It is difficult to know how well Cheyne’s proposed eclectic jumble of causes and cures (including the importance of diet, exercise, greed, consumerism and state-of-the-art knowledge of physiology and the workings of the nerves) was received at the time. Most people could not read, let alone afford to buy a book (Stone, 1969), so Cheyne’s ideas would have been seen by a tiny minority of the population on which he was commenting. In this respect, MacDonald’s (1981) analysis of the notes made by the seventeenth-century English medic Richard Napier perhaps give us a rare insight into the maladies suffered by ordinary people who sought help, and the available treatments before there were any recognisable specialist mental health professionals. While we might take some care not to simply translate Napier’s categories (listed in the table below) into modern equivalents, the list that MacDonald creates does certainly look remarkably familiar (see Table 1.1).
Table 1.1
(Source: based on MacDonald, 1981, Table 4.1, p. 117)
The most common varieties of unhappiness seem to be versions of anxiety and fear, or of sadness: grief, melancholy and mopishness. MacDonald (1981) suggests that patients overwhelmed with feelings of sadness and lethargy and who were drawn from the peasant classes were likely to be labelled as ‘mopish’ by Napier, while those from the wealthier echelons with similar complaints were likely to be viewed as ‘melancholic’ (with its associations to delicacy and thoughtfulness). Contemporary questions about social class and diagnosis are taken up in other parts of this book, particularly Chapter 19.
MacDonald also analysed Napier’s thinking around the causes of such maladies. He found that they could be divided into three categories:
supernatural referred to astrological concerns
divine and diabolic referred to the actions of God and the Devil
natural referred to ‘ordinary’ adaptive responses and included grief, disappointments in love, physical problems, too much study or the balance of the ‘humours’.
In terms of treatments, Napier was eclectic in his therapeutic outlook. Various interventions were aimed at the body, including those intended to restore the balance between the four bodily humours, or fluids (an idea that stems from an ancient understanding of good health). Thus, there were recommendations for purges: emetics and laxatives, as well as various forms of bloodletting (such as the application of leeches). Medicines, such as opiates (for lunacy and madness), were prescribed alongside astrological guidance and advice on diet, rest and exercise. MacDonald emphasises the holistic approach and the continuity with apparent everyday concerns, but mourns the fact that Napier was one of the last of his kind. There were already powerful forces gathering that would no longer construe mental unhappiness in such holistic terms. MacDonald suggests that the main driver for this change was the growing culture that venerated science and rationality and thus nurtured the medical speciality of psychiatry.
The following century, which witnessed the stirrings of this specialism was, in MacDonald’s words, ‘a disaster for the insane’ as they became subject to crueller treatments and ‘confined to madhouses and asylums’ (MacDonald, 1981, p. 230). In making this claim, MacDonald, like many critics of the emergence of psychiatry, gestures towards the significance of Michel Foucault’s work on the history of psychiatry. Foucault is perhaps the most influential critic of psychiatry, so it is worth dwelling on the crux of his argument, which can be summarised by this often quoted passage from the preface of his 1967 book Madness and civilisation: a history of insanity in the age of reason:
In the serene world of mental illness, modern man no longer communicates with the madman… As for a common language, there is no such thing; or rather, there is no such thing any longer; the constitution of madness as mental illness, at the end of the eighteenth century, affords the evidence of a broken dialogue, posits the separation as already effected, and thrusts into oblivion all those stammered, imperfect words without fixed syntax in which the exchange between madness and reason was made. The language of psychiatry, which is a monologue of reason about madness, has been established only on the basis of such a silence.
(Foucault, 1967, p. xii)
Foucault suggests that, before the ‘age of reason’, madness was a part of all of us and our communities. The modern era of reason, often called ‘the enlightenment’, was marked by great scientific endeavours that led to the Industrial Revolution, which demanded rational thought and behaviour from people. Any previous ways of thinking that were deemed irrational, illogical or erratic were no longer acceptable. To Foucault, psychiatry was an important mechanism for enforcing such norms. It invented a language that talked about insanity as if it were an object that was separate from one’s self. Those judged to be ‘insane’ were banished from normality, so efforts could be made to separate, confine and treat ‘them’. This perspective also applies to even the most benign-looking initiatives, such as ‘moral treatment’ (discussed below) and the various ‘talking cures’ (described in Chapter 3) that followed.
2 The birth of psychiatry as the medical specialism of the mind
Accounts of the history of psychiatry tend to place the origins of recognisable forms of a specialist profession at the very beginning of the nineteenth century (Porter, 2002; Scull, 1979a), with the formal establishment of professional associations and journals occurring in the 1840s. Before this there were ‘mad-doctors’ who ministered to the insane and confined them in ‘madhouses’, while occupying ‘a niche slightly above a witch doctor in the public imagination’ (Boime, 1991, p. 79).
The transformation was energised by two innovations that involved the identification of ‘the mind’ of the patient as itself a significant field of enquiry and treatment. Firstly, there was the emergence of moral treatment, a landmark that initiated the practice of systematic ‘psychological’ treatment. While on the one hand this was arguably a significant precursor to many different forms of psychological treatment that were to follow, it was also a key argument that justified the large-scale building of asylums across many parts of Europe and North America in the nineteenth century (Scull, 1979a). The asylums came to dominate the landscape of mental illness for well over a century and in many ways we still live in their shadow (Rogers and Pilgrim, 2014). Secondly, there was the development of a set of ideas that construed some instances of serious criminality (particularly involving violence) as symptoms of mental disorder. This claim of expertise in criminal and legal matters was fundamental to the aspiration for professional status and recognition (Goldstein, 1987). Both innovations were underpinned by the relatively novel idea of a psychological domain – a world of the mind – which could be explored and treated by those with sufficient expertise (Jones, 2017a).
Examination of these ideas illustrates how the development of psychiatry needs to be understood as a product of various and often contradictory forces. Alongside the intention to find ways of alleviating distress were the more entrepreneurial pressures of those who wanted to build professional status and earn a living. There were also the anxieties of governments conscious of the threat posed by those who did not conform to social norms.