A couple of things spurred me to write this post. First, in a matter of days (and along with colleagues Vicky Long and Despo Kritsotaki), I will be submitting a book proposal on the history of deinstitutionalization, the process by which most of the world's psychiatric hospitals were emptied out during the last fifty years. Deinstitutionalisation and After promises to examine why this occurred, what happened to the patients and whether the promises of deinstitutionalization were realized (a quick hint, they weren't).
The other thing was a new BBC radio series called "In Search of Ourselves" on the history of psychology. I didn’t think it was that bad myself, but the reaction to it by some of my historian colleagues was not particularly warm. As one of them stated, this is what happens when you get a history of psychology program written by a journalist with medical, not history, experts.
Now this could be sour grapes (it would have been nice to have been involved myself), but I am certainly not surprised. The history of asylums has probably been the most controversial topic in the history of psychiatry, arguably in the history of medicine. We all know about London’s Bedlam, and have a sense of other infamous mental hospitals, ranging from Bellevue Hospital in New York to Danvers State Hospital, the birthplace of lobotomy. It has generated reams of pages, and continues to do so. For a start, the very dilemma—should we lock up society’s ‘mad’—is divisive in itself, but adding to the problem has been how historians and, even more so, non-historians have analyzed the issue. Unlike many traditions within the history of medicine, which began celebrating medicine’s progress and gradually became more critical (largely because professional historians, rather than retired doctors began doing the research), those writing the history of mental illness have been critical from the start.
Although there were a number of previous attempts to account for the history of psychiatry, efforts to do so really got started in the early 1960s, when a disparate assortment of philosophers, psychiatrists, sociologists, and others began turning to it. Arguably, the most influential of the lot for historians was Michel Foucault (1926-1984), whose work Madness and Civilization (1961) contended that thousands of France’s undesirables—petty criminals, prostitutes, the homeless—were institutionalized during the Great Confinement of the Enlightenment period in an attempt to make society more rational and efficient. The Great Confinement represented a major shift from Renaissance notions that the mad had some kind of wisdom which allowed them to transcend the banal world of the rest of us. Asylums, for Foucault, were largely tools of social control, an argument that was effectively applied to mental illness more generally.
Writing at the same time was Erving Goffman (1922-1983), a Canadian-born sociologist who worked in the US. Goffman’s Asylums was based on fieldwork he conducted at St Elizabeth’s hospital in Washington, DC. Goffman argued that, once admitted, patients had to learn how to behave in a mental hospital, a process he described as “institutionalization.” This was much more of a survival mechanism than anything therapeutic, and did little for people if and when they were released. An analogy for this was to take a drowning man of a lake, teach him to ride a bicycle and then put him back into the lake.
There were many others who joined in on the attack on asylums, including Thomas Szasz, R. D. Laing, and Franco Basaglia, and using history to do so. Political beliefs, personal turmoil, and the spirit of the 1960s—not to mention the beginning of deinstitutionalization—all played a role in shaping their arguments, as such factors usually do, even in the most “scientific” areas of medicine. Books like One Flew Over the Cuckoo’s Nest by Ken Kesey also intensified the debates. Soon, bonafide professional historians, such as David Rothman, Richard Fox, and Andrew Scull got in on the act, attacking asylums as dehumanizing, corrupt, and unhealthy places.
It did not take long, however, for other historians, including Gerald Grob and Nancy Tomes, began revisiting the issue of asylums, examining in detail why people were sent there, what happened within their walls, and if patients were cured. Once the specifics were analyzed, often by delving deeply into the history of one particular asylum, a more complicated picture emerged. While some asylums were, frankly, terrible, others were quite humane, and although prognosis was often grim, some patients were successfully treated. Not only were many people voluntarily committed, but families, rather than state authorities, often brought their troubled relatives for help. The devil was in the detail. As Diana Gittins’ oral history of Severalls Hospital in Colchester indicated, many patients found a home in the asylum that they failed to find elsewhere.
In recent years, historians have become even more equivocal about asylums, hesitant to make any broad pronouncements about whether they were good or bad, overall. To a degree, there is nothing wrong with that. It is difficult to generalize when there were so many asylums of varying quality, and when the details tend to undermine the theories one might derive about them (as Foucault’s critics continue to point out). But that doesn’t mean that, as historians, we shouldn’t try to draw some general lessons from the history of asylums. Given the history of what’s happened after deinstitutionalization, there is a place for asylums in the twenty-first century. They should be places where humanitarianism and understanding, along with therapeutics, have to be central. Given the sordid recent history of care homes in the UK, this is not an easy thing to achieve. They should also be places where mental illness can be explored in all its dimensions. Note that I didn’t use the word “researched.” They should also serve a role as a refuge from an often unforgiving world, places where people worn down and disturbed by life’s tribulations can escape, reassess, and start again. With pressure on healthcare systems to cut costs, I’m not sure that such asylums are financially justifiable, but they most likely should be.