Book Review: Madness and Modernism

Madness and Modernism by Louis A. Sass, Basic Books, New York, (1992).

In addition to being a source of profound suffering, schizophrenia is the most enigmatic of afflictions. Many hypotheses have been adduced for the plethora of bewildering behaviours it engenders, including regression or fixation and/or impaired ego-boundaries, impaired "attentional filters", over-concreteness and over-abstraction, over- and under-inclusiveness, and various neurobiological models to explain these clinical phenomena in turn. Despite their obvious differences, as Sass points out, all these theories follow the 19th century tradition of Hughlings Jackson and Emil Kraepelin, by interpreting schizophrenia as symptomatic of a failure defect or deficit due to a loss of higher mental functions and voluntary controls

In Madness and Modernism, Louis Sass reviews these theories in detail, and does a splendid job of refuting them all while acknowledging their fidelity to certain aspects of the disorder, and synthesizing them into a more comprehensive and coherent picture. Relying on an existential-phenomenological approach, Sass adopts a bold and fertile hypothesis; namely, that the baffling complexity of schizophrenic dysfunctions are the result, not of a deficit, but of an excess or hypertrophy of certain normal mental functions, and more specifically of reflective self-awareness and the need (or desire?) to exercise control over one's own mental processes, coupled with a deadening passivisation of the person that engenders a progressive impoverishment of affect and motivation.

Moreover, Sass continues, many of the same tendencies to 1) introverted, self-referential thinking, to 2) the fragmentation and dissociation of the subject, to 3) frantic activity and inactivity, to 4) the experience of the world (and one's own body) as being bizarre, dead, mechanical and frankly hostile to life, are vividly apparent in modernist and postmodern art and literature, which implies that schizophrenic experience and behaviour may merely be an intensification of widespread social psychological disturbances — the kind of low grade, schizoid detachment which Erich Fromm, in a different context, termed "the pathology of normalcy" (Fromm, 1992). Sass illustrates his thesis with copious examples and persuasively demonstrates that the alienated reduplications of consciousness that pervade modernist art and literature and schizophrenic productions are not merely similar entities, but expressions of the self-same processes. The result is not so much a theory as a whole new vision of schizophrenia, one that is long overdue.

In addition to being of interest to clinicians, of course, Madness and Modernism will be of enormous use to social and cultural critics and historians, sociologists, philosophers and others. This interdisciplinary breadth and depth is itself a rare accomplishment, when you consider the pervasive scientism and narrowness that is customarily inculcated by an education in the mental health professions Another of Sass's achievements is to show that the radical otherness of the schizophrenic, as experienced and attested to by E. Bleuler, K. Jaspers, and H.C. Rumke among others, is partly a product of our own inability to recognize certain features of ourselves writ large as H. S. Sullivan, R. D. Laing and Michel Foucault insisted. And to his credit Sass has gone much further than they in illustrating the extent to which these same schizoid features pervade modern art, literature and philosophy. Having flagged the issue indirectly, however, Sass is silent regarding their origins in emergent structures and systems of economics, technology, kinship and culture in the last three or four centuries and the way these condition and interact with microsocial, intrafamilial, and intrapsychic processes in the social production of madness, and how to reckon the pertinent neurobiological factors into the picture - something Laing and Foucault refused to do.

Nevertheless, and though he does not (and cannot) address all the pertinent socio-economic issues here, one of the book's great strengths is its author's refusal to succumb to reductionism of any kind. Jackson, Kraepelin, et al spawned a neurobiological approach to schizophrenia which robs the behaviour of the schizophrenic of meaning and intentionality, treating any bizarre or unintelligible utterances attitudes or postures as the epiphenomena of genetic disorder and neurological disease. The result is a tacit dehumanization of the person by divesting them (in theory) of conscious volition and treating them as malfunctioning automata in need of (neuro)mechanical repair before they can resume a truly human existence (Laing 1960).

In dramatic opposition to the medical model, the existential-phenomenological approach as embodied for example, in the ideas of Laing and Thomas Szasz (and in another direction, by Michel Foucault) accords a significant degree of meaning and intentionality to schizophrenic discourse, even if its underlying intention merely is to confuse or mislead one's audience, or to pretend one is pretending to be "crazy" - a double (and presumably unconscious) pretence, innured to its own falsity, a willful denial coupled with angry and exhibitionistic self-indulgence. But the implicit humanism of this school, which restores schizophrenics to the wider human community, and places their behaviour on the same explanatory continuum, steadfastly refuses to recognize any underlying neurophysiological substrates to the various anomalies of schizophrenic experience and behaviour.

Taken on their own terms, both the medical and existential-humanist approaches seem quite compelling to insiders. By the same token, they are anathema to their opposing orthodoxies (of the Laingian, Szaszian or Foucaultian variety). But their pursuit of logical and ideological purity polarizes discourse and inquiry in the mental health disciplines in a way that does a disservice to everyone. An integrated approach, such as a Sass represents, is the most balanced and productive in the long run.

No author can address every aspect of a deep and complicated subject in the narrow compass of a single volume, however large, but there are several issue Sass raises and then gives scant attention to, or neglects almost altogether. Anyone who has worked with schizophrenics knows the mixed emotions they engender in others, ranging from awe, perplexity, compassion, pity and hope to fear, irritation, loathing, des-pair and contempt. Some of these effects are achieved quite deliberately as a result of their intentional behaviour. Others are due to their paradoxical paralysis in the face of their own fear, confusion, and often enough, of their own oppositionalism and malice - subjects Sass discusses with penetrating insight. With the possible exception of R.D. Laing (1985) few have pondered the anomalous no man's land 'between act and affliction' that characterizes so much schizophrenic behaviour with such insight and sensitivity. But while Sass goes a considerable distance toward accounting for these visceral responses among friends, family members and therapists indirectly, he doesn't explore the practical consequences of these feelings and attitudes from the standpoint of treatment, case management and our collective attitudes toward the insane. Indeed, he says nothing about treatment at all - past, present and future. One only wished he had, and that in due course, he will.

Having said all that, however, it must be admitted that what Sass is deliberately silent about is not really grounds for reproach, and pales beside his positive accomplishment. Hopefully, we can expect more along these lines in future. Without exaggeration, Madness and Modernism is the most important book on schizophrenia since R.D. Laing's The Divided Self It deserves the serious and sustained attention of anyone interested in schizophrenia and will hopefully kindle interest in deepening an open and even - tempered existential Phenomenological approach to this seemingly intractable practical and theoretical problem

Daniel Burston