Psychiatry’s history is manageably short – barely 200 years. The mentally deranged have always been recognized and where they could not be cared for within the family some makeshift provision was made – private madhouses and spas for the rich and workhouses for the poor. Workhouses contained everyone who could not care for themselves – the feeble-minded, the sick, the feckless, and the unemployed. Conditions were grim (deliberately so to discourage the burden on the public purse) and the mentally ill often fared badly from other inmates who were impatient with them or took advantage of them. Private madhouses were hardly that much better. There was no training required to own or run them. Their main purpose seemed to be to hide mad members of rich families from view, either to protect the family’s reputation or to appropriate their fortunes. The harsh treatment of the much loved King George III generated powerful antipathy towards them in late 18th-century England.
Bedlam was the first major public madhouse, opened in London in 1685 and still in existence as the much-reformed Bethlem Royal Hospital. The exhibition of the inmates was a popular public pastime in the early 18th century and generated revulsion in more educated quarters. France had established its Hotel Dieu and Hôpital Général in 1656 (the Bicêtre for men and Salpêtrière for women) which, despite their names, were not hospitals, but general establishments for custodial care more akin to workhouses. Tollhäuser (fools’ houses) had been established in medieval Europe. The first US insane ward was established in a Boston Almshouse in 1729 and the first US Psychiatric Hospital in 1773 in Williamsburg, Virginia.
The York retreat
The impetus to separate the mentally ill and provide more appropriate care came not from doctors but from social reformers and reflected an emerging concern with the dignity of man. In our risk-obsessed days it is sobering to realize that asylums were proposed more to protect the deranged individual from society than vice versa. In France in 1792, Pinel dramatically and symbolically removed the chains from inmates in the Bicêtre and in England a Quaker family, the Tukes, proposed and built the first Asylum in York. The Tukes were convinced by the writings of Pinel and Esquirol that a calm and harmonious environment, close to nature and with kindness and predictable routines (‘moral therapy’), would bring peace to a troubled mind. The York retreat was built to contain 30 patients; opened in 1796 it achieved remarkable results – many early patients were discharged home improved or even cured. It attracted attention from all over the world and visitors came from the US and throughout Europe to study and replicate it. The UK developed early a liberal regime, reluctant to use mechanical restraints such as chains or belts (later championed by John Connelly in the ‘non-restraint movement’).
The asylum movement
In the 1820s the asylum movement began and over the next 70 years hundreds were built for the reception of indigent ‘lunatics’ in each county in England, in most European countries, and across America. The scale of investment is hard to conceive of now, with enormous, well appointed buildings to house several hundred patients each. The physical conditions within the asylum (space, heating, food, recreation) would have been significantly better than most patients could have expected at home with their families. The principles of moral therapy dictated that asylums should be spacious, away from busy towns, placed in the countryside with extensive grounds. High airy locations were selected because of current theories implicating mists and ‘miasmas’ in disease.
1. Narrenturm (‘Fools’ Tower’) situated alongside the Vienna General Hospital, the first modern general hospital in Europe, built by Emperor Joseph II in 1787
Doctors were put in charge of asylums primarily because they were easy to hold accountable to the board of governors. There were few effective medical interventions and the medical superintendent’s role was predominantly administrative and disciplinary. He didn’t even have the power to admit or discharge patients – that was usually held by the local magistrates.
Asylums started well, often admitting recent cases – many of whom recovered. They soon seized up, however, with those who did not recover and so became overcrowded. Throughout the latter part of the 19th century and early 20th century, the recovery rate in mental hospitals declined steadily because of an increasing concentration of these more severe cases. Therapeutic optimism gradually faded and conditions (though still much better than the workhouse) deteriorated.
Throughout the 19th century investment in asylums was maintained. They were kept high on the agenda in the US by the influential social reformer Dorothea Dix and the physician Benjamin Rush and in England by strong central support from the influential social reformer Lord Shaftsbury. Initially quite small institutions, they rapidly grew to several hundred inmates each in Europe and up to several thousand in the US, where the building programme started a bit later and continued longer. Between 1903 and 1933 the number of patients in US mental hospitals more than doubled from 143,000 to 366,000. Most of these were in institutions of more than 1,000 beds and US mental hospitals continued to expand. The largest was the Georgia State Sanatorium at Milledgeville which by 1950 housed over 10,000 patients.
2. Georgia state sanatorium at Milledgeville: the largest state mental hospital in the USA. At its height in 1950 it housed over 10,000 patients
The non-restraint movement
Cultural values are strongly reflected in the care of the mentally ill. This is still the case despite the globalization of mental health research. At the start of the asylum movement the UK and US focused on human rights and, particularly in the UK, on treating patients with as little physical restriction as possible. John Connelly, the physician superintendent at Hanwell Asylum, became the leading proponent of managing patients without strait-jackets or chains. He emphasized the value of well trained and unflappable staff and used isolation to allow patients to calm down. A US visitor to Connolly commented that English patients must be more tractable and that the approach would ‘never work at home’. This tradition has continued and the UK became the first country to run some mental hospitals entirely without locked doors (Dingleton in Scotland was a fully ‘open-door’ hospital by 1948 – before the new drugs, see Chapter 3). The UK approach remains unusual in its total absence of mechanical restraints to control agitated patients. Whether its reliance on medication to achieve this is always a good thing is, of course, open to question.
Psychiatry as a profession
Medical superintendents were responsible for running the asylums – ensuring there was enough food, sacking drunken staff, preventing abuse, and proposing discharge to the board if patients recovered. Some of the more able (such as John Connelly) became highly skilled in man-management and also took a leading role in the design of new asylums. The early asylum movement produced some remarkable architectural achievements but relatively few therapeutic ones. There was no specific training to be an asylum doctor – you went there and worked alongside the superintendent and if you were lucky you eventually replaced him. These were, however, generally thoughtful men (they were all men) and interested in science. In the 1840s they founded their own professional bodies – the Association of Medical Superintendents in the UK in 1841 (later to become, 1865, the Royal Medical Psychological Society and in 1971 the Royal College of Psychiatrists). The formation of this professional association in 1841 coincided with the naming of the dinosaur – a coincidence not lost on the profession’s detractors.
‘Germany’ – psychiatry’s birthplace
In the second half of the 19th century there was a remarkable intellectual flourishing in German-speaking Europe. The collection of states that came to make up modern Germany were rivals of each other and characterized by local centres of government with prestigious universities and institutions. Unlike France at the time (where everything happened in Paris) there were several culturally and linguistically linked, but independent, centres of innovation – Munich, Berlin, Vienna, Zurich. From these came the great founding fathers of modern psychiatry: Griesinger, Morel, Alzheimer, Kraepelin, Bleuler, Freud, Jung. The first professor of psychiatry was established in Berlin (Griesinger 1864) and there were six by 1882. Compare this to England where the first professor of psychiatry was appointed in 1948.
These academic posts were not, on the whole, placed in mental hospitals nor were they dedicated to the treatment of the legions of psychotic and demented patients who inhabited them. Most research was conducted in university clinics and most was focused on detailed examinations of the nervous system in an attempt to elucidate the mechanisms of the ‘degeneration’ that was thought to underlie mental illnesses. Three of the most influential figures found their way into the area for more personal reasons. Falling in love was the reason for both Kraepelin and Freud and family concern for Bleuler. Freud and Kraepelin had successful research posts in university departments (Freud was dissecting the nervous system of eels). A research career at that time was incompatible (in terms of both income and time) with marriage and a family. However, both had met the women they wanted to marry so there was no alternative but to relinquish their promising research posts and look for a ‘real’ job. Luckily we know that both had long and happy marriages. Bleuler was born and brought up in the Zurich cantonment and didn’t want to move. His sister suffered from schizophrenia and he was close to her and it seemed logical to return to a job at the Burghölzi hospital where she was cared for. These three men moulded modern psychiatry.
3. Emil Kraepelin (1856–1926): distinguished dementia praecox (later called schizophrenia) from manic depressive disorder and laid the foundation for a rational classification of psychiatric disorders
Kraepelin moved with his new wife in 1886 to become an asylum doctor in Dorpat in what is now Estonia. The professional classes spoke German but his patients didn’t – consequently he didn’t understand a word they said and could not usefully interview them. What he did do was study their case notes and observe the fluctuations in their illnesses. From this he made the distinction between schizophrenia (which he called ‘dementia praecox’ meaning early dementia) and manic depressive disorder. Although in their acute phases it was difficult to distinguish the two disorders, important differences emerged over time. The dementia praecox patients never (he believed) fully recovered and with each bout of acute illness became more disabled. Based on the course of the illnesses he established the classification into the two major functional psychoses that persists to this day.
‘Kraeplinian’ implies a pessimistic view of schizophrenia (if defined by its poor outcome it can only be diagnosed if there is a poor outcome) and of exaggerating its difference from manic depressive disorder. However demonstrating that you could successfully classify the psychoses at all brought enormous benefits. Once you can distinguish different groups you can begin to make sensible predictions about outcome (‘prognosis’) and develop a clearer picture of each illness. Having distinguished these two it allowed psychiatrists to start distinguishing the others (dementia, cerebral syphilis, intoxications). At the simplest level it gave psychiatry a reason to pay more attention to patients’ illnesses and provided a basis for some rudimentary predictions and development of treatments.
Kraepelin became a celebrated and influential figure who travelled widely in his own lifetime. He was a passionate advocate for the temperance movement and on a lecture tour of Italy it was not so much his radical diagnostic ideas that amazed his Italian colleagues as the fact that he refused to drink wine. Indeed, he considered his campaign against alcohol his main contribution to humanity.
4. Eugen Bleuler (1857–1939): first used the term ‘schizophrenia’, in 1911
Eugen Bleuler (1857–1939)
Bleuler first coined the term schizophrenia in 1911. It followed many years of careful study in the Burghölzi hospital in Zurich. Bleuler’s situation could hardly have been more different from Kraepelin’s. He had grown up using the same dialect as his patients, lived in the hospital where his sister was a patient with schizophrenia, and often spent evenings talking to his patients. In every way he was primed to try to understand and make sense of their inner world rather than just observe as Kraepelin had done.
His definition of schizophrenia is based on the content of the patient’s experience. This approach allowed him to make the diagnosis (providing the features were present) even if the outcome was good. Of course there were many schizophrenia patients with poor outcomes but Bleuler confirmed there were some with good outcomes.
Bleuler considered that the primary disturbances in schizophrenia were a withdrawal from close relationships and disturbances of thinking and mood. He believed that hallucinations and delusions were attempts by the patient to make sense of these experiences. He defined schizophrenia using his famous ‘Four As’ – Autism (withdrawal), Affect (mood disturbances), Association (thought disorder – different associations or meanings being attached to words), Ambivalence (lack of direction and motivation). Bleuler’s approach has been superseded in recent years by a focus on the ‘positive’ symptoms (delusions, hallucinations, thought disorder) because of their greater ease of recognition and responsiveness to drug treatment. His was certainly a more humane approach to this, the most devastating of the mental illnesses, which accords meaning to the experiences of even the most deteriorated patient.
Sigmund Freud (1856–1939)
Like Kraepelin Freud had to abandon his preferred career for marriage. He pursued the only available alternative for a Jewish doctor at that time – private practice. Freud had little experience of asylums and worked almost exclusively with neurotic patients; he always recognized the limitations of his approaches for more severely ill patients. However, a careful reading of his case histories leaves little doubt that he treated some pretty disturbed individuals. His investigations took him in a completely different direction: the founding of psychoanalysis (Chapter 3). He thought of himself as much a scientist exploring the mind as a doctor curing it. He always believed that physical treatments (medicines) would eventually be the cure for mental illnesses.
5. Freud (1856–1939): the father of psychoanalysis
We might anticipate antagonism or avoidance between these groups a century ago but this doesn’t appear to have been the case. This was still a ‘pre medical-model’ psychiatry. Working in large asylums, all that was available to the doctors after they had classified their patients into broad diagnostic groups was to talk with them. Moral therapy evolved into a rough and ready psychotherapy. Few believed this cured the disease, but the role of doctors has never been restricted to just cure, but also to bringing relief from suffering. The journals of asylum doctors of this time testify to the time spent talking with patients – attempting to bring comfort and using reasoning to calm them.
The work of another great German psychiatrist, Karl Jaspers (1883–1969), exemplifies this. Jaspers wrote his masterpiece in Heidelberg by the age of 30: General Psychopathology (1913). This book is still in print and has never been bettered as a description of the mental processes in psychotic illnesses. Jaspers was initially quite comfortable with the writings of the psychoanalysts and his book clearly distinguishes the two different approaches to researching mental illnesses. The first is verstehen‘understanding’ and the second erklären ‘explaining’. Both were considered legitimate and necessary: what is the meaning of what the patient says and what is causing it? This is a dichotomy that still causes conflict in psychiatry – particularly between the psychologically minded and the biologically minded. Jaspers eventually lost patience with Freud because he felt that he implied that to understand was to explain. In its origins psychiatry needed and valued both approaches.
The first medical model
The end of the asylum era (Chapter 3) was foreshadowed by the ‘first medical model’ in the 1920s and 1930s. Interest in psychiatry had received a boost during the First World War with the need to treat shell-shocked soldiers, while at the same time the asylums had become even more overcrowded and neglected. It was only from the 1920s onwards that really effective treatments were discovered and introduced. These caused widespread changes in attitudes and restored optimism. ‘Lunatic’ was replaced with ‘mental patient’, ‘asylum’ with ‘mental hospital’, ‘certification’ with ‘involuntary admission’, and voluntary admissions became common for the first time: a truly revolutionary change in perspective.
There had been a steady improvement in the drugs used to control agitation prior to this time but two new treatments were epoch making – malaria treatment for cerebral syphilis and electro-convulsive therapy.
Julius Wagner-Jauregg (1857–1940) and malaria treatment
Wagner-Jauregg was the only psychiatrist to be awarded the Nobel Prize for Medicine before Sigmund Freud in 1939. He received it for his 1917 introduction of malaria treatment for cerebral syphilis (then called general paralysis of the insane, GPI). Before effective treatments for syphilis, a small proportion of chronically infected patients went on to develop the disease in the brain with disastrous consequences. It often took 20 years to develop, by which time the patient might be a settled family man. The terror it represented for 19th-century society is vividly captured in Ibsen’s play Ghosts. Onset of mental symptoms was sudden and dramatic. The philosopher Nietzsche inexplicably embraced a horse that was being abused in the street in Turin and within days was confined to a mental hospital; he died 11 years later never having recovered. Deterioration was tragic and humiliating. It was often associated with delusions of grandeur (hence all those cartoons of patients convinced they were Napoleon), and ended in dementia.
Wagner-Jauregg’s treatment consisted of infecting the patient with malaria parasites and waiting, with careful nursing, while the high fever raged. Over 10–12 cycles this killed the syphilis germs. The malaria could afterwards be treated with quinine. This treatment was difficult and risky but the alternative held no hope. GPI was effectively cleared from mental hospitals long before effective antibiotics arrived. Malaria treatment restored optimism to mental hospitals and strengthened the professional pride of the doctors and nurses who had to manage this difficult, but effective, treatment. It also forged clearer links with general hospitals where the patients often had to go to be treated. In doing this it became clear that involuntary patients would often cooperate with treatment and this stimulated a reassessment of the need for so much compulsion.
While malaria treatment is purely of historical interest, electro-convulsive therapy (ECT) is still widely used. Psychiatrists knew that epileptic seizures often caused profound changes in mood – either exciting or calming patients in the hours after a fit. It was also thought that epilepsy was uncommon in patients with schizophrenia so the idea developed that perhaps fits protected patients against this disease. Fits were induced in schizophrenia patients from 1935 by getting them to inhale camphor or by injecting a chemical called metrazol. The results were promising, with many patients improving. Unfortunately the experience (in particular the minutes leading up to the fit after the metrazol was injected) were very unpleasant indeed, with mounting dread, so many patients refused the treatments.
An Italian, Cerletti, came up with the idea of using a weak electric current to initiate the fit and used it on his first patient in 1938 with striking results. Several psychiatrists started to use ECT and its results were truly remarkable. While it did calm very agitated schizophrenic patients, its most dramatic results were with depressed patients, many of whom made sustained recoveries. If this all sounds a bit barbaric it pays to remember that depressed patients in the 1930s (even in very good mental hospitals) often stayed for years and up to one fifth died during the admission.
Initially ECT was given without anaesthetic and clearly was a frightening experience often with complications of small fractures if the fit was very strong, headache, and memory loss. For the last 50 years patients have received a short-acting anaesthetic and a chemical to block the muscle contractions so there is no fit to see and no risk of fractures. Headache and memory loss are still problems but patients don’t recall the actual seizure.
The discovery and durability of ECT is typical of many developments in psychiatry. The idea that started it (that epilepsy protected against schizophrenia) was wrong but the treatment worked, although more in depression than schizophrenia. We still don’t know why it works, but it certainly does. It remains one of the most effective treatments in psychiatry and (despite its wider reputation) the one that most patients who have had it say they would want again.
Mental health legislation
Psychiatry is unique within medicine in being able to compel treatment against a patient’s clearly expressed wishes. Consequently most countries have evolved specific legislation to permit this and to monitor it. The whole of the asylum movement was firmly based in such legislation. The developments in England in the 19th century are easy to follow because it was an early nation-state with centralized government and little scope for regional variation.
The first legislation was to regulate madhouses. All this did was to register them. It set no standards but could close an individual madhouse in the event of flagrant abuse. The purpose of the Asylum Act of 1808 and the Lunacy Act of 1845 was to ensure that care was provided and prevent exploitation of the vulnerable mentally ill. It allowed for ‘the removal of the furiously mad’ from workhouses to the asylum.
Over the next half century, public concerns shifted from the neglect and abuse of the indigent mentally ill to the spectre of malevolent incarceration of the sane to rob them of their wealth. The ‘Alleged Lunatics’ Friends Society’, with an admiral of the fleet as chairman, gained considerable parliamentary and public support in late 19th-century Britain. Georgina Weldon (a ‘spirited, attractive, wealthy and well connected woman’) filled the Covent Garden Opera House in London in 1883 for a rally to challenge her recent incarcerations, and eventually won her case. Increasing public disquiet was reflected in the 1890 Lunacy Act. This highly legalistic document, several hundred pages and 342 sections long, prioritized the protection of patients’ rights to such an extent that early and voluntary treatment became virtually impossible. The leading historian of mental health legislation, Kathleen Jones, wrote that ‘it stopped progress in mental health policy in its tracks for half a century’.
So swings the pendulum of public attitudes to mental health. Virtually every developed land is struggling to balance legal rights and therapeutic needs, to balance society’s needs with the patient’s. We will return to this in Chapter 6 but it is sobering to be reminded that we have been here before.
Asylums limped onwards for another 50–60 years, mired in legislation and inhibited from innovation apart from the welcome treatment advances in the 1920s and 1930s. It was to be another 30 years before this awesome international institution was finally challenged and moved towards its end. This is the subject of Chapter 3.