Robert Barrett Review

REVIEW ESSAY

ROBERT J. BARRETT

THE ‘SCHIZOPHRENIC’ AND THE LIMINAL PERSONAIN MODERN SOCIETY

Louis A. Sass, Madness and Modernism: Insanity in the Light ofModern Art, Literature, and Thought . New York: Basic Books, 1992,595 pp.

INTRODUCTION

Louis Sass has turned schizophrenia on its head.Madness and Modernism:Insanity in the Light of Modern Art, Literature, and Thoughtbringstogether more than a hundred years of cumulative writings, observationsand theories about schizophrenia, lays bare the traditional frameworkof assumptions which underpins this considerable body of knowledge,then proposes in its place an alternative way of organizing the evidencewhich is so radical that it amounts to a new paradigm for understand-ing schizophrenia. Though encyclopaedic and authoritative,Madness andModernismis effortless to read because Sass is a gifted essayist whoselucid style complements his meticulous scholarship. He holds schizophre-nia in one hand and modernism in the other, inviting us to look backand forth from one to the other as he draws attention to their vari-ous affinities, connecting threads and common origins. His purpose isto illuminate schizophrenia in the light of modernism, though he shedsconsiderable light on modernism in the process. He examines each facet ofschizophrenia in turn – the precursors and early signs, the disturbances ofthought, perception and language, the disordered sense of self, hallucina-tions and delusions, and the biological and cultural aspects of the illness.As he begins to demonstrate more and more common ground betweenschizophrenia and modernism, the traditional theories of the illness beginto look increasingly dubious and a novel interpretation of schizophreniaemerges.

This review essay examines the major arguments put forward inMadness and Modernism.Its broader purpose is to identify the core mean-

Culture, Medicine and Psychiatry22: 465–494, 1998.© 1998Kluwer Academic Publishers. Printed in the Netherlands.

466 ROBERT J. BARRETT

ings that are attributed to schizophrenia, and to examine the processeswhereby an illness such as this is invested with meaning. It asks how thetraditional theories that Sass so effectively demolishes might have arisenin the first instance, and seeks to elucidate the cultural logic which enablesthese old paradigms to be inverted to form new ones. Within the psychiatricliterature generally, the term ‘schizophrenic’ is usually understood to referto a disease, yet in actual usage it commonly refers to a type of person – the‘schizophrenic.’ InMadness and Modernismthe latter usage predominates,and this becomes the focus of my critical attention. I argue that becausethe ‘schizophrenic’ is conceived primarily as a category of person, it isnecessary to develop a sociologically based account of this category –an account which emphasizes the social processes which endow it withdistinctive qualities. This paper outlines a number of such processes. Itargues that the category ‘schizophrenic’ is constructed through psychiatricpractise and writing as an anomalous type of person or, in more dynamicterms, as a liminalpersona.Whether one examines conventional theoriesor the counter theories proposed by Sass, the underlying themes of anom-aly and liminality are reproduced throughout the literature. This view ofthe ‘schizophrenic’ as a social category draws on anthropological perspec-tives, particularly those of Mary Douglas and Victor Turner. Their workhelps to explain why people included in the category may be regarded asstrange, bizarre, and potentially dangerous, not only by others but also bythemselves. This paper further postulates that there is a particular nexusbetween schizophrenia and society, for anomalies are always reflectionsof the wider social order. That is to say, my critique outlines the culturalconditions which make it possible for a book to juxtapose schizophreniaand modernism.

A NEW PARADIGM

Traditional perspectives – dementia and primitivity

Conventional theories of schizophrenia, argues Sass, are based on two coreideas. One is the idea of a deficiency in that quintessential human quality,reason. Some would see this as a defect in logical inference, others as a lossof introspective capacity, or an impairment of language and cognition, butall of these are variations on the basic concept of a mental deficit. Largelyunder the influence of Kraepelin, this concept has become crystallized intoa “dementia” model, in which schizophrenia is seen as a progressive formof mental deterioration caused by neuronal degeneration.

THE ‘SCHIZOPHRENIC’ AND THE LIMINAL PERSONA IN MODERN SOCIETY 467

Excess is the second core idea – an excess of passion or desire, im-pulsively bursting through and overwhelming all forces of restraint. Thisidea has been shaped by psychoanalysis into a ‘primitivity’ model ofschizophrenia, in which it is proposed that regression to a primitive,infantile level leads to an outpouring of drives, urges or emotions. Puttogether, this pair of ideas, dementia and primitivity, form the basis of mosttwentieth century theories of schizophrenia.

Sass demonstrates the influence of these ideas by systematically exam-ining each aspect of schizophrenia, beginning with the prodromal features.These include the uncanny aura (known in the clinical literature astremaor anticipatory stage fright), an enigmatic atmosphere accompanied bya mood of dread in which reality itself seems to be altered in an unset-tling, disturbing way. It may be associated with the so-called “apophanousmood” of enhanced meaning in which things assume a heightened signifi-cance. Sass shows how these strange premonitory states have traditionallybeen viewed in terms of cognitive defect or regression to a primitive state.Sass states that according to McGhie and Chapman, they stem from abasic deficit in selective attention leading to stimulus overload; accordingto Conrad and Matussek they are caused by a deficit in the capacity forGestalt perception. On the other hand, according to Sass, psychoanalystssuch as Sechehaye, Federn, and Arieti have tended to interpret them asa regression to the lowest and earliest evolutionary levels of infantile orfoetal function, where the boundary between self and world weakens,where primitive logic applies, and where repressed traumatic memoriesresurface.

Similar theories, argues Sass, account for the aberrant thinkingobserved in schizophrenia. This has been defined in several ways: forBleuler (1950) it is a loosening of associative links between one thoughtand the next; for Goldstein, a loss of capacity for abstraction; for Cameron,the problem is over-inclusiveness. There are two postulated causes. VonDamarus puts it down to a cognitive deficit manifesting as a failure oflogical reasoning. Arieti sees it as a paleological form of thought whichcan found in all immature forms on the evolutionary scale, as he definesit. (His evolutionary scale includes the brain damaged, children, preliter-ate humans, and higher animals.) But Sass shows how these traditionalinterpretations are wanting. For a start, they fail to capture the extraordi-nary heterogeneity of thinking styles observed in schizophrenia. WhereasGoldstein would assert that there is a loss of abstraction, there are manyclinical accounts and research reports of an excessively abstract style ofthought. Whereas Cameron can only see over-inclusiveness, other author-ities in the field demonstrate under inclusiveness. In fact, argues Sass,


people with schizophrenia occupy both extremes of the abstract/concretespectrum and both extremes of the over-inclusive/under inclusive spec-trum. Many appear to be located off these spectrums altogether, for theirway of dividing up the world into categories is simply unconventional andidiosyncratic: it reflects a bizarre private logic as opposed to pragmaticcommon-sense reasoning. The diversity of thinking and its sheer eccentric-ity is scarcely compatible with a brain deficit, nor does it bear comparisonwith the ‘primitive’ logic of the child or the higher animal.

Sass makes the point that language, in schizophrenia, can also beidiosyncratic, cryptic, obscure. It does not serve to communicate, to linkthe person pragmatically to his outer social world, but instead it expressesan inner, private world. From the conventional information-processingperspective of experimental psychology, such abnormalities are manifes-tations of a dysfunction in the biological mechanisms responsible forcognition and language. Yet Sass makes it clear that this perspective doesnot begin to account for the unusual meanings conveyed by this language,its purposive quality, or its relation to the lived-world in which it spoken.From the psychoanalytic perspective, language abnormalities represent re-gression to infantile egocentrism and fusion with instincts. Yet here too,there is little evidence that language in schizophrenia chiefly revolvesaround instincts, sexuality, aggression, emotions or childhood images.

The force of Sass’s analysis, as he moves from one clinical domain tothe next, lies in his ability to demonstrate the pervasiveness of the demen-tia/primitivity paradigm. He shows how the views of the psychoanalystand the biologically oriented psychiatrist, who usually regard each other asoccupying opposite corners, are both generated by the one paradigm. Theanalyst perceives an upsurge of id forces in a weakened, regressed ego;the neuroscientist perceives a release of lower, archaic, subcortical brainfunctions due to failure of inhibition normally exercised by higher corticalcontrols. Schizophrenia, for both of them, is a deficiency in higher reasonthat permits the lowly primitive to burst forth. The same paradigm maybe found even further afield beyond the boundaries of conventional psy-chiatry. Antipsychiatry reproduces the primitivity theme when it celebratesthe true authenticity of ‘schizophrenic,’ authenticity referring to the unre-strained, ecstatic expression of primal passion and desire. Likewise, for theavant-garde in art and literature, the madman is the quintessential Wildmanwho exemplifies the glorious struggle against forces of rationalism andrepression. Both antipsychiatrist and avant-gardist share more commonground with the conventional psychiatrist than either would care to admit,differing only in that they celebrate the Dionysian aspects of schizophreniarather than attempting to civilise them by means of therapy.


If there is a shortcoming in Sass’s argument it has to do with thequestion of degeneration which, although mentioned, deserves far moreemphasis. The dementia model of schizophrenia does not just posit thepresence of a static cognitive deficit. It posits a deficit which gradually butinexorably worsens over time. All conventional conceptions of schizophre-nia have been built around the idea of a deteriorating course: From Morel,for whom démence précoceexemplified the “law of progressivity” andthe theory of degeneration (Carlson 1985; Huertas 1992); to Kraepelin, forwhom dementia praecox represented incurable deterioration (Peters 1991);to Bleuler, who held the expectation that his patients would slowly worsen(Abrahamson 1993); to contemporary clinical definitions which includethe diagnostic criterion of a decline in social function. Where Sass writesof dementia as a mental deficit, it should be recognized that it conveysideas of deterioration and degeneration with equal force.

The problem of heterogeneity

By challenging the conventional explanatory theories,Madness andModernismraises serious doubts about the very concept of schizophrenia.If we are forced to jettison the dementia/primitivity paradigm, does thismean that schizophrenia is nothing more than a myriad of observationswithout an organizing framework? The symptoms that fall under the rubricof schizophrenia are certainly disparate. They include disorders of think-ing, emotion, perception, will, and judgement, as well as a disturbanceof the sense of self. While in some cases there is concrete thinking, inothers we find abstract thinking; in some, there may be a heightening ofthe emotions, in others a deadening.

Faced with such diversity and inconsistency, Sass appears close to aban-doning the concept of schizophrenia altogether but instead of doing so, headopts a position closely aligned to that of Jaspers. However diverse theyare, argues Jaspers, people with schizophrenia have the following featuresin common: they are strange, they are enigmatic, they are alien, they arebizarre. They are unknowable. You cannot empathize with them. Theirsymptoms lie beyond the realm of human meaning, beyond the possibil-ity of human interpretation. They are, not to put too fine a word on it,“ununderstandable.”

It is fitting that Jaspers should have seen schizophrenia in this particularway. Tillich (1994) makes the point that his philosophy was essentially amoral philosophy. From his early days in psychiatry to his later period as aphilosopher, his project was to discover what it is to be human. The answer,for him, centred on the issue of interpretation. What is human lies withinthe realm of what is amenable to interpretation – what is understandable.


The importance of schizophrenia, for Jaspers, is that it lies beyond thepossibility of interpretation.

This position forms the point of departure for Sass, although he does notagree with Jaspers in every respect. Whereas Jaspers would banish peoplewith schizophrenia beyond the realm of human understanding, Sass wouldrescue them, at least in part, bringing them back into the “community ofhuman understanding.” He seeks to redefine schizophrenia in a way whichwill render it meaningful without underestimating how bizarre, alien andcontradictory the schizophrenic experience can be. To achieve this, hesearches for something just as bizarre with which to compare it. Hencethis voyage through the strange and alienating world of modernism, takingin a broad compass from modernism’s precursors in post-romantic (that is,proto-modernist) thought to its most recent expression in post-modernism.

Making sense of schizophrenia through modernism

Modernism is a movement in art, literature, music and philosophy that,according to Sass, is characterized by an iconoclastic defiance of tradition,authority, and convention, coupled with a relentless pursuit of innovation.It is so off-putting, so difficult to grasp, so bizarre, that it serves as a usefulpoint of comparison for schizophrenia. For example, Sass finds somethingakin to the trema and the apophanous mood in the defamiliarization of theRussian formalists or in the mysterious images of the French surrealists.And for him, one of the best descriptions of the fragmentation and distor-tion of perceptual reality is to be found in Sartre’sNausea. The heightenedsense of awareness and meaning as well as the associated feeling of detach-ment in the prodromal phases of schizophrenia are analogous, he says, tothe intense, microscopic focus on detail and the radical disengagement thatepitomize modernism. Both prodromal schizophrenia and modernism arecharacterized by “detached hyperconsciousness,” a far cry from Dionysusor from dementia.

Turning to schizophrenic thought disorder, Sass casts about for a moretelling point of comparison than Arieti’s primitive, and finds it in Borges’sfanciful account of an imagined classificatory system which is so arbitraryand freakish as to seem ludicrous or even unimaginable. He proceeds toshow how thought disorder has a close affinity with the dadaist idiosyn-crasies of Duchamp, or the utterly impractical, illogical ideas, witticismsand ironies of Jarry and his theatre of the absurd. Insofar as schizophreniccategorization departs from common-sense, it loses coherence, fragment-ing into contradictory points of view, akin to the multiperspectivism ofPicasso’s cubism. In the light of these comparisons, argues Sass, it isno longer tenable to view schizophrenic cognition as a result of lowered


intellectual functioning; it is the product of a style of thought whichis unconventional and impractical, idiosyncratic and odd, incongruousand inconsistent. Like modernist thought itself, it vacillates between oneperspective and next.

Sass also finds parallels between the curious, cryptic, private languageof schizophrenia and the language of modernism. In both instances, theelements of language can become conspicuous in their own right ratherthan serving as a transparent medium to convey referential meaning.Thus, in schizophrenia, the flow of language can be driven along by thelook or the sound of words rather than by their conventional meanings.Similarly, within modernism, there is a cast of mind which glorifies theelements of language – Sass calls it the “apotheosis of the word.” Itwas first articulated by Mallarmé with his vision of a poetry that wouldbe driven by the qualities of language itself (the acoustic properties ofwords, their graphic appearance), and reached a high point among thepost-structuralists, notably Derrida.

Seeking a model for the dissolution of self that occurs in schizophre-nia, Sass turns to the modern novel, drawing on the insights of Sarraute.She contends that traditional narrative structures have been replaced inmodernism by a relentless introspection, leading to the dissolution of thecharacter and the author as integrated, coherent selves. Self-reflection atthis level of intensity – Sass terms it “hyperreflexive involution” – createssuch a distance from inner thoughts and feelings that they appear to takeon an independent existence external to the self. One of Sarraute’s protag-onists, Alain, inBetween Life and Death,watches the play of sensationsand words across his conscious mind. The more closely he observes them,the more remote they become, until he loses that over arching sense ofself which might otherwise have identified them as his own. The paral-lels with schizophrenia are obvious: the same turning inward, the samerelentless scrutiny of conscious thoughts, and the same ensuing sense ofalienation from these thoughts, actions and feelings. Sass’s argument iscompelling. The loss of self associated with schizophrenia stems directlyfrom hypertrophied reflexivity rather than primitive regression.

The same argument is applied to the celebrated case of Judge Schreber,as documented inMemoirs of My Nervous Illness,an intimate accountby Schreber himself of a late-onset paranoid schizophrenic illness. In re-analysing this case, Sass joins an august circle – Freud, Bleuler, Jung,Jaspers – who have pored over the memoirs, sifting through Schreber’severy symptom for evidence in support of their own interpretation. Duringhis illness Schreber suffered the most agonizing self-scrutiny, but nothinglike the intensity of the posthumous psychiatric scrutiny. Sass throws down


the challenge to his illustrious predecessors by diagnosing hyper-reflexia,or “relentless self-consciousness.” It makes its appearance, says Sass, inSchreber’s earliest symptom, an “uncontrollable heightening of aware-ness.” It is manifest in the way he turns in on himself, and in the voicesthat talk at him persistently even when he himself is talking. It is moststrikingly evident in his belief in a bizarre and elaborate world of “nerves”(physical filaments that vibrate in response to external influences, theirvibrations corresponding to mental events) and “rays” (transformations ofGod’s nerves that constantly watching over him, forcing Schreber to think“ray thoughts” in a special grammatically incomplete form of languagethat he calls “nerve-language”). Nerve-language, suggests Sass, may belittle other than the normal “inner speech” we all use to think with – agrammatically condensed and silent variant of vocalised social speech –but Schreber feels obliged to fill out each sentence of this language to acomplete and correct expression. Little wonder that Schreber mutters andbellows. This behaviour is not a regression to a primitive state; it is hisonly defence against debilitating self-consciousness; it is the only way todrown out the voices.

As he touches on each clinical feature, Sass mounts a convincingargument that a far more incisive understanding of schizophrenia canbe achieved by replacing the dementia and primitivity with their oppo-sites. Instead of a lowering of cognitive functioning there is heightenedconscious awareness – hyper-reflexivity. And instead of immersion ininstincts and emotions there is detachment, disengagement – alienation.Schizophrenia looked like it was falling to pieces but Sass has managed tohold it together by recasting it in a modern framework of hyper-reflexivityand alienation.

However, there are two aspects of the thesis advanced inMadnessand Modernismthat deserve critical attention. One concerns themadness:What is meant by the term ‘schizophrenic’? The other concerns themodernism: Why should modernism or modern society mirror schozophre-nia? In order to address these questions I suggest an alternative approachwhich draws on the concepts of anomaly and liminality in order to focuson how the category ‘schizophrenic’ is socially constituted.

THE ‘SCHIZOPHRENIC’ PERSON AS AN ANOMALY

‘Schizophrenic’: A type of illness or a type of person?

There are two main ways in which Sass uses the term “schizophrenic.”Firstly, it refers to a type of psychiatric illness (“schizophrenia,” or


“schizophrenic-type illness”) and a spectrum of related disorders (includ-ing schizo-affective and schizophreniform disorders, as well as schizotypaland schizoid personality disorders). In keeping with this use, the wordcan describe characteristic symptoms of the illness (“schizophrenic delu-sions and hallucinations”). Secondly, the term is used to qualify a type ofperson rather than an illness. Thus we can have “schizophrenic patients,”“schizophrenic individuals,” or “schizophrenic persons.” The adjectivechanges, by stealth, into a noun, to give us the “schizophrenic” (e.g. “Asone schizophrenic named Lawrence put it”).

It is the second usage which becomes central to my analysis becauseit suggests that ‘schizophrenics’ are regarded by Sass as a category ofpeople. They are portrayed as individuals who have something quintessen-tially schizophrenic about them. It is as if the essence of their illness hasseeped out and infiltrated their personal identity. This schizophrenic infu-sion appears to be so penetrating that it dominates all other aspects of theiridentity, much as certain partial attributes (genius, blonde), roles (used-carsalesman, vicar), or behaviours (murder) can pervade one’s total identity.

Such usage of the term enables Sass to lump diverse people togetherinto a single group and suggest that attributes of one such ‘schizophrenic’may apply to all. Two examples illustrate this point:

“. . . schizophrenics can tacitly ascribe a subjective status to many of their experiences”(p. 285).“Even when a schizophrenic forgets or loses this awareness of other conscious beings,thereby manifesting akind of egocentricity, a residual perspectivism or subjectivism maystill operate” (p. 278).“Schizophrenics can, in fact, be persons of considerable intelligence and mental com-plexity . . . ” (p. 7).

By using vague qualifiers (“tend to,” “may,” “can” or “often”) the authorconveys the implication that all ‘schizophrenics’ have the potential toexhibit these qualities.

Recognition that ‘schizophrenic’ refers to a category of person as muchas it refers to a type of illness (thereby making explicit what is only implicitin Sass) encourages us, if we are to develop an adequate account of thiscategory, to shift from a purely clinical approach to a more sociologicallygrounded approach. It draws attention to the institutional practices andcultural traditions that give shape and definition to the category. Suchan account would examine the role of psychiatric institutions, concen-trating on the clinical and scientific practices whereby knowledge aboutpsychiatric disorders is produced. It would explore the extent to whichthese institutions are embedded within a web of related institutions – thepharmaceutical industry, universities, consumer groups and carer groups– and how this might influence the production of official knowledge of


schizophrenia. It would also be relevant to look back to the precursorsof modern hospitals, the asylums, where the term ‘schizophrenic’ wascoined. An important strand threading its way through these institutionsis the cultural tradition which stretches back at least to classical Greekthought, and which, as Sass shows, brings together ideas of madness,passion, primitivity, and unbridled Dionysian excess into a single theme.

The anthropological literature on personhood is germane to this sort ofenquiry because it sheds light on the social processes whereby persons aredefined. Stemming, in large measure, from a seminal paper given in 1938by Marcel Mauss (1985), this literature marshals a body of ethnographicevidence from diverse cultures to show that entities other than humans maybe defined as persons (ancestors, certain animals), and that living humansare not automatically considered fully fledged persons (slaves, foetuses).Drawing on this literature, and particularly on the work of Pollock (1985), Ihave proposed that in a wide range of societies (could it perhaps be univer-sal?) thecapacity for interpretationis a fundamental defining feature ofpersonhood. Entities are socially defined as persons in so far as:

a. they are attributed the capacity to interpret the actions of others; andb. they can be interpreted by others as engaging in meaningful action

(Barrett 1996: 179).

Though it is based on a different body of evidence and a differenttradition of enquiry, this proposition is not far from Jaspers’s notion ofunderstandability as a quintessential human quality.

Where is the category ‘schizophrenic’ positioned by those people andinstitutions (psychiatric, legal, medical) with the responsibility to definewhat is, or is not, a person? I would argue that it is located at the margin,at the outer edge of understandability, at the farthest limits of human inter-pretation, on the boundary line between person and non-person. It is, inSass’s words, “an important limit-case of the human condition” (p. 7).

‘Schizophrenic’: An anomalous category of person

Because the category ‘schizophrenic’ straddles this outer boundary line itis not just a marginal category but an anomaly. By anomaly, I refer to anirregularity, an incongruity (OED:76), something which does not conformto a system of classification: “an anomaly is an element which does not fit agiven set or series” (Douglas 1966: 37). The set, in this instance, is a simpledichotomy: person versus non-person. The category ‘schizophrenic’ is thusseparate – neither person nor non-person. It is outside the classificatorygrid, off the series altogether.


As an anomaly, it canalso be thought of as partaking incongru-ously in both sides of the dichotomy. Hence, someone categorized as‘schizophrenic’ may be simultaneously regarded as a person and not aperson. He or she may deemed to be capable and incapable of interpret-ing other people (usually both at the same time). The thought, speech,and actions of a ‘schizophrenic’ may be simultaneously regarded asmeaningful and nonsensical.

If it is the case that we are dealing, first and foremost, with an anom-alous category of person, then Mary Douglas’s well known discussion ofanomaly would lead us to predict that ‘schizophrenics,’ like cultural anom-alies in all societies, are likely to be avoided, to be treated as pollutingand contagious, and to be regarded as dangerous (Douglas 1966: 39–40). Historically, ‘schizophrenics’ have in fact encountered extreme levelsof social avoidance, chiefly by means of long-term seclusion in asylumssituated at a distance from population centres. And within psychiatrichospitals themselves, it is this group that is avoided, perhaps more than anyother. Douglas makes the point that in secular societies, ideas concerningpollution and defilement are commonly presented in a medicalized idiom.Although they are actually to do with social avoidance, they are couchedin terms of aesthetics, hygiene, or a germ theory of disease. There is noequivalent belief that schizophrenia is a contagious bacterial disease butthere have been ideas of ‘psychic contagion.’ In the past, these ideas havemanifested in a sort of psychiatric lore, usually in the form of cautionarytales told to one another by mental health workers, warning that spendingtoo much time with ‘schizophrenics,’ or getting too close to them emotion-ally, may have a detrimental affect on one’s own sanity. Maintaining acertain interpersonal distance has been seen as essential, both for the sakeof the mental health professional and for the patient.

The sense of social danger associated with any structural anomaly isrendered, in the case of the ‘schizophrenic,’ into ideas about the phys-ical danger that this type of person poses to society. The link betweenthe ‘schizophrenic’ and public danger is a powerful and deeply rootedcultural theme which is regularly reproduced by the popular press. News-paper reports of crimes committed or allegedly committed by people witha diagnosis of schizophrenia frequently place emphasis on the schizophre-nia itself, implying a causal connection between the illness and the crime.The question of a possible association between schizophrenia and violentcrime has been studied extensively, although contradictory findings arereported in the literature (Glancy and Regehr 1992). The balance ofevidence indicates that people with this diagnosis are somewhat moreprone than members of the general population to commit violent crimes


including homicide. Such a modest conclusion, however, is not sufficient towarrant the sensationalist reporting in the press. The association betweenthe ‘schizophrenic’ and danger thus remains fixed in the public imagina-tion, which means that it is also fixed in the private imagination of peoplediagnosed with schizophrenia, some of whom therefore come to regardthemselves as a potential danger to others, even though they have neverbehaved violently and are never likely to.

Further evidence that we are dealing with a category that bears the hall-marks of a classificatory anomaly can be found by examining the clinicaldefinition of schizophrenia itself. There is a diagnostic tradition withinpsychiatry of differentiating schizophrenia from the disorders which lieon either side of it. To one side lie the mood disorders. This group ofillnesses, unlike schizophrenia, is amenable tounderstanding. It is possi-ble to understand delusions and hallucinations in depression or mania, toempathize with the way in which they emerge from the underlying mooddisturbances. To the other side lie the dementias. This group of illnesses,unlike schizophrenia, are amenable to an adequateexplanation. The abnor-mal behaviour can be explained in terms of demonstrable brain disease. Inother words, there is a fundamental dichotomy within psychiatric classifi-cation, first clarified by Jaspers (1974), and it is based on the distinctionbetween understanding and explanation (it corresponds roughly to thedistinction between interpretive psychology and biology). Classificatorypsychiatry perches schizophrenia on the fence – no longer psychologicallyunderstandable like the mood disorders, but not yet neuropathologicallyexplicable like the dementias.

The dichotomy identified by Jaspers runs through the centre of psychi-atry, indeed is constitutive of psychiatry itself as a hybrid profession, partpsychology part medicine, part psychoanalysis part neurobiology. Thedichotomy is also a variant of the mind/body dichotomy; psychiatry isthereby aligned to the central traditions of Western thought. ‘Schizophre-nia’ is thus constituted as a classificatory anomaly, and one which liesat the heart of Western psychiatric nosology. Although other diagnosticcategories partake to a lesser degree in these dualisms, it is schizophre-nia which lies right in the middle of them – it epitomizes classificatoryanomaly.

Friendly disputes may then arise. Some, like Jaspers himself, contendthat ‘schizophrenics’ lie beyond the fence; others, like Sass, maintain thatthey are on our side, but only just. Yet others say they are a bit of both.These debates are only possible because the ‘schizophrenic’ is constitutedfrom the outset as an anomaly with one foot on either side.


Ambiguity

Ambiguity is the hallmark of the anomaly, for structural contradictiongives rise to double interpretation, and the category ‘schizophrenic’ is noexception. So pronounced is the ambiguity and contradiction with whichthe category is invested, that descriptions of ‘schizophrenics’ characteris-tically proceed by statement and counter statement, thesis and antithesis.Sass provides a good example:

Schizophrenics can be hypersensitive to human contact but also indifferent. They can bepedantic or capricious, idle or diligent, irritable or filled with an all-encompassing yetsomehow empty hilarity. They can experience a rushing flow of ideas or a total blocking;and their actions, thoughts, and perceptions can seem rigidly ordered or controlled (exhibit-ing a “morbid geometrism”), but at other times chaotic and formless. They will sometimesfeel they can influence the whole universe, at other times as if they can’t control eventheir own thoughts or their own limbs – or, in what is one of the supreme paradoxes ofthis condition, they may have both these experiences at the same moment. They may beextremely negativistic, responding to requests either by doing the exact opposite or byrefusing even to acknowledge the requester’s existence; yet it is inaccurate to characterizethem, as is often done, simply as oppositional or even as out of contact with their socialenvironment. For, at other times, the same schizophrenic may be afflicted with “suggestionslavery” – veritable “fits of servility” in which he complies instantly with every request(although sometimes exaggerating his performance to a ridiculous degree). (Sass 1992:26)1

This is not just Sass’s idiosyncratic interpretation. Like all his work, theabove citation is methodically referenced (six footnotes in one paragraph)suggesting that his view is broadly representative of a mainstream traditionof academic thought on schizophrenia.2 One is reminded that the termschizophrenia itself encodes the idea of a splitting of psychic functions(Bleuler 1950: 9) and this is usually conceived in terms of diametric oppo-sites such as the cognition/emotion polarity. The same cultural theme isalso evident in popular beliefs about the ‘schizophrenic’ as a split person-ality, someone who can suddenly change into his or her opposite. Suchbeliefs are so deeply ingrained that they simply refuse to go away, evenin the face of active public education campaigns seeking to dispel them.People with this illness, just as much as the scholars who study it and themental health professionals who treat it, have grown up amidst these ideas.They experience their illness through the same set of tropes: the samedualisms and contradictions, the same feeling of containing two opposingpersons, the same sense of having a split consciousness.

Ambiguity may be couched in terms of a question with two equallyplausible answers. In several chapters ofMadness and Modernism, Sassquestions whether the symptoms of schizophrenia may be viewed as an“act” or an “affliction.” Are certain symptoms voluntary or involuntary?


Are they under conscious control or not? Are they part of a wilful strat-egy or are they imposed by a disease? Are they manifestations of adefence or a deficiency? Is the ‘schizophrenic’ an actor or a puppet? Theanswer is always equivocal. At times Sass concludes that symptoms area complex mixture of both, at other times neither, seeming to “occupy ananxious twilight zone somewhere between act and affliction” (p. 74). Thesequestions and answers concern another basic dimension of personhood –agency. To be equivocal as to whether or not the ‘schizophrenic’ possessesagency is, again, to be equivocal as to whether the ‘schizophrenic’ is afully qualified person. The very lack of resolution within this discussionserves to reinforce that the ‘schizophrenic’ is culturally constituted as ananomaly, a question mark, at the outer edge of personhood.

THE ‘SCHIZOPHRENIC’ AS A LIMINAL PERSONA

Suspended liminality

A concern frequently raised about the type of argument just outlined is thatit is overly static, placing too much emphasis on classificatory schemes,stable cultural categories, and ultimately, on a concept of society as a fixedstructure. In response to this criticism, it is customary to look at the sameproblem from a different angle – one which gives more emphasis to thedynamic social processes that generate and sustain such anomalous cate-gories. The psychiatric hospital is a suitable place to enquire into theseprocesses because it remains, despite deinstitutionalization, the principalsite where patients are first diagnosed, receive their initial treatment, andundergo radical changes in their personal identity.

The concept of the illness trajectory, first developed by AnselmStrauss, provides a useful framework for this sort of enquiry. The trajec-tory emerges from the interaction between the patient, members of theimmediate family or social network, the unfolding psychotic illness, andthe psychiatric hospital practices designed to treat it. I have previouslysuggested that these dynamic processes effect changes in the patient’sidentity: he or she is transformed from a person with “acute psychosis” to a“chronic schizophrenic,” a transformation which affects the patient’s innerperception of self as well as his or her outer public identity (Barrett 1996).For patients who have a diagnosis of schizophrenia, a striking feature of thetrajectory is that it is indeterminate, open ended. It has no point of closure.The ceremonial aspects of hospital practice (the diagnostic assessment, thehospital admission procedures, the full clinical work up, the case historydocumentation) concentrate on the phase of induction. They ensure that


the person embarks on the trajectory. But there is no corresponding officialprocess that brings the trajectory to an end, nothing to ceremonially markthe person’s transformation back into health. In contrast to the complexadmission procedures, there is no passing out ceremony to celebrate theperson’s ‘graduation’ from the hospital. Hence, requests by a hospitalpatient with schizophrenia for an official written “statement of mentalhealth” seem odd or amusing to the treating staff – “We don’t do that sortof thing here.” Patients are thus set off on an outward trajectory which issupposed to recurve so that they can re-enter the community of healthypersons, but they remain out there, suspended indefinitely – “chronics.”

These processes of psychiatric assessment and treatment, especiallytheir sequential ordering, bear a strong resemblance to cultural processesof transformation that have been described in the anthropological liter-ature, most notably by Victor Turner. Examining the clinical processesby which schizophrenia is defined, one is reminded of the first two ofvan Genep’s three phases of the classicalrite de passage. One is struckby the observation that a person with schizophrenia is indeed separatedout from the immediate social group and marked off, entering a liminalphase in anticipation of a return to the community of the healthy (cf.Gutknecht 1982). It is in the liminal phase, however, that he or she becomessuspended, caught betwixt and between, locked in transition, never tobe reincorporated ritually into the group, even in this age of communitytreatment.

Turner’s approach is particularly helpful because it leads us beyondthe static concept of anomaly as structural contradiction to the dynamicconcept of “ ‘liminality’ as an interstructural situation” (Turner 1967: 93).It encourages us to concentrate on the liminar (the one who is making thispassage from one structural state to another) and in particular the liminalpersona(the identity of this person and how it is symbolized).

Liminality and chronic illness

A number of authors have used the concept of liminality to analyse chronicillness and disability, and the way in which these states are culturally signi-fied. Objections could be raised that it is inappropriate to take a conceptthat arose from the study of ritual in small-scale societies and apply it tothe analysis of treatment processes and illness categories found in modernsituations. It is widely acknowledged therefore that ritual analysis needsconsiderable modification if it is to be applied in a secular context. Thisissue has been addressed inSecular Ritual(Moore and Myerhoff 1977) acollection of essays examining the distinctive nature of ritual in industrialsociety, with its heterogeneity and fragmented ideology, with its orien-


tation to progressive change rather than stability, where participants inceremonial, for example, are very often strangers, and where the sacred (inthe sense of that which is unquestionable) extends far beyond the provinceof religion.

Turner himself has speculated on the nature of liminality in moderncontexts. In relation to rites observed in tribal societies, he goes to consid-erable lengths to define liminality as a transition (a period, a phase, aprocess, a becoming, a passage between states), and to distinguish it fromthe concept of a state, which refers, broadly speaking, “to any type ofstable or recurrent condition that is culturally recognized” (Turner 1967:94). However he argues that in large-scale societies, as the division oflabour becomes progressively more complex, and culture becomes morespecialized, liminality may itself become an institutionalized state, thoughretaining elements of its “passage” quality (Turner 1969: 107). He citesthe monastic and mendicant states within the great religions, such as theFranciscan order with its rule of radical poverty which placed the friars atthe margins of economic and social space and rendered their entire life intoa permanently liminal state, a prolonged passage to heaven. For the laity,on the other hand, pilgrimage took on many of the attributes of liminality(Turner and Turner 1978: 34).

Liminality may have another face, suggests Turner, which is germaneto the experience of illness, for it can encompass chaos, disorder and inse-curity. “Liminality may be the scene of disease, despair, death, suicide, thebreakdown without compensatory replacement of normative, well-definedsocial ties and bonds. It may be anomie, alienation, angst, the three fatalalpha sisters of many myths” (Turner 1982: 46). Citing the above passage,Frankenberg (1986) employs Turner’s processual symbolic analysis tobuild on Strauss’s concept of a trajectory. His purpose is to develop abetter understanding of the performative, expressive or symbolic aspectsof disease than is possible within Strauss’s framework. He argues that it isparticularly pertinent to chronic illnesses which, compared to short-livedillnesses, require more complicated, longer lasting, and demanding waysof being sick.

For similar reasons, Robert and Yolanda Murphy have searched for amore ethnographically accurate understanding of physical disability thanis possible within the conventional sociological models, which have tendedto view disability in terms of social deviance and stigma, or as an exten-sion of the sick role (Murphy et al. 1988). The concept of liminality,they argue, draws attention to the dynamic social processes which, thoughaiming toward rehabilitation, lead to the disabled being cloistered, sociallysecluded, and endowed with specific cultural meanings. It accounts for the


fear, the revulsion – people even behave as if they are somehow conta-gious – the structural “invisibility,” and the ambivalence with which theyare regarded. The disabled occupy a socially indeterminate limbo some-where in between health and illness, between life and death. “The dynamicand processual character of the ritual interpretation lends itself to a betterunderstanding of the relativistic, arbitrary and socially constructed natureof these meanings, thereby allowing us to see them as culturally and histor-ically malleable, rather than as rooted in and fixated by biology” (Murphyet al. 1988: 241–242).

Mwaria (1990) shows how patients with severe brain injury areattributed similar meanings. Those who remain comatose for prolongedperiods are regarded as neither alive nor dead and, as a consequence,there is considerable ambiguity in the interpretation of certain elementsof their behaviour (is it a true response to communication or merely areflex action?). Furthermore, they fall between the standard institutionalfacilities (acute care, nursing home care, and home care). Family memberstoo, are ultimately pulled into this liminal state, resulting in extreme socialisolation for many.

The application of liminality to illness is best limited to settings inwhich ritual can be empirically demonstrated, otherwise it becomes littlemore than a synonym for danger (Manson 1984), aberrant experience(Shokeid 1992), transition (Prout 1989) or marginality (Sandstrom 1990).The advantage of limiting its application in this way is that it enables usto examine the processes that freeze liminality into a permanent state. Inrelation to the psychiatric institutions that deal with schizophrenia, I havesuggested that, in contrast to the dramatic rites of separation, the ritesof reaggregation are vestigial or even absent altogether. Shomaker (1989)makes a similar observation in relation to Alzheimer’s disease, where thesame lack of resolution leads to a state of permanent ambiguity in whichthe person is treated as if simultaneously living and dead. Deegan (1975)makes the intriguing suggestion that the prolonged liminality of the phys-ically disabled is resolved only by death, for only then do they achieve afixed, unambiguous status. The final rite of incorporation, she argues, isactually the funeral.

Symbolism of transition

Turner shows how liminal personae in many cultures are invested withthe symbolism of transition, drawing chiefly on biological images. Theymay be images of death and the decomposition that is associated withit, or images of gestation and parturition. The liminar may be treatedas a corpse or a new-born, quintessential points of transition in the life


cycle. These observations may help to provide a better understanding ofthe two traditional models of schizophrenia identified by Sass, for it couldbe argued that the dementia model likens the ‘schizophrenic’ to a processof degeneration and decomposition, whereas the primitivity model likensthe ‘schizophrenic’ to a foetus or a neonate.

I previously emphasized that degeneration was the central conceptwhich underlay the dementia model, as it was taken up and developedby Morel and Kraepelin. Kraepelin, in particular, used the term (dementiapraecox) to mean a neurophysiological deterioration as well as a destruc-tion of the inner unifying forces of personality that led to a dissolutionof the ego. Although the illness clearly began at an earlier age than theclassical senile dementias, it was thought to follow a similar course ofprogressive and inexorable decline culminating in an incurable state. Itis remarkable that the dementia model has endured for so long for it hasnever been possible to establish unequivocal evidence of neuronal degen-eration. There is no solid evidence, for example, of the gliosis that onewould expect to find (Wyatt, Kirch and Egan 1995: 932). Furthermorethe expectation of a deteriorating course in schizophrenia has persisted,in spite of evidence, first compiled by Manfred Bleuler, that the prog-nosis in many cases can quite good in the long run. Thus the dementiamodel of schizophrenia gives us a picture of a degenerative brain disorder(but one which cannot yet be identified neuropathologically) leading toa progressive decline (but one which cannot be demonstrated over thelonger term). In fact it describes a state of arrested deterioration. Theperson with schizophrenia is decomposing, both at the biological leveland at the personality level, but remains, for the present, in a state ofsuspended decomposition. The persistence of this model with so littleempirical support is testament to the capacity of cultural concepts of illnessto set the agenda for psychiatric thought and medical research.

Not far behind the ideas of deterioration, degeneration and decompo-sition lie images of death. Family members report that they feel as if thepatient is no longer the same person, as if he or she has died and yet contin-ues to live on among them in an empty way. From the patient’s perspective,Sass provides accounts from people who feel “dead but hyper alert” or like“a corpse with insomnia” (p. 8). In fact, the theme of death as metaphor forschizophrenia runs throughMadness and Modernism.Sass himself regardsschizophrenia as “a sort of death-in-life” (p. 7). The ‘schizophrenic’ is thusconceptualized as a person who is no fully longer alive but not yet fullydead, suspended permanently in transition between life and death.

At the other end of the life cycle is birth. The primitivity modelof schizophrenia describes a person who is caught somewhere in this


transitional phase. According to the psychoanalytic view, the personhas regressed, slid backward down the developmental ladder, and therehe or she remains, developmentally arrested or fixated. Psychoanalysisapplies this regression/fixation model to all conditions but in the caseof schizophrenia the regression is especially profound, and may lead theperson back prior to birth into the womb. Thus we have a cluster of psycho-analytic adjectives for the ‘schizophrenic’ – infantile, oral, neonatal, foetal,embryonic – which are centred around gestation, birth, and infancy. Whenthis symbolism is not sufficient to convey sufficient degree of primitive-ness, the Darwinian scale is invoked: the person is depicted as havingslipped down the evolutionary ladder to an even more primitive state offunctioning (somewhere between higher animal and man). Much the samesort of logic is evident in theories which compare the ‘schizophrenic’ withprehistoric mankind.

The primitivity model thus describes a person who is metaphorically anembryo, a foetus, a new-born, or an infant, but one which is not growingand developing. Instead of a child who climbs steadily up the developmen-tal ladder, we have a person who has slipped down and remains stuck onone of the lowest rungs. The ‘schizophrenic’ is locked in a permanent stateof embryonic or infantile transition – suspended development.

Thus, a person categorized as ‘schizophrenic,’ like liminalpersonaeinmany societies, is socially defined as a person in transition, and culturallysignified by means of models of illness that are based on degeneration anddevelopment. I suspect that the templates for these ideas, in turn, derivefrom the two most important moments of biological transition, death andbirth. The symbolism of degeneration is furnished by biological psychia-try; the symbolism of development by psychoanalysis. Together, they posita person who is in a perpetual state of decomposition and growth. To becast as a ‘schizophrenic’ is to enter a permanent limbo, degenerating ordeveloping, deteriorating or child-like, yet never quite dying or growingup.

The ‘schizophrenic’ and modern society

A further implication of my argument is that the category ‘schizophrenic,’if it is a culturally specific variant of the liminalpersona, is likely to beportrayed as an analogue of society. Because it is interstructural (emerg-ing in mid-transition between structures) the liminalpersonaexposes “thebasic building blocks of culture” (Turner 1967: 110). Because it is essen-tially unstructured, it can be seen as a reflection of the basic structuralcomponents of society, either a negative image or a distorted image that iscomposed of the components rearranged in bizarre juxtaposition. Douglas


makes a similar point in relation to anomalies. They reaffirm and rein-force the social definitions and values to which they do not conform. Theanomaly clarifies “the outline of the set in which it is not a member”(Douglas 1966: 38). Because of its ambiguity, it can incorporate the majorcontradictory elements of a culture into a single, unifying pattern.

People categorized as ‘schizophrenic’ have long been entrusted withthis duty of symbolizing society, its structural elements, its definition ofpersonhood, its contradictions, its paradoxes.Madness and Modernismis the most recent example of a genre in which the ‘schizophrenic’ isportrayed as a reflection of society. To examine what aspects of societythis type of person might reflect, it is necessary to recall what Sass meansby modernism.

When using modernism in the narrow sense to refer to an aestheticor a philosophy, Sass is comparing the ‘schizophrenic’ with somethingthat is bizarre and alienating. Though he seeks only to compare andclarify, not evaluate (p. 9), he has nevertheless chosen a value ladenpoint of comparison, for modernism is, amongst other qualities, “off-putting,” “hard to understand or feel one’s way into,” “difficult to grasp,”“alien,” “convoluted,” “paradoxical,” and “self undermining” (pp. 8–9).Sass describes it as negativistic, defiant, antagonistic, rebellious, obscure,mocking, alienating, nihilistic, and dehumanizing. Its works of art haveno soul, they celebrate chaos, they portray the human world as meaning-less and absurd, and “pour scornful laughter on the whole of existence”(p. 36). The comparison with modernism has the advantage of providinga way of understanding experiences that are strange and disturbing. Butsuch comparison is not devoid of peril. Likening the ‘schizophrenic’ tomodernism, itself such an odd fish, may have the effect of pasting anotherlayer of bizarreness onto this cultural category. It may unwittingly recon-firm and reinforce the symbolism associated with liminality, where wemight, instead, seek to understand the dilemma of those who are typecastas liminal personae. For individuals defined as ‘schizophrenic,’ it may notbe helpful to be compared with a movement that is so bizarre and alienatingas to make you believe your experiences were more bizarre than you firstthought, or make you feel typecast as an alien.

An alternative strategy might be to identify the metaphors that peoplewith schizophrenia use to make sense of their illness. Those I have en-countered in my clinical and research work do not choose modernism.Most are not familiar with it (a reflection, perhaps, of their educationaland class background) but those who know about modernism do not spon-taneously use it as a point of comparison. Instead, they draw on metaphorswhich are much more accessible than modernism and postmodernism:


from religion, science, drugs, rock music, art as a form of inner expres-sion, historical myth, and personal biography. They make sense of theirexperience by means of tropes which, though not mundane, are sufficientlyconventional that they provide a bridge to connect that person with theordinary everyday world, rendering bizarre experiences at least partly plau-sible. Without wishing to generalize to all cases of schizophrenia, I haveobserved that a number of people with a diagnosis of schizophrenia workcreatively with these tropes in the process of coming to an understandingof themselves and their illness. Modernism, as a point of comparison, isdistancing and alienating because in its pure form it is a movement asso-ciated with a small elite of artists, novelists, architects, and philosophers.Understanding people with schizophrenia may better be pursued by study-ing how they themselves forge a connection with (but maintain a discreetdistance from) the cultural mainstream.

Yet it could be argued that modernism in art, literature and philosophy ismore than a narrow, elitist, side stream; it could be argued that it is a sensi-tive indicator of the undercurrents that run through society at large. This,I believe, is what Sass intends. He explicitly employs the link betweenschizophrenia and modernism to “illuminate, if not the modern conditionin general, at least certain of its more disturbing potentialities – as theseare refracted through the most exaggerated or pathological of examples”(p. 12). The schematic structure of his argument is:

A is like B; B reflects C; ergo, A reflects C.

A is schizophrenia, B is modernism, and C is modern society at large:“the modern condition,” “modern culture,” “the modern social order,” “themodern . . . sensibility,” “modernity” or “the modern social and culturalframework” (at least its more negative aspects).

An example of this logic may be found in Sass’s discussion of theschizoid personality type. (Some regard this personality type as predis-posing to schizophrenia, some as aforme frusteof schizophrenia, andsome think it captures the essence of schizophrenia – introversion anddistance.) Detached, unfeeling, aloof and indifferent to others, the schizoidperson is a combination of coldness and oversensitivity. Sass shows howthe core features of this personality type (A, above) apply to Kafka andBaudelaire: He writes of Kafka with his solitude, his hypersensitive intro-version, and his cold indifference to others; and Baudelaire, who retreatsto an inner magical paradise in a pique of scornful disdain for the banaland repulsivehoi polloi. Sass contends that in their life and their literarywork (B, above), both figures illustrate the inward turn that has become aleitmotif of modern culture (C, above). And they both reflect the alienation


experienced by individuals in modern society. Thus, the schizoid person-ality (A) epitomizes the modern condition (C) with its reflexivity and itsdisengagement.

Sass underlines the argument by showing that this type of person is notto be found in premodern societies, be they contemporary or historical.In small-scale, nonliterate, or tribal societies which are more communal,homogenous and integrated (say among the Dinka in southern Sudan),the typical person is not perceived as an individualistic self separate fromthe group but as a sociocentric self that is embedded in social roles. Andthe same applies to Europe before the Middle Ages (look at the ancientGreeks or the Vikings for example). The modern age produces a distinc-tively egocentric concept of person, one that is introverted into an internalpsychological self.

The problems associated with comparing “modern society” with everyother society (us versus them) are well known. To lump diverse non-modern societies into a single category – the Dinka end up in the sameboat as the Vikings – ignores the vast differences that arise over the span ofcenturies as well as the dramatic ethnographic variation observed amongcontemporary societies. Similarly, to treat modern society as monolithicfails to account for the plurality of modern life. Do these generalizationsapply to both women and men, adults and children, middle class andworking class, Roman Catholics and Southern Baptists? When Sass writesof the alienation, distance and fragmentation experienced by members ofmodern society, is he referring to members of the armed forces, lovers,people who like twelve tonal music, Quakers, community nurses? Who?

In many instances, such broad scale comparisons tend to pit the illsof the modern world against the integration and communal security ofpremodern or tribal life, thereby reproducing a primitivist theme that hasrun through the comparative literature since the Enlightenment (Lucas andBarrett 1995). In the tradition of Rousseau, modern society comes outpretty badly and primitive society is romanticized – an Arcadian visionof the primitive. Not that we wish to hear an apology for modern society,for this soon reverts to a second variant of primitivism which celebratesscience, progress and rational secular society by contrasting it with prim-itive peoples, their superstitions, their magic, their traditions, and theirproneness to uncontrolled sexual extravaganzas or outbursts of tribalviolence. Here the primitive is depicted as a Barbarian. Sass, who wouldpaint a bleak picture of modern society, contrasts it with an Arcadian prim-itive, whereas those who would extol modern society contrast it with aBarbarian primitive, as set out schematically in Figure 1.


Figure 1.

It is instructive to examine the fate of the primitive inMadness andModernism.It first appears in the image of the Barbarian primitive (irra-tional, impulsive, id ridden, emotional, sexual, violent, Dionysian), atraditional metaphor for schizophrenia. At the beginning of the book, Sasseffectively disconnects this dark primitive from schizophrenia, but it doesnot go away altogether. Instead, it changes into its other, more positiveguise, the communally oriented, integrated, Arcadian primitive, and re-appears toward the end of the book as a point of contrast with modernsociety (self oriented, alienated). The ‘schizophrenic’ does not benefitfrom this transformation. It is, without doubt, a relief no longer to becompared with the Barbarian primitive, with all its negative associations.But it is no comfort to be likened instead to modern society, with all itsnegative associations. The ‘schizophrenic’ relinquishes a negatively valuedprimitivity in exchange for a negatively valued modernity. In Figure 1, itmoves from cell 2 to cell 3, carrying the negative valence with it.

The question of whether modern society is a good thing or a badthing is academic unless you are being likened to it. And inMadness andModernism, people with schizophrenia are likened, in the final analysis, toa modern society which is a desperate state of affairs. It is a modern ordercharacterized by alienation, rationalization, secularization, bureaucratiza-tion, and industrialization. At the level of individual experiences, there isanonymity and impersonality, as well as a demand for rationality, abstractthought and perception rather than synthetic-intuitive thinking.


The modern episteme, argues Sass, is confounded by paradox, equivo-cation, incongruity, and duality. At its nub lies the conundrum of modernconsciousness that Foucault has called the “empirico-transcendentaldoublet.” Consciousness is both subjective (hence we have the transcen-dental subject, the constitutor of conscious experience, the free, sponta-neous self) and it is objective (empirical, constrained, determined by thecausal forces of the nature). Given this duality, the hyper-reflexivity ofmodernity produces paradoxical effects. The external world, which onemight suppose to be objective, becomes subjective and derealized, whereasthe inner self, which one might suppose to be subjective, becomes objecti-fied and reified: “insofar as I focus on the world, it will seem likemyworld;but insofar as I focus more directly on thoughts or feelings, these will seemto exist out there and apart” (p. 338). In a curious double reversal, objectsbecome subjectified and the subject becomes objectified. Sass shows howthe Romantics and early moderns had no doubt about the modern episteme:they regarded it as misleading and corrupting, a perversion of authen-tic experience. It represented a malaise. The symptoms were division,dissociation, disarticulation, detachment, despair, estrangement, devital-ization, dessication. For them, the “striking parallels between modernismand schizophrenia would simply be further proof, if such were needed,of the essential fallenness of the modern mind . . . ” (p.343). Accord-ing to Sass, even post-moderns, who celebrate hyperreflexivity, use itto interrogate and denounce the illusory, fictive and fraudulent basis oftheir own work. Modern life itself, they propose, is founded on duplicityand dissimulation and therefore fundamentally inauthentic. The modernperson is inevitably faced with the predicament of internal dividedness andalienation.

Thus, in Madness and Modernism, the ‘schizophrenic,’ the modernperson, and modern society come to mutually signify each other. The bookis a comparison between a sick person and a sick society, a crazy personand a crazy society, a traditional theme reworked by Sass into a novelconfiguration. The problem this may create for people who have beendiagnosed as suffering from schizophrenia is that it may lead to them beingrestigmatized. Like scapegoats, they may have to carry the responsibility ofrepresenting an alienated, fragmented, meaningless, self-absorbed society– a schizophrenic society. (The adjective ‘schizophrenic’ has itself enteredthe vernacular as a way of describing a world that is beset by impossibledivisions and contradictions.) Not only must they put up with hallucina-tions and jumbled thoughts, but they must struggle under the weight ofrepresenting symbolically much of what has gone wrong in the modernworld. This does not happen to the same extent with illness categories


that are more conventional and unambiguous – illnesses that are not, bydefinition, anomalous. It would be inconceivable to write on the parallelsbetween mood disorders and society (say, “Manic depressive disorder andthe economic cycle: A Keynesian perspective,”) or between dementia andmodernity (“Dementia and Disintegration: Alzheimer’s disease and thedecline of modern society”). But it is possible to write a book that juxta-poses modernism and madness because the ‘schizophrenic’ has encodedin it, as an anomalous and a liminal category, the capacity to symbolizesociety and its ills. The societal analogy is prefigured in the categoryitself.

CONCLUSION

In the spirit of his times, Sass has embarked on a journey of deconstructionwhich has enabled him to reveal and delineate the two master tropes thatorganize the traditional view of schizophrenia – dementia and primitivity.He replaces them with their opposites – hyper-reflexia and alienation –and thereby accomplishes a remarkable reconstruction of schizophrenia.He encompasses a biological perspective without treating the people whohave this illness as objects. They appear on the pages of this book as humanand, though strange, understandable. This is the principal achievement ofMadness and Modernism.It restores the task of understanding people whohave schizophrenia to its rightful place alongside the task of elucidatingthe biological correlates of the disorder.

This critique seeks to continue the journey that Sass has initiated. LikeSass, it preserves the concept of schizophrenia as a disease with estab-lished biological correlates but, unlike Sass, it focuses attention on the‘schizophrenic’ as a category of person. It proposes that the category is,in structural terms, a classificatory anomaly or, in processual terms, a limi-nal persona.There is evidence to support this proposition. It includes thedanger attributed to people defined as ‘schizophrenic,’ the social avoid-ance they experience, and the more subtle notions of a psychic contagiouseffect that may be attributed to them. I argue that the traditional theoriesidentified by Sass, dementia and primitivity, themselves arise from thesymbolism with which liminalpersonaeare characteristically invested.While some of these features apply to other psychiatric disorders, to otherchronic illnesses and to states of disability, all apply,par excellence, to the‘schizophrenic.’ Ambiguity and contradiction, I contend, are also distinc-tive features of the category. It is often described in terms of diametricoppositions and contrasting theories, and in this regard Sass’s work is noexception, for its main thrust is to replace two traditional models of illness


with their opposites. At a clinical level, his argument is convincing for themodels of hyper-reflexia and alienation provide for a richer understandingof the clinical features of schizophrenia than was previously possible.

However, it is not sufficient simply to attribute new meanings toschizophrenia by inverting old ones. There would be nothing to preventfuture scholars, working according to the same logic of oppositions andcontradictions, from replacing hyper-reflexivity and alienation with yetalternative formulations. Instead, what is required is an account of thesocial processes whereby the category itself is invested with cultural mean-ings. This paper has pointed to those psychiatric institutions and practicesthrough which anomalous and liminal categories of person are generatedand attributed specific meanings, and it has sought to identify the culturallogic which produces novel transformations of these meanings. An im-portant aspect of this logic is the way in which the category is constructedas an analogue of society. In traditional formulations there was the implicitanalogy with primitive society, but in Sass this is transformed into ananalogy with a fractured modern society.

It is anticipated that the type of enquiry proposed in this paper willlead to a better understanding of the relationship between culture andschizophrenia. As with epilepsy and neurosyphilis, a more complete ex-planation of the biological aspects of schizophrenia may emerge, and themetaphors with which we now make sense of it may fade to the extent thatthey become of historical interest. This scenario implies a view of cultureas a set of essentially false beliefs that are tacked on to a disease to help usmake sense of it when we cannot not fully explain the underlying organicprocesses at work.

Alternatively, the biological aspects of schizophrenia will find a moremodest place (as the major explanation for a small subset of cases, or asone among many causal factors in a wider range of cases), and it willbe necessary to become more sophisticated in our understanding of thepsychological and cultural aspects of the disorder. Instead of regardingculture as false belief, this scenario implies a view of culture as a morepowerful set of factors that play an important role in constituting the cate-gory itself, including the way it is experienced and the way it is treated. Itimplies a view of the ‘schizophrenic’ as a socially constructedreality.

In this paper the concept of liminality has been restricted to the analy-sis of the ‘schizophrenic’ as a category of person, concentrating on thedistinctive ways in which this category is signified within the psychi-atric literature. There are risks inherent in this project, particularly therisk of implying that people with schizophrenia are, in some fundamentalway, liminal people. ‘Liminal’ would then be added to the list of essen-


tial attributes of the ‘schizophrenic,’ already burdened with many suchattributes. For this reason, I have been careful to preserve liminality asa tool with which to examine the practices through which the category‘schizophrenic’ is constructed and symbolized, and the way in whichpeople defined as ‘schizophrenic’ are then positioned in society.

Can liminality, as an analytic tool, also be used to understand the waypeople with a diagnosis of schizophrenia experience symptoms of theirillness? Can liminality provide an analytic framework for a phenomenol-ogy of schizophrenia? These questions cannot be addressed within thescope of this paper, for they require additional investigation, workingdirectly with people who have active symptoms of the disorder. Suffice itto say that an attempt to understand every clinical feature of schizophreniain terms of liminality would be stretching the point, and would lead ulti-mately into sociological reductionism. Nevertheless, I would tentativelysuggest that liminality may be a useful framework in which to examinethe basic phenomenological parameters of delusional and hallucinatoryexperience. Delusional reality, for example, is commonly located outsidemundane time and space. Delusions take you to other planes, other worlds,other planets, other eras.3 The indeterminate spatial location of the sourceof “voices,” the notions of extraordinary power deriving from God, thebizarre imagery of schizophrenic symptoms, the combination of male andfemale gender identity that sometimes occurs: all these features are poten-tially amenable to analysis within the framework of liminality. Such anapproach would move beyond the conventional view of culture as patho-plastic (merely shaping psychotic experiences and giving them content)to a view of culture as playing a role in the very structure of psychoticexperience itself.

The analyses offered inMadness and Modernismand in this critiquesuggest a number of therapeutic avenues worth pursuit. If the notion of theprimitive is a powerful metaphor for schizophrenia, it may be important toexplore with patients the extent to which this influences their self conceptand the way they are regarded by those around them. If the idea of a defectpervades thinking about schizophrenia, it is probably necessary to dealwith the impact this has on patients’ self esteem. People with schizophreniamay have the idea that they are dangerous, that they carry within them atall times a propensity to erupt, explode or fall apart, and in these cases, itmay be fruitful for them to consider other ways of thinking about them-selves. If liminality is an issue, patients may feel as if they are neither sicknor well but stuck, ambiguously, somewhere betwixt and between. Theymay feel suspended in a timeless zone, or destined to live outside society.By exploring these metaphors with patients it may be possible to gain


a better understanding of the phenomenal experience of schizophrenia.This, in turn may give rise to specific strategies to deal with indeterminate,ambiguous limbo of chronic schizophrenia.

ACKNOWLEDGMENTS

I wish to thank Rodney Lucas, Megan Warin, Anna Chur-Hansen, MitraGuha and Judy Liney for their comments on earlier drafts of this paper.Financial support was provided by a Project Grant (930971) from theAustralian National Health and Medical Research Council.

NOTES

1. Similarly the prodromal period is described in terms of radical opposites – meaning-fulness and meaninglessness, significance and insignificance. In this period, accordingto Sass (p. 44), the world is normal yet uncannily transformed, reality is heightened ordiminished, the familiar becomes strange and the unfamiliar becomes familiar, thereis bothdéjà vuandjamais vu.

2. In reviewingMadness and Modernism, Littlewood (1995) echoes Sass with anothersuch list of opposites which include “both ‘concrete’ thinking and abstruse spec-ulation; ‘dementia’ praecox, yet striking insights on conventional social life whichcontinue to intrigue the empathic physician; word salads but truth telling; the dissolu-tion of the self in the world, yet also the dissolution of the world in the self; eternalpunishment but divine omnipotence; pain and hilarity.” Like Sass, Littlewood presentsthese “paradoxes of schizophrenia” as simple statements of fact rather than questioningwhy the illness should be so tied up with contradictions.

3. Compare with Hazan (1984) on “limbo time.”

REFERENCESAbrahamson, D.

1993 Institutionalisation and the Long-term Course of Schizophrenia,British Journal ofPsychiatry162: 533–538.

Barrett, R. J.1996 The Psychiatric Team and the Social Definition of Schizophrenia: An Anthropo-

logical Study of Person and Illness. New York: Cambridge University Press.Bleuler, E.

1950 Dementia Praecox or The Group of Schizophrenias. New York: InternationalUniversities Press.

Carlson, E. T.1985 Medicine and Degeneration: Theory and Praxis. In J. E. Chamberlin and S. L.

Gilman (eds.),Degeneration: The Dark Side of Progress(pp. 121–144). NewYork: Columbia University Press.


Deegan, M. J.1975 The Symbolic Passage from the Living to the Dead for the Visibly Injured,

International Journal of Symbology6(3): 1–14.Douglas, M.

1966 Purity and Danger: An Analysis of the Concepts of Pollution and Taboo. London:Routledge and Kegan Paul.

Frankenberg, R.1986 Sickness as Cultural Performance: Drama, Trajectory, and Pilgrimage Root

Metaphors and the Making Social of Disease,International Journal of HealthServices16(4): 603–626.

Glancy, G. D., and C. Regehr1992 The Forensic Psychiatric Aspects of Schizophrenia,Psychiatric Clinics of North

America15(3): 575–589.Gutknecht, D.

1982 Ritual and Liminality in Psychiatric Treatment: Therapeutic Rites of Passage,Human Mosaic16(1): 50–61.

Hazan, H.1980 The Limbo People: A Study of the Constitution of the Time Universe Among the

Aged. London: Routledge and Kegan Paul.Huertas, R.

1992 Madness and Degeneration, I: From ‘Fallen Angel’ to Mentally Ill,History ofPsychiatry3(4): 391–411.

Jaspers, K.1974 Causal and ‘Meaningful’ Connexions between Life History and Psychosis. In S.

Hirsch, M. Shepherd and L. Kalinowsky (eds.),Themes and Variations in Euro-pean Psychiatry(pp. 81–93). Charlottesville, VA: University Press of Virginia.

Littlewood, R.1995 Review ofMadness and Modernism: Insanity in the Light of Modern Art,

Literature and Thought,Transcultural Psychiatric Research Review32: 78–86.Lucas, R. H., and R. J. Barrett

1995 Interpreting Culture and Psychopathology: Primitivist Themes in Cross-culturalDebate,Culture, Medicine and Psychiatry19: 287–326.

Manson, W. C.1984 Desire and Danger: A Reconsideration of Menstrual Taboos,The Journal of

Psychoanalytic Anthropology7(3): 241–255.Mauss, M.

1985 A Category of the Human Mind: The Notion of Person; The Notion of Self.In M. Carrithers, S. Collins and S. Lukes (eds.),The Category of the Person:Anthropology, Philosophy, History(pp. 1–25). Cambridge: Cambridge UniversityPress.

Moore, S., and B. Meyerhoff1977 Secular Ritual. Assen: Van Gorcum.

Murphy, R. F., J. Scheer, Y. Murphy, and R. Mack1988 Physical Disability and Social Liminality: A Study in the Rituals of Adversity,

Social Science and Medicine26(2): 235–242.Mwaria, C.

1990 The Concert of Self in the Context of Crisis: A Study of Families of the SeverelyBrain Injured,Social Science and Medicine30(8): 889–893.


Peters, U. H.1991 The German Classical Concept of Schizophrenia. In J. G. Howells (ed.),The

Concept of Schizophrenia: Historical Perspectives(pp. 59–73). Washington:American Psychiatric Press.

Pollock, D.1985 Personhood and Illness Among the Culina of Western Brazil. PhD Dissertation,

University of Rochester.Prout, A.

1989 Sickness as a Dominant Symbol in Life Course Transitions: An IllustratedTheoretical Framework,Sociology of Health and Illness11(4): 336–359.

Sandstrom, K. L.1990 Confronting Deadly Disease: The Drama of Identity Construction Among Gay

Men With AIDS,Journal of Contemporary Ethnography19(3): 271–294.Sass, L. A.

1992 Madness and Modernism: Insanity in the Light of Modern Art, Literature, andThought. New York: Basic Books.

Shokeid, M.1992 Exceptional Experiences in Everyday Life,Cultural Anthropology7(2): 232–243.

Shomaker, D. J.1989 Age Disorientation, Liminality and Reality: The Case of the Alzheimer’s Patient,

Medical Anthropology12: 91–101.Tillich, P.

1994 Heidegger and Jaspers. In A. M. Olson (ed.),Heidegger and Jaspers(pp. 16–28).Philadelphia: Temple University Press.

Turner, V.1967 Betwixt and Between: The Liminal Period in Rites de Passage. InThe Forest of

Symbols: Aspects of Ndembu Ritual(pp. 93–111). Ithaca, NY: Cornell UniversityPress.

1969 Liminality and Communitas. InThe Ritual Process: Structure and Anti-structure(pp. 94–130). New York: Aldine.

1982 From Ritual to Theatre: The Human Seriousness of Play. New York: PerformingArts Journal Publications.

Turner, V., and E. Turner1978 Image and Pilgrimage in Christian Culture: Anthropological Perspectives. New

York: Columbia University Press.Wyatt. R. J., D. G. Kirch, and M. F. Egan

1995 Schizophrenia: Neurochemical, Viral, and Immunological Studies. In H. I. Kaplanand B. J. Sadock (eds.),Comprehensive Textbook of Psychiatry VI(pp. 927–942).Baltimore: Williams and Wilkins.

Address for correspondence:Dr Robert J. Barrett, Senior Lecturer, and Director ofClinical Services, University of Adelaide, Department of Psychiatry, at the Royal AdelaideHospital, North Terrace, Adelaide, SA, Australia 5005Phone: +61 8 8222-5141; Fax: +61 8 8232-3298;E-mail: [email protected]

Documents

Robert Barrett Review