Darwin’s On the origin of species (published in 1859). What emerged was a rather eugenical turn as assumptions were made about the heritability of criminality among an apparent underclass. These played out in programmes of confinement and sterilisation, most notably in the US (Rembis, 2011), leading up to their catastrophic use by the Nazi regime in the middle of the twentieth century (Breggin, 1993).
One important consequence of the medical profession’s shift away from the psychological realm was that the ground of psychological enquiry became available to other professions for developing theories and treatments of the mind. As Chapter 3 will explore, it was initially psychoanalytic ideas, instigating the ‘talking cures’, that opened a new domain of psychological methods of investigation and treatment. To an extent a split was established between the medical specialism of psychiatry – which has tended to maintain a strong allegiance to the medical model – and those who have sought the further exploration of ‘psychological’ treatments. The boundaries are porous, however; while the roots of psychiatry are firmly embedded in the world of physiology, the profession has also been significantly shaped by the belief in a ‘mind’ that is amenable to treatment (Jones, 2017a). At the same time, the assumptions of the medical model – that there is an illness located within the body (including the mind) of the individual – are quite widely accepted within the world of mental health, including in many models of counselling.
Medical model The idea that physical and mental difficulties experienced by an individual can be understood in terms of an identifiable disorder existing within that individual.
3 The fall of asylums and the move to community care
Whatever the motivations of those who planned and built the asylums across many countries in Europe and North America, there can be no doubting their popularity, as their populations greatly outgrew the intended numbers. The hopes of providing peace, rest and pleasant interaction with purposeful staff were dashed by overcrowding and understaffing. Asylums largely came to deserve their characterisation as dismal prisons, or warehouses for those who were unable to look after themselves or who were rejected by their families and communities (Scull, 1996). This all lent support to those who pointed to the coercive and controlling nature of the psychiatric enterprise itself. Just as the more subtle and psychological model of moral insanity failed to survive amid the storm of a hostile press, moral treatment also failed within the wholly underfunded new asylums. This failure pushed psychiatry back to a more despondent understanding of mental disorder, one based on assumptions of inherited weakness (Scull, 1996).
Asylum populations began to fall in the middle of the twentieth century, peaking in England in 1954 and falling rapidly after that (Tooth and Brooke, 1961). The reasons for this fall have been contested (Rogers and Pilgrim, 2014). Some have argued that the development of drug therapies (particularly the phenothiazines) allowed more people to live without confinement (e.g. Gelder, Mayou and Cowen, 2001). Others suggest that the development of the welfare state in the post-war period allowed families and communities to care for dependent people at home (Rogers and Pilgrim, 2014).
There was also a series of critiques of psychiatry that gained momentum from the 1950s through to the 1960s. In addition to Foucault’s view of the significant role played by psychiatry in enforcing particular ways of being (as discussed in Section 1), some psychiatrists drew attention to meaning that might be found within apparent ravings of those judged to be ill (e.g. Laing, 1965). Others drew attention to the negative impact of the asylum environment itself (e.g. Goffman, 1961), and the potentially harmful effect of receiving such a stigmatised label (Scheff, 1966). Some questioned the logical impossibility of the idea that the mind could be regarded as suffering from a disease (Szasz, 1970). The critiques of psychiatry were also taking place within the profession itself as the effectiveness of the asylums was questioned (Brown and Wing, 1962).
Whatever the reason, by the 1980s the decline of the asylum population meant that the upkeep of these old-fashioned, and expensive-to-maintain buildings was a drain on resources. The government of the day therefore accelerated the closure of the asylums with its overt policy of ‘community care’ (Audit Commission, 1986). This policy promoted a shift of resources across a range of health and social care services, away from long-term institutional care and towards the support of people in their homes and communities. In some respects, this was nothing revolutionary; as will be described in Chapter 4, the post-war period witnessed an expansion of the diagnostic categories of mental disorder, which meant that mental illness was viewed as something prevalent across wider social groups. Thus, efforts were made to make services available to more people. While this book will discuss a number of initiatives in detail, an important dimension of all of them was the rise of child guidance clinics (Stewart, 2012). These may be the most remarkable sign of a government belief in the significance of mental health to the overall good of society. Monitoring children and treating poor mental health was considered to be an overall social good. These developments can be viewed through the different lenses of the contested perspectives – either as progressive developments that provided support for a greater range of difficulties, or as sinister means of control and manipulation. A significant move was attempted by the introduction of the Mental Health Act 1959 (in England and Wales). It sought to fully incorporate psychiatric services within the newly emerged National Health Service and the associated arms of an enhanced welfare state.
Conclusion
This chapter has provided a brief introduction to the complex topic of the history of psychiatry. Such a brief survey can only point out some important features of this contested terrain on which the buildings of the asylums loom large. Contrasting perspectives present different understandings of the development of the asylums, fuelled as they were by the idea of moral treatment. Was the development of moral treatment, as Foucault and Scull suggest, an oppressive tactic of a society that was desperately anxious to enforce particular standards of behaviour, and to physically confine those who threatened the social order? Or was this a far more humane response to distress and dependency? In favour of the more cynical view are the links that can be made between poor law legislation and the development of workhouses (and then prisons). Indeed, despite the nobler aspirations, the asylums did become the gloomy warehouses of misery that have haunted the imagination of the world of mental health.
Public and media responses to mental health problems have formed a very significant force that shaped psychiatry. Arguably, there is no other area of medicine and perhaps social policy that has been so much debated and fought out in the public sphere. It would only be fair to conclude that psychiatry has been shaped by anxieties about the threat to social order potentially posed by people who were viewed as different – something that could be ‘remedied’ by their confinement and treatment in order to ‘normalise’ their behaviour.
Alternatively, it can be claimed that the idea of moral treatment suggested a kinder regime that was reflected in the architecture of the asylums, which was profoundly different from that of the prisons and workhouses. By the middle of the nineteenth century, the asylums were being built in the fashion of fine country houses with often extensive and pleasant grounds. Likewise, medics who were searching for new diagnostic categories to explain serious offending were doing so with the immediate motivation of saving the accused from execution, which they would inevitably face if they were judged to be ‘sane’ (and therefore guilty).
Whichever version is ‘truer’, it is certainly the case that the legacy of the asylums was to be considerable. The mass construction of asylums dominated the context for mental illness until the last decades of the twentieth century – with subsequent community care polices being an overt reaction to the asylum tradition. In addition, moral treatment can also be regarded as a forerunner of the talking cures.
The birth of psychiatry was also significantly linked
