The Origins of Mental Health Services

Joanna Moncrieff, MD
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In order to explore the current political context of mental health services, as I will be doing in some upcoming blogs, it is necessary to establish what the modern mental health system actually consists of and what function it serves. It is only by tracing the historical development of mental health services, and analysing how and why the system arose, that we are able to fully comprehend its actual purpose.

In England up until the 19th century, managing the problems posed by those who lost their minds was primarily the responsibility of the family, backed up by the social welfare system known as the Poor Laws.

Caring for the mentally disturbed was not so different from caring for the physically sick. Both groups needed feeding, clothing and housing. If the family was reasonably wealthy, the needs of one individual could be borne by the rest of the family unit. Alternatively, the family could make private arrangements for care, such as paying another relative or a neighbour to take the afflicted individual into his or her home. By the 18th century private ‘madhouses’ had emerged to cater to families looking for someone to care for a mentally disturbed relative. These madhouses took in ‘boarders’, as they were referred to, at the expense of the boarder’s family. The owners might employ ‘keepers’ to guard the residents, and in the 18th century a set of public scandals revealed the unscrupulous nature of this ‘trade in lunacy’(1).

If the family was poor, however, it was thrown onto the assistance of local rate payers, especially if the sufferer happened to be the family breadwinner. The Poor Laws that were enacted from the 16th century onwards made local parishes responsible for the care of the poor, and mandated that all areas should collect a tax to provide for those unable to provide for themselves. The system replaced the medieval system of charitable care provided by religious institutions such as monasteries.

The records of the Poor Law have provided a rich insight into how people were cared for before the specialist institution of the insane asylum arose. They indicate a variety of arrangements for the care and containment of the mentally deranged, which formed part of a coherent attempt by local communities to provide for their dependent members, balancing ‘welfare and social order priorities’ with an eye to the expense placed on the rate payers(2, pp50).

When an individual fell sick or went mad the family could apply to the local parish authorities who administered ‘poor relief’. The parish officials could grant the family financial assistance, or help in kind in terms of food and clothing. They could also pay other members of the local community to provide care for the individual concerned. By the 18th century, in the larger parishes at least, there was a ‘small army of people (both men and women) employed to “watch” the sick, including the mentally deranged’ (2)(pp 43). The parish officials, along with the next tier of government, the county magistrates, were also responsible for ensuring the peace and safety of their jurisdiction. If the sufferer was considered to be dangerous, and if officials were not satisfied that he or she could be safely cared for at home, they could make alternative arrangements. Initially these might consist of temporary confinement by neighbours or local officials, but where this was felt to be inadequate, the individual could be incarcerated in the nearest prison or ‘House of Correction’(3). This was also the fate of some of the vagrants and beggars that increasingly populated 17th and 18th century England.

The cost of maintaining an individual in an institution like the House of Correction, or later the ‘workhouse,’ had to be met by local parishioners, unless the family could be made to pay. There was an incentive, therefore, to have such individuals released and returned to the local community as quickly as possible.

Then, as now, rate payers complained that officials were being too generous with their money, and that many of the poor did not deserve the payments they were awarded. This attitude became more strident with the increasing demands on welfare caused by the displacement and impoverishment that ensued from the agricultural and industrial revolutions. The Elizabethan Poor Law had distinguished between the able bodied and non able-bodied poor, with the instruction that the able bodied should be provided with work. By the early 19th century, with the country in the grip of the post Napoleonic war recession, there was near hysteria about the burden of the ‘undeserving poor’. The Poor Law Amendment Act of 1834 was designed to deter the lazy and work-shy from claiming off the local rate payers.

However draconian the law became, however, what confronted local officials was neediness and suffering. The large numbers of able-bodied poor who were to be thrashed back into work never materialised, and the Workhouses filled up largely with the old and frail, the sick and the mad(4).

The demands of the emerging capitalist system exacerbated natural problems like sickness. People had to be fit enough to work long and arduous shifts in order to produce surplus value. There were few productive roles for the semi-fit, as there were in smaller, agricultural communities. Moreover, with all able bodied family members working, fewer people were left at home to provide care for those who needed it.

The Essex County Asylum (Warley Hospital)
The Essex County Asylum (Warley Hospital)

Hence the Victorian era saw the emergence and consolidation of large-scale social provision for those who were unable to maintain themselves. The system included the Workhouse, the poor law infirmaries, often attached to the workhouse, and the asylum. The 1834 Poor Law required all regions to build a local Workhouse, and prohibited the payment of ‘outdoor relief’ to those who were capable of being put to work. The new Workhouses were intended as places where the poor would be set to hard labour, and provided with such Spartan conditions as to deter anyone but the truly desperate(5).

The work of philosopher Michel Foucault and historian Andrew Scull has outlined how the modern mental health system, initially embodied in the asylum, arose out of the need to sequestrate the mad from the workhouse environment (or from the earlier but similar institution of the Hôpital Général in France)(6;7). Indeed, the 1834 Poor Law specifically endorsed the separation of the insane on the grounds that they should receive treatment in a specialist environment. The early 19th century was a period of therapeutic optimism, and asylum keepers touted the appealing idea that their treatment could cure insanity, thus reducing the burden of providing long-term maintenance for the chronically dependent. More importantly, maybe, people who were mentally disturbed were difficult to contain in the workhouse, and disruptive to the workhouse regime(8). The mad had to be removed from the workhouse in case they affected the endeavour to motivate and discipline the undeserving poor; those who needed to be impressed with the necessity of work.

The asylum was more expensive than the workhouse, and an asylum with a humanitarian regime that eschewed the use of physical restraints was more expensive still(8). Consequently many of the mentally disordered continued to languish in the workhouse, especially if they were quiet and undemanding. Despite the image that the old asylums were places that no one left alive, there was a financial incentive to release people whenever possible. Historical research over the last couple of decades has shown that up to 60% of people admitted to asylums were discharged within a year. By the end of the 19th century, two thirds of patients stayed less than two years(9;10).

Thus the Victorian asylums, which constituted the first recognisable system specifically designed to cater for the mentally disturbed, arose from, and were part of, publically funded social arrangements to provide welfare and maintain social order. The asylums simultaneously provided sanctuary for the temporarily deranged, containment for the aggressively mad, and care for those deemed incurably insane who were not housed elsewhere.

The complex web of provision that consisted of the family, the local community, poor relief and places of confinement was replaced in the 19th century by specialist care provided within the asylum system, overseen from the mid-century by the medical profession. With the recent demise of the large-scale asylum, its functions have been replaced by a network of institutions and services providing a mixture of financial assistance, care and control. Although the expense is now largely met by the State or the health insurance industry, rather than directly by the family of the sufferer, the introduction of competitive tendering and the increasing role of the private sector have recreated a ‘trade in lunacy.’

Since the 19th century, mental health services have been claiming to provide something more than care and containment, however. As madness started to be conceptualised as a medical condition, its management has been portrayed as a therapeutic endeavour, one that aims to cure or rectify the underlying problem. The specialists who touted for the business in the 19th century claimed to be able to effect cures through ‘moral’ treatment. In the 20th century attention turned to various physical procedures, such as insulin coma therapy and ECT, followed by the drug treatments we are familiar with today. Although modern treatments can effectively subdue some of the more extreme manifestations of madness, there is little evidence that any of the numerous interventions administered to the mentally disordered over the years influence the natural course of the condition. What they have done, however, is obscure the underlying functions that mental health services undoubtedly still serve. And if we wish to think about how to address the problems posed by mental disturbance in the most rational, economical and humanitarian way, we need to keep those functions at the front of our minds.

Reference List

(1) Parry-Jones WLI. The Trade in Lunacy: a study of private madhouses in England in the eighteenth and nineteenth centuries. London: Routledge and Kegan Paul; 1972.
(2) Rushton P. Lunatcis and Idiots: mental disability, the community, and the Poor Law in North East England, 1600-1800. Medical History 1988;32:34-50.
(3) The House of Correction was a place of confinement and enforced labour most often used for those who had committed petty offences that threatened the social order.http://www.londonlives.org/static/HousesOfCorrection.jsp
(4) http://www.english-heritage.org.uk/discover/people-and-places/disability-history/1832-1914/the-changing-face-of-the-workhouse/
(5) For information on workhouses and the Victorian Poor Law seehttp://www.workhouses.org.uk/poorlaws/1834intro.shtml
(6) Foucault M. Madness and Civilisation. London: Tavistock; 1965.
(7) Scull A. The Most Solitary of Afflictions. New Haven: Yale University Press; 1993.
(8) Forsythe B, Melling J, Adair R. The new Poor Law and the county pauper lunatic asylum- the Devon experience. Social History of Medicine 1996;9:335-55.
(9) Ellis R. The asylum, the Poor Law, and a reassessment of the four-shilling grant: admissions to the county asylums of Yorkshire in the nineteenth century. Soc Hist Med 2006 Apr;19(1):55-71.
(10) Wright D. Getting out of the asylum: understanding the confinement of the insane in the nineteenth century. Soc Hist Med 1997 Apr;10(1):137-55.

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This blog first appeared on Joanna Moncrieff.com

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UNE Center for Global Humanities and its founding director, Anouar Majid, host Joanna Moncrieff on “The Myth of the Chemical Cure: The Politics of Psychiatric Drug Treatment.”
Youtube →


Interview with Joanna Moncrieff, author of “The Myth of the Chemical Cure: A Critique of Psychiatric Drug Treatment”

8 COMMENTS

  1. Thanks for the detailed research. I would like to recommend that you and others check out Shakespeare and especially focus on the characters of King Lear and Tom o’Bedlam. This is a tragedy of madness and touches on the role of the Bedlam Hospital in England closer to the 16th and or 17th centuries. Throughout his plays and other poetic writings he brings up the theme of madness and skillfully enters into its depths.

    I would also suggest looking into the lives of the early English poets such as John Clare and Christopher Smart both gifted writers who surcumbed to mental illness. Both Samuel Johnson and his chronicler James Boswell had mental health issues. Aubrey’s “Lives of the Poets” would also give an insightful look into the personal lives of those affected by mental illness.

    However, it most be noted, they are – everyone – white males and mostly from the upper classes. The voices of women, poverty stricken men, other races, and children are not heard as in some cases today. Besides looking at historical accounts I think it behooves us to look at the contiuium of literary work as a another path way to view and understand madness of the past.

  2. Thank you for this….

    For junkies the work of the 7th Earl of Shaftsbury is relevant for his work on the Lunacy Commission… http://en.wikipedia.org/wiki/Anthony_Ashley-Cooper,_7th_Earl_of_Shaftesbury

    Anyone visiting Piccadilly Circus in central London can see the monument erected in his honour….
    http://en.wikipedia.org/wiki/Piccadilly_Circus#Shaftesbury_Memorial_and_the_Statue_of_Eros

    Funnily enough he was a tory….a funny sort of tory….also responsible for the Factory Act…

    Thats enough…

  3. Two poets come to mind as I read your interesting article: the English poet John Clare and the German poet Holderlin. I am not sure what I would call their conditions. On the one hand as Oliver Sachs has amply demonstrated there are simply people with brains that are damaged by accidents or diseases. I am not sure the label mental illness is very useful here.
    In any case the best circumstances would seem to be for individuals to remain in their communities if they have one which once they mostly did. I am afraid science has been less a friend to the human species than its promoters like to think. It has been more the pursuit of power than of knowledge. And by its standards wisdom is too hard to quantify and therefore has a doubtful existence.
    Civilization is clearly the source of most of what we call mental illness. Civilization with its hierarchy creates crime and madness surely. It seems to be the arrangement whereby the few live a life of luxury and imagination while the masses live in one or anther kind of misery. People smart and perceptive enough to figure this out experience depression though despair is the better word. It seem very doubtful that a pill will do much for them.
    Well, we are still stuck today with the fear that the lazy will end up living better than they ought to–and in the USA even smoking pot!; hence, the desire in some states to drug test these dead beats. In any case, whether impoverished or crazy, it will be the too rare kind hearted and compassionate person who will make the difference. I really doubt that anyone is inherently lazy. But without some guidance and something worth doing there are persons who imitate catatonia.
    Today’s mental health facilities in the USA whether private or state run asylums or out patient clinics are the sort of drab places that would drive a sane person towards if not into madness. Bad food and the noise of TV. An environment stripped of things that make life worth living. And of course on a slender budget. And then the endless pill distributions. Pills that are criminal to even give out but are forced on some by judges who barely listen to the psychiatrists who barely know what they are doing. Giving rat poison might be kinder as one can recover from that more easily than from anti-psychotics, etc.
    Good article. Write more on the subject.

  4. Dr. Moncrieff,

    I am so grateful to you for all your work. I’m certain if the psychiatric industry does continue to exist in the long run, it will some day be highly embarrassed by their lack of respect for your current contributions. I am very grateful for the books and journal articles I’ve read, that you have written. I know with 100% certainty your concerns and perspectives are much more valid, than the beliefs of the mainstream pharmaceutical industry biased and deluded psychiatry of today.

    Thank you, for your work that is currently being inappropriately disregarded by your greed only deluded industry. Those of us who have been harmed, are so grateful for the ethical, within today’s too voracious mainstream medical industry.

  5. Dr. Moncreiff,
    I join other posters here in thanking you for your profound work. I just viewed your presentation at UNE, which was excellent – not at all surprising, in light of your other work.

    A few comments on the video:

    You have a wonderful way of presenting information in an impartial and non-inflamatory way that must greatly reduce the risk that disease centered adherents will react defensively. I do think, however, that you sometimes let questioners off easy – especially the pharmacy dean who cited peer reviewed literature to support a disease centered view. Much evidence (especially presented by David Healy) indicates that peer reviewed literature often functions as a PhARMA marketing arm and a cozy incubator of unsupported medical model assumptions (ghost written articles, peer reviewers with multiple conflicts of interest, publication bias, sequestered data, etc.)

    Your presentation of what one would tell patients about a drug, based on the disease model vs. the drug model, is very clear and helpful. But I would add that even using the drug centered model is far from giving patients the ability to give informed consent. Patients should also be told that numerous psychosocial interventions often prove to be more effective long term, with far fewer adverse effects than drugs. Moreover, given the tidal wave of PhARMA-funded disease based promotion, informed consent requires at least a brief statement, based on your video, that what patients see in direct to consumer ads “ain’t necessarily so.”

    I recommend both your books to others. Thank you again for your very important work.

  6. I find it interesting that 60℅ of the people became well enough to leave after 1 year with no real help – just Sanctuary. It looks like the Victorian Paradigm was a lot better than the Modern Day Paradigm, which keeps people permanently sick.
    Your Articles are easy to read and very educational.

  7. Thank you for this comprehensive glimpse into how we, as a society and individuals, respond to human suffering.

    “Although modern treatments can effectively subdue some of the more extreme manifestations of madness, there is little evidence that any of the numerous interventions administered to the mentally disordered over the years influence the natural course of the condition.”

    I would argue that these interventions which we question and which many of us reject, categorically, as effective, do, in fact, influence the natural course of the condition. I believe they influence negatively the natural course of healing. These interventions stop or distort the natural flow of energy, which only serves to keep a person off track. Nature is healing, and most of the interventions of which I’m aware in current mental health practices go against nature, which would only create illness and grave imbalance, rather than to encourage, trust, and witness a natural healing process.

    “What they have done, however, is obscure the underlying functions that mental health services undoubtedly still serve. And if we wish to think about how to address the problems posed by mental disturbance in the most rational, economical and humanitarian way, we need to keep those functions at the front of our minds.”

    I do agree with this (about how any potentially positive mental health service has become obscured by harmful practices) because, for me, I cannot conceive of what positive influence is provided by current mental health services. At least here, in the United States, in my almost 20 years of involvement with mental health services (as a student, clinician, social worker, client, advocate, and ultimately, defector) I have failed to see long term satisfying results from any and all mental health services; whereas I have seen and experienced complete and utterly remarkable healing in healing environments having nothing to do with focusing on our psychology, but more on our heart and spirit.

    I wonder, as you or others might suggest, if I am generalizing from all that I’ve witnessed and experienced in the mental health field which made me angry and to feel so critical of this field, because it was misleading and disorienting at best, and lethal at worst. I’m open to seeing evidence of honest to goodness complete healing, but as of yet, I have not.

    I especially enjoyed and appreciated your video interview. In it, you say,

    “We don’t know how to interpret the evidence…”

    For me, this is one glaring and vital issue, how we interpret—whether it’s evidence from a study, or evidence of the life around us. We manifest our feelings and realities by our interpretation of what we see and experience. We have choices as to which perspective we wish to choose from which to witness anything. In mental health, I find most people are interpreted cynically, as if they are ‘diseased’ or inherently disadvantaged, and will be dependent on outside support for the rest of their lives. So much so that clients internalize this, which I believe to be so damaging and self-sabotaging to walk around with this self-belief. From it, we will create a life reality for ourselves (in general) of being needy. In turn, this further creates a toxic and imbalanced society. It’s a tragic hamster wheel.

    “That doesn’t mean that we’ve cured anything…”

    Thank you for this comment, especially. I think one of the great myths, and most stigmatizing beliefs, of addressing mental health is that, when we find ourselves to be out of balance, somehow (which happens to everyone at many times in life—it is human, and part of our process of growth and evolution), that many times, it cannot be cured and rectified completely.

    Again, very damaging and self-defeating to the human spirit. Everything can heal and everything can come back into balance, one way or another. We all have our own way of doing this; it is our path and creative process which dictates this. Society, or any aspect of it–medical or otherwise– cannot dictate what is ‘appropriate’ for another person. That is up to the individual. In short, it is between ‘them and their God.’

    Once the individual can connect to how they feel about this experience or that, then they can make appropriate choices to their well-being, because they will know what feels good to them, and for me, this is what would constitute ‘cure.’

    Life is trial and error, and we should all be allowed to take our journeys. ‘Support,’ to me, means good and loving witnessing and encouragement, along with positive and authentic feedback, if asked for it.

    “Children are being taught that they need a crutch to manage their emotions, and that is one of the prime tasks of growing up, to manage our emotions and to learn how to control our behavior.”

    Indeed, self-responsibility is our most effective guide and healer in life. If parents are not self-responsible, chances are the kids will not be. Or, a kid could grow up feeling responsible for the parents’ feelings, which would then translate into feeling responsible for the whole world, which can cause debilitating burnout in an adult, and self-negligence, on behalf of others.

    As you imply, calling ‘mental illness,’ of any kind, a brain disease only serves to allow toxic (abusive, oppressive, shaming, guilting, double-binding) individuals and dysfunctional societies off the hook. As you say, “It is easy” to do this, which, indeed, causes us to ignore and avoid the truly problematic issues. For sure, like you say, this makes it easy for politicians to scapegoat others, causing them to ignore and neglect the well-being of society as a whole.

    I really like how you put forth that our mainstream response needs to be questioned, as it is, undoubtedly, a very damaging message that one person is responsible for the comfort and well-being of those around them, or otherwise, this individual will be deemed ‘the problem.’ In general, a person labeled as ‘marginal’ or ‘ill’ because they make others uncomfortable is a wake-up call that something is wrong with that environment or society. This is how individuals get scapegoated in the family, and later on, by society. The media sure does encourage this, which is, in my estimation, is simply awful, and totally illusory. But yes, it does let others off the hook, unjustly.

    More than ‘employment’ in society, I believe the solution is about personal fulfillment and knowing our own power to create the life we most desire, based on loving life. I believe we all have this within us, but we have been convinced that we need others, or are responsible to others. For me, this usually translates into lack of love or self-love. At the very least, it is a measure of lack of unmitigated self-respect.

    We are employed by life. Being traditionally employed by others keeps us believing that our role is to help others become rich and powerful. We really are our own bosses in life, if we allow ourselves to be, and trust our processes. To me, this is radical self-responsibility, and is what leads to well-being. This is how we learn to believe in ourselves, wholeheartedly.

    When you ask, ‘Why are people depressed or acting out?’ I’d respond that, more than likely, in general, it is because we have not been allowed to be ourselves and to follow our own unique process, due to an uptight and judgmental environment, modeled with no sense of self-responsibility; and that if we are transparent in our unique creativity, we will be judged, labeled, ridiculed, or marginalized. We will be considered ‘the problem,’ rather than being recognized as embodying our truth, which is true courage and self-ownership. Rather than being the problem, I would call this person ‘the example.’

    I do not believe, in any way, that we are on this earth and in this life to appease others. We are here to find joy and fulfillment, and to honor our heart’s desires. Imagine how much love would manifest on the planet if we were all allowed to honor ourselves this way. At least, this is what I firmly believe.

    If our processes are thwarted, discouraged, and invalidated, who wouldn’t be depressed? In many cases, over long term, it causes rage. Some call it ‘psychosis.’ I call it reasonable.