Understanding Mental Health and Counselling. Группа авторов
peak had well over 1000 inmates.
Figure 1.2 A contemporary drawing of Joint Counties Lunatic Asylum, which was built following the Lunacy Act 1845 and County Asylums Act 1845. It is quite typical in style: the country-house appearance was considered as important as the confinement that it provided.
These asylums were built under architectural assumptions that were very different from those of prisons and workhouses. They were designed to mimic grand houses and were placed within often large and pleasant grounds in order to create an atmosphere of calm and peace, thought crucial for cure (Edginton, 1997). In some important respects, their rapid success was their undoing. Scull (1979a) traces the increase in the numbers of so-called pauper lunatics (as a reasonable measure of the population of the asylums) and finds the numbers leapt from 16,821 in 1844 (representing a rate of 10.21 for every 10,000 of population) to 77,257 in 1890 (26.27 for every 10,000). This trend continued into the twentieth century. At their peak, in 1954, there were over 140,000 patients (in England) in psychiatric hospitals.
The substantial increase in the numbers of asylum inmates undoubtedly helped establish the idea that the psychiatric institutions were a necessary component of a modern society, but it also undermined the possibilities of moral treatment, as the new asylums quickly became overcrowded, underfunded and understaffed. They began to fully deserve the condemnation aimed at them through a new series of scandals about the poor conditions, even in the new asylums (Scull, 1996). Thus, eventually there was a turning away from the asylums through the second half of the twentieth century. Nevertheless, the asylums provided an institutional base for the emerging profession of psychiatry, while the claims for expertise in the criminal justice system were to raise its public profile.
Methodology: The connection between research and understanding history
Critics of psychiatry (such as Foucault) have often focused on the history of the profession. This might be for a number of reasons, including an interest in making links to past practices that can often appear barbaric. It might also be because an understanding of where our ideas and practices have come from can help us question our current assumptions.
The disciplines of psychology and psychiatry have been accused of being ahistorical – they do not take account of their own history and the circumstances that have created their own assumptions.
As this chapter suggests, however, there can be important differences between ways of understanding past events. Studies of history cannot use experiments as they are used in natural sciences, medicine and psychology. One might therefore pose the question: How do we decide which version of the past is the most accurate? Indeed, why might history (and one’s understanding of it) be important to understanding psychiatry and psychology?
2.2 Moral insanity and criminological expertise
The earliest signs of the formal recognition of categories of ‘insanity’ come from processes of legal justice. For as long as we have written records, we know that systems of justice have recognised that those who were deemed to be suffering from insanity ought to be treated with some leniency (Walker, 1968). While the principle was recognised across time, there has been a long debate about how insanity might be reliably detected. The claim of expertise in this territory became an important facet of the case for recognition of the profession of psychiatry. Some of these developments are described in Chapter 18. For the purposes of this chapter we observe a series of initiatives in Germany, France, Britain and the US that aimed to define disorders of the mind that might be associated with criminality (Jones, 2016). Particular claims were made about ‘monomanias’, ‘partial insanity’ and moral insanity. These all emerged from the idea that the mind could be understood as an object of exploration, and that it was possible to identify particular aspects of the mind that might be disordered in a way that could lead to criminality and violence.
Moral insanity A term used in the nineteenth century to refer to a supposed psychological disorder that was associated with antisocial and criminal behaviour.
Despite some success in the courts, these ideas were considered too radical when debated in the public arena, fuelled by the relatively new phenomenon of a widespread and popular press. The newly formed profession of psychiatry moved away from these more nuanced psychological ideas and back towards their medical and physiological roots (Jones, 2017b). By the 1860s an unfortunate alliance was made between the new profession’s need to profess expertise in the field of criminality and ideas about the significance of hereditary. The latter were given a new respectability thanks to Charles Darwin’s On the origin of species (published in 1859). What emerged was a rather eugenical turn as assumptions were made about the heritability of criminality among an apparent underclass. These played out in programmes of confinement and sterilisation, most notably in the US (Rembis, 2011), leading up to their catastrophic use by the Nazi regime in the middle of the twentieth century (Breggin, 1993).
One important consequence of the medical profession’s shift away from the psychological realm was that the ground of psychological enquiry became available to other professions for developing theories and treatments of the mind. As Chapter 3 will explore, it was initially psychoanalytic ideas, instigating the ‘talking cures’, that opened a new domain of psychological methods of investigation and treatment. To an extent a split was established between the medical specialism of psychiatry – which has tended to maintain a strong allegiance to the medical model – and those who have sought the further exploration of ‘psychological’ treatments. The boundaries are porous, however; while the roots of psychiatry are firmly embedded in the world of physiology, the profession has also been significantly shaped by the belief in a ‘mind’ that is amenable to treatment (Jones, 2017a). At the same time, the assumptions of the medical model – that there is an illness located within the body (including the mind) of the individual – are quite widely accepted within the world of mental health, including in many models of counselling.
Medical model The idea that physical and mental difficulties experienced by an individual can be understood in terms of an identifiable disorder existing within that individual.
3 The fall of asylums and the move to community care
Whatever the motivations of those who planned and built the asylums across many countries in Europe and North America, there can be no doubting their popularity, as their populations greatly outgrew the intended numbers. The hopes of providing peace, rest and pleasant interaction with purposeful staff were dashed by overcrowding and understaffing. Asylums largely came to deserve their characterisation as dismal prisons, or warehouses for those who were unable to look after themselves or who were rejected by their families and communities (Scull, 1996). This all lent support to those who pointed to the coercive and controlling nature of the psychiatric enterprise itself. Just as the more subtle and psychological model of moral insanity failed to survive amid the storm of a hostile press, moral treatment also failed within the wholly underfunded new asylums. This failure pushed psychiatry back to a more despondent understanding of mental disorder, one based on assumptions of inherited weakness (Scull, 1996).
Asylum populations began to fall in the middle of the twentieth century, peaking in England in 1954 and falling rapidly after that (Tooth and Brooke, 1961). The reasons for this fall have been contested (Rogers and Pilgrim, 2014). Some have argued that the development of drug therapies (particularly the phenothiazines) allowed more people to live without confinement (e.g. Gelder, Mayou and Cowen, 2001). Others suggest that the development of the welfare state in the post-war period allowed families and communities to care for dependent people at home (Rogers and Pilgrim, 2014).
There was also a series of critiques of psychiatry that gained momentum from the 1950s through to the 1960s. In addition to Foucault’s view of the significant role played by psychiatry in enforcing particular ways of being (as discussed in Section 1), some psychiatrists drew attention to meaning