The man who abolished madness

Subversive yet compassionate, enduring yet marginal. This is how the work of a key figure in the 1960s, a leader of the counter-culture, the Scottish psychotherapist R D Laing, was characterised at a meeting to re-assess him which took place at the Mahatma Gandhi Hall in central London on Sunday. It was a gathering of 100 or so admirers, of people who want to carry on developing his insights.

Laing's work and writing started from the assumption that schizophrenia is not a disease with symptoms in any conventional sense. No malfunctioning of the brain has yet been detected that explains mental illness. Thomas Szasz, a contemporary of Laing, said that minds could be "sick" only in the sense that jokes were "sick" or economies are "sick".

In The Divided Self, Laing's most influential book, he wrote that it was possible to know just about everything that could be known about schizophrenia without being able to understand one single schizophrenic.

It is from this starting point that flowed both Laing's subversive intent and compassionate response. He was one of the founders of the anti-psychiatry movement which persists to this day. In this view, psychiatry is seen as akin to penology; it is primarily concerned with keeping mad people out of society's way rather than with improving their condition. Its history is a history of constraint.

We even get a glimpse of this in Boswell's life of Johnson. The great man was asked to comment on the unfortunate poet Christopher Smart, who was "confined in a mad-house". Burney had asked Johnson how does "poor Smart do?". He replied: "I do not think he ought to be shut up. His infirmities were not noxious to society. He insisted on people praying with him; and I'd as lief pray with Kit Smart as anyone else. Another charge was, that he did not love clean linen; and I have no passion for it."

One hundred years later new state institutions were set up, with locked wards, padded cells and strait-jackets. Instead of prisons, prisoners and warders, there were mental hospitals, patients and nurses. Later, from the 1930s to the 1950s (when Laing was working in a Scottish mental hospital), came the use of insulin-induced comas, lobotomy and electroshocks. Since then constraint has largely been achieved through the agency of tranquillising drugs. For Laing, the state system which he had seen from inside was worse than useless, because its methods could have perverse results.

At the heart of his analysis was the notion of a person so utterly insecure that in the ordinary circumstances of living, he or she may feel more unreal than real, more dead than alive, precariously differentiated from the rest of the world, so that his or her identity was always in question. Such people may feel more insubstantial than substantial, and they may feel their selves as partially divorced from their bodies.

In these circumstances, everyday life constitutes a continual and deadly threat. Their incomprehensible talk, their weird behaviour, their catatonic states are all to be seen as defensive strategies, designed to protect their poor tortured souls from engulfment, implosion or depersonalisation.

Schizophrenics could be understood and helped, argued Laing, only with compassion and with therapy rather than medical intervention. At the meeting on Sunday, all the talk was of the need to be with people before you could help them, to stand by attentively, of developing an "attuned" understanding of the schizophrenic's situation, of cultivating an ability "to be with". What patients needed, it was said, was an experience, not an explanation such as psychoanalysis offers. Somebody who had worked with Laing said that his patients found themselves as part of a general enterprise of understanding what it is to be human.

It follows that the appropriate setting for such work is a therapeutic community rather than a hospital. For five years in the 1960s, Laing ran such a place, Kingsley Hall in the East End of London, where it became a notorious feature of the counter-culture of the decade. It was chaotic and anarchic and a nuisance to its neighbours.

Clancy Sigal, in his obituary of Laing, wrote that "we were not looking for cures, because there was no madness ... if we stopped thinking in terms of madmen and madwomen and started participating more joyfully in the unhappiness (called "madness") of others, there was some possibility - none of us in our right minds called it more than that - that people in trouble might be helped."

Along with criticisms of conventional psychiatry, the Kingsley Hall initiative has also been developed and refined. In this country a number of small communities have been founded, often called "households" to imply the creation of a sort of family structure. The more ordinary these refuges appear, the more tranquillity they impart. In the United States, ambitious projects have been attempted. On Sunday , Loren Mosher gave an account of two houses he established in California, which operated for 12 years until their funding eventually dried up.

He set out to "de-hospitalise" madness, de-medicalise madness (ie, it is not a disease), to de-professionalise it with the use of staff without mental health qualifications whose first duty was "to be with patients", and to de-drug it. A study has subsequently shown that the outcomes were as good or better than those for patients treated in hospitals. Mr Mosher is having similar success with a much larger undertaking in Washington DC.

None the less, these initiatives and the beliefs which underpin them remain marginal. Thirty years have passed since such notions were first discussed; Laing was their leading exponent. Neither side has been able, once and for all, to vanquish the other in argument, because neither can show convincing proof of its assertions.

Laing's followers argue that therapeutic communities are cheaper to run than state facilities, but the argument does not convince and the medical establishment continues to view schizophrenia as a disease which can be ameliorated, if not cured, with sophisticated drugs.