Author: HHS Contributor

Cheryl Mattingly, Rasmus Dyring, Maria Louw, and Thomas Schwarz Wentzer (eds.) Moral Engines: Exploring the Ethical Drives in Human Life. New York: Berghahn Books, 2018; 266 pages, hardcover $135.00/£99.00; ISBN 978-1-78533-693-5

By Paul van Trigt

What does it mean to be human? It feels like a cliché to ask this question, but it is undeniably high on the agenda of public and scholarly debates. Technological developments have fed these discussions, as well as identity politics, in which the human norm presented as a white, heterosexual man is questioned. An interesting contribution has recently been delivered by a collective of anthropologists and philosophers, under the banner of ‘new humanism’, which is characterized by a charming combination of theoretical and empirical approaches. In this review I will discuss one of their main contributions, the volume Moral Engines: Exploring the Ethical Drives in Human Life (2018), by situating it in scholarly debates and by exploring the meaning of their enterprise for other disciplines, history in particular.

In the prologue of Moral Engines one of the editors, anthropologist Cheryl Mattingly, describes the book project as partly a local history: ‘The Aarhus Story’. By this she refers to an interdisciplinary network at Aarhus University on ‘Health, Humanity and Culture’ founded by the philosopher Uffe Juul Jensen, led by the ‘very strong belief that philosophy could not, by itself, think through crucial issues like health (or suffering) without reaching out to create a cross-disciplinary conversation that not only spanned different disciplines but also involved health practitioners’.[i] An intense collaboration between philosophers and anthropologists arose within this network and led to various publications, including Moral Engines.

Before I turn to this volume, I will first discuss the introduction to a special issue in HAU: Journal of Ethnographic Theory in which some of the same editors explain the agenda of their philosophical anthropology. Thomas Schwarz Wentzer and Cheryl Mattingly start by considering what they believe to be, ‘an increasing dehumanization of social sciences in the aftermath of poststructuralism and the rise of various naturalisms’. Although they do not doubt that ethnography will keep its focus on living human beings, they argue that more reflection on the ‘human’ and humanism is needed. Moreover, they aim to integrate the anti- and posthumanist critiques in their new humanist project. With this concept they refer to a model of an ethnographically based philosophical anthropology, which acknowledges the situatedness of human life, keeping in mind its reference to humankind.[ii] Moreover, societal debates about climate change challenge to reflect on the human influence on our species and planet.[iii]

Interestingly, the authors link this societal challenge to the ‘ethical turn’ in anthropology. The protagonists of this turn are ‘concerned to give an account of situated human (inter)subjectivity’ that seems to be relevant in times of climate change and debates about the role of human’s responsibility. These protoganists have in common that they consider humans as ethical beings, who ‘act in the space of ethical claims to which they must respond, often through deliberation and judgment’. Wentzer and Mattingly’s aim is, however, not an intervention in societal debates. They mainly want to convince fellow scholars that the ethical domain marks ‘a fundamental feature of the human’.[iv]

It is right there, where the volume Moral Engines takes its starting point. The first sentence of the volume’s introduction says: ‘in the last two decades there has been a virtual explosion of anthropological literature arguing that ethics or morality (we use the terms interchangeably) should be considered a central dimension of human practice’. Within this ‘explosion’ the question of, ‘what actually commits and drives us to understand our lives in ethical terms?’ has remained underexplored. That is why the volume has ethical drives or moral engines as its focus.[v] The authors were asked to ‘engage the question of what the moral drives in human life are, where they are located and how they present themselves to us’.[vi] As the editors explain, the authors have approached these questions in three fundamental ways. I will discuss these three approaches and try to give some representative snapshots from individual chapters.

The first approach to moral engines highlights the ‘category of “moral facts”, of cultural, historical, discursive schematics that grant certain practical possibilities’. This approach is indebted to a Durkheimian understanding of morality, focussed on rules and regulations, but is in addition sensitive to ‘an Aristotelian focus on action and practical judgement’.[vii] The chapters in which this approach is applied are written by the anthropologists Michael Lambek, Joel Robbins and James Laidlaw who reflect on the central concepts of the volume, moral engines in particular. Robbins, for instance, argues that values are ‘moral engines that have the ability to act as drivers of people’s moral behaviours’. In a Durkheimian understanding of morality people combine a ‘sense of both duty and desire’ and, according to Robbins, values have to be related to the latter. Based on his fieldwork on exemplarity in the Urapmin community in Papua New Guinea, Robbins argues that values often do not come to people in abstract form, but through ‘people and institutions that exemply them’.^[viii]

The focus of the second approach is on moral experience and a first-person perspective. The key term of this approach is (ethical) responsiveness, which refers to often unreflected and unintended responses to what people experience and highlights the relevance of taking ‘pathos, sentiments, moods’ into account.[ix] Five chapters apply this approach and present case studies about the narrative selves of mothers in a Los Angeles hospital (Cheryl Mattingly), regret, morality and mood in the Yap Sate (Jason Throop), ethical striving and moral aporias among Sufis in Uzbekistan (Maria Louw), forgiving after war in Northern Uganda (Lotte Meinert) and the moral experience that Marco Evaristti’s art installation Helena and El Pescador elicits (Rasmus Dyring). How moral experience is approached in this volume becomes clear, for instance, in Maria Louw’s chapter ‘Haunting as Moral Engine’. Louw starts her chapter with the story of Rustam, a young Sufi, who told her that he is feeling ‘evil things’ such as improper thoughts about girls ‘as even stronger forces in his life the more he attempted to avoid them’ since he has entered the Sufi path. In her research she has come across Sufis who ‘are frequently haunted by the moral choices they could have made’. This haunting is often part of their everyday life and is a reminder of ‘how every intersubjective encounter may be a moral “engine” in the sense of having the potential to redirect one’s care and concern’. Louw positions this findings in the recent literature about self-cultivation through religious practice in Islam and in particular Saba Mahmood’s study of religious women in Egypt who has provided ‘important critiques of liberal assumptions about agency’. She also includes critiques against the focus on self-cultivation, as formulated by Cheryl Mattingly and Samuli Schielke, because people often balance between different values and have to deal with value conflicts. Moreover, she highlights the moral force of emotions. According to her the haunting as experienced by Rustam and other informants often takes ‘the form of shifting moods and emotions that seemed to have a life of their own, overwhelming them in ways that were beyond their control and understanding, complicating moral principles and decisions, and revealing moral concerns in flux’.^[x]

The third approach to moral engines, which is applied in the last three chapters, is closely related to the ‘new humanism’ agenda and explores the relationship between ethics and the human condition. This approach tries to not ‘presuppose too much about what it means to be human or to be an ethical being’ and recognizes, comparable to the second approach, how humans are always ‘respondents, not absolute beginners’.[xi] In a chapter about anti-drug war activism, Jarrett Zigon shows the limitations of a well-known concept such as ‘dignity’ and proposes instead ‘dwelling’ as a relatively open concept to investigate the human condition. In discussion with anthropologists, Thomas Schwart Wentzer developes in his chapter a responsive ethics that takes up ‘human responsiveness to be the existential condition that helps us to understand the roots – rather than the engine – of ethics and human agency’. Finally, Francois Raffoul’s chapter ‘The History of Responsibility’ contains a genealogy of philosophical approaches to this concept and argues to understand responsibility as ‘responsiveness to a call, rather than as the traditional accountability of the willful and powerful subject or agent’.

All the chapters show, in their own way, that philosophical anthropology offers a very sophisticated approach to understand how humans live. I have not previously come across such a rich analysis of what propels humans to act in light of ethical ideals in my own discipline, history. Historians have of course reflected on the classic distinction between agency and structure and studied the history of ethics and morality, but the ‘borderland inquiry’, as presented in this volume, has resulted in fine-grained understandings of human life from which historians only can benefit. Disability history, for instance, one of the historiographical subfields related to my own work, tends sometimes to favor an activist’s understanding of agency, assuming a self-reliant and reflective subject. Philosophical anthropology offers an approach to agency in which very different ways of being in the world could be included: for instance, the agency of people with cognitive disabilites, as shown by anthropologists Patrick McKearney and Tyler Zoanni.[xii]

Interdisciplinary exchange was, and is, important for the development of the above mentioned approaches. In the ‘ethical turn’ in anthropology, philosophy has already played an important role. In anthropological reflections on the relations between ‘selfhood’ and ‘world’, and agency and structure, philosophers such as Alisdair MacIntyre and (the late) Michel Foucault have been intensively discussed. Reflection about issues such as the possibilities of human freedom ‘presses inquiry into the very basic ontological considerations about the human condition as such’. However, philosophers are not only needed as ‘professional experts in ontology’, the editors of Moral Engines advocate for a more intensive ‘borderland inquiry’.^[xiii] They aim for a dialogue in which participants ‘take up “roles” generally associated with the other discipline’.^[xiv] This dialogue is possible because, as Karen Sykes has put it, cultural phenomena could be understood as responses to ontological questions.^[xv]

The dialogue between anthopology and philosophy that underlies this volume has clearly enriched the understanding of ethical drives in human life. It was probably thanks to this dialogue and collaboration that the editors, in this volume and elsewhere, position themselves under the flag of ‘new humanism’: a very careful position, but nevertheless a position from where they are challenged to pronounce normative statements about what it means to be human. Here I would suggest that the ‘border inquiry’ could benefit from inviting other disciplines, history in particular. Not only because history enriches the understanding of humans as ethical beings, as Louw for instance does by understanding her interlocutors against the background of the post-Soviet era. But also because history enables philosophical anthropology to historicize the categories used by informants (emic) and by scholars (etic). As Cheryl Mattingly and Jason Throop have argued, ‘one of the driving forces motivating some of the earliest contributions to the ethical turn’ was a concern ‘to distinguish it from the realm of the political’.^[xvi] It is probably no accident that the ethical turn was put forward in a neoliberal era characterized by a specific configuration of the ‘political’ and by ‘responsibilization’ policies. How does an anthropology of ethics and morality relate to this neoliberal regime? In order to better understand this relation, a next step after this excellent volume could be the integration of (conceptual) history in order to further evaluate the scholarly drive beyond the exploration of ethical drives in human life, and to reconsider the political.

Paul van Trigt (@paulvantrigt) is postdoctoral researcher in the ERC-project Rethinking Disability: the Impact of the International Year of Disabled Persons (1981) in Global Perspective at the Institute for History, Leiden University. He has published about the modern history of the welfare state, human rights, disability and religion. His monograph Blind in een gidsland (Blind in a guiding country) was published in 2013. Currently, he is writing a genealogy of the United Nations Convention on the Rights of Persons with Disabilities.

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[i] Cheryl Mattingly, ‘Prologue’, in Cheryl Mattingly, Rasmus Dyring, Maria Louw, and Thomas Schwarz Wentzer (eds.), Moral Engines. Exploring the Ethical Drives in Human Life (New York: Berghahn Books, 2018) 6.

[ii] Thomas Schwarz Wentzer and Cheryl Mattingly, ‘Toward a new humanism. An approach from philosophical anthropology’, HAU: Journal of Ethnographic Theory 8, 1/2 (2018) 145-157: 145, 146.

[iii] Wentzer and Mattingly, ‘Toward a new humanism’, 147.

[iv] Ibidem, 148-149.

[v] Rasmus Dyring, Cheryl Mattingly and Maria Louw, ‘The Question of “Moral Engines”: Introducing a Philosophical Anthropological Dialogue’, Moral Engines, 9-36: 9.

[vi] Ibid, 20.

[vii] Ibid, 21.

[viii] Joel Robbins, ‘Where in the World are Values? Exemplarity and Moral Motivation’, Moral Engines, 155-173.

[ix] Dyring, Mattingly and Louw, ‘The Question’, 28.

[x] Maria Louw, ‘Haunting as Moral Engine: Ethical Striving and Moral Aporias among Sufis in Uzbekistan’, Moral Engines, 83-99.

 [xi] Dyring, Mattingly and Louw, ‘The Question’, 30-31.

[xii] Patrick McKearney and Tyler Zoanni, ‘Introduction. For an Anthropology of Cognitive Disability’, The Cambridge Journal of Anthropology 36, 1 (2018) 1-22.

[xiii] Dyring, Mattingly and Louw, ‘The Question’, 13.

[xiv] Dyring, Mattingly and Louw, ‘The Question’, 14.

[xv] Ibidem, 15.

[xvi] Cheryl Mattingly and Jason Throop, ‘The Anthropology of Ethics and Morality’, Annual Review of Anthropology 47 (2018) 475-492: 483.

Ariane Hanemaayer. The Impossible Clinic: A Critical Sociology of Evidence Based Medicine. Vancouver, Toronto: UBC Press, 2019; 198 pages, hardcover £60.00; ISBN 0774862076

By Sahanika Ratnayake

To begin with a caveat, I am somewhat  unsuitable reviewer for Ariane Hanemaayer’s The Impossible Clinic, a historical and sociological account of the Evidence Based Medicine Movement (EBM). I am an analytic philosopher of science working on contemporary psychotherapies, reviewing a book in sociology. My interest in the book is thus from a cross-disciplinary perspective. What I am unable to offer is something the book thoroughly deserves —  an evaluation on its own terms, as a contribution to the sociological literature on EBM and more broadly, the sociology of medicine and governmentality.

EBM by now is a staple of contemporary medicine, with all manner of fields from psychotherapy and nursing, to new pharmaceuticals and medical technology claiming to be evidence-based. It is a strange chimera, at once an evaluation of interventions, a justification for healthcare policies and a claim to a certain kind of legitimacy. The early development of EBM is similarly multifaceted, with (at least) two main threads, each corresponding to a particular geographic region.

The first concerns the appraisal of evidence for clinical interventions in medical research. Randomised control trials are used to measure the efficacy of clinical interventions and these trials are in turn amalgamated and appraised via systematic reviews and meta-analyses. This thread in the development of EBM, the history of which is still to be written, centers largely on the United Kingdom and involves key developments such as the widely publicised use of a randomised control trial to test the efficacy of streptomycin for tuberculosis, Archie Cochrane’s critique of the prevailing medical research literature and  the resulting establishment of the Cochrane Collaboration in 1993 by Iain Chalmers. 

The second thread concerns the exercise of clinical judgement. In the late 60’s, medical authority came under scrutiny, as the basis for clinical judgements seemed to be based on nothing more than the authority of practitioners,  resulting in variation across practitioners and interventions that were at best inefficacious and at worst, dangerous for patients.  Championing the need to ground clinical judgement in something other than the intuitions of practitioners, David Sackett and various colleagues such as Brian Hayes and Gordon Guyatt at McMaster University in Ontario, Canada, developed first the application of epidemiological principles to clinical judgements, then a novel program of medical training to improve the ability of clinicians to engage in “critical appraisal” of the research literature, so that the results of research could applied directly to the bedside. Naturally these two threads are intertwined in that moving the ground for clinical judgement away from the authority of individual practitioners and towards evidence, involves an understanding of what constitutes good evidence.

The focus of Hanemaayer’s book is on this second thread. Using a Foucauldian genealogical approach to consider the emerging field of clinical epidemiology, and later EBM at McMaster University, Hanemaayer asserts that “EBM is an impossible project” as it ultimately produces a situation that is antithetical to the original goal of promoting clinical appraisal (p.ix-x).

Chapter 1 provides a background to the critiques, both internal and external to medicine, which brought clinical judgements under scrutiny and demonstrates how clinical epidemiology was developed as a response to these critiques. Chapter 2 considers the various background and institutional forces which supported the development of clinical epidemiology as well as the new training site and program for the McMaster Medical School. Chapter 3 describes the training program and the advent of “Problem Based Learning” which aims to train clinicians who can independently appraise research evidence for use in practice. Chapter 4 describes the creation of Clinical Practice Guidelines, which arose out of a need to summarise the ever-growing research literature and to further standardise clinical decision making. In Chapter 5, Hanemaayer reiterates her central argument: instead of creating clinicians that are capable of exercising their own critical judgement, judgement is instead externalised to Clinical Practice Guidelines. The concluding chapter situates her work within the sociological literature on EBM and studies of governmentality.

There is a desperate need for work such as The Impossible Clinic as the current literature on EBM, tends to focus on the first thread and insofar as there is a history or background to EBM, it is recounted predominantly by those within the discipline such as Sackett.  For instance philosophical work on EBM focuses on the claim to “evidence” and its various shortcomings, as in the work of Nancy Cartwright, Jeremy Howick and Jacob Stegenga. The book’s focus on the training of clinicians and the shaping of clinical judgement provides an opportunity to see the way in which these two threads are linked. For example, flawed as the methods of meta-analysis are, they become somewhat more understandable when we consider the need to summarise a large body of research for use in clinical practice. The main historical account of EBM by Jeanne Daly, draws largely on interviews with key individuals. As such, Hanemaayer’s contribution — focusing as it does on archival research — is a valuable complement to existing work by historians.

The sheer range of archival resources considered in the book — from clinical epidemiology textbooks, private correspondence, policy documents, to records of licensing board hearings — is an impressive accomplishment, presenting a rich picture of the early days of EBM. I was thrilled at the inclusion of building plans for the new medical school, which provide a striking illustration of the adoption of new ideas into medicine through the sharing of physical space with other disciplines (namely, biostatistics and clinical epidemiology), and also the way in which the novel teaching programme was reflected in the new teaching rooms and resources.

I must admit that, in the context of cross-disciplinary interest in EBM, Hanemaayer’s book might be a difficult read. Key players such as Sackett and Guyatt are mentioned or quoted casually early on (p. 4-5) without the usual short description of their importance that typically accompanies first mentions in historical accounts. Those not conversant on the technical details of EBM are also likely to face some confusion with key terms such as ‘randomised controlled trials’ explained cursorily (p.34). More ‘signposting’ and explanation in introducing EBM would have made the book far more accessible for a cross-disciplinary audience. This is perhaps not so much a criticism of the work — as Hanemaayer understandably takes herself to be engaging with extant sociological scholarship and thus assumes a level of familiarity with the area — but rather a caution for others working on EBM, to note that their work will be read with intense interest by those outside their discipline.

I found the central thesis of the book not wholly persuasive, as it suffers from the same issue as Foucauldian genealogical accounts more generally when they attempt to demonstrate an internal tension or failing. In the case of Foucault, whether one thinks the prison apparatus has failed in its goal of punishing humanely and educating prisoners (Discipline and Punish as cited on p.174) depends on whether this was in fact the goal. Similarly, whether EBM has failed in its goal depends on whether fostering critical appraisal in clinicians was the goal.

As Hanemaayer herself notes, “the history of EBM should not be thought about as a linear correction of the problems of clinical judgement” (p. 190). If we take the goal of EBM to be grounding clinical practice in evidence rather than the idiosyncratic views of clinicians or to improve healthcare outcomes for clients it is unclear that EBM has failed.  The studies cited in Howick’s The Philosophy of Evidence Based Medicine (p. 168-176), suggest that EBM recommendations consistently outperform individual clinical judgements. Furthermore, the striking case with which the book opens — the administration of soapy enemas before childbirth — and the lapse in the practice as a result of EBM, invites reflection on whether the situation for clients has improved following the introduction of EBM. That there is a certain irony and tension in the fact that critical appraisal has been replaced by Clinical Practice Guidelines is undeniable, but given the multiple threads to EBM, it is unclear that it has failed outright.

Not only does The Impossible Clinic fill in the gaps of the development of EBM and reorient the tale towards the neglected thread of clinical judgement, itdoes what all good historical investigations, particularly genealogies do — it allows us to look at what has become tacit and familiar with fresh eyes. I read the book as I taught ethics to medical students and found myself understanding certain peculiarities — such as their tendency to tackle normative questions with the same approach that one would use to scrutinise experimental design and the strange fact that a philosopher was teaching them in the first place — which have their roots, at least in part, in the interdisciplinary training program developed at McMaster. 

Sahanika Ratnayake (@SahanikaR) is a PhD candidate at the Faculty of Philosophy at the University of Cambridge. Her PhD project is a philosophical appraisal of Cognitive Behaviour Therapy. She recently received an honourable mention for the 2020 Jaspers Award by the Association for the Advancement of Philosophy and Psychiatry; the paper is entitled, “It’s Been Utility All Along: An Alternate Understanding of Cognitive Behavioural Therapy and The Depressive Realism Hypothesis”. Her previous work on mindfulness can be found at the Journal of Medical Ethics and the online magazine Aeon.

Stephen Frosh. Those Who Come After: Postmemory, Acknowledgement and Forgiveness; London: Palgrave Macmillan, 2019; 246 pages, hardcover £64.99; ISBN 978-3-030-14852-2

By Roger Frie

How do we live with inherited traumatic memories of genocide and racial violence? Is it possible to ever atone for crimes against humanity, let alone forgive perpetrators of such crimes? What is the nature of historical responsibility and how does it relate to the silent complicity? Can we be implicated in injustices that we did not personally cause? These are the kinds of questions that reading Stephen Frosh’s deeply perceptive new book, Those Who Come After, evokes in the reader.

With his characteristic depth of analysis and breadth of knowledge, Frosh guides his readers through a complex ethical terrain while addressing the ever-present reality of historical trauma. Drawing variously on psychoanalysis, philosophy and social theory, Frosh invites us to struggle with him as he explores the history’s shadows and the afterlife of mass crimes that shape our current lives. At a time when the meaning of history is often questioned and governments seek to dictate how the past is remembered, Frosh emphasizes the effects of history’s traumas and considers why we are obligated to respond.

Those Who Come After is organized around interrelated themes and concepts: postmemory and the ghosts of traumatic history; silence and silencing; acknowledgement and responsibility; atonement and repair; and perhaps most difficult of all, reconciliation and forgiveness. Each theme is expanded in chapters on the politics of encounter, memorialising, the role of art and music in memorialisation, and German philosophy under National Socialism. Frosh doesn’t just engage in theoretical analysis but locates themes within a specific time and place drawing, for example, on the traumas unleased by the Holocaust and the challenge of post-Holocaust memory; the policies of apartheid South Africa and the role of the Truth and Reconciliation Commission; and the history of slavery and its afterlife in the United States. He also analyses the political histories and current realities in regions as diverse as Brazil, Israel, the Palestinian Territories, and Germany.

Using an interdisciplinary approach, Frosh weaves together different levels of experience: spatial, interpersonal, perceptual and embodied. The point, of course, is that the afterlife of traumatic history is encountered in various ways and on multiple levels. Memory is always affectively charged. In this sense as well, Frosh is right to draw on thinkers from different disciplines ranging from Hirsch and LaCapra, Benjamin and Butler, Levinas, Heidegger and Arendt, to Derrida and Žižek. There are others, and I list these interrelated themes, experiential realms, disciplines and thinkers only to offer a glimpse of the sheer scope and richness of Frosh’s book, which can be read sequentially or in individual parts. What should be clear is that this book will reward the reader who, like me, chooses to return to it time and again.

How a reader responds to what Frosh says will depend in part on their own subject position, to where they are located at the intersection of culture and history. As a German descendant whose grandparents were members of the German generation of perpetrators and bystanders, many of the themes Frosh explores are familiar to me. Yet they are not easily addressed, whether in one’s personal life or in our social interaction with others. This became patently clear to me when, relatively late in life, I discovered that my maternal grandfather, whom I had known and loved as a child, was a card-carrying member of the Nazi party (Frie, 2017). It was an unspoken family history that had been covered over by a blanket of shame and silence and was revealed only by my chance discovery of a photograph of my young grandfather in uniform. Like many German descendants, I had been raised with an understanding of the importance of knowing about and remembering the Holocaust and Germany’s heinous crimes under National Socialism. After learning of my own family’s unspoken Nazi past, I struggled with memory its implications. What did it mean for me to inherit a dark past that took place before I was born, a history that I did not participate in, but to which I am inherently connected by way of family, language, and community? How do we understand the dynamics of German postwar memory which obligates descendants to engage in collective remembering but often enables private family memory of the Nazi past to be kept at bay? My family’s history, it turns out, is hardly unusual. There are many third-generation Germans who feel a sense of responsibility to remember, but know very little about the degree to which their own relatives supported the Nazis, enabled their hateful policies, or were directly involved in the crimes of the Holocaust. How, ultimately, do we respond to unwanted perpetrator legacies?

I am implicated in the community of silence in which I grew up and have an obligation to remember and to speak out. But as Frosh asks, what of the issues “to which I have had very limited exposure and of which I have no direct experience?” (xviii). Does my complacency in the face of past crimes and current societal injustices make me in some way complicit in them? What does it mean to be implicated? For example, as a white German-Canadian male I inevitably benefit from the history of colonialism that has shaped Canadian society. How do I address the legacy of suffering experienced by the First Nations in Canada, or by African-Canadians whose ancestors were enslaved and continue to experience injustice as a result of systemic racism? What is my role in this process and how do I respond to the discomfort I feel when I begin to acknowledge it? As Frosh points out, “This is what it means to be implicated; it is not comfortable and it is not always clear what one should do to turn a general ethical impulse into practical action that is not self-abnegating yet is open to the needs of the other, towards whom one has a responsibility” (p. 81).

At several points in his analysis, Frosh draws on Christina Sharpe’s important book, In the Wake: On Blackness and Being.  The wake of the slave ships that forcibly carried some twelve million Africans to a life of enslavement in North and South America have continued to shape black lives despite the passage of time. The cruelty and suffering of the past have carried on into the present. In the United States, African Americans have been subjected to slavery, lynching, Jim Crow, and now mass incarceration. In a similar sense, we might say that the wake of those slave ships has ensnared members of the white majority, a great many of whom continue to engage in denial and silence even as the growth of white nationalism has come to pose a clear and present danger.

Frosh is sensitive to the challenges of considering the interconnections between victims and perpetrators and their descendants, the kind of relationship that the German-Jewish historian, Dan Diner once described as a negative-symbiosis. As Frosh states: “In claiming the right to engage with any experiences, even those that are not my own, I risk setting myself up as a translator of things that perhaps should not be translated, potentially taking them away from those who actually ‘own’ them and have the sole entitlement to articulate them” (pp. xiii-xiv).  This is a very real concern, yet Frosh concludes, “being an ethical subject means knowing that you cannot avoid taking responsibility for another’s suffering by saying that they haven’t actually asked for help” (p. 30). In this sense, at least, he invokes Emmanuel Levinas’s well-known injunction that our responsibility for the other person is always primary.

On the difficult theme of forgiveness, Frosh turns to Heidegger’s engagement with National Socialism and the contrasting responses of Levinas and Arendt. As Frosh makes clear, the issue is highly complex. But in the briefest sense we might say that that Levinas was unable to forgive Heidegger for his embrace of the Nazis, while Arendt, who was romantically linked to the philosopher, was more equivocal. From there Frosh turns to the narrative of the black South African, Pumla Gobodo-Madikizela, who grew up under apartheid. Gobodo-Madikizela’s account of her relationship with the apartheid killer, Eugene de Kock, has become well-known and gives way to a nuanced discussion of culpability, atonement and the possibility of forgiveness in South Africa. Frosh carefully considers the different positions and their ramifications, while recognizing the need to find a route towards a shared experience that can move beyond the victim and perpetrator dyad. This is difficult terrain to be sure, and Frosh concludes that “murder in the service of apartheid; sadistic and cruel violence; abusing one’s position to explicitly advance Nazism? There is a limit, surely, and maybe these examples are where it has been breached” (p. 147). Finding a path forward is incredibly hard, yet vitally important. Acknowledgement, atonement and reparations cannot, in themselves, absolve anyone of the grievous wrongs committed, though they may at least open a space for dialogue and the possibility of future reconciliation.

Reconciliation between the victims and perpetrators of the Holocaust was quite impossible to imagine, but the circumstances for their descendants have proved different. Eva Hoffman, on whose work Frosh draws, makes a related observation when she acknowledges the way in which the children of Holocaust survivors like herself are paradoxically connected with the children of the German perpetrators and bystanders:

The Germans born after the war, I began gradually to realize, are my true historical counterpoint. We have to struggle from our antithetical positions with the very same past.…While the conflict for children of victims is between the imperative of compassion and the need for freedom. … How can you [the German second generation] ever come to terms with the knowledge that your parents, your relatives, the very people for whom you have felt a natural, a necessary affection, are actually worthy of moral disgust? That the relative who was fond of you, or a neighbor who treated you nicely, or indeed your mother or father, may have performed ghastly deeds? Or that the whole previous generation, which has served as your first model of adulthood, is tainted by complicity with such deeds? (pp. 118–119)

As Hoffman suggests, in the aftermath of genocide and racial violence the work of memory is laden with emotion, conflicted loyalties, fears, and fantasies. In a related sense, I believe the work of historical responsibility requires us to confront our emotional investments in long-cherished narratives and look for counter-narratives that can be difficult to discern. As long as the perpetrators and enablers remain abstract historical figures, questions of responsibility and implication are kept at bay. But what separates “us” from the perpetrators and enablers of past genocides may be little more than historical experience. As current rates of racial violence suggest, like them, we also have the capacity to dehumanize, mistreat and deeply injure others.

Those Who Come After is indispensable for anyone wishing to understand how the legacies of suffering that have resulted from the perpetration of mass crimes continue to shape us long after they are committed. The book’s interdisciplinary scope, like that of the Studies in the Psychosocial series in which it was published, forms a valuable addition to a field that is often dominated by narrow disciplinary accounts. Like Frosh’s earlier writings, Those Who Come After is filled with nuance and sophistication and asks to be revisited, rewarding the reader each time anew. Drawing on a rich and diverse body of knowledge, Frosh lays bare the human struggle with historical trauma, its lingering effects into the present, and the possibility of reconciliation and forgiveness in the future.

Roger Frie is a Professor and Clinical Psychologist at the Faculty of Education at Simon Fraser University in British Columbia, Canada. He lectures and writes widely on historical trauma, cultural memory and human interaction and additionally is a practicing psychotherapist and psychoanalyst. He is author most recently of Not in My Family: German Memory and Responsibility After the Holocaust (Oxford University Press, 2017).

References:

Frie, R. (2017). Not in my family: German memory and responsibility after the Holocaust. New York, NY: Oxford University Press.

Hoffman, E. (2004). After such knowledge: Memory, history and the legacy of the Holocaust. New York, NY: Public Affairs.

Sharpe, C. (2016). In the Wake: On Blackness and Being. Durham, NC: Duke University Press.

Anne Harrington. Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness; New York, NY: W. W. Norton & Company, 2019; 384 pages; hardcover $27.95: 978-0-393-07122-1  

By Violeta Ruiz Cuenca

In 2013, the American Psychiatric Association published the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The DSM was first created in 1952 with the purpose of defining and classifying mental conditions in order to aid diagnosis and treatment. Since this first edition, the manual has undergone multiple changes and revisions, the most notable of which is the decrease of the influence of psychoanalysis in favour of biological theories of the cause of mental disorders. This so-called ‘biological turn’ in psychiatric thinking, which took place over the 1980s, supposedly as a result of discoveries in neuroscience, genetics, and psychopharmacology, is the focus of Anne Harrington’s new book, Mind Fixers. In it, she argues that the current dominant narrative among psychiatrists that presents the ‘biological revolution’ as a triumph over the erroneous Freudian ideas of the 1940s and 50s is incorrect. Instead, she shows how the popularisation of psychoanalytical ideas in the early twentieth century, followed by the biological turn later in the century, is more a result of professional crises within the groups than of the discovery of any decisive piece of science.

Harrington’s study begins by focusing on the debates that took place between (and within) the biological and psychoanalytical theories as each tried to identify the causes of mental illnesses during the late-nineteenth and twentieth centuries. The first part of the book centres on the development of nineteenth-century brain psychiatrists, the popularisation of psychoanalytical theories after the First and Second World Wars, and the progressive overhaul of these ideas by biological psychiatry in the second half of the twentieth century. She convincingly argues that the root cause of the debates, especially during the twentieth century, was one of professional rivalry. Debates over expertise and authority were rampant and often arbitrary, since psychiatric theories were commonly a result of new therapies that seemed to give insight into how the mind and brain worked, rather than the other way around (that is, preceding the development of new forms of treatments). In this section, Harrington demonstrates how psychiatry has a guilty past in which it effected abuse on patients, covering notorious examples such as Edgar Moniz’s popularisation of lobotomies in the 1930s and the classification of homosexuality as a mental disorder until the DSM-III-R (1987), as well as lesser known ones, like the medical director Henry Cotton’s abuse of the therapeutic effort to treat schizophrenic patients through the extraction of supposedly infected organs in the body at the New Jersey State Lunatic Asylum in the 1910s and 20s.

The second part of the book focuses on three different diseases – schizophrenia, depression, and bipolar disorder – in order to show that there was never one single, dominating theory that explained each condition. Instead, biological and psychoanalytic theories co-existed and even influenced each other in the development of new ideas. Furthermore, Harrington shows that these changes in the theories were not only caused by psychiatrists and their research, but were also highly influenced by other factors, such as changes in the psychopharmaceutical legislation, social movements like the feminist and anti-psychiatry movements of the 1960s and 70s, popular responses to unethical scientific studies and the questionable application of psychiatric ideas to court cases. This allows the author to convincingly argue that psychiatry’s search for a biological explanation of mental conditions was pluralistic (and messy), and cannot be told in a simple, linear way.

Finally, in part three, Harrington reflects on the ways in which the promises made by biological psychiatrists to offer the key to managing mental illness have unravelled since the 1990s, arguing  that psychiatry has paid the price for its arrogance in former years, having made promises that it could not deliver. This section includes her own first-hand experiences, like the pessimistic atmosphere that permeated the launch of the DSM-5. Rather than presenting a set of conclusions, Harrington opts for an Afterthought where she presents a new way of doing psychiatry, one in which patient well-being is at the centre of treatment, and in which dialogue between patients, families, and doctors serves to generate powerful leverage against big pharma.

Throughout the book, it becomes evident that the true protagonists of the story are not the professionals, but rather the patients and their families, who suffered the practical consequences of the changing medical discourses, competing theories, and arguments over professional expertise and authority. Her interviews with these groups, and perhaps in particular with the mothers who lived with mental illness in their families through the 1970s, makes Harrington especially sympathetic to their plight. The popularisation of different theories since the 1940s, like the “dissociative-organic types of parents” or “refrigerator mom”, that blamed the development of autism in children or schizophrenia in adults on the parents, had severe consequences on the families, while patients were affected by either the over-medicalisation of their disease with drugs that often turned out to have dangerous side-effects, or with the lack of access to drugs in a system that overvalued the success of psychoanalysis.

Mind Fixers certainly serves to stir debate among psychiatrists and is clearly a useful tool for patient/family activist groups at present. It is likely that the main purpose of the book is precisely that; the engaging writing style and the affordable price make it readily accessible to a general audience. However, as a work of scholarship in the History of Medicine, it has some serious methodological shortcomings that limit its usefulness to an expert audience. One of the main drawbacks is the attention paid to individual actors and their motivations, often giving character evaluations and presenting new ideas as ‘discoveries’ that seem to emerge out of their genius (or malice, or absurdity), failing to contextualise the political, social and cultural context in which they emerged. For instance, in chapter one, she describes Emil Kraepelin as an impassioned workaholic who developed his approach to the classification and diagnosis of mental conditions because he decided to ‘shift gears’, and the degree to which it was accepted by his colleagues depended on his individual ability to persuade them. One doesn’t have to be an expert in Kraepelin to know that this characterisation of his persona is problematic. Despite criticising heroic origin stories for generating caricatures of historical actors, she generates the same kind of narrative, which has long been inadmissible in the field of History of Science.

Harrington’s focus is admittedly on the twentieth century and the USA, but a significant issue with grand narratives is that they run the risk of over-simplification. Harrington’s leaps from different national contexts, characteristic of these types of narrative, are problematic in this sense, since they not only assume a static interpretation of concepts, but also obviate the fact that these ideas had to be transported to different contexts, very often undergoing a process of appropriation, therefore making these processes far more complex than they might initially seem. Following on from the example above, a deeper reflection on how Kraepelin’s ideas were appropriated in the USA, and the reasons why they were accepted, contested, or modified, would have provided a richer history than that which is on offer.

Additionally, while Harrington argues that a plurality of interpretations existed, her narrative still leans towards the linear: one dominant interpretation is replaced by another without an exploration of how multiple theories of mental illness co-existed at the same time. For example, in chapter three, ‘A Fragile Freudian Triumph’, she claims that the consolidation of psychoanalytic theories after the Second World War had more success than physical therapies because the human fellowship they appealed to seemed to have more long-lasting effects than any physical treatment; ‘[a]nd then drugs arrived’, in Harrington’s words, and changed the state of affairs.  The book’s analysis of the reasons for this plurality – economic, social, political, and cultural – remain superficial, while mentions of race and gender issues are brief and serve to argue the case that psychiatry failed in its mission, rather than to explore the ways in which power was instituted to oppress or benefit different groups. These issues result in an overly simplistic analysis, which can be useful for political purposes, but is disappointing to the historian.

Harrington’s analysis of the actors involved suffers from the same problem, and is especially salient in the case of the patient and family groups, whom she presents as a homogenous bloc who were victims of, and stood together against, the professional rivalry that plagued psychiatry. This generates a single narrative about patients and their families, and how they were affected by the discipline and its institutions, obfuscating the plurality of attitudes towards psychiatry within these groups. For instance, Harrington makes no mention of grass-roots movements and radical patient groups who self-identified (and identify) as survivors of the psychiatric system, and who were often forced into psychiatric detention by their families.  Furthermore, Harrington places too much emphasis on a single factor – often the development of a new pharmaceutical drug – as the cause for change, rather than showing the messy and disjointed way in which change happens.

Although the point of the book is to show that the idea of ‘progress’ in psychiatry is erroneous (an idea that is well-accepted within the History of Science), Harrington occasionally makes statements that suggest an inclination towards this idea, even if it is not explicitly articulated. The book’s description of neurasthenia, a late-nineteenth-century disease considered to be a result of the modern condition of the struggle for survival that characterised the period, as a ‘fictive’ disease in the afterthought is surprising. It reduces the condition to nothing more than a label without contextualisation within the moment from which it emerged – something the book does not do when it comes to discussing schizophrenia, depression, or bipolar disorder.

Mind Fixers reads better as an introductory text for undergraduate medical and psychology students who are training to be practitioners, or for family and patient groups who are interested in the history of the profession, than for historians of psychiatry or of any other sub-discipline within the field. It reflects the disillusionment that currently plagues the field of psychiatry, especially since the publication of the fifth Diagnostic and Statistical Manual (DSM-5) in 2013, and the frustrated struggle of patients and families to find a solution to the way in which their lives are affected by mental health, poor institutional support, and lack of adequate treatment for their condition. Still, it holds hope that a new approach within psychiatry is in the making, one which builds on the interdisciplinary relationship between the humanities and the sciences. In that sense, Harrington’s book is certainly a success.

Violeta Ruiz is a PhD candidate in the Centre for the History of Science at the Universitat Autònoma de Barcelona. Her thesis explores the links between neurasthenia and modernity in Spain between 1880 and 1930, focusing on the points of intersection between medical, national and gender discourses and the constructions of identity at the time. During her PhD, she has carried out research residencies at the Department of History, Classics and Archaeology at Birkbeck, University of London (winter/spring 2016) and at the Centre for the History of Emotions at the Max Planck Institute for Human Development in Berlin (autumn/winter 2018-2019). She recently delivered a paper titled “Ambition, Responsibility, and ‘The Struggle for Survival’: The Medical Discourse of Neurasthenia in Spain in the Fin de Siècle” at the ‘Diseases and Death in Premodern and Modern Era’ Workshop that took place from the 10-11^th of December 2019 at the University of Pardubice, Czech Republic.

Andreas Killen. Homo Cinematicus: Science, Motion Pictures, and the Making of Modern Germany; Philadelphia, PA: University of Pennsylvania Press, 2017; 280 pages; cloth edition £65; ISBN: 9780812249279

By Anna Toropova

Andreas Killen’s rich and incisive study takes its title from a 1919 press article linking the cinematic medium to the emergence of a new psycho-physiological type – a ‘cinematically conditioned mass man’ who was easily swayed and misled, held captive by the images unfolding on screen (2). Cinema’s power over the minds of its viewers continued to present a source of concern for German officials and scientific and medical experts in the interwar period.  Conservative critiques of the cinema as a public health risk that sapped viewers’ bodily capacities and corroded their morals and will could be heard in both the Weimar Republic and Nazi Germany. As Killen shows, however, the medium’s capacity to act on and shape its publics was a source of intense fascination as well as anxiety. Showcasing the varied potentialities that cinema embodied during this period, Killen explores attempts to reform the medium and harness its powers for the tasks of enlightenment, scientific investigation and political persuasion. Whilst acknowledging that cinema’s harnessing to the task of social reform reached full fruition under the Nazis, Homo Cinematicus traces the origins of this enterprise to the period of the First World War. The cinema, Killen argues, formed a constitutive part of a new form of politics that set its sights on the regulation and management of the social body.  Exploring cinema’s participation in the project of human and social remaking, Homo Cinematicus is a valuable addition to the growing body of scholarship on cinema’s coincidence with an ‘art of government’ centred on the cultivation and ‘improvement’ of human life, as well as a vital contribution to scholarship on the entanglement of cinema and medicine.

The book’s five chapters explore different facets of the interface between scientific and medical expertise, politics, and cinematic technology. Chapter one traces the deployment of film as an investigative, diagnostic, documentative and pedagogical tool, as well as a means of translating scientific ideas to a mass public. Killen’s account of film’s emergence as a resource across a wide range of scientific disciplines (including industrial psychology, neurology, psychiatry and psychoanalysis) showcases the medium’s development in parallel with the human sciences coming to assume an increasingly dominant role in the interpretation and resolution of social problems. Deployed in psychiatric classification and intelligence testing the cinematic medium was relied upon to produce new forms of knowledge about the population. The chapter’s exploration of cinema’s function not only as a means of scientific documentation but as a mass-media platform for voicing popular anxieties about the power of scientific knowledge introduces one of the book’s central themes— the unstable boundaries between the scientific and the fiction film.

Taking the extended campaign to cleanse the cinema of ‘trash’ as its subject, Chapter 2 hones in on physicians’ efforts to medicalise the problem of Schund, as it was called in German. Killen shows how the First World War enabled scientific experts to shift the terms of the censorship debate to the adverse health effects of ‘trash’ cinema. If Kara Ritzheimer’s recent work on the anti-Schund campaign in Germany drew attention to the depiction of censorship as a social welfare measure specifically targeted at protecting children and adolescents, Killen’s approach is to hone in on the new language assumed by censorship bodies after the war, a rhetoric that abounded with ‘medical tropes of disease, addiction, infection, and contagion’ (81). The Weimar period would see medical experts assuming an increasingly pivotal role in the evaluation, production and censorship of films. Homo Cinematicus thereby ties the aims of the cinema reform movement to the tasks of social and mental hygiene, situating the anti-Schund drive within broader medical campaigns to improve the population’s health. Chapter 3 turns the focus onto hypnosis, exploring not only its prominent place in scientific and medical discourses on the cinematic medium but also its emergence as a central theme in Weimar cinema. While the contemporary anxieties surrounding cinema’s ‘hypnotic properties’ will be well known to readers familiar with the work of Scott Curtis and Stefan Andriopoulos, Killen’s linking of cinematic portrayals of powerful mind-doctors in films such as Dr. Mabuse the Gambler (Lang, 1922) to popular anxieties over the post-war expansion of human scientific knowledge casts the topic in a new light.  

The most well known ‘product’ of the cross-fertilisation of cinema and the human sciences in early twentieth-century Germany – the health enlightenment film – is the subject of chapter 4. Opening with reference to a Nazi production that makes the case for compulsory sterilisation (Inheritance, 1935), the chapter traces the origins of the race hygiene propaganda film to the social and sexual hygiene films of the Weimar era. Killen unravels the enlightenment film’s characteristic hybridity – its reliance on the conventions of commercial as well as scientific filmmaking – against the backdrop of post-war calls for ‘imperceptible’ or ‘veiled’ propaganda and greater attention to questions of viewer engagement. The chapter’s concluding reading of the audience strategies deployed in Inheritance illuminates the ‘hygienic’ mode of vision cultivated by the enlightenment film. The book’s final chapter turns the focus on a campaign that paralleled the drive to rid German cinema of Schund – hygienists’ protracted battle against superstition, culminating in the 1941 campaign against medical charlatanism. Despite forceful attempts to suppress lay practices of hypnosis and to reclaim the practice for medical science, the lines between charlatan and ‘man of science’ remained ill defined. The mesmerising occultists and corrupt clairvoyants incarnated on screen served, Killen argues, as the uncanny doubles of ‘all-powerful’ and ‘all-knowing’ medical experts. 

As Homo Cinematicus rightly acknowledges, one of the most striking manifestations of the early twentieth-century overlap between science, medicine and cinema was the emergence of attempts to scientifically study and manage film’s effects on audiences. The book’s persistent emphasis on the significance of ‘the science of reception’ is not, however, matched by an in-depth exploration of this development in interwar Germany. To be sure, chapter one refers to experimental attempts to test the impact of film stimuli on the psychophysiology of adult viewers in 1913 and chapter four mentions Nazi-era psychological research on adolescent and young adult viewers. A more extensive analysis of the research methods deployed in such investigations and the impact of audience studies on either official policies or film industry practices would help to further substantiate the book’s claim that scientists became ‘authorities on questions of audience reception’ (21).

Nevertheless, Homo Cinematicus is a rigorous, thought-provoking, eloquently argued and nuanced account of the partnership between cinema and science in political projects of mind-body transformation. In bringing to light the intricacies of cinema’s involvement in the task of human engineering, Killen is commendably sensitive to the limitations and frustrations of this undertaking. The desire to take full command of cinema’s ‘exceptional powers as a medium of “mass influencing”’, Homo Cinematicus contends, was an ambition that was only partially realised (197). The campaign against cinematic Schund, for example, was undermined by the sexual enlightenment film’s unsettling of the very distinction between ‘trash’ and ‘edification’. The difficulty of delimitating what was trash and what was not, Killen argues, continued to undermine censorship efforts. The persistence of public anxieties surrounding medical authority is another example of the disappointments encountered by efforts to mobilise cinema’s opinion molding potential. As Killen persuasively shows, Weimar cinema’s tradition of presenting ‘doctors of the mind’ as mesmerising criminal figures (an image underwritten by anti-semitic fantasies) proved difficult to diffuse in the context of Nazi policies that often seemed to confirm the public’s long-held suspicions of ill-intentioned physicians.

Many readers of Homo Cinematicus will be struck, no doubt, by the parallels between the medicalised discourse on the power of cinema in post-war Germany and efforts to transform the cinema into a tool of edification elsewhere. The foundation of the International Institute of Educational Cinematography in Rome in 1928 – a League of Nations-sponsored research centre that published its findings in five different languages – testifies to the way in which experts across interwar Europe and the US sought to harness cinema’s influence for the purpose of bettering society. Killen’s close attention to the particularities of the German case in Homo Cinematicus will be an invaluable source for future comparative work.

Anna Toropova is a Wellcome Trust Research Fellow at the University of Nottingham. Her current project aims to shed light on the intersection of cinema and medicine in early Soviet Russia. She has recently published articles from this project in the Journal of Contemporary History and Slavic Review. Her monograph, Feeling Revolution: Cinema, Genre, and the Politics of Affect under Stalin, will be published by Oxford University Press in 2020.

Rebecca Reich. State of Madness: Psychiatry, Literature and Dissent After Stalin; DeKalb, IL: Northern Illinois University Press, 2018; 280 pages; hardback £45.00; ISBN: 0875807755

By Hannah Proctor

Rebecca Reich’s State of Madness focuses on discourses surrounding punitive psychiatry in the Soviet Union in the years between Stalin’s death in 1953 and the collapse of the Soviet Union in 1991. Much of the existing literature on the pathologisation of dissent, stories of which began to emerge and spread via samizdat in the 1960s, has an institutional emphasis, whereas Reich focuses on relationships between literature and psychiatry. In the context of a state system of psychiatry that understood dissent as a form of insanity and attributed ‘political resistance to a distinctive state of mind’ (p. 62), resistance was imagined by those resisting as a sane response to a mad system. Dissidents–a broad term that does not necessarily imply engagement in political activism–worked to ‘validate a norm of inakomyslie, or “thinking differently”’ by challenging the state’s authority to diagnose insanity (p. 217). Reich demonstrates that literature was a key site for contesting psychiatric diagnoses, becoming a ‘source of diagnostic authority’ in its own right (p. 6). State of Madness is always working with and through contested dichotomies; there is neither dissent nor madness without a norm. Sanity then becomes a question of who is responsible for defining and assigning the diagnostic categories.

State of Madness examines literature from a range of genres produced during the period after Stalin’s death that challenged the theoretical frameworks and practices of psychiatry. In the case studies considered by Reich the boundaries between the aesthetic and the psychiatric  – along with those between sanity and insanity – are often blurred. Reich does far more than merely analyse aesthetic representations of psychiatry, however. Not only does she discuss how psychiatrists themselves deployed aesthetic conventions in their clinical documents, but her analysis of the interplay between literature and psychiatry is grounded in an understanding of life in the Soviet Union as thoroughly aestheticised: ‘the state went about constructing socialism by applying its creative principles to reality itself’ (p. 50). The question of identifying distinctions between art and life was an urgent one for some of the figures she discusses precisely because it was so hard to discern.

In her introduction, Reich traces the ‘deceptive similarities’ between Soviet dissident narratives and the works of Michel Foucault, noting that although his discussions of the normative impulses of psychiatry echoed Soviet concerns, his analyses pertained to liberal societies and thus cannot fully account for the authoritarianism of the Soviet Union. (Though it could be noted that this does not mean dissent has not been pathologised in the kinds of societies Foucault was analysing, as Jonathan Metzl’s The Protest Psychosis: How Schizophrenia Became a Black Disease demonstrates with regard to Ionia State Hospital in Michigan in the 1960s.) In addition to identifying such theoretical convergences and divergences, Reich later situates Soviet abuses of psychiatry in relation to contemporaneous Western critiques of psychiatry, often bracketed together under the baggy and contested term ‘antipsychiatry’. News of the pathologisation of Soviet dissidents emerged in the West at the very moment these ideas were at their most popular, and chimed with the notion that psychiatric institutions and nosologies were inherently oppressive. More interestingly, Reich also discusses how the repudiation of antipsychiatry in mainstream Soviet psychiatry journals ironically led to those ideas circulating in the Soviet Union. She discusses examples of people who acquainted themselves with this material and found that it spoke to the Soviet experience: ‘trickling down through sanctioned and unsanctioned channels, Western antipsychiatric ideas informed the critical vocabulary through which Soviet dissidents exposed abuse’ (p. 65).

Reich begins by discussing the literary discourses Soviet psychiatrists themselves engaged with, underlining that the psychiatric norms dissidents were reacting against were expressed in terms that were congruent with Soviet literary conventions. She thus establishes from the very beginning that the lines of influence between psychiatry and aesthetics flowed in both directions. By applying a formal literary analysis to clinical documents, Reich convincingly demonstrates that the discipline of psychiatry was structured according to an ‘established aesthetic framework’ borrowing from the ‘literary doctrine of Socialist Realism’ (p. 27, p. 29). Psychiatrists framed their diagnostic practices as a kind of artistic endeavour and pathologised aesthetic modes that deviated from the standards of Socialist Realism.

According to Reich, diagnostic categories furnished psychiatrists with ‘predictive templates for narrating’ the lives of dissidents (p. 43). The psychiatrist drew out the ‘essence’ of a patient’s life story through a spoken discussion and effectively muffled the patient’s own account in the process, which Reich frames, drawing on the work of Soviet literary scholar Bakhtin, as a shift from dialogue to monologue (p. 44). A further stage of mediation then occurred when the ‘essence’ extracted verbally was converted into writing in the form of a clinical report in which the subjective interpretations of the psychiatrist, along with the aestheticising qualities of diagnosis, tended to be obscured by the neutral tone of medical objectivity. Yet Reich argues that in spite of their authors’ impartial intentions, forensic reports nonetheless amplified the always partial voices of Soviet psychiatrists, whom Reich argues narrated their patients’ conditions in a manner that conformed to the teleology of the Socialist Realist ‘master plot’, situating syndromes and processes of recovery in a progressive narrative.

Psychiatrists also turned their diagnostic gaze on the artistic and literary outputs of their dissident patients. In line with state-sanctioned understandings of art, figurative work was associated with sanity and aesthetic harmony was associated with mental healing. Normative aesthetic judgments and literary categories were transferred from artworks to individual psyches which, Reich argues, betrayed a failure to understand the sophisticated artistic movements of the period – such as Moscow Conceptualism or Sots-Arts – that relied heavily on irony, kitsch and parody, and self-consciously critiqued Socialist Realist tropes.

But literature was – conversely – a site for contesting psychiatry’s art of diagnosis, which Reich moves on to discuss in the book’s second chapter and in three subsequent case studies. The ambiguities of psychiatric discourse and diagnostic categories facilitated their punitive use, but writers also played with these ambiguities for their own ends: ‘their psychiatric narratives reveal a shared perception that psychiatric abuse had resulted both from the ambiguity psychiatric discourse itself and from the state’s conflation of inakomyslie, or ‘thinking differently’, with insanity’ (p. 60). The monologism Reich identifies as characteristic of Soviet psychiatry in the first chapter is replaced in the second by the dialogue introduced by dissidents ‘that embraced singularity, irony, and open-endedness’ (p. 93). If psychiatrists had absorbed the conventions of Soviet Socialist Realism as part of their pathologisation of dissidents in these counter examples, by contrast, ‘literary discourse assimilates psychiatric discourse to depathologize inakonmyslie and to pathologize both society and the state’ (p. 96).

The book’s first ‘case’ focuses on Joseph Brodsky with an argument animated by his reversal of Marx’s dictum ‘existence conditions consciousness’. Here dialogism becomes literalised through a discussion of his narrative poem ‘Gorbunov and Gorchakov’, set in a psychiatric hospital, which takes the form of a discussion between two characters embodying different concepts. Brodsky is not deemed to have been hospitalised for punitive reasons and, unlike the dissidents discussed in the previous chapter, was not a political activist. But the significance of his diagnosis and institutionalisation for Reich is ‘the sense it appears to have given the poet that the primary purpose of the psychiatric profession was to enforce a linguistic regime of existence’ (p. 108).

Andrei Siniavskii (along with his pseudonymous alter ego Abram Terts) is the second of Reich’s three case studies. In 1965 he was arrested and found imputable by psychiatrists who examined his literary output for evidence of pathology, thus enacting the very melding of life and art that his previous works critiqued. Siniavskii developed an understanding of the aesthetic process at odds with that espoused by the state, which propounded a vision of creativity in line with Lenin’s ‘reflection theory’ [teoriia otrazheniia]. This extended the dictum of Marx, that Brodsky drew upon, by claiming that consciousness and existence – or humanity and nature – existed in a mutually transformative relationship with one another; people were shaped by their circumstances but could also intervene in the world to transform it. This, Reich explains, had a counterpart in psychiatry in the form of reflex theory [reflekornaia teoriia]. According to Reich, mirrors and other reflective surfaces litter Terts’s works, figuring as surfaces that distort the reality they claim to show: ‘It was by concealing rather than revealing reality’s essence… that the state had driven society mad.’ (p. 184). His works imagined art, alternatively, as the site where it might be possible to promote a deeper awareness of reality by highlighting its strangeness and artifice, departing from Lenin and drawing instead on Viktor Shklovskii’s notion of ‘defamiliarization’ [ostranenie] as an ‘antidote to creative madness’ (p. 153). For Siniavskii/Terts, who developed a form of Fantastic Realism as a counterpart to the officially sanctioned conventions of Socialist Realism, the antidote to reflection in art was not achieved through a greater fidelity to reality but, paradoxically, through estrangement from it.

Reich’s concluding ‘case’ focuses on Venedikt Erofeev, a writer whose chaotic and often inebriated life paralleled the social deviance of his literary heroes, who also bore his name. Here the smudged line between life and art and Erofeev’s self-conscious attempts to play with this blurriness, returns in the guise of a tussle between madness and its simulation. The theatrical feigning of mental illness as a means of avoiding imprisonment was a practice Soviet psychiatrists were aware of, and Reich situates Erofeev’s work in this context arguing that it ‘captures the risks of simulating madness in an irrational world of ever more meaningless diagnostic categories’ (p. 188).

Alcohol was Erofeev’s primary material in his performative experiments which danced along the border between sanity and insanity, a pair of categories that had a counterpart in the relationship between simulation and dissimulation: at what point does the performance become a reality? Or does simulating madness as it is defined by a ‘mad’ state paradoxically stave off real madness? Erofeev eventually lost control of his own experiment and sought out treatment as the alcohol induced hallucinations and delirium that had characterised his writing became a part of his lived experience. The staged pathologisation soon became inseparable from life.

As in other chapters of State of Madness, in Erofeev’s work distinctions are constantly breaking down: between sanity and insanity, simulation and dissimulation, the theatrical and the real, the asylum and society, and, ultimately, between literature and real life. The mask of madness gradually became indistinguishable from the face beneath. Yet if, as Reich argues, Erofeev’s play Walpurgis Night exposes ‘the fact that it is society that has lost its mind’ (p. 203), the question remains whether sanity can ever really exist or even be defined within a crazy world: ‘how were they to calibrate their health in a society where, as they so frequently portrayed it, madness was the psychological norm?’ (p. 15) Ultimately for Erofeev, ‘the only certainty is the theatricality with which both categories [sanity and insanity] manifest themselves’ (p. 205). Reich describes dissidents stuck in a ‘discursive trap’ and the examples she considers describe these traps from within or sometimes construct new ones but they struggle to find ways of escaping altogether (p. 61). It’s enough to drive anyone mad.

If dissent is the norm then what happens when society changes? I would have been intrigued to read an epilogue considering what became of these discourses after the Soviet Union – and its attendant master plots and meta-narratives – collapsed. Of the three writers Reich discusses in most detail, Brodky and Siniavskii both lived past 1991. Brodsky left the Soviet Union in 1972 but the implication is that this geographical displacement did not lead to a sudden sanity and he instead experienced ‘the maddening freedom of exile’ (p. 20). The Soviet ‘state of madness’ may have had particular contours but this suggests that there may be no such thing as a ‘state of sanity’. The dissident writers Reich discusses ‘assumed the role of psychiatrists to an authoritarian state that had lost its mind’ (p. 19), but the lingering anxiety remains that identifying this madness could provide neither an individual nor societal cure. Reich’s book attests that literature nonetheless remained a privileged site for contending with the impasse. As Brodsky wrote in ‘A Part of Speech’ (1975-76):

It may be the heel that’s slipping on ice, or it may be the earth

that’s turning beneath the heel. (p. 137)

Hannah Proctor is Wellcome Trust Research Fellow at the Centre for the Social History of Health and Healthcare at the University of Strathclyde.

Susan Lanzoni. Empathy: A History; New Haven and London: Yale University Press; 408 pages; hardback $30.00; ISBN: 9780300222685

by Sarah Chaney

A couple of years ago, I attended a colloquium on empathy at the University of Oxford. The organisers of this event were rightly concerned by the vague and varied definitions of empathy in medical research and practice and sought to remedy this. While they had found a number of clinical trials that purported to measure empathy, the introductory lecture noted, every single one of these gave a slightly different definition of what it was they were actually measuring! As Susan Lanzoni’s comprehensive history of empathy shows, this conceptual confusion around empathy is not new. Even after an explosion of interest in the term through the 1950s and 1960s, in 1979 the American social psychologist Kenneth B. Clark declared himself dismayed by the lack of “clear definition and a comprehensive theoretical approach” to the subject (p. 248).

As Lanzoni shows in this genealogy, the confusion lies to some extent in the fact that the meaning of the term has “shifted so radically that its original meaning transformed into its opposite” (p. 8). Lanzoni makes this shift clear by outlining a huge range of examples of studies in which empathy does not mean what the modern reader might expect. To take just one example of many, when the psychologist Edward Bullough found in 1908 that his subjects described coloured lights as having a particular temperament or character he called this “empathy” (p. 52). Even in the twenty-first century, many forms of empathy exist: “from emotional resonance and contagion, to cognitive appraisal and perspective taking, and to an empathic concern with another that prompts helpful intervention” (p. 252). While the book takes a chronological approach to the subject, the diversity of different meanings at play in any one period are thus made clear throughout.

Lanzoni records the first use of the term “empathy” simultaneously in English in 1908 by the psychologists James Ward and Edward Titchener, used in both cases as a translation of the German Einfühlung. Jeffrey Aronson has dated this a little earlier, finding the English word empathy in The Philosophical Review of 1895. Quibbles about the exact date aside, however, Lanzoni rightly emphasises the importance of the origins of empathy in the aesthetic Einfühlung (empathy was later translated back into German psychology as “empathie”). Empathy thus emerged from the appreciation of art and was first conceptualised as an ability to project oneself into an artwork or object; early psychological definitions also incorporated this notion of empathy as an extension or projection of the self. By the post-war period, however, empathy increasingly became viewed as a way of understanding others, a notion that was particularly prominent in the field of social work. It was this latter idea of empathy that was popularised after the Second World War.

Of course, the distinction is not so clear or neat in practice. Indeed, Lanzoni cites the German psychologist and philosopher Theodor Lipps as having suggested that Einfühlung was a way to understand the emotions of others as early as 1903, while modern neuroscientific definitions often hark back to aesthetic empathy through the links made to visual images and movement (p. 265). For ease of narrative, however, Lanzoni divides the history of empathy into nine historical stages. She begins with empathy in the arts as a way of “feeling into objects” and closes with mirror neurons as an expression of empathy in the modern neurosciences. On the way, the book takes in the experimental laboratory, art and modern dance, the psychiatric hospital, social work, psychometrics, popular depictions of empathy and the politics of social psychology. While the early chapters, on the introduction of the word, include aesthetic and psychological research across Europe, the second half of the book tends to focus more closely on the United States. This is perhaps the opposite of what one might anticipate, as the post-war era moved towards a supposedly international culture. Further explanation of the reasons for the chosen focus would thus have been helpful to the reader, or the occasional reflection on how the North American field complemented or differed from research elsewhere.

The chapters vary in their presentation: some chart changes over a period in a particular area such as social work, others focus in more detail on a specific person or theory. A good example of the former approach is chapter six, on the post-war measuring of empathy, a comprehensive account of North American efforts to test for empathy in the wake of Rosalind Dymond’s student test at Cornell University in 1948. These tests are highlighted by Lanzoni as they marked a shift in understanding of empathy from a creative enterprise to an “accurate understanding of another’s thoughts” (p. 176). In contrast, chapter 8 on the 1960s relationship between social psychology, race and politics, focuses largely on the social psychologist Kenneth B. Clark. This seems to be a particular interest of Lanzoni’s (she has also written about Clark for the Washington Post) and she sensitively weaves Clark’s concerns about the centrality of capitalist greed in White American society, and prejudice as a social disease, into his psychological research on the topic of empathy. This culminated in the publication of Clark’s Dark Ghetto in 1965, an ethology of Harlem explicitly aiming to “inform, to engender feeling, and to galvanize social action” (p. 240).

At times, the sheer amount of content means that Lanzoni veers into a rather descriptive style. Some chapters are heavy on chronological lists of contributions with less focus on how these fit into a broader picture. Chapter 3, on empathy in art and modern dance, for example, might have been edited down and combined with the previous chapter to indicate the links between experimental psychology and aesthetics in a more directed way. And while the material on Clark is undoubtedly interesting, a greater degree of contextualisation into the contemporary civil rights movement (which is merely nodded at in passing) would have been useful. There are also some significant absences. For instance, while occasional debates around the distinction between empathy, sympathy and compassion briefly surface (such as Edward Titchener’s claim that sympathy referred to fellow feeling, whereas empathy reflected an imagined but unfamiliar feeling [p. 66] ), the reader is left wondering why more attention was not paid to the interplay and conflict between these ideas.

Overall, however, Lanzoni’s book ably charts the complex changes in meaning that empathy has undergone over the last century, and convincingly argues that much of this confusion remains today. This is important, given how often empathy is invoked in a wide range of arenas in the modern world – from politics to education to health and medicine. As Lanzoni recognises, empathy is frequently emphasised as a vital human capacity, something that has the power to shape society for the better. Does it matter that we remain unable to convincingly explain what exactly it is or how it functions? Perhaps not, Lanzoni concludes, so long as we are aware of this complexity. Across all its definitions, empathy is characterised as a “technology of self”. This means that understanding its complex history can serve to increase our ability to make connections.

Sarah Chaney is a Research Fellow at Queen Mary Centre for the History of the Emotions, on the Wellcome Trust funded ‘Living With Feeling’ project. Her current research focuses on the history of compassion in healthcare, from the late nineteenth century to the present day, and includes an exhibition to open at the Royal College of Nursing Library and Heritage Centre in December 2019. Her previous research has been in the history of psychiatry, in particular the topic of self-inflicted injury. Her monograph, Psyche on the Skin: A History of Self-Harmis published in paperback in July 2019 (first published 2017).