To Foucault, psychiatry was an important mechanism for enforcing such norms. It invented a language that talked about insanity as if it were an object that was separate from one’s self. Those judged to be ‘insane’ were banished from normality, so efforts could be made to separate, confine and treat ‘them’. This perspective also applies to even the most benign-looking initiatives, such as ‘moral treatment’ (discussed below) and the various ‘talking cures’ (described in Chapter 3) that followed.
2 The birth of psychiatry as the medical specialism of the mind
Accounts of the history of psychiatry tend to place the origins of recognisable forms of a specialist profession at the very beginning of the nineteenth century (Porter, 2002; Scull, 1979a), with the formal establishment of professional associations and journals occurring in the 1840s. Before this there were ‘mad-doctors’ who ministered to the insane and confined them in ‘madhouses’, while occupying ‘a niche slightly above a witch doctor in the public imagination’ (Boime, 1991, p. 79).
The transformation was energised by two innovations that involved the identification of ‘the mind’ of the patient as itself a significant field of enquiry and treatment. Firstly, there was the emergence of moral treatment, a landmark that initiated the practice of systematic ‘psychological’ treatment. While on the one hand this was arguably a significant precursor to many different forms of psychological treatment that were to follow, it was also a key argument that justified the large-scale building of asylums across many parts of Europe and North America in the nineteenth century (Scull, 1979a). The asylums came to dominate the landscape of mental illness for well over a century and in many ways we still live in their shadow (Rogers and Pilgrim, 2014). Secondly, there was the development of a set of ideas that construed some instances of serious criminality (particularly involving violence) as symptoms of mental disorder. This claim of expertise in criminal and legal matters was fundamental to the aspiration for professional status and recognition (Goldstein, 1987). Both innovations were underpinned by the relatively novel idea of a psychological domain – a world of the mind – which could be explored and treated by those with sufficient expertise (Jones, 2017a).
Examination of these ideas illustrates how the development of psychiatry needs to be understood as a product of various and often contradictory forces. Alongside the intention to find ways of alleviating distress were the more entrepreneurial pressures of those who wanted to build professional status and earn a living. There were also the anxieties of governments conscious of the threat posed by those who did not conform to social norms.
2.1 The asylum movement and moral treatment
Activity 1.1: Experiences of asylums
Allow about 10 minutes
What thoughts and feelings come to you when you hear the word ‘asylum’? Are they largely positive or negative? Can you identify what images give rise to these positive or negative feelings?
Spend some time trying to tease out why you feel the way you do.
Discussion
While the word ‘asylum’ – with its literal meaning of protection and safety – ought to have positive associations, for many the word will have negative meanings. Perhaps the negative associations are connected to the old asylums. As you have read, although the asylums were perhaps built with the intention of providing rest and safety, they became overcrowded, neglected and gloomy places. Perhaps our feelings are also influenced by the stigma that surrounds mental illness.
It might be interesting to reflect on whether this chapter changes your view of asylums.
The idea of confinement for those deemed insane was not new. Small-scale, private asylums operated by entrepreneurs who offered a paid service to take in and ‘care’ for the insane had proliferated through the eighteenth century. By the nineteenth century these institutions were being encouraged by a government which had a long-standing interest in controlling those whose deviant behaviour might threaten the social order. Since at least the sixteenth century, the government and local parishes had discouraged vagrancy and begging through a series of legislative initiatives called ‘poor laws’ (Brundage, 2002). The means of discouragement were frankly often cruel, with punishments such as whipping and branding dealt to those found vagrant.
As the perceived scale of the problem posed by the workless and destitute grew, a network of workhouses was built to provide minimal sustenance and accommodation to those too poor to support themselves. They also aimed to ‘train’ people in the values of labour and routine amid harsh environments that discouraged dependency. Whatever our moral judgement of the philosophy, too many people were simply unable to respond to the regime, and the workhouses filled with people who were old, ill or had disabilities. The next move was to differentiate ‘the poor’ so that particular kinds of shelter might be offered to those who were unable to benefit from the workhouse regime. A significant milestone came with Section 20 of the Vagrancy Act 1744, which charged local magistrates with responsibility for paupers and so-called pauper lunatics in their district (Bynum, 1974).
Pauper lunatic A term used in the eighteenth and nineteenth centuries to identify individuals who required local authority support due to poverty and who were also recognised to be suffering from insanity.
The identification of the ‘pauper lunatic’ as someone who required local authority support encouraged the expansion of private madhouses as they became a convenient means for local parishes to discharge their duty. These were controversial institutions, growing up as unregulated places of confinement with unclear rules about who could be confined against their will. In the early decades of the eighteenth century, the writer and journalist Daniel Defoe (author of Moll Flanders and Robinson Crusoe) noted the proliferation and wondered ‘how many ladies and gentlewomen’ were being locked away (Defoe, 1729, p. 23). He suggested that these private madhouses needed to be ‘suppress’d, or at least subject to daily examination’ (Defoe, 1729, p. 23). He reserved particular ire for a ‘vile practice’ that he suspected was common among wealthy men of ‘sending their wives to mad-houses at every whim or dislike’, allowing them to be ‘undisturb’d in their debaucheries’ (Defoe, 1729, p. 31). This claim was to be picked up in the twentieth century by a number of feminist critics of the psychiatric system. Chesler (1972) and Showalter (1985) argued that the institution of psychiatry and the various treatments that emerged through the nineteenth and into the twentieth centuries were profoundly patriarchal and were meant to pathologise and control women. The idea that the categories of insanity were aimed at women, and that asylums were correspondingly full of women, has been beguiling (Ussher, 1991).
Detailed analysis of asylum records, medical texts and cultural images suggests, however, that this was too simple a picture. As Busfield summarises, the idea that madness in the nineteenth century became ‘a distinctly female malady’ was certainly mistaken – it would be better to understand that ‘assumptions of gender’ were embedded within the multiplying ‘diversification of medical categories of madness’ (Busfield, 1994, p. 276).
Pause for reflection
Do you think there are differences in the way that men and women are portrayed as suffering from mental health problems?
Nevertheless, distaste grew about conditions in the private madhouses, and in the anxiety that ‘anyone’ might find themselves confined within them. This led the British Parliament to pass the Madhouses Act 1774 that brought the unregulated private asylums under supervisory control through systems of licencing and inspection. It was into this space of regulation and care that the new profession was to emerge. The emergence of
