelands which sickness had created to haunt but had left sterile and long uninhabitable. For centuries these reaches would belong to the non-human. From the fourteenth to the seventeenth century, they would wait, soliciting with strange incantations a new incarnation of disease, another grimace of terror renewed rites of purification and exclusion…Finally Leprosy disappeared, the leper vanished, or almost, from memory; these structures remained. Often in these same places, the formulas of exclusion would be repeated strangely similar to two or three centuries later. Poor vagabonds, criminals and “deranged minds would take the part played by the leper, and we shall see what salvation was expected from this exclusion, for them and for those who excluded them as well. With an altogether new meaning and in a very different culture, the forms would remain—essentially that major form of rigorous division which is social exclusion. (Pg. 7)

Foucault goes on to describe how the “mad” replaced the leper to become the moral equivalent and has been treated thusly for centuries. What I find so disturbing is that for the mentally ill little has changed. They are still isolated, excluded, stigmatized and now left to fend for themselves on our streets, as if they still contain and bear the marks of the disease of leprosy. They have become the modern equivalent of “social lepers.”

In previous centuries things we now would find outrageous occurred. Foucault describes this unique form of humiliation and exploitation.

Something new appears in the imaginary landscape of the Renaissance soon it will occupy a privileged place there: the Ship of Fools, a strange “drunken boat” that glides along the calm rivers of the Rhineland the Fleming Canals.” This ship of fools had a cargo of “the Mad,” who would be shipped from one city to the next and then the passengers would be forced to be displayed (perform) for audiences. Apparently the custom was for the police to arrest them and then they were handed over to boatmen, in 1399 seamen were instructed to rid the city of madmen who walked about the streets naked. “Sometimes the sailors disembarked these bothersome passengers sooner than they had promised. Often the cities of Europe must have seen these “ships of Fools approaching their harbors. (Pg. 8)

Foucault raises a very important question.
Why does the figure of the Ship of Fools and its insane crew all at once invade the most familiar landscapes? Why, from the old union of water and madness, was this ship born one day, and on just that day? Because it symbolized a great disquiet, suddenly dawning on the horizon of European culture at the end of the Middle Ages. Madness and the madman become major figure, in their ambiguity: menace and mockery, the dizzying unreason of the world, and the feeble ridicule of men. (Pg. 13)

Simply put, the mad make us terribly uncomfortable. They do not behave predictably or normally, and somehow in their irrationality and bizarre behavior, they hold before us a mirror of how vulnerable we all are; that madness is not that great a leap for most of us. We fear, we isolate, we avoid, we exclude and as Foucault has documented we exploit and humiliate those we do not understand or with whom we can’t empathize.

Is it a valid excuse to say little was known about the causes of mental illness in this era? In fact medical science was still in its infancy. Even so, we still are in a quandary about what to do with individuals so afflicted. It is common knowledge that the seventeenth century became the century of confinement, that as many as one out of four individuals; inhabitants of the city of Paris were confined. What is quite significant is that confinement became the solution for all sorts of social problems. The civil authorities and the church colluded to solve several problems at the same time. This is the period where the police and the church used their “moral authority” to decide the fates of anyone they deemed “useless” individuals. So those who were not only “mad” would be found mingled in the cells of prisons with the poor, with the unemployed, and with criminals. Foucault comments:

It is within the walls of confinement that Pinel and nineteenth century psychiatry would come upon madmen; it is there –let us remember they would leave them, not without having boasted of having “delivered” them. From the middle of the seventeenth century, madness was linked with this century of confinement and with the act which designated confinement as its natural abode. The very character of these institutions was due to a “complicity” between the government and the Church. These great hospitals, houses of confinement, establishments of religion and public order, assistance and punishment of governmental charity, and welfare measures are a phenomenon of the classical period. (Pg. 33)

Foucault concludes:

Measured by their functional value alone, the creation of the houses of confinement can be regarded as a failure, a transitory and ineffectual remedy: a social prescription clumsily formulated by a well intended bureaucracy composed of church and state. This in part was due to the policy of inclusion of all those designated as “useless” people, the mad were yet to be seen as a special form of a medical problem. The art of psychiatry had yet to figure out the complexities of this disorder. But certainly the age of confinement produced many brutal and humiliating practices which ultimately led to their demise. (Pg 54)

It is clear that incarceration did not have as its main purpose treatment or alleviation of suffering, quite the contrary. One such practice was to parade the prisoners before windows in the walls of the prisons and charge spectators a fee to watch the “insane on parade”.

As late as 1815 …the hospital of Bethlehem exhibited lunatics for a penny, every Sunday. Now the annual revenue from these exhibitions amounted to almost four hundred pounds, which suggests the astonishingly high number of visits a year…The madmen at Richere were shown like curious animals, to the first simpleton willing to pay a coin. One went to see the keeper display the madmen the way a trainer at the Fair put the monkeys through their tricks. (Pg. 68)

It was quite some time before attempts were made to approach the problem of the “mad” as possibly related to a medical problem. There were many extant theories at the time: delirium, unregulated passion, and evil spirits. Hysteria was considered to be a problem of “a wandering uterus.” Melancholia, for example was explained in the following manner:

Now this clear and coherent syndrome was designated by a word that implied a single causal system, that of melancholia: I beg you regard closely the thoughts of the melancholics, their words, visions, actions and you will discover how all that their senses are depraved by a melancholic humor spread through their brain. Partial delirium and the action of black bile were juxtaposed in the notion of melancholia, unrelated for the moment beyond a disjunct confrontation of a group of signs by a signifying name. (Pg. 118)

Modern medical science has “evolved” through several centuries of primitive conceptions of biles, spirits, vibrating nerves and erroneous attempts at therapeutics that led to the asylums and now progressed to the point that in the Diagnostic and Statistical Manual of the American Psychiatric Association there are several hundred diagnostic categories covering over 600 pages. I find it interesting that it was only a few years ago that they got around to declassifying homosexuality as an “official diagnosis.” Even though psychiatry can categorize elaborately the various disorders, they have yet to definitively arrive at a cause for mental illness. There have been many theories. Most today are now looking at various possible genetic and neurological problems in the brain: while others look at early attachment experiences and social conditions for their contributions to abnormal behavior. Suffice it to say we are still a long way from understanding and being able to effectively treat the seriously mentally ill. For example, I had a colleague in graduate school brag to me that all therapists would be out of business in 10 years because of the advances in neuropathology of the brain. Forty years later I am still waiting. It wasn’t until the 1950’s that various medications were thought to be the panacea for mental illness. And while this was going on primitive measures of incarceration, shock treatment and lobotomies were being routinely practiced. Many of these were documented in the film, “Cuckoo’s Nest.”

Though our attitudes toward the mentally ill are somewhat more sophisticated, they are still regarded as outcasts and second class citizens. They are the shadow population that lives on our sidewalks and parks and in encampments in outlying areas. How this came to be will be the subject of my next blog.

In the meantime let us consider some sobering statistics which indicate how prevalent mental illness is in our culture and that every day, ordinary individuals suffer from some form of mental disorder. For example,

NAMI • The National Alliance on Mental Illness • 1 (800) 950-NAMI • www.nami.org 3803 N. Fairfax Drive, Suite 100, Arlington, VA 22203 provided the following information on
numbers of Americans affected by Mental Illness.

• One in four adults−approximately 61.5 million Americans−experiences mental illness in a given year. One in 17−about 13.6 million−live with a serious mental illness such as schizophrenia, major depression or bipolar disorder.1
• Approximately 20 percent of youth ages 13 to 18 experience severe mental disorders in a given year. For ages 8 to 15, the estimate is 13 percent.2
• Approximately 1.1 percent of American adults—about 2.4 million people—live with schizophrenia.3,4
• Approximately 2.6 percent of American adults−6.1 million people−live with bipolar disorder.4,5
• Approximately 6.7 percent of American adults−about 14.8 million people−live with major depression.4,6
• Approximately 18.1 percent of American adults−about 42 million people−live with anxiety disorders, such as panic disorder, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), generalized anxiety disorder and phobias.4,7
• About 9.2 million adults have co-occurring mental health and addiction disorders.8
• Approximately 26 percent of homeless adults staying in shelters live with serious mental illness and an estimated 46 percent live with severe mental illness and/or substance use disorders.9
• Approximately 20 percent of state prisoners and 21 percent of local jail prisoners have “a recent history” of a mental health condition.10
• Seventy percent of youth in juvenile justice systems have at least one mental health condition and at least 20 percent live with a severe mental illness.11

Getting Mental Health Treatment in America
• Approximately 60 percent of adults12, and almost one-half
of youth ages 8 to 15 with a mental illness received no mental health services in the previous year. 13
• African American and Hispanic Americans used mental health services at about one-half the rate of whites in the past year and Asian Americans at about one-third the rate.14.
• One-half of all chronic mental illness begins by the age of 14; three-quarters by age 24.15 Despite effective treatment, there are long delays−sometimes decades−between the first appearance of symptoms and when people get help.16

The Impact of Mental Illness in America
• Serious mental illness costs America $193.2 billion in lost earnings per year.17
• Mood disorders such as depression are the third most common cause of hospitalization in the U.S. for both youth and adults ages 18 to 44.18
• Individuals living with serious mental illness face an increased risk of having chronic medical conditions.19 Adults living with serious mental illness die on average 25 years earlier than other Americans, largely due to treatable medical conditions.20
• Over 50 percent of students with a mental health condition age 14 and older who are served by special education drop out−the highest dropout rate of any disability group.21

• Suicide is the tenth leading cause of death in the U.S. (more common than homicide) and the third leading cause of death for ages 15 to 24 years.22 More than 90 percent of those who die by suicide had one or more mental disorders.23
• Although military members comprise less than 1 percent of the U.S. population24, veterans represent 20 percent of suicides nationally. Each day, about 22 veterans die from suicide.25
25 U.S. Department of Veterans Affairs, Mental Health Services, Suicide Prevention Program. (2013). Suicide Data Report,

What to make of these numbers? 1) It appears as if mental disorders affect a significant portion of our population, 2) that a large portion does not receive appropriate services, and that the poor and impoverished and young suffer a greater percentage of disorders. It appears as if we have become better at identifying and treating individuals and they are no longer excluded and exploited or humiliated the way they were several hundred years ago. But it is still clear that they are still stigmatized and the severe cases that live on our streets are still a huge problem for our society which appears to ignore rather that deal with the problems in a humane manner.

What should concern us all is the number of isolated, alienated and hidden individuals who suffer from serious illness and are not diagnosed: alienated, ostracized children, adolescents and adults. We have had too many examples of these individuals exploding in our midst with guns blazing, taking out their rage on innocents in theaters, schools, universities and shopping centers. These are the alienated outcasts who appear invisible until their rage and distorted thinking leads to violence. The question is how do we do a better job of identifying and treating this shadow population of mentally ill individuals in our midst?

Given the prevalence of mental illness throughout our society we must do more to understand the sources of these disorders and find more effective forms of identification and treatment, and not only that, but make delivery of treatment more available and less of a stigma attached to those seeking help. We have come a long way from indiscriminate mass incarceration however; there is still a high percentage of the mentally ill who are mixed in with the general population of our jails and prisons. This is simply due to the lack of treatment facilities available for those in need.

When Pinel unchained the mentally ill and began the procedure of treating the patients like human beings he started a movement of treating the mentally ill with dignity and the humanity they deserved and in so doing he found they responded to being set free from their chains and were able to accept responsibility for themselves. Foucault concludes:

Now the combat was always decided beforehand, unreason’s defeat inscribed in advance in the concrete situation where madman and man of reason meet. The absence of constraint in the nineteenth-century asylum is not unreason liberated, but madness long since mastered. (Pg. 252)

I would argue that it is still not mastered and remains one of the most significant causes of suffering and social disruption, not to mention waste of human talent and resources in our society today. Mental illness is still not mastered nor fully understood and its sufferers remain isolated, excluded, and marginalized: still outcasts waiting at the gates of our cities for inclusion and humane treatment. Until then, policing them will remain a source of conflict and unfortunate mishandling of people who are unable to conform to our “civilized” ways. They do not need to be brutalized. As Charlie Beck, Los Angeles Chief of Police said so eloquently: “Compassion ends the moment resistance begins.” Therein lays the problem.

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