The World Congress was chaired by Jean Delay, a leading figure in psychiatry, one whose name is linked with pharmacology for his role in the clinical characterisation of chlorpromazine, the first major tranquilliser or antipsychotic drug (the name given these agents, beginning with chlorpromazine). His achievements, important in themselves, obscure another of Jean Delay's major contributions, the desire to organise a major exhibition of graphical work by the mentally ill at the Paris Congress. He delegated this task to a colleague, Robert Volmat. nevertheless, it was Jean Delay, who was the driving force behind the event. The cultural work of this psychiatrist is less well known. Among other things, he authored a magnificent biography of André Gide, in which the personality and psychology of a work's creator are examined as an integral part of the analysis.

Jean Delay had a special intuition about the dynamics of his patients, even though he knew many of them only indirectly, affected as he was by a near-phobia of contact with them. Many remember the discussions of cases and his great ability to identify dynamics that others missed, enabling his students to verify the symptoms directly.

Robert Volmat, the art exhibit organizer, was then a young assistant. He, too, was a man of culture. He was a part of a European tradition of psychiatry based on the humane sciences and not yet focused on the mechanics of the body. These individuals were part of a group of humanist psychiatrists whose absence is acutely felt today.

Volmat devoted himself to bringing the works together, and the resulting exhibition served as the theme for his book L‘Art Psychopathologique, published in 1956. The initial World Congress exhibition was the starting point for an analysis of styles and the relationship between the graphical product and pathology. Evaluation was done in the analysis of the use of colours, while another study examined the techniques and instruments used in representation. A new, empirical vision of the relationship between graphical activity and insanity emerged.

A second key date was 1959. This time it was not in Paris but in Verona, a small city in northern Italy already known to psychology as the birthplace of Cesare Lombroso. In honor of Lombroso, each year a study day was organised on the occasion of his birthday and in 1959 it was celebrated with a major exhibition of psychopathological art organised around the works produced in a unique environment: the atelier of the San Giacomo della Tomba mental hospital. This style and type of output had attracted attention throughout Europe, and was the starting place for painters of international fame both in the world of psychiatry and art world in general producing names such as Carlo Zinelli.

The Lambroso celebration saw the establishment of the Société Internationale de Psychopathologie de l´Expression (SIPE). There was now an established organisation devoted to fostering interest in this form of communication by the mentally ill, charged with the duty of organising international conferences. The goal of the group was to transform what had hitherto been a collection of unsystematic observations into a proper scientific discipline that examines graphical activity both as a sort of ergotherapy and as a form of non-verbal expression. This is especially important in cases where normal communication is difficult (schizophrenia, for example). Another interest of the organization was tracing a language closely tied to the unconscious, a possibility indicated by the observations of other psychiatrists, notably Jung, thus bringing the study into the clinical realm. The society (SIPE) has grown in the number of psychiatrists involved in the field, kept to its mission and over the years, has promoted meetings and expanded the range of its interests. Thus, the 1950 exhibition surveyed the graphical activity of the mentally ill, while the 1959 exhibition witnessed the establishment of a society devoted to the study of such work because of its clinical significance, both as an occupation and as a way of liberating content that would otherwise go unexpressed.

Visual signs could become dear expressions of symptoms, but obviously, there is always the possibility that the patient would produce a work of artistic significance. The latter aspect has always been somewhat ambiguous, because although one could be struck by the beauty of some of the products of madness, there was nevertheless a feeling that the psychiatrist should not invade the world of the art critic, never mind formulate aesthetic judgements. lt was for this very reason that the “art psychopathologique" of 1950 become the ”psychopathologie de i'expression" of 1959.

We have now arrived at 1999 in Hamburg with half a century of history and an occasion not so much to celebrate what has been accomplished, but rather to ask ourselves if it is possible to compare the output of the mentally ill today with other works produced over this span. Any attempt to make such a comparison raises the problem of whether the graphical activity of the mentally ill taps a collective unconscious linked to a historical dimension, or if it is influenced by the culture of a society. A culture that at the level of the individual patient could well have been modified by mental alterations or by the socially-closed environment of the mental hospital.

A remarkable number of conferences and symposia have been organised over these fifty years by SIPE, which has gradually added national sections developing a network of interests and activities. The history of these conferences charts the developments of these past fifty years and it would be a valuable exercise to analyse the results that the various conferences have produced in this field. In short, we should treat the annals of non-verbal communication with the same tools that historians have used in examining the congresses of the Communist International. Obviously, such a task lies outside the scope of this presentation. Here discussion is limited to a number of fundamental strands of work that provide a summary view of the development of this field.

One such strand involved the aim of developing a “graphical chart", which would enable us to associate the different expressions of psychiatric pathology with certain “graphical signs". Special attention was paid to schizophrenia, but efforts were also made to identify correlations with other forms of pathology, from depressive syndromes to manic states and oligophrenia. A second strand involved the use of graphical activity as therapy. The idea was that graphical expression could be used as a way of elaborating conflicts, or even of gaining awareness, and thus hastening the healing process. In fact, many cases have been recorded of patients improving during graphical activity, with violent behaviour going into remission. Such work appears to exert a sedative effect thanks to its power to restrain anxiety and provide a new channel for exchange with the external world. However, there have also been cases where little or no therapeutic effect was observed, or where the situation has even deteriorated. The hope that pencils and watercolours could be used reliably as therapeutic instruments has thus been dashed.

The third strand of research has been examining the graphical activity of the mentally ill within the themes of the unconscious, for which the most methodologically-structured form of interpretation is psychoanalysis. Psychoanalysts had initially used graphical expression to describe dreams, as a more direct and complete means of reproducing their contents. Elements that verbal recounting might miss could be recovered through images. Non-verbal expression subsequently became a form of relationship on its own, an instrument of transference. Underlying this vision were studies in infant psychology and the efforts to apply a Freudian approach to mental disturbances in the very young. Especially in autistic children, where communication may even be non-existent. As Anna Freud herself argued - drawing, gestures, mimicry, become the only way to penetrate the unconscious and establish transference.

Attention then passed from the world of children to that of adults, with the hope that graphical works could be used in the analysis of the ego. This was especially the case with psychotic patients, who could be considered heterodox subjects in the Freudian theory that they would be incapable of transference owing to the loss of the unity of the ego (which is still quite present in the neurotic subject). We therefore have many examples of non-verbal communication being used in psychoanalytical work.

This strand was of great importance because it attempted to look at graphical activity as a language, with its own semantics, syntax and grammar (the art studios were even called ”graphical language laboratories"), with specific characteristics that distinguishes this work from art. The analysis of this language within a psychoanalytical interpretation gave special weight to the graphical symbol, viewing it as a hidden form of communication to be decoded. Accordingly, the graphical analogues of metaphor and metanomy in verbal language were sought. Paintings were seen as a sort of “Rosetta Stone", where the discovery of a symbol could be the key to interpreting a relational difficulty, a symptom or a pathology. Naturally, the way this approach was used varied according to the school of psychoanalysis involved. The most enthusiastic were the Jungians, but less so, the orthodox Freudians. The various schools showing considerable interest in this approach took their inspiration from Lacan, the schools of psychoanalysis applied to psychosis or as mentioned above, the world of children.

Graphical activity thus took on a certain significance, gaining a place within an organised body of psychoanalytical knowledge. At the same time, however, it was also treated as an adjunct, unlike the specificity long accorded to verbal expression. Of particular interest were the studies of the origin and development of the graphical symbol, which at times revealed a slow metamorphosis: a sign became “other" until it configured itself as a symbolic representation that was subsequently elaborated. In these cases the content of the symbol could be read in terms of the object representation from which it was drawn. A mad painter thus emerged from the traditional environment of the hospital atelier. Psychoanalysis deconstructed the location of pictorial activity, reducing it to the locus of the psychoanalytical setting. Although the hopes of the first two strands of investigation were not realised, this third line of enquiry remains alive and, in certain aspects, it represents the surviving use of psychopathological expression.

There remains the problem of place, i.e. where the work was to be produced. Traditionally, this was done within the studio, usually with a group of persons that would come together for a few hours from the various wards of the mental hospital. These art studios had developed systems for the collection and storage of materials, in order to enable serial analysis of the work, following the dynamics of its development, with all its changes in style and representation, rather than limiting analysis to individual works.

In the last fifty years we have seen the gradual closure of the mental hospitals in Italy. Those that survived have seen their size reduced, number of patients reduced and stays shortened. The ateliers thus lost much of their significance. The mentally ill are now handled by a network of mental health services, where they can move from one unit to another, destroying the continuity of graphical work that in some cases had lasted for years or decades over the span of their stay in the hospital. These developments in institutional psychiatry have been accompanied by a change in the way the mentally ill are treated. There has been elimination or reduction of the role of the atelier and the increased emphasis on the psychoanalytical setting, in which any activity is conducted within that setting and is thus tied to that particular moment, with no systematic cataloguing of the work over time. Given that the role of psychiatric institutions will continue to diminish, this use of graphical activity could well come to dominate.

This is the starting point for a new development that keeps alive the hopes of those convinced of the value of long-term graphical activity: art therapy. This new approach to using non-verbal communication is completely different from the traditional, moribund, strand of the psychopathology of expression. It focuses on achieving a therapeutic result using every available instrument, including graphical work. Under this approach, drawing regains its function as a liberating and therapeutic activity in the various settings. Art therapy is based on the psychoanalytic use of non-verbal language but simplifies its interpretative methodologies. In fact there are completely empirical schools of art therapy or group art therapy, while others make no reference to psychoanalysis whatsoever. Art therapy has come to dominate the field of non-verbal communication in a number of countries, especially the Anglo-Saxon world. Obviously, we are talking about completely methodological approaches, both as regards the long years of work in the hospital ateliers and the analytical content. Nevertheless, it is probably the most promising sector of endeavour, although in our view it needs more solid structural foundations than easy empirical enthusiasm. These, then, are the major strands of work that recount the story of SIPE.

Let us now look back to 1983, a landmark year in the Organisation of studies in this field. SIPE was an independent grouping, whose work was enriched by the contributions of historians and artists, with other input coming from graphologists, philosophers, art critics and psychiatrists. There was a risk that it would stray from the field of psychiatry entirely, and with this, any medical and scientific foundation. For this reason a group headed by Robert Volmat (the long-time president of SIPE), decided to apply for recognition in the World Psychiatric Association (WPA), asking that the psychopathology of expression be accepted as a Section of the WPA. This request in a sense represented a return to the origins of the field, given that the 1950 exhibition was organised under the auspices the First World Congress of Psychiatry, and SIPE itself had been established in Verona with a typically psychiatric orientation.

There was a feeling at the time that it was essential to bring this field back within psychiatry, to involve researchers within the framework of the international psychiatric community. They were years of crisis for SIPE with poorly attended conferences, lack of funding for an international publication devoted to the field, and so on. The president of the WPA at the time was Prof Piseau. For Volmat, dealing with a president who had long expressed an interest in non-verbal communication was a dream come true. Piseau readily accepted the proposal and worked to convince the leadership of the organisation of its validity. At long last, the psychopathology of expression became a section of the WPA, complete with a statute modeled on those of the other WPA sections.

The psychopathology of expression section thus had an enormous opportunity to present its own symposia and conferences and disseminate its studies and research. The field could now stand on its own among equals in an arena without parallel. By way of example, the last World Congress in Madrid was host to 10,000 psychiatrists. It was now possible for the psychopathology of expression section to take an active role in world psychiatry, helping to stimulate interest in non-verbal communication.

Thus, since 1983, there have been two organisations involved in this field; SIPE, which has continued along its traditional path, and the Section for the Psychopathology of Expression of the WPA, whose efforts are more tightly focused on clinical psychiatry. The two bodies are not redundant. The statute of SIPE, which is the product of a long and independent history, provides scope for work on the most varied issues in a broad cultural context, while the Section for the Psychopathology of Expression of the WPA has a narrower focus on psychiatry and its problems.

A problem that needed to be addressed within the WPA was whether an exclusively psychiatric section could alter its foundations. This is why we requested that members of the psychiatric therapy team without medical training be admitted. In other words, we wished to open membership in the section to psychologists. Nevertheless, its psychiatric identity is very strong, an essential condition for continued membership in the WPA.

It is to be hoped that these two bodies can continue to function independently while maintaining their fundamental integration. Those who would argue that one or the other is superfluous are wrong. They have a poor grasp of the history of the field and thus misinterpret the great achievement of 1983.

Any history of the psychopathology of expression must include an account of the congresses of the WPA, which have served as a stage for the graphical world of the mentally ill and non-verbal communication. This year's Hamburg congress is an example, playing host to four symposia on the psychopathology of expression in addition to the exhibition that is the subject of this catalogue.

At this point, however, we should return to an issue that we have mentioned only in passing. That is the purely artistic interest of the work of the mentally ill. We noted the shift in emphasis from ”art” to “expression" in the early stages of the field's history. It was argued that the psychiatrist is not competent to issue an artistic assessment of such work. This cannot be the end of the story, however, even if we only wish to argue that it would be unjust to exclude a priori the possibility that a person suffering from mental illness could produce a work of art. From a theoretical point of view such a restriction is untenable. Recall Cesare Lombroso, who argued the very opposite, i.e. that the madman is favoured by his condition because he lives beyond the rational world, because he is detached from the quotidian, and therefore can directly tap the freedom that is necessary for creation.

A psychiatrist has the right to ask that the art critic assess the works produced by the mentally ill without reference to the background of the painter, which could otherwise channel the response into the standard framework of the incompatibility of art and insanity. Obviously, the madness of the author should be considered but it should not be allowed to affect the aesthetic judgement. This is important because the incompatibility of art and madness has been sustained not only in abstract treatises on aesthetics but also in the real world, with such work being denied exhibition space and ridiculed. I do not believe in any necessary connection between art and insanity. However, neither do I believe that we can argue that creativity is ruled out by or dependent on madness. The hospital studios have never been considered the best schools of the time, but we cannot deny that some patients have achieved a high level of creativity, earning the praise of the broader public. The psychiatrist cannot evaluate the artistic value of a work. At best he can decide to hang the work in his home. Still, he can insist that those who are qualified to make such a judgement use the same measure to assess a work by a person suffering from paranoia in an asylum as they would to judge the work of an authentic bohemian. There is nothing to exclude the possibility that the most insane person might express himself artistically.

In this regard, we should now examine the phenomenon of art brut. Art brut emerged as a movement around 1940-41, the creation of Jean Dubuffet, who decided to collect the works of art produced by artists brut, i.e., people who produced what he called ”art non culturelle". These were artists who had not been trained in the academies or in the studio of a master artist, who did not belong to what he called the ”asphyxiating culture” of art. These were the beginnings of the collection that after the war found a home at 137 Rue de Sèvres. The Companie de Art Brut was composed of a small group of close friends, who were the active, decision-making members of the company. As a member admitted in 1966, I was thus able to follow this other strand of work produced by the mentally ill. In fact, 85% of Dubuffet's collection was work produced by the mentally ill. In other words, his definition of “non culturelle" and art was closely linked to mental illness.

When in the early seventies it was no longer possible to keep the works in their original home, there number having increased considerably, the Compagnie de l'Art Brut decided it was time to establish a permanent museum open to the public. The idea was to create an art museum largely dedicated to the work of painters who had experienced madness. The Compagnie decided to donate the entire collection to France, asking in return for an appropriate site and a commitment to continue the collection. The Government of the time rejected the proposal out of hand, influenced by the painters' union, which argued that the insane should not be confused with real artists. It was a grave disappointment to discover that a world we had thought would be more open-minded the, ”creative world” was instead ignorant and prejudiced.

It was then decided to offer the collection to another country as long as the basic conditions were met. The City of Lausanne made the offer that most closely matched our wishes and the collection of art brut was ceded to the city, which continues to manage it very well to this day.

I was the only psychiatrist in the Compagnie de l´Art Brut, with the exception of André Breton, who was trained as a psychiatrist but did not practice. The group was formed of artists and others from a wide variety of cultural, humanistic and philosophical backgrounds. I mention this fact because art brut became associated with insanity. It was in a certain sense a response that a psychiatrist could request of someone in the art world to look at the work of the mentally ill produced in a hospital art studio in Mont Martre or New York and apply the artistic criteria you normally use to the work.

This attitude led to the discovery of a number of good artists among the mentally ill and a very small number of geniuses. The three most impressive are Aloise, Adolf Wölfli and Carlo Zinelli, who have rightly received close attention from the art world. In fact, Zinelli is recognised as one of the most significant painters of this century.

Clearly, the issue of art in madness requires many distinctions. There are painters who have gone mad, mentally ill persons who had never painted before entering a mental hospital and painters who painted both before and after the onset of their illness, demonstrating differences in style and manner between the two periods. Dealing with all of these is far beyond our scope here. Accordingly, we shall continue to focus on art brut and the efforts of the Compagnie, which deserves praise for following through with an intuition that has led to the creation of a collection of highly significant works that would otherwise have been lost. It brought attention to an anonymous world and found a place for some in the world of ”Art”. This is a major achievement, both in terms of the creativity it unearthed and the humane approach it embodies.

However, it is not possible to be entirely satisfied with the approach, which should now be more of historical interest than anything else. It is still important but with significant limitations in relation to our needs today. If the mentally ill produce work that is artistic, then this work is art. There is no need for any modifying adjective. The meaning of “cultured" or “uncultured", "cultural” or "brut" was already highly debatable during the movement's period of greatest enthusiasm. It is even more suspect today. We cannot automatically call someone with a low level of education "brut", because he may well be highly cultured in other ways. By the same token, this adjective, which proved very powerful at the time (leading as it did to the creation of a movement and a museum), cannot represent a category of art. We must go beyond such classifications and speak of art alone. Hence, no special museums and no more absurd rules that prevent an artist brut from selling work, because the market was considered a degeneration and falsification of art. In fact, it is hard to understand why Dubuffet the painter could belong to the world of art and have his work shown in museums, while the artist brut had to remain outside. This is a form of “ghettoisation" that must be banished.

If we wish to address the problem of art in mental illness, we must discuss art alone, as it exists at that moment in time, without absolute definitions. The work of the mentally ill should be assessed by the critics of the time, applying the criteria that are used to judge any other work regardless of provenance. If the work meets certain criteria, then it is art and should be treated as such, whether this involves being sold in the market, shown in galleries or hung a major museum. It must no longer be restricted to Rue de Sèvres or the Lausanne museum. The latter is worth maintaining as an example of helpful, but dated, archaeology. I cannot say if the works exhibited in Hamburg at this year's World Congress and published in this catalogue are art or not. I do ask, however, that those who are qualified to make such an assessment do so without prejudice regarding its origin. If it is indeed art, let this evaluation speak for itself, avoiding additional adjectives that serve only to diminish, isolate, or denigrate. This issue will become a matter for discussion because it is an area that is not directly part of psychiatry but which nonetheless contributes to psychiatry. It reminds us that insanity is not a wasteland of degeneration, but in fact retains enough humanity even to aspire to Art.