In Search of Madness: A soulful history of psychiatry

On a recent and “glorious” morning, Brendan Kelly – an Irish professor of psychiatry – was sitting quayside in Wexford town. The sun was warm, two dogs were sitting beside him, and “rather incongruously” he was reading an early 19th-century government report “concerning the lunatic poor” in Ireland.

Intrigued?

Consider, then, the report’s account of these lunatic poor, which Kelly has salvaged from the confines of history in his latest book: “When a strong young man or woman gets the complaint, the only way they have to manage is by making a hole in the floor of the cabin not high enough to stand up in, with a crib over it to prevent his getting up, the hole is about five feet deep, and they give the wretched being his food there, and there he generally dies. Of all human calamity, I know of none equal to this.”

Human calamity abounds in the ambitious but approachable In Search of Madness, in which Kelly traces the history of mental illness across the globe – from Wexford quays to Russian prisons, through stirring case histories from his own clinical practice and asylum archives. Spoiler alert, but the “madness” Kelly finds is not within the individuals who “get the complaint” – although he does provide sensitive insight into depression, manic depression and schizophrenia – but with how society treats people with mental illness.

The likeness he finds between an 1843 report on an Irish asylum and a 2019 report on the mentally ill in an Irish prison makes for grim reading, and underlines his argument that we have transitioned from the bygone “era of the asylum” to a contemporary “era of neglect”.

Kelly stresses the point that socioeconomic and geopolitical forces define this era, creating “gross and deadly inequity of access to effective care”. He frames this issue both locally and globally: highlighting, for example, the impact of our housing crisis and nonexistent primary care mental-health service on one hand, and that just 13 psychiatrists practice in Zimbabwe (population: 15.6 million) on the other. No surprise, then, that the book ends with a concise and must-read manifesto for change and a quote from Rudolph Virkow: “Medicine is a social science, and politics is nothing but medicine on a large scale.” (I always preferred Virkow’s pithier quote, “the physician is the natural attorney of the poor,” but Kelly’s writing the book and I’m writing the review.)

In Search of Madness contains multitudes, and Kelly does a fine job of engaging the reader’s attention as he shifts gears between social historian, science communicator, public health advocate, and unabashed “traveloguer”. It is a testament to his craft as a writer, not to mention his diligence as a researcher, that he ties these strands into a cohesive narrative and an easy, enjoyable and informative read.

If the first chapter suffers slightly from dense blocks of archival text, the book quickly finds its footing as Kelly’s voice comes to the fore. He casts light on the darker chapters of psychiatry (from the familiar but grisly lobotomies, to the unfamiliar but equally grisly insulin comas), and deepens this analysis – diagnosing as root cause an identity crisis in a field obsessed with legitimacy, one rendering it vulnerable to “uncritical therapeutic enthusiasm” for new but untested ideas. He is self-aware enough to wonder how current clinical practice will stand the test of time.

Raising questions

Perhaps the most endearing and disarming aspects of this book is Kelly’s willingness to raise questions for which simple answers do not exist (as foreshadowed on the back cover: “Who is ‘mad’? Who is not? And who decides?”), to tolerate ambiguity and promote humility as a professional virtue. In his own words, psychiatry is “established but contested, useful but incompletely understood, necessary and still mysterious”.

He is at his most persuasive and hopeful when arguing that the humanities and social sciences ought reclaim conceptual and practical (i.e. funding) territory in a field dominated for decades by neurosciences. “We are not just brains; we have souls, too,” he writes, aligning himself with the great American novelist and essayist Marilynne Robinson, who also questions the overreach of neuroscience into the mysteries of human life. “I find the soul a valuable concept,” Robinson has it, “a statement of the dignity of a human life and of the unutterable gravity of human action and experience.”

Given Kelly’s findings in this brief but rather brilliant survey of psychiatry, is it any wonder that he too seeks to centre the soul as a guiding light to a brighter future?