The social aspects of psychiatry and the asylum system

By the end of the eighteenth century it was recognized that the study of mental alienation was part of medicine. However, mental diseases were of such a nature that it was not possible to treat the insane in the same conditions as patients affected by other diseases. Their most obvious manifestations had social consequences. According to the prevailing philosophical vew, the mentally ill were deprived of free will by their illness. In practice, they were unable to participate in the normal life of the society and were often considered as potentially dangerous. Because of this they had generally been confined in madhouses of various kinds. One of the aspects of the reforms initiated by Pinel had been to make more explicit the difference in nature between the socially deviant behaviour of the insane, which, being the consequence of an illness, belonged exclusively to medicine, and the other deviations which society had to control and eventually to repress. The implementation of this fundamental distinction during the first half of the nineteenth century helped to give psychiatry its specific shape as a profession by being at the origin of forensic psychiatry and by leading to the formulation of precise rules concerning the commitment of the insane to institutions of a strictly medical character.

The legal code promulgated by Napoleon in 1810 stipulated that 'no crime or delict exists if commited in a state of dementia', with the old term dementia being used as a synonym of Pinel's mental alienation. This legal provision, introduced in similar forms in other countries, opened an important domain of activity to the medical profession of psychiatrist. Because of their now recognized specialized knowledge, the alienists were to help the judges in determining whether the mental state of an individual convicted of a 'crime or delict' was normal or pathological, with decisive consequences on the subsequent decision. The title of Esquirol's Treatise mentions explicitely that it describes the mental diseases 'in their medical, hygienic and medico-legal aspects'. The conflict (which still exists) between the judges, usually supported by public opinion, who took a restrictive view of the concept of mental disease, and the psychiatrists, who tended to expand it to include new types of deviant behaviour, is illustrated by the violent controversies provoked by Esquirol's description of 'homicidal monomania'. They had an even more famous counterpart in England. J.C. Pritchard, an admirer of Esquirol, had isolated 'moral insanity' as a specific mental disorder in two books published in 1837 and 1842; in the second he examined its 'relations to jurisprudence'. Half a century later, in 1897, Henry Maudsley, who was in favour of the use of this diagnosis, recognized that this category, although internationally accepted by the psychiatrists, corresponded to:

... a form of mental alienation which has so much the look of vice and crime that may persons regard it as an unfounded medical invention'. Judges have repeatedly denounced it from the bench as a 'most dangerous medical doctrine', 'a dangerous innovation' which, in the interest of society, should be reprobated.

The general acceptance of the new medical concept of mental alienation implied the existence of adequate facilities for the treatment of the patients. The creation of new asylums—the term was retained—and the reorganization of the old ones was the answer. The French law of 1838 which fixed the detailed rules for the expansion of the new system to the whole country and for its functioning and financial support had a model character. Similar results were obtained in, for example, England with the Asylum Act 1828 and the Lunacy Act 1845. Outwardly the new system was the extension, under more humane conditions, of the previous institutional practices. However, it had radically original features. While recognizing the necessity of protecting society, it stressed the fact that the insane had a fundamental right to be protected and medically treated in a competent way. The deprivation of liberty for the patients which it still implied was strictly controlled to prevent possible misuse and anyway was justified, according to Esquirol and most contemporary psychiatrists, not only by the loss of free will, which was a consequence of the illness, but also by the therapeutic value of separation from a pathogenic milieu.

The asylum system became the central element of psychiatric care and was both the consequence and the determining factor of the emergence of psychiatry as a medical specialty to which it gave, until the end of the nineteenth century and even beyond, an original character. The asylums acquired a quasi-monopoly in the care of the mentally ill. The few private institutions reserved for the wealthier members of the population, which often belonged to alienists in charge of an asylum, were generally submitted to the same legal rules. Private practice with ambulatory patients, as existing today, was exceptional or dealt with cases which were not then considered to belong to mental alienation. As a result, the study of mental illness was predominantly restricted to the more severe forms of disorder. Another consequence was that the alienists in charge of patients committed to the asylums had a dual function, a fact that differentiated them from other hospital physicians. In addition to their medical duties, they were involved in the legal procedures which determined the conditions of admission, stay, and eventually release of the mentally ill. As superintendents, they also often had economic and financial responsibilities, being in charge of the material as well the medical aspects of the functioning of their institutions.

Despite the fact that the laws now strictly differentiated the nature of the limitations of liberty in asylums and in prisons, the participation of the alienist in a form of social control was eventually perceived negatively by the public, and often by other physicians, and contributed to accentuating the specificity of psychiatry inside medicine. During the third and the fourth decades of the nineteenth century, which saw the birth of the asylum system, the psychiatrists became really conscious of their identity as a professional group. In England, France, Germany, and the United States they founded societies and began to publish journals with specialized scientific goals. Such a description oversimplifies an evolution which was progressive and in some cases took different directions. The creation and the extension of the asylum system took many years; it did not reach its classical form until the last part of the century, as testified by the famous campaign conducted in the United States during the 1840s by Dorothea Dix who complained that many of the mentally ill were still incarcerated in almshouses and prisons. The moral treatment practised in the institutions was eventually used to justify brutal measures, alleged to be therapeutic, and the behaviour of the attendants, who were not usually medically trained (significantly, they were known as surveillants in France), was too often of a purely repressive character. It was a long time before the proposals made in 1856 by the British psychiatrist John Conolly in his book The Treatment of the Insane without Mechanical Restraints were put into practice everywhere.

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