The Unjustified rise of Psychiatry
Although human suffering and distress is a universal human phenomena, considering it a medical problem is relatively recent. For thousands of years, those who acted "mad" were generally considered possessed by spirits, demons, or touched by God. Lewontin, Kamin and Rose (1985) explain that this change in what people consider "normal" is a relatively recent, cultural development. "It is clear that definitions of normality are themselves time--and culture--bound. Joan of Arc--who heard voices which she claimed were those of angles telling her to crown the French Dauphin and drive out the English-became a heroine of the French nation... Today she would almost certainly be diagnosed as schizophrenic..." (199). It is only in the past two hundred years that madness has been considered a medical "problem" requiring special intervention (usually involuntarily) by trained professionals (psychiatrists, psychologists, etc.). This change of perspective had less to do with science and more to do with politics, economics, and social upheaval. In short, mental health was a solution to difficult problems that society wanted to avoid.
The orthodox history of psychiatry claims that during the Enlightenment, intellectuals gradually discarded the theological view of mental illness as being caused by divine spirits, demons, or supernatural agencies. It was increasingly recognized that madness was probably a product of a diseased brain, making medical interest in madness acceptable. During this change in perspective, horrible abuses still occurred. However, in Europe, especially in England and France, the philosophy of moral treatment became adopted and allowed the mental patient to be treated with relatively more respect and dignity. Focus on accurate "diagnosis" became important. Research aimed to identify the underlying brain pathology or environmental characteristics that "caused" the illness. Advances in medical treatments in this century, such as drugs and electro-convulsive therapy brought an increased optimism and belief that mental illness could effectively be treated. Society later emphasized integrating the ill back into the community, so outpatient clinics and other programs were adopted (Johnstone 1989, 173).
Although the view presented above is generally accepted, there are many who consider it a self-serving and biased piece of propaganda. Andrew Scull, for instance, argues that the supposed legal advances concerning the insane are based on a view"'... which is hopelessly biased and inaccurate: one which relies, of necessity, on a systematic neglect and distortion of the evidence'" (Johnstone, 173). He portrays a less flattering, and more sinister, picture of psychiatry's development a powerful political special interest fighting for recognition and power.
Robert Castel (1988) traces the development of psychiatry in France from the late 1700's (just after the French Revolution) through the 19th century. He vividly shows how those often victimized by political or economic circumstances were often rounded up and sent off to "charities" sponsored by the government (Castel, 33). He describes the problems French officials faced. They wanted to guarantee everyone freedom from arbitrary detention, yet still wanted to use force and coercion against those who disrupted the social order. Before the development of psychiatry, in order to be deprived of legal rights, various legal procedures were required.
There were two official ways a person could be deprived of legal rights. The first were either "special orders" or "judicial orders" provided by the judicial branch. They were defended by the obligation of the state to maintain law and order. The other method to legally hold a person was by "royal orders" called "lettres de cachet." They could be written by the king or any of his appointees, or could be requested by the family of the person in question. These were the most elaborate and complicated ways of restraining a person. (15-16) However, both of these methods were unsatisfactory.
The citizens of France viewed the judicial orders as arbitrary and dangerous to civil liberties. This sentiment grew greatly as the impending French Revolution approached. The lettres de cachet were ineffective because the whole legal procedure was costly, which prevented many poor people from using it. It was also under increasing suspicion for being arbitrary and tyrannical because these orders were not only used against the insane, but other groups as well. "Thus the problem relating to the mentally deranged only represented one subcategory of kinds of offenses... The different types of deviance were therefore less lumped together but rather assembled upon the basis of common repressive requirements" (Castel 20).
The other group that threatened the French social order were the poor and indigent. Although these people had not broken any laws, there presence was bothersome (just like the panhandlers and homeless in New York City) and it was thought there should be ways to gather these people from the streets. But there was a problem. If society condemns and punishes these people, it assumes that they are mostly responsible for their plight. But if there were factors that lead to their poverty that was out of their control, then punishment was cruel and unjust. There was also a responsibility on society to aid them in some way. Laws were created that rounded up the poor into special institutions, and were defended on under the guise of "philanthropy." Supporters argued that although we condemn their behavior, they are entitled to some assistance. In this way, social repression and government assistance were presented as inseparable (Castel, 32-33).
The person considered mad or insane posed a particular problem because his behavior could not be understood like a criminal. A criminal willfully broke the social contract. The mad, however, could act strangely with or without breaking laws. Either way, his behavior was not able to be understood as reasonable. The insane were considered to be suffering from a disease that prevented the use of reason. If a mad person has no reason, then it is senseless to punish them, but something must be done about them. This is where the "philanthropy" of the government steps in. Since he cannot be classified in any legal category, society feels pity and must take care for him, as he does not know his own best interests.
Although most detained by the judicial or royal orders (except criminals), were all warehoused in the same institution, this system was increasingly being attacked. The whole institution system cost a lot of money, and the poor were not benefiting from it. There were moves to create programs were the poor would not be moved from their place in the community, but were aided in the community by the government. This was to prevent the "fit poor" from being admitted into a hospital when there was no need (Castel, 54-55). This process did not happen for the insane. The medical intervention for insanity only began to increase at this time because various doctors and "experts" claimed madness should be considered a medical matter (Castel, 48-50). The government did not mind delegating authority to the doctor because this would present less problems for the legal system, and it would look as if truly scientific decisions were being made about who should be deprived of his or her rights. It also gave the liberal a good feeling, thinking he was helping the sick regain his health.
As society and lawmakers viewed insanity as a medical matter, it was only logical to create "hospitals" for these "sick" people. As institutions were created for them, there had to be a new profession in charge of running the institution. The benevolent doctor was the perfect candidate. Who else does a sick person go to when he or she needs to regain health?
As the profession grew, gained status and became more organized, well-respected "experts" developed theories about the causes of insanity and what were the most effective treatments. The two schools of thought developed at the time were "moral" (psychological) and "medical" (physical interventions i.e..: bloodletting, various medicines, etc.).
Moral treatment philosophy stated the mentally disordered could be taught better ways of behaving. They had an essentially educational approach. The important values were teaching self-control and responsibility. The medical model emphasized the physical interventions and reiterated the ideology of insanity as a sickness. As the effectiveness of moral treatment became more evident, some started to question the need for doctors to treat the insane. This and other issues were the focus of debate in the early 1800's. Moral treatment founders asserted that care for the insane required no special skills other than compassion and common sense. Although the evidence was on their side, they still referred to the asylum inmates as "patients" and their intervention as "treatment." This allowed doctors to argue that they had cures for the illness of insanity, and that doctors were the most qualified to apply both the techniques of moral treatment and medicine (Johnstone, 174-76). [History does indeed repeat itself. There was a similar turf war between the psychiatry and psychology when mental hospitals were being shut down and community mental health was being marketed in the 1960's.]
This debate ended with the medical professional becoming the dominant leader and administrator of the asylum. He was granted a vast amount of power. Giving it to the doctor/administrator was justified on therapeutic grounds. " '[The doctor] must be in some way the living principle in a hospital for the insane. It is through him that everything must be set in train. He directs every action, called upon as he is to regulate every thought... The actions of the administration, which controls the material means of the institution, the supervision that this same administration must exercise over all the staff, must be covert; never will the director question a decision made by the doctor, never will he intervene... The doctor must be invested with an authority from which none can be exempt' " (Castel 130-31). With this amount of power, the doctor could do as he wished.
Since the medical profession claimed medical and moral methods were required to cure the insane, various "experiments" were done to prove the effectiveness of medical intervention. Administrations of various drugs and emetics, sudden immersion in cold water, pouring 10 to 50 buckets of icy water on patients heads, applying leeches or ants, revolving chairs, and other absurd and cruel "treatments" were tested and abandoned. Laws were also passed for building enough asylum space to serve the local population. Most of the time, the buildings were overcrowded and the alleged treatments were being used for inmate discipline rather than therapeutic reasons (Johnstone, 178-79).
Considering the pattern of abuse, error, and fraud throughout the history of the mental health profession, why is it we are always able to see the errors and sins that our predecessors made, but not begin to question the motives behind our own actions? Patients, the public, and lawmakers should maintain a healthy skepticism towards mental health professionals. Few disciplines in recent history have been as susceptible to fads and unproven claims of success as the mental health profession. If there is one piece of advice to heed, Albert Einstein said it best: " 'If you want to find out anything...about the methods they use, I advise you to stick closely to one principle: Don't listen to their words, fix your attention on their deeds' " (Szasz 1974,2).
Castel, Robert. (1988). The Regulation of Madness: The Origins of Incarceration in France. Berkley, CA: University of California Press.
Johnstone, Lucy. (1989). Users and Abusers of Psychiatry: A Critical Look at Traditional Psychiatric Practice. New York, NY: Routledge.
Lewontin. R.C.. Kamin. Leon J.. Rose. Steven. (1984). Not in Our Genes: Biology, Ideology, and Human Nature. New York, NY: Pantheon Books.
Szasz. Thomas. (1974). The Myth of Mental Illness: Foundations of a Theory of Personal Conduct. New York, NY: Harper and Row Publishers Inc.
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