Madness and Method
- The Anatomy of Madness: Essays in the History of Psychiatry Vol. I: People and Ideas, Vol. II: Institutions and Society edited by W.F. Bynum, Roy Porter and Michael Shepherd
Tavistock, 316 pp, £19.95, November 1985, ISBN 0 422 79430 9
- Madness, Morality and Medicine: A Study of the York Retreat 1796-1914 by Anne Digby
Cambridge, 323 pp, £27.50, October 1985, ISBN 0 521 26067 1
Traditional histories of psychiatry, and those which preface the standard medical textbooks on the subject, are good examples of Whiggish historical writing. The dark ages for madness last until the end of the 18th century when Pinel’s dramatic removal of the chains of lunatics at Bicêtre, and the establishment of the York Retreat by William Tuke, inaugurate the psychiatric enlightenment. The development of the asylum bears witness to the increasing ability to distinguish between the mad and the poor, idle and criminal classes, and to attempts by various reformers, notably the Tukes and John Conolly, to institute a system of humanitarian care for their patients. After these early steps away from the cruel and barbarous treatment of the mad of the preceding centuries, the medical profession began the process of putting the treatment of the mental illnesses on a more scientific footing. The 19th century saw the identification of a number of organically-based mental diseases, while the early 20th century saw the development of a scientific psychological medicine, informed by the writings of both Meyer and Freud, which could integrate non-organic factors into the aetiological picture of the various conditions. More recently, the development of ECT and the post-war chemotherapy revolution have made possible the management of patients in the community and a partial phasing-out of the now decaying institutions in which they had been housed. While much remains to be done, there can be no doubt that the treatment of the mentally ill has advanced immeasurably since the dark days of the 19th century and before, when the mad were chained, whipped, imprisoned in straw-strewn cells, and exhibited to a curious public for the price of a penny.
This ‘in-house’ account of the history of psychiatry has been subjected to wide-ranging criticism by a generation of sociologists and historians who were influential in or influenced by the anti-psychiatry movement of the 1960s and early 1970s. The orthodox view has been inverted: the ‘dark ages’ are re-characterised as a period in which the existential moment of madness was allowed free play; the era of moral management led by Pinel and the Tukes is seen as substituting ‘mind-forged manacles’ of guilt and self-control for the chains of the old order; the incarceration of the insane in asylums, and their subjection to the ever watchful gaze of their keepers, emerge as part of a broader development of administrative machinery for the maintenance of social control through the surveillance and discipline of the subject populations of modern bureaucratic states. The medical profession enter the scene as empire-building moral entrepreneurs seeking to enlarge their domain of practice. Instead of being a site for the display of psychiatric expertise, the asylum is the ‘condition of possibility’ for this expertise. It acts as a receptacle for those who fail to conform to the rules and conventions of society – a heterogeneous collection of rebellious, socially inadequate, distressed and disruptive individuals. Psychiatric classification comes into being to order this polymorphous mass of the socially perverse. Medical methods are applied to a problem of social order; social deviance is taken as indicative of organic pathology; and the social and moral order is thereby transformed into a natural order of human behaviour. This transformation has wider implications: conformity signifies health, deviance sickness; to diagnose madness is to lay down the law, while to attempt to treat it is to reaffirm the unequivocally rational nature of the social order. If traditional histories of psychiatry are Whiggish, anti-psychiatry histories (particularly that of Michel Foucault) are often relentlessly pessimistic: while the former insist upon our developing grasp of psychiatric conditions, the latter see only our developing conditioning by the therapeutic state.
Anne Digby’s monograph on the history of the York Retreat, and the two volumes of essays edited by Bynum, Porter and Shepherd, pay eloquent testimony to the transformation effected in the history of psychiatry over the last twenty or thirty years. The works of Foucault, Erving Goffman, Thomas Szasz and R.D. Laing, and more recently the contributions of Andrew Scull and a new generation of historians, have made it impossible to accept the Whig view of psychiatry’s history. Yet, if these writers have managed to convince historians that work in the subject must take account both of the wider social and political context and of the methodological and philosophical problems involved in the history of ideas and the philosophy of science, they have not succeeded in establishing a convincing alternative framework for the field. One reason for this, as the editors of The Anatomy of Madness argue in their Introduction to Volume One, is that we are still sufficiently ignorant about most aspects of ‘madhouses, mad-doctors and madmen’ to leave the field wide open for substantial revaluation of existing claims. Any such revaluation must depend on detailed empirical work – much of which remains to be done – and on conceptual revision. The essays in The Anatomy of Madness, and Digby’s monograph, make valuable contributions in both respects. They are not intended to provide a single vision: the essays are aptly characterised as a ‘dispatch from the front’, and are offered as a ‘stimulus’ and ‘irritant’ for those working in the field. The result is a collection of pieces which are heterogeneous in their subject-matter, methodological commitments and conclusions. There is ample justification for this heterogeneity, as the editors indicate: ‘The mix of depth, detail and diversity to be found here reveals a complex historical fabric, and raises again and again the problems which historians must face in relating intentions to outcomes, science to ideology, knowledge to control, and the overt to the latent functions of actions and institutions.’ This is not editorial licence. The essays do indeed engage in different ways with the complex problems faced by a sociologically and philosophically-informed historiography; most do so in an informative and challenging way, some do so with considerable flair. While most pieces have some virtues, some are really exceptionally good.