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Madness: A Brief History

Roy Porter <em>Oxford University Press, 192pp, £11.99</em>

ISBN 0192802

My experiences of seeking help for my own "mental health problems" as a teenager bear out one of the themes that run through Roy Porter's useful and readable mini-history of madness - that "sanity" and "insanity" are very subjective issues indeed. Depending on where and when you are living, as well as the training, mood and ability of the professional or institution at whose mercy you throw yourself, you are likely to receive widely divergent diagnoses, treatments and speculations as to causes and prognoses, like an extreme version of postcode prescribing.

Although on each occasion I presented the same (or at least roughly similar) symptoms, the range of public and private practitioners whom I saw variously diagnosed my chronic drug addiction, and the behavioural problems associated with the condition, as a monomania, as a symptom of a more complex illness, as a primitive attempt to medicate an underlying organic depression, or as a way of masking my sociopathic anger. It was a genetic problem. It was brought on by a chemical imbalance. It was a spiritual condition, a social problem, or it was somatic. It was my way of expressing my anger at my parents, or it was a manifestation of childhood trauma. It was curable, treatable, incurable.

A head psychiatrist at a main London hospital wrote down that I was "terminally addicted" and prescribed a course of electroconvulsive therapy. I would be made better by being shouted at and cleaning toilets with a toothbrush, by taking any number of psychotropic drugs, by clinical psychology, by exorcism (no kidding), by yogurt-weaving or dance therapy in an institution. One shrink recommended that I take up sadomasochistic sexual practices, and another - highly thought of, highly paid - attempted to analyse me while driving in his Porsche at 130mph down the M1. All this because I liked to get high, and behaved a little oddly from time to time. Imagine what would have been suggested if there actually had been anything wrong with me.

Madness: a brief history shows that an inability to agree on diagnosis or a course of treatment for mental illness, or even whether mental illness exists at all, has been the case since the birth of medicine. As Porter follows the mad and those who would treat them, from Greek and Roman times through medieval witch-hunting, the Enlightenment, the golden age of the asylum and into this century's enthusiasms for psychoanalysis and psychopharmacology, it becomes painfully clear that progress in the field has been far from linear. Rather, new ideas are seized on with enthusiasm, practised widely - usually too widely - then discredited. They then drop out of sight for a while, before reappearing with a new name and a new champion, but they rarely go away. Aretaeus of Cappadocia, in the first century BC, noted patients who suffered from a mixture of mania and melancholy. After various other incarnations, this manic depression resurfaced as double insanity or circular insanity in 19th-century France, though nowadays patients suffering from this fashionable-again condition are bipolar.

Talk therapy and shock therapy had their origins in Graeco-Roman times. Surgical procedures similar to trepanning are still in use, and the enthusiasm with which new drugs are prescribed across the board has echoes in such practices as bloodletting and leech-work.

Porter doesn't really attempt to answer what madness is. Instead, he concentrates on a few core questions: Who has been identified as mad? What has been thought to cause their condition? And what action has been taken to cure or secure them? He has given himself a big subject, but manages to reduce it to a little more than 200 pages with skill and restraint. What makes this book so satisfying, however, is Porter's ability to combine broad brush strokes with telling little details of the lives of the mad and their minders, and their uneasy symbiosis. I loved Nathaniel Lee's quote on being committed to Bedlam: "They called me mad, and I called them mad, and damn them, they outvoted me."

The closure of so many asylums (the result of left-wing idealism and right-wing pragmatic cost-cutting) may be cause for muted celebration. But who does not feel uneasy and a little unsafe over the consequences of those closures? In my neighbourhood, in west London, "Care in the Community" is known as the "Smoke Crack and Drink Super-T in Doorways" programme. It's hard not to conclude that the whole business is in a terrible mess.

"More people seem to be diagnosed as suffering from more psychiatric disorders than ever," Porter gloomily concludes. "Is that progress?" Well, yes, in a way it is. It is no longer us and them (or them and us). The psychiatric profession has caught up with what we have suspected all along: we're all touched in one way or another. Some just hide it better than others.

Julian Keeling was the first Briton since the Sixties to register as an opium addict