This is a going to be a bit of rambly blog post on some methodological problems I am coming across in my historical research that are linked to how diseases are written about in the past, but have wider implications for the ways that we view psychological health, disorder and illness. Changes to society and lifestyle seen in the wake of the measures taken to limit the spread of COVID have led to certain public health officials warning of the impact these may have on our psychological wellbeing. Sensitivity to the links between mental health, society and culture can be heightened if policy makers are aware of historical work that establishes and explores them. Whilst I think it may be difficult to get a policy unit to read a whole book on the connections between mental health and say Victorian society, it might be possible for historians to make the case a more convincingly by clearly articulating their methodologies to a general audience in shorter pieces. In this blog post, I will explore how this may be achieved by writing about diseases in the past mainly because this seems like the most effective topic through which to address these current anxieties over mental health.
I will begin with what I hope is a very clear question: is there any benefit to using concepts from today to understand past events, historical figures and ideas? To illustrate, a very good 1995 adaptation of Richard III did just that, setting the play sometime in the mid-20th century in a United Kingdom turned fascist to pose a number of interesting questions, amongst them are whether this huge figure in British history could have been a proto-fascist? In employing the modern concept of fascism to pose this question, it asks whether Germany followed a unique path to fascism, the Sonderweg as it is sometimes referred to, or was there the potential for fascism to triumph in the UK, something deeply lodged in the culture for centuries?
Counter to this view is that we need to respect the distance of the past, not try to frame it and its people with the concepts that we have. To put it in more practical research terms, historians who use modern concepts to freely to understand the past are in danger of doing a violence to the history
Aware that the debates between historicists and their opponents seem to have resolved not very much, I side stepped this sticky issue in my thesis. This was not especially difficult to do – my thesis was providing a treatment of a new case study in the history of psychiatric classification, so as long as that was done to an acceptable standard, my work was both an original contribution to the field and publish-able (the ‘able’ being often forgotten by many a hapless PhD student). During my viva, my examiners pressed me on whether I thought mental disorders were socially/culturally constructed or mind independent/natural objects. We had a really fruitful discussion and I learnt a lot during the two hours, but my mind still remains undecided and perhaps the framing of mental disorders as being in these divisions is perhaps part of the problem.
In short, I think perhaps that the concepts used to frame the structures of the mind are historically and socially contingent, and culture can imprint itself to some degree on the body by modifying physiological states in very subtle ways that are manifest in context specific mental disorders. I think that this could be the case with depression and anxiety, but at the same time, it seems wrong to me to say that people in the 1860s were suffering from what we now call manic depression – there are a number of reasons for this which I hope will become apparent in the following discussion and which may be relevance now given the current changes to the way we live during COVID lockdowns (https://www.theguardian.com/society/2020/dec/27/covid-poses-greatest-threat-to-mental-health-since-second-world-war), which may change the kinds of mental disorders that are cropping up amongst those who are working from home, those who are on furlough and those who are ong-term unemployed.
These methodological issues are now rearing their head as I prepare funding applications that require a strong methodology rooted in a theoretical approach that is linked to the goals of the research. As a historian of psychiatric knowledge, this is especially important but quite hard to do – you have to make sure the very grand aims you have are realisable through the methodology you adopt, and the theory that you rely upon. For me the crucial and pivotal questions are: what theoretical position do I adopt when analysing the terminology that psychiatrists in the past used to diagnose patients, and how do I account for the changes in these terms over time, changes which are captured in the historical records I consult. In a more concrete but quite crude example, say we argue after careful analysis of his personal memoirs and perhaps the testimonies of friends, family, colleagues and medical people who examined him, that Napoleon was autistic. We use a concept that was first formulated long after his death, but which itself has undergone changes during its existence. It is probable that we would use the present one, under the assumption that this is the ‘best’ one that has been developed by clinical medicine. But what do we mean by best? The most clinical efficient and the most scientifically valid perhaps, but these are not always the same, and can be at odds with one another, especially in psychiatry, as is shown with the debates over the DSM. In addition, it is not really clear what is being achieved with this retrospective diagnosis – perhaps a leader having a disorder like this raises awareness, shows that it is possible to be very successful (in some sense) and destigmatises the disorder due to it not being one that transcends culture and social context, and is present even in great historical figures.
I am going to argue against the potential benefits of this by targeting a book here that although may be an easy target for an historian since it was written by a psychiatrist, is in in the mainstream because it was mentioned recently on the three part BBC documentary on Donald Trump’s presidency – Nassir Ghaemi’s A First Rate Madness: Uncovering the links Between Leadership and Mental Illness. As the title suggests, Ghaemi argues that there are certain disorders, including depression and certain personality disorders, that are not only conducive to good leadership, but are necessary for leaders to excel during times of extreme turmoil. In making this argument, Ghaemi takes examples from history that he diagnoses with depressive and personality disorders to prove his point, including Franklin Roosevelt, Martin Luther King, William Sherman, Abraham Lincoln, Gandhi, and JFK – leaders whose success follows what the author calls ‘the Inverse Law of Sanity’ which he defines as:
‘when times are good, when peace reigns, and the ship of state only needs to sail straight, mentally healthy people function well as out leaders. When our world is in tumult, mentally ill leaders function best.’
These ‘mentally ill’ leaders are countered by those who are ‘mentally healthy “normal” leaders who failed in moments of crisis: Richard Nixon, Neville Chamberlain, and possibly George W. Bush and Tony Blair.’ Ghaemi uses the tools of modern ‘scientific’ psychiatry to diagnose these men through analysis of personal memoirs and details of their biography garnered from secondary sources
Ghaemi’s argument that there are times when possessing what a psychiatrist in the 21st century would diagnose as a mental health disorder is on the surface quite a noble one: it seeks to dispel the demonisation of mental health disorders by arguing that in certain exceptional circumstances, figures having disorders that could be diagnosed by a modern psychiatrist can lead to fortunate outcomes, and what would be regarded as mental health can be a bad thing. There are environments that only allow those with mental disorders to thrive and excel in leadership, suggesting that mental disorders are not simply products of a damaged brain, but are adaptive responses to circumstantial pressures. There is nothing ‘wrong’ with those who are diagnosed with mental health disorders, instead they are suited to different sets of environmental pressures, and the heightened creativity that comes with manic depression, or exceptional powers of resilience, empathy and realism that come with certain personality disorders leave a person particularly suited to crisis leadership. In contrast, emotionally well-balanced and conventional personalities that Ghaemi identifies with Chamberlain, Nixon and Blair, are shown up during times of adversity – because of their unremarkable personalities, these figures are able to handle the hum-drum of normal political processes, but lack the abilities that come with mania and depression.
Apparently Trump was obsessed with a version of Gahemi’s idea when an aide mentioned a version of the central conceit of this book to him: that insanity can lead to good leadership. It’s not hard to see how Trump might find this idea appealing given that he bought into his own cult of personality, and believed that he had a political Midas touch that did not need reason to his methods, and instead believed in a quad-mystical ability to get it right, get the deal done. The more mundane and hum-drum reality though is that he has continued to make poor decisions because this idea reinforced the lack of need to fulfil the daily tasks of a president: read reports, act strategically, keep to script. And he could keep to the belief that there was a kind of divine madness to his leadership because the up-turn is just around the corner. This quite magnificently blew up in his face after contracting COVID and his fantasies met reality brutally – I am convinced that this is what turned swing voters in places like Michigan and Georgia against him – it’s his Dukakis moment (https://www.youtube.com/watch?v=DF9gSyku-fc).
And this is the problem with retrospective diagnosis – it allows us to reinforce our own beliefs about the past and its figures through the knowledge that we have. History fails to challenge our present ideas, and allows us to find all sort of justification for our conceptions, institutions and ideas about things.
To end, aside from the distinctions between the disordered and the healthy here being somewhat questionable, this is not a particularly new argument. My PhD supervisor assigns a reading on his second year history of psychiatry module that was written by the British psychiatrist William Sargant in 1959 in which he argues that there are some circumstances where those diagnosed with schizophrenia and psychopathy individuals might be more resilient to the powers of brainwashing than those deemed to be mentally normal. Written at the height of the Cold War, Sargant based these claims on the belief that both sets of individuals may have problems with empathy and this might actually be a valuable trait in a period of turmoil, or when a country is governed by a totalitarian power. Defence services might actually want to devise ways of identifying schizophrenic and psychopathic individuals for recruitment purposes, because typical character types who possess normal powers of empathy would be more susceptible to torture and other forms of psychological manipulation. Sargant was very much against the psychoanalysis that Ghaemi spends much of his book fighting against (he also was enthusiastically in favour of ECT to a degree that colleagues in this documentary from the BBC describe as ‘evangelical’).
Ghaemi then show his ignorance on two fronts – one a lack of realisation of the history of his discipline, and two, an obliviousness to diagnosing at least two of his subjects, in William Sherman and Abraham Lincoln, with a disorder that would not have been formulated until at least sixty years later (manic depressive syndrome). Furthermore, during the lifetime of Gandhi, Luther King and JFK, the diagnosis of manic depressive disorder was still far from a consensus, with there being disparities between how it was administered in the UK and the US. Despite these disparities, Ghaemi writes as if the psychological classifications were set in stone, and that it is possible to identify disorders across space and time through retrospective diagnosis. In this book then, we have a psychiatrist using the concepts of C21st psychiatry to identify diseases in the past. A great deal has been written about retrospective diagnosis, and I’m going to go out on a limb here and say that there is no literature that convincingly argues that it is beneficial, and it is frequently a position assumed by non-professional historians, frequently of medicine. Turner claims that it may perhaps furnish us with an understanding of the disorders that we know now, and how they would have been present in the past. Yet his view is frequently dismissed as projecting present disorders into the past. Although case notes may suggest to the researcher willing to cherry pick evidence the presence of modern psychopathologies, those of a more historical bent may view the projection into the past of disorders that had not even been described at that point in the medical literature as illegitimate.
Kevin Matthew Jones 