What unites antipsychiatry, psychiatric survivors, peers, consumers,
(ex)patient/service user, voice hearers, and the recovery movement?
Within the communities that surround Mad in America one is likely to hear reference to ‘the movement.’ The basic meaning of this phrase seems clear enough. The movement broadly refers to the groups of people actively rethinking the mental health system, and the treatment of persons labeled as mentally ill, in the United States and abroad. Upon further inspection, however, we realize that there is no centralized ethos uniting these groups. There may be consensus that the current mental health models are troublesome, but within each subset of ‘the movement’ there are many different perspectives about such troubles’ causes and solutions.
In recent years many articles and books have been published, and many conferences held, outlining various problems facing the mental health system in this country. Each person speaking out seems to have their own solution to these problems. There does not appear, however, to be any work that outlines, compares, and synthesizes the broad array of what we call ‘the movement,’ as a whole, with all its the varying proposed solutions, perspectives, and reform initiatives.
In this forthcoming blog series, my aim is to outline the history of this diverse movement. This is, in part, a project collecting bits and pieces to make a map that is less scattered. I intend to interview those members of the movement who have emerged as leaders, but my hope is that this will be a much more collaborative effort. As a digital community, Mad in America already connects many of the people who actually compromise this movement. By way of comments, emails — and who knows what else — I hope readers will also become contributors, offering necessary pieces in patching together these histories.
But in such a survey, what histories are to be included? I will focus on the history of the United States. This will allow me to research primarily within my native language, and within the geographic, cultural, and political regions with which I am most familiar. At a glance I am concerned with the history of those who would work to change the mental health system. The mental health system includes institutional, residential, community-based as well private individualized care, as affected by the disparate domains of psychiatry, pharmacology, psychology, social work, social services, and the penal system. Part of the movement may also be concerned with addressing individual, familial and societal aspects of ‘mental illness’—advocating for pluralistic acceptance of mental differences; combating stigma and stereotypes; addressing societal causes of distress and marginalization—and certainly such work also deserves attention.
Who is to be considered in this history, and for what work? The concept of peers, survivors, and consumers may lead us to focus solely on those who have once sought help from, or perhaps were unwillingly subjected to, the system. Yet a history of this movement focusing solely on ‘peers’ leaves out the important albeit controversial legacies of people like Thomas Szasz and Dorothea Dix. Whether psychiatric survivor groups would willing associate themselves with Dix is another question.
In a history of resistance and reform, I propose focusing on these two categories of people. Those whom, having been recipients and subjects of the mental health treatment, become involved in the treatment of mental illness. This would include not only those individuals who are primarily concerned with critique of the system, but everyone who advocated from the perspective of personal experience. By this standard, the “peer” model of Alcoholics Anonymous would be worthy of historical inclusion, as would consumer advocate groups that do not explicitly question the status quo of mental health treatment. While inclusion of such “non-radical” groups might seem egregious to some, I do not want this history to become fodder for ideological battles amidst various groups.
The second group to be included in this history is those who are inspired to change or dismantle the mental health system due to significant criticisms. It is natural that the fields of psychology, psychiatry, and social services change over time, for many different reasons. These changes often involve intense debate and criticism, but to include all such forerunners of change would render the theme of ‘resistance and reform’ meaningless. Psychotherapy in the United States, for example, has significant roots in hypnotism and although inspired by individual who sought to provide better treatment for mental illness, the innovations that brought about psychotherapy in lieu of hypnotism will not be considered here. Nonetheless, in these early posts involving history prior to the 1900s, I focus in detail on the origins of our mental health system. This seems necessary to understanding subsequent resistance and reform but as opposed to the numerous works focusing on the history of ‘the system,’ my overall emphasis is on resistance and reform.
The labels of mental illness and mental disorder are currently receiving widespread scrutiny. In the U.S., critical discussions of insanity, mental illness and disorder, trauma, and lived experience take place, or divest from, specific frameworks of psychiatric and psychological theory, but throughout human history, there have been many ways of conceptualizing and relating to distress. The history of human distress treatments that have never been subsumed under the guise of mental illness will not be considered here, as they do not pertain to the topic at hand: Catholicism, for example, presents an entirely different way of understanding human distress and its treatment (distress is caused of original and moral sin; relief is provided by pious life and priestly absolution). I do not wish to assume that Catholicism was just a primitive way of thinking about psychology; such disparate frameworks may not be comparable at all, and I wish to avoid presentist history. Scientology’s religious framework for treating human distress, on the other hand, is inextricably defined through its relationship to psychiatry (defined as “not psychiatry”). As such, it is a specific attempt to move away from pathologizing, and as such is to be included in the present history.
I begin now by outlining the specific groups and histories that seem, at present, most notable. Whatever I leave out, I hope, you will inform me. Once an outline is established of those individuals and groups that have been most influential, my future blog posts will explore these specific histories in more depth. I begin by reviewing this country’s early history, drawing extensively on Gerald Grob’s Mental Institutions in America and Mental Illness and American Society, texts recommended to me by George Makari.
A note: my language and word choice reflects a combination of past as well as present worldviews; when I employ a phrase like the ‘indigent insane,’ for example, this is not reflective of my personal lexicon but rather I intend to illustrate how language worked in the past. My reference to the treatment of mental illness is a pun: while referring to the ways in which we have conceived of helping those labeled as mentally ill (treatment), I refer also the way we as a society have dealt with such persons (to treat a person, well or poorly).
I do not know whether far-reaching and systematized forms of treatment for those deemed mentally ill existed before colonization of the land now called the United States. Likely the first immigrants to this land came across the Bering Strait, along the land and ice bridge that once connected Eurasia and present-day Alaska; the Paleoamericans arrived during the Late Pleistocene era, and migrated south from there some 18,000 years ago. In the subsequent millennia, the various regions now called the “United States” were populated by many different peoples. Thus if we were to truly assess the history of this geographical region, we would begin with the histories of the Clovis culture, the Folsom complex, Na-Dené-speaking peoples, Athabascan-speaking peoples, Poverty Point culture, peoples of the Woodland period, Hohokam culture, and the Mississippian culture. Whether any of these peoples considered ‘mental illness’ or its ‘treatment’ in ways that are comparable to our present day conceptions, I do not know. A truly thoroughgoing history of ‘madness in America,’ however, would have to start by asking these questions. Although our mental health system was created predominately within urban areas on the eastern half of the country, a complete history would also need to examine what regionally-bound conceptions and treatments may have been in place contemporaneously, amongst indigenous populations, in the Spanish missions, in the rural South, and along the so-called American frontier.
In colonial America mental illness was not considered a widespread problem. People unable to provide for themselves due to poverty, illness, old age, orphanage or insanity were taken care of either by family members or the community. Caring for the insane generally did not involve any kind of psychological treatment; the chief problem was that as a whole dependents persons were not able to work, and there could not provide for themselves. Community support was a matter of social custom, but also a dictate of poor laws. These laws were carried over from England. Widespread poverty was by no means a novel phenomenon in England, but as rural populations changed into centralized townships during the 14th century development of commerce and money currency, new kinds of poverty emerged amidst urbanity, and poor laws developed to dictate how townships should respond. Urbanity was not yet a problem, however, in 17th century colonial America. Populations were still small, and the numbers of dependents were accordingly few. As townships grew in the 18th century, colonies adopted almshouses. In the absence of widespread regulation, living conditions and care within poorhouses varied widely. As in England, almshouses indiscriminately housed orphans, the sick, the elderly, and the insane; growing concern about this would give rise to the creation of hospitals specifically designed for the insane, especially in the mid-198h century.
As general population grew along with the numbers of insane persons, townships became increasingly concerned with the derelict influence of insane persons and actual as well as perceived threats of danger. Determining who should be confined was generally viewed from the perspective of safeguarding the community, not the individual. Some “madhouses” confined furiously insane persons within their rooms, and by the end of the 18th century townships also began imprisoning their insane persons.
There were also efforts to differentiate between idiots and distracted persons, as opposed to lunatics and the furiously mad. Early America was also a place of widespread religious beliefs, and sometimes distressed individuals were seen as suffering from spiritual afflictions (like demonic possession). People could be persecuted because of their perceived or actual religious beliefs and powers, as in the case of witchtrials. Whether there were any early social reformers who sought to view religious afflictions not as a matter of spirit, but relating to insane mind, I do not know. Certainly these people, if they even existed, would be of historical importance.
In the 1750s, hospitals began to open in the States’ growing urban areas. Seen as necessary to address the new concentrations of urban dependents, early hospitals were funded by private philanthropists but with the intention of treating everyone—paying as well as nonpaying patients. While some hospitals focused at least in part on caring for insane persons, all early hospitals were small, admitting perhaps a hundred patients per year—twenty of which might be insane. Such a small scale was consistent with the small size of contemporary urban populations; in 1800, a city with more than 10,000 residents was very rare.
For the first hundred years individual hospitals were not unified by any overarching ethos, regulation, or theories of treatment. They existed primarily in isolation, and did not affect widespread social change regarding treatment or public opinion of insanity. Early hospitals attempted to provide treatment for insanity, as opposed to almshouses which typically provided custodial services, and confinement. Bleeding, diet, the use of purgative drugs like mercury, hydrotherapy, physical restraint and sensory deprivation were all employed as forms treatment.
How are we to view such “treatments” in the present? For the moment my thought is brief: while it is certainly possible that some hospital staff sadistically enjoyed administering such treatments, one must also remember that such practices were the common medical treatments of the day, administered in cases of physical and mental illness alike.
By 1800 there were 16 ratified States in the Union and the constitutional republic’s centralized government was only eleven years old. Although differentiation was beginning, insane persons were still largely regarded within the generalized conglomerate of dependent persons. Communities were, however, beginning to discriminate between idiots and distracted persons as compared to lunatics and the furiously mad, and as separate from other kinds of dependents. Although the former group was unable to work and therefore needed support, they were not perceived as a threat to the larger community. If such persons had family, they would be cared for by their family; if not, they would seek support from an almshouse. The latter group was considered dangerous and confined accordingly in almshouses and jails, and later hospitals. When towns had a hospital, insane persons might seek treatment there. As income allowed, some people would pay for their family member’s hospital stay; paying patients helped fund the hospitals, which in turn provided care for non-paying patients. Hospitals believed in the prospect recovery, and provided contemporary medical treatment—many persons were deemed “recovered” and released, although others were not. Unlike in Europe, history does not seem to report many widespread critics of the United States mental health system prior to the 19th century, because systematization did not yet exist. There would be many critiques, however, in the decades to come.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.