health problems, how we treat them, and how we regard them.
It looks at the stigma attached to mental health and at our lack of kindess towards people who are mentally ill.
It examines how our thinking has grown out of past experience, and tells the history of attitudes towards people with mental illness. It asks whether we are any more enlightened than our ancestors were, and whether our new drugs and other interventions make the lives of those with enduring mental illness any easier.
It looks at whether we use the mental health system as a form of social control and ask whether the experience of innumerable cases where things have gone very wrong tell us that those who work in mental health do not care for their patients.
It will also examine the increasingly risk-averse public policy climate and ask if the mental health world can ever be risk free. And it will also ask whether, if the views of service users were taken more seriously, there might not be better outcomes, with people being able to work and live comfortably, secure in the knowledge that if a crisis arises there will be proper care available from a team already known to the individual.
Finally, it will ask the essential question: if we were seriously concerned to care for, and even cure, those with enduring mental illness, would we ever have invented anything remotely like the present system?
Psychiatry as Social Control
We are not alone in our attitudes towards mental health. Many countries, many systems, are the same. How we treat people with enduring mental illness is a blot on the consciences of most of the developed nations, and on quite a few of the developing nations as well. In addition, there has always been the risk of political manipulation: in many countries those who have opposed the ruling system have found themselves confined to the asylum. This was most prevalent in the former Soviet Union, when dissidents were pumped full of drugs and left in the mental wards to rot. Nazi psychiatrists, too, took part in the most appalling destruction of people with mental illness and learning disabilities in the 1930s, long before the extermination of Jews and gypsies. The so-called T-4 programme was devised by psychiatrists alongside Nazi ideologues. The programme was finally ended in 1941, but not before an estimated 80–100,000 people had been killed, including the so called mercy killings of the ‘insane’ and of roughly five thousand ‘deformed’ children.*
This history of the use of psychiatry as a means of social control led to a critique of psychiatry in the late 1960s and early 1970s led by Thomas Szasz, Professor of Psychiatry at Syracuse University, New York. He argued that mental illness was a man-made myth and suggested that psychiatry as a discipline was a pseudo-science, comparable to alchemy and astrology. Michel Foucault, the profoundly influential French historian of culture and ideas, rather agreed. For him, and for Szasz, psychiatrists became, as Roy Porter puts it, villains, and their discipline akin to a form of magic. Martin Roth and Jerome Kroll argued precisely the opposite–that there had been real progress in the study, diagnosis, and treatment of madness and psychopathologies and that there was a real organic basis to mental illness.
The truth is that there has been a terrifying and disgraceful history of using psychiatry and its antecedents as a means of social control, whilst at the same time some of the treatments, both pharmacological and psychotherapeutic ‘talking’ remedies, have proved beneficial and effective for some, but not all, sufferers.
To understand how we view mental illness now, at the beginning of the twenty-first century, we must look back at the history of mental illness and its treatment.
Possession by demons and other evil spirits may not be part of our intellectual armoury now, yet when we bury our dead (in Jewish ritual anyway, and in many other practices) we still stop up bodily orifices to prevent them being invaded by evil spirits, and pause on our walk to the grave to shake off any lurking demons. Belief in evil spirits is just below the surface in many of us, as we touch wood, avoid walking under ladders, and look askance at black cats. Yet all this is intimately tied up with how we view those who have mental illness. Do we think they are possessed? (Sufferers themselves often take that view.) Or do we regard them in the same way as we would do if they had a physical illness? If so, why don’t we allocate them the same resources, and treat them with the same consideration, as those suffering from physical illness? Do we believe they need to be controlled, as their containment in the old asylums would suggest? If so, is that for their protection or ours? All these questions may have half-answers in our minds; but society is split, and individuals within it are confused, about mental illness and how to care for those who suffer from it.
Historical Reflections
Before the witch craze of the fifteenth to seventeenth centuries, treatment of mental illness was often kinder. Much mental derangement was viewed as being inflicted by Satan and was therefore susceptible to the saying of masses, pilgrimages, or indeed exorcism. Protestants had a different view. The Anglican divine Richard Napier doubled as a doctor and specialized in healing those ‘unquiet of mind’. He thought that many of those who consulted him were suffering from religious despair (something still cited by many of those with mental illness in the twenty-first century, and less than comprehensible to many of the rationalist, post-religious, mental health professionals). They feared damnation, the seductions of Satan, and the likelihood of being bewitched. Napier’s treatment was prayer, Bible readings, and counsel–the talking therapies so many people with mental illness ask for now.
The excessively religious were also thought of as mad. Many of Wesley’s followers in the early days of Methodism were thought fit only for Bedlam (the Bethlem Hospital, now part of the Bethlem and Maudsley hospitals configuration), even though Wesley himself still believed in witches and demonic possession. His followers, at what might be described as revivalist meetings, would cry out and swoon uncontrollably. Many thought this must be madness. The same was said of Anabaptists, Ranters, and Antinomians. They were thought to be sick (puffed up with wind) and doctors and others who believed in social control pointed out that the religious fringe and outright lunatics shared much in common: they all spoke in tongues (glossolalia, now prevalent in much of the evangelical side of modern Christianity), and suffered convulsions and spontaneous weeping and wailing. Towards the end of the eighteenth century, with the rise of rationalism, doctors and scientists berated the Methodists for preaching hellfire and damnation, which they said led people to abuse themselves and commit suicide. Religious visions became a matter of psychopathology, and those who experienced religious yearnings and visions were thought mad.
As belief in witchcraft diminished new scapegoats appeared–beggars, vagrants, and criminals. But the idea of the rational had come to stay. Religion itself had to be rational–why else would John Locke write The Reasonableness of Christianity (1695), and why else would Freud and his allies later describe God as wish fulfilment? Belief was all too real. Its object, however, was not real at all; it was a projection of neurotic need, explained, as Roy Porter describes it, in terms either ‘of the sublimation of suppressed sexuality or the death wish’.* Porter also points out that, in time, the medical profession replaced the clergy in dealing with the insane.
The religious view had been accompanied since ancient times with a different, scientific, view. Galen, the ancestor of modern medicine, had described melancholy and other mental illness and Aretaeus of Cappadocia (c. 150-200), a contemporary of Galen’s, had already identified bipolar affective disorder with his descriptions of the depths of depression and the delusions that could accompany it and the patches of mania, the rapid extreme mood swings, that define classic manic depression. Not until Richard Burton’s Anatomy of Melancholy (1621) was a better, fuller description given of depression, as he reviews the old explanations of blood, bile, spleen and brain, whilst adding lack of activity, loneliness, and many causes. His recommendations
