Читать книгу The Moral State We’re In - Julia Neuberger - Страница 20

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’.* 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,?^† ‘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.* 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’.^†

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.’* 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.