"[...][B]oth empirically and interpretively, extant histories of psychiatry reveal a vastly greater degree of difference among themselves than historical accounts of any other discipline"[1] Without doubt a short essay cannot provide the insight and analysis required for giving a complete account of the vastly differing views, theories and ideas that are connected with the history of psychiatry. Instead, this text will concentrate on the comparison of two major schools of interpretation in psychiatric history, one commonly labelled the "Whig" school, the other known as the "social revisionist" school of interpretation. In the following essay, I will provide a rough characterisation of the strongly opposing views held by either of these camps, accompanied by a brief historical contextualisation and critical evaluation of their ideas. Finally, I will attempt to provide some reasons for the "[...] controversy-ridden, attention-attracting [...]" nature of the history of psychiatry. [2]
One of the most striking, seemingly paradoxical, characteristics of the so-called Whig school of psychiatric history is that, in spite of its strong belief in progress and new developments, it is nowadays generally considered old fashioned. This esteem is already reflected in its name being derived from a political party long extinct. Originally, a "Whig" was "a member of the English political party or grouping that opposed the succession to the throne of James, Duke of York (1679-80), on the grounds that he was Catholic. [...] In the late 18th and 19th centuries, the Whigs represented the desires of industrialists and Dissenters for political reform."[3] Derived from this belief in reforms, the term "Whig" has been, and is still being, used to describe a progressivist approach on history, focused on steady scientific advancement and largely ignorant of darker periods in history.[4]
Major works of historical Whiggism appeared in the years between 1930 and 1960, a period "[...] which corresponded with the height of the professional prestige of psychiatry in Europe and America [...]". Furthermore, a considerable number of those works were written by psychiatric practitioners themselves, most of whom did not make an effort to provide genuinely original historical research, but rather sticking to a well-known body of existing major theoretical texts.[5] Thus, the optimistic and uncritical nature of their conclusions comes as no surprise. Generally speaking, the Whig view of the history of psychiatry is that of a long, straight road heading towards a gleaming, bright future, paved with milestones. A quote of one of the most widely read psychiatric histories in its time, the Russian psychoanalyst Gregory Zilboorg's "History of Medical Psychology", helps to illustrate this view: "The history of psychiatry is essentially the history of humanism. Every time the spirit of humanism has arisen, a new contribution to psychiatry has been made."[6]
To illustrate their idea of scientific and humanitarian progress, Whig historians often presented past events as part of "[...] a dual historical movement, from cruelty and barbarism to organized, institutional humanitarianism, and from ignorance, religion, and superstition to modern medical science. They often consisted of dramatically juxtaposed dark ages, enlightenments, and revolutions that heralded the way to the present."[7] This becomes evident when looking at an example dealing with the emergence of a new approach to treating the mentally ill at the end of the 18th century. The method described is the "Moral Treatment", brought forwards independently, yet simultaneously, by men like Pinel in France and Tuke in England. [8] The chosen text is Albert Deutsch's "The Mentally Ill in America", published in 1937. Before quoting it, though, it needs to be said that Deutsch's work is not typically Whiggish in every respect: Firstly, the author was not a member of the psychiatric profession - he was rather a kind of self-taught sociologist and "[...] public servant in the new York State mental hygiene movement [...]". And secondly, he does refer to a number of previously unpublished, primary source materials.[9]
Still, when describing "The Rise of Moral Treatment", Deutsch employs a typical Whig narrative. He makes every effort to emphasise the revolutionary nature of Pinel's and Tuke's new ideas and to distinguish them from the miserable treatment the mad had received before: They were, Deutsch rightfully claims, kept in institutions that where "purely custodial" rather than therapeutic. The very dramatic, descriptive writing style he uses to illustrate this point, however, is nowadays perceived as decidedly non-scientific. Harshly opposed to the explicitly described "dark ages" before the reform comes the "good doctor" Pinel who carries the light of progress into the asylum: "[The Bicêtre in Paris, Pinel's first assignment] looked like a circle of the inferno [...]. The lunatics lay all about, raving, riveted with chains and irons. They were regarded as desperate, dangerous animals on a lower plane than criminals [...] Their cries of anger, agony and frustration, induced by intolerable confinement, mingled with the endless clanging of chains and the crack of keepers' whips."[10] In came Pinel: "Here was the man who would clean these Augean stables, the miserable asylums for the insane. [...] Pinel proposed a radical change. He planned to strike off the chains from these miserable creatures and to inaugurate a regimen based on kindness and sympathy."[11]
Of course, Deutsch does not fail to take further scientific progress into account, making it clear that innovation did not stop back in 1792 and implying a seamless and uninterrupted scientific progress thereafter: "Imperfect though his [Pinel's] system was, it served as a cornerstone upon which further psychiatric progress was built."[12] The parallel achievements of William Tuke in his York Retreat are portrayed in a less dramatic, yet equally approving manner, the only criticism being that, "[i]n their minimization of medical therapy, the managers swerved too far to the extreme."[13]
A closer look at the history of the York Retreat, however, reveals that its history (just like psychiatric history on the whole) does not only consist of courageous steps forward in the development of an ever more philanthropic, humanitarian and humanistic science: An increased number of patients (which made an individual treatment more difficult), a more commercially orientated approach towards running the asylum, and a growing distance to the religious, Quaker roots of Tuke's ideas of the moral treatment led to a number of retrograde steps in the York Retreat's evolution. From the middle of the 19th century, "[...] patients increasingly were regarded [...] like untrained animals [...], as in the eighteenth-century view of the lunatic."[14] And even though the increased use of medical therapy need not necessarily be condemned as a step back, it came along with "[...] the deterioration of the Retreat's well-publicised moral treatment into a more repressive moral management."[15] Moreover, it is important to note that the publicised views of an asylum's head are not necessarily fully reflected in the treatment of the inmates. "Nowhere did this gap between objectives and their fulfilment become more obvious than at the York asylum." [16]
Considering the above, it becomes obvious that the aforementioned, long, straight Whig road into a gleaming, bright future of psychiatry may be paved with a number of milestones - but that it is also potholed. Consequently, the beginning of the 1960s saw the emergence of a forceful counter-movement to Whig historiography, which eventually, at the end of the 60s, led to a full-fledged movement against psychiatry itself.[17] Just like the major works of Whig history between the 1930s and 50s, the "social revisionist" works of the 60s and 70s where heavily inspired by the reigning Zeitgeist. They were intensely sceptical of society and its norms and often inspired by Marxist ideas. The unbridgeable gulf between Whig and social revisionist views on the history of psychiatry becomes evident when citing a passage from a book that "[...] has easily been the single most influential text of psychiatric historiography in the second half of the century", Michel Foucault's "Madness and Civilization"[18].
In Foucault's eyes, the Moral Treatment, highly acclaimed not only by Whig historians, is no more than a "[...] gigantic moral imprisonment which we are in the habit of calling [...] the liberation of the insane by Pinel and Tuke."[19] Foucault asserts that madness is a manifestation of unreason, an undesired deviation from the general norms of society in "the age of reason".[20] The asylum, as reformed by Pinel and Tuke, becomes then a means of re-educating the mad according to the norm and, thus, to successfully eradicate unreason. "The asylum reduces differences, represses vice, eliminates irregularities. It denounces everything that opposes the essential virtues of society."[21] Even though Pinel and Tuke drastically reduce the use of physical means of restriction, they do not really free the mad. Instead of being physically constrained, the mad are now expected to restrain themselves and to behave as expected. Since they are steadily watched and any disobedience will be immediately punished, they live in a state of "perpetual anxiety".[22] In the asylum, a subtle system of law and order is established, far more strict and merciless than the justice outside its boundaries. "[...] [I]t is a juridical space where one is accused, judged, and condemned, and from which one is never released except by the version of this trial in psychological depth - that is, by remorse. Madness will be punished in the asylum, even if it is innocent outside of it."[23] Like this, the Moral Treatment results in nothing more than the "[...] conversion of medicine into justice, of therapeutics into repression."[24] On top of the hierarchy in this system of legitimate torture reigns the "essential figure of the asylum", the physician.[25] As a combination of supreme judge, dictator, and father figure, his authority is unquestioned. As a scientist, though, his role is rather unimportant: "It is thought that Tuke and Pinel opened the asylum to medical knowledge. They did not introduce science, but a personality [the physician or homo medicus], whose powers borrowed from science only their disguise, or at most their justification."[26] Helpless, powerless, and inferior in status much the same way children are, the patients cannot help but surrender themselves "[...] to a doctor both divine and satanic, beyond human measure in any case."[27] Even though, long after Pinel, Freud abandoned the idea of the asylum, "[...] he did not deliver [the mad] from what was essential in [the asylum's] existence; he regrouped its powers [and] extended them to the maximum by uniting them in the doctor's hands [...]."[28]
In another social revisionist text, Robert Castel draws similar conclusions. He views the physician as the central figure in the "enlightened medical despotism" of the asylum, the person "who stands at the center of the web and controls all its threads".[29] By creating an atmosphere "[...] where one breathes only the pure oxygen of bourgeois morality [...]", the asylum apparatus is used to "[...] exert a normalizing influence over individuals who have not yet interiorized the norm or who have rejected it [...]". - an undertaking which "[...] does not differ substantially [...] from any educational enterprise."[30] Compared with Foucault, Castel puts more emphasis on "the analogy between the child and the lunatic", rather than following Foucault's idea of "perpetual judgement".[31]
The ideology behind both texts, however, is nearly identical, being one of "[...] romantic anti-statism and anti-institutionalism [...]"[32]. Even though the social revisionist movement doubtlessly sparked a whole array of interesting and inspiring new ideas and theories about psychiatry and its history, it must not be forgotten that its authors where as influenced by contemporary ideology as the Whigs were - though, of course, by a vastly differing one. "[...] [T]heir political agendas served to select their subject matters, to shape their methodologies, to texture their interpretations, and to predetermine their conclusions" - a fact they were quite often no more aware of than the Whigs were in their heyday: "[...] the two main traditions of commentary about the history of psychiatry in the past half-century have been equally lacking in self-reflexivity."[33]
In addition to the apparent ideological bias, there are other apparent criticisms towards social revisionist historiography. Just as with many works in the Whig tradition, the social revisionists' works very often lacked genuinely original historic research. Instead of finding new, virgin primary source materials, they concentrated on developing and pointing out their own ideas (Foucault being the most prominent example for this approach). Furthermore, the social revisionists may have succeeded in criticising the weak spots and drawbacks of psychiatry and psychoanalysis - but utterly failed at offering a serious alternative. And finally, "[...] neither Foucault nor anyone else can have a definitive answer as to whether [his] accusations [against the moral treatment, the asylum, and psychiatry as such] are valid or invalid, because relevant evidence on patients' states of mind does not exist in sufficient detail. [...] [A]t some stage the mad, or some of them, might wish to leave the 'freedom of unreason' for the world of reason (and even Foucault speaks of 'cure')[...]" - something they most probably will not be able to do without conforming to a certain set of commonly accepted social norms.[34]
Considering the above, it becomes obvious that neither of the examined schools can claim to pursue the single valid approach towards psychiatric historiography. And even though new, profoundly researched, works by authors such as Goldstein and Digby have left the boundaries of the traditional schools of interpretation behind them in order to provide new insights, to contextualise and to explain the past of psychiatry, its history will remain the controversial subject it has been ever since the emergence of this science itself. The reasons for the controversial and diversely interpretable nature of the history of psychiatry are too manifold to mention all of them in this limited space. Some significant reasons, however, include the following: Firstly, the "[...] disciplinary origins [of psychiatry] lie scattered in a multitude of areas of past activity and inquiry, including primitive medicine, mythology, hypnotism, theology, philosophy, law, anthropology, literature, and popular lay healing [...]", thus making it difficult to pin down the nature of psychiatry right from the start, and, consequently, making it impossible to portray its evolution as a clear and continuous process (the failure of Whig historiography helps to prove this point).[35] Secondly, these diverse origins and the vast array of topics covered or at least touched by psychiatry attracted the attention of scientists from many different fields, including sociologists and historians as well as psychiatrists, neurologists and others. This results in a multitude of different viewing angles on the subject, both enriching and complicating the debate.[36] And finally, treating mental illnesses is a process far more intimate, far closer to the innermost self of the human individual than ordinary medical operations like healing a broken leg, making it a highly delicate object of discussion. Psychiatry "[...] raises questions about the very nature of the Self, about the relations of body and mind, about our emotions and our sexuality, about the individual and the expert, about the nature of disease and illness, about the status and limits of applied science, and about compulsion and state power."[37] All these aspects make the history of psychiatry very tempting for ideological exploitation by constructing "usable pasts" which justify certain views on society and even mankind as such. Since these views are continually changing, new, groundbreaking works will appear, fuelling new debates and giving new directions and inspirations for scientific research. Some of them might turn out to be as influential as major works of the social revisionists - the next "Foucault" may already be in print.
[word count without foot notes: 2583]
Butterfield, Herbert: "The Whig Interpretation of History" (1931).
Castel, Robert: Moral treatment. Mental Therapy and Social Control in the Nineteenth Century (1971), in: Cohen, Stanley, Scull, Andrew (eds): Social Control and the State. Historical and Comparative essays (1981), pp 248-265.
Deutsch, Albert: The Mentally Ill in America. A History of Their Care and Treatment from Colonial Times (1937).
Digby, Anne: Madness, Morality, and Medicine: A Study of the York Retreat, 1796-1914 (1985).
Foucault, Michel: Madness and Civilization. A History of Insanity in the Age of Reason (1961).
Goldstein, Jan: Console and Classify. The French Psychiatric Profession in the Nineteenth Century (1987).
Leuret, F.: Du Traitement Moral de la Folie (1840).
Micale, Mark S., Porter, Roy: Reflections on Psychiatry and its Histories, in: Micale, Porter (eds.): Discovering the History of Psychiatry (1994), pp 3-36.
Sinclair, J.H. (ed.): Collins English Dictionary, 3rd, updated edition (1994).
Zilboorg, Gregory: A History of Medical Psychology (1941).
[1] Roy Porter, Mark S. Micale: Reflections on Psychiatry and its Histories, in: Porter, Micale (eds.): Discovering the History of Psychiatry (1994), p 5.
[2] Porter/Micale, p 3.
[3] Sinclair, J.H. (ed.): Collins English Dictionary, 3rd, updated edition (1994), p 1748.
[4] Essential in coining, and critically discussing, the term "Whig history" with its associated meanings was, without a doubt, Herbert Butterfield's work "The Whig Interpretation of History" (1931).
[5] Porter/Micale, p 7.
[6] Gregory Zilboorg: A History of Medical Psychology (1941), pp 524-525.
[7] Porter/Micale, p 6.
[8] "Cursorily defined [...] the moral treatment meant the use for the cure of insanity of methods that engaged or operated directly upon the intellect and emotions, as opposed to the traditional methods of bleedings and purgings applied directly to the lunatic's body. While it did not entail a total abandonment of the old repertory of physical remedies, it did entail an acknowledgement of their grave insufficiency." - Jan Goldstein: Console and Classify. The French Psychiatric Profession in the Nineteenth Century (1987), p 65. The concentration on Pinel and Tuke as the originators of the moral treatment is, of course, more than slightly simplifying. In her account of the emerging psychiatric profession in France, Jan Goldstein gives a more thorough account of Pinel's sources of inspiration and its lesser known predecessors.
[9] Porter/Micale, p 9.
[10] Albert Deutsch: The Mentally Ill in America. A History of Their Care and Treatment from Colonial Times (1937), pp 89-90.
[11] Deutsch, pp 89-90.
[12] Deutsch, p 91.
[13] Deutsch, p 94.
[14] Anne Digby: Madness, Morality, and Medicine. A Study of the York Retreat, 1796-1914 (1985), p 76. Looking at the writings of French psychiatrist Leuret, member of the circle of patronage formed by Pinel's scholar Esquirol, some equally non-philanthropic tendencies become evident: "My aim is not to cure through a specific means, but through all possible means; and if, in order to stir [a madman], it is necessary to appear hard and even unfair, why should I shrink from such means? Strange pity!" - F. Leuret: Du traitement moral de la folie (1840), pp 120-121.
[15] Digby, p 2 of preface.
[16] Digby, p 10. In her work on the York Retreat, she points out that "the image of the institution that is [usually] presented is to some extent a misleading one. It is derived from Samuel Tuke's [William Tuke's son] Description of the Retreat, written in 1813 [...]. In the past Tuke's view of the Retreat has been serviceable in helping to construct a Whiggish identification of the rise of the asylum with psychiatric progress." - Digby, p 1 of preface. Another good example for the disparity between theoretical writing and practical realisation is to be found in the writings of the Manchester asylum's head, Dr. Ferriar, and their actual effects on the inmates' treatment. - Digby, page 10.
[17]Porter/Micale, p 8.
[18] Porter/Micale, p 23, Michel Foucault: Madness and Civilization. A History of Insanity in the Age of Reason (1961).
[19] Foucault, p 278.
[20] The "[...] norms that reign society [include] work, discipline [and] strict organization of the use of time [...]" - Robert Castel: Moral treatment. Mental Therapy and Social Control in the Nineteenth Century (1971), in: Stanley Cohen, Andrew Scull (eds): Social Control and the State. Historical and Comparative essays (1981), p 256.
[21] Foucault, p 258. He continues to explain that the vices the asylum opposes include "celibacy [...], debauchery, misconduct [...]", drunkenness and laziness.
[22] Foucault, p 244.
[23] Foucault, p 269.
[24] Foucault, p 266.
[25] Foucault, p 270.
[26] Foucault, p 271.
[27] Foucault, p 275.
[28] Foucault, p 278.
[29] Castel, pp 256-258. Other than Foucault, Castel bases his study on a central, primary source, a lecture about the Moral Treatment given in 1854 by J.P. Falret, a member of the influential psychiatric circle formed by Pinel's student Esquirol - it needs to be said, though, that this is a very narrow base of evidence.
[30] Castel, pp 258, 255.
[31] Castel, p 255.
[32] Porter/Micale, p 11.
[33] Porter/Micale, pp 11-12.
[34] Digby, p 75.
[35] Porter/Micale, p 5.
[36] Porter/Micale, p 4.
[37] Porter/Micale, p 26.