century, we must look back at the history of mental illness and its treatment.
Possession by demons and other evil spirits may not be part of our intellectual armoury now, yet when we bury our dead (in Jewish ritual anyway, and in many other practices) we still stop up bodily orifices to prevent them being invaded by evil spirits, and pause on our walk to the grave to shake off any lurking demons. Belief in evil spirits is just below the surface in many of us, as we touch wood, avoid walking under ladders, and look askance at black cats. Yet all this is intimately tied up with how we view those who have mental illness. Do we think they are possessed? (Sufferers themselves often take that view.) Or do we regard them in the same way as we would do if they had a physical illness? If so, why don’t we allocate them the same resources, and treat them with the same consideration, as those suffering from physical illness? Do we believe they need to be controlled, as their containment in the old asylums would suggest? If so, is that for their protection or ours? All these questions may have half-answers in our minds; but society is split, and individuals within it are confused, about mental illness and how to care for those who suffer from it.
Historical Reflections
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