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"I am not a professional historian; nobody is perfect." - Michel Foucault (Cited in Gutting, 1994)
An article in the Johannesburg Star, by health writer David Robbins (1994) features the work of South African psychiatric reformer professor Carlo Gagiano(1). Gagiano has been credited with reducing the inpatient census at the Oranje Hospital in Bloemfontein by more than a thousand percent in ten years - from 1250 in 1984 to 108 in 1994. When Gagiano first arrived at the hospital as chief of psychiatry, he found patients crowding at the bars, pleading to be released; his response was to order the bars cut away. This is how Robbins (1994) has him describe what happened:
As the hacksaws were busy at the main entrance to one of the wards the patients began to scream and rave inside. I told the warden to unlock the outer door. He demurred. I told him that I would take the consequences. When the door was flung open, most patients in the ward surged out and disappeared. The staff wanted to give chase. I said let them go.
"Amazingly," Robbins (1994) continues the story, "Gagiano's gamble paid off. Within 30 minutes all the patients had returned" (p. 11).
Without detracting from the authenticity of this account it is easy to recognise in it a reenactment of countless similar dramas performed over the past 300 years, in which the mad are set free so that they may present themselves voluntarily for readmission. In this and the following chapter I review such tales of madness rendered tractable through the paradox of liberation, and attempt to place these endlessly repeated readmission rituals in their historical context.
In claiming to detect broad patterns from a jumble of chronological facts this kind of re-telling of psychiatric history inevitably classes itself with the numerous arbitrary forms of periodisation imposed on the development of the profession by psychiatric historians (2). What distinguishes the present account from such psychiatric histories is, firstly, its more modest scope. Relying in the main on secondary sources, I set out to tell not the story of madness or mad-doctoring, but one aspect of that story - the evolution of the discourse and practice of readmission. Secondly, unlike traditional psychiatric histories, which almost uniformly assume that psychiatry has benefitted from scientific progress, my account is inspired by the critique of scientific and human progress in medicine and psychiatry set out by Foucault (1967(3), 1973), and elaborated by the new generation of critical historians of psychiatry.
Foucault divides the story of madness into three parts - the middle ages and early Renaissance when lunatics wandered freely from town to town (or later were set adrift on 'ships of fools'), the Great Confinement of the 17th century, and thirdly the Moral Confinement of the 19th. Foucault's system represents a thorough-going reversal of the standard medico-psychiatric idea of a progression from cruelty to humanity and from incarceration to liberation, and it is at this level - as a manoeuvre in the battle for the status of the present - that his work should be understood, rather than as a dispassionate historical exposition(4). The essence of Foucault's strategy consists of showing how the ostensible liberation of the insane has resulted in ever more aggressive forms of incarceration, or, put differently, to show how discharge has invariably been followed by readmission.
In what follows I draw on Foucault's ideas to describe how physical release has resulted in a form of moral readmission (e.g., submission to the authority of reason, self-normalisation, the silencing of madness), but also by actual readmission (either openly or covertly in the form of revolving door admissions and through transcarceration from one institution to another) and how this has been justified, either as a form of cure or as the inevitable consequence of chronic illness. My account is roughly chronological, trying to describe in sequence the journey of the mad as they were in turn admitted and expelled from a variety of physical and mental structures.
Free at first: Madness before the Enlightenment
Foucault's ideas about the care-free and nomadic existence the insane enjoyed until the middle of the 17th century are often quoted as historical fact (e.g., Harland, 1987), and it may well be so. That the first Bridewell or house of correction (in which the insane were kept together with the indigent and criminal) was built in London long before the Enlightenment, as early as 1555, followed by numerous similar institutions throughout Europe during the next century (Scull, 1984), does not necessarily disprove Foucault's chronology and may be seen as a gradual erosion of freedom which culminated in the Great Confinement. Porter (1987b), while critical of the overly-romanticised presentation of the insane during the middle ages, concedes that during the 17th century their existence did become less free:
We need not go all the way with [Foucault's] ... romantic primitivism. But we can accept his further contention that from the seventeenth century onwards movements were activated which led for the next three centuries to mad people increasingly being segregated from sane society, both categorically and physically. In particular, the institutionalization of the insane inexorably gathered momentum (p. 14).
Foucault (1967) himself does not present the change from freedom to incarceration as being sudden, but rather as proceeding in a series of steps from the image of the ship of fools, to the image of the madhouse, to the reality of the Hôspitaux Généraux in Paris, 1656. Once again, however, the historical detail is perhaps less important than the rhetorical intent of Foucault's argument. Traditional psychiatric histories paint the middle ages as a period of superstition and cruelty to the insane, against which is offset the various acts of psychiatric liberation: Johann Weyer's publication in 1563 of The Deception of Demons, with which he supposedly rescued witches from their non-scientific tormentors (e.g., Colp, 1989); Tuke and Pinel's dramatic gestures (which are discussed in greater detail below); and the various more humble attempts since at emulating these examples. Contrary to this, Foucault draws the middle ages as a time of relative tranquillity for the mad from which they had no need to be liberated.
Irrespective of whether Foucault's idyllic picture corresponds to any kind of objective fact, the concept of readmission (which, as will be shown, is central to both critical and mainstream constructions of psychiatry) clearly requires a primeval state of freedom which each readmission prevents the mad from returning to, and which has to be ruptured by some original act of incarceration.
The Great Confinement
Madness and civilization, in which Foucault (1967) sets out his contrasting scheme for an early history of psychiatry, is in the English translation subtitled A history of insanity in the age of reason. It is in this period of Enlightenment thought and scientific discovery(5)
(from about 1650 to 1815) that conventional histories of psychiatry also typically place the origin of the discipline. However, the difficulty for such histories is, as Porter (1987b) puts it:
There was no Newton of insanity, no Copernican revolution in psychiatry discovering the secrets within the skull. The real watershed in attitudes towards, and the treatment of, the mad came rather from a long-term shift in policy towards those displaying delinquent and dangerous traits: the rise of exclusion (p. 13).
This is what Foucault (1967) calls the Great Confinement, when all over Europe the poor, mad and criminal - all those who were perceived as a menace to the new age of reason - were cast into prisons, hospitals, converted leper colonies, madhouses, houses of correction, poor houses, work houses and houses of industry. At the height of the Great Confinement, according to Foucault, 1 in 100 inhabitants of Paris were confined. Thus what Foucault shows is that it was not prejudice and superstition which imprisoned the insane in the Dark Ages, but science and rationality in the Age of Reason.
In England the Poor Law Act was passed in 1601 compelling parishes to act against vagrancy and begging, and to put the poor (including lunatics) to work (Allderidge, 1990). The same Act enabled parishes to levy special taxes to pay for the inevitable cost of such an enterprise (Scull, 1984). The Act was followed in 1691 by the Bristol Poor Act, which allowed for the joining together (as the Corporation of the Poor) of several parishes, an example which was followed elsewhere in England, and which led to the creation of numerous work houses so that by the 1760s few of the larger British towns were without their own workhouse. For the next 100 years, "wherever workhouses, poor-houses, or houses of industry were set up, these were the most usual places to be used for the accommodation of pauper lunatics" (Allderidge, 1990, p. 38). Despite these developments, however, there is little evidence from this period for anything like a Great Confinement in England comparable in scale to what Foucault describes for France (Porter, 1987a). For England, at least, Foucault's chronology appears to be out by between one and two hundred years, and the Great Confinement did not get fully underway until the 19th century.
Nevertheless, the period from 1650 to 1800 clearly did see some significant expansion in the technology(6) and bureaucracy of physical incarceration in England and its colonies: Numerous new prisons were built - 27 public and 125 private prisons in London (Scull, 1984) in the early 1700s - and workhouses and almshouses spread rapidly (Scull, 1984), with the first lunatic admitted to the original Bristol workhouse in 1707 (Allderidge, 1990). A rash of American almshouses were constructed (Scull, 1984) - in Boston, Philadelphia (1731), New Orleans (1734) and New York (1736). Although large-scale centralised incarceration of the insane did not occur in Great Britain and its colonies, as Foucault describes it in France, many insane were accommodated in these decentralised and often privately run institutions, a situation allowed for in common law for several centuries before being taken up in a 1714 Act (Porter, 1987a).
Some provision was also being made specifically for the mad, such as the hospital for the insane built at Norwich in 1713, the oldest outside London (Allderidge, 1990), and the special ward for Lunatics established at Guy's hospital in 1728. There was a multiplication of private madhouses - 15 in London alone (Howells & Osborn, 1975) - and such local enterprise has been described as "the hallmark of hospital development in the 18th century" (Allderidge, 1990). In South Africa (then still a Dutch colony) a separate apartment was built for lunatics at the Cape Hospital in 1711 (Kruger, 1980; Moyle, 1987) and the first lunatic was confined to Robben Island as far back as 1718 (Kruger, 1980).
The picture that emerges for the English speaking world is therefore not of a totalising Great Confinement, but perhaps rather of a heterogenous 'little confinement'. As Porter (1987a) describes it:
Many possibilities were tried including domiciliary care, boarding out in the community, sending the insane to stay with a clergyman or physician, placing them in private asylums, applying to Bethlem(7), or, particularly if violent, securing them in houses of correction. Better-off patients often lived with their own personal attendant (p. 278).
Although it would probably be incorrect to assume that the mad were permanently and continuously incarcerated in these various general and specialised structures, the question of cure and readmission, as it exists today, apparently did not at first arise.
Curing the insane I: The eighteenth century
However, according to Porter (1987b), "increasingly, from perhaps the mid-eighteenth century, the case for segregating the insane was reinforced by a new faith in therapy and the dream of curing" (p. 17). This change is well illustrated in the difference between the 1714 Act for the More Effectual Punishing such Rogues, Vagabonds, Sturdy Beggars, and Vagrants, and Sending them Whither They Ought to be Sent, among whom were included the 'furiously mad or dangerous', (Porter, 1987a) and the 1774 Act for Regulating Private Madhouses, "which stressed that inmates of asylums were to be 'cured'; they were no longer regarded as hopeless incurables to be incarcerated for the protection of society" (Howells & Osborn, 1975, p. 192). Although it could be argued that I) this latter act licensed abuses, rather than prevented them (Porter, 1987a); ii) it applied only to madhouses within a seven-mile radius of London (Ingram, 1991); and iii) it excluded pauper lunatics sent to madhouses by their parishes (Allderidge, 1990), it clearly signalled a change in the management of the insane - in Foucaultian terms a move from sovereign power (which operates through punishment and exclusion) to disciplinary power (which operates through the humane dissemination of knowledge).
The Act came in the wake of a long period of increased public concern about the conditions in which the insane were kept, and about callous assumptions regarding their incurability. In 1763, under public pressure, a parliamentary Select Committee was appointed to investigate the affairs of public asylums (Howells & Osborn, 1975) and it is from the deliberations of this committee that the 1774 act followed. Accordingly, in the face of public suspicion and exposure of cases of illegal confinement in the 1760s (Porter, 1987a), the more astute madhouse keepers took pains to present an image of humane treatment and efficacy in bringing about cures. The following pamphlet, published in 1779 (quoted in Porter, 1987a, p. 143), is a case in point:
WILLIAM FINCH of MILFORD, near Salisbury, [has] for many years had great success in curing people disordered in their senses ... the many cures he has performed on Lunatics ... can be attested by the greatest satisfaction he can say, that every person he has had charge of, has, with the blessing of God, been cured and discharged from his house perfectly well. The friends of such unfortunate persons who are committed to his care, may depend on their being treated with the greatest tenderness and humanity, by their faithful humble servant,
WILLIAM FINCH, Milford
Nor was the enthusiasm for cure limited to small private asylums. Already in 1851 William Battie had founded St Luke's Hospital for Lunaticks in reaction to what had come to be seen as the scandalous treatment meted out to the mad at Bethlem (Allderidge, 1990; Crammer, 1994; Howells & Osborn, 1975). Unlike Bethlem, where it was more or less assumed that nothing could be done about madness, St Luke's claimed two cures in three (Porter, 1987a). Similar results were achieved at other hospitals modelled after St Luke's, such as the Manchester Lunatic Hospital, opened in 1766, and the York Asylum opened in 1777 (Porter, 1987a). Meanwhile madness was touted as a curable condition in Battie's Treatise on Madness of 1758, Bejamin Faulkner's Observations on the General and Improper Treatment of Insanity of 1785 and (in France) Joseph Daquin's Treatise (Warner, 1994).
Although Monro, superintendent at Bethlem, tried in his Remarks on Dr Battie's Treatise on Madness (1758), to justify his harsher treatment of the insane and more pessimistic view of their prognosis (Ingram, 1991), public viewing at Bethlem was stopped in 1770 (Porter, 1987b); in 1815 there was a Commons enquiry into the institution (revealing amongst other atrocities the case of one James Norris, "confined for eighteen years in a grotesque custom-built harness made of chains and rods, preventing virtually all movement"; Porter, 1987a, p. 124); and in the same year it was closed down and moved to a new location. Elsewhere in Europe, custodialism was also being replaced by reform and a belief in the curability of insanity, some examples being the reforms instituted in 1787 by Joseph Daquin at the Chambery Hospital in Italy (Mora, 1975) and at the Bonifazio hospital in 1789 by Vincenzo Chiarugi(8) (Mora, 1975; Warner, 1994).
What were the reasons for this newfound enthusiasm for curing the insane, this 'little liberation' after the 'little confinement'? Warner (1994), who interprets the various oscillations between incarceration and decarceration in the care of the insane in economic terms, ascribes it to the increased need for labour sparked by the American Revolution of 1776 to 1783 and the British Industrial Revolution of the 1780s. Foucault (1980) would ascribe it to the rise of disciplinary power.
Whatever the reasons, the events of the second half of the 18th century in many ways prefigured the larger scale movements of the insane which were to follow in the 19th and 20th. One similarity is that some of the cures turned out to be temporary, and as a consequence periodic readmission was common (Allderidge, 1990). Another pattern established as early as the 1750s was that readmission (with its implication of failed cure) was disguised by means of transcarceration. In particular, dischargees from St Luke's (Battie's show-piece public asylum) often landed up in his private asylum, "the public asylum providing a 'feeder' to the private" (Porter, 1987a, p. 131).
Turning the subject: George III and the mad-doctors
In November of 1788, only months before the start of the French revolution, George III of England lost his senses. As Ingram (1991) describes it:
In the early hours of the morning of Friday, 7 November 1788, after two days of delirium, George III arose from his bed and walked into the next room to find a conference of his sons, his physicians, his equerries and his pages. He expressed amazement and consternation. He demanded to know the meaning of the gathering. He grew angry, and publicly berated his personal physician, Sir George Baker, penning him into a corner and calling him an old woman whose advice he never should have followed. No one had the temerity to intervene until at last one of those present, a Mr Fairly, took him by the arm and got him back to bed (p. 1).
Despite the king's protestations of sanity ("I am not ill, but I am nervous: if you would know what is the matter with me, I am nervous"; Ingram, 1991, p. 3), it soon became evident that his delirium was ongoing and beyond the control of the royal doctors. In desperation Francis Willis, a flamboyant mad-doctor who, bettering Battie's two in three recovery rate, claimed nine in ten (Porter, 1987a), was summonsed. Unlike the king's own doctors, Willis had no hesitation in applying the strait-waistcoat and other harsh measures to establish his dominion over the king, while at the same time making it quite plain that these were contingent on the king's behaviour, so that "when George rattled on, Willis would warn the obstreperous King that he was talking himself into restraint"(9) (Porter, 1987b, p. 48). When the king behaved in an acceptable manner, however, Willis "equally boldly - most thought rashly - allowed the King a razor to shave himself, as a way of demonstrating confidence in his royal charge" (Porter, 1987a, p. 209). Whether the king was cured is equivocal (he had relapses in 1801, 1804 and 1810, from which last bout he never recovered(10)), but he was back to normal by 1789, in time to learn of the revolution in France and to forestall the Regency Bill in England (Porter, 1987b).
George's case neatly illustrates the moral subjugation of the mad, set free to negotiate an implacably reasonable (but not to be reasoned about) system of rewards and punishments. When Willis spoke to the king it was to lecture, and when he tried to speak back he was gagged, so that "mad language, if it has any sense, goes into retreat in the face of sane treatment" (Ingram, 1991, p. 43). Willis's speciality was "fixing patients with the eye" (Porter, 1987a, p. 209; Ingram, 1991), and there are countless descriptions of raving lunatics rendered manageable by this method. Dr William Pargeter, a close associate of Willis', describes one incident where he used the technique (quoted in Porter, 1987a, p. 210):
When I was a pupil at St Bartholomew's Hospital employed on the subject of Insanity, I was requested ... to visit a poor man ... disordered in his mind ... The maniac was locked in a room, raving and exceedingly turbulent. I took two men with me, and learning that he had no offensive weapons, I planted them at the door, with directions to be silent, and to keep out of sight, unless I should want their assistance. I then suddenly unlocked the door - rushed into the room and caught his eye in an instant. The business was then done - he became peaceable in a moment - trembled with fear, and was as governable as it was possible for a furious madman to be.
It was in 1791, three years after George III's first brush with insanity, that Jeremy Bentham published his Panopticon; or, the Inspection-House: Containing the Idea of a New Principle of Construction Applicable to Any Sort of Establishment, in which Persons of Any Description Are To Be Kept under Inspection, a device used by Foucault (1980) to symbolise the transition from sovereign to disciplinary power, i.e. from power as the exercise of the will of the powerful over the powerless, to power as "the invitation that modern discourse makes to us to assume full responsibility for our acts and intentions" (Parker, 1989a, p. 62). By subjecting the king to the kind of surveillance needed for this form of power to work, by fixing him with the eye, Willis was able to remove him from the straight-waistcoat, even allow him a razor, confident that he would exercise his sovereignty in a reasonable manner.
Breaking their will: Pinel and the liberation of the insane
On 21 February 1793 Philippe Pinel(11), as a member of the National Guard, witnessed the execution of another king (Birley, 1990). In the same year he was appointed as physician at the Bicêtre, the men's hospice near Paris, and struck the chains from the madmen kept there (Moyle, 1987; Pelicier, 1975); in 1795 he was put in charge of the Salpêtrière (Allen & Postel, 1992), the women's prison, "and here too he adopted the same generous attitude" (Pelicier, 1975, p. 125). Or at least so the official version goes.
If not 'wholly fictitious' (Scull, 1991a), these events are no longer believed to have occurred in quite such a straight-forward manner. Although Pinel was appointed to the Bicêtre in 1793, and took a special interest in the several hundred madmen in Ward 7, he 'kept a low profile' (Allen & Postel, 1992) during the 19 months he stayed there, busying himself with work on the classification of mania (Weiner, 1992). Amongst other similar cases, in Ward 7 were three patients shackled for 15, 25 and 45 years respectively. Pinel made no attempt to remove the shackles or even to replace them with strait-waistcoats. It was in fact the non-medical director of the Bicêtre, Pussin, who initiated such reforms in 1797, followed three years later, in 1800, by Pinel at the Salpêtrière (Weiner, 1992).
Despite the inaccuracies in the account of Pinel's actions at the Bicêtre, he served as a prototype for numerous strong, male, medically-qualified reformers during the succeeding two centuries, who are ritualistically described as being outraged at the condition of the insane at some institution to which they had been newly appointed, and as instituting far-reaching reforms almost immediately. I have already mentioned the case of Gagiano in 1984. Other examples are Langermann, who is said to have freed the insane in Germany shortly after Pinel (Fischer-Homberger, 1975); Baron Pisani who took charge of the Real Casa de Matti in Palermo in 1824 and "in less than three years ... abolished the systems of restraint then in use" (Mora, 1975, p. 66); Dr James Barry(12) who exposed the filthy conditions in which lunatics were kept in the Old Somerset Hospital at the Cape (Hurst & Lucas, 1975; Moyle, 1987); the Belgian psychiatrist Guislain who in 1826 "denounced the abuses perpetrated in psychiatric institutions" (Pierloot, 1975, p. 144); Dr Sabler who in 1828 in the Moscow hospital saw to it that "chains were abolished, occupational and recreational activity introduced, case histories utilized, and annual reports published" (Howells, 1975b); Mihály Viszánik, the Hungarian-born chief physician of the Narrenturm ('Tower of the insane') in Vienna who "had to remove a considerable number of chains still binding the patients there as late as 1839" (Horánszky, 1975); John Conolly, who became resident physician at Hanwell Asylum in the same year and promptly set about instituting a system of non-restraint(13) (Colp, 1989; Crammer, 1994; Howells & Osborn, 1975); and H Campbell Hyed who exposed conditions at the Pak Klong Sarn mental hospital in Thailand where as late as 1910 patients were "chained to the floor like fierce animals" (Sangsingkeo, 1975, p. 652).
Another famous example of this genre is Henry Cotton who in 1907 became superintendent at Trenton State Hospital in New Jersey, where patients were kept in deplorable conditions, many being restrained for years without anyone knowing why. "Within two months, he had eliminated all mechanical restraint, freeing 96 patients from their shackles, and tossing aside more than 700 restraining devices"(14) (Scull, 1990, p. 147).
Despite the flaws in the original historical account of Pinel's activities, he is not totally unworthy of being regarded as the model upon which these men patterned their lives. This is particularly so with regard to his invention of traitement moral(15), which he described in his Memoir on Madness, presented in 1794 to the Society for Natural History in Paris. The society, rather appropriately, voted to forward the memoir to the revolutionary Committee for Public Safety (Weiner, 1992). Pinel's methods of taming madness are remarkably similar to Willis', including a belief in its curability, an unwillingness to listen to mad-talk, and reliance on a mixture of kindness and intimidation - and the doctor's all-seeing eye.
As regards cure, Pinel (1794(16)) was pleased to report that "I had the satisfaction of seeing 25 of 200 - that is 1/8 of them - recover" (p. 728). Although an even larger number (28) died in the time Pinel was at the Bicêtre, and these figures are paltry compared to the two in three or nine in ten claimed by Battie and Willis, they represent a considerable achievement given the kind of long-term inmates Pinel was dealing with. Along with the need to bring about cure, there is, as in Willis, an impatience with the ravings of the insane: "The exalted imagination of poets also leads sometimes to madness, and I am often importunated by a confabulator who urges me to read his productions, while I see only the urgent need to subject him to treatment for madness" (p. 728).
And what does moral treatment actually consist of? In essence, it is the careful titration of confinement and liberty in the quantities demanded by the particular case: "I mean a kind of supervision adapted to the nature of their madness, the prevention of dangerous consequences of their impetuous outbursts without any mistreatment, a timely deprivation of liberty, or permission to move about freely within the hospice" (p. 731).
Pinel's (1794) description of what to do should things go wrong bears a close resemblance to the Willis method of 'caching the eye', backed up by physical force:
If a madman suddenly experiences an unexpected attack and arms himself with a log, a stick, or a rock, the director [Pussin] - always mindful of his maxim to control the insane without ever permitting that they be hurt - would present himself in the most determined and threatening manner but without carrying any kind of weapon, so as to avoid additional vexation. He speaks with a thundering voice and walks closer toward the maniac in order to catch his eye. At the same time the servants converge on him at a given signal, from behind or sideways, each seizing one of the madman's limbs, an arm, a thigh, or a leg. Thus they carry him to his cell while thwarting his efforts and chain him if he is very dangerous or merely lock him up. That is how one dominates agitated madmen while respecting human rights (p. 731).
Here, in its earliest (and therefore most easily recognisable) form, is the dual nature of modern subjectivity, which has "allowed a system of right to be superimposed upon the mechanisms of discipline in such a way as to conceal its actual procedures, the element of domination inherent in its techniques, and to guarantee to everyone, by virtue of the sovereignty of the State, the exercise of his proper sovereign rights" (Foucault, 1980, p. 105). Or, in Pinel's words:
One of the fundamental principles of the conduct one must adopt toward the insane is an intelligent mixture of affability and firmness. When they are obstinate one must sound totally superior and unshakable so as to convince them to bow to the will of the directors. But one must avoid any unnecessary constraints and use only enough force to restrain them (p. 731).
Sometimes, in the interests of the patient, it may of course be necessary to extend intimidation into the realms of terror:
Thus one of the major principles of the psychologic management of the insane is to break their will in a skilfully timed manner without causing wounds or imposing hard labor. Rather, a formidable show of terror should convince them that they are not free to pursue their impetuous willfulness and that their only choice is to submit (p. 732).
Having been freed of their chains, the mad are thus subjected to "the lucid firmness of Pinel, who masters in a word and a gesture the two animal frenzies that roar against him" (Foucault, 1967, p. 242). Expelled from a state of pure brutish insanity, they are reinducted into a form of psychological imprisonment.
Madness reduced to silence: The York Retreat
In 1790 a Quaker woman, Hannah Mills, died under suspicious circumstances at the York Asylum - one of the model asylums constructed some twelve years earlier under Battie's influence. When the church elders investigated, they were appalled at the conditions. In 1796(17) William Tuke(18), a prominent Quaker, founded, at the age of 64, a competing institution - the York Retreat (Howells & Osborn, 1975; Moyle, 1987; Porter, 1987a; Kaplan & Sadock, 1981). Designed for no more than 30 patients, the Retreat was everything the Asylum was not: Spacious grounds, comfortable rooms, individual attention and a general air of tranquillity, described by Foucault (1967) as "the patriarchal calm of Tuke's home, where the heart's passions and the mind's disorders slowly subside" (p. 242). Every effort was made to remove any impression of incarceration or restraint, and even "the iron sashes of the windows were disguised to look like wood" (Warner, 1994, p. 103). Patients were treated like children in a family. "They would be resocialized into the ways of Quaker fellowship through walking, talking, and taking tea with the superintendent and his family" (Porter, 1987a, p. 223).
The Foucaultian interpretation of the Retreat is the same as for Pinel's reforms: "The Retreat could do away with manacles of iron, because it was enclosing patients in manacles of mind; internalized control of patients' consciences through creating guilt was so much more thorough, silent, and far less scandalous" (Porter, 1987a, p. 225). As with Willis and Pinel, the Tukes were not interested in the nature of their patients' delusions, or in talking to them about the details of their madness (which they dismissed as 'dialogues of delusion'); rather, the intention was to distract with exercise, walks, conversation, reading and other recreation - "the business of the Retreat was not analysing insanity but restoring normality" (Porter, 1987a, p. 232). This is a sentiment which would continue to echo through the history of psychiatry, leading Benjamin Rush (the 'father of American psychiatry'), for instance, to comment that for the sake of good manners "it will be necessary for a physician to listen with attention to [the patient's] tedious and uninteresting details of his symptoms," but that these could in no way influence the treatment (Alexander & Sheldon, 1966, p. 163). Foucault (1967) formulates it thus: "Madness is responsible only for that part of itself which is visible. All the rest is reduced to silence. Madness no longer exists except as seen" (p. 250).
Foucault (1967) closes his account of madness at this point, with the insane everywhere silenced and in psychic chains. Unfortunately, however, this is not where it ended. Given the apparent efficacy of releasing the insane from one method of control while readmitting them into another, what more could possibly be required to make a perfect world? The answer explicitly stated at the end of Pinel's Memoir, and implicit in the success of the Retreat, was: More, bigger, and better asylums.
Asylum-building in the nineteenth century
Foucault's main argument is that in the late 18th and early 19th century the mad progressed from physical to mental imprisonment. He also points out that physical incarceration continued: "It is within the walls of confinement that Pinel and nineteenth-century psychiatry would come upon madmen; it is there - let us remember - that they would leave them, not without boasting of having 'delivered' them" (Foucault, 1967, p. 39). In this section I will show that it is not only that the mad were left in a state of incarceration, but that many, many more were recruited to join their ranks and that the nineteenth century in many ways come closer to Foucault's idea of a Great Confinement than did the eighteenth. Where asylum building in the 18th century was tentative and sporadic, in the 19th it was unbridled.
According to an 1807 Commons Committee enquiry there were 45 registered madhouses then operating in England and Wales, mostly small private institutions (Crammer, 1994). These were however thought to be insufficient, especially in terms of caring for pauper lunatics. Accordingly, the 1808 County Asylums Act (also known as "Wynn's Act"; Smith, 1994) was framed, authorising (although not yet compelling) justices of the peace in every county to borrow money over a 14 year period to build an asylum for the lunatic poor (Crammer, 1994; Howells & Osborn, 1975, p. 193). By 1827, 27(19) of the 52 counties had done so (Porter, 1987a). Maintenance money for these asylums came from local taxes, while food and personal requirements were paid for by each lunatic's parish (Crammer, 1994). The Act was partly aimed at desegregating the poor and the insane, and the first madhouses to open "were in rural districts where pauperism was severe and subsistence farming declining" (Warner, 1994, p. 108).
Although most of these institutions started out on a small scale, by the mid 1840s their average size had grown from 115 to 300 (Barham, 1992). This growth, which often led to overcrowding, may have been the impetus for the 1845 Lunacy Act, which established the 'Commissioners in Lunacy' with jurisdiction over the whole of England and Wales - no longer London only (Crammer, 1994; Howells & Osborn, 1975) - and "made compulsory the provision of asylums by counties and boroughs" (Howells & Osborn, 1975, p. 194). As it was markedly more expensive to house lunatics in such asylums than in workhouses, the Act was seen as a philanthropic move, but "the reality almost immediately betrayed the hope" (Bebbington, 1987, p. 12). Despite the large-scale building programme which resulted from the Act, rather than relieve the pressure on asylums and workhouses, after 1845 overcrowding and understaffing simply built up even further (Crammer, 1994), so that by 1870 each asylum contained on average 542 lunatics, and 961 by 1900 (Barham, 1992). By 1854, the dream of small, curative asylums was dead, and Thomas Kirkbride's On the Construction, Organization, and General Arrangements of Hospitals for the Insane became a blueprint for building large, centralised asylums (Morrisey & Goldman, 1980).
In France the equivalent of the 1845 Act was an 1838 law creating a lunatic asylum in every département. According to Colp (1989) Germany built even more asylums than France. Elsewhere in Europe numerous asylums were opened. A 300 bed mental hospital was built in Portugal in 1848, with two more in 1893 and 1895 (Lopez Ibor, 1975). The first private mental hospital was founded in Hungary in 1850, followed in 1868 by a state mental hospital, which soon proved too small for the demands made upon it, so that another, larger, hospital had to be founded in 1883 at Angyalföld. However, even this proved insufficient, and in 1896 an old public building was adapted to provide another even larger mental institution (Horánszky, 1975). In Italy, the number of mental hospitals grew from 21 in 1840 to 35 in the 1870s, to 50 in the 1880s (Mora, 1975).
In America asylum building also surged ahead. Starting with the Friends' Asylum in Pennsylvania in 1817 (Warner, 1994), the second oldest in the USA and the first where chains were not used (Zilboorg & Henry, 1941), innumerable asylums, penitentiaries, workhouses, orphan asylums and juvenile reformatories were founded in the course of the century (Scull, 1984; Warner, 1994) - six private asylums between 1820 and 1870 in New York alone (Johnson, 1990). Originally small and based on principles of non-restraint - such as Bloomingdale Asylum in 1821 and the Retreat at Hartford in 1824 (Warner, 1994) - these asylums soon grew to massive proportions and frankly custodial intentions, for example the Willard Asylum for the Chronic Insane established in New York in 1865 for 1500 patients (Morrisey & Goldman, 1980). By 1890 there were 120 public and 40 private asylums in the United States, containing a total of 91,152 patients (Scull, 1984).
In South Africa asylum building also progressed inexorably, although at a more modest pace. The first civilian hospital at the Cape, known as the Hospital and Lunatic Asylum, or Baily's Hospital (later Somerset Hospital) was built in 1818 (Hurst & Lucas, 1975; Kruger, 1980; Moyle, 1987) and accommodated an increasing number of lunatics. In 1834 this hospital started serving the interior as well, with 10 lunatics transported overland from Gramhamstown (Moyle, 1987). In the same year slavery was abolished in the Cape, and the Slave Lodge was turned into an alms house for paupers, including lunatic paupers (Moyle, 1987).
In 1843 the rather ingenious 'Montagu Plan' was accepted for turning Robben Island into an asylum for lunatics, lepers, paupers, and the chronically sick, while at the same time making the convicts until then kept on the island available for an ambitious programme of road construction. In this way Bain's Kloof Pass, Mitchell's Pass, and Sir Lowry's Pass, amongst others, were built, while the pressure on the Somerset hospital was relieved by moving the lunatics to the former convict station on Robben Island - where they were kept until 1863 when Somerset hospital was reopened (Moyle, 1987; Visser, Haasbroek & Bodemer, 1989). By 1868(20) it was clear that the Somerset hospital had become too overcrowded to serve the interior and the Town Hill asylum was founded in Pietermaritzburg, followed in 1875 by the Grahamstown Lunatic Asylum and Sick Hospital, located at the Fort England barracks (Hurst & Lucas, 1975). In 1889 another mental asylum was founded at Port Alfred (Hurst & Lucas, 1975; Moyle, 1987). These Eastern Cape asylums were all for whites only, so that in 1894 it became necessary to build an asylum for blacks in Fort Beaufort (Hurst & Lucas, 1975; Moyle, 1987; Swartz, 1994a)
Despite these asylum-building efforts in the interior the demand for accommodation for the insane in Cape Town continued to grow, and in 1891 the Valkenberg Asylum was founded (Hurst & Lucas, 1975). Initially for whites only, it was only in 1916 that a 'black side' was added to the asylum (Swartz, 1994a). By the end of its first year of operation, Valkenberg was filled to capacity (Moyle, 1987) so that in 1898 a new building was added with facilities for 310 patients (Moyle, 1987).
The Boer republics were also facing an increasing accommodation crisis for the insane. In 1875 the Orange Free State Volksraad gave the president powers to have lunatics taken to Bloemfontein, where provision had been made for them to be kept in a government building (Moyle, 1987). By 1881 the building was overcrowded and the Bloemfontein Kranksinnigengesticht was opened in 1883 (Moyle, 1987), later to be known as the Oranje Hospital(21) (Hurst & Lucas, 1975). In 1890 a section for black inmates was added (Moyle, 1987).
In the Transvaal Republic lunatics were at first held in the Pretoria jail (Moyle, 1987), until the Weskoppies asylum, officially known as De Kranksinnigengesticht te Pretoria, was founded in 1892 (Hurst & Lucas, 1975). Before the asylum opened, there had been 25 mental cases in various jails in the Transvaal; by the end of the year the asylum held 29 patients, of whom 15 were white (Minde, 1975). By 1897 Weskoppies had become very crowded, and by 1898 it was so crowded that no further male admissions were accepted and some patients were again being confined in jails (Minde, 1975).
This catalogue of asylum building is of course scarcely different from what one would expect for any other kind of institution - whether hospitals, schools or prisons. The growth in institutional provision for the insane could thus be explained simply in terms of population growth and urbanisation. The English population did, for example, double in the second half of the nineteenth century (Barham, 1992) and, as Bebbington (1987) puts it: "The most salient demographic feature of 19th century Britain was the speed of urbanization(22)" (p. 12). Alternately, the increase in the number and size of asylums could be taken to support Foucault's (1967; 1980) ideas about the rise of a 'carceral principle' not limited to insanity. One example of this kind of process is the case of habitual alcoholic inebriation, which in terms of two British Acts in 1878 and 1879 became grounds for compulsory detention (Berridge, 1990).
However, the case of insanity does appear to be special. In 1807 a Commons Committee found that there were 1765 pauper lunatics in Poor Houses and Houses of Industry in England and Wales (Allderidge, 1990), but by 1844 the number of certified lunatics had increased to 20 809(23) and to 117 200 by 1904, representing a fivefold increase over the second half of the century alone (Barham, 1992). Thus, where "around 1800, no more than a few thousand 'lunatics' were confined in England in all kinds of institutions; by 1900 the total had skyrocketed to about 100 000" (Porter, 1987a, p. 2).
Even when expressed as a proportion of the population (see Figure 2.1), the number of insane in public asylums in England and Wales increased sevenfold between 1850 and 1930 - from 4.03 per 10 000 to 30.14 per 10 000 - dipping only briefly during the first world war (Scull, 1984).
Figure 2.1. Patients in public asylums in England and Wales, 1850-1930
(source: Scull, 1984)
The same number of persons may have annually become deranged fifty years ago as in 1877, and yet if of the former a larger proportion were neglected and died, the existing number of lunatics would vary greatly in the two periods. This is what has actually happened. The insane succumbed in large numbers from neglect or cruelty half a century ago; now they live on to a fair age, some of them to very advanced life (p. 49).
Tuke's (1878) argument rests on two implicit and by then relatively uncontroversial claims: That the mad received more humane physical treatment than they had in the past, and (as will be shown in the next section) that their madness was itself not amenable to treatment. Foucault's inversion of the former claim has already been discussed, but the latter is more puzzling. As has been shown, the asylum-building spree of the nineteenth century received its initial impetus from the belief that moral treatment cured insanity and that what was therefore needed was more, bigger and better asylums. How did the belief in curability become transformed into its opposite, and why did this not result in an end to asylum-building? Both these questions, I will try to show, can be addressed with reference to the concept and practice of readmission.
Curing the insane II: The nineteenth century
It is generally agreed that the nineteenth century started with a firm belief in the curability of madness, specifically through moral treatment in asylums. Thus asylums, according to Barham (1992) "were not intended as repositories for the excommunicated. Far from it; in their original purpose and design they were seen as reformatories through which the wayward and unproductive could be brought into more promising and acceptable lines of communication" (p. 72).
This optimism was particularly prevalent in the United States, where enthusiasm for the new technology of mental treatment was combined with the general spirit of evangelical reform which preceded the Civil War (reflected, for instance, in the various movements for temperance, women's rights, public education, the rights of the poor, the abolition of slavery) to produce greatly expanded facilities for the insane (Grob, 1980; Luchins, 1992).
The spirit prevalent in the mad-business in the early years of the century has been called a 'cult of curability' (Luchins, 1992; Schneck, 1975), and examples are often quoted of the apparently inflated cure-rates claimed by asylum supervisors. Schneck (1975), for instance, mentions the case of William Maclay Awl whose claims were so extravagant that he came to be known as Dr Cure-all Awl. Other examples include the Hartford Retreat where "within four years of establishment, its report for 1828 made the remarkable announcement that about ninety per cent of the patients admitted that year had been cured" (Shryock, 1940, p. 17); the Worcester State Hospital, where Woodward in 1840 published recovery rates since 1833 of between 82% and 91% (Grob, 1980; Schneck, 1975; Warner, 1994); and the Eastern Virginia asylum, where John Galt in 1842 claimed cure rates of between 53% and 92% (Warner, 1994). Typical of the times is the opinion expressed by Amariah Brigham of the Utica State Hospital that "no fact relating to insanity appears better established than the general certainty of curing it in its early state" (Warner, 1994, p. 122).
In England the 1845 Lunacy Act, which was intended as "a mechanism for providing the mentally ill with the early treatment thought necessary for cure" (Bebbington, 1987, p. 12), reflected the continuing prevalence of similar sentiments.
Statistics compiled under the influence of the cult of curability were used to great effect by the American reformer Dorothea Dix in her campaign to establish more public mental hospitals, which resulted in the founding of more than 30 such institutions (Morrisey & Goldman, 1980; Warner, 1994). In South Africa most asylum building occurred in the second half of the century, by which time the American and English 'cult of curability' had already subsided. Nevertheless Greenlees (1895) presents, with evident satisfaction, a 28% recovery rate for 'native' patients (plus 16% 'relieved')(24) at the Grahamstown Asylum, compared to the 10% then being achieved at the Somerset hospital and the 3% at Robben Island (Moyle, 1987). It was partly in response to such figures that the Valkenberg asylum was founded in Cape Town in 1891, as an institution specifically for curable cases of insanity. (As it turned out, however, only 3 of the original 36 patients ever recovered, compared to 24 who died in the asylum after an average stay of 14.4 years; Swartz, 1994a).
How real were the high cure rates at first reported, especially at American asylums? Warner (1994) has argued that cures were indeed being achieved due to the special nature of the early asylums which were small enough and sufficiently well staffed to facilitate recovery. It is only as asylums became larger and more overcrowded that the cure rate started dropping off. A very careful follow-up study conducted late in the 19th century by Park suggested that 58% of those discharged as recovered from Worcester never had a relapse (Grob, 1980).
However, it has also long been claimed that the figures were skewed because first admissions and readmissions were not distinguished (Shryock, 1940) and thus cure rates were "artificially exaggerated by repeated recovery of readmissions" (Schneck, 1975, p. 445). Morrisey and Goldman (1980) quote Park's 1879 observation about cure rates at Worcester as follows:
It is a sad and almost cruel blow to the worth of the earlier tables of this Hospital, which gave 70, 80, and even 90 per cent of recoveries, to know ... that many a patient who helped to swell the tables of recoveries to the large per cent mentioned, returned again and again to this Hospital, and finally died here; the many more, after repeated admissions to this and other hospitals, died in the town or city almshouse (p. 60).
Psychiatric recidivism, like its criminal equivalent, thus almost immediately started eroding the new institutions' claims to efficacy. As Foucault (1980) describes it:
The prison was meant to be an instrument ... acting with precision upon its individual subjects ... The failure of the project was immediate and was realised virtually from the start. In 1820 it was already understood that the prisons, far from transforming criminals into honest citizens, served only to manufacture new criminals and to drive existing criminals even deeper into criminality (p. 40).
In the psychiatric context readmission soon became evident even at the two original sites where moral treatment was practised. Prichard (1837) claims that 105 of the 334 patients admitted to the York Retreat between 1812 and 1833 relapsed and were readmitted, while 68 of the 546 admissions to the Bicêtre and Salpêtrière up to 1834 were readmissions. One person was admitted as many as 14 times.
The high point in using readmission figures to debunk the 'cult of curability' came in 1876 with the publication of Pliny Earle's The Curability of Insanity (Overholser, 1940), in which, with reference to the Worcester figures, he "made much of the fact that the same patient may be counted as "recovered" after every relapse and that percentages of recoveries were calculated on the basis of those discharged, not on the numbers admitted" (Warner, 1994, p. 124). It has since been shown that counting the readmissions properly would have made a difference of less than a quarter percent to the Worcester cure rate, and follow-up studies in the 1890s and 1950s have tended to confirm the genuineness of the cures (Warner, 1994). However, irrespective of the statistical accuracy of the reported cure rates, it is evident that readmission was rhetorically very effectively deployed to counter the idea of curability. Whether as a self-fulfilling prophecy or for one or more of a host of other possible reasons, it is in any case true that cure rates did start declining from the 1830s onwards, dropping particularly sharply in the second half of the century (Figure 2.2).
Figure 2.2. Percentage of admissions discharged as "recovered" from the Worcester State Hospital (source: Warner, 1994)
Readmission in the nineteenth century is therefore in the first place a symbol of the ineffectiveness of treatment, and thus of the incurability of insanity. However, just as in the eighteenth and twentieth centuries, readmission should be seen not purely as an oscillation between freedom and incarceration, but as part of a larger pattern of trans-carceration. In both England and America the insane were continually on the move between families, private and public asylums, and institutions for the indigent poor.
Scull (1991a) describes the tensions which developed between asylum and workhouse superintendents in America as the former transferred some of the insane to workhouses and the latter some of the poor to asylums. A favourite ploy was to move 'incurables' out of asylums and into almshouses: "If a patient had not improved enough to live with his own family, it was thought that perhaps he could get along in the almshouse" (Hamilton, 1940, p. 88). By 1856 superintendents of almshouses had had enough of the situation and asked to be relieved of the insane, with the result that in 1869 the Willard Asylum was built for 1500 patients, followed by numerous similar institutions for the incurable (Hamilton, 1940). New York State passed an Act in 1890 formally transferring the mentally ill from county almshouses to state hospitals, and in the decade following the state hospital census rose from 5402 to 21 815. The New York model made it possible for counties to shift costs to the state level and was copied throughout the United States, eventually leading to the end of almshouses by 1920 (Johnson, 1990). Apart from almshouses and asylums, around 30% of mental patients were still being cared for at home or in private institutions towards the end of the century (Howells & Osborn, 1975).
Thus what distinguished a reformer such as Dorothea Dix is not so much that she either freed or incarcerated the insane, but that she imposed coherence on an otherwise chaotic pattern of admissions, readmissions and transfers. Under Dix's influence the insane were shifted "from the small, inadequate quarters of the almshouses and jails ... to small local institutions, then to county hospitals newly constructed, and finally to the larger state hospitals that replaced them" (Schneck, 1975, p. 446).
In England, too, the insane were shunted from pillar to post, and there was an 'element of rivalry and contempt' between the Poor Law Commission and the Commissioners in Lunacy (Crammer, 1994). In South Africa it has already been shown how lunatics migrated back and forth between the Somerset Hospital and Robben Island. The same happened with the new asylum at Valkenberg. Of the 36 'curables' initially admitted, 8 were transferred to other institutions, of which 3 were sent back to Robben Island (Swartz, 1994b). In the interior, Greenlees (1895) accounted for many of the non-recoveries at the Grahamstown Asylum by noting that they had been discharged to "other institutions" (Greenlees, 1895, p. 73).
The terrifying system
What characterised the system of care from which the insane were continually being discharged and readmitted in the course of the 19th century, was its growing rationalisation and efficiency. A person who indulged in insane behaviour around 1800 was inducted into a legal and professional structure far less sophisticated and consolidated than would her equivalent around 1900. Along with the endless list of asylums built in the 19th century goes a series of legal reforms. In England we have, amongst others, the Criminal Lunatics Act or "Act for the Safe Keeping of Insane Persons charged with Offences" of 1800 (Porter, 1987a); the Act to Regulate the Care and Treatment of Insane Persons of 1828 which established the Metropolitan Commissioners in Lunacy and made it compulsory for private madhouses to appoint doctors for weekly visits (Crammer, 1994; Porter, 1987a); the New Poor Law Act of 1834 (Bebbington, 1987; Porter, 1987a); and the Lunacy Act of 1890 which provided for a rigid system of certification and required asylum superintendents to be medically qualified (Allderidge, 1990; Crammer, 1994; Walk, 1990).
In South Africa an equivalent set of reforms was enacted, for example the instructions promulgated by the Burger Senate in 1825 which prohibited the flogging of lunatics (Moyle, 1987) and various ordinances of 1833, 1837, 1879, 1891 and 1897 which culminated in the Mental Disorders Act of 1916 (Hurst & Lucas, 1975; Swartz, 1994b).
These legal structures were designed to guard against human rights violations in terms of both unjust incarceration and inhumane treatment. Thus there are a series of legally-instigated scandals in the course of the century, such as the report of the British committee of enquiry into private and public madhouses of 1815 (Howells & Osborn, 1975); the 1844 and 1847 reports of the British Commissioners in Lunacy (Crammer, 1994); and the 1859 parliamentary Select Committee report (Walk, 1990). In South Africa there is the official report of 1826 revealing that patients were being tied up and flogged at Somerset Hospital (Hurst & Lucas, 1975; Moyle, 1987); the parliamentary Select Committee report of 1855 which found Somerset Hospital to be beyond repair (Moyle, 1987); and the 1861 commission of enquiry into conditions on Robben Island (Moyle, 1987).
Even as these legal measures helped to prevent the abuse of power, they facilitated the deployment of a different form of (disciplinary) power which further entrenched madness as a condition defined by the tension between freedom and incarceration. Hand in hand with this went the emergence of the profession of psychiatry, which "could flourish once, but not before, large numbers of inmates were crowded into asylums" (Porter, 1987b, p. 17). Thus in the course of the century "insanity was transformed from a vague, culturally defined phenomenon afflicting an unknown, but probably small proportion of the population into a condition which could only be authoritatively diagnosed, certified, and treated by a group of legally recognised experts" (Scull, 1991b, p. 149). Apart from asylums, psychiatry set up for itself an entire professional infrastructure. Professional journals started appearing such as the Magazin für psychische Heilkunde in 1805 (Colp, 1989); the American Journal of Insanity (forerunner of the American Journal of Psychiatry) in 1844 (Schneck, 1975); the Allgemeine Zeitschrift für Psychiatrie in the same year and the Annales Médico-Psychologiques a year later (Colp, 1989; Schneck, 1975); the British Journal of Psychological Medicine and Mental Pathology in 1848 (Rollin, 1991); and the Asylum Journal of 1853, which became the Asylum Journal of Mental Science in 1855 and the Journal of Mental Science in 1858 (Rollin, 1991). Professional associations were founded, such as the British Association of Medical Officers of Asylums and Hospitals for the Insane formed in 1841, reactivated in 1845 (Walk, 1990), and later to become the Royal College of Psychiatrists (Howels & Osborn; Walk, 1990); the German association of Directors of Lunatic Asylums founded in 1844 (Rollin, 1991); and the Association of Medical Superintendents of American Institutions for the Insane (renamed the American Medico-Psychological Association in 1892 and the American Psychiatric Association in 1921) founded in the same year (Grob, 1980; Johnson, 1990; Schneck, 1975).
Specialist courses in psychiatry were started for medical students, for example in 1843 at the University of Vienna (Horánszky, 1975) and in 1870 in England and Wales (Crammer, 1994); as well as courses for psychiatric attendants, for example in 1891 in Britain (Nolan, 1991). Textbooks were published, such as Bucknill and Tuke's 1858 Manual of Psychological Medicine (Colp, 1989; Crammer, 1994); and Kraepelin's 1883 Lehrbuch which went through nine editions until 1927 (Alexander & Selesnick, 1966). Pelicier's (1975) remarks about Kraepelin's text can equally be applied to all these moves towards professionalisation:
Within the first edition of his handbook of psychiatry in 1883 and the edition of 1896, Kraepelin enclosed European psychiatry in a terrifying system: every clinical picture had its place, every patient's destiny was predetermined. The psychiatric hospital was like the firmament of Kepler in which the position and movement of the stars and planets are determined (p. 132).
What was this 'terrifying system' which had closed over the insane even as it promised to restore their human rights? The century started of course with moral treatment, that careful mix of paternal charisma and individual accountability which replaced physical restraint, and this is the system at first used by Woodward and his contemporaries - together with a considerable reliance on narcotics such as morphine and opium "to quiet the patient and thus make him amenable to moral treatment" (Grob, 1980, p. 26). What psychiatry, as Foucault leaves it at the start of the century, thus at first represents is the triumph of modernity in which social order is guaranteed not through the exercise of repressive power, but through classification, surveillance and the doctrine of free will. Psychiatry at the turn of the century demonstrates that even raving lunatics can be tamed by the doctor's eye, and even those who have lost their senses can have their individual accountability restored to them. Hill (1839; quoted in Bebbington, 1987, p. 12) explains the system as follows:
But it may be demanded, What mode of treatment do you adopt in place of restraint? How do you guard against accidents? How do you provide for the safety of attendants? In short what is the substitute for coercion? The answer may be summed up in a few words, viz - classification - watchfulness - vigilant and unceasing attendance by day and night (p. 12).
Connolly describes the essential conditions needed for this form of power to work in similar terms:
One of the first of these is, a properly constructed building, in which the patients enjoy the advantages of light and air, and a cheerful prospect, and ample space for exercise, and for classification, and means of occupation and recreation. The next is the constant and watchful superintendence of humane and intelligent officers, exercising full but considerate and just control over an efficient body of attendants (Connolly, 1846, p. 9).
Connolly's system still held some currency in South Africa in 1864 when the new superintendent of Robben Island expressed his opposition to mechanical restraint (Moyle, 1987), and this was the case even as late as 1894(25), but in America by the mid-1840s it was already an anachronism. In his reports Connolly (1845, 1846) makes repeated reference to sceptical visitors from America and when Henry Tuke visited America in 1845 he "was troubled by much that he saw" (Hamilton, 1940, p. 109). Far from practising moral treatment, American psychiatrists such as Benjamin Rush (the 'father of American psychiatry') had become convinced of the inaccuracy of the original cure rates and had turned to advocating the healing value of restraint instead. Even in England, moral treatment had started to lose its meaning before mid-century. Prichard (1837), who was one of the Commissioners in Lunacy, discusses moral treatment under four heads:
1. seclusion and confinement (almost invariably depicted as a good thing);
2. "other means of abstracting them from the morbid impressions and associations" (p. 205) - e.g., travel, exercise, walking, gardening and embroidery;
3. moral discipline and personal control, which is described as "a union of firmness in determination with the greatest gentleness of manner" (p. 216), although "it is often necessary to confine violent patients with the strait-waistcoat" (p. 216) while "occasionally it is better to confine them by straps round the legs, fastened down in an arm-chair, or shut up in their rooms, according to circumstances" (p. 218); and
4. "treatment of their understandings in relation to their illusions" (p. 205), which involves playing tricks of deception.
Similarly in Belgium Leuret published in 1840 Du Traitement moral de la folie in which he described an evolved version of Pinel's method, involving coercion, pain and terror (Vandermeersch, 1991).
By 1884, when Daniel Hack Tuke visited America, the mood had shifted sufficiently in England that he was much less displeased with the various paraphernalia for restraint - straitwaistcoats, cupboard showers, covered hot baths to tranquillise excited patients - than his grandfather had been forty years earlier (Hamilton, 1940). In his 1885 book The Insane in the United States he even went so far as to defend these various forms of mechanical restraint, secure in the knowledge that many British mad-doctors in any case saw Connolly's views about non-restraint as 'pious opinion' (Schneck, 1975).
It is not, however, that restraint came to be seen as a better form of cure than moral treatment, but that the idea of cure was, especially from 1850 onwards, abandoned. Released from the obligations of moral treatment, patients were recruited back into an ideology of prognostic pessimism (Digby, 1987; Porter, 1987b; Scull, 1991a), so that by the mid-1850s almost all American asylum superintendents had come to believe in the incurability of insanity (Cockerham, 1981) and even in Britain by 1877, after Connolly's death, "the pretensions of the asylum to curing inmates had gone" (Bebbington, 1987, p.12) and "the idea that insanity was largely incurable was divested of its controversial or contestable aspect and taken very much for granted" (Barham, 1992, p. 75).
This pessimism was related to a growing belief, especially in the second half of the century, that insanity was a physical rather than a mental affliction. Griesinger published his Mental Pathology and Therapeutics in 1845, which proclaimed psychiatry as a medical specialty focused on the brain and which "became the authoritative text for a generation of psychiatrists" (Colp, 1989, p. 2138). From 1857 onwards Morel propagated a similar somatic line, suggesting that insanity is a form of hereditary degeneracy (Scull, 1991a): "Inheritance, incurability, physical types; these were the dominant notes of his findings, confirmed in his travels and through contacts with the directors of the most prestigious European hospitals" (Huertas, 1992, p. 393). Morel's theory of degeneration was further popularised in Germany by Krafft-Ebing, in France by Magnan and Esquirol, in Italy by Lombroso, and in England by Maudsley (Alexander & Selesnick, 1966; Huertas, 1992; Mora,1975; Pelicier, 1975). Even where environmental factors were admitted, these were always in interaction with genetic predisposition, and the outcome remained inevitable. In Maudsley's (1899) words:
Were all the circumstances, internal and external, scanned closely and weighed accurately it would be seen that there is no accident in madness; the disease, whatever form it had, and however many the concurrent conditions or successive links of its causation, would be traced as the inevitable consequence of its antecedents, just as the explosion of a train of gunpowder may be traced to its causes, whether the train of events of which it is the issue be long or short. The germs of insanity are most often latent in the foundations of the character, and the final outbreak is the explosion of a long train of antecedent preparations (Maudsley, 1899, p. 140).
This move towards somatic aetiology occurred not only in response to the apparent failure of moral treatment, but also in the context of rapid scientific progress in biology, medicine and neurology. To name but a few: Darwin published his Origin of Species by Means of Natural Selection in 1859; Lister introduced the practice of antisepsis in the 1860s; Broca discovered cerebral localisation in 1861; Dax demonstrated the left lateralization of language in 1863; Lombroso published his 'discoveries' on the hereditary nature of genius and insanity in 1864; Wernicke published his work on aphasia and brain dominance in 1874; Koch discovered the causative micro-organism of cholera in 1883; Korsakov described alcohol-induced psychosis in 1890.
Given this intellectual climate, it is therefore scarcely surprising that in 1893 Dr Smeenk, the medical officer of Weskoppies, should report: "Ik het waargenomen dat erfelykepredispositie prima facie, de grootste bron van geesteskrankheid in de Z.A. Republiek is"(26) (Minde, 1975, p. 369). Greenlees of the Grahamstown asylum also found heredity to be a leading cause of insanity, although "the statistics for white and black patients differ strikingly, with many more white than black patients being said to have inherited their predisposition to insanity" (Swartz, 1994a, p. 10).
In the course of the nineteenth century asylums therefore lost their curative function and became "a convenient apparatus allowing for the collection of dead souls in a network of cemeteries for the still-breathing" (Scull, 1991a, p. 161). Hamilton (1940) provides a poignant description of what had become of the insane liberated by Pinel a hundred years earlier:
Utica had a one-story ward for disturbed men who were kept in restraint all day. They were seated in large and fairly comfortable chairs and fastened there. The hands were confined to the chair arms and the knees could not be raised very high, leaving an opportunity merely to swing the feet back and forth; on the floor of this ward are slight depressions worn by swinging feet prior to 1890 (p. 107).
Where at the start of the century the practice of mad-doctoring was in the vanguard of modernity, helping to demonstrate the practicability of the new forms of social control, by the end of the century it had come to represent the dark, more overtly coercive, side of power. Thus the 'terrifying system' into which the institutionalised mad had been readmitted in the course of the century consisted in the first place of somaticism in aetiology, pessimism in prognosis and custodialism in therapy. However, at the same time psychiatry was starting to venture beyond the walls of the asylum:
The rigid and pessimistic somaticism which increasingly pervaded psychiatric discourse provided a powerful rationalization for the profession's dismal therapeutic performance ... But psychiatry simultaneously sought to transform the failure to redeem its therapeutic promises into the basis for obtaining a wholly new importance in the battle to contain social pathology and to defend the social order. The march it now undertook into the 'borderlands of insanity', its embrace of the 'demifous', the neurasthenic and the hysteric marked the opening shots of a campaign to secure an 'awesome extension of the medical role' in policing the boundaries of society, and in the regulation of asocial behaviours (Scull, 1991a, p. 159).
Now comes the era of neurasthenia, invented by Beard in 1868, and hysteria, invented by Charcot in 1871, and of the various cures for these afflictions - the rest cure, the talking cure, animal magnetism. These patients, of whom there were potentially many more than those until then incarcerated, were far more likely to prove amenable to treatment. It has been suggested that it is for this reason rather than any other that Freud's ideas became popular, e.g. "It seems to us that his theories began to gain acceptance because his therapy offered hope rather than because they were effective" (Forrest, 1973, p. 8); "His work by promising some hope of a cure in a field where no successful treatment was possible or in sight, produced some much-needed optimism" (Hays, 1964, p. 27).
However, Foucault (1967) as usual has a more sinister interpretation of what psychoanalysis was really up to:
It would be fairer to say that psychoanalysis doubled the absolute observation of the watcher with the endless monologue of the person watched - thus preserving the old asylum structure of non-reciprocal observation but balancing it, in a non-symmetrical reciprocity, by the new structure of language without response (p. 250-251).
In psychiatry the nineteenth century therefore starts and ends with cure. Between these two poles the insane, whose ranks are continually swelled by new recruits, are admitted, discharged, readmitted, transferred within an ever-more sophisticated system of professional care.
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Scull (1990) describes psychiatry at the start of the twentieth century as being in desperate straits: "Presiding over a ramshackle and decaying empire of ever-more over-crowded and run-down institutions, and swamped by legions of the poor, the aged, and the chronically disabled, institutional psychiatrists could do little more for their charges save to provide a dubious haven from a heartless world" (p. 144). In Europe Sigmund Freud's psychoanalytic and in America Adolf Meyer's 'psychobiological' approach pointed the way to an alternate practice which, while continuing to pay lip service to the primacy of the biological component of mental illness, made possible a psychological technology for dealing with non-incarcerated patients.
Those who followed Freud and Meyer did not attempt to reform the asylum, but set up parallel structures in private consultation rooms, outpatient departments and child guidance clinics to deal with and forestall the growing assembly of neurotic disorders. At the same time the numbers of those incarcerated in asylums continued (until the mid-50s) to grow steadily, even exponentially, although (at least until the mid-30s) institutional psychiatry continued to be characterised by neglect and apathy (Cunningham Dax, 1975).
Outside of the asylum, Kovel (1981) has depicted 1905-10 as a 'critical period' in the psychologisation of society, in which people "are no longer undesirable, bad, mad or possessed: they are sick" (p. 82). Particularly significant in this period is the founding, under Meyer's direction, of the Mental Hygiene Movement in 1908, which on a practical level helped set up sites for psychiatric practice outside the asylum, and on the level of ideology served to objectify the notion of mentality, linking mental health to the removal of psychic dirt.
Scull (1990) tells the horrifying tale of Henry Cotton, a protégé of Meyer's, who, as superintendent of the Trenton State Hospital, took these ideas quite literally and waged a decades long battle against 'focal infection' - localised infections which supposedly spread to the brain and cause mental illness. Like so many before and after him, Cotton was concerned to bridge the gap between psychiatry and mainstream medicine, hankering like the rest of the medical profession to have illness spread out before the clinical gaze (Foucault, 1973), and visible in the depths of the physical body. From 1916 to the late 1950s thousands upon thousands of infected teeth and tonsils were removed at Trenton and elsewhere, together with massive colonic irrigations and 'reconstructive surgery' of the stomach, duodenum, small intestine, gall bladder, sinuses, womb, appendix, colon, and the genito-urinary tract. For some of these operations the mortality rate was as high as 25%, while independent studies (which Meyer helped to suppress) showed their worth in curing or preventing madness to be nil.
It is however another protégé of Meyer's, Clifford Beers, who became the official hero of the Mental Hygiene movement. Beers had been a mental patient at, amongst others, the Hartford Retreat, one of the asylums famed for its high cure rates in the 1820s. There he was subjected to the alternate regime which had long since replaced moral treatment: The straitjacket, force-feeding and forced medication. On his recovery, Beers started writing a book to expose these malpractices, but under Meyer's influence he gradually abandoned this project and when A mind that found itself appeared in 1908 it was more a testimony of the power of positive thinking than an exposé of institutional psychiatry. In the same year Beers helped found the National Committee for Mental Hygiene, with Meyer as one of the charter members, followed by an International Committee in 1919 (Alexander & Selesnick, 1966). Working with luminaries such as Meyer, William James and Weir Mitchell (the inventor of the rest cure for neurasthenia), Beers' committee was little concerned with patients' rights(27), and responded in a lukewarm manner to appeals for intervention from incarcerated individuals (Porter, 1987b). Rather, Mental Hygiene "was a creed for psychological success. Under its umbrella, books were published with titles like Understanding Yourself, a self-help of the psyche advocating a sort of mental keep-fit, jogging for the mind" (Porter, 1987b, p. 197). Mental Hygiene was about personalising health, about recruiting individuals into taking responsibility for their own personal sanitation. Not surprisingly, therefore, the committee hosted, in 1909, a visit by Sigmund Freud and (despite Freud's radically less optimistic view of the psyche) helped to popularise a version of his ideas in America. The American Psychoanalytic Society was founded two years later in 1911 (Davies, 1990).
Mental Hygiene societies were subsequently also founded in several other countries, such as the Social Hygiene Council in England (Porter, 1987b); the National League for Mental Hygiene in 1924 in Italy (Mora, 1975) and the Hungarian League for the Protection of the Mentally Ill in the same year (Horánszky, 1975). In South Africa the Mental Disorders Act was passed in 1916, in terms of which a Commissioner for Mental Hygiene was appointed (Minde, 1975), and in 1920 the National Council for Mental Hygiene was formed (Hurst & Lucas, 1975)(28).
Meyer's intention with Mental Hygiene was both preventive, and to ensure that where psychiatric hospitalisation did occur it would be followed by adequate aftercare - thus forestalling the need for further readmissions. "Originally envisioned as a kind of friendly visiting, the aftercare model was soon defined as an important adjunct to a psychiatrist's treatment, in which the social worker not only helped the patient adjust after discharge but also modified the home environment that had provoked his symptoms in the first place" (Johnson, 1990, p. 13). Meyer's wife, a social worker, was active in instituting aftercare, and several Child Guidance Clinics (mostly funded by private philanthropies) were founded, but the envisaged ties to state mental hospitals never fully materialised, so that these for the most part continued to exist as purely custodial institutions parallel to, but largely uninfluenced by, psychiatric social work and the activities of the Child Guidance Clinics (Johnson, 1990).
One hospital, the Worcester state hospital, is reported as having introduced reforms such as liberalised discharge and visiting policies, and the use of social workers, as early as 1912 (Morrisey & Goldman, 1980), but this appears to have been the exception rather than the rule. The following description of Worcester hospital in the 1930s illustrates the extent to which asylums had remained worlds unto themselves:
The hospital was located on a 350-acre tract of land on the eastern edge of the city, removed from the major residential areas. It had its own radio station; 200 acres of farm land with facilities for processing and canning the produce; prize herds of cattle and swine; a security force; staff dormitories and recreational facilities; medical-surgical services for staff as well as patients; a chapel; and libraries for staff and for patients (Morrisey & Goldman, 1980, p. 82).
In the Soviet Union an integrated system similar to what Meyer had in mind, involving supported home care, outpatient clinics, day hospitals, and custodial hospitals, is reported actually to have been instituted shortly after the 1917 revolution (Howells, 1975). Although the Mental Hygiene movement never achieved this kind of success, there was a gradual progression in Western countries between the two wars towards the boundary between mental hospital and society becoming more permeable. Of those discharged as disabled from the U.S. Army in the first world war, 20% were for reasons of mental illness (Johnson, 1990), although most of these were not candidates for long-term confinement, often suffering from the newly-invented and more-or-less transient syndrome of 'shell shock' (Howells & Osborn, 1975). In the United Kingdom the Mental Treatment Act of 1930 for the first time allowed for voluntary admissions (Howells & Osborn, 1975) and provided for the creation of outpatient clinics (Barham, 1992). Thus from the mid-1930s British mental hospitals began to be inhabited by a new population which both came and went more freely, leading to a steady rise in first admissions and readmissions (Barham, 1992).
Contemporaneously, the growth of non-institutional psychiatry led to "a paroxysm of experimentation among institutional psychiatrists with various forms of physical therapy" (Scull, 1991a, p. 165): Metrazol and insulin shock treatment in 1933-35 (Alexander & Selesnick, 1966; Colp, 1989); leucotomy in 1936 (Schneck, 1975); electric shock in 1938 (Mora, 1975). These developments are discussed more fully in the next chapter.
With the advent of the Second World War there was again an influx of new psychiatric cases, this time suffering from 'battle fatigue', 'combat neurosis' and 'demoralisation' in addition to 'shell shock'. Of the 15 million men examined by the US army, 856 000 were judged to be mentally ill, and 700 000 mentally retarded. What these men often seemed to require was brief hospitalisation (Johnson, 1990), thus further eroding the custodialism of the mental hospital. In South Africa a military hospital with a psychiatric section was built at Potchefstroom in 1942 to deal with World War II psychiatric casualties. After the war the officer commanding, H.J. Moross, founded Tara hospital in Johannesburg - the first in South Africa for non-certified patients (Minde, 1975; Reid, 1986).
In the United States, the Veterans Administration began in 1945 "the largest hospital program in American history: the construction of 69 general hospitals, each with a psychiatric unit, and 16 mental hospitals" (Colp, 1989, p. 2141). These psychiatric wards and hospitals differed significantly from the custodial institutions which preceded them and although some of their inmates received the dreaded diagnosis of schizophrenia, "the proportion of schizophrenic people out of hospital at follow-up increased significantly from around 50 or 55 per cent before 1940 to more than 70 per cent in the immediate postwar period" (Warner, 1994, p. 74).
In Europe there occurred at this time a "social psychiatry revolution" (Fleck, 1990; Warner, 1994), also contributing to the softening of the stark boundaries between mental hospital and community, with hospitals set up as miniature 'therapeutic communities' (Arthur, 1971; Jones, 1968; Warner, 1994) in order to ease the transition from community to hospital and from hospital to community.
In 1949, at Dingleton Hospital in Scotland, George Bell, like so many psychiatrists before and after, unlocked (or perhaps more accurately gave orders to unlock) the doors of all the wards, heralding an Open Door Movement which gained numerous adherents throughout the West (Warner, 1994, p. 86), with at least seven British hospitals reinstituting an open-door policy between 1949 and 1956 (Colp, 1989).
It is in these immediate post-war years that Mental Hygiene was rechristened Mental Health, which could be interpreted as a further move from repressive sovereign power (as is still partially implicit in the idea of policing the public's mental hygiene) to constructive discipline. In the United States in 1946 Congress passed the National Mental Health Act, establishing the National Institute of Mental Health, which opened in 1949 (Colp, 1989; Morrisey & Goldman, 1980). In South Africa the National Council for Mental Hygiene became the National Council for Mental Health, spawning a number of local mental health societies. And in the United Kingdom the National Health Service Act of 1946 laid the foundations for the National Health Service which came into operation in 1948. In terms of this Act mental hospitals received equal benefits to general hospitals, and psychiatrists were for the first time put on a par with specialists in other fields (Howells & Osborn, 1975).
The National Health Service epitomises the rise of the welfare state in the post-war West, characterised by social pensions, unemployment and sick benefits, and free compulsory education (Wing, 1990). Warner (1994) argues that it is this safety net of social services which made it possible to start releasing the insane, who would otherwise often not have been able to fend for themselves. The era of the psychiatric social worker, foreshadowed by Meyer, had thus finally arrived. In 1953 the California health department took the innovative step of employing 120 social workers to serve 10 000 psychiatric patients on 'convalescent home leave' and in 1954 the first major conference of American psychiatric social workers was held, allowing for the discussion of topics such as job placements for patients, family involvement, community residences, and recreation programmes (Kanter, 1991).
The process of decarceration thus set in motion can be illustrated with reference to Worcester hospital, described earlier as the epitome of a self-sufficient asylum cut off from the broader social world. In 1949 psychiatrists (several of whom were ex-military) started re-assessing each chronic patient at Worcester with a view to reducing the census. Between 1950 and 1955 a 6% decline in the hospital population was achieved, while annual admissions went up by 13%. "Whereas the number of first admissions remained relatively constant during this period (at about 618 per year), the annual number of readmissions had more than doubled (from 241 to 568)" (Morrisey & Goldman, 1980, p. 87).
However, despite the example of a few hospitals like Dingleton and Worcester, the emptying-out of the asylum was at first a slow process, and world-wide the number of psychiatric patients continued to rise. The high point in the mental hospital population in England and Wales - 148 100 patients or 33.45 per 10 000 (Scull, 1984) - was reached in 1954, with the high point in the USA - 558 900 patients - following a year later (Barham, 1992). After this the mental hospital population dropped sharply, both in absolute terms (Figure 3.1) and relative to the population (Figure 3.2). The long process of incarcerating the insane had finally come to an end.
The probable reasons for the sudden decline in psychiatric inpatient numbers after 1954 have already been briefly mentioned in Chapter 1. They are:
Ideological. Starting with Mary Ward's The Snake Pit in 1946 and Albert Deutsch's The Shame of the States in 1948 (Johnson, 1990) and reaching a peak in the 60s with the publications of Szasz (1967), Cooper (1967) and Goffman (1961), the decades after the war were marked by a strong resurgence of critiques of institutional psychiatry.
Figure 3.1 State mental hospital census in the United States of America (source: Barham, 1992; Scull, 1984)
Economic. Warner (1994) is a strong advocate of the notion that psychiatric patients could only be released once the National Health Service (in the UK) and Medicaid (in the US) were in place. Using historical data he shows how before this, admission rates to mental hospitals had regularly increased during periods of economic decline since the mid-18th century. In Warner's (1994) view, "rather than psychiatric treatment having a big impact on schizophrenia, both the course of the illness and the development of psychiatry are governed by political economy" (Warner, 1994, p. 75).
Technological. Chlorpromazine, the first of the antipsychotic drugs, was experimentally used by Delay and Deniker in the University Clinic of Paris in 1952 (Alexander & Selesnick, 1966; Colp, 1989; Pelicier, 1975) and introduced to the United States (as Thorazine) in 1954. It was at first seen primarily as a medical and surgical drug, with only 39 of the 563 journal articles published about Thorazine until 1956 concerned with its role in psychiatry (Johnson, 1990). However, within eight months of the initial three uncontrolled(29) psychiatric studies (involving a total of 243 patients) in 1957, it had been given to two million patients (Johnson, 1990). Although this is well after the trend towards deinstitutionalisation had begun, Fleck (1990) is no doubt correct in arguing that "with the impact of psychopharmacological treatments and the ensuing accessibility of many patients for therapeutic and rehabilitative work, or at least the docilization through these agents, a more optimistic and therefore also more therapeutic atmosphere began to prevail in many hospitals" (p. 51).
Figure 3.2. Mental hospital population in England and Wales as a proportion of the total population (source: Barham, 1992)
Explicit political initiatives. In the United Kingdom the 1959 Mental Health Act allowed for "more diversified community service embracing a range of agencies" (Barham, 1992, p. 11). A year later the then Minister of Health, Enoch Powell delivered his famous 'water-tower' speech to the National Association of Mental Health: "There they stand, isolated, majestic, imperious, brooded over by the gigantic water-tower and chimney combined, rising unmistakable and daunting out of the countryside - the asylums which our forefathers built with such immense solidity" (quoted in Barham, 1992, p. xi). Inspired by this the Ministry of Health in 1962 published its 'Hospital Plan' setting out a programme for the deinstitutionalisation of the mentally ill (Ekdawi & Conning, 1994).
In the United States the Joint Commission on Mental Illness and Health in a 1961 report titled "Action for Mental Health" recommended that state hospitals should convert from custodial to treatment centres (Morrisey & Goldman, 1980). The year after, Kennedy made his "bold new approach" speech condemning "cold custodialism" and calling for comprehensive community care. In the same year he signed the Community Mental Health Centers Act (Colp, 1989; Morrisey & Goldman, 1980) which, as was the case with child guidance clinics at the start of the century, set up parallel institutional structures, largely unconnected to the mental hospital system, but radiating the disciplinary power of psychiatry into increasingly intimate and decentered spaces.
As significant as the drop in the inpatient census brought about by deinstitutionalisation was the steep rise in admission rates, for example from 78 586 p.a. in 1955 to 170 527 p.a. in 1968 in England and Wales and from 185 000 p.a. in 1956 to 393 000 p.a. in 1970 in the United States (Scull, 1984). In South Africa, admissions rose by 40% between 1964 and 1989, while the number of mental hospital beds declined by 8 800 (Visser, Haasbroek & Bodemer, 1989). As was the case in the 1750s and the early 1800s, this rise in admissions was in large measure due to readmissions rather than first admissions. According to Warner (1994) "about half the patients released from U. S. psychiatric hospitals in the early 1970s were readmitted within a year of discharge" (Warner, 1994, p. 90). Where patients were not readmitted to a mental hospital, some other institution often served the same purpose so that, again as before, deinstitutionalisation often turned out to be little more than transinstitutionalisation. Despite the sharp decline in mental hospital patients in the United States in the early 60s, the number in nursing homes increased to such an extent that the total institutionalised population was actually higher in 1969 than in 1963 (Warner, 1994). Not only were nursing homes cheaper(30), but where state governments had to pay for those in state mental hospitals, the costs of private nursing home care could be billed to Medicaid or Medicare, which are mostly funded by the federal government (Warner, 1994).
Nursing homes, board-and-care residences and the like have been severely criticised - Scull (1984) describes them as "a poor alternative to living" (p. 165) - although it is a common finding that residents view them more positively than they do the supposedly better equipped mental hospitals (Lehman, Possidente & Hawker, 1986; Lehman, Slaughter & Myers, 1991).
Together with this by now familiar pattern of an increase in admissions, readmissions and transfers, there has also been an enormous increase in psychiatric 'care episodes' at sites other than the traditional mental hospital. In the United Kingdom, day hospitals have become common (Warner, 1994), and even where full hospital admission occurs, 33% of these were, already by 1977, to psychiatric units in district general hospitals rather than to mental hospitals (Barham, 1992). At the same time the archetypal form of psychiatric incarceration, compulsory admission, has steadily declined. In the United Kingdom one in four admissions in 1955 was compulsory, dropping to one in five in 1964 and one in eight in 1974 (Kruger, 1980). In South Africa many of the worst aspects of incarceration are still in place, for instance at the privately run and notoriously under-resourced Smith-Mitchell institutions, which in 1986 housed 9 500 involuntary patients (Haysom, Strous & Vogelman, 1990)(31). Nevertheless, psychiatric outpatient attendances have increased by 834% between 1961 and 1989 (Visser, Haasbroek & Bodemer, 1989).
Again, as in the previous century, changes in psychiatric incarceration mirrored changes in the criminal justice system, where "from the late 1960s onwards, probation began to be used in an historically unprecedented way" (Scull, 1984, p. 47) as part of a move to a community-based correction system.
The fact that deinstitutionalisation occurred on such a large scale suggests that yet again the belief had arisen that the insane could be cured and released into the community. As Barham (1992) puts it: "The 'community' came to possess a null value - it was not seen as a therapeutic site or as the arena for an interrogation of the moral crisis in the relations between people with mental illness and the larger society, but just as the place to which people were to be sent back after medicine had cured them" (Barham, 1992, p. 14).
The end of deinstitutionalisation I: Lost to aftercare
As happened to the previous 'cult of curability' in the 1800s, dissenting voices soon arose. Bachrach (1987) produces evidence that warnings of the possible adverse effects of deinstitutionalisation and the too-easy glorification of the community concept were published from 1964 onwards. An example of such early critiques is a paper by Dunham (1967) who lampooned the community approach and argued that there was no reliable information on its enabling the prevention of psychiatric disorders nor on how psychiatric disorders could be treated through community interventions. This kind of critique has gathered momentum over the past three decades so that the term 'deinstitutionalisation' is now used almost exclusively in a pejorative sense; and there is general agreement that since the mid-80s we have been in a post-deinstitutionalisation era (Shadish, Lurigio & Lewis, 1989).
The backlash against deinstitutionalisation has taken two forms. In this section I review more extreme reactions, which essentially advocate a return, in one form or another, to the asylum. The more 'humane' (and therefore probably more lasting) option is reviewed in the next section.
By the early 70s resistance to the community approach had started to create 'moral panics' with exemplary tales told in the media of violence committed by ex-patients(32) and of the bad conditions in which the deinstitutionalised were accommodated (reviewed in Scull, 1984). "Often," so the story went, "they [hospital administrators] do not even know where those they have dumped back on the rest of us are to be found" (Scull, 1984, p. 1). The idea of madness being indiscriminately dumped, in a flagrant reversal of mental hygiene, occurs again and again (e.g., "many severely and chronically disabled patients have been 'dumped' in the rooming houses and decaying hotels of innercity areas": Morrissey, Goldman, & Klerman, 1980b, p. 3) as does the alarmist notion that the mad may have escaped beyond the reach even of surveillance:
In November 1986 the National Institute of Mental Health admitted that the whereabouts of 58 per cent of people with a history of schizophrenia was unknown. As many as 937 000 had been lost to aftercare, and only 17 per cent were in receipt of outpatient care (Barham, 1992 p. 107).
In South Africa accusations of dumping the mentally ill on society have also gone hand in hand with tales of their spectacular violence. Health Department plans to start a programme of community care in accordance with the White Paper on Health (1997), have been described as a scheme "to shunt thousands of mental patients out of state- run institutions and into the care of their families and friends" (Hess, 1997), and lurid accounts have been published of patients released from Valkenberg hospital killing seven people, including two children (Duffy, 1998). The head of Valkenberg's forensic unit explains the situation as follows (Duffy, 1998):
Either we've got to watch them closely, or someone else must, but we have great difficulty keeping an eye on everyone. The only way we can keep control of them is to keep them in our walls.
Coupled with these concerns and fears is a strong resurgence of official sympathy for the 'plight of the mentally ill': "Thousands of 'deinstitutionalized' patients", wrote Morrissey, Goldman and Klerman (1980b), "have been returned to communities only to encounter hostility and rejection by citizens and the new community centers alike" (p. 3). The 'homeless mentally ill' are endlessly dissected (cf. Bachrach, 1988; Cohen & Thompson, 1992; Morrison, 1989; Mulkern & Manderscheid, 1989; Santiago, Bachrach, Berren & Hannah, 1988; Torrey, 1988) - how many of them are there, what should be done with them, how should homelessness be defined?
One implication of this combination of loathing and sympathy is that the mad should be humanely disposed of. When in October 1939 Hitler decreed that patients with incurable diseases should be done away with, medical personnel arranged for 270 000(33) mental patients to be killed (Colp, 1989). Displaying an attitude which has been described as tödliches Mitleid (deadly compassion), psychiatrists saw to it that patients were discreetly collected for this purpose in grey vans purporting to be from the Community Patients' Transport Service (Barham, 1992). While, thankfully, the likelihood of such events being repeated in the modern world seem remote, there is a recognition that perhaps a more permanent solution than community care may now be required. As Minkoff (1987) argues, "some patients are simply too sick or dangerous to ever leave the hospital" (p. 948), and even where this is not the case "a longer initial hospitalization can serve as a watershed experience that facilitates a more stable lifelong adaptation to illness" (p. 948).
Thus we see patients being collected from their 'rooming houses and decaying innercity hotels', if not by grey vans then by ideologies of dangerousness, inability to cope, and chronicity, and returned safely to the asylum. There they find that the 'therapeutic community' has long since closed down and in its stead have come aggressive new somatic therapies (reviewed in the next chapter), consisting chiefly in the various forms of medication, but not excluding old favourites such as restraint and seclusion.
Way and Banks (1990) in a survey of 23 adult psychiatric hospitals in New York state found that between 0.4% and 9.4% of patients were secluded or restrained at some point during their stay. Norris and Kennedy (1992), sensitive to psychiatry's long-fostered tradition of liberating the insane, point out that although "empirical evidence has supported the use of seclusion for managing out-of-control psychiatric patients ... the act of forcibly locking a patient in a room generally leaves the staff with unsettled, uncomfortable feelings" (p. 7). One of the ways of dealing with these unsettled and uncomfortable feelings is to ensure that the patients are at least settled and comfortable, even to the extent of gathering patient 'input' on the preferred temperature, colour of the walls and attitudes of the nurses whilst in seclusion (Norris & Kennedy, 1992). Thus one should 'plan carefully' for seclusion (Kendrick & Wilber, 1986), giving due consideration to difficult questions such as whether seclusion rooms should be visible to other patients or not (Wise, Mann, Leibenluft, Goldberg & McElvain, 1989).
The argument, in summary, is therefore that deinstitutionalisation has perhaps gone too far (in Krauss and Slavinsky's, 1982, words: "an overreaction to bad care in bad hospitals", p. 84) and that many patients may in fact need to be more-or-less permanently readmitted to protect them from the cruelty, exploitation, stress, pauperism, isolation, self-harm and harm to others which only the mental hospital can provide (Wing, 1990). However, the opposite argument, that deinstitutionalisation has not gone far enough, is heard even more frequently - a view which (as will be shown) does not differ as fundamentally as might be imagined from that calling for reincarceration.
The end of deinstitutionalisation II: The timeless trajectory
Deinstitutionalisation was never simply an effort to do away with the mental hospital, but rather to reposition it in a larger network of psychiatric services. In South Africa, Moross (1969) was already emphasising the importance of involving the patient's family in aftercare and of getting former patients to visit out-patient clinics. Reid (1986) quotes a 1963 promotional movie, This is Tara, about the hospital where Moross was superintendent as follows:
... And so today there is a new way of thinking ... not the patient coming to Tara, but Tara going to the patient. This is the forward trend (p. 14).
Thus the patient need no longer experience the inconvenience and stigma of spending time in hospital, but can receive psychiatric services 'in the community', while the ex-patient can continue to enjoy the care and sense of belonging which the mental hospital provides without the need for an actual readmission:
There is also a Tara Social Club to which ex-patients belong, and which preserves the link between patient and hospital after active treatment has ended. Ex-patients have regular meetings in Johannesburg, organise excursions together, and come to Tara at the weekend for sport and social activities (Minde, 1975, p. 373).
A clear-cut distinction can no longer be made between hospitalisation and ordinary life: One is no longer either ill and in hospital or well and out of hospital. Or such, at least, is the ideal. The majority of critiques of the present era of community care do not call for whole-sale rehospitalisation, but simply complain that not enough is being done to create a properly integrated system and to make community care more like hospital care.
The problem, as Johnson (1990) sees it, is that if experts on mental illness from another planet were to visit the United States they "would see a big, chaotic system, uncoordinated and incoherent, one that utterly fails to fulfil its mission, which is the ongoing care and treatment of the mentally ill" (Johnson, 1990, p. 180). Words and phrases like 'fragmented' (Bachrach, 1989; Dill & Rochefort, 1989; Hadley, Turk, Vasko & McGurrin, 1997; Shadish, Lurigio & Lewis, 1989; White Paper, 1997), 'lack of integration' (Hadley, Turk, Vasko & McGurrin, 1997) and 'disorganisation' (Dill & Rochefort, 1989) leap out at one from the literature on post-deinstitutionalisation; against these are ranged the desiderata of 'coordination', 'continuity' and 'effective management' (Dill & Rochefort, 1989; Hadley, Turk, Vasko & McGurrin, 1997; White Paper, 1997). It is argued that Community Mental Health Centres should have established more formal linkages to state hospitals (Morrissey, Goldman, & Klerman, 1980b); more places should have been provided in local authority hostels (Barham, 1992); perhaps those who refuse treatment should be issued with Community Treatment Orders, the equivalent of certification (cf. the discussion in Barham, 1992; Lawson, 1988); psychiatry should abandon the acute care model and develop a longitudinal perspective (Mechanic, 1986); and patients should be trained in community living before release (Gittelman & Freedman, 1988).
In short, community care should "attempt to provide for its patients the full range of functions that are associated with institutional care, namely: long-term care; asylum or place of refuge; accommodation and food; medical treatment; social and vocational help; supervised accommodation (custody) for those who have broken the law or engage in behaviour which will not be tolerated elsewhere; a comprehensive service; and secure employment for professionals" (Ekdawi & Conning, 1994, p. 30).
Exemplifying this notion of turning the community itself into an institution, Ekdawi and Conning (1994) discuss the idea of 'hostel-wards', a cross between hospital wards and community hostels located on the edge of hospital grounds and providing graded community accommodation: "This arrangement should allow [for] ease of movement into and out of the Community and facilitate continuity of care by maintaining contact with those who move out of the Community" (p. 120). One such service in London "looks after approximately 350 long-term patients, and yet has only 34 hospital beds" (Ekdawi & Conning, 1994, p. 121).
Although complaints about the inadequacy of community care continue unabated, it is clear that much has been done recently to bring about this kind of utopia for everybody, with two thirds of community residential programs for the mentally ill in the United States having been established since 1980 (News and Notes, 1989), and more than 1000 partial hospitalisation programmes operating in America by the end of the 1980s (Parker & Knoll, 1990). A 1984 survey in 16 American states showed that 93 353 'chronics' were being served, of whom 91% had at some point been in hospital, and 87% were on psychotropic medication. Although 75% were unemployed, very few were homeless or in prison (Mulkern & Manderscheid, 1989).
Yet the literature abounds with appeals for even greater integration, communication, collaboration and liaison between hospital and community psychiatric staff (cf. Hadley, Turk, Vasko & McGurrin, 1997). In South Africa, the White Paper on health makes repeated mention of the need for psychiatric services to become more 'coordinated' and 'integrated', with greater emphasis on 'intersectoral coordination', even going so far as to recommend that 'collaboration' with traditional healers should be explored (White Paper, 1997).
In a fully integrated system readmission to a hospital is no longer to be considered a sign of failure (Simpson, Seager & Robertson, 1993), since "even the most intensive programs cannot eliminate the intermittent necessity of psychiatric hospitalization" (Kanter, 1991, p. 34). Thus, in their programme evaluation of a day hospital, Ferber, Oswald, Rubin, Ungemack and Schane (1985) do not use its capacity to deflect full-scale hospitalisation (the original purpose of such hospitals) as an outcome measure, but rather evaluate its efficacy in recruiting and maintaining patients in the psychiatric world:
This high retention rate appears to result from the day hospital's focus as the entry point to a large and flexible network of long-term services in the same location and with familiar staff ... Because patients may need treatment and other support services indefinitely, the day hospital often is the first stage in a long process of working with the patient (p. 1297-1298).
It is in this context that Ferber et al. (1985) can use the fact that 62% of the day hospital patients ("far above the national average") remained in long-term treatment six months after the acute intervention (and that 50% were still receiving services two years later) as an index of success rather than failure.
The name most commonly given to this new therapeutic ideology is rehabilitation - not in the old-fashioned sense of restoring to sanity, but of restoring to and maintaining at the optimal level of functioning allowed for by the degree of unalterable mental impairment. According to Mechanic (1986), "good rehabilitation treats acute psychiatric episodes, ensures appropriate medication monitoring, maintains nutrition and general health, makes provision for shelter and reasonable levels of activity and participation, provides crisis support, and builds a patient's personal capacities through continuing educational efforts" (p. 892). In terms of the rehabilitation ideology, schizophrenia, bipolar disorder, and 'related psychoses' have biological aetiologies and "treatment, therefore, involves both psychopharmacologic interventions to control the primary symptoms and psychosocial interventions to assist the ill person to acknowledge, bear, and accept the illness" (Minkoff, 1987, p. 947). Like those suffering from diabetes or chronic heart disease, mentally ill people must be taught to accept that they have a life-time illness and to value the help they are offered (Barham, 1992; Minkoff, 1987) - "the challenge is to preserve function and limit disability" (Minkoff, 1987, p. 894).
Uys (1991) identifies various eras in the development of psychiatry, and labels the current one the rehabilitation era: "Just as it suddenly was realized that institutions were not necessarily therapeutic, we now realize that simply moving the patient into the community does not necessarily increase the quality of life or level of health" (p. 1). Outcome measures of the success of rehabilitation are functional status (the patient's 'daily living ability'), severity of symptoms, 'quality of life', and hospitalisation - with the latter, as we have seen, no longer interpreted simply as readmission frequency (Uys, 1991). It is fully accepted that "there is an increasing number of disabled people who, until the 1950s, would have been continuously hospitalized for many years but who are now either not admitted to hospital or, alternatively, have brief multiple admissions" (Ekdawi & Conning, 1994, p. 3).
Rehabilitation efforts have been shown to reduce readmission frequency (Belcher, 1993; Hadley et al., 1997), but -
Hospitalization, however, should not be taken at face value as denoting failure of rehabilitation ... In some cases, the purpose of planned hospital admissions is to provide respite and to forestall crises and they may therefore indicate a positive rather than a negative outcome (Ekdawi & Conning, 1994, p. 136).
According to Johnson (1990), one of the most important things chronically mentally ill patients should be given "is permission to regress occasionally in the course of treatment and the ability to be rehospitalized at once when they need it" (Johnson, 1990, p. 185). In fact, it is often the health care professional's task to get the patient into the hospital rather than keep her out:
[The community mental health care nurse] must be sensitive to changes in behavior that signal that the patient is decompensating psychiatrically ... and possibly arrange for early rehospitalization. Such foresight can result in a shorter acute hospital stay, and the nurse can then continue support in helping the patient to readjust, once again, to community living (Hellwig, 1993, p. 22).
The kind of chronicity thus constituted is not at all like the static (or slowly deteriorating) institutional chronicity encountered at the end of the previous century. Rather, it is a chronicity which is always on the move without ever going anywhere, a 'timeless trajectory' (Rawnsley, 1991):
The crises requiring hospitalizations are followed by periods of stabilization of varying duration ... exacerbations and remissions; difficulty distinguishing between the effects of the disorder and the effects of the interventions; temporary comebacks, but no restoration ... The circular weave of psychosis diffuses direction (Rawnsley, 1991, p. 209).
Yet the new chronicity is also not at all like the mobile curability which came about at the end of eighteenth century. Where in the days of moral treatment the mad-doctor stood at the centre of the patient's therapy, this position has gradually been eroded, so that in the rehabilitation era the psychiatrist (however much he or she continues to be the titular head of the mental hospital ward) has come to occupy a somewhat peripheral role in the overall treatment system.
In the place of the psychiatrist stands the therapeutic team, involving not only psychiatric nurses, psychologists, social workers and other para-medical personnel, but also the family, because, as everyone agrees, one "should include them in the loop of service delivery" (Belcher, 1993, p. 22). Far from being the cause of mental illness, "there has been an increasing recognition that relatives could be a positive resource in the management of patients when given the opportunity of information, training and support by the psychiatric services" (Ekdawi & Conning, 1994, p. 6). The consensus is overwhelming: Families should be 'engaged' in therapeutic programmes to a greater extent, family interventions should be 'integrated' with rehabilitation programmes, there should be more 'co-ordination', 'continuity' and 'liaison'. Families should be recruited at 'multiple entry points', for example "acute admission units, out-patient and maintenance medication clinics, day centres, and voluntary groups" (Smith & Birchwood, 1990, p. 658) in order to set up an 'informed partnership' (Smith & Birchwood, 1990) between professional care givers and the family.
In South Africa, where psychiatrists have often invoked the idea of an organic African essence which is contaminated by contact with Western culture (Laubscher, 1937; Swartz & Foster, 1984) the need for engaging with the family is given an ethnic twist:
Until recently the majority of psychiatric patients were contained and treated within the community, unless their behaviour represented a major threat to the social order of that community. With the gradual acceptance of the Western concept of institutionalization, however, increasing numbers of Nguni patients are being admitted to psychiatric hospitals. These hospitals are usually far away from the patient's home; the close family ties, generally regarded as prerequisites for successful rehabilitation, are disrupted, and this often leads to rejection of the patients by the family (Cheetham & Griffiths, 1980, p. 168).
Given that the links have been broken it is now incumbent on mental health workers to restore them. The name of the game is case management (i.e. doing a lot of engaging, integrating, coordinating and liaising on behalf of the patient), and the case managers are typically social workers, psychiatric nurses or 'mental health workers', frequently working together as a team (Minkoff, 1987; Hadley, Turk, Vasko & McGurrin, 1997; White Paper, 1997). In the United Kingdom the National Health Service and Community Care Act provides for the appointment of such case managers, who identify people in need of care, assess individual needs, "act as brokers in the planning of care" (Barham, 1992, p. 133), and so on. Although case management services were by the mid-90s only provided upon discharge from one in four American hospitals, the practice is becoming increasingly common (Dorwart & Hoover, 1994).
Case managers and case management teams are encouraged to engage in what is called 'assertive community treatment' (Bond, McDonel, Miller & Pensec, 1991; Santos, Deci & Lachance, 1993) or 'aggressive outreach' (Hadley, Turk, Vasko & McGurrin, 1997). In this new dispensation, one can expect not only to visit one's case manager at the outpatient clinic, but also to have her pay a visit to one's home or place of work. Ekdawi and Conning (1994) describe how when a group of chronic ex-patients are visited by their psychiatric nurse at their place of employment she would "discreetly slip into the rest room to give the injections" (Ekdawi & Conning, 1994, p. 32). Not all case managers are that discreet: "Aggressive outreach, as it is called, means aftercare staff have to call the errant patients up or even go visit them when they do not show up" (Johnson, 1990, p. 185). What becomes important when first encountering a patient in such a system is no longer merely to find out about her symptoms, social background, family history and so on, but also "relevant chronological details of the individual's past treatment and contact with psychiatric services including hospital admission are documented, together with reported factors which may have a bearing on the course of illness and the frequency of contact with services" (Ekdawi & Conning, 1994, p. 38).
Hadley et al. (1997) describe a highly sophisticated and effective case management system instituted after the closure of the Philadelphia State Hospital. The system is aimed at 'empowering' clients by focusing on their "strengths, abilities, vision for the future and aspirations, while also being keenly aware of the medical/psychiatric issues which impact on the client' (p. 81-82). The system makes use of Team Leaders (minimum qualification 'a degree' with three years mental health experience) who supervise Case Managers, whose job it is to draw up 'personal plans' for clients. Case Managers also supervise Case Manager Technicians who provide "hands on assistance to the consumer such as going to the bank, shopping, teaching mobility training and implementing the details of the client's personal plan" (p. 85). In no instance does the time between contacts with clients exceed two weeks. Standing to the side of this is the psychiatrist, who merely provides periodic medication reviews and is 'available for consultation' should the need arise.
The case manager's task is to find the right balance between improving the life quality of the chronic patient and minimising costs while helping clients to "negotiate the maze of community services" (Belcher, 1993, p. 21). Two models of case management are brokering (where the mental health worker acts as a kind of recruiting agent for psychiatry by putting up to 100 clients in contact with community and hospital services), and clinical case management, where the mental health worker looks after 10 to 20 clients more intensively, in which case "chronically mentally ill clients often use case managers as an auxiliary ego" (p. 22). It is to this 'auxiliary ego' that the patient may confess the contours of her timeless trajectory. One approach is the use of time lines and life lines, the purpose of which is to "reframe experiences in a more positive way and to reconstruct memories that reflect the accomplishments rather than the disappointments in one's life" (Quam & Abramson, 1991, p. 28). The procedure is to 'facilitate' the construction by the patient of a chart on which events are chronologically plotted, positive events above a dividing line, negative events below, thus two-dimensionalising experience on a plane described by the axes of time and affect (Figures 3.3 & 3.4).
Figure 3.3 A life line (from Quam & Abramson, 1991)
Not surprisingly, apart from the obligatory reference to family and employment history (and the very occasional mention of symptomatology), these life lines trace the extended slow-motion dance between the chronic patient and the psychiatric care system which has created her. Admissions, readmissions, residence in group homes, participation in sheltered workshops - these are the stuff a life is made of. Hospital admissions and readmissions have a particularly interesting role in this confessional. Although still plotted at the extreme negative end of the scale, they almost invariably represent a turning point for the good. As Quam & Abramson (1991) helpfully speculate, "perhaps a late-life hospitalization may lead to a more stable community placement" (p. 31).
Figure 3.4. Life line of a 65-year-old male (from Quam & Abramson, 1991)
Conclusion: Free at last
Arguing for an end to racial disparities in psychiatric service provision, Dommisse (1987) quotes Nelson Mandela's 1964 Rivonia trial speech as follows:
Africans want a just share in the whole of South Africa ... Above all, we want equal political rights, because without them our disabilities will be permanent (p. 756).
Although the equal rights agenda has not been fully achieved in either the political or the medical field, nor will be for many decades, there is now for the first time the prospect that this will come to pass. Although this is without doubt cause for celebration, it is also certain that as the mechanisms of overt repression are removed, South African society will be subjected to ever more sophisticated mechanisms of disciplinary power.
In this and the previous chapter I have tried to show how this process of modernisation has proceeded in Western psychiatry over the past three centuries. Through endlessly repeated cycles of discharge and readmission more and more individuals have been recruited into and confirmed in their status as psychiatric subjects until finally their disabilities have indeed become permanent - not in the sense that they suffer from real chronic illnesses (this may or may not be the case), but in that for many there is no longer any (real) prospect of an existence outside the world of psychiatry.
I would argue, along with Rose (1986a), that "rather than seeking to explain a process of de-institutionalization, we need to account for the proliferation of sites for the practice of psychiatry" (p. 83). This proliferation is clearly evident in the brief historical overview presented in this and the previous chapter, even though my focus has for the most part been limited to practices in some way linked to the psychiatric hospital. Also evident is a consistent movement, despite frequent oscillations between therapeutic optimism and pessimism, towards a socialising and softening of coercive practices. At least since Pinel, psychiatry has struggled to recognise the 'human rights' of its subjects while maintaining an appropriate degree of control. Today even institutional psychiatry functions by talking of patients as 'clients' and 'consumers', by 'empowering' patients through the drawing up of 'personal plans', by giving them 'permission to regress', by asking for 'patient input' on the colour of the walls in seclusion rooms, and by encouraging patients to narrativise their lives in terms of individualised scripts. It is easy to expose such tactics as threadbare attempts at respectability from what remains essentially a coercive discipline, but this is so perhaps purely because institutional psychiatry has set itself the task of managing and reproducing difficult-to-manage individuals. The system of surveillance, confession, human rights and free choice within which the rest of us become subjectified operates with almost seamless coherence, and it is only at the outer limits of its effectiveness (such as when dealing with serious 'mental illness') that one can begin to recognise its inherent contradictions.
Outside the institution, beyond the reach even of the numerous tentacles that extend from the institution into the community, psychiatry and its allied disciplines have in the mean time found innumerable new sites of practice where they can operate in an economy of free choice and without so much as a hint of scandal:
One can point, on the one hand, to the proliferation of the psychotherapeutic technologies of marriage guidance, child rearing, sexual difficulties, and the problems of everyday life and, on the other, to the ever-increasing demand for pharmacological products to assuage personal unhappiness. The contemporary psychiatric system operates predominantly through free choices made in the personal domain, in which mental health is both a private objective and a personal responsibility; the promotion of the self is conducted through the voluntary enlistment of help from skilled technicians. Opposition to the 'coercive' aspects of psychiatry has been central to its modernization (Rose, 1986b, p. 213).
1. 1 Another version of these events, as presented for scientific consumption, can be found in Fourie and Gagiano (1987).
2. 2 For example Howells' (1975a) assertion that "viewing the development of world psychiatry, it is possible to discern a series of eras, each dominated by a theme. There is a world wide movement through the eras in a predictable direction" (p. ix). Howells divides psychiatric history into six periods: Primitive, rational, religious, somatic, and holistic. In the next chapter other, equally self-serving, forms of periodization are reviewed.
3. 3 I consulted the English translation by Richard Howard, which is of a greatly abridged French edition of Histoire de la folie à l'âge classique. An English translation of the full text is said to be imminent (Gutting, 1994).
4. A useful distinction here is between 'histories of the past' which in medicine almost invariably speak of continuity and progress versus 'histories of the present' which do not treat their subject as a given (Butchart, 1995). In the case of psychiatry, histories of the past typically show how increased scientific understanding and humane management of mental illness lead up to the present, while histories of the present would show how mental illness is inconsistently and differently fabricated at different historical moments.
5. 5 To give some idea of the intellectual and scientific flavour of the time: Plater's Practice of Medicine, Observations of Diseases Injurious to Body and Mind (the first natural science-style medical text) appeared in 1602, Harvey's Motion of the Heart (describing the circulatory system) in 1628, Descartes' Discourse on method in 1637, Newton's Mathematical principles of natural philosophy in 1687, and Locke's Treatise on Civil Government in 1690.
6. 6 It is also perhaps worth noting that the straight-waistcoat was introduced, as a more humane alternative to chains, in the early 1700s (Ingram, 1991).
7. The small but notorious public madhouse in London that had been in operation since the middle ages.
8. 8 Vincente Chiarugi according to Fleck (1990)
9. 9 As a consequence, when the doctor was out of the room George "rambled wildly on various subjects, but when the doctor returned he turned the subject, played his cards better and talked more cautiously" (Greville, quoted in Porter, 1987b).
10. 10 It has been suggested that the cause of George's erratic behaviour was actually porphyria.
11. 11 Emile Pinel according to Fleck (1990)
12. 12 Ironically, Barry was later the subject of scandal when it was discovered, post mortem, that she was a woman.
13. 13 Connolly also published a book The treatment of the insane without the use of mechanical restraints in 1856. Instead of mechanical restraint he used whirling chairs, spinning beds, purging, emetics, bleeding, the douche and so on (Wing, 1990).
14. 14 The alternate regime to which Cotton subjected these patients is discussed later.
15. 15 Translated as moral treatment in English, although more accurately translated as psychological treatment.
16. 16 All extracts are from Weiner's (1992) reprinting of Pinel's Memoir.
17. 17 The date is often given as 1792 (e.g., Bebbington, 1987; Warner, 1994; Wing, 1990), but it appears that this is the year that planning for the Retreat started (Birley, 1990).
18. 18 James Tuke according to Fleck (1990).
19. 19 18 according to Allderidge (1990).
20. 20 1875 according to Moyle (1987)
21. 21 The same hospital from which Gagiano freed the insane a hundred years later in 1984.
22. 22 In 1891 for first time the majority (53.6%) of the population in England and Wales lived in cities of 20 000 or more (Scull, 1984).
23. 23 Crammer (1994), quotes the following figures from the 1844 Commissioners in Lunacy reports: 3 579 lunatics in public asylums, 2 559 in licensed houses, 4 080 in workhouses and 3 940 at home or with friends.
24. 24 The figure for 'European' patients was even better.
25. 25 In this year the medical director of Weskoppies, a Dr Smeenk, especially imported from Holland, wrote in his first report under 'dwangmiddelen': "Deze zyn door my niet toegepast, aangezien ik het 'no restraint' stelsel volg" (Minde, 1975, p. 368). [Coercive measures: These are not permitted by me as I follow the 'no restraint' system.] Ironic proof that Smeenk must indeed have used moral treatment comes from an 1899 pamphlet by a former Weskoppies inmate, F.B. Higginson, in which "Dr Smeenk is accused of personally ill-treating Higginson. He glared at him through thick spectacles and threatened to lock him in his cell 'day and night', and to feed him on bread and water" (Minde, 1975, p. 368).
26. 26 "I have observed that hereditary predisposition is prima facie the greatest source of mental illness in the South African Republic."
27. 27 Ironically Beers himself died in an asylum, in 1943, all the while protesting that the doctors assigned to his care were 'impersonators' (Porter, 1987b).
28. 28 In this country mental hygiene often translated into racial hygiene (Swartz, 1994a), as also at times in the United States where Congress instituted immigration quotas in the 1920s (Johnson, 1990).
29. 29 The first double-blind study of chlorpromazine occurred only in 1964 (Colp, 1989).
30. 30 In 1973, with the United Kingdom's inpatient population shrunk to a fraction of its former size, 300 million pounds were still being spent annually on inpatient care, compared to only 6.5 million on residential and day care (Scull, 1984). In South Africa in the late 80s, 82% of the mental health budget still went on hospital care, and only 7% on outpatients (Visser, Haasbroek & Bodemer, 1989).
31. Several exposes during the 1970s and 1980s revealed abuses at these centres, including excessive drug use and patients being admitted for not carrying pass books or for arguing in public. Connie Mulder, minister of information in the apartheid government was a director of several of the institutions (Theil, 1997). The institutions were later renamed 'Life Care' centres and are, ironically, now part-owned by the black empowerment group, Real Africa Investments (Hess, 1997).
32. 32 Monahan and Shah (1989) review the voluminous literature which has since arisen around the perceived dangerousness of psychiatric patients. Two of the highlights of this research are that psychiatrists habitually over-predict dangerousness and that patients are far more likely to be dangerous to themselves than to others. Monahan (1992) nevertheless cautions against completely denying the modest empirical relationship between madness and violence.
33. 33 'Upwards of 100 000' according to Barham (1992).
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