AT THE BEGINNING of the seventeenth century, there were no mental hospitals, as we now know them. To be sure, there were a few facilities— such as Bethlehem Hospital, better known as Bedlam—in which a small number, usually less than a dozen, of pauper insane were confined. By the end of the century, however, there was a flourishing new industry, called the “trade in lunacy.”
To understand the modern concept of mental illness, one must focus on the radically different origins of the medical and psychiatric professions. Medicine began with sick persons seeking relief from their suffering. Psychiatry began with the relatives of unwanted, troublesome persons seeking relief from the embarrassment and suffering their kin caused them. Unlike the regular doctor, the early psychiatrist, called mad-doctor, treated persons who did not want to be his patients, and whose ailments manifested themselves by exciting the resentment of their relatives. These are critical issues never to be lost sight of.
Annoying, unconventional behavior must have existed for as long as human beings have lived together in society. Psychiatry begins when people stop interpreting such behavior in religious and existential terms and begin to interpret it in medical terms. The fatal weakness of most psychiatric historiographies lies in the historians’ failure to give sufficient weight to the role of coercion in psychiatry and to acknowledge that mad-doctoring had nothing to do with healing.
Higher mammals, especially humans, remain dependent on their parents for some time after birth. Because only women can bear children and because caring for infants is a time-consuming job, societies have adopted the familiar gender-based job differentiation, females caring for the young and tending the shelter, males providing food and protection for the family.
Once a society advances beyond the stage of subsistence economy, mother surrogates often replace the nurturing role of the biological mother. For centuries, parents who could afford household help delegated the task of child care to servants—governesses for infants and young children, tutors for older ones.
The belief that all parents passionately love their children and would like nothing better than be able to take care of them is a modern fiction and self-delusion. Taking care of children, day in and day out, is not a very interesting activity. Many adults dislike being merely in the company of a small child. Most people feel similarly disinclined to care for an insane adult, that is, for a person who is selfish and self-absorbed, demanding and dependent, intemperately happy or unhappy, perhaps even threatening and violent. Stripped of three hundred years of psychiatric-semantic embellishments, the fact is that a mad person appears to relatives as an unpleasant individual whose company they would rather avoid. Burdened by such an unwanted individual, they use psychiatric “care” to dispose of their family member.
Mad adults are, however, not children. Children have neither the physical strength nor the political power to resist being controlled by their parents and their deputies who possess lawful authority over them. The adult does. Other adults, whether parents or siblings, have no rights over their adult relatives, provided they are sane. Before adults can be treated as a mad, they must first be divested of their rights. Reframing the political status of the insane adult as similar to that of a child needing care accomplishes this task.
Historically, psychiatry’s first order of business was to establish insanity as a genuine disease, that is, as neither malingering nor an (immoral or illegal) act carried out by a responsible adult. Its next business was to distinguish insanity from other diseases and assign to it the singular characteristic of having the power to deprive the patient of his higher mental faculties, rendering him childlike, and justifying controlling and caring for him against his will. Hence the close association between severe head injury, brain disease (neurosyphilis), and insanity. This whole package was required by the political character of seventeenth-century English society, where, for the first time in history, a people dedicated themselves to honoring the values of liberty and property. It is not by accident that the ideas of limited government, the rule of law, and insanity as an infantilizing illness all arose and developed in England. Both the medicalization of madness and the infantilization of the insane were, and are, needed to reconcile a society’s devotion to the ideals of individual liberty and responsibility with its desire to relieve itself of certain troublesome individuals by means other than those provided by the criminal law.
The idea of insanity as a condition requiring the mad-housing of the insane was invented by those who needed it, the members of the dominant classes of seventeenth-century English society. It was they who had to carry the burden of being responsible for their mad relatives by having to provide for their needs and who, at the same time, had to conform their behavior to the requirements of a social order that placed a high value on the liberty of persons and the ownership of property. What was a man to do with his spouse, adult child, or elderly parent who flaunted convention and perhaps neglected his own health, but who was considered to possess a basic right to liberty and property? The time was past when such a troublesome individual could be treated as a clan member, responsible to the group, devoid of individual rights in the modern sense. The rule of law liquidated the autocratic prerogatives of elders vis-a-vis deviant adults. From the seventeenth century onward, the adult members of families were held together more by cooperation and compromise, and less or not at all by direct coercion. Regrettably, cooperation and compromise are useless vis-a-vis persons who are unable or unwilling to cooperate and compromise.
These political and legal developments placed family members faced with a disturbing relative in a difficult situation. Though embarrassed and victimized by their (mad) kinfolk, the (sane) relatives could not control their relative by means of the informal, interpersonal mechanisms normally used to harmonize relations in the family. They had only two options, both useless. One was to set the engine of the criminal law against offending family members (provided they had broken the law), a course that would have led to the social or physical death of the mad relative and the abject humiliation of the family. The other was to expel them from their homes, a course that would have required the sane relatives to possess more power than those they wanted to expel and would therefore have been most impractical when it was (felt to be) most necessary. It was an intolerable impasse. Sane (or perhaps merely scheming) family members had to come up with a socially acceptable arrangement to enable them to control, by means of a noncriminal legal procedure, the unwanted adult relative (who was senile, incompetent, troublesome, or perhaps simply in the way). That was the need that generated the concept of mental illness, and that is the reason why the concept of mental illness differs so radically from the concept of bodily illness. The point is that the physically ill person can be cared for without requiring coercive social control, but the so-called mentally ill person cannot be cared for in this way because he or she (rightly) rejects the patient role.
In what way did a property-owning madman in England in, say, 1650 endanger his relatives? He did so in one or all of the following ways: personally, by embarrassing them; economically, by dissipating his assets; and physically, by attacking his relatives. In this connection, it is necessary to acknowledge that a person who spurns our core values—that life, liberty, and property are goods worth preserving—endangers not only himself and his relatives but, symbolically, society and the social fabric itself. The madman’s embarrassing behavior gave his family impetus for hiding him; his improvidence, which provided an important conceptual bridge between the old notion of incompetence and the new idea of insanity, gave them an impetus for dealing with him as if he were incompetent. The law had long recognized mental retardation as a justification for placing the mentally deficient person under guardianship. Now the law was asked to do the same for the mentally deranged person. Medieval English guardianship
procedures lent powerful support to the emerging practice of madhousing. Both procedures grew from the soil of English political-economic and legal tradition, grounded in the value of preserving landed wealth and ensuring its stable transmission in the family. As far back as the thirteenth century, common law recognized two classes of incompetents: idiots, mentally subnormal from birth, who were considered to be permanently impaired; and lunatics, normal persons who went mad, who were considered to be capable of recovery. The procedure for declaring a person a lunatic was similar to that of declaring him incompetent: “Commissions examined such persons before a jury that ruled on their sanity….. Physicians played essentially no role in the certification process itself.”
Long before pauper lunatics were exiled to madhouses, propertied persons considered to be mad were managed in a manner that presaged the practice of mad-doctoring: “Physical supervision and care of the disabled party was commonly handled by retaining a live-in servant, the so-called ‘lunatics keeper,’ a person usually of the same gender as the disabled individual….. Boarding out the lunatic or idiot at a private dwelling, in the company of a servant, was also commonplace; this practice in some respects anticipated the development of private madhouses in the eighteenth century.”
Thomas Szasz – The Medicalization of Everyday Life