The Moral State We’re In

Before the witch craze of the fifteenth to seventeenth centuries, treatment of mental illness was often kinder. Much mental derangement was viewed as being inflicted by Satan and was therefore susceptible to the saying of masses, pilgrimages, or indeed exorcism. Protestants had a different view. The Anglican divine Richard Napier doubled as a doctor and specialized in healing those ‘unquiet of mind’. He thought that many of those who consulted him were suffering from religious despair (something still cited by many of those with mental illness in the twenty-first century, and less than comprehensible to many of the rationalist, post-religious, mental health professionals). They feared damnation, the seductions of Satan, and the likelihood of being bewitched. Napier’s treatment was prayer, Bible readings, and counsel–the talking therapies so many people with mental illness ask for now.

The excessively religious were also thought of as mad. Many of Wesley’s followers in the early days of Methodism were thought fit only for Bedlam (the Bethlem Hospital, now part of the Bethlem and Maudsley hospitals configuration), even though Wesley himself still believed in witches and demonic possession. His followers, at what might be described as revivalist meetings, would cry out and swoon uncontrollably. Many thought this must be madness. The same was said of Anabaptists, Ranters, and Antinomians. They were thought to be sick (puffed up with wind) and doctors and others who believed in social control pointed out that the religious fringe and outright lunatics shared much in common: they all spoke in tongues (glossolalia, now prevalent in much of the evangelical side of modern Christianity), and suffered convulsions and spontaneous weeping and wailing. Towards the end of the eighteenth century, with the rise of rationalism, doctors and scientists berated the Methodists for preaching hellfire and damnation, which they said led people to abuse themselves and commit suicide. Religious visions became a matter of psychopathology, and those who experienced religious yearnings and visions were thought mad.

As belief in witchcraft diminished new scapegoats appeared–beggars, vagrants, and criminals. But the idea of the rational had come to stay. Religion itself had to be rational–why else would John Locke write The Reasonableness of Christianity (1695), and why else would Freud and his allies later describe God as wish fulfilment? Belief was all too real. Its object, however, was not real at all; it was a projection of neurotic need, explained, as Roy Porter describes it, in terms either ‘of the sublimation of suppressed sexuality or the death wish’.* (#litres_trial_promo) Porter also points out that, in time, the medical profession replaced the clergy in dealing with the insane.

The religious view had been accompanied since ancient times with a different, scientific, view. Galen, the ancestor of modern medicine, had described melancholy and other mental illness and Aretaeus of Cappadocia (c. 150-200), a contemporary of Galen’s, had already identified bipolar affective disorder with his descriptions of the depths of depression and the delusions that could accompany it and the patches of mania, the rapid extreme mood swings, that define classic manic depression. Not until Richard Burton’s Anatomy of Melancholy (1621) was a better, fuller description given of depression, as he reviews the old explanations of blood, bile, spleen and brain, whilst adding lack of activity, loneliness, and many causes. His recommendations for treatment (or possibly containment-living with melancholy rather than curing it) consist of a variety of classic later advice: exercise (still recommended), diet, distraction, and travel, as well as hundreds of herbal remedies and music therapy, also often recommended in modern practice.

But it was the French philosopher Descartes (1596-1650) who brought about the biggest shift in the rational approach to mental illness. If, as Roy Porter puts it,?

(#litres_trial_promo) ‘consciousness was inherently and definitionally rational’, then ‘insanity, precisely like regular physical illnesses, must derive from the body or be a consequence of some very precarious connections in the brain. Safely somatized in this way, it could no longer be regarded as diabolical in origin or as threatening the integrity or salvation of the immortal soul, and became unambiguously a legitimate object of philosophical and medical inquiry.’

This was a deeply influential approach and in the late seventeenth century some began to take the optimistic view that people who are mad could be retrained to think correctly and rationally. But folk beliefs in witches and possession persisted, and the treatment of the mad was by no means totally predicated on this new, optimistic view of humanity, even though there were an increasing number of private asylums where treatment was more humane and some form of talking therapy-aimed at retraining the mind-was available.

The practice of locking up people suffering from all kinds of mental illness and disability had started to grow from the fourteenth century. The religious house of St Mary of Bethlehem in Bishopsgate (Bedlam, now the Bethlem and Maudsley Hospitals in London) was founded in 1247 and started catering for lunatics in the late fourteenth century. Some time between 1255 and 1290 an Act of Parliament, De Praerogativa Regis, was passed that gave the king custody of the lands of natural fools and lordship of the property of the insane. The officers in charge of this were called escheators, and they also held inquisitions to decide if a landholder was a lunatic or an idiot. Already by 1405 a Royal Commission had inquired into the deplorable state of affairs at Bethlem Hospital, suggesting that concern has been prevalent for centuries about how people with mental illness were treated.

By the eighteenth century asylums for the insane were widespread, though from 1774 certification was instituted so that confinement in a madhouse had to be done on the authority of a medical practitioner (with the exception of paupers, who could be locked up on the say so of a magistrate.) In Catholic countries, asylums were under the rule of the Church, with care provided by religious orders. In Protestant countries, care varied, but the state gradually played a greater part. Michel Foucault regarded shutting people up in asylums, not as a therapeutic practice, but as a police measure-a divide still found in mental health treatment and policy to this very day. He describes how houses of confinement such as the Bicêtre in Paris gradually came to be seen as a source of infection and concern was expressed that this would spread to the poor ordinary decent criminals who were thrown in with the insane.* (#litres_trial_promo) Asylums became spectacles and objects of fear at the same time: at the new Bethlem Hospital, a beautiful building in Moorfields, one could pay to view lunatics until 1770.

But, for the inmates of these asylums, the regimes were cruel. There was annual bloodletting at the Bethlem and general use of strait jackets and purges. There were, however exceptions. One of the most distinguished was William Battie (1704-76), physician to the new St Luke’s Asylum in London, who also owned a private asylum. A small proportion of the insane did, in his view, suffer from incurable conditions; but the majority, he argued, had what he described as ‘consequential insanity’-derived from events that had befallen them-and for whom the prognosis was good. So instead of bloodletting, purges, surgical techniques (such as removing ‘stones’ from the brain, a particularly vile treatment), and restraint, what was needed was what he described as ‘management’-person to person contact designed to treat the specific delusions and delinquencies of the individual. Battie considered that ‘madness is…as manageable as many other distempers’.

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And so a humane period-relatively speaking-in the treatment of mental illness began. Amongst others, Francis Willis (1718-1807), who was called in to treat George III, pioneered a ‘moral management’ school of treatment, where the experienced therapist would outwit the patient. At Willis’s Lincolnshire madhouse everyone was properly dressed and performed useful tasks in the gardens and on the farm, with exercise being a key feature. Similarly, the York Retreat developed moral therapy in a domestic environment. The Quaker tea merchant William Tuke (1732-1822) started a counter-initiative to the local York Asylum, which had been bedevilled by scandal. Patients and staff at the York Retreat lived, worked, and dined together. Medical therapies had been tried but dispensed with in favour of kindness, mildness, reason, and humanity, all within a family atmosphere.

But this enlightened approach was not to last. Although from 1890 onwards two medical certificates were required to detain any patient, the result was to close off mental institutions to the outside world. They were hard to get into-and even harder to leave. Little treatment, let alone comfort, was provided and the reputation of the new asylums began to sink as it became clear that they were silting up with long-stay, zombie-like patients. Criticism of such institutions began in the late nineteenth century but it took a hundred years before the last of the old long-stay mental hospitals closed.

Scientific thinking about madness had begun to degenerate too. John Stuart Mill criticized the operation of writs de lunatico inquirendo: ‘the man, and still more the woman…[who indulges] in the luxury of doing as they like…[is] in peril of a commission de lunatico and of having their property taken from them and given to their relations.’* (#litres_trial_promo) Science was beginning to believe that madness was caused by heredity, like the first Mrs Rochester in Charlotte Bronte’s Jane Eyre (1847), and most real progressive thinking was being carried out in specialist institutions such as the Maudsley, leaving the asylums, gradually starved of resources, to become the chronic patients’ permanent home. Only there could we be sure that the bad, the mad, and the other were kept away from us all. And since the newer asylums were built on the outskirts of towns and cities, or in the country, most patients were kept confined long term at some considerable distance from their homes, families, and friends, who all too quickly lost touch with them. When patients died, after being confined for life because their condition was thought to be incurable, their brains were examined in post mortems for signs of the cerebral lesions that many thought were the basis of all insanity. Psychiatry had become a tool of social restraint. In Britain this continued well into the twentieth century and remained the case until the creation in 1948 of the National Health Service, which largely took over responsibility for the asylums.

Twentieth-Century Policy and Practice

The twentieth century started with an obsession about degeneracy of the ‘stock’. It was feared that a ‘submerged tenth’ of the population would outbreed everyone else. The Royal Commission on the Care and Control of the Feeble Minded (1904–8) suggested that mental defectives, so described, were often prolific breeders and that, if allowed, would resort to delinquency, excessive sex, and alcohol. Winston Churchill, then Home Secretary, supported proposals for the forcible sterilization of 100,000 moral degenerates. His views were thought too extreme, however, and his plans were thought so sensitive that they were kept secret until 1992. But he was not alone.

Some forcible sterilizations did in fact take place, and in 1934 the Brock Committee recommended voluntary sterilization as a cheaper means than physical segregation of separating moral defectives from the nation’s gene pool. Homosexuals continued to be ‘treated’ in mental health units into the mid 1970s, the treatments including oestrogen therapy, electric shock therapy, psychoanalysis and behaviour aversion therapy.* (#litres_trial_promo)

All this has to be set against a gradual change in thought. Freudian theory, as well as the work of Jung and Adler, with their insights into the importance of the unconscious mind on emotions and behaviour, was just beginning to influence the way people thought about mental health. Containment, however, was still the order of the day, and concerns that the mentally defective would affect the genetic character of the nation only disappeared gradually. Even in the 1990s there were discussions about the forcible sterilization of young women with learning disabilities, ostensibly to protect them from unwanted pregnancies but presumably also because of fears about the children they might produce. Broadly speaking, however, theories about degeneracy and contamination of the gene pool had become unfashionable because of their Nazi associations. Therefore the assumption had to be made, for want of any other theory, that mental ‘defectiveness’, as well as insanity, was a health issue. With the establishment of the NHS, local authority hospitals were transferred to the Ministry of Health, but there was little change in conditions.

However, the drugs did change. Largactil, along with other anti-psychotic phenothiazines, appeared around 1955. It controlled symptoms without the sedative effects of the old drugs. Despite being a form of control, such drugs were widely used and community care became easier and less risky. In 1953, almost half the beds within NHS hospitals had been for mental illness or mental ‘defectiveness’. However, after 1954, the number of patients in mental hospitals began to decline and moves were made to change mental hospitals into institutions like those for physical diseases.

In 1959, the Mental Health Act excluded promiscuity or other immoral conduct as grounds for detention under the Act. The idea of moral degeneracy was beginning to fade, as well as the beginning of a realisation that institutionalizing people was bad for them.

No new large-scale asylums were built after the Second World War, but hospitals for mental ‘defectives’ continued to be built until 1971. And the old institutions remained. By 1966 there were still 107 mental illness and 66 mental handicap hospitals with two hundred or more beds. The following year Sans Everything was published, a collection of articles by Barbara Robb about how elderly people were treated in institutions, particularly in psychiatric and geriatric care. It caused a storm, and the official investigation, in 1968, substantiated most of what she said.

The Era of Inquiries

And so we come into the great era of inquiries, from the early 1970s onwards, and the gradual shaming of the institutions for the mentally ill and of those who worked in them. Virginia Beard-shaw’s later work for Social Audit in the late 1970s and early 1980s pulled together a great deal of the evidence from those inquiries about who blew the whistle on what was going on in some institutions for the mentally ill.

For example, there is the case of Ken Callanan and Art Ramirez, two student nurses who were forced to stop training at Brookwood Hospital in Surrey after staff and management united to discredit them. In August 1978, Callanan, a former merchant seaman aged 29, began training as a psychiatric nurse at Brookwood Hospital School of Nursing. His introduction to nursing included a lecture on nursing ethics during which his Director of Nurse Education told the class that: ‘If I find that any of you have ill treated a patient or failed to report ill-treatment by other staff, your feet will not touch the ground. I will personally show you the door.’* (#litres_trial_promo)

After twelve weeks of training he was sent for his second practical posting on Tuke 4, a ward named after that great reformer of mental health services two centuries earlier. Tuke 4 was a ward for the chronically mentally ill–in other words, a long-stay ward. Here, in early 1979, Callanan witnessed repeated abuse of patients by the ward’s charge nurse, who had been at Brookwood for years and was well liked.

Callanan’s next posting convinced him that what he had seen on Tuke 4 reflected systematic abuse and malpractice. A fellow student, Art Ramirez, told him that he had seen the same charge nurse kick a patient. So, in a confidential letter, Callanan told his unit Nursing Officer about the ill treatment he had seen. The investigation was delegated to the Senior Nursing Officer, who knew the charge nurse well. The investigation continued for about a month, but even before its results were known feelings against Callanan and Ramirez were running very high and staff threatened a walk-out unless the pair were suspended. Management ‘compromised’, as Beardshaw puts it. The two were sent to the training school, with nothing to do.

After the SNO’s investigation, the charge nurse was completely exonerated. Callanan’s ‘inexperience’ had led him to ‘misinterpret’ what he had seen. Despite the official exoneration of the charge nurse, the other staff continued to threaten to walk out if Callanan and Ramirez were allowed back and the local branch of COHSE (Confederation of Health Service Employees, as it then was) voted to recommend Callanan’s expulsion from the union.

Callanan and Ramirez were offered a deal: they could return to work if they were prepared to accept, sight unseen, the internal investigation’s findings and a new procedure for making complaints. The students agreed to the complaints procedure in principle, but could not agree to accept the internal investigation’s results without having seen it.

On the Royal College of Nursing’s advice, the pair took their concerns to the Beaumont Committee, which Surrey Area Health Authority had set up to look more widely at conditions in mental institutions. A string of staff witnesses defended the charge nurse, both to the Beaumont Committee and to the General Nursing Council Disciplinary Committee, to which Callanan had referred the case. But the strength of the students’ evidence did convince a lot of outsiders. In February 1980, a year after the abuse was first witnessed by Ken Callanan, the charge nurse was finally struck off the General Nursing Council’s register, after five charges of ill treatment and drug abuse were found proven. He was dismissed from Brookwood. In April, the Beaumont Committee upheld the students’ allegations, saying that the pressure they had been put under by fellow and senior staff and the union was deplorable. Art Ramirez left Brookwood and trained elsewhere. Ken Callanan became an ambulance man, a great loss to mental nursing.

We see the same pattern in inquiry after inquiry. A few brave staff members–people of great conscience, who are prepared to take risks with their own livelihoods and reputations for the sake of others–tell the authorities what they have seen and heard, but it rarely does them any good. Few of them ever reach any kind of senior position, even after allegations are proven.