The Moral State We’re In. Julia Neuberger

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СКАЧАТЬ rather than curing it) consist of a variety of classic later advice: exercise (still recommended), diet, distraction, and travel, as well as hundreds of herbal remedies and music therapy, also often recommended in modern practice.

      But it was the French philosopher Descartes (1596-1650) who brought about the biggest shift in the rational approach to mental illness. If, as Roy Porter puts it,?^† ‘consciousness was inherently and definitionally rational’, then ‘insanity, precisely like regular physical illnesses, must derive from the body or be a consequence of some very precarious connections in the brain. Safely somatized in this way, it could no longer be regarded as diabolical in origin or as threatening the integrity or salvation of the immortal soul, and became unambiguously a legitimate object of philosophical and medical inquiry.’

      This was a deeply influential approach and in the late seventeenth century some began to take the optimistic view that people who are mad could be retrained to think correctly and rationally. But folk beliefs in witches and possession persisted, and the treatment of the mad was by no means totally predicated on this new, optimistic view of humanity, even though there were an increasing number of private asylums where treatment was more humane and some form of talking therapy-aimed at retraining the mind-was available.

      The practice of locking up people suffering from all kinds of mental illness and disability had started to grow from the fourteenth century. The religious house of St Mary of Bethlehem in Bishopsgate (Bedlam, now the Bethlem and Maudsley Hospitals in London) was founded in 1247 and started catering for lunatics in the late fourteenth century. Some time between 1255 and 1290 an Act of Parliament, De Praerogativa Regis, was passed that gave the king custody of the lands of natural fools and lordship of the property of the insane. The officers in charge of this were called escheators, and they also held inquisitions to decide if a landholder was a lunatic or an idiot. Already by 1405 a Royal Commission had inquired into the deplorable state of affairs at Bethlem Hospital, suggesting that concern has been prevalent for centuries about how people with mental illness were treated.

      By the eighteenth century asylums for the insane were widespread, though from 1774 certification was instituted so that confinement in a madhouse had to be done on the authority of a medical practitioner (with the exception of paupers, who could be locked up on the say so of a magistrate.) In Catholic countries, asylums were under the rule of the Church, with care provided by religious orders. In Protestant countries, care varied, but the state gradually played a greater part. Michel Foucault regarded shutting people up in asylums, not as a therapeutic practice, but as a police measure-a divide still found in mental health treatment and policy to this very day. He describes how houses of confinement such as the Bicêtre in Paris gradually came to be seen as a source of infection and concern was expressed that this would spread to the poor ordinary decent criminals who were thrown in with the insane.* Asylums became spectacles and objects of fear at the same time: at the new Bethlem Hospital, a beautiful building in Moorfields, one could pay to view lunatics until 1770.

      But, for the inmates of these asylums, the regimes were cruel. There was annual bloodletting at the Bethlem and general use of strait jackets and purges. There were, however exceptions. One of the most distinguished was William Battie (1704-76), physician to the new St Luke’s Asylum in London, who also owned a private asylum. A small proportion of the insane did, in his view, suffer from incurable conditions; but the majority, he argued, had what he described as ‘consequential insanity’-derived from events that had befallen them-and for whom the prognosis was good. So instead of bloodletting, purges, surgical techniques (such as removing ‘stones’ from the brain, a particularly vile treatment), and restraint, what was needed was what he described as ‘management’-person to person contact designed to treat the specific delusions and delinquencies of the individual. Battie considered that ‘madness is…as manageable as many other distempers’.^†

      And so a humane period-relatively speaking-in the treatment of mental illness began. Amongst others, Francis Willis (1718-1807), who was called in to treat George III, pioneered a ‘moral management’ school of treatment, where the experienced therapist would outwit the patient. At Willis’s Lincolnshire madhouse everyone was properly dressed and performed useful tasks in the gardens and on the farm, with exercise being a key feature. Similarly, the York Retreat developed moral therapy in a domestic environment. The Quaker tea merchant William Tuke (1732-1822) started a counter-initiative to the local York Asylum, which had been bedevilled by scandal. Patients and staff at the York Retreat lived, worked, and dined together. Medical therapies had been tried but dispensed with in favour of kindness, mildness, reason, and humanity, all within a family atmosphere.

      But this enlightened approach was not to last. Although from 1890 onwards two medical certificates were required to detain any patient, the result was to close off mental institutions to the outside world. They were hard to get into-and even harder to leave. Little treatment, let alone comfort, was provided and the reputation of the new asylums began to sink as it became clear that they were silting up with long-stay, zombie-like patients. Criticism of such institutions began in the late nineteenth century but it took a hundred years before the last of the old long-stay mental hospitals closed.

      Scientific thinking about madness had begun to degenerate too. John Stuart Mill criticized the operation of writs de lunatico inquirendo: ‘the man, and still more the woman…[who indulges] in the luxury of doing as they like…[is] in peril of a commission de lunatico and of having their property taken from them and given to their relations.’* Science was beginning to believe that madness was caused by heredity, like the first Mrs Rochester in Charlotte Bronte’s Jane Eyre (1847), and most real progressive thinking was being carried out in specialist institutions such as the Maudsley, leaving the asylums, gradually starved of resources, to become the chronic patients’ permanent home. Only there could we be sure that the bad, the mad, and the other were kept away from us all. And since the newer asylums were built on the outskirts of towns and cities, or in the country, most patients were kept confined long term at some considerable distance from their homes, families, and friends, who all too quickly lost touch with them. When patients died, after being confined for life because their condition was thought to be incurable, their brains were examined in post mortems for signs of the cerebral lesions that many thought were the basis of all insanity. Psychiatry had become a tool of social restraint. In Britain this continued well into the twentieth century and remained the case until the creation in 1948 of the National Health Service, which largely took over responsibility for the asylums.

      Twentieth-Century Policy and Practice

      The twentieth century started with an obsession about degeneracy of the ‘stock’. It was feared that a ‘submerged tenth’ of the population would outbreed everyone else. The Royal Commission on the Care and Control of the Feeble Minded (1904–8) suggested that mental defectives, so described, were often prolific breeders and that, if allowed, would resort to delinquency, excessive sex, and alcohol. Winston Churchill, then Home Secretary, supported proposals for the forcible sterilization of 100,000 moral degenerates. His views were thought too extreme, however, and his plans were thought so sensitive that they were kept secret until 1992. But he was not alone.

      Some forcible sterilizations did in fact take place, and in 1934 the Brock Committee recommended voluntary sterilization as a cheaper means than physical segregation of separating moral defectives from the nation’s gene pool. Homosexuals continued to be ‘treated’ in mental health units into the mid 1970s, the treatments including oestrogen therapy, electric shock therapy, psychoanalysis and behaviour aversion therapy.*

      All this has to be set against a gradual change in thought. Freudian theory, as well as the work of Jung and Adler, with their insights into the importance of the unconscious СКАЧАТЬ