in England at that time, where institutions were largely private, entrepreneurial ventures, rather than State-governed. In accord Shorter (1997) states that there was slow development of the public-sector traditional asylum in England, which numbered only seven charity-run institutions apart from Bethlem and the numerous privately-run institutions. These served to modestly supplement the numerous privately run institutions, where the early version of the ‘alienist’ practiced or attended the afflicted wealthy in their own home. Furthermore, despite the rise of asylums in England at this time, admission numbers remained remarkably low:
By 1826, when national statistics became available in England, only minimal numbers of individuals found themselves in either private or public asylums. Not quite five thousand insane people confined in any form, 64 percent of them in the private sector, 36 percent in the public. Bethlem and St Luke’s together numbered only 500 patients, and a further 53 insane individuals were in jails – this in a country of 10 million people (Shorter, 1997: 5).
In keeping with the new spirit of optimism towards the asylum as curative, as opposed to segregatory and punitive, the view that insanity could be retrained into rationality manifested itself in a form of care known as ‘moral treatment’, as exemplified by William Tuke’s institution for mentally ill Quakers, ‘The Retreat’, at York in 1729. Here the emphasis lay equally upon firmness but kindness in dealing with the antics of the insane, helping them to conform to the boundaries of rational behaviour and civil discourse, with work playing an important part in occupying hands and minds (Black, 1988). As Porter (1983: 36) elegantly states, the Enlightenment drew upon the analogies of wider State politics and the individual psyche to create the representation of the ‘rational government of the parts, madness the appetites’ insurrection’. Foucault’s (1971) analysis of power and madness accordingly argues that Tuke’s demand for rational behaviour among residents was the less than benign substitution of the (terrifying) freedom of madness from normal constraints by the madman, to the imposition of the crushing awareness of self-responsibility.
Moral treatment was not applied to the mentally ill alone, for in the American colonies it was also considered appropriate care for physical illnesses, in which there was displayed as considerable a concern for moral and spiritual aspects, as for physical rehabilitation (Luchins, 1989).
The ideology behind hospital admissions during this period was consequently based more on ‘social and moral criteria than on the nature of the person’s illness’ (Luchins, 1989: 587). Perhaps not surprisingly, given such rationale, we learn that hospitals in the late eighteenth and early nineteenth century were regarded as highly stigmatising charitable institutions. Moral treatment in hospitals, similar to asylum care under the same philosophy, emphasised the removal of afflicted individuals from the contaminating influences of their home and peer environment, thus rehabilitating them into ‘humane, civil, productive and responsible citizens’ able to withstand the ‘temptations of their neighborhoods’ (Luchins, 1989:587).
The concept of the ideal asylum evolved from the eighteenth up to the twentieth centuries and was seen to be one that was designated into functional areas, which in turn would be replicated through reinterpretation in the colonies These areas provided, in literally concrete terms, a means for guiding the patient into the orderly rhythms of normality. The building in itself was seen as a material method of rehabilitation; suitable architecture therefore providing metaphorically the rational parameters necessary for the promotion of rational living (Saris, 1996; Turner, 1992). Lindsay Prior (1993) notes that documentation from as late as the 1940s describes the ideal hospital environment as a completely segregated, self-contained community located in a large, secluded rural area where all categories of patients could be cared for. This may have seemed something of an ideological departure in respect of one of the earliest institutions for the insane - Bethlem (Bedlam) - which as the conurbation grew, would later be more centrally situated in London at Bishopsgate (Ng and Chee, 2006). In the sixteenth century, however, the institution stood slightly beyond the parameters of the compact city.
These enclosed institutions in pastoral settings, to which Prior (1993) refers, historically included not only the mentally ill, but a miscellaneous population comprising the mentally retarded, the sick, vagrants and criminals (Shorter, 1997). The concept of the self-enclosed community offers a chilling description that is immediately recognisable as conforming precisely to Erving Goffman’s definition of the ‘total institution’ (Goffman, 1968: 296; Goffman, 1991).
The humane and rational treatment of the insane could be delivered reasonably well in England and the Empire, with only a limited number of individuals accommodated in asylums. Unfortunately, the early nineteenth century saw a massive rise in admissions – a phenomenon that also occurred in Europe, the American colonies and, as will be seen, at a later date in colonial Malaya as well as in several other colonial psychiatric institutions (Ernst, 2010; Jackson, 2005; Sadowsky, 2003). The late nineteenth-century asylum would of necessity abandon much of the rehabilitative content of care and more importantly would become an increasingly closed community, heavily custodial and characterised by locked wards. Duly these responses to overcrowding would be re-enacted in asylums in the Malayan, Indian subcontinent and African regions (Clark, 1966; Ernst, 2010; Fernando, 2010; Jackson, 2005).
Shorter (1997) states that within the first decade of the nineteenth century there were sixteen new asylums built in the London area alone, including Colney Hatch, which held 2,200 beds and the Hanwell Asylum, West London with 2,600 beds.
What were intended by early Victorian reformers as small country houses to provide refuge for not much more than one hundred inmates had been transformed by the end of the century into sprawling ‘stately homes’ that behind their elegant facades reproduced the worst conditions of urban overcrowding (Barham, 1992: xi).
The reason for this enormous increase in the number of detainees in asylums is a highly contested area: for Sutton, asylums in England appear to have been used for a large scale exercise in socio-behavioural control, where they became a ‘dumping ground’ for the physical and mental wrecks of industrial capitalism (Sutton, 1997: 52). Shorter responds by ascribing the increase to three main factors. Firstly, the enormous rise in neurosyphilis and secondly to a significant increase in alcohol abuse. Finally, Shorter, following Scull, points to a radical change in the structure of the family, which would no longer accommodate the disruptive presence of the insane in its midst (Shorter, 1997; Scull, 1979). Furthermore, Lis and Soly (1996) suggest that upper-class families initiated the search for custodial care for unruly, violent and immoral relatives, followed eventually by proletarian families, and this largely on economic grounds, so that asylum admission would represent only a temporary suspension of labour, particularly in the case of men.
Complicit psychiatry
Historical overviews of the birth of psychiatry have inevitably expanded to include these developments in the colonies; and the transported evolution of asylums from concentrated sites of colonial activity to macro-scale national assimilation and adaptation. Comparisons often depend upon the numbers of psychiatric institutions, trained staff and budget allocation prior to the postcolonial period, with the exponential growth in these areas since, which is constructed as an unqualified good. Accordingly, we learn that while there were only four, albeit very large, psychiatric hospitals in the Dutch East Indies, by the 1970s this number had doubled in Indonesia (Pols, 2006). Likewise, in Pakistan, since Independence the numbers of psychiatric institutions has grown exponentially (Gilani et al., 2005). Deva (2004) in turn reports similar developments that have taken place in Malaysia, of which more will be said.
Goldberg et al. (2000) provide a useful context by which to measure these apparent improvements, by pointing out that the overwhelming majority of the world’s population live in the developing world and many of these countries have experienced colonialism. Thus, the historiographies of biomedicine have intersected with those of colonial rule; and the latter, as Keller (2001) points out, has been duly strengthened by a Foucauldian
