Back in the 1960s in his pathbreaking Madness and Civilization: A History of Insanity in the Age of Reason the French thinker Michel Foucault argued that madness had been silenced and that one of the agencies of this shutting up had been the literal shutting up of the insane in institutions in the movement gathering pace from the seventeenth century that he called 'the great confinement'. Just as one of the great psychotherapeutic projects since Freud has been getting the disturbed to talk (and even more important, listening to them when they do), so in a parallel manner historians of psychiatry have recently been trying to recover the voice of the asylum patient. Thanks to books like Dale Peterson's A Mad People's History of Madness (1982) - an anthology of mad people's writings down the centuries - we are now far more familiar with what patients said, felt and thought, and are better attuned to hearing the sense in what used to be dismissed as rank nonsense.
The irony is that, as we have come to know the pleas of the asylum patient better, we have grown unaccustomed to the voices from the other side. What was being said in the superintendent's office, in the governors' board room, or across the consultants' lunch table? At least in Britain, it is astonishing how few of the thousands of psychiatrists who have been involved in mental hospitals this century have published memoirs of their experiences in these total institutions.
It's a particularly telling silence, in view of the fact that their Victorian precursors seem to have been vocal on the subject to the point of garrulity. Both private asylum proprietors and the directors of the great charity and county institutions relished setting down their opinions for the public and posterity, explaining the latest thinking about institutional caring and curing, and spelling out grandly optimistic plans for the future glories of the asylum system. A string of luminaries recorded their experiences and visions - Samuel Tuke, one of the inspirations behind the York Retreat, John Conolly, the great pioneer of non-restraint, Thomas Clouston, the laird of Morningside Asylum in Edinburgh, and dozens more.
All were proud of their achievements. In the year that Queen Victoria came to the throne, Dr W.A.F. Browne, head of the Montrose Royal Lunatic Asylum, delivered a set of lectures which he turned into a book called What Asylums Were, Are and Ought to Be. On the basis of his experience, which he documented at length, he presented an idyllic picture of the asylum of the future - which he then went on to try to create at the Crichton Royal in Dumfries:
Conceive a spacious building resembling the palace of a peer, airy, and elevated, and elegant, surrounded by extensive and swelling grounds and gardens. The interior is fitted up with galleries, and workshops, and music-rooms. The sun and the air are allowed to enter at every window, the view of the shrubberies and fields, and groups of labourers, is unobstructed by shutters or bars; all is clean, quiet and attractive. The inmates all seem to be actuated by the common impulse of enjoyment, all are busy, and delighted by being so. The house and all around appears a hive of industry. When you pass the lodge, it is as if you had entered the precincts of some vast emporium of manufacture; labour is divided, so that it may be easy and well performed, and so apportioned, that it may suit the tastes and powers of each labourer. You meet the gardener, the common agriculturist, the mower, the weeder, all intent on their several occupations, and loud in their merriment. The flowers are tended, and trained, and watered by one, the humbler task of preparing the vegetables for table, is committed to another. Some of the inhabitants act as domestic servants, some as artisans, some rise to the rank of overseers. The bakehouse, the laundry, the kitchen, are all well supplied with indefatigable workers. In one part of the edifice are companies of straw-plaiters, basket-makers, knitters, spinners, among the women; in another, weavers, tailors, saddlers, and shoemakers, among the men. For those who are ignorant of these gentle crafts, but are strong and steady, there are loads to carry, water to draw, wood to cut, and for those who are both ignorant and weakly, there is oakum to tease and yarn to wind. The curious thing is, that all are anxious to be engaged, toil incessantly, and in general without any other recompense than being kept from disagreeable thought and the pains of illness. They literally work in order to please themselves, and having once experienced the possibility of doing this, and of earning peace, self-applause, and the approbation of all around, sound sleep, and it may be some small remuneration, a difficulty is found in restraining their eagerness, and moderating their exertions. There is in this community no compulsion, no chains, no whips, no corporal chastisement, simple because these are proved to be less effectual means of carrying any point than persuasion, emulation, and the desire of obtaining gratification
Such is a faithful picture of what may be seen in many institutions, and of what might be seen in all, were asylums conducted as they ought to be.
Browne's assumption was that it was within the power of the energetic, idealistic head to translate these dreams into reality. Such hopes fired many a Victorian superintendent who saw himself as holding a noble public trust and an honourable commission, rather like being the captain of a Royal Navy frigate or the head of a public school.
Herein, of course, lies the seed of the explanation of why the twentieth-century superintendent fell silent. The dreams of the curative asylum proved illusory; by the end of the Victorian era, even the most sanguine psychiatrist had come to recognise that psychiatric institutions were more custodial than curative, and nobody any longer looked upon them as wonder-working, as in the daydreams of Browne.
It would be unfair to represent the twentieth-century psychiatric hospital as entirely paralysed, almost as if anticipating that moment in the 1970s or '80s when the campaign to close the institutions and decant patients back into the community received official blessing and many were sentenced to closure. Far from it: a succession of innovations over the decades transformed the late Victorian closed and regimented institution into a far more open and experimental site. Voluntary patients were admitted, occupational and art therapies introduced, doors were unlocked, therapeutic communities set up, and many other schemes set in motion. Nevertheless, for all these local initiatives, the typical psychiatric hospital had long assumed the air of a holding-operation; its fabric aged, and its staff and patients with it. The superintendent wrote his obligatory annual reports, but had no special urge to tell the public all.
Indeed, the best-known account by a doctor of the functioning of an ordinary mental institution comes not from some eminent superintendent but from an outsider. Dr Montagu Lomax worked temporarily at Prestwich Asylum in Lancashire helping to plug staff shortages due to the Great War. He was appalled at what he found: gross overcrowding, demoralising institutionalisation, brutalisation, neglect, lack of beds, poor food, apathy. He felt compelled to blow the whistle in The Experiences of an Asylum Doctor, with Suggestions for Asylum and Lunacy Law Reform (1921); so great was the stir his book created that it sparked a series of official cover-ups and whitewashings.
Little has been written by insiders about those great public hospitals which, until recently, held in this country over 100,000 patients. Hence everyone interested in recent psychiatry and the role played in it by the psychiatric hospital will be delighted that David Clark has recorded his personal memories of a lifetime spent in running a large, public psychiatric institution. Trained at the Maudsley, Clark joined Fulbourn Hospital, on the outskirts of Cambridge, back in the 1950s; he stayed on and transformed the institution. When he entered, it differed little from the establishment that had witnessed the death of Queen Victoria.
The Fulbourn Clark inherited was neither the utopia envisioned by Browne nor the hellhole depicted by Foucault and other critics of psychiatry. In its development Fulbourn was not untypical of the English county asylums set up under legislation of 1845 that required each county to provide sufficient accommodation for its pauper lunatics (in those days middle-class patients would mainly go to private institutions). Like all the rest, it had expanded too fast, it suffered from chronic lack of funds, resources and staff, and in due course its buildings deteriorated. Physical neglect was matched by psychological indifference, and its troubles were (as Clark recalls) exacerbated by the sprinkling of the drunken, odd and frankly disturbed senior staff that English asylums, Oxbridge colleges, the army and public schools tend to attract. It is clear that around 1950 Fulbourn was hardly a thriving institution and its morale was low.
In a book doubling as a history of the Hospital and an autobiography, Clark discusses the changes he was able to effect and his thoughts about the present crisis in psychiatric care. A rich irony reveals itself: our age, which has seen the agitation for the closing of traditional asylums come to fruition, has also been the time when many of them have been, at long last, most therapeutically innovative and successful. It is almost as though there proved some final swansong of truth in Browne's vision.
Frank, modest and written with a wry sense of humour, David Clark's account of a career in Fulbourn is a rare document, fascinating to read and invaluable as historical evidence. It is a pleasure to see it in print. One hopes his peers will also be provoked into putting down their experiences for posterity.
The Human Nature Review © Ian Pitchford and Robert M. Young - Last updated: 28 May, 2005 02:29 PM