Insanity and the beginnings of moral treatment

While suffering from 'nerves' may have enjoyed some social cachet, being insane certainly did not. The Scottish novelist and doctor, Tobias Smollett, caught this distinction in his novel, Sir Launcelot Greaves, when he described this exchange between patient and clinician:

Doctor, (said our hero) if it is not an improper question to ask, I should be glad to know your opinion of my disorder - "O! sir, as to that - (replied the physician) your disorder is a - kind of a - sir, tis very common in this country - a sort of a - "do you think my distemper is madness doctor?" - "O Lord!

Sir, - not absolute madness - no - not madness - you have heard no doubt, of what is called a weakness of the nerves, sir . . ."13

The visual arts and the asylum

In the visual arts, William Hogarth depicted Bedlam in his series of etchings, entitled 'The Rake's Progress', which charted the downfall of Tom Rakewell whose dissolute life leads to his eventual incarceration in the London madhouse (see Plate 1).14 There is the strong implication that madness is the result of moral weakness, although Hogarth was also pointing to the madness of society as a whole. In the nineteenth century, George Cruikshank was to pay homage to Hogarth's work by etching his own moral tale in which alcohol excess is shown to end in madness and suicide. The end of the eighteenth century saw the building of public asylums, although private madhouses and some institutions for the insane, such as London's Bethlem hospital and church-run asylums in Spain were in existence before this.

A powerful image of the new discipline of psychiatry was Robert-Fleury's painting of the great French alienist, Philippe Pinel, striking off the chains from a female inmate of the Salpetriere in Paris at the time of the French Revolution. Although it is unlikely this incident occurred quite as the painting portrayed it, Pinel did remove physical restraints from the insane and strove to bring more sensitivity to the doctor-patient encounter. In benign accounts of the history of psychiatry, his work is seen as ushering in a new era of humane treatment of the mentally ill. Rather than employing coercion, Pinel and like-minded clinicians would take a psychological approach that was christened 'moral treatment'. This would involve treating patients with respect, rewarding good behaviour and ensuring that they were provided with occupation and activities to retrain their disordered minds. Moral treatment was championed by the Tuke family at the York Retreat, which was to act as a model for other asylums throughout Europe.

Michel Foucault: madness and civilisation

This somewhat sunny view of the evolution of psychiatry was challenged by Michel Foucault in his 1961 book, Madness and Civilisation.15 Foucault contended that the new discipline had actually introduced more sophisticated forms of control. Instead of chains, more subtle ways of restraining the mad were developed: patients were induced to construct their own 'chains', but these were mental in origin and served to constrict self-expression or any deviance from bourgeois ideas of decorum - they were, to quote the words of William Blake, 'mind-forg'd manacles'. By these means, Foucault argued, 'the voice of unreason' was silenced. Interestingly, he suggested that the voice of unreason could still be heard in those artists who had gone over the edge of sanity: Friederich Holderlin, Friederich Nietzsche, Gerard de Nerval, Vincent Van Gogh and Antonin Artaud.

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