Deconstructing Paranoia: An Analysis of the Discourses Associated with the Concept of Paranoid Delusion
David J. Harper PhD Thesis June 1999
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Histories of suspicion in a time of conspiracy:
A reflection on Aubrey Lewis's history of paranoia(1)
1.1 WRITING INSANITY'S PAST: FROM GRAND TO LOCAL HISTORIES
In this chapter, I will develop a reading of an account of the history of the category of mental disorder known as 'paranoia', written by an eminent British psychiatrist, the late Sir Aubrey Lewis. The analysis will draw on both the ideological context in which the account is embedded and the interests dominant and subjugated within the text. I will argue that Lewis's paper depicts the history of paranoia as continuous, scientific, coherent and empirically optimistic and thus renders itself acontextual, failing to pay regard to a whole range of influences (ideological, professional, political and so on) both on its development as a concept and in its practical usage(2).
The historiographical literature dealing with psychiatry and insanity is marked by a wide diversity of orientation and content. However, the field appears to be moving from grand generalizations (either about the wonders or the horrors of psychiatry) to more localised and specific accounts. Rose (1986), for example, has called for a focus on the 'proliferation of sites for the practice of psychiatry'; the 'psychiatrization of new problems and the differentiation of the psychiatric population'; the 'new distribution of professional powers'; the 'free market in [mental health] expertise'; and the 'multiplicity of techniques of normalization' (1986, pp.83-84).
Berrios (1988) has argued that some of the unhelpfulness of linear accounts of the history of psychiatry and 'abnormal psychology' can be resolved if accounts can be developed of histories of 'psychopathology' as an enterprise in general and psychopathological phenomena in particular. Although accounts of the historical developments of particular categories of disorder might be useful, a number of challenges present themselves. First, categories can only be studied within the broader context of categorical development in general. Manuals like those produced by the American Psychiatric Association (APA) -- for example the Diagnostic and Statistical Manual of Mental Disorders: DSM-IV -- and the World Health Organization (WHO) -- for example the International Classification of Diseases, Tenth revision: ICD-10 -- are relatively recent developments. Second, there is considerable debate about whether categories refer to the same phenomena over time. Bynum et al., (1985) ask 'is there any such natural object of "madness" at all?' (1985, p.3) since the meaning of such terms 'change profoundly from epoch to epoch, in ways inexplicable unless viewed within wider contexts of shifting power relations, social pressures and ideological interests' (1985, p.4). The work of Smith (1988) and Danziger (1990), casting similar doubt over psychological terms in general, concurs with this view.
Moreover, categories can no longer be seen as gradual refinements in concepts which remained essentially the same over time. The evidence cited for the existence of certain phenomena are often problematic as Boyle (1990) has noted. There is wide use of case material sometimes only briefly described. Barrett's (1988) work has shown how the ambiguity and complexity of what is said in the context of a psychiatric interview becomes transformed into uncomplicated objectified symptoms in psychiatric case-notes. Furthermore, we rarely have first-hand accounts of experiences of distress, only second-hand and highly interested case descriptions by 'mad-doctors'. Indeed, even where autobiographical accounts exist (eg Porter, 1987) more space tends to be given to professional interpretations than to the authors' views.
Finally, there is a need to differentiate between 'the history of words, concepts and the behavioural phenomena involved' (Berrios, 1991, p.7). A history of the term 'anxiety' might be different from a history of the emotional state as it is currently defined in Western psychiatric texts (eg feelings of worry and so on). Thus Kendler (1995) notes how his history of delusional disorder is a history of the 'clinical construct' and not the term. However, such distinction between term and concept often betrays an essentialist approach to the definitions of certain terms. Could a certain emotional state or abnormal behaviour be said to have existed if there were no terms to discriminate it from other states and behaviours - surely any concept requires some form of descriptive language? Following such an analysis there might be some truth in the view that the delimination of a new psychiatric concept actually 'creates' cases which fit its description. Rose (1990) has noted that the vocabularies of the 'psy' professions are 'languages of government [which] do not merely mystify domination or legitimate power. They make new sectors of reality thinkable and practicable' (Rose, 1990, pp.105-106). Psychiatric cases are thus 'brought forth' by the availability of a language to describe them in ways which differentiate them from similar cases (Méndez et al., 1988). However, psychiatric concepts are often dependent on 'lay' notions. MacDonald's (1981) account suggests that 'suspiciousness' was regarded as a symptom of mental distress in the 17th century long before de Sauvages' use of paranoia (by which he denoted a more general form of madness than simply unwarranted suspicion) and its first use in English in the 19th century (Hoad, 1986). Moreover, the associated word 'delusion' had been in use in English since the 15th century (Hoad, 1986). Tracing the history of a term is difficult enough, but comparing particular manifestations across time is daunting. MacDonald (1981), in his study of madness in 17th century England, for example, describes how 42 of Richard Napier's patients had symptoms of suspiciousness (1981, p. 243). Does this mean the same as a present-day symptom such as 'persecutory delusion'?
Although such issues are difficult to grapple with, an account of a particular typology or category can be extremely useful in 'identifying the surfaces of emergence of psychiatric phenomena' (Miller, 1986, p. 39) and in detailing the ways in which 'governance of the soul' is achieved through the discourses of science, the establishment of accredited experts and through the infiltration of personal desire as opposed to solely coercive professional practices (Rose, 1989, 1990). Hepworth & Griffin (1990) have developed an interesting analysis of the 'discovery' of 'anorexia nervosa' in the late 19th century by examining three papers written by W.W. Gull between 1868-1888 and a report by C.E. Lasègue in 1873. They argue that this new category of mental disorder, constructed through a number of discourses, served to medicalize self-starvation, presenting it both as a typically feminine condition and as a natural corollary of feminine irrationality. The rhetorical strategies which enabled the creation of such a condition involved reference to clinical discourses, and discourses of femininity, of medical science, of discovery and of hysteria. Such investigations help detail the contours of the interests engaged in the emergence of a new psychiatric condition. The benefit of concentrating on a specific category of disorder, then, is less that it is easier to write the history of the disorder, but more that a space is created in which to describe a critical genealogy of that particular disorder and to examine in more detail the interests at stake in its construction.
1.2 LEWIS (1970) AS AN EXEMPLAR OF PSYCHIATRIC HISTORIES OF PSYCHIATRY
The focus here is a history of paranoia by Aubrey Lewis (Lewis, 1970). The reason behind the selection of one specific account of history is, as I will argue, that the writing of histories of psychiatry and psychiatric concepts, like paranoia, are of interest in themselves. The concentration is less on this account's status as a history but much more on its status as a text. Here, then, there will be less of a concern with the accuracy of the text's assertions but rather with what the text does and what interests it serves(3). The study of rhetoric in the human sciences is becoming increasingly popular (eg Simons, 1989) and the identification of the purposes of history-writing has come to be seen as a legitimate activity (eg Smith, 1988). Although any kind of text of history-writing could have been chosen, the value of choosing a history of a particular disorder is that the peculiar contexts and interests at play in the construction both of the disorder and the text can be described in more detail. In examining both what is said and what is not said in this example, the present study will be conducted in a manner similar to current formulations of discourse analysis (Edwards & Potter, 1992; Parker, 1992).
The motive for concentrating solely on paranoia is that, as I have already suggested, given the charges levelled at essentialist historians of psychology by commentators like Danziger (1990) and Smith (1988), studying the historical development of certain categories of mental disorder allows a more detailed analysis of the context of their emergence and transformation over time and facilitates the identification of some of the themes noted in broader historical accounts. An increasing number of researchers are studying particular psychiatric disorders and psychological concepts, some from a critical perspective: anorexia nervosa (Hepworth & Griffin, 1990); inhibition (Smith, 1992); delusion (Berrios, 1991); 'obsessions' (Berrios, 1985); the reflex (Canguilhem, 1989); schizophrenia (Boyle, 1990) and 'shell-shock' (Stone, 1985). Berrios (1993) and Sims (1994) have reviewed a number of recent historical studies of clinical concepts.
What is so significant about Lewis? Lewis's account is particularly interesting for a number of reasons. First, although other histories are available (eg Bone & Oldham, 1994; Dowbiggin, 1995; Kendler, 1995; Kendler & Tsuang, 1981; Scharfetter, 1983; Schifferdecker & Peters, 1995; Turkat, 1985) none of them are as ambitious in scope or as widely cited as Lewis's monograph. The Social Science Citations Index lists 12 citations of Lewis's text between 1970-1980. The Institute of Scientific Information's on-line Social Science Database and Science Database list 30 citations of Lewis (1970) between 1981-June 1998(4). Altogether, 42 citations over a 28 year period. This, taking into account the highly specific nature of the paper suggests it is seen by many writers in the psychiatric literature as an important description of the history of paranoia.
Second, Aubrey Lewis was an important figure in mainstream British psychiatry -- indeed, the dust-jacket of his collected later papers declares him to be 'the most important psychiatrist of his generation' (Lewis, 1979). Shepherd's (1986) work demonstrates his enormous influence on the Maudsley Hospital's Institute of Psychiatry -- a focal point for the development of British psychiatry -- both as its chair from 1945-1966 and, after his retirement, as emeritus professor(5). The late Professor Michael Shepherd, one of Lewis's junior colleagues later to become a major figure in British psychiatry himself, editing the esteemed psychiatric journal Psychological Medicine, has noted 'it is now apparent that at the Institute of Psychiatry Sir Aubrey Lewis played the major role in the laying of the foundations of academic psychiatry in Great Britain' (Shepherd, 1968, p. xi). Kety (1968) states how Lewis's 'broad erudition and wisdom give him a rightful place among the world's leaders in psychiatry. His inspiration, judgement and indefatigable but unassuming energy have made the Institute of Psychiatry at the Maudsley Hospital a bulwark of sound and scientific psychiatry' (Kety, 1968, p. 5)
Third, not only is Lewis an important figure in British psychiatry, he is also important in British psychiatric history-writing. Shepherd has described how, in his later years, Lewis was able to concentrate on 'fundamental issues relating to the definition and classification of mental disorders and the relevance of an historical perspective to the theory and practice of psychiatry' (Shepherd, 1979, p. ix). Lewis's doctoral thesis on 'melancholia' -- published in the Journal of Mental Science in 1934 -- marked Lewis's early interest in the history of psychiatric concepts. The collection of his later papers contains eight published articles historical in content -- six of them, interestingly, appearing in Psychological Medicine. These include explorations of the concepts of 'anxiety', 'drug dependence', paranoia, 'endogenous and exogenous depression', 'psychogenesis', 'psychopathy', 'hysteria' and 'phobia'. In most of these articles, Lewis uses historical records to argue a particular point about the definition or classification of a disorder, at times suggesting a category is dropped, often recommending a 'correct' definition distilled from his historical researches. They tend to be marked by a great number of decontextualised quotations which, perhaps, also reflects the particular selection of books available at the Institute of Psychiatry's library(6).
In some ways therefore, Lewis's description of the history of paranoia provides an establishment figure's perspective both on the nature of paranoia and on the nature of the history of psychiatry(7). In examining this text both in terms of what is said (and how it is said) and what is left unsaid, an opportunity is provided to describe a politically dominant version of the history of British empirical psychiatry in general and paranoia in particular (perhaps, implicitly, the history of paranoia). It is useful therefore to examine Lewis's text in more detail in order to explore which histories are privileged (and which not) and to suggest reasons why. Rather than trying to uncover the 'real' meaning of the text or to speculate on what the author's intentions were in writing, Lewis's article will be taken as an exemplary text. For the reasons outlined above, the paper could be said to have exemplified the views of British mainstream psychiatric orthodoxy at a particular moment in history. This analysis will therefore draw on some of the social and historical factors which may have influenced Lewis's writing of history. This should not be interpreted as a personal attack on Lewis but rather as an analysis of the interests which shape the production of his text as with any text(8). From the fact that historians can only draw on those things which are recorded (which arguably, are the least important facets of everyday life) to the interests and orientations of those who write it, history, perhaps more than any other field, could be said to be dramatically influenced by a number of contextual factors.
1.3 'PARANOIA AND PARANOID: A HISTORICAL PERSPECTIVE'
Space precludes a detailed summary of Lewis's paper and interested readers should read the original in full. For present purposes it will suffice to describe the broad structure of his review. The paper, of approximately 8,000 words, appeared as the first article in the first volume of Psychological Medicine. It begins by noting that words which have passed from psychiatric to lay usage, like paranoia, have loose meanings due to the fact that their technical meanings have wavered over time. Lewis traces the word back to Greek literature where it was a general term for madness. He reports no other use of the word before de Sauvages who used the word to represent both dementia (in his 1759 Pathologia Methodica) and 'amentia'(9) (in his 1763 Nosologia Methodica). Lewis does not explain why de Sauvages in the 18th century should choose an ancient Greek word although he states that it was revived to 'meet classificatory needs' (1970, p. 2). Nearly half of the manuscript deals solely with the German literature. Heinroth is first mentioned, with his involvement in establishing paranoia as a synonym for 'Verrcktheit' being noted. An equal portion is devoted to Kahlbaum. Lewis then deliberates on 'the paranoia question' outlining sources of disagreement amongst German psychiatrists and pointing to the increased use of the term paranoia rather than 'Verrcktheit'. A further page details the work of Kraepelin who is seen as 'the best guide to central opinion' (1970, p. 5) and a similar amount is dedicated to the ideas of Kretschmer, Lange, Gauppe and Kolle. In contrast to the space given to German debates, 'French views' takes up only a page describing discussions 'parallel but independent' to the German literature. Lewis notes the contribution of Esquirol (who he credits with delineating 'monomania' or 'Délire Partiel'), Lasègue, Falret, Magnan and Séglas. He closes this section by noting that commentators like Génil-Perrin, de Clérambault and Lacan used the term but that French psychiatrists had not 'collectively taken' to the word. He argues that he cannot justify further detail on French accounts since it would 'lead too far from the theme of this article, the vicissitudes of the word "paranoia" -- a word never heartily welcomed in France' (1970, p. 8).
Lewis's interpretation of British views is stark, detailing the opinions of Tuke, Maudsley, Norman and Clouston. His dealing with American ideas is even briefer (only 10 lines long) with only Spitzka and Meyer being mentioned before the paper moves into a discussion of Freud. The case of Schreber is touched upon as well as the importance of personality in diagnosing paranoia. The ideas of Leonhard are reviewed and some space is taken up with Lewis's contention that although paranoia is felt to be rare there is much 'looseness' in how it is used. He complains that the 'literary and vernacular use of "paranoid" as meaning "resentfully distrustful" is as inexact as the corresponding use of "hysterical" ' (1970, p. 9). Current continental (ie German, Swiss and French) views are summarised in half a page. Contemporary British and American usage gets a little more space with the views of Cameron taking some prominence. This section concludes with Lewis acknowledging that the article has been largely Euro-centric but, he suggests, wider investigation 'might reveal only slight variations from what has been evident in the countries referred to above' (1970, p. 10).
Lewis concludes his paper with a prescriptive question: 'How, then, is "paranoid" to be defined so that it has the least subjectivity and the most tenable basis possible ...?' (1970, p. 1). Without any reference to the preceding historical discussion he states that a paranoid syndrome covers a wide-range of self-referential delusions. He argues that a paranoid personality refers to a person exhibiting features of a paranoid syndrome but where there are dominant ideas rather than delusions. He suggests paraphrenia should be subsumed within this category. He concludes by stating 'the syndrome will eventually be classifiable in one of the major categories of mental disorder' (1970, p. 11)
1.4 RE-READING LEWIS: A CRITICAL OVERVIEW
... the past ... must be revisited, but with irony, not innocently.
Eco (1985, p. 67)
Attempting to summarise Lewis's account is a difficult enterprise since it is at once both extremely detailed and superficial. For example, although it is not clear what purpose it serves, he quotes several extracts from important figures in their original language (Latin, French and German). However, he also passes over the contributions of many other commentators and devotes little space to important debates. He apologises on several occasions for not describing other views in more depth because of limitations of space, his lack of knowledge of other languages and because he sees the aim of the paper as describing the 'vicissitudes of the word "paranoia"' (1970, p. 8). The paper could be seen as a number of decontextualised quotations linked together by Lewis's narrative. Indeed, his placing of these quotations in their original language gives an impression of allowing historical figures to 'speak for themselves' although clearly Lewis's choices are, of necessity, highly selective(10). His historiography tends towards the conservative with the analysis drawing mainly on internal factors although it is implicitly allowed -- through the way the paper is ordered -- that writers (especially same-language writers) referred to each other. However, there is virtually no discussion of external factors -- not even of intellectual developments in allied disciplines like philosophy. Lewis gives little detail of historical context in his description of changes but, by using an implicit rhetoric of scientific progress he tends towards justificatory presentist concerns. He combines a 'great men' and a Zeitgeist approach although stressing the role influential individuals (all men and all white) played in developing theoretical changes.
Edwards & Potter (1992) in their argument for a discursive psychology have suggested that texts incorporate a variety of rhetorical strategies which have particular effects. The main issue in their work is how speakers manage to construct certain accounts as 'facts' -- often when there is some disagreement about 'the truth'. It is reasonable to suppose that similar strategies might be used in the writing of history. Moreover, as I argued in the introduction, particular discourses can be seen as furthering certain institutional interests. One of the effects of Lewis's approach is to increase the historicity of the account and to persuade the reader that the writer has been able to omit irrelevant detail in order to provide a broad sweep of historical development. This persuasion can be furthered by providing evidence that they have studied in great detail by providing verbatim quotations from original sources. However, such an approach also helps to provide a sense of continuity where there may, perhaps, not be one.
In Lewis's account of a history marked more by discontinuity and disagreement than continuity and agreement, the provision of a sense of continuity is a central issue. Interestingly, for example, Lewis begins his paper with a discussion of how the word paranoia was used by the Greeks. The abstract to his paper states the 'history of the words paranoia and paranoid is traced from the Greeks to the present day and their fluctuations of usage and concept are explored' (1970, p. 2). However, as a closer look at his account shows, there was no historical connection between the ancient Greeks and the modern day other than de Sauvages' choice of a Greek word. It may well be that de Sauvages chose the word in order to create a sense of authenticity for the concept following the common medical and scientific practice of using Greek and Latin terms to denote categories. Indeed the appeal to history is a common rhetorical strategy and was one of the criticisms of paranoia made by Henry Maudsley in his 1895 text: 'To christen it mental derangement would appear plain nonsense: to call it so in Greek passes for scientific nomenclature' (quoted in Lewis, 1970, p. 8).
The fact that Lewis traces the use of a particular word over time provides a paradoxical sense of continuity in that although the meaning changes, the word is still the same. Lewis's description of paranoia is similar to his accounts of other concepts in that he holds an essentialist view, arguing that meanings of the particular concepts 'waver'. This is no surprise, given his nosologic concerns, nor is it unusual(11). At other times Lewis concentrates not on the word paranoia but on the concepts underlying it (as in his discussion of French work). Once again, this leads the reader to feel that although writers may call a concept by different names, there is still a certain amount of agreement between them. Moreover, Lewis, like any writer, provides a sense of continuity through his writing. As the reader is led through a number of different, sometimes contradictory views, the voice of the narrator relativizes the differences through different appeals and techniques. For example, Lewis treats time in different ways depending on his apparent aims. Thus he argues that Heinroth launched paranoia on a second career after 'a retirement of 40 years' (1970, p. 2). The gap (which was actually only 35 years) is matched in a number of places by other intervals of time (eg 27 between Heinroth and Griesinger; 26 years between Lasègue and Falret) which do not even merit comment.
A further method of suggesting continuity is Lewis's treatment of differences of view. His main way of doing this is simply to report the differences and move on, with little comment or judgement, to the next chronological figure allowing the dynamic of the narrative to provide continuity. Another approach is to direct attention to a figure who holds a consensus view. Thus, after noting the general disagreement about the definition of paranoia, Lewis states that a 'firm effort to tidy the semantic confusion was made by Westphal in 1878' (1970, p. 4). At another time, Lewis notes that it was 'hardly possible to speak of a consensus amid the wrangling, but the nearest approach to one in the 1890s was provided by Snell...' (1970, p. 4). Later, Lewis comments that it was:
noteworthy that in spite of the apparently irreconcilable views separating the Kraepelinian from the Kretschmer concepts, Johannes Lange, Kraepelin's pupil and closest associate, was content to say that Kraepelin's paranoia was extremely rare and that it sometimes arose on the basis of a mild schizophrenic defect or schizoid character: or even became evident in the lingering phases of a manic-depressive psychosis.
(1970, p. 6).
At other points, Lewis highlights what is agreed between protagonists: 'Almost all writers during this period stress that in paranoia consciousness is clear ...' (1970, p. 5). In this way, sharp disagreements and discontinuities in the use of the word and the concept are, if not silenced, at least subjugated by a dominant and essentialist view of history.
Another way of portraying a continuity of history is Lewis's implicit use of a rhetoric of increasing knowledge and scientific advancement. Such a discourse is enabled by concentrating on certain historical figures devoid of a detailed historical, social, political and philosophical context. Indeed, Lewis, at points, displays an enigmatically uncritical view of history describing historical change at one point as a 'turn of the wheel' (1970, p.8). The figures chosen are examples of 'great men'. Thus Lewis selects Kraepelin because of 'the great influence he exercised and the clarity and honesty with which he expressed his changing views' and since he was a guide to 'central opinion' (1970, p. 5). Lewis notes, with approval, the choice of empirical methods modelled on the natural sciences and an emphasis on course and outcome in, for example, his description of Kahlbaum's and Kraepelin's work although commentators like Boyle (1990) have argued that they did not employ scientific methods despite the rhetoric of the time. The highlighting of the increased use of empirical methods is matched in this account by suggestions that nosological differences exist because of non-empirical factors, for example the 'theoretical moves that sometimes enlivened and sometimes dessicated German psychiatry' (1970, p.7).
Lewis makes few critical comments during his historical discussion. This is all the more surprising in view of the fact that strong views are expressed in the introductory and concluding parts of the paper. For example, he complains of 'looseness' (1970, p.9) in the way paranoia is used and argues that the vernacular meaning of the term is 'inexact' (1970, p.9). At the end of the paper he moves from his historical review into a prescriptive mode, asking how paranoia should be defined so it is least subjective and most tenable. Straightforwardly, he states that 'a paranoid syndrome is one in which there are delusions of self-reference which may be concerned with persecution, grandeur ...' (1970, p.11). Here, there is no mention of disagreement or debate. Indeed there is certainty, expressed in the comment that the 'syndrome will eventually be classifiable in one of the major categories of mental disorder' (1970, p.11). The statement of what paranoia is, from a position of authority is surprising after 10 pages of discussion of confusion and disagreement. At various points paranoia has been presented as: both a general term for and rare form of madness; a phenomenon both with and without hallucinations; an inevitably tenacious and a mild disease; and as the end-stage or mid-point of a disease process. To move from such conflict to a definition is surprising.
Such certainty is part of the rhetoric of scientific advancement noted above but is also, perhaps, a function of Lewis's powerful social position in British psychiatry. Parker (1989) notes how eminent figures have more freedom to state their own opinions and argues that this 'reflects and reproduces social status positions (in which those higher up give their "thoughts"...and the minions have to offer "facts" ' (p.155). When his paper was published, Lewis had already occupied a role as a 'standard-setter, the repository of wisdom, experience and common-sense' (Shepherd, 1986, p.17). After his retirement in 1966, Lewis made what Shepherd calls his 'most significant contribution' of that decade in his series of papers on 'the derivation and meaning of several terms and concepts in common psychiatric use' (1986, p.18). Shepherd (1986) also casts some light on the urgency in the text to close down discussion of disagreement and confusion and instead move towards prescription and certainty since, during this time, Lewis was 'steering the British and the WHO glossaries of psychiatric terminology through their various stages' (1986, p.19)(12). These had the aim of enabling psychiatrists 'regardless of their native tongue and their theoretical persuasion, to adopt a common language for the purposes of communication' (1986, p.19).
It is thus reasonable to suggest that Lewis's linguistic history of paranoia was partly motivated by a nosological agenda of asserting what paranoia was and how it should be defined. Such concerns often go hand-in-hand with essentialist positions and they are a common feature of Lewis's histories of other terms (see Lewis, 1979). Interestingly, eleven years after Lewis's paper was published, Kendler & Tsuang (1981) commented:
In the past substantial disagreements have existed as to the proper nosologic classification of the paranoid psychotic disorders. A review of current diagnostic systems shows that this disagreement persists to the present day.
Kenneth Kendler, an influential American psychiatrist, was and is involved to a large extent with the development of the APA's diagnostic manuals(13). His and Tsuang's discussion following their historical review of paranoia also had a clear empiricist nosological agenda similar to Lewis's in that they aimed at developing a 'truly scientific basis' (1981, p.609) for psychiatric nosology and, to this end, made a number of suggestions about specific diagnostic criteria. The appeal to history could be said to provide a powerful warrant for the views of powerful psychiatric figures. The move from historical review to prescription found in Lewis's history is matched in other accounts (eg Bone & Oldham, 1994 and Scharfetter, 1983).
So far then, it is possible to discern a dominant version of history as told by Lewis -- a kind of historicism with presentist nosologic and justificatory agenda. It is also possible to speculate on some of the functions and reasons for that dominance including, for example, psychiatry's portrayal of itself as an advancing and legitimate scientific discipline. As well as this dominant version reported by Lewis, however, there are other competing, conflictual and discontinuous stories which are either subjugated or silenced altogether. The rest of this chapter aims to flesh out some of the stories and issues subjugated in this dominant account.
1.5 UNSPOKEN, SILENCED AND SUBJUGATED STORIES IN LEWIS'S HISTORY OF PARANOIA
I read, not to believe what the manifestoes said, but to look beyond them, as if the words meant something else. To help them mean something else, I knew I should skip some passages and attach more importance to some statements than to others ... They were a coded message to be read by superimposing them on a grid, a grid that left certain spaces free while covering others ... Having no grid I had to assume the existence of one. I had to read with mistrust.
Eco (1990, p.394)
I have argued that Lewis's account has certain effects in order to fulfill a number of functions - largely to do with the development of psychiatry - but an analysis must dwell not only on what is said in a text, it should also attend to what is not said (Parker, 1992).
1.5.1 The historical and philosophical context of paranoia
books always speak of other books, and every story tells a story that has already been told
Eco (1985, p.20)
A history of paranoia is, to some extent, a history of delusion. We have seen above how paranoia can be traced back to the 19th century and delusion back to the 15th century. However, Lewis's account (in common, it should be said, with most of the other histories of paranoia cited here) largely ignores any of the intellectual context (both inside and outside of psychiatry) of the development of paranoia as a term. Many histories of psychology and psychiatry examine developments in ideas as if writers were not influenced by other texts. Berrios (1991) has provided a historical and philosophical corrective to such a view by arguing that current conceptions of delusions (of which paranoia is currently seen as a sub-set within most psychiatric texts) are based on 19th century views of belief and that although Jaspers is often credited with the commencement of the 'received view' of delusions, he, in fact, borrowed terms and concepts in common use -- particularly by philosophers -- in the 19th century. Berrios (1991) suggests that the philosophical underpinnings of later psychiatric theories of delusions can be traced back to 17th century debates. For example, both Hobbes and Locke, in their different ways, propounded views that helped develop intellectualist notions of insanity whereby delusions were seen to be almost synonymous with insanity.
Berrios notes that it was only by the 1820s that delusions and hallucinations were conceptually separated. Through the 19th century a number of philosophical developments laid the foundations for current conceptions of delusions. These included the displacement of Lockean associationism by faculty psychology; the separation of knowledge and belief; views of delusions as conceptions and of hallucinations as disturbances in perceptual processes; a concentration on the form rather than the content of individual symptoms (which Berrios, 1988, terms the 'anatomo-clinical' model of disease); the viewing of delusions as 'morbid beliefs'; and the growth of theories of personality. However, Berrios' agenda is to argue that since current conceptions of delusions are based on 19th century views of belief, newer ideas about beliefs should be used to re-conceptualize delusional phenomena:
Such conceptual bases include an obsolete theory of language, the epistomology of introspection sponsored by classical psychology, and views of intentionality that did not allow for the existence of 'empty' speech acts. Progress has since been made in all three areas, but little effort has been made to update the conceptual structure of delusion: indeed, it may well be the case that such updating could precipitate its disintegration.
Berrios (1991, pp.6-7)
Berrios argues that delusions are not really beliefs anyway and are, instead, 'empty speech acts that disguise themselves as beliefs' (1991, p.8) since they do not fulfill certain abstract criteria for belief. It is possible to challenge such a view since such criteria do not take account of discourse analytic work suggesting that essentialist notions of 'attitudes' and 'beliefs' are problematic (Harper, 1992). However despite the existence of a presentist agenda Berrios's paper is interesting in making links between psychiatric and philosophical theories. Moreover, he makes a number of interesting points about the linguistic differences between psychiatric terms hiding conceptual differences (eg the English delusion referred to a solely intellectual condition whereas the French délire involved emotional and volitional elements as well).
Both Berrios (1991) and Walker (1991) view Jaspers as the main historical figure behind current conceptions of delusions. Lewis (1970) does not address any of his paper to developments in the history of delusion although it is clearly a related phenomena that would have influenced how paranoia was viewed. Moreover, it is noteworthy that some historians, like Walker (1991), argue that although current texts cite Jaspers as the main proponent of the view that it is the form (eg bizarreness, conviction and falsity) of the delusion which is important rather than its content (eg persecutory themes), he actually suggested it was instead the relationship between the origins of the delusion and the person's personality which was important. This suggests that the citing of Jaspers in support of the view that delusional form is central is another example of the use of history as a warrant to give current conceptions of delusions authority and legitimacy.
1.5.2 The nosological context of paranoia
A history of paranoia is also a history of nosology, or classification. Lewis discusses the variations in the use and definition of paranoia as if it were an isolated problem. However, the difficulties with diagnosis and classification are general and have a long history. Moreover, psychiatric classification is not an unproblematic scientific endeavour. Commentators like Widiger & Trull (1991) and Robins & Helzer (1986) note how diagnostic classifications serve a number of (often opposing) purposes and that they reflect a consensual, rather than a straightforwardly empirical, view of diagnosis. Indeed, within the APA, committee decisions are sometimes voted on (American Psychiatric Association, 1987, p.xx). In 1973 the APA Board of Trustees voted to remove homosexuality per se from the DSM although a related category was retained (Wilson, 1993). Moreover, there is evidence both of exceptionally stringent acceptance criteria for some new diagnoses and of establishment duplicity (Caplan, 1991). Wilson (1993) has provided a useful history of the DSM-III, placing it in its professional, political, social and intellectual context.
Boyle has reviewed some of the beginnings of diagnostic classification, describing early attempts as being:
distinguished mainly by their vagueness and multiplicity; by the last decades of the nineteenth century it was obvious, even to the most uncritical observer, that the result was chaos.
Boyle notes how, in 1885, the Congress of Mental Medicine appointed a Commission to develop one classificatory system. This was duly accepted by the then International Congress of Mental Science in 1889. However, there were no data quoted in support of them and no properly explicit definitions. They did not enjoy extensive use and Boyle suggests this was because of the lack of empirical evidence concerning patterns of 'abnormal behaviour' and the lack of any interest in scientific approaches by the asylum doctors. She argues that the continuing lack of empirical evidence meant there were no meaningful classificatory systems developed although popular categories like Kraepelin's dementia praecox and Bleuler's schizophrenia were used giving 'an impression of progress where none existed' (Boyle, 1990, p.89).
Boyle (1990) traces the next stage of psychiatric classification from the WHO's revised International Statistical Classification of Diseases, Injuries and Causes of Death (ICD) in 1948. However, she criticises both ICD-6 and the APA's DSM-I for a failure to provide explicit correspondence rules. One response to the lack of extensive use of these manuals was for the compilers to provide operational definitions which they did for the first time with ICD-8 and DSM-II. However, Boyle asks of those who tried to find correspondence rules for diagnostic constructs 'how it could possibly be known which constructs justified the search -- what criteria were to be used in choosing them?' (1990, p.92). She argues that this problem bedevilled future revisions including ICD-9 which was preceded by a series of seminars for 'experts' who attempted to agree on constructs -- a process Boyle characterises as 'opinion surveys' (1990, p.94). She notes that DSM-III was the first manual to specify clear operational definitions but argues that it still assumed that its constructs had empirical validity -- a claim she goes on later to dispute(14).
1.5.3 Psychoanalytic views on paranoia(15)
Lewis's account also gives little space to the psychoanalytic literature although he references both Freud and Lacan. However, psychoanalysts have made a number of important contributions. For example, Lacan's thesis for his medical doctorate was on paranoia and was published in 1932 (Lacan, 1932). Freud discussed paranoia in letters to both Jung and Fleiss (Bone & Oldham, 1994) and he wrote nine articles on the topic beginning in 1895 with an unpublished manuscript, developing his ideas through a number of case histories (Rothgib, 1973). In 'Paranoia' (Freud, 1895) Freud postulated that paranoia was a pathological mode of defence with the purpose of fending off an idea incompatible with the ego, by projecting its substance into the outside world -- this was Freud's first use of the term 'projection'. Interestingly, Freud applied the idea of paranoid projection to the 'Grande Nation' that invents a delusion of betrayal because it cannot face the idea of defeat. There was no mention at this time of the notion of paranoia as a consequence of the repression of homosexual desires which was to become memorable later. By 1896, Freud was suggesting, in his presentation of the case of Frau P., that paranoia proceeded from the repression of distressing memories and that the form of the symptoms were determined by the content of what was repressed. By 1911 with Freud's interpretation of the memoirs of Daniel Schreber he was asserting that the main causative factor in paranoia was repressed homosexual desire. In 1915 Freud described the case of a young woman which appeared to run counter to his theory. He concluded that the main issue was that the paranoia was a defence against desiring the persecutor. He continued to believe that repressed sexual desires (although not necessarily homosexual) were the driving force.
Although Freud's interpretation of Schreber has gained prominence there are other more plausible and interesting accounts. For example, Sass (1987) uses both Schreber's autobiographical account and the interpretation by Schatzman (1973) in arguing that Schreber's experiences were related to his experience of physically and psychologically abusive child-rearing at the hands of his father, an influential paediatrician, who published several books on the subject of bringing up children. However, Sass develops Schatzman's analysis by suggesting that Schreber's crisis is the crisis of the modern soul. He draws on Foucault's (1977) description of the Panopticon, a device which enabled prisoners to be watched without them necessarily being aware of being watched. Prisoners were thus induced into behaving as if they were continually watched and hence regulating themselves without the need for external intervention. Sass argues that Schreber's symptoms were related to his dual experience of himself as watcher and watched and that the reification of self-scrutiny through the various techniques developed by his father led to his becoming alienated from himself.
1.5.4 Histories of conspiracy, suspicion and paranoia outside psychiatry
But now I have come to believe that the world is an enigma, a harmless enigma
that is made terrible by our own mad attempt to interpret it as though it had an underlying truth.
Eco (1990, p.95)
Lewis's account of paranoia leaves aside the political and social context of conspiracy and does not include an analysis of how paranoia and a belief in conspiracy have, in the past, and are today, located in everyday discourse. Feelings of persecution and suspicion and the identification of conspiracies have occured throughout history in a range of contexts, few of them concerned with that area we now term 'mental health'. Possibly unwarranted feelings of persecution can be traced back to ancient texts. The Psalmist cries:
All day long they carp at my words,
their only thought is to harm me,
they gather together, lie in wait and spy on my movements,
as though determined to take my life.
New Jerusalem Bible (1985, Psalm 56, 5-6)
Porter (1992), in his history of political espionage, notes that the imagining or inventing of spies has a longer history than that of the espionage profession itself. His is a fascinating account of how excessive and unwarranted suspicion of conspiracy was a political strategy used by the British security services to further develop their agencies. Moreover the excessive secrecy both of home and foreign secret services meant that many suspicions were undeserved and were, in effect, driven by secrecy. He has wryly observed differences between those who believe in the power of conspiracies to shape history and who know how easily people can be persuaded or subverted and those who believe conspiracies cannot work because of the large number of circumstances that would need to be manipulated in order for a significant conspiracy to succeed.
Hofstadter (1966), in describing the paranoid style in North American politics, further highlights that suspicion is socially and politically constructed. He draws out its political functions and significance by suggesting that, in North America, conspiratorial rhetoric has been the preferred style of minority movements. However, although often such conspiratorial polemic reflects minority views this does not necessarily mean they have no power (witness the McCarthyite America of the 1950s). For Hofstadter, the paranoid style characterised as 'overheated, oversuspicious, overaggressive, grandiose, and apocalyptic' (Hofstadter, 1966, p.4) is not distinguished merely by the suggestion of the existence of conspiracies but also by the imperative that adherents 'regard a "vast" or "gigantic" conspiracy as the motive force in historical events' (Hofstadter, 1966, p.29, emphasis in original).
Conspiracies have long existed as explanatory resources and Graumann & Moscovici's (1987) volume demonstrates the pervasiveness of conspiracy theories throughout history and cultural groups. Groh (1987a) argues that conspiracies cannot be related to any one particular historical period and offers a tentative model of the development of group conspiracies. He goes on (Groh, 1987b) to describe a wide range of case studies of conspiracies throughout history including the 'Jewish conspiracy' of the late middle ages; the Witch-hunts in the late middle ages; the 'conspirations' of rebellious peasants in the seventeenth and eighteenth centuries and so on. Indeed, anti-Semitism is a theme of another three chapters in the volume (Billig, 1987a; Poliakov, 1987; Zukier, 1987) -- Jewish people being one of a number of the 'favourites' for conspiracy theorists as well as witches, Jesuits, Freemasons and Communists (Graumann, 1987). In the next chapter I will examine the ways in which paranoia is used to position groups and individuals like this who are seen as Other and how conspiratorial rhetoric may be mobilised to perform a variety of functions.
1.5.5. Critical accounts of psychiatric history
Another ommission from Lewis's history is any mention of critics of psychiatry or of a crisis of psychiatric legitimacy. The same year that Lewis's paper was published saw the American publication of Thomas Szasz's book The Manufacture of Madness following his 1961 work, The Myth of Mental Illness. The few years before Lewis's paper had seen the publication of important texts critical of mainstream psychiatry by the likes of Goffman, Laing and Scheff. More importantly perhaps for a writer of history, Foucault's Madness and Civilization had been published in Britain in 1967. Lewis did not appear to entertain the view that there might be other views of paranoid phenomena. Of course, one might hypothesize that the omission of this topic communicates something about the interests of the author and his location in a powerful position in orthodox British psychiatry. There is something interesting in the turn to history at the time of a contemporary crisis of psychiatric legitimacy.
Quite apart from the lack of reference to critics of psychiatry, Lewis's account ignored any general contextual changes in psychiatry -- for example the waxing and waning of the asylum movement. Of course, this omission of practical factors in the development of psychiatric thought was characteristic of the time in which Lewis was writing although this appears to be changing to some extent (see Beer, 1995). However, the development of asylums, the establishment of professional organisations and journals for the 'mad-doctors', the increasing role of psychiatry in the arena of law over the course of its history (Dowbiggin, 1995; Foucault, 1978) and the growth in 'scientific' diagnostic manuals like those of the WHO and APA (together with the requirement by American health insurance companies of a recognised psychiatric diagnosis before releasing funds for treatment) have all contributed to the general context of psychiatric diagnoses and theories.
1.5.6. Autobiographical and non-pathological accounts of paranoia
Kroll (1995), in a recent review of psychiatric historiography criticises much current writing for its remoteness from and ignorance of the patient. But this is also characteristic of much psychiatric writing. In Lewis's article, for example, there is little discussion of the users(16) of psychiatric services. In chapter 3 I will examine this issue in more detail but the exclusion of users' views and experiences is significant. Indeed, the only time an autobiographical account is mentioned, that of Schreber, more space is given to the analysis by Freud (who never even treated him) than to Schreber's own views. This is the kind of thing Kroll appears to want: not (perhaps critical) views but rather a rendering of someone's experience into the psychiatric language of symptoms and illness. Within Lewis's text the discourse is a professional one. Many texts dealing with first-person accounts of mental illness (eg Porter, 1987) actually still give a great deal of space to analytic interpretations rather than the views of the people themselves.
In contrast to this professional appropriation of accounts by the consumers of psychiatric services, the development of the psychiatric users' movement (eg Survivors Speak Out) has led to the creation of outlets where service users' views appear with little or no professional glossing or interpretation. Examples include MIND's Mindwaves, Asylum and the Hearing Voices Networks Voices.
Lewis's text has been criticised for being presentist but a more accurate complaint would be that it adopts an unreflexive presentism which seeks only to justify the present rather than, in the sense of a Foucauldian 'history of the present', attempt to understand how the present came about. Kroll (1995) and Sullivan (1995) have noted the importance of reflexivity in writing histories of psychiatry. Of course, an accusation of unreflexive presentism could be made about this chapter. Through the use of particular rhetorical strategies (eg referencing, verbatim quotes from Lewis and others, mobilising anti-psychiatry discourses and so on) I could be said to have simply attempted to pursue my own interests. Obviously no history or critique is uninterested and, perhaps, the only way out is to clarify what those interests might be so readers might take them into account in reading the text -- since this will be a recurring theme throughout this thesis I have attempted to reflect on these issues in chapter 7.
1.6 BACK TO THE FUTURE OR FOWARD TO THE PAST?
Since, I would argue, the critical historian's role is not simply to employ suspicious interpretation in negative critiques but also positively in the production of a multiplicity of histories, it is important to address how more authentic histories could be developed. One way is to write histories which do not collude with the subjugation and silencing of the aspects noted here.
What questions might a critical genealogy of paranoia have to answer(17)? First it would have to look at the links between the development of psychiatric taxonomies and practice in the context of culture. For example what is the history of suspicion and conspiracy -- when were they first marked out as noteworthy? How did these developments map onto the important classificatory, excluding and dividing practices of Church and State? What made the concept of paranoia necessary? Moreover what was enabled through the concept of paranoia -- what kinds of realities were made thinkable and practicable? How has it been used concretely in practice as well as in psychiatric journals and text-books? What significance is there in the fact that it resides in a number of different diagnostic categories? Some of these questions are touched on in the following two chapters, especially chapter 3.
'Not bad, not bad at all,' Diotallevi said. 'To arrive at the truth through the painstaking reconstruction of a false text.'
Eco (1990, p.459)
1. An article which formed the basis for this chapter was previously published in History of the Human Sciences (Harper, 1994a).
2. Kendler (1982) has demonstrated that people diagnosed as paranoid are more likely to be poorer; belong to 'lower' social classes; have less education; be more socially disadvantaged; and be immigrants, than people receiving related diagnoses.
3. Although I am not advocating that historical accuracy is unimportant, I have not attempted, in this account, to check Lewis's text for accuracy against the originals he cites although an anonymous referee suggests at least some of Lewis's quotations are inaccurate -- Shepherd (1994) suggests that such comments are without foundation. I have also tended to focus largely on the English-language literature in commenting on Lewis's review. The examination of non-English work is tremendously important but is beyond the scope of this chapter.
4. It should be noted, however, that of these citations, three are in papers written by me and another is in an article commenting on one of them.
5. More background information on Lewis is contained in Lewis (1979), Shepherd (1986) and Shepherd & Davies (1968).
6. I am indebted to an anonymous referee for this observation.
7. Shepherd (1994) disagrees with this assessment, suggesting that 'far from being an "establishment figure" he was always a quintessential outsider'.
8. One problem with DA is that it can be easily read as imputing intentionality and, as Parker (1997a) notes, can all too easily import intentionality into its analysis -- Shepherd (1994) for example, commenting on the article on which this chapter was based felt that my analysis was 'vitiated by an evident and misleading bias against Aubrey Lewis himself'.
9. I have italicised non-English words but followed Lewis's (1970) convention by not doing this for Latin words in common use in British psychiatry.
10. Other papers by Lewis use quotes in their original language. See for example his articles on psychogenesis, psychopathy and hysteria (in Lewis, 1979).
11. Turkat, for example, following his historical review states 'in short, although the concept of paranoia has been around for thousands of years and is widely accepted as valid today, how to classify it, subclassify it, understand it, and treat it remains highly controversial' (Turkat, 1985, p.163).
12. Indeed, a year before his death in 1975, the WHO published the Glossary of Mental Disorders and Guide to their Classification containing a foreword written by Lewis.
13. For example, the introduction to the DSM-III-R notes that Kendler sat on the 'work group' to revise DSM-III and three advisory committees on diagnostic categories: 'psychotic disorders'; 'mood disorders'; and 'personality disorders' (American Psychiatric Association, 1987).
14. Despite, indeed perhaps because of, 'private' disagreement about its definition, paranoia has become an enshrined part of many diagnostic classificatory systems. Categories which elude clear definition are therefore available to be used flexibly in a range of circumstances and this, of course, can have enormous practical advantages for psychiatry (Harper, 1994b).
15. Oldham & Bone (1994) give further detail on the history of psychoanalytic writing on paranoia including the work of Ferenczi, Klein, Arlow, Meissner and Blum. They argue that it was Freud's interpretation of the so-called Wolf Man which became influential in psychoanalytic formulations of paranoia, rather than his writing on Schreber. Berke et al. (1998) includes more recent psychoanalytic work.
16. The term service-user or user will be used throughout this thesis rather than 'client' or 'patient' (cf. Rogers & Pilgrim, 1993).
17. Blackman (1994a, 1994b) has given an outline of how history might be used to detail the conditions of possibility for psychological objects (eg 'hearing voices').
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