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Until the nineteenth century, the care of the insane was largely a communal and family responsibility rather than a medical one. The vast majority of the mentally ill were treated in domestic contexts with only the most unmanageable or burdensome likely to be institutionally confined.[106] This situation was transformed radically from the late eighteenth century as, amid changing cultural conceptions of madness, a new-found optimism in the curability of insanity within the asylum setting emerged.[107] Increasingly, lunacy was perceived less as a physiological condition than as a mental and moral one[108] to which the correct response was persuasion, aimed at inculcating internal restraint, rather than external coercion.[109] This new therapeutic sensibility, referred to as moral treatment, was epitomised in French physician Philippe Pinel's quasi-mythological unchaining of the lunatics of the Bicêtre Hospital in Paris[110] and realised in an institutional setting with the foundation in 1796 of the Quaker-run York Retreat in England.[6] From the early nineteenth century, as lay-led lunacy reform movements gained in influence,[111] ever more state governments in the West extended their authority and responsibility over the mentally ill.[112] Small-scale asylums, conceived as instruments to reshape both the mind and behaviour of the disturbed,[113] proliferated across these regions.[114] By the 1830s, moral treatment, together with the asylum itself, became increasingly medicalised[115] and asylum doctors began to establish a distinct medical identity with the establishment in the 1840s of associations for their members in France, Germany, the United Kingdom and America, together with the founding of medico-psychological journals.[6] Medical optimism in the capacity of the asylum to cure insanity soured by the close of the nineteenth century as the growth of the asylum population far outstripped that of the general population.[a][116] Processes of long-term institutional segregation, allowing for the psychiatric conceptualisation of the natural course of mental illness, supported the perspective that the insane were a distinct population, subject to mental pathologies stemming from specific medical causes.[113] As degeneration theory grew in influence from the mid-nineteenth century,[117] heredity was seen as the central causal element in chronic mental illness,[118] and, with national asylum systems overcrowded and insanity apparently undergoing an inexorable rise, the focus of psychiatric therapeutics shifted from a concern with treating the individual to maintaining the racial and biological health of national populations.[119] Emil Kraepelin (1856–1926) introduced new medical categories of mental illness, which eventually came into psychiatric usage despite their basis in behavior rather than pathology or etiology. Shell shock among frontline soldiers exposed to heavy artillery bombardment was first diagnosed by British Army doctors in 1915. By 1916, similar symptoms were also noted in soldiers not exposed to explosive shocks, leading to questions as to whether the disorder was physical or psychiatric.[120] In the 1920s surrealist opposition to psychiatry was expressed in a number of surrealist publications. In the 1930s several controversial medical practices were introduced including inducing seizures (by electroshock, insulin or other drugs) or cutting parts of the brain apart (leucotomy or lobotomy). Both came into widespread use by psychiatry, but there were grave concerns and much opposition on grounds of basic morality, harmful effects, or misuse.[121] In the 1950s new psychiatric drugs, notably the antipsychotic chlorpromazine, were designed in laboratories and slowly came into preferred use. Although often accepted as an advance in some ways, there was some opposition, due to serious adverse effects such as tardive dyskinesia. Patients often opposed psychiatry and refused or stopped taking the drugs when not subject to psychiatric control. There was also increasing opposition to the use of psychiatric hospitals, and attempts to move people back into the community on a collaborative user-led group approach ("therapeutic communities") not controlled by psychiatry. Campaigns against masturbation were done in the Victorian era and elsewhere. Lobotomy was used until the 1970s to treat schizophrenia. This was denounced by the anti-psychiatric movement in the 1960s and later. |
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