The Victorian lunatic asylums of my city were magnificent, from the purely architectural point of view. Municipal pride, manifested by artistic embellishment without utilitarian purpose, shone out from them. They were built on generous grounds in what were then rural areas, outside the city bounds, on the theory that rustic peace had a healing effect upon fractured mindsand also that remoteness would protect the sane of the city from distressing contact with the insane. The city expanded and soon engulfed the asylums, but the grounds remained, often the only islands of green in a sea of soot and red brick. These grounds, right up until the asylums closed, were tended with a care that spoke of love and devotion.
For all who worked in them, the asylums provided a genuine sense of community. Indeed, by the time of their closure, they were the only real communities for miles around, the surrounding society having been smashed into atoms. They held annual cricket matches and other sporting contests on their spacious lawns, and hosted summer and Christmas balls. The staff were often second- or third-generation employees, and the institution was central to their lives.
The patients benefited from the stability; the asylum was a little world in which they could behave as strangely as they pleased without anyone caring too much. They were free of the mockery and disdain with which people elsewhere would greet their strange demeanor, gestures, and ideas: for in the asylum, the strange was normal. Within its bounds, there was no stigma.
But of course, there was a very dark side as well. Physical conditions, especially for those patients so chronically ill that the wards were in effect their homes, were appalling. There was no privacy, with beds sometimes packed so closely together that no one could walk between them. The smell of urine so deeply impregnated the furnishings and floors of the dayrooms that it seemed ineradicable (not that anyone tried to eradicate it). The stodgy food and physical inactivity meant that chronic constipation was universal; and most patients looked as if they had filtered their food through their shirts, blouses, and sweaters. Aimless wandering in the corridors was the principal recreation for many patients, who rarely saw a doctor, therapeutic impotence being more or less taken for granted. Individuals had lived in these conditions for more than half a century; and it was possible until the late 1980s to find women who had been committed to the asylums in the 1920s merely for having borne illegitimate children. As in the Soviet Union (though to a far less sinister degree), deviance was sometimes labeled madness and treated accordingly.
Most of the staff were kindly and well-meaning, but, as in any situation in which some human beings have unsupervised care of and power over others, opportunities for sadism abounded. Usually these were minor: I often saw nurses denying cigarettes to patients, telling them to come back in a few minutes, for no other reason than the pleasure of exerting power over a fellow being. But from time to time, far worse cruelty would surface, always hushed up in the name of institutional morale. This was easily done, since very few outside the asylum concerned themselves with what went on inside.
For most of their existence, the asylums were custodial rather than therapeutic institutions. Their methods now strike us as laughably crude. One asylum doctor published a memoir just after World War I in which he described how he and his colleagues treated suicidal melancholics and agitated paranoiacs. They sat the melancholics against a wall, placing a bench in front of them to prevent them from moving, while an attendant watched them to ensure that they did not do away with themselves. Croton oil, a very powerful laxative, subdued the agitation of the paranoiacs, who became so preoccupied with the movement of their bowels that they had no time or energy left to act upon the content of their delusions.
Attempts at cures were often more desperate than well-advised. One of the asylums of my city had the best-equipped operating theater of its time, where an enthusiastic psychiatrist partially eviscerated his patients and also removed all their teeth, on the theory that madness was caused by a chronic but undetected and subclinical infection (called focal sepsis) in the organs that he removed. Later, a visiting neurosurgeon used the theater to perform lobotomies on patients who were scarcely aware of what was being done to them. Doctors also tried more advanced treatments, such as insulin coma therapy, in which they gave schizophrenic patients insulin to lower their blood sugars to the point at which they became unconscious, sometimes with fatal effect.
It was not difficult, then, to present asylums as chambers of horrors, where bizarre sadistic rituals were carried out for reasons unconnected with beneficent medical endeavor. And it so happened that one of the most powerful critics of both the asylum system and psychiatry as a wholepowerful in the sense of having had the greatest overall effectpublished his attack in 1961, not long after the introduction of medications so efficacious in the treatment of psychosis that the asylum populations had already begun to decline, as patients were discharged back into the outside world. The name of the critic was Michel Foucault, and within a few years his Madness and Civilization had spawned an entire movement, though of somewhat disparate elements.
Foucault was not so much concerned by the cases of abuse or the poor conditions in asylums, as a mere reformer might have been. In the tortuous prose then typical of French intellectuals, he was concerned to assert that the separation of the mad from the sane, both physically and as a matter of classification, was neither intellectually justified nor motivated by beneficence. Instead, it was an instance of the exertion of power by the rising bourgeoisie, which needed a disciplined and compliant workforce to fuel its economic system and was therefore increasingly intolerant of deviancenot only of conduct but of thought. It therefore locked deviants away in what Foucault called the great incarceration of the seventeenth and eighteenth centuries, of which the asylums of the Victorian era were a late manifestation.
In Foucaults Nietzschean vision, all human institutionseven, or especially, those of avowedly beneficent intentare expressions of the will to power, because such a will underlies all human activity. It is not really surprising, then, if asylums had turned into nothing but chambers of horrors: for psychiatry, and indeed the whole of medicine, to the rest of which Foucault soon turned his undermining attention, were not enterprises to liberate mankind from some of its travailsenterprises that inevitably committed errors en route to knowledge and enlightenmentbut expressions of the will to power of the medical profession. The fact that this will was cloaked under an official ideology of benevolence made it only the more dangerous and sinister. This will needed to be unmasked, so that mankind could liberate itself and live in the anarchic Dionysian mode that Foucault favored. (A sadomasochistic homosexual, the French philosopher later lived out his fantasies in San Francisco, and died of AIDS as a result.)
Foucault inspired subsequent critics of psychiatry, of varying degrees of scholarliness, rationality, and clarity of exposition. Among the best was the influential historian Andrew Scull, whose history of the origins of asylums, Museums of Madness, nevertheless implied that the arrogation of insanity to the purview of doctors in the eighteenth century did not grow out of any natural connection between the phenomena of madness and the endeavor of medicinestill less out of the practical ability of doctors of the time to cure madness (witness their failure in the case of George III)but on the medical professions entrepreneurial drive to increase its influence and income. The fact that the mad eventually came under the care of the medical profession was thus an historical accident, the result of the shrewd maneuvering of the doctors: some other groupthe clergymen, for example, or the tailorsmight have occupied the same position had they maneuvered as successfully. Founded on so illegitimate a basis, psychiatry was by implication a totally false undertaking.
This argument overlooks a few obvious facts, however. What could have been said of madness could have been said of dysentery and pneumoniathat the doctors of the time had no power to cure them and that therefore these diseases were not properly the province of physicians and might just as well have been handled by tinkers or topographers. If the Foucauldian style of thought had prevailed at earlier times, with that mind-sets failure to understand imaginatively what is required to go from a state of complete ignorance to one of partial knowledge, and how it is often necessary to act in a state of ignorance, no one would ever have discovered anything about the cause or treatment of disease.
Moreover, the connection between madness and medicine is not entirely arbitrary and unfounded, as Scull suggested (though in my opinion the scope of psychiatry has since expanded illegitimately, especially in the grotesque overprescription of psychotropic medication). The eighteenth-century doctors had in this respect a better grasp of reality than Professor Scull, for organic conditions leading to madness and dementia must have been very common at the time. It has been plausibly suggested (though not conclusively proved) that George III was suffering from porphyria, possibly exacerbated by lead poisoning, for instance, and at the end of the nineteenth century, up to a quarter of the population of the asylums was suffering from general paralysis of the insane, the last stage of syphilis. Dare I mention that were it not for modern medicine, I myself would long ago have ended up in an asylum, one of those apathetic creatures that the physiognomists of madness in the nineteenth century so eloquently portrayed in their drawings, because I suffer from hypothyroidism, which is the most common of all endocrine diseases and which untreated can lead to madness and finally to dementia?
Another rhetorically powerful critic of psychiatry, also influenced by Foucault, was R. D. Laing, himself a psychiatrist. It was he who, in the 1960s and 1970s, gave currency to the idea that madness was an alternative, and in some ways superior, way of being in the world: that madness was in fact true sanity, and sanity true madness, insofar as the world itself was quite mad in its political, social, and domestic arrangements. According to Laing, it was the unequal power within families, and the distorted communications to which this inequality gave rise, that caused the condition in young people known as schizophrenia. To hospitalize them and treat them against their will was thus to punish them for the sins of their parents and to maintain an unjust social order at the same time.
This view became extremely popular in an era that uncritically criticized all institutions. The psychotic came to be viewed by right-thinking people as victims of injustice rather than as sufferers from illness (an attitude reinforced when it was discovered that young men of Jamaican origin living in Britain had a rate of schizophrenia six, seven, or eight times that of young white men). What was required was not treatment but restitution.
These ideas paved the way for an ill-conceived and hasty deinstitutionalization of the mentally ill. Thanks to effective treatments, the numbers requiring to be institutionalized were declining anyway; politicians hoped to save money by deinstitutionalization and were all too willing to believe that the mentally ill could be managed almost without any institutions whatever; and finally, criticisms of the Foucauldian moldthat society had no right to impose restraint upon the madentered common consciousness. Madmen had a right to wander the streets, and other citizens had the duty to put up with it.
The asylums of my city closed within a few short years. The patients were sent to live in what bureaucrats insisted upon calling the community, because of that terms connotations of warmth and welcome. With varying degrees of assistance and supervision, they were expected to live independently; they were given their autonomy, whether they wanted it or not. Many coped adequately with their newfound freedom, but many did not. And meanwhile, hospital provision for the mentally ill declined to such an extent, both for budgetary and ideological reasons (hospital admission was to be avoided at all costs, in a fetishistic kind of way, irrespective of the logic of the individual case), that every time it became imperatively necessary to admit a psychiatric patient, the entire system experienced a crisis. Madmen were left in police cells for days on end while hospital beds were found for them; sometimes, not a single such bed could be found in an area with a population of 4 or 5 million.
Every day in my work as a prison doctor, I witnessed the effect of this lack of provision. Ironically, the splendid new hospital wing of the prison, built with few expenses spared, rose on the grounds of an asylum that had just been closed down; but inside the hospital, we were re-creating the conditions of eighteenth-century Bedlam. Modern walls do not a modern hospital make. Unearthly screams rent the air; foul smells offended the nostrils. Madmen threw their clothes through the windows, started fires in their cells, tore up their sheets, wrapped towels around their heads, angrily addressed their hallucinatory interlocutors while standing stark naked on their beds, refused all food as poisoned, and spat at passersby. All that was lacking were visitors from the outside world who had paid their pennies to laugh at the lunatics; I suggested that we re-institute this great tradition to improve the prisons finances.
The cases would go like this: a madman would commit an offensesay, a completely unprovoked assault on a person in the street (unprovoked, that is, from the victims point of view; the perpetrator would believe that the victim had been threatening or insulting him). The police would arrest him and take him to the police station. They would recognize that he was madhis speech would be rambling and incoherent, he spoke of things that were not, and his behavior was completely beyond the bounds of reason. They would call a doctor, who would say that yes, the man was mad, but that no, he could not be admitted to a hospital to be treated, because there were no beds available.
The police then faced a dilemma. They could either release the man back into the community, whose sense of social solidarity he had so reinforced by his unprovoked attack on a random stranger, or they could charge him and put him before the courts. Sometimes they would do the one, sometimes the other. I have known lunatics released from police custody who clearly had intended to kill their victims in the street (and were handed back the weapons with which they intended to do it), because a policeman did not want to charge a man who was so obviously not responsible for his actions.
At other times, depending on who knows what factors, the police would bring the man before the courts, where a system of psychiatric screening had been set up. Theoretically, the accused found to be psychiatrically unwell by the examining nurse would be diverted from the criminal justice system into the psychiatric system. But the nurse, knowing that no hospital beds would be available were she to declare the accused mentally ill, and not wishing to accept the labor of Hercules involved in trying to find such a bed, declares the madman (so mad that it requires no expertise at all to detect his madness) to be fully sane, or a malingerer, or to be currently under the influence of marijuana, so that his madness will pass within a short time and results from voluntary intoxication, which is no excuse under the law for his crime. Thus the madman is remanded into custody; and the nurse calms her conscience with the hope that the prison doctor will recognize the mans madness and will try to find a hospital bed for him.
Unfortunately, things do not go smoothly in the prison. The doctor cannot find a hospital bed for his mad patient; the psychiatrists outside the prison consider that the patient is now in a place of safetythe prisonwhere he will not be deprived of medical attention, and he is therefore of lower priority for a hospital bed than a lunatic still at large in the community. He is thus kept, often for months, in the prison on remand.
As the law now stands in Britain, prison doctors are not permitted to give treatment against a patients will, except under the direst emergency, for fear that they might abuse such power and forcibly sedate whomever they choose contrary to the patients human rights. Hence psychotic patients are now kept in prison hospitals for months without any treatment whatsoever, thus taking part in an interesting if not altogether pleasing experiment in the natural history of psychosis, such as has not been conducted for many years.
Recently, for example, I observed a psychotic patient for several weeks, who addressed the world night and day through his prison window in words of muddled religious exaltation, who refused all food on the grounds that it was poisoned, his flesh melting away before my eyes, who attacked anyone who came within reach, and who painted religious slogans on the walls of his cell with his own excrement, thus imparting a nauseating feculent smell to the entire hospital.
It might, of course, be alleged that he behaved in so disturbed a fashion because he was incarcerated, and that his conduct was (in the opinion of R. D. Laing) a meaningful and enlightened response to his terrible social situation, and that he, of all the 1,400 prisoners in the prison, was acting in the most appropriate way under the circumstances. But this would be not only to ignore his medical history but also the fact that he was incarcerated in the first place because he had viciously and without provocation attacked a 79-year-old woman in a church, injuring her badly while reciting verses from the Bible, which suggests that his disturbed mental state preceded his incarceration and was not a consequence of it.
I checked the situation with lawyers. Although he had a fully documented history of psychosis and an entirely favorable response to treatment, attested to by both doctors and relatives (who said that when treated he was a pleasant and intelligent man), I was not entitled, in the name of human rights, to treat him against his will. In the name of human rights, therefore, the prison officers and the other prisoners had to endure weeks of revolting air, as well as disturbed nights in which sleep was all but impossible, while he lived in conditions that Hogarth might well have painted with justified moral fury.
The doctors to whom I proposed to send the patient accepted the conditions in which he lived with Buddha-like calm that would have been admirable had the suffering been theirs. Only the prison officers, among the most despised of all public servants, seemed to be moved by the scandal of the situation. The doctors, by contrast, were now so inured to such situations that they accepted it as normal and nothing to get excited about. The shortage of beds and the administrative difficulties that this shortage caused had steadily eroded their common humanity. It was only when I threatened to expose the scandal publicly and had taken photographs of the mans cell and said I would send them to the government minister responsible for prisons (a proceeding completely against the rules, but supported by the prison warden, who did not want his prison turned into a surrogate lunatic asylum) that the man was finally found a place in a hospital, where he could be treated.
Of course, Foucault might have put a completely different construction on the outrage of the prison officers and the desire of the mans relatives for him to be treated and returned to normality. He might have interpreted all this as an intolerant refusal to accept the mans alternative way of life, a refusal even to try to interpret the meaning of the communications that he coded in his own excrement. For Foucault, their concern, couched in the terms of humanity, concealed a drive for power and domination, used to produce conformity to debilitating and dehumanizing bourgeois standards. But such an interpretation would surely mean that common humanity and a feeling for others are qualities whose very possibility he would radically deny: that the only relations that could exist between men are those of power, and that all else is illusion.
I am aware that hard cases make bad law, but I could cite many such cases as the one above; of cases, for example, where doctors have changed their diagnoses in order to avoid the responsibility of finding hospital beds for their patients, and where they have even perjured themselves in court to evade that responsibility, to the great detriment of the patient and the safety of society alike. These are now part of everyday practice.
The shortage of beds, brought about by the desire to make financial savings in the context of an ideological assault on the notion of psychiatric illness, has corrupted doctors and nurses by slow but inexorable steps.
I am also aware that many horror stories could be told of doctors who have been overzealous (to put it mildly) in their attempts to cure their patients or to spread their fields of operations to their own material and social advantage. There is no simple formula for avoiding the Scylla of zealotry on the one hand and the Charybdis of abandonment of responsibility on the other. The art is long, life is short, the occasion fleeting, and judgment difficult. But the difficulty must be faced.
One thing is certain: that Foucault and his ilk are no guides to how to treat a man like the one I have described (and such as I have come across every day). Should he have been let free, to continue his Dionysian assaults on defenseless old ladies, on the grounds that they were life-enhancing? I cannot see that this represents anything but a preference for barbarism.