refers to an individual’s state of mind that is ‘out of touch’ with reality. The individual has no understanding that they are in this state. Typical symptoms include hallucinations (hearing, smelling or seeing things that are not there) and delusions (believing something to be true that others deem impossible).
This chapter aims to:
demonstrate how the field of psychiatry has been shaped through its development as a medical speciality, but also by the emergence of a psychological outlook that theorised a ‘mind’ that could become disordered and, therefore, could be subject to psychological treatment
show that wider issues of social policy and criminal justice have also left their mark on the field of psychiatry
highlight the considerable public debate surrounding the field, and the influence of popular opinion
explore the increasing scope of psychiatry, which now covers all areas of life (from cradle to grave) and an ever-growing array of disorders.
1 ‘Madness’ before psychiatry
While the recognisable profession of psychiatry only emerged in the nineteenth century, ‘madness’, as Porter (2002, p. 10) suggests, ‘may be as old as mankind’; follies, fools, madness, grief and despair are staples of Shakespeare’s plays (performed for the first time roughly between 1590 and 1610), for example. By the time that popular ideas and everyday concerns were being written down and printed (a process only just beginning in the seventeenth century), there was apparent interest in what we would now view as ‘mental illness’.
Psychiatry The specialist branch of medicine concerned with the treatment of mental illness.
Often mentioned as a milestone on the path to the establishment of a systematic literature was Robert Burton’s (1638) The anatomy of melancholy, first published in England in 1621. The word ‘melancholy’ here appears not to specifically mean ‘sadness’ in the modern sense, but rather conveys some general malaise or mental distress. It is a sprawling compendium of seventeenth-century knowledge and philosophy and an attempt to grapple with the causes of human happiness and unhappiness. It was to be a hundred years later that books more recognisable as medical texts on mental illness began to emerge. Notable was The English malady written by George Cheyne in 1733, or as its subtitle further explained, ‘a Treatise of nervous diseases of all kinds; as spleen, vapours, lowness of spirits, hypochondriacal, and hysterical distempers, etc.’. Cheyne (1733, p. i) notes the observation of an English malady that came from ‘foreigners and all our neighbours on the continent’, and acknowledges its accuracy, suggesting as many as one-third of the population were so afflicted. He proposed that among the causes were ‘the moisture of our air, the variableness of our weather’ as well as modern social conditions including ‘the richness and heaviness of our food’, the ‘wealth and abundance of the inhabitants’, the sedentary lifestyles of the better off, and the difficulties of ‘living in great, populous, and consequently unhealthy towns’ (Cheyne, 1733, pp. i–ii).
It is difficult to know how well Cheyne’s proposed eclectic jumble of causes and cures (including the importance of diet, exercise, greed, consumerism and state-of-the-art knowledge of physiology and the workings of the nerves) was received at the time. Most people could not read, let alone afford to buy a book (Stone, 1969), so Cheyne’s ideas would have been seen by a tiny minority of the population on which he was commenting. In this respect, MacDonald’s (1981) analysis of the notes made by the seventeenth-century English medic Richard Napier perhaps give us a rare insight into the maladies suffered by ordinary people who sought help, and the available treatments before there were any recognisable specialist mental health professionals. While we might take some care not to simply translate Napier’s categories (listed in the table below) into modern equivalents, the list that MacDonald creates does certainly look remarkably familiar (see Table 1.1).
Table 1.1
(Source: based on MacDonald, 1981, Table 4.1, p. 117)
The most common varieties of unhappiness seem to be versions of anxiety and fear, or of sadness: grief, melancholy and mopishness. MacDonald (1981) suggests that patients overwhelmed with feelings of sadness and lethargy and who were drawn from the peasant classes were likely to be labelled as ‘mopish’ by Napier, while those from the wealthier echelons with similar complaints were likely to be viewed as ‘melancholic’ (with its associations to delicacy and thoughtfulness). Contemporary questions about social class and diagnosis are taken up in other parts of this book, particularly Chapter 19.
MacDonald also analysed Napier’s thinking around the causes of such maladies. He found that they could be divided into three categories:
supernatural referred to astrological concerns
divine and diabolic referred to the actions of God and the Devil
natural referred to ‘ordinary’ adaptive responses and included grief, disappointments in love, physical problems, too much study or the balance of the ‘humours’.
In terms of treatments, Napier was eclectic in his therapeutic outlook. Various interventions were aimed at the body, including those intended to restore the balance between the four bodily humours, or fluids (an idea that stems from an ancient understanding of good health). Thus, there were recommendations for purges: emetics and laxatives, as well as various forms of bloodletting (such as the application of leeches). Medicines, such as opiates (for lunacy and madness), were prescribed alongside astrological guidance and advice on diet, rest and exercise. MacDonald emphasises the holistic approach and the continuity with apparent everyday concerns, but mourns the fact that Napier was one of the last of his kind. There were already powerful forces gathering that would no longer construe mental unhappiness in such holistic terms. MacDonald suggests that the main driver for this change was the growing culture that venerated science and rationality and thus nurtured the medical speciality of psychiatry.
The following century, which witnessed the stirrings of this specialism was, in MacDonald’s words, ‘a disaster for the insane’ as they became subject to crueller treatments and ‘confined to madhouses and asylums’ (MacDonald, 1981, p. 230). In making this claim, MacDonald, like many critics of the emergence of psychiatry, gestures towards the significance of Michel Foucault’s work on the history of psychiatry. Foucault is perhaps the most influential critic of psychiatry, so it is worth dwelling on the crux of his argument, which can be summarised by this often quoted passage from the preface of his 1967 book Madness and civilisation: a history of insanity in the age of reason:
In the serene world of mental illness, modern man no longer communicates with the madman… As for a common language, there is no such thing; or rather, there is no such thing any longer; the constitution of madness as mental illness, at the end of the eighteenth century, affords the evidence of a broken dialogue, posits the separation as already effected, and thrusts into oblivion all those stammered, imperfect words without fixed syntax in which the exchange between madness and reason was made. The language of psychiatry, which is a monologue of reason about madness, has been established only on the basis of such a silence.
(Foucault, 1967, p. xii)
Foucault suggests that, before the ‘age of reason’, madness was a part of all of us and our communities. The modern era of reason, often called ‘the enlightenment’, was marked by great scientific endeavours that led to the Industrial Revolution, which demanded rational thought and behaviour
