Mental Hygiene and Psychiatry in Modern Britain

J. Toms

• Publisher: Palgrave Macmillan
• Year: 2013
• ISBN:
  9781137320018
• Topic: Histoire
• Subtopic: Histoire des sciences

Through an examination that uses previously unavailable archives and little-used primary literature, this book places the twentieth-century mental hygiene movement within the broad sweep of modern British psychiatry, offering its own reinterpretation of important elements of this history.

1

Moral Treatment and ‘The Dialectic of the Family’

Could we ever truly know David Wills’ thoughts and emotions as he prepared to disembark ship at New York harbour? The year was 1929 and this was Wills’ first trip abroad. A few days after his arrival he began a daily journal. His first entry reflected, ‘I was far too thrilled, tired and miserable (if there can exist such a combination!) to write it in the first two days’.¹

Wills was joining the New York School of Social Work and would soon become one of the earliest English psychiatric social workers to be trained in the USA. Psychiatric social work was the new and radiant profession of the US mental hygiene movement. Full of youthful hope and ambition it was eager to apply the modern knowledge of ‘the new psychology’ within psychiatry, within social work, anywhere. Wills had hopes and ambitions, too. He hoped to find out more about this so-called new psychology on which the mental hygiene movement rested its claims, to apply it to his interest in rehabilitating delinquent boys and, at the same time, gain a useful professional qualification.

Wills was a Quaker. A few years after his return to England he was to have a letter published in the Quaker periodical The Friend appealing to the community to support a more humanitarian and radical approach to the treatment of young offenders. He soon made contact with a group of educationists and psychotherapists attempting to organize a similar experiment. Their subsequent collaboration was closely associated with the mental hygiene movement, and, though short lived, it was extremely influential, as we’ll see.

There are echoes here of a much earlier Quaker venture. Back in the 1790s Quakers in York had been called upon to develop a more humanitarian approach to the treatment of people considered mad. The result was the Quaker Retreat at York and its development of a form of ‘moral therapy’ known as ‘moral treatment’. But the links between Wills’ experiment and the Retreat go beyond a shared religion. In fact, they go to the heart of this history of the English mental hygiene movement.

Moral therapy’s importance in the history of psychiatry is often highlighted. There are, to begin with, obvious commonalities between moral treatment at the Retreat and contemporary psychiatric ideology. The approach emphasized that early detection and treatment of mental troubles was essential for successful recovery. Treatment should be without recourse to violence and avoid restraint wherever possible. An emphasis was placed on encouraging the ‘healthy’ aspects of the patient’s mind. No patient was considered to be beyond all calls of reason or affection; engagement with an encouraging relationship aimed to re-connect the rational mind and promote recovery. Isolation and inactivity simply appeared to encourage mental problems, and so purposeful activity was encouraged. The actual application of these beliefs in contemporary psychiatric practice has been doubted frequently, but their rhetorical place in psychiatric ideology is not. As will become clear, the twentieth-century mental hygiene movement was a carrier of all these principles.

But, hidden at the heart of these values there lies a more fundamental issue. It runs like a thread from moral therapy, through to the mental hygiene movement and beyond. This is the issue of authority. As we will see shortly, it was crucial to moral therapists. Likewise, it was central to the concerns of mental hygienists.

During the 1960s a new academic questioning of the history of social welfare emerged. Psychiatry was an important target and moral therapy one area to come under analysis.² The earliest, and still the most notorious, academic critique was contained in the French philosopher Michel Foucault’s book, Madness and Civilization.³ A look at its essentials offers us a means to appreciate the importance of authority to our story and a starting point from which to unravel its thread.

Foucault began the section that dealt with moral therapy and the York Retreat with these words:

We know the images. They are familiar in all histories of psychiatry, where their function is to illustrate that happy age when madness was finally recognized and treated according to a truth to which we had too long remained blind.⁴

This was the signal for an attempted demolition of the identification of medicine and psychiatry with ‘progress’ and ‘enlightenment’. Indeed, it was an attempted demolition of the very ideas of ‘progress’ and ‘enlightenment’.

Outright rejected by some historians, embraced by others, Foucault’s analysis of moral treatment and the Retreat was part of a grander project. In its early rendition, as expressed in Madness and Civilization, this took the form of a radical critique of Reason itself, by means of a historical description of the forms in which it had cast ‘madness’. Foucault’s history couldn’t help but appear romantic, the more so because of its flamboyant writing style.

But how could Foucault provide a history of ‘madness’ if the practice of history was itself an aspect of Reason? How, in fact, could Foucault avoid performing another manoeuvre that enclosed ‘madness’? The philosopher Jacques Derrida was soon to ask the question. As Gary Gutting later put it, it seemed as if Foucault was depicting madness as an ‘infrarational source of fundamental truth’.⁵ The criticism hit home, and Foucault rapidly shifted his position.

Foucault’s solution, in a nutshell, was to substitute the commonly accepted couplet of logic, ‘knowledge/truth’, with a newer one, ‘knowledge/power’ or ‘power/knowledge’, as he was to order it. Ask any theorist now the one word that immediately conjures up Foucault’s thought and the answer will inevitably be ‘power’. Yet, look back at his chapter on moral therapy in Madness and Civilization and you will see that, in fact, it is authority, just as much as power, that leaps off the page at you as a crucial component, through which the ‘free terror of madness’ was replaced with ‘the stifling anguish of responsibility’.⁶

The York Retreat opened in 1796. It was a response to a very particular set of circumstances. A scandal at the local York asylum, in which a Quaker patient had died, precipitated calls from a group of Quakers for an asylum to cater for their brethren. The practices that they evolved there are elements of what the historian Roy Porter has called a ‘psychological turn’, which took place after 1750. This can’t, of course, be located only in approaches to madness. But, the particular form it took in this sphere is expressed in the general activities of reform across Europe known as moral therapy, or moral treatment. To social reformers, such activities seemed a sign that newer, more rational and humane approaches to madness were at hand.

Inspired, in particular, by John Locke’s sensationalist theory of the human mind, alienists began to see the ideas and associations of the mind as the main target for investigation and treatment.⁷ Madness could be attributed to misplaced association of thoughts and feelings, leading to a loss of authority over one’s mental state. In this sense it was a failure of ‘self-government’ and a form of mental ‘alienation’.⁸ Moral therapists aimed to reconstruct self-government in the minds of the mad through a personal relationship of authority.

Foucault didn’t refer to Locke in his analysis of moral therapy. He relied, instead, on Descartes’ ‘cogito’ to represent the transformation through which rationality placed itself in a position of supreme opposition to madness. He saw the pre-eminent issue regarding the Retreat and moral therapy in general as the introduction of a form of surveillance and judgement that was ‘a mediating element between guards and patients, between reason and madness’. Before this, he claimed, there was only an ‘abstract, faceless power’ which kept mad people confined and didn’t penetrate madness itself.⁹

Foucault emphasized that moral treatment adopted the bourgeois family as its model of care and treatment. This has since been noted by other writers. But Foucault made much more of it than most. The family was the most immediately recognizable, and concretely understood, social institution. Foucault described it as ‘simultaneously imaginary landscape and real social structure’ and made clear that, at the Retreat, it wasn’t just a model of care—it was both an organizing principle for conceptualizing madness and a methodology for treating it. In this it accomplished a psychological task. For Foucault, the Retreat made the family ‘perform a role of disalienation’.¹⁰ This family was a hierarchical structure of authority and power. Taking the form of patriarchy it played a primary role in structuring the external conceptualization of madness and the internal experience of it. Its structure would now constitute both the ‘truth’ of madness, and the imperative for its treatment.

In his Description of the Retreat Samuel Tuke had remarked that ‘There is much analogy between the judicious treatment of children, and that of insane persons’.¹¹ Foucault recognized that dealing with mad people by analogy with children had a much longer history, but he saw the sentiment expressed by Tuke to be of a different order. Moral treatment turned previous analogies of madness with childhood into a psychological mode of relation. For Foucault, it meant that madness was made to take on a perpetual ‘minority status’.

Along with this imposition of a ‘minority status’ the bourgeois family also instilled its belief in the moral value of work. Tuke explained this at the Retreat in terms of the empirical discovery that it provided the patients with purpose and encouraged those elements of their minds which remained un-affected by madness. For Foucault, work had long been an element of moralizing power. At the Retreat, it took on only the guise of a therapeutic. Beneath this it was another means to structure the very experience of madness, and enclose it in order and control.¹²

So the moral therapy exemplified at the Retreat was a form of power and authority that organized the experience of madness on its own terms. Madness couldn’t exist except as a form of childhood. And the frame for this childhood was a set of hierarchical relations founded on an ideal of patriarchal family relations. In Foucault’s eyes these produced not only a conceptualization and treatment of madness, but a way in which madness must experience itself. What Foucault gave us was a description of the family with a capital ‘F’—it was the Family. It was both organizing principle and methodology, and, in the face of it madness, was ‘alienated in guilt’.¹³ His analysis remains useful and illuminating.

Yet Foucault’s examination of authority was truncated. He relayed a passage from Samuel Tuke’s Description of the Retreat to depict the role of the moral therapist:

The superintendent was one day walking in a field adjacent to the house, in company with a patient, who was apt to be vindictive on very slight occasions. An exciting circumstance occurred. The maniac retired a few paces, and seized a large stone, which he immediately held up, as in the act of throwing at his companion. The superintendent, in no degree ruffled, fixed his eye upon the patient, and in a resolute tone of voice, at the same time advancing, commanded him to lay down the stone. As he approached, the hand of the lunatic gradually sunk from its threatening position, and permitted the stone to drop to the ground. He then submitted to be quietly led to his apartment.¹⁴

‘Something had been born’, commented Foucault, ‘which was no longer repression, but authority … The space reserved by society for insanity would now be haunted by those who were “from the other side” and who represented both the prestige of the authority that confines and the rigor of the reason that judges’. But, actually, Foucault’s pitting of ‘Reason’ against ‘madness’ entailed a slippage away from analysing the dynamics of authority along with power. He wrote that ‘In fact, though, it is not as a concrete person that he [the superintendent] confronts madness, but as a reasonable being, invested by that very fact, and before any combat takes place, with the authority that is his for not being mad’, adding that ‘unreason’s defeat [is] inscribed in advance’ in the battle between ‘madman and man of reason’.¹⁵ So any examination of the relations of authority between moral therapist and madman was lost through a description that implied a dis-embodied and binary split between power as Reason, and madness. In fact, Foucault’s image of madness suggested something with all the qualities of a spirit. And his ‘man of reason’ stalked madness like a cleric performing an exorcism—except, of course, that he, too, appeared a spook.

Samuel Tuke, however, clearly saw a dynamic relationship between authority and power in the treatment of madness. He was not, for instance, unaware that paternalistic authority might itself need restraining:

What a reflection upon human nature, that the greatest calamity to which it is incident, should have been frequently aggravated by those who had the power, and whose duty it was to employ means of mitigation. Hence, we may derive a practical comment on the observation of the wise Montesquieu, which every one interested in establishments for the insane ought constantly to remember:

“Cest une expérience éternelle, que tout homme qui a du pouvoir est porté, à en abuser; il va jusqu’ à ce qu’il trouve des limites. Qui le diroit! La vertu même a besoin des limites^*

L’Esprit des Loix, Liv. II. Cap. IV.

^*Experience continually demonstrates, that men who possess power, are prone to abuse it: they are apt to go to the utmost limits. May it not be said, that the most virtuous require to be limited?¹⁶

So Foucault’s analysis of the Retreat offered an illuminating description of the Family as organizing principle and methodology. But, though he cited authority as an intrinsic element, any examination of its dynamics slipped away under a rendition that emphasized a binary battle of power.

Foucault concluded that ‘Henceforth, and for a period of time the end of which is not yet possible to predict, the discourse of unreason will be indissociably linked with the half-real, half-imaginary dialectic of the Family’.¹⁷ In retrospect it’s a curious statement. In Britain moral treatment died out as the nineteenth-century public asylum system rapidly expanded along with medical practitioners’ dominance within it. Foucault maintained that, in fact, psychoanalysis became the exemplar of the Family principle as its ‘dialectic’ progressed. Yet, even if we accept this as it was baldly stated, he offered no examination of intermediary processes.

And Foucault’s use of the terminology of the dialectic might also seem odd, as his entire corpus can be read as a sus...

Table of contents

• Cover
• Title Page
• Copyright
• Contents
• Preface and Acknowledgements
• List of Abbreviations
• 1. Moral Treatment and ‘The Dialectic of the Family’
• 2. Moral Treatment for the Community at Large
• 3. The Mental Hygiene Movement’s Emotional Contradictions
• 4. Dialectic Rightside Up?
• 5. Developing in the Womb of the Old?
• 6. Alternative Dialectics
• 7. Alienation Revisited
• 8. Dialectic Dismembered
• Afterword
• Notes
• Bibliography
• Index