The saying, "You don't have to be mad to work here, but it helps," adopts a light-hearted attitude towards the subject of madness. Occasionally though, it is much more serious and the world does indeed seem a totally mad place to be. I need only mention the shocking events of September 11th, 2001 and the terrorist atrocities and outrages perpetrated in the USA to underline the fact. These events showed 'madness' to be a frightening experience, shaking the very soul of a nation.

We have all been exposed to madness or troubled by it at some time in our lives. But what does it mean to say that someone or something is 'mad'? Is there a consensus on what constitutes 'madness' and what informs our judgements about it? Is it a separate category of existence or does it exist only in relation to what society upholds as normal and civilised? Is there a deeper purpose and necessity to madness and, if so, can we turn to what is 'normal' for clarification? These seem pertinent questions to address in order to better understand madness and its multiple manifestations.

Definition of Madness

Madness is a universal term often used pejoratively to describe someone who has 'lost their senses' or 'out of their minds'. As an abstract concept, its meaning is based on personal judgement and thus open to interpretation. Theories of madness are therefore likely to say more about the theorist than the madness they attempt to describe.

Madness is idiosyncratic in the sense that what is odd, bizarre or dangerous to some people, can be normal to others. It seems that perspective is all important. For instance, 'madness' can mean 'messing up' the delicate balance of the earth's ecology: destroying the ozone layer, polluting the seas, deforesting the land, endangering wildlife, and eroding indigenuous lifestyles. Transnational companies, however, may see things differently, with unregulated markets and free trade and the exploitation of natural resources as a pragmatic solution and a price worth paying to sustain progress and development. To some, the existential dread of the M25 and its notorious traffic 'gridlocks' epitomise madness, whereas, the oil companies have a vested interest (and perverse incentive) to encourage full roads.

Madness can be fleeting, controllable and harmless, as well as something more serious and enduring. According to the Oxford English Dictionary, madness is characterised by a state of insanity, of having a disordered, dysfunctional mind. However, when used colloquially, 'mad' (as in 'madly keen' for instance) can simply refer to the manner or style in which some project or other is undertaken, whether with great intensity, enthusiasm, or extreme eagerness.

Loosely applied to diverse situations and having many shades of meaning, one needs to establish and examine the specific context in which 'madness' or insanity appears to make sense of it. This is crucial, for instance, in the criminal justice system where proving insanity in the event of homicide(s) determines the level of responsibility and outcome of the crime¹.

There are clinically-based criteria for determining or judging madness. As abnormality, it can be defined in terms of: deviation from norms, maladaptive behaviours, and personal distress. Each of these will be looked at separately.

The Nature of Madness

From ancient to modern times, theories of causation of 'madness' have been legion: theological and demonological visitations, the influence of heavenly bodies, atmospheric changes, the result of occult forces and witchcaft, the effects of sin and self-indulgence, bodily derangements and even the assent to certain political and economic doctrines.

Ideas about madness, and its treatment and cures, reflect the preoccupations of the age. For example, in medieval England, madness was seen in religious terms, as a sign of the end of the world. Since the 17th century the scientific community and technological developments have largely determined the origins and methods of controlling 'madness'. Science now asserts mental illness to be genetically pre-determined.

A complex set of material and cultural conditions is significant in determining how a society defines its 'mad' and how accommodating it is towards them. Oliver² notes that practices in relation to disabled people vary enormously between cultures - from infanticide to endowing them with special spiritual gifts. He argues that the ideology underpinning the redistribution of wealth may greatly influence how accepting societies are of its disabled members.

Many (in)famous individuals, in one way or another, have been
perceived as 'mad.' For example, the term 'mad' or insane can describe the actions and exploits of: Attila the Hun, Genghis Khan, Emperor Nero, Christopher Columbus, Gallileo, Oliver Cromwell, King George III³, Shakespeare's King Lear, Lady Macbeth and Ophelia, Cortez, Don Quixote, Rasputin, Friedrich Nietzsche, George Custer, Vincent Van Gogh, Adolf Hitler, Ernest Shackleton, The Wright Brothers, Ted Bundy, Fred and Rosemary West, Sid Barrett and countless others.

This assortment of illustrious, afflicted, and often notorious, characters represent humanity in its various guises. An extended list may encompass: scientists, artists, philosophers, explorers, inventors, professors, kings, queens, despots, dictators, heretics, rogues, pop icons, lovers, thrill-seekers, gold-seekers, child murderers, serial killers, political and religious fanatics, and charlatan messiahs.

This above list of names show that madness can appear in the high places as well as in the low; in the guise of exceptional talent and visa versa⁴. It testifies to the diverse forms 'madness' takes, reminding us of its ambivalent nature out of which creative or destructive acts might spring. It may also reinforce the mistaken notion that 'madness' is something that happens to other people, even if labelled 'eccentricity' with the rich and privileged. However, madness in the form of everyday events ranging from 'crazy' notions to a nervous breakdown means no one is immune.

As a transpersonal force 'madness' might be considered less a personal disease and more an archetypal presence: that is, originating beyond the human realm, beyond the medical model, and touching on the mythical. Returning madness to a mythical background is tantamount to finding other realities in which to make sense of, and re-vision, the pathology of madness. For instance, the tragic events of the Oedipus myth provide a rich vein of metaphors for mental illness, insight into psychic functions, and a context for understanding psychopathology (or 'madness') as a mythical enactment.

To lose sight of these mythical figures is, according to James Hillman⁵, to become psychologically insane: that is, by not 'keeping in mind' the myth in madness we go 'out of our minds.'

What then are the defining characteristics of 'madness'? To draw out common elements is problematic since it affects people in very different ways, at different times, and for different reasons. Rather than treating 'mad people' as an homogenuous group, there are unique personalities and styles of consciousness governing the individual patterns of madness.

Madness, though causing profound turmoil, can be an enriching and renewing experience, deepening one's emotional existence. So-called 'mad people' can be unorthodox and pioneering⁶, at the 'cutting edge' of their particular interest or profession. They can be deeply spiritual, full of innate wisdom and compassion, bringing inspiration, hope and empowerment to others.

But madness can also be a curse as well as a blessing. Depending on the degree, severity and duration of symptoms, madness can lead to loss of social role and identity, social withdrawal, exclusion, and personal distress. Madness can be a world without soul, a cold barren landscape of the heart. It may also be a refuge, a place to retreat to when we lose reason or take figments of the mind as real.

Severe psychological and emotional disturbance may result from a 'shutting off' of unbearable outer experiences (e.g. childhood abuse, witness to suicide, fatal accident or disaster) or critical life events (e.g. sudden death of a loved one). Individuals may cope by escaping the traumatic reality of such events. This is often achieved through defence mechanisms of denial and repression for the sake of maintaining the illusion of sanity, and preserving integrity and stability.

The philosopher Hegel saw insanity as inherent in the soul's nature, having a psychological necessity and providing the soul with an experience that cannot be gained in another manner⁷. In insanity, he adds, the soul strives to restore itself to the perfect inner harmony out of existing contradiction.

For James Hillman, madness is a crucial event for the soul, a mode of its being and expression, part of its fantasy and affliction. The medical profession, in its treatment fantasy, views madness as a sickness to be 'got rid of.' Hillman, from an archetypal perspective, sees this approach as abusive and detrimental to psychic health and finding soul in the symptoms of madness⁸.

Moon Madness

As a divine or celestial influence the moon is strongly implicated in madness. The words luna and lunatic have a common derivation, being associated with the moon of Lilith, of the night and the dead.

Traditionally, the 'dark side' of the moon is inhabited by waiting and dead souls, daimones, shades and ghosts whose presence is felt most strongly during a full moon. Lunatic fantasies then descend from the moon to inhabit our dayworld and affect our daily affairs. Astrologically, the moon's psychological role relates to the feminine principle of sensitivity (and thus vulnerability) and adapting to the external world⁹.

The poor souls who have 'lost their minds' or 'gone out of their minds' are segregated from society, kept in a place of safety, waiting for return to the light of the sun. The behaviour of inmates of the now defunct mental asylums were said to become more agitated and unmanageable when the moon was full - providing evidence of the strong link between the moon and susceptibility to emotional disturbance.

The Medicalisation of Madness

In the popular imagination the state of madness is closely linked to mental illness, with the two terms often used interchangeably and indiscriminately. 'Madness' is also equated with 'badness' with the result that society has shunned and excluded those with a mental illness, often denying them full citizenship, work, and respect.

Madness, influenced by the media, conjures (and reinforces)stereotypical images of erratic, inexplicable and often violent, anti-social behaviour. Sometimes to be 'mad' is to be a 'crazed lunatic.' This depicts perfectly the arch-villain in 'James Bond' movies who is typically, and predictably, a megalomaniac with delusions of grandeur.

To equate madness with illness or badness, however, is misguided, unhelpful and erroneous. While some people with a mental illness are a positive danger to themselves or others the majority certainly are not, leading relatively ordinary lives in the community with little or no contact from professional services. Sometimes such lives can be sedentary and unremarkable, with quality of life hampered by difficulties with concentration and motivation. Many people with a psychotic illness (i.e. 'voices' and 'strange worrying beliefs') are successfully maintained in the community by anti-psychotic medications and 'out-reach' support. However, continued engagement with mental health services, non-compliance with medication, and risk management are key issues affecting government policy, as well as service-user groups.

Modern medicine, and the 'medical model' in which it operates, makes a distinction between two kinds of existence: sickness and health. These are often thought of as distinct entities or principles, but in actuality there are only differences in degree between two extremes. That is, nobody alive is 100% sick or healthy, and every living thing exists along a continuum between these two states. Even so, the polarisation of health and sickness means that the former 'desired' state is privileged over the 'devalued' latter state.

In psychiatry, the conceptual division between madness (conceived as 'sickness') and sanity (conceived as 'health') has not only created 'difference' but also a fear of being thought mentally ill. Couched in psychiatric terminology, sickness equates with a clinically-diagnosed mental disorder or disability of mind, categorised according to either of the two leading psychiatric diagnostic manuals: American Psychiatric Association's DSM-IV (The diagnostic and statistical manual of mental disorders) and the World Health Organisation's ICD-10 (International Classification of Disease). The term 'madness' is reserved as a colloquial expression to describe a person with severe impairment of mental functioning.

In the psychiatric world severe mental illness is characterised by a marked impairment of reality, disturbances of thought and perception, and bizarre behaviours. This can take many forms, most notably psychotic symptoms due to schizophrenia (characterised by delusional beliefs, auditory and/or visual hallucinations) and psychoactive substance abuse, primary degenerative dementia of the Alzheimer type, and anti-social and pervasive criminal tendencies in personality disorders. Pervasive disorders are characterised by deeply-ingrained maladaptive behaviours and cognitions that constitute inappropriate ways of coping and relating to others.

The assessment and diagnosis of mental illness, personality disorder and psychotic states lays the foundation for prescribed care, treatment and rehabilitative psychosocial interventions.

Sectarianism

'Madness' is not confined to individuals. Groups and small organisations, too, are considered deviant and on the 'lunatic fringe' because of their radically differing beliefs and practices. There are many examples in recent times of terrorist organisations (and 'cells' within organisations) whose fundamentalist ideas and aims are deemed incompatible to those of mainstream, civilised societies. Extreme difference is thus the basis of intolerance and rejection. Driven by ideological motives or following hard-line, quasi-religio-political agendas, such organisations often employ paramilitary-style tactics or urban guerilla warfare to further their cause. Typically comprising fanatics who are prepared to sacrifice themselves in the line of duty (e.g 'suicide bombers'), they pose a serious threat to the established order of world democracies.

Another type of group found on the fringes of society are doomsday, apocalyptic cults. These are often controlled by power-hungry, charismatic leaders who exert considerable influence and set the agenda for the group's activities. The most notorious of these include: The 'Reverend' Jim Jones and 'the People's Temple' at Jonestown, Guyana; David Koresh and the Branch Davidians at the Mount carmel, Waco, Texas; Shoko Asahara and the 'Aum Shinrikyo' at Mount Fuji, Japan; Charles Manson and 'The Family' at Spahn Ranch, California; Marshall Herff Applewhite and 'Heaven's Gate' at San Diego, CA; and Luc Jouret and the international 'Solar Temple.'

The extreme behaviour and exploits of such cults, sometimes culminating in killings and suicides, can stem from taking religious or esoteric knowledge too literally, 'acting out' their fundamentalist beliefs in the world. Other main features include indoctrination of its members, feelings of exclusivity and superiority ('chosen' people or delusions of grandeur?), intolerance toward those holding opposing views, and a fear of retribution from within and persecution from without.

Part Two

The Politicisation of Madness

Since the 17th century, the century of Descartes and Mersenne, problems have been seen as individual, with solutions offered to people being individualised too. This is important since the notion of 'madness' individualises what is often acknowledged as a societal problem. Challenging assumptions about the origin of madness therefore implies recognising societal discrimination and the tendency to see 'mad people' as irrational, different and 'other' (i.e. 'us-and-them' thinking).

Dr. Ronald Laing, believing madness to stem from dysfunctional society rather than the individual, posited that people's madness is an attempt at sanity, or is sanity itself, in a world gone insane¹⁰. Laing's approach to schizophrenic madness (and the 'divided self') is that it has an 'initiatory' meaning, and that a psychotic breakdown may actually be psychological breakthrough.

The polarisation of sanity and insanity, of mental health and mental illness, and the pressures to conform to socio-political norms can, in the worse case scenario, lead to oppression, segregation, deprivation and loss of civil liberties. This is particularly prevalent in 'developing' nations. The social control function of the state, and victimisation and detention of people labelled as mad or insane, allude to the manufacture of madness as a way of exercising power and tyranny. This relates to the raison d'être of organisations such as Amnesty International, Release, etc.

Foucault¹¹ argues that madness is constructed according to cultural preoccupations and the main ways that power relations are established in society. When an abnormality and its corresponding norm is defined, it is always the normal person who has power over the abnormal.

'Insanity' can therefore be used as justification for the dehumanisation of (wo)man. According to Dr. Thomas Szasz ¹² institutional psychiatry in the western world has the overarching function of controlling social behaviour, with medicine being the means to disseminate and assert the dominant values of society. Though a universal phenomenon, the interpretation of madness would seem to be culture-specific, construed according to the socio-political ideologies and prevailing norms of a society.

Madness is also highly contagious and, like street riots and terrorist attacks, can break out spontaneously and without warning. This can create mayhem and panic in the wider community, leading to mindless acts of wanton destruction in local neighbourhoods, opportunistic violence and looting, etc. This is a far cry from the madness one associates with mental illness.

On a much larger scale, world wars seem a higher order of insanity, bearing witness to events that transcend the human condition, and invoking powers more than the human can fully grasp. This is the realm of titanic madness¹³ visited upon humankind and imparting visions of global conquest or annihilation (depending on one's perspective). Given the magnitude of such madness, we are possibly confronting the dark necessity of the world and the shadow or primitive side of humans.

This is exemplified by 'insane' collective projections upon other people, whole nations and races. We had a bitter taste of this in the aftermath of September 11th with the fear of escalating conflict between Christian and Muslim communities. These events clearly demonstrate that madness exists in relation to fundamentalist, monotheistic beliefs about one god, one truth, one reality, and intolerance towards different beliefs and interests. Facing the pathology and dynamics of madness, in the wider scheme of things, may stress that our common humanity matters more than our differences, also having survival value to the human species.

Treatments

In certain native American healing ceremonies such as Navajo 'sings' helping someone recover from madness means encouraging them to perform rituals alongside the extended family and significant others. This is the case in present-day African countries such as Zimbabwe where madness is treated as a form of witchcraft and a punishment for wrongdoings by ancestral spirits. Rather than delivering individualised treatment, it is the communal spirits that need to be appeased.

In the West, early physical treatments for 'madness' include bloodletting and blood transfusion, as well as herbal remedies. These were commonly used in the evacuation of the bad humours or evil spirits which were believed to be causing the illness. In the late 19th century hysterectomy was but one of a range of surgical procedures carried out on women considered mad. Diagnosed as hysteric, they were incarcerated for reasons such as wanting to marry the wrong man, or planning to leave home for a career. By the early 20th century women were diagnosed as morally insane and compulsorily
admitted into mental institutions after falling pregnant out of wedlock.

The development of modern psychiatry is closely allied to drug-based attempts to modify moods and unacceptable behaviour. To pacify unruly patients in overcrowded Victorian institutions, for instance, the use of morphine was widespread. This was later replaced by interventions such as insulin coma and psychosurgery (notably lobotomies and leucotomies¹⁴), being treatments of choice in cases of severe behavioural disturbance. The two major psychotropic drugs of the 20th century, Chlorpromazine and Lithium, were introduced largely as a way of suppressing unwanted behaviour and only later has their use been justified on the grounds of brain biochemical imbalance.

Water, in particular fresh spring water, has always been considered a natural remedy for bodily and mental sickness. Its cleansing, purifying action appealed to those who believed that mental illness resulted from sin and immorality. Bathing and taking the waters were therefore important in producing purgation and promoting inner cleanliness¹⁵.

Suddenly surprising the patient with a plunge into cold water was practised from ancient times to the 19th century. Boats were constructed which would break up and force patients to swim to the shore in the cold water and there were bridges which would collapse when patients were crossing them. The cold water shower or plunge was a 'shock' treatment designed to bring a deranged person to his/her senses. In more modern times the 'short, sharp, shock' is administered in the form of electroconvulsive therapy (ECT)¹⁶.

Modern psychotherapy, which can be traced back to Freud's explorations in psychoanalysis, is essentially about finding explanations and solutions to present psychological ills by returning to our parents and childhoods. In native shamanistic cultures this would be a preposterous idea, and casting spells, the breaking of tribal custom and taboos, and missing reverence to the Gods would more readily account for a disturbed mind.

In the West, 'madness' is usually classified according to a diagnosable condition prior to treatment. The medicalisation of 'madness' and the label of 'mental illness' is therefore a passport to receiving both hospital- and community-based psychiatric care. To access these services it needs to be established that the individual presents a serious risk of harm either to him/herself or to others in the community. In this respect, a mental health act assessment is undertaken to evaluate the degree to which the person's symptomatology affects their ability to function normally and remain safe.

However, difficulties can arise when the client denies the existence of a problem and refuses to be voluntarily admitted into hospital. Compulsory detention under a section of the Mental Health Act (1983) may then be necessary in the interest of individual and public safety, and for treatment purposes. Though legal, incarceration can be extremely unpleasant and controversial, engendering as it does issues of compliance, consent and civil liberties.

In assessing mental state a person's mood, thought processes, perceptions, appearance, speech and behaviour will normally be observed and recorded. However, the main purpose of an assessment is to reach an accurate clinical diagnosis based on the nature, intensity and duration of presenting problems and individual symptom characteristics. The diagnosis will then determine the individual's future care plan and treatment.

Paranoid or schizoid personality disorder is a chronic condition for which there is usually no cure. However, the condition, which is an extreme form of schizophrenia¹⁷, can be treated with ongoing medication and therapy. People who suffer from it can have constant feelings of being watched, followed or persecuted. Usually hallucinations, delusions or disturbing thoughts cause the fears and misunderstandings that lead to violence or aggression. However, sufferers are more likely to become victims of violence themselves.

In simple schizophrenia and bi-polar disorders the prognosis is usually better; odd and risky behaviours may still exist but in less severe forms. The risk of self-harm and suicide among people with serious mental illness is, however, significantly higher than the general population. This makes it important to encourage engagement with professional services or informal support networksThis includes family, friends, neighbours, service-user groups, etc.in order to minimise risk and reduce the distress caused by psychotic symptoms. In acute services, treatment will focus on establishing a safe environment and a collaborative therapeutic relationship between carer and client. Building empathy, trust and a shared understanding of problems is important for identifying needs and promoting the active participation of the individual in the recovery process. Rehabilitation commonly involves interventions to increase coping effectiveness in daily living and social interactions.

Cognitive behavioural therapy (CBT) can be effective in psychosis, though this depends on the person's receptivity to treatment, level of insight, and motivation to change. CBT, recognised as efficacious in serious mental illness, can address dysfunctional thoughts and assumptions, and negative self-appraisals affecting behaviour. It can also be helpful in exploring the meaning of psychosis for the individual and in reducing the risk of relapse.

The use of anti-psychotic medication can help alleviate distressing symptoms, including hallucinations and delusions. Other prescribed drugs can also help stabilise mood, reduce anxiety, improve sleep, concentration, etc.

In spite of the increasingly sophisticated models of care, the proliferation of different psychotherapeutic approaches, and psychiatry's cornucopia of drugs it is the need to be listened to and taken seriously - not to be dismissed as a non-rational, chaotic 'case' requiring only medication - that often makes a big difference in recovering from serious mental illness and psychosis. It is often when we listen to people's stories (as in narrative therapy¹⁸) and keep an open mind that we can be most effective. A personal narrative and storytelling approach offers an antidote to the depersonalisation of modern psychiatry. Used therapeutically it can help make sense of psychotic experience, and provide meaning, context, and perspective for the client's predicament. Reconnecting to the myths and stories that shape our lives, that we are host and hostage to, may help develop a sense of self separate from the clinical symptoms and diagnosis, and promote a more constructive and adaptive context for recovery and living.

A most pressing task facing the mental health world is the overcoming of prejudice and social exclusion, which can lead to losing one's status, work or role in the community. Effectively restoring people experiencing mental health problems to active life in their community is paramount, but may depend on recognising that: discriminatory attitudes perpetuate fear of madness and exert a powerful influence on the way people with mental illness are treated and accepted in the community; being 'different' does not mean having a lesser value; and, the experience of psychosis is seen as important to the whole community and not just the individual.

The rapid growth of the user/survivor movement, including self-help and self-advocacy groups, reflects a growing disillusionment over receiving the right kind of support from mainstream psychiatric services. Anti-psychiatry campaigning groups such as Mad Pride firmly believe that only by speaking out and taking direct action can public and professional attitudes change towards 'mad' people. Refusing victim status, challenging discrimination and human rights violations, and promoting a positive image of 'madness' are key to gaining acceptance and paving the way for more enlightened and empowering approaches to mental health care.

Euphemisms¹⁹ and Colloquialisms

Finally, I offer a truly international list of euphemisms and colloquialisms for being slightly crazy, absent-minded or eccentric. This list has been compiled with the help of the h2g2 community²⁰.

• A few clowns short of a circus
• The wheel is spinning, but the hamster's dead
• Got a screw loose
• Nutty as a fruit cake
• Bats in the belfry
• Chink in one's armour
• Lost the plot
• Out to Lunch
• Not on the ball
• Odd ball
• Loopy
• Potty
• Doolally
• Mad as a hatter
• As sharp as a marble
• Suffering from a marble deficiency
• There's a rip in his marble's bag
• Losing your marbles
• Basket case
• Mad as a monkey on a trike
• Not firing on all cylinders
• A kangaroo loose in the top paddock
• Hasn't got both hands on the steering wheel
• Hasn't got both oars in the water
• One wave short of a shipwreck
• A few bricks short of a load
• One scout short of a posse
• One card short of a full deck
• An olive short of a pizza
• A sandwich short of a picnic
• A sausage short of a barbecue
• Four quarters short of a dollar
• Ten pence short of a pound
• Five cans short of a six-pack
• A tinny short of a six-pack (australian version)
• A few french fries short of a happy meal
• One put short of a par
• He or she is living in cloud cuckoo land (nine)
• If I gave a penny for his/her thoughts I'd get change back
• Not the brightest bulb on the tree
• Not the sharpest tool in the box (shed)
• About as bright as a burnt out lightbulb
• There are no phones on planet Pluto
• Wired up to the moon
• A few slates missing from the roof
• A tile (screw)loose
• Not quite the full shilling (ticket)
• Driving on only three wheels
• Knitting with only one needle
• The lift doesn't go all the way to the top
• The lights are on (the door is open) but there's no one at home

For more 'maddisms' the reader is advised to watch the highly popular TV quiz show, The Weakest Link, hosted by the inimitable, grand inquisitor Anne Robinson. Her snide and disparaging comments about the contestant's mental abilities and her generally contemptuous, belittling manner, though somehat contrived, are deserving of mention in any formulation of madness and its hall of famous euphemisms.