The Patient’s Turn Roy Porter and Psychiatry’s Tales, Thirty Years on

Abstract

Yes, I am ill. But you know dozens, hundreds of madmen are walking about in freedom because your ignorance is incapable of distinguishing them from the sane. Why am I and these poor wretches to be shut up here like scapegoats for all the rest? You, your assistant, the superintendent, and all your hospital rabble, are immeasurably inferior to every one of us morally; why then are we shut up and you not? - Anton Chekhov, ‘Ward No. 6’ (1892) This past year marked the thirtieth anniversary of Roy Porter’s seminal 1985 article, ‘The Patient’s View: Doing Medical History from Below’. 1 Few works in the history of medicine have received so enthusiastic a reception. Porter’s call to reclaim the voice of the voiceless has had an extraordinary echo, becoming not only a necessary reference but also a classic trope. This is especially the case among historians of psychiatry. In a field where patient narratives have long formed their own subgenre, shedding light on these hitherto unheard stories taps into popular fantasies probed by Porter himself – images of gothic madhouses and their gloomy inhabitants; whispers and cries; dark corridors encased in windowless walls, their interiors mirroring the mind gone astray. 2 So ubiquitous is this imagined space that some have recently proposed to create an independent research area dedicated to ‘Mad Studies’. 3 Fetishised, mythicised, ostracised, the psychiatric patient has emerged as an unlikely protagonist, capturing the scholarly, cultural and artistic imagination alike. Yet recent assessments suggest that Porter’s call has not fully been heard. The history of the patient remains ‘curiously underwritten’ in several areas, some have claimed. 4 Others have maintained that, on a conceptual level, ‘the history of the patient’s view is as undeveloped now as it was back in the mid-1980s.’ 5 Porter’s exhortation, for the most cynical, has acted as little more than a seductive proposal to lure audiences without bringing anything new to the understanding of medical processes or patient experience. 6 In view of historians of psychiatry’s special love affair with the world of their protagonists, a critical review of these recent developments seems all the more pertinent. This special edition explores the varied ways in which patients’ voices have guided psychiatry’s construction, deconstruction and reconstruction from 1800 to the present. In this respect, the thirtieth anniversary of Porter’s seminal article acts as an opportune occasion to re-examine the field using fresh historical and historiographical perspectives. 7 In what ways have historians of psychiatry taken on the project of a history ‘from below’? How have they turned such tales into objects of study? What do their works reveal? And how has this focus on patient narratives shaped our understanding of the processes by which mental illness is understood and treated in the twenty-first century? These are timely issues. Over the past few years alone, a number of major changes in mental health care legislation throughout Europe and North America, and also China and other non-western countries, have significantly affected the experience, management and representations of mental illness. The recent revision in 2013 of the ‘psychiatric bible’ – the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) – was described by the previous director of the US National Institute of Mental Health as nothing less than an ‘absolute scientific nightmare’. 8 In Europe and the United States, criticism of ‘deinstitutionalisation’ has become widespread, with many arguing that the turn to community care has created more problems than it has solved. 9 Groups of patients and so-called ‘Mad activists’ have been increasingly vocal and effective in promoting their cause, inspiring the formation of a new independent field amidst controversial political reforms. 10 In other spheres, a flurry of successful international exhibitions points to the growing public appeal of patient creations, 11 just like the popularity of first-person accounts signals a vivid interest towards ‘madness narratives’ 12 in the cultural psyche. 13 The academic community, for its part, has sought to integrate various new complementary actors to fill the voids in standard histories of psychiatry. 14 These developments are taking place against the backdrop of ever-vulnerable institutional foundations. Amidst these formidable tensions, questions abound. What can historians of psychiatry gain from adopting a performative view of the patient’s role? Conversely, what can members of the psychiatric community learn from ‘listening to insanity’? 15 These issues are thorny indeed. Three decades on, historians remain divided between two broad historiographical currents. On the one hand, the success of Porter’s proposal has brought a new scholarly focus on testimonies left by those deemed mentally ill. On the other hand, however, the still ubiquitous Foucauldian legacy has led many to consider those patients who managed to voice their opinions as exceptional rarities. 16 The contributors to this special edition take issue with this latter idea. Inspired by recent research, they highlight the fact that it is actually possible to write a history of collective ‘mad’ cultures. Of these cultures still little is known. Their role in the formation of medical discourses needs to be investigated. We submit, then, that writing ‘from below’ not only casts new light on psychiatry’s past; it is in fact necessary for a comprehensive picture of the field’s ongoing history. Thirty years on, the time has come to ask new questions and revisit these tales afresh. 1. The Patient’s Turn Framed as a critique of the aims, methods and objects of the history of medicine as it had hitherto been practised, Porter’s programmatic 1985 essay called for a radical shift in perspective. The history of medicine ought to be written not only by and about physicians, but also by a new generation of professional historians who would ask different questions. Health and healing ought to be studied not only through the prism of scientific progress, but also as veritable cultural systems. Illness ought to be understood not only as a biological event, but also as a resolutely social phenomenon involving its own practices and rituals. The focus ought to be not only on cure but also on care; not only on doctors’ achievements but also on the whole range of patient experience. Porter, then, encouraged the medical historian to turn to new narratives. His was a new model – indeed the model of the ‘future’ 17 – that placed the sufferer at centre stage. To be sure, he was not the first to put forth these ideas. 18 Yet he was perhaps the one to most explicitly articulate them. He also did it in such a way as to resonate with the spirit of his times. By the mid-1980s, a number of widespread and vocal challenges to the medical authority had permeated popular and academic circles alike. 19 In the academic community, Porter’s essay joined the chorus of the newly refashioned social history, effectively placing patients in the category of other traditionally under-represented groups. Noteworthy in this respect is his indebtedness to British historian Edward Palmer ‘E. P.’ Thompson. In his 1963 book The Making of the English Working-Class – which had ‘opened [Porter’s] eyes to how history could be written’ 20 – Thompson famously challenged classical Marxist accounts of workers’ history by offering a new vision of subjectivity. Neither powerless nor fully dominated by external forces, his subjects were active participants in the cultural negotiations of their identities. 21 To an extent, Porter thus merely shifted Thompson’s vision of a ‘history from below’ 22 to the medical world. The very socio-political context within which he was operating was also profoundly changing the treatment, management and representation of the sufferer. Published in 1980s Britain, Porter’s patient-centric call to arms in many ways echoed broader institutional reforms intended to strengthen the patient’s role. This specific context helps explain why Porter’s views resonated so strongly in the psychiatric field. Coloured by heated discussions over issues of patient rights and mounting ebullition about psychiatric mistreatment, the post-1960s mental health sector became the theatre of great outcries amidst a flurry of rapid and radical changes: deinstitutionalisation, pharmacological revolution, growing emphasis on standardised diagnostic tools, increasing distrust of psychoanalytical models, and so on. Researchers from the social sciences and humanities played an important part in these developments. Erving Goffman’s sociological depiction of asylums as ‘total institutions’, Phyllis Chesler’s articulation of the profoundly gendered nature of mental health practices, Gregory Bateson’s radically novel ‘double bind’ conceptualisation of schizophrenia, Frantz Fanon’s sociological study of the dehumanising processes of colonial domination – all contributed to this growing re-examination of psychiatry’s aims and methods. Willingly or not, many of these figures became associated with a burgeoning movement of ‘critical psychiatry’. 23 Among historians, Michel Foucault rapidly emerged as this movement’s designated champion. The publication in 1961 of Folie et déraison 24 initiated a wide-ranging reappraisal of the field’s traditional narrative. Foucault put into question a ‘Whiggish’ history of medical progress, capturing the cultural imagination with a decidedly new picture. Psychiatry’s mythical birth represented for him neither progress nor a radical rupture with the past. It merely reproduced and in fact deepened structures of exclusion under medical disguise. The Foucauldian patient – subjugated, submissive, docile, powerless – became a symbol of medicalisation gone wrong. Nowhere was the silencing of oppressed voices depicted more vigorously than in the Foucauldian universe. The asylum, in particular, stood as the ultimate symbol of medicine’s woes. And just as the language of the insane had been absent from history, it similarly had no place in modern discourse: Everyone dreams of writing a history of the mad, of going over to the other side and tracing the great evasions of the subtle retreats into delirium from the beginning. Yet, under the pretext of tuning in and letting the mad themselves speak, one already accepts the division between the two as a fact. It’s necessarily better to put oneself at the point where the machinery that makes these qualifications and disqualifications is actually operative, and putting the mad and the non-mad on two sides facing each other. 25 Elsewhere, Foucault made his point even more forcefully: patient autobiographies simply could not be used to write the history of madness. These texts, however ‘enthralling’, belonged to a different ‘discursive universe’. They were ‘irreparably’ out of history. 26 Foucault thus displayed profound ambivalence in his interpretation of psychiatry’s past. On the one hand, he criticised deeply ingrained myths and insisted that the medicalisation of insanity had but sharpened the divide between the sane and the insane. On the other hand, he effectively replicated this divide by rejecting the possibility of including the lunatics’ voices in historical accounts. 27 Even when he did publish the memoirs of the ‘deranged’ parricide of Pierre Rivière in 1973, Foucault again insisted on the impossibility of incorporating the actor’s viewpoint. Rivière’s narrative was to remain ‘untouched’, unexamined, for it would be meaningless – indeed disrespectful – to try to ‘superimpose’ any kind of historical analysis on his experience. 28 To quote Carlo Ginzburg, in the process of revealing history’s purported ‘archaeology of silence’, Foucault himself confined the mad to a ‘genuine silence’. 29 It was with this polarised view of the doctor–patient dynamics that Porter took issue: We should stop seeing the doctor as the agent of primary care …What we habitually call primary care is in fact secondary care, once the sufferer has become a patient, has entered the medical arena. And even under medical control, patients have by no means been so passive as the various ‘medicalization’ theories of Foucault and Illich might lead us to believe. 30 While agreeing with Foucault’s overall analyses about the processes of segregation that accompanied the birth of the hospital, Porter emphasised the sufferers’ sense of agency. Manufactured through the ever-tyrannical ‘clinical gaze’, the Foucauldian patient embodied victimising structures of ‘biopower’, knowledge, discourse and control. He was in many ways a ‘by-product of medicine’. 31 Against this pessimistic view – and indeed against its simplistic re-appropriations – Porter adopted a more optimistic vision of patients’ potential for empowerment. 32 In its Anglo-American incarnation, the anti-psychiatry movement offered alternative critical avenues. On one side, there was the call for a ‘return to the patient’ along with an increased focus placed on subjective experience and its (many) stories. 33 On the other side, there was strong criticism of the psychiatric institutions and theoretical presuppositions that sustained them. 34 In presenting ‘a view of lay initiative, resilience, and capacity to play the system’, these alternative accounts offered for Porter ‘a salutary counterbalance’ to the Foucauldian model. 35 Theirs was a path to a new narrative, clothed in the language of protest. It is perhaps no coincidence, then, that when Porter set out to apply his own research programme he turned to the very historical protagonists whom Foucault had portrayed as characteristically voiceless: the mad. In 1987, two years after his seminal article, he published Social History of Madness: Stories of the Insane. In this pioneering work Porter articulated a specific idea of his vision. He situated his approach between two positions that he found problematic. The first was the practice of retroactive diagnoses. Rather than ‘read[ing] between the lines’ or ‘search[ing] out hidden meanings’, his aim was ‘simply and quite literally’ to see ‘what mad people meant to say’. 36 But in so doing, Porter’s goal was not to turn his actors into historical heroes or martyrs manicheanly placed against the purported villainy of physicians. Rather, he aimed at showing the “‘dialectic of consciousness” between the mad and their times’. In sum, his was an attempt to write ‘a history, not just of psychiatry, but of madness itself’; for ‘[i]nsanity is not just an individual atom, a biological accident, but forms an element in the history of sub-cultures in their own right’. 37 2. Three Decades of Psychiatry ‘From Below’ Porter opened up new paths. In the past thirty years many scholars have followed his footsteps by turning to a wealth of new patient-focused sources: journals, correspondences, asylum notes and autobiographies. Anthologies of first-person accounts and case studies, in particular, have witnessed a remarkable explosion. 38 This is notably the case for women’s narratives. 39 The female patient’s voice, argued the second-wave feminists, had largely been edited (if not altogether written over) by psychiatry’s (male) authors. Here the fin-de-siècle hysteric emerged as an emblem of protest, heroically playing out in her symptoms the ills of past times. At once feared and desired, she came to be interwoven in contemporary fancy with that other, mythical figure – the Madwoman. 40 Another significant development has been the expansion of this programme to new sociocultural settings. Initially bearing the imprint of Porter’s scholarship at the UK-based Wellcome Trust Centre for the History of Medicine, the historical study of psychiatry ‘from below’ spread beyond Britain. Gradually, patient stories arose from such diverse environments as Japan as well as colonial and post-colonial cultures. 41 In an attempt to highlight the multi-dimensionality of asylum life, some scholars have similarly moved beyond the strict patient–doctor dyad to include previously neglected actors who have played a significant role on the psychiatric stage. 42 Porter’s plea also found a niche among broader audiences. In recent years, a burgeoning group of activists and scholars who combine anti-psychiatric with psychiatric survivor approaches have emerged as vocal champions of patient voices. This group includes various social critics, revolutionary theorists, historians and radical professionals who challenge medical paradigms of mental illness and often look to history as a guiding force. Wielding the rhetoric of defiance and liberation, this self-proclaimed ‘alternative community’ has organised into a distinct field known as Mad Studies. In this context, madness is no longer reviled – either as a label or as an Otherising concept: By Mad, we are referring to a term reclaimed by those who have been pathologized/psychiatrised as ‘mentally ill’, and a way of taking back language that has been used to oppress …We are referring to a movement, an identity, a stance, an act of resistance, a theoretical approach, and a burgeoning field of study. 43 Ever the elusive term, madness is employed here ‘to celebrate a plurality of resistances and subversive acts against sanism.’ 44 Characteristic in this respect is the mission statement of the Icarus Project, a network of so-called Mad activists created at the dawn of the twenty-first century by a group of individuals diagnosed with bipolar disorder. The network’s very name is symbolic – an ode to the young Icarus who, according to Greek mythology, perished by flying too close to the sun with the wings of wax and feathers that his father Daedalus built for him to escape persecution by Cretan King Minos. The identification is made explicit: Defining ourselves outside convention, we see our condition as a dangerous gift to be cultivated and taken care of rather than as a disease or disorder needing to be ‘cured’ or ‘eliminated’. With this double-edged blessing we have the ability to fly to places of great vision and creativity, but like the mythical boy Icarus, we also have the potential to fly dangerously close to the sun into realms of delusion and psychosis and crash in a blaze of fire and confusion. Proud, defiant, impervious to medical and societal orthodoxy, here is a community whose members navigate the fine line between hubris and humility, recognising their identity as humans rather than gods and knowing all too well that ‘the most incredible gift can also be the most dangerous’. 45 But this is not just about identity. Deeply concerned about psychiatry’s current lack of resources, Mad activists and scholars wish to subvert the current state of mental health services. As such, they acknowledge that ‘to take up “madness” is an expressly political act’. 46 Whether centred on marginalised and minority ethnic communities (eg., the Survivor Research collective), 47 specific national contexts (eg., the Chinese Network for Users and Survivors of Psychiatry), 48 or artistic performances (eg., the ongoing ‘Mad Love’ project), 49 their goal is to transform the community from below. To this effect, the collective activities they organise are aimed at directly influencing the psychiatric discipline in the hope of emulating past accomplishments – witness the removal of homosexuality from the DSM in the 1970s. 50 3. Porter and Foucault, the Impossible Compromise With these considerations in mind, it is interesting to reflect on the selective appropriation of theoretical models undertaken by these various groups of scholars and activists alike. Foucault’s concept of the social construction of mental illness, blended with the rhetoric of oppression and resistance, is frequently conflated in their accounts with Porter’s views on the primacy of patient experience. Yet it will be remembered that by pointing to a bona fide ‘sub-culture’ of psychiatric patients, Porter directly contradicted Foucault (who some ten years prior had characterised the idea of historians ‘letting [patients] speak for themselves’ as nothing less than a ‘dream’). 51 This phenomenon is actually characteristic of current scholarship on the history of psychiatry. Indeed, the dissonance between the Foucauldian and Porterian models has deeply influenced the reception of the latter’s work over the past three decades. This has taken unique forms in various national contexts. In France, for example – where, as Jan Goldstein has noted, every statement about the history of psychiatry must still be accompanied by a ‘pro-’ or ‘anti-’ Foucault stance – 52 it is only very recently that historians have begun to openly champion Porter’s ideas. 53 (Intellectuals who dare oppose or even qualify Foucauldian views may indeed be accused of ‘fascism’, as illustrated by the latest controversy between philosophers Didier Eribon and Marcel Gauchet. 54 ) There is another element that helps explain why it has been particularly delicate to argue in favour of a patient-focused history in Foucault’s country. In France, perhaps more than anywhere else, the association between psychiatry and the abuses of power became a dominant trope after it was discovered at the Liberation that half of the psychiatric patients had starved to death during the war. This was not the Nazis’ doing. In that country, then, the asylum came to be perceived less as a ‘total’ than a ‘totalitarian’ institution – one in which doctors did not merely silence their patients but also effectively let them die. 55 This tragedy has profoundly coloured French post-war critical psychiatry discourses. Such a context has made the idea of several independent ‘mad voices’ throughout history difficult to conceive. 56 In contrast, Britain’s history of patient advocacy associations since the mid-nineteenth century rendered more credible Porter’s notion of a history of psychiatry ‘from below’. 57 This – coupled with the aforementioned specificities of Anglo-American anti-psychiatric discourses – not only helps understand Foucault’s and Porter’s drastically different views on patient agency; it also brings new light on the different receptions of their work in the French- and English-speaking worlds. When Porter’s ideas became popular in the mid-1980s, the Foucauldian corpus was being newly circulated in Anglo-American academic circles. Unlike in France, it was also rapidly criticised. 58 The weight of local cultural contexts must therefore be taken into account when reflecting upon the diverse interpretations of Porter’s call to do history ‘from below’. In any case, the resulting academic stance has often been one of compromise between the field’s two patron saints. Historians emphasise the importance of turning to the stories of the insane, following in the footsteps of Porter. Meanwhile, by embracing a more Foucauldian approach, they highlight the historical rarity of such stories. Consequently, many have postulated that those actors who did manage to write or speak were exceptional anomalies (save for a few icons such as Daniel Paul Schreber, Charlotte Perkins Gilman and Antonin Artaud). Quite logically, then, historians of psychiatry have tended to answer Porter’s plea by exploring the lives of those extraordinary ‘rebels’ through detailed case studies or anthologies of their writings. 59 Despite its interest, this tendency is not without its limitations. 4. Critical Reflections What to make of all this body of work? In 2007, Swiss historian Flurin Condrau offered a rather provocative answer to this question. He acknowledged that, although Porter’s exhortation to write medical history from the patient’s perspective was an attractive suggestion, his call had not fully been heard. After Porter, researchers have allegedly been lured by the ‘charm of the sources’, proceeding to collect one autobiography after another without any actual ‘methodological innovation’. 60 Thus Condrau’s pessimistic assessment: Unlike other areas of research, such as the history of medical sciences or the history of disease, not much further methodological reflection has taken place and this has left the history of patients intellectually less stimulating than other research fields. 61 According to Condrau, the history of patients mostly gave birth to disparate collections of individual cases. These myriad personal stories, although unique and at times interesting, are all enclosed in their singularity. Historians ‘from below’ have reportedly learnt little, if anything,of those global forces that govern history, nor of the evolution of those discursive, institutional, or social processes that shape representations of illness and broader healthcare systems. The authors of this introduction do not share Condrau’s pessimism. We do, however, believe that the time has come to undertake a critical evaluation of what it is precisely that historians do (and can do) with these various ‘madness narratives’. To be sure, a number of the aforementioned remarks are justified with regard to the history of psychiatry. Some scholars do seem to assume that the patient’s voice is always de facto interesting, by paying little or no attention to methodological implications. In many cases, Porter’s article effectively serves as an all-encompassing reference, as if quoting his plea for a history ‘from below’ validates all originality. And the charm of the source certainly contributes to this phenomenon. In other words, calling for history from below and actually accomplishing it in any systematic and constructive fashion are different enterprises. As seen above, Porter himself insisted on the fact that historians should not only focus on individual stories but also study the ‘dialectic of consciousness’ between the subjects and their times. He did not elaborate as to how his successors should go about this. Neither did the content of his Social History of Madness indicate any concrete methodological paths. Instead, it consisted in a thematic presentation of diaries and autobiographies written by famous institutionalised individuals: Vaslav Nijinsky, Robert Schumann, etc. Porter emphasised that he was not ‘advocating a “great madman” approach’. 62 He also implied that his book was but a tentative attempt at opening a new field of research. Nevertheless, he left his readers on a rather frustrating note, giving no real clue as to how one could go about studying more ‘ordinary’ patients or relating individual subjective experiences to the formation of a broader ‘sub-culture’. Porter’s call, then, was more an exhortation than a description of his own practice. 63 In recent years, researchers from various fields have brought fresh intellectual and methodological perspectives to this discussion by turning to different corpi. Some have analysed the experiences of more ordinary patients, notably through medical files 64 and asylum newspapers. 65 Others have adopted complementary approaches, such as literary criticism, to tackle new questions. In a recent book on the nineteenth-century poet Paulin Gagne, for example, literary scholar Pierre Popovic explored his protagonist’s experience in all its socio-poetic entanglements. Sharing Condrau’s belief that analyses of patient voices are often unduly ‘romanticised’, Popovic begins by dismissing fashionable categories such as folie littéraire (‘literary madness’). These, for him, are but ‘aporetic illusions’ that prevent scholars from ‘truly understanding and reading marginal works’. 66 But Popovic goes further, exploring Gagne’s written productions through an in-depth so-called socio-critical analysis. In the process, he revisits the historical case study. Challenging previous descriptions of Gagne’s writings as perfect examples of (a-historical) ‘literary madness’, Popovic reveals that far from being acontextual, Gagne’s inner world bears a close intertextual relationship with the social, political and intellectual cultures of his time. The ambitious theoretical model proposed by Popovic highlights the importance of a shared ‘social imagination’ (imaginaire social) in shaping individual subjectivity. Similarly, Laure Murat’s recent book, The Man Who Thought He Was Napoleon, casts light on the complex ways in which patients’ apparently incoherent ideations are decidedly inscribed in history. 67 By reflecting in their symptoms the evolution of political torments, her actors show that various social and political events have each produced a special kind of folly. The above suggests that there lurks, even in the most extravagant of voices, historical material that ought to be analysed and conceptually reflected upon. 68 But the reverse is also true. If patients’ productions are never actually ‘raw,’ 69 if they are always embedded within a specific sociocultural setting, the very settings in which they evolve also bear marks of their actions. The Foucauldian idea that madmen have always been ‘outside of history’ is just one side of the story. In fact, we could even argue that patients have never talked more than after having been reduced to silence. By creating asylums and large-scale inmate populations, psychiatric modernity has also rendered this population more visible. It has created a collective identity. A comprehensive longue durée history therefore remains to be written on the emergence of a patient ‘counter-voice’. 70 Whether looking at John Perceval’s Alleged Lunatics’ Friend Society (1845) or Louisa Lowe’s Lunacy Law Reform Association (1883), the early ‘anti-alienist’ or anti-psychiatric movements in France and Germany, these patient groups – their periods’ own Mad activists – existed well before the 1960s. Some (eg., those of Louisa Lowe in the UK, Elizabeth Packard in the US and, later, Clifford Beers in the US) have even had an important impact on shaping mental health policies. 71 The psychiatric discourse, as well as the broader social and political world, has thus at times been considerably influenced by voices ‘from below’. In sum, we would go beyond Porter by claiming that there is not only a ‘sub-culture’ of psychiatric patients, but a veritable culture in the full sense of the word – indeed a plurality of cultures with their own topoi, figures and references; cultures that have circulated within and beyond asylum walls; cultures that have not only influenced the various psychiatric discourses but also popular, cultural and political thought. Put differently, the patient’s voice should not be a mere tangential addendum to psychiatry’s history. It should, on the contrary, be interactively included with other madness discourses. Without this, the project of a history ‘from below’ ceases to be performative and is reduced – as its critics have claimed – to a compilation of individual cases. The time, then, has come to write new scripts. We ought to take into consideration the large variety of psychiatry’s main protagonists. We ought to renew our sources beyond the textual to include different modes of expression. We ought to extend chronological and geographical boundaries. We ought to realise that patient-centred narratives answer different aims and take several forms. We ought to understand how madwomen and madmen have mattered in the past to better understand how their perspective can also be relevant in the present. 5. Tales from the Asylum This special issue aims at providing a fresh and novel look into psychiatry’s past and present tales. From ‘outsider art’ to clinical diaries, from popular accounts to autobiographical novels and from heated manifestos to asylum scribbles – patients have cried out their ills in a variety of forms. These real and imagined stories of mental illness help throw light on the complex ways in which psychiatry has been construed, explained and fictionalised since its inception. How have individual subjects influenced the construction of clinical categories? How have patients (and indeed their loved ones) come to play a decisive role in effecting medical and extra-medical changes? In what ways have patients chosen to voice their experience? How have their demands been met by the legal system? And how have various methods of treatment been accepted or rejected by those actors in differing social, cultural and political settings? By focusing on psychiatry’s ever-fluid identity, this volume investigates the varied ways in which the patients’ voices have guided this discipline over the past two centuries. The five contributions below deal with the above topics from resolutely inter-disciplinary perspectives. Themes include non-western patient accounts, the impact of class and gender on formulations of mental illness, the juxtaposition of views ‘from above’ and ‘from below’, the influence of the anti-psychiatry debate, unedited correspondences between patients and physicians, challenges to traditional theoretical approaches, the boundaries between fact and fiction, the influence of changing socio-political contexts on experiences of madness, the role of patients in altering diagnostic classifications and curative methods, alternative accounts and the fluctuating nature of the psychiatric patient over time. Written by a new generation of scholars, these articles bring fresh perspectives to the history of psychiatry ‘from below’ by opening new paths and moving away from pessimistic views of patient agency. Harry Yi-Jui Wu’s piece centres on the development of bei jingshenbing, a set of new phenomena that emerged in Chinese media and popular culture during the past few years. This neologistic expression refers to someone who has been misidentified as exhibiting symptoms of mental illness and admitted to a mental hospital. By charting the rapidly changing role of bei jingshenbing individuals ranging from protesters against psychiatry to structured self-advocacy groups, this paper reveals an important facet of the Chinese people’s recent experiences with psychiatric modernity. It also underlines the complex nature of patient agency against a rapidly shifting social, cultural, political and medical landscape. Perhaps most importantly, Wu shows that these various voices should not be considered subaltern narratives. Instead, the actors of bei jingshenbing have played an important part in transforming mental health policies and lay opinions about psychiatry. Their activities should thus be read not as tangential accounts but as powerful contributions to a new cultural phenomenon. Through archival research and ethnographic fieldwork, Wu offers a timely treatment of emerging developments that have important implications for China’s mental healthcare system and society. But under-explored contexts are not merely geographical, as suggests Benoît Majerus in his paper. If Porter’s call resulted in a fetishisation of the archive, it also created an historical narrative shaped by the presence and availability of sources. This has given rise to a disproportionate focus on the eighteenth and nineteenth centuries. By analysing the unedited patient records of Brussel’s Institut de Psychiatrie after the introduction of neuroleptics and antidepressants in the 1950s, Majerus provides a novel glimpse into patients’ own experiences of the so-called chemical revolution. Such investigations ‘from below’ are rare when it comes to the historical study of drugs, the author reminds us. This is largely due to the dominance of such fields as Science and Technology Studies in which the focus tends to be less on human subjects than on their chemical counterparts (eg., drug trajectories). 72 However, it is also due to the influence of canonical texts and their emphasis on psychiatry’s mythical origins. The Foucauldian ‘medical gaze’ is here given a post-war twist through the articulation of a decidedly more complex story illustrating patients’ sense of agency. So too is Porter’s agenda. For although the ‘medical encounters’ he evoked in his programmatic essay occurred among a multiplicity of actors, historians have only begun to incorporate these additional characters beyond the traditional patient–doctor dyad. 73 By studying the transcriptions left in patients’ letters alongside physicians’ records and nurses’ notes, Majerus shows the intricacy of hospital dynamics in post World War II settings. Drugs did not necessarily contribute to silencing patients’ voices. Eschewing those accounts because of the advent of new purportedly ‘silencing’ therapeutic technologies thus offers an incomplete picture of psychiatry’s past. Also highlighted in this volume is the multidimensionality of asylum life. By centring on two patients at Bethlem Hospital who actively participated in the formulation of contemporary medical discourse, Sarah Chaney leads us to reconsider a story that we thought thoroughly exhausted. Chaney shows that, rather than being merely passive, patients sometimes had input into the way madness was represented and understood. In this respect, the British notion of ‘voluntary boarding’ – usually associated with the 1930 Mental Treatment Act – offers an important (if under-studied) angle for interpreting these Victorian tales. One of the two patients examined here was a boarder; the other, a ‘certified lunatic’. Chaney analyses the impact of this distinction on asylum experiences and on therapeutic relations. Both of her protagonists seemingly accepted certain elements of the patient role while rejecting others. Both also, however, took on additional identities and even contributed to medical debates over the ways in which madness could be defined and represented. There is no such thing as a single history of asylums, the author reminds us; just like there is no such thing as a single history of patients. Chaney’s account brings up a number of fundamental issues central to the history of psychiatry: the value of individual case studies, the notion of a ‘typical asylum patient’ and, indeed, the active (and sometimes fruitful) collaborations among patients and their various caregivers. 74 Burkhart Brückner’s paper provides a vivid illustration of what Porter called the ‘Brechtian survival strategies’ deployed by those deemed mentally ill. 75 His subject is Friedrich Krauss, a travelling salesman from Southern Germany who in 1852 published a 1000-page account accusing a Flemish family of trying to assassinate him. Convinced that he had been the victim of ‘mesmerist forces’ since 1816, Krauss kept records of his consultation with several prominent physicians of the time in wide-ranging enquiries into any possible (orthodox or unorthodox) ‘cure’ for his symptoms. But Krauss is an unlikely patient, for he never perceived himself as mentally ill. His story would be interpreted as schizophrenia only upon the rediscovery of his manuscript in 1967. That tome makes for unusually rich historical reading. It also brings to mind that other nineteenth-century narrator of paranoia – Daniel Paul Schreber, whose Memoirs of my Mental Illness was made famous by Freud at the dawn of the twentieth century. Yet Krauss’s case remains largely unknown. Brückner’s historical and historiographical analysis offers original insights into the selective appropriation of medical knowledge by a layman of that time. The author shows a Krauss in constant negotiation with each physician he consulted; a Krauss who strove to be fully heard without surrendering his sense of dignity. Such a case highlights how the interaction of discourse ‘from above’ with that ‘from below’ should not be construed in terms of a strict dichotomy. Rather, the individual is embedded within a cultural network that shapes conceptions of self, illness and identity. Capturing these polyphonic interactions became easier with the introduction of new recording techniques. By focusing on case notes from Glasgow’s Gartnavel Mental Hospital in the 1920s, Hazel Morrison offers ‘a history from below’ of clinical practices and institutional procedures. This is made possible because Gartnavel’s superintendent, David Kennedy Henderson, instigated a routine of keeping verbatim records of the conversations between patients and practitioners. The resulting materials preserved the patient’s voice with a high degree of faithfulness, capturing with remarkable clarity some of the anxieties exhibited by patients and psychiatrists as they interacted with one another. By exposing the complex interplay among Gartnavel’s various actors – which also include clinical clerks, medical officers and stenographers – Morrison brings out the subtleties behind narrative co-construction. Also highlighted here are the transnational intellectual networks in the rapidly changing interwar psychiatric scene. As the author shows, Henderson was highly influenced by the work of Swiss-born American émigré Adolf Meyer, who championed the use of the patient’s ‘own language’ as the basis for therapeutic intervention. 76 Unlike Freud, Meyer taught his students and colleagues to defer from transforming patient stories into complex, theory-laden narratives. The unusually rich material provided by the Gartnavel case notes thus allows the historian to undertake an in-depth content analysis of those interactions. Yet it also begs some fundamental questions. How (un)filtered are these notes? How ‘truthfully’ do they capture the patient’s voice? And, indeed, do they perhaps reveal more about the medical staff than they do about the patients themselves? 77 This special issue, then, is itself a symptom. Though understood metonymically, the asylum in the volume’s title looms large over the aforementioned stories. A symbolic and protean space, it has allowed for complex variations of experience. In Bedlam late-nineteenth-century drawings, the patients depict themselves as birds in a giant dome circled by the asylum staff. In a 1962 animated film made by patients at Lausanne’s Cery Hospital (Switzerland), the protagonist’s dreams – represented by wooden birds in a cage – are taken away from him upon his admission to the clinic. In recent Mad activist rhetoric, this metaphor of entrapment has given way to individuals taking wing towards freedom…lest they fly too close to the sun. 78 Historians, of course, have different aims from those of Mad activists. And this is perhaps where it becomes most relevant to re-examine such tales. In an era where the ‘astounding silence of the mad’ 79 still reigns, doing history ‘from below’ may help generate a meaningful dialogue among historians, patients and psychiatrists. 80 In the process, it will bring novel perspectives on the way in which madness has been (and continues to be) staged, voiced and managed – debunking old myths and creating new ones in the process.