Mental Health and Punishments

Critical Perspectives in Theory and Practice

Paul Taylor, Sharon Morley, Jason Powell

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781351240598
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

How might we best manage those who have offended but have mental vulnerabilities? How are risks identified, managed and minimised? What are ideological differences of care and control, punishment and therapy negotiated in practice? These questions are just some which are debated in the eleven chapters of this book. Each with their focus on a given area, authors raise the challenges, controversies, dilemmas and concerns attached to this particular context of delivering justice.

Taking insights on imprisonment, community punishments and forensic services, this book provides a broad analysis of environments. But it also casts a critical light on how punishment of the mentally vulnerable sits within public attitudes and ideas, policy discourses, and the ways in which those seen to present as risky and dangerous are imagined.

Written in a clear and direct style, this book serves as a valuable resource for those studying, working or researching at the intersections of healthcare and criminal justice domains. This book is essential reading for students and practitioners within the fields of criminology and criminal justice, social work, forensic psychology, forensic psychiatry, mental health nursing and probation.

1
The rise of psychiatry

Mental illness/disorder and social control

Barbara McNamara and Jason Powell

This chapter is a focus on the rise and consolidation of psychiatric power and its control of individuals and populations who have become problematised and classified as mentally ill and madness throughout a long and enduring history of the present. For example, Michel Foucault (1982) describes how the patient and madness are socially constructed through disciplinarian techniques, such as the ‘medical gaze’ – the use and abuse of surveillance to control societal ills and give credibility to medical institutions and professional power as the instigator as the truthful arbiter of labelling mental illness (Porter, 1990). The key aim of Foucault’s point here has been “to create a history of the different modes by which, in our culture human beings are made subjects” (1982, p. 208). The history of how people are classified as subjects as having a medical disorder or mental illness is about revealing how psychiatry became embedded in the occidental culture in particular to have the legitimacy and power to define people as problems of scientific knowledge sanctioned by its truth claims that were rarely contested (Scull, 1993).

Indeed, in path-breaking work such as Madness and Civilization (1965), Foucault traces changes in the ways in which madness and mental illness were discussed which has obvious implications for psychiatry and the management of disorder and mental illness. Foucault utilises the distinctive methodology of archaeology for these studies that aim to provide a “history of statements that claim the status of truth” (Davidson, 1986, p. 221).

In order to trace the emergence of legitimacy of professions of psychiatry, one has to understand the contextual backdrop of how its knowledge formation was legitimised by science so any attempt to sanction the definition, management and control of madness and mental illness was never challenged as if science was seen as the master narrative of ‘truth’, who can challenge or resist it? Once science becomes absorbed into professions, it moulds what those professions become, and the people who come into interaction with psychiatry, in particular, has found it difficult to resist the power and control of its profession and subsequent classification practices and processes of medicalisation (Foucault, 1965; Scull, 1993).

This is unashamedly a critical theory of psychiatric power and an understanding of how people become seen as a ‘problem’ which has consequences for those individuals who have been defined as mentally ill (Porter, 1990). The irony, of course, is in the rise of modernity, the more professions professed liberation and empowerment, the more they controlled. Furthermore, psychiatric power as Sim (1990) has eloquently claimed, the more ‘humane’ it claims as its truth status, the more it controls and constructs the conditions of mental illness for powerless individuals and subjugated populations.

It becomes a surveillance technique used to classify and monitor the behaviour of ‘mental disorder’ of patients which uses deviancy conceptual dualities of normality/abnormality to simplistically characterise human behaviour which is more complex and open to historical and contemporary interpretation (Sim, 1990). The chapter traces the historical emergence of asylums, Bedlam and the devastating implications it had in terms of treatment of individuals. We then explore psychiatric power and its relationship to mental illness which was seen as a subtle change to managing social and moral order. We move to evaluate some of the theoretical implications psychiatric power has if it is unchallenged in its hegemony of creating grand narratives of mental illness for powerless individuals and populations. We also track the current treatment structures of ‘virtual asylums’, hospitalisation and rise of community-based services framed by contemporary political debates and gendered issues of psychiatric units. We finally assess the possibilities and challenges of resisting psychiatric power through opportunities for self-determination, self-exploration and the rethinking of psychiatry itself.

Understanding the past is crucial in unravelling the emergent power of psychiatry in the present and implications and possibilities for the future in terms of resistance to dominant modes of power, surveillance and classification practices of mental illness and disorder and the consequences attached to it in terms of institutional confinement and the potential for meaningful human agency.

‘Digging into the past’: historical roots of psychiatric power

Tracing the historical development and consolidation of treatment of medical disorder and its relationship with its patients, uncovers the existence of a general consensus, that the treatment of the mentally ill has reflected how society conceptualised both mental illness and the mentally ill person at a biological and interpersonal level (Carron & Saad, 2012). According to these authors, there exists documented evidence depicting, on the one hand, cruel and inhumane acts, while on the other hand, the delivery of compassionate and benevolent care.

The origins of psychiatric services date back to 1247 when a monastic priory The Priory of St Mary of Bethlehem, shortened to Bedlam, was founded by the church in London (Symonds, 1995) and through its conversion to a hospital in 1357 became Europe’s first insane asylum (Allderidge, 1997). Bedlam has been housing the mentally ill, as in those described by the Stow’s Survey of London (1720) as raving and furious and capable of cure; or, if not yet, are likely to do mischief to themselves or others; and are poor and cannot otherwise be provided for (Allderidge, 1997).

However, for over 600 years, its inmates have survived in conditions of inconceivable abuse, and worst of all their suffering became a source of entertainment for the rest of London (Allderidge, 1997; Symonds, 1995). For example, to increase its funding, the historical hospital was open to the public and the inmates were put on display and their bizarre behaviour and cruel treatment was considered to be a form of theatre (ibid.). McMillan (1997) has demonstrated how patients, who suffered from illnesses now recognised as schizophrenia, dementia, depression, autism and epilepsy, to mention but a few, were confined in badly ventilated apartments and never discharged but by death.

As was true as much of medicine at this time, the treatment was rudimentary, often harsh and generally ineffective (ibid.). For example, ‘the quiet’, ‘the noisy’ and ‘the violent’ were all congregated together, a majority of which were chained to beds by their wrists or ankles and subjected to a range of treatments including immersion in icy water, starvation, bloodletting, purging, beating and spells in isolation (Clouette & DesLandes, 1997). Some received a treatment known as rotation therapy which involved spinning the patient in a chair suspended from the ceiling until they vomited (ibid.). Indeed, as McMillan (1997), Allderidge (1997) and Symonds (1995) note, many patients who may have survived their illness died from their therapy, and what became apparent for Davison and Neale (1997) was that the management of the ‘insane’ appeared more important than the medical procedures.

Linked to this, such increased medical treatment, therefore, was formed in the ‘project of modernity’ (Foucault, 1965, 1982) based on Enlightenment notions of progress and bringing social order to individuals’ lives. In modernity, asylums as a form of social control were characterised by the processes of normalisation, discipline and surveillance (Foucault, 1977) originally linked with the development of the modern prison but increasingly reflected in diffuse use of surveillance via new forms of knowledge (Foucault, 1977).

However, within the early nineteenth-century concern for the wellbeing of patients who have mental illness gradually increased and at the recommendation of the House of Commons select committee, county asylums were set up in 1807 to probe into the state of lunatics (Hunter & MacAlpine, 1974). Further legislation followed, including the Wynn’s Act of (1808) advocating for the better care and maintenance of lunatics, being paupers or criminals and the Shaftesbury Acts of (1845), arguing for the better regulation of the care and treatment of lunatics (Hunter & MacAlpine, 1974).

In an arguably more positive vein, Bendiner (1981) illuminated how Pinel’s Treatise on insanity (1806) within a Parisian ‘madhouse’ known as the Menagerie recognised that the mentally ill were suffering from a disease requiring differential diagnosis, prognosis and therapy. Pinel’s revolutionary diagnosis and treatment therefore, promoted the removal of chains and shackles in a bid to provide more affectionate and supportive care in a more therapeutic setting (ibid.). Importantly, Pinel’s revolutionising work paved the way for recognising that the mentally ill was suffering an illness out of their control and by implementing the concept of ‘moral treatment’ a new philosophy emerged suggesting that mentally ill patients should be viewed with compassion and care and afforded their dignity as individual human beings (Davison & Neale, 1997).

Throughout the nineteenth century, most asylums were built on the outskirts of major cities and operated as self-sufficient communities with their own water supplies, farms, laundries and factories (Andrews et al., 1997). Consequently, they were isolated from the local community and the psychiatrists working with them were isolated from their own colleagues and those in other medical specialities (Ibid.). With the idea of self-sufficiency and emergence of ‘moral therapy’ around the turn of the nineteenth century, the idea of patient work became, according to Scull (1993, p. 102), “a major cornerstone” of treatment.

As described by Jeremy Bentham (as cited in Porter, 1990, p. 131) work was an economic necessity and the workhouse, for example, was: “a mill to grind rogues honest and idle men industrious”. Alongside Pinel’s Treatise on insanity (1806) The York Retreat emerged in Great Britain as the epitome of this kind of reformed regimen, whereby asylum superintendents and psychiatrists argued in favour of patient work to facilitate self-improvement through the patients acceptance of social morality, adoption of self-governance within a social community and retaining self-restraint during religious services (Carron & Saad, 2012). However, this philosophy was abandoned in the latter part of the nineteenth century when the moral era took a different ‘medical’ turn.

Re-framing the treatment of controlling mental illness: psychiatric benevolence or malevolence?

So far, as detailed above, it is possible to see that psychiatry was perceived progressively becoming more humane in its approach, as clinicians developed more effective treatments for the mentally ill (Beveridge, 2014). Nevertheless, this philosophy was abandoned in the latter part of the nineteenth century when the moral era conceded to a more medically based paradigm of treatment for the mentally ill and this transition paved the way for what is known as the modern asylum, which lasted until the 1950s (Digby, 1985).

In terms of admission criteria, and progression towards the establishment of a more modern asylum, the Lunacy Act (1890) set the parameters, providing a legal system in which a patient had to be certified as insane in order to be admitted to the asylum (Andrews et al., 1997). During this period no psychiatric opinion was sought before admission, and thus medical officers in mental hospitals had no control whatsoever over the selection of the patients they were expected to treat, nor was there any opportunity to follow up upon discharge into the community (Rollin, 1990).

There was no legislative provision for patients to be treated voluntarily in the asylum, yet, the situation remained somewhat different in registered hospitals such as the Bethlem where admissions continued to take place free from certification (Andrews et al., 1997). For example, by 1900, only 3% of the patients admitted to Bethlem were certified, compared with 97% of the asylum population (ibid.). Importantly, these differences in admission criteria contributed to an enormous rise in the asylum population, as demonstrated in the growth of the Colney Hatch Asylum, the largest in Europe, originally built to accommodate 1,250 patients yet, was enlarged within ten years to expand capacity to 2,000. In 1937 (when it was renamed Friern Hospital), there were more than 2,700 patients and the rise in population was due to a number of factors, including first, the admission of many severely disabled patients who could never be discharged; second, patients were admitted with an increasing number of inadequately understood and untreatable conditions presenting with psychiatric symptoms such as metabolic disorders, lead poisoning, syphilis and intracranial tumours (Hunter & MacAlpine, 1974).

As noted by these authors once admitted to the asylum, medical officers classified patients as either curable or incurable and took into account other factors including the duration of their illness and the manifestation of any other complications including epilepsy and paralysis (ibid.). In a bid to address the increase in the asylum population, the Mental Treatment Act (1930) was introduced to extend the voluntary admission procedure to asylums, which stimulated the establishment of outpatient departments. Here, applicants could be examined to ascertain their fitness for reception as voluntary patients into asylums, and by 1935 there were 162 outpatient departments compared to just 25 in 1925 (Hunter & MacAlpine, 1963). These were the origins of community psychiatric services that we have today (Andrews et al., 1997).

The establishment of the National Health Service (NHS, 1948), the introduction of phenothiazine drugs in the 1950s and the changing social and political climate around this time were all factors that influenced the gradual closure of the large Victorian institutions (Department of Health and Social Security (DHSS), 1957). Instead, it was envisaged that by keeping patients in hospital when they have recovered from the acute stage of illness, was an infringement of their human rights.

The Royal Commission (1957) on the Law Relating to Mental Illness and Mental Deficiency (DHSS, 1957) recommended that no patient should be retained as a hospital inpatient when he or she has reached the stage at which he or she could go home. Here, the Mental Health Act (1959) was heralded as the first piece of mental health legislation providing clarification as to why an individual might need to be admitted to hospital and treated against their will (Fenton et al., 1997). In doing so, this Act provided a distinction between voluntary and involuntary treatments and provided a much clearer pathway especially in the form of compulsory assessment and treatment for the mentally ill when a “failure of agency itself” is encountered (Greco, 1993, p. 357).

So far, according to Beveridge (2014), the history of psychiatry was written mainly by psychiatrists and was a rather benign progress facilitating change as brought about by the actions of eminent individuals at the expense of consideration afforded to explore the wider social, cultural and political context. Indeed, this kind of history was seen by non-medical people as complacent, self-congratulatory and ser...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• List of contributors
• Preface
• Introduction
• 1 The rise of psychiatry: mental illness/disorder and social control
• 2 Mental health and the criminal courts: fitness to plead, culpability and the defence of insanity
• 3 Causal relationships or casual associations? Assessing the nature and character of mental illness/disorder and crime
• 4 Containing them, liberating us: the shadow side of criminal psychopathy
• 5 Community punishment and mental illness and disorder
• 6 Uneasy bedfellows: imprisonment, mental health and public service austerity
• 7 Continuity and change in penal policy towards personality disordered offenders
• 8 The therapeutic management of child sex offenders
• 9 Mental health, young people and punishments
• 10 ‘Securing’ treatment for female prisoners with mental health issues
• 11 Intellectual disability and punishments
• Index