“the absolute madmen… are not answerable for their actions, they should not be permitted the liberty of acting unless under proper control, and in particular, they should not be suffered to go loose, to the terror of the king’s subjects. It was the doctrine of our ancient law, that persons deprived of their reason might be confined till they recovered their senses, without waiting for the forms of commission or other special authority from the crown; and now by the vagrant acts, a method is chalked out for imprisoning, chaining, and sending them to their proper homes.”
In a previous posting I did threaten to write about mental health legislation as a form of social control.
So, how far have we come in the last 200+ years to progress the needs of those “absolute madmen”?
In 1763, the Select Committee of the House of Commons debated the private operation of “madhouses”, where the admission and detention to a madhouse was often extended to admit those beyond definition of ‘lunatics’, and such ‘boarders’ were frequently accepted. ‘Boarders’, who did not require the same medical assertion as their ‘lunatic’ companions, were, nevertheless, contained in the same manner as their ‘lunatic’ counterparts. This seems to be the first form of legislature aimed at the protection of individuals for whom the private incarceration of individuals was found to be an unacceptable immoral practice.
Even prior to the 1774 Madhouses Act and the Criminal Lunatics Act 1800, legislation has been enacted for the control of others. De Praerogativa Regis 1324 ; Statute of Cambridge 1388 ; Vagabonds and Beggars Act 1494; all bespeak to the moral recognition, containment or control of those persons so indicated under the Act.
The Kings Prerogative of 14th century, as described by Blackstone, does retain the seemingly noble acumen of parens patriae for idiots and natural fools which would appear to have been set out merely for the protection of their estates until such time as they either healed or died, whereupon estates were passed to the family. However, commentary notes on Blackstone further explore the common law doctrine that made provisions for the poor;
“These poor were principally of two sorts: sick and impotent, and therefore unable to work; idle and sturdy, and therefore able, but not willing, to exercise any honest employment. To provide in some measure for both of these, in and about the metropolis, his son Edward the sixth founded three royal hospitals; Christ’s, and St. Thomas’s, for the relief of the impotent through infancy or sickness; and Bridewell for the punishment and employment of the vigorous and idle.”
Such a simple argument is difficult to refute as it clearly delineates between those who can’t and those who won’t. Such beneficence towards those ’sick or impotent’ is commendably humanistic. However, for what purpose should the ‘poor law’ extend itself to incarcerate those who simply refuse or decline to work? The implication of such a categorisation, and lawful action, being that those who were poor constituted either a moral responsibility or burden on society. The place of such containment and likely treatment received, would therefore depend on the moral reasoning given to why someone was poor and, under such legal framework, cleansing of the streets of beggars, vagrants, tramps and vagabonds.
It is also interesting to note that, in the establishment of Bridewell, for those vigorous yet idle, it was given recognition as a ‘hospital’ establishment which would imply it’s focus to be that of ‘treatment’. It did later become a prison, but such nomenclature changes did little to alter the ‘admission’ criteria or the ‘treatment’ modalities for those who simply did not conform to the moral virtues of the larger society.
Mucha describes Bridewell as
“a place that literally locked away for a short time members of society who were unfit and would be considered outcasts in society. [..Michel Foucault] … explains that ideas of discipline and punishment were supposed to correct those of doing wrong or help those born into the poor class.“
In Andrew’s History of Bethlem, he describes how, for those who were not found sick or impotent,
“[t]he insane were sometimes admitted to Bridewell until further inquiry might be made into mental state and/or settlements, or until a vacancy arose at Bethlem“.
Having to transition through the Bridewell ‘hospital’ of moral reform before being more humanely placed in a hospital for the treatment of such mental disorders would indicate appropriate displacement of those mentally ill was of less concern than the physically sick and impotent and those morally compromised. It would be arguable that such ostracism of the socially ‘fourth class’ mentally ill citizens still exists today in the same manner.
Szasz, who writes extensively of the continuing use of mental health legislation as social control, suggests, in Ideology and Insanity (1970), psychiatry is nothing more than a form of “moral suasion and political coercion“; that, rather than being in. at least, a constant tension betwixt the interests of the individual and that of society, mental health legislation exists merely to serve the needs of it’s bigger master, or rather, the state. His argument, which still stands uncontested today, is that one beneficence cannot exist without harm to the other. He convincingly demonstrates the ideology of mental illness to be nothing more than another form of social control that, by virtue of the omnipotence afforded it’s medico-legal keepers, is not subject to the same scrutiny and human rights as even those who are imprisoned as criminals for their immoral behaviours. It is somewhat strange to consider that, when M’Naghten rules were first considered as ‘protecting and understanding’ by ‘acquitting’ those of a compromised state of mind and, ergo, not culpable for their offence, that Daniel M’Naghten himself spent the entire remaining time of his life incarcerated in Bethlem then Broadmoor until his death in 1865, some 22 years later.
In order to understand the true nature of mental health legislation, one must resolve the dichotomy of “For whose purpose does mental health legislation exist?”. In considering the implications for someone who is detained under such legislation, they are not detained for the presence of mental illness, but for the fear that such an “illness” may or has precursored a dangerous act. The purpose of “treatment” is not for the beneficence of the individual, who incidentally did not ask to be involuntarily admitted, but for the purposes of social and moral coercion to conduct themselves in manner more acceptable to society. Indeed, if they felt their actions needed redress, they are more likely to do so, or to seek support voluntarily.
With the plethora of debate on “risk”, the treatment of a ‘mental illness’ is very much a side-issue to the overall ‘treatment’ of an individual incarcerated under mental health legislation. Particularly, in today’s over-medicalising and fallacious representation of “psychiatric illness” as entirely a brain ‘disease’ (though does not begin to explore the functional, emotional and social trauma for someone who actually lives with the experience of schizophrenia, which is more what we mental health professionals try to mitigate with the interventions currently available), the ‘mentally ill’ person, abrogated of criminal responsibility under the ‘insanity defence’, has inevitably undergone significantly more intrusive and controlling intervention than his criminal counterpart and further, once eventually discharged, continues to be ‘provided’ for through lawfully enforceable ‘coercion in the community’. Why is it then, that the criminal counterpart, who presumably simply chose to act unlawfully of his own free will, is permitted to go at large following a fixed length of time, in which he is not required to show any moral or social improvement to mitigate the risks of recidivism once released?
In another previous posting, I raised (somewhat frivolously) the argument that incarceration of people with mental illness, who also breach the law, should be time-limited, as are their criminal counterparts. In the absence of such limitations, it is not only conceivable, but is occurring, where people who do not conform to the highest standards of social reform are remaining incarcerated far beyond that which seems humane.With this argument in mind, it would be worthy to review the nature of detention under mental health act legislation:
When a person remains actively unwell, yet in the absence of any morally or socially compromising behaviours, is this sufficient to warrant detention?
When a person is no longer actively unwell, yet continues to display, say, anti-social traits of violence, is this sufficient to warrant detention?
When a person is detained in an institutional environment, where ’survival’ is more than just overcoming one’s own personal issues, how are we to estimate the social or moral adjustment of someone who is required by coercion and control to conform to the institution in every whim and to also preserve themselves against the oppressive existence amongst such, apparently, socially and morally corrupt mentally ill others?
What the psychiatric profession could really do with considering is, with all this legislate that has equipped us with legal frameworks to allow us arbitrary employ of coercion, control and containment for the existential management of the individual and preservation of social moral virtues, why do we continue to call ourselves “health professionals” when in reality, are we simply nothing more than the “moral and social engineers of the state“?
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20 Comments
The coercive/social control aspects of being a mental nurse are those that give me most pause to reflect and feel a bit crap about what I am doing, ’specially when a chap I normally get on well with called me “paedophile scum” and “worse than the shit shovellers who shovel shit for British Rail” when I tried to read him his section 3 rights. . . still, I appreciated his inventive turn of phrase.
Thank you for another thought provoking post, Mr Ian.
I think you are misrepresenting the mainstream view of mental illness by describing it as asserting that mental illness as “entirely a brain disease”. Every psychiatrist, nurse, psychologist researcher and indeed patient I know argues, with varying degrees of emphasis, that mental illness is predominantly an illness of the brain with genetics and environmental factors both playing an impotant part in how the illness is expressed. Ask Sanean over at Pole to Polar.
A recent report published by Rethink into the side effects from anti psychotic medication concluded that,
“considering the positive and negative effects of medication, on balance 76% (of those surveyed Npop=2,222) felt medication was helping, 17% were unsure and 7 % did not feel the benefits.”
For a condition that is not primarily a brain condition that is one hel of a placebo effect. Brain imaging techniques is also revealing previously undreamt of complexity that may in time go a long way to explaining the very nature of conciousness, and by implication, mental illness.
Thomas Szasz along with RD Laing is largely discredited now and not without reason. As for Muchel Foucault he was MAD and FRENCH need I say more
Also see:
Linking Mind and Brain in the Study of Mental Illnesses: A Project for a Scientific Psychopathology by Nancy C. Andreasen.
http://www.sciencemag.org/cgi/...../5306/1586
I suspect the general public see the label “mental illness” almost entirely relating to actual brain disease (messed up chemistry or whatever). Seeing the messed up chemicals as the causative factor. Instead of seeing a much more complex relationship between what happens inside the brain and the environment. We deal with all types in mental health. From dementing conditions (almost entirely brain disease with huge social implications) to bereavement (not what I would consider a brain disease at all, but extended grief probably messes up the brain chemsitry eventually).
Of course most members of the general public are dribbling idiots who should be soundly ignored.
Wonderful article Mr Ian.
Don’t know if we are moral engineers. But we are certainly lowly social engineers. The question is are we benefitting society? Or are we just dealing with problem people society is not willing to manage?
E:
??% of people who get pissed on Friday night are “happy”. Cos their brain is mushed on mind altering drugs. They’re still in the same shite marriage, same mortgage, same crappy jobm, they even stil might have that brain tumour. The alcohol is a good way to intoxicate the mood and mind into believing something your life is not.
Psychiatric drugs do not alleviate the causality of the problem. They alter the neurobiological function of the brain that may reduce symptoms or just cause a different ‘feeling’.
“Psychiatric illness”, not mental illness, tho semantics, as I stated, denoting the original condition that may well be a brain disease. Doesn’t mean everything that follows, such as emotional dischord, social stigma, job loss, is also a “disease”. Curing the original ‘disease’ will (should) resolve the associated trauma. We have no cure - since we have no cause. Meanwhile, we continue to only treat symptoms.
There is inevitably a ‘causality’ that involves the function of the brain. As it will involve the (dys)function of an organ, I’d agree this is a disease; but I believe the ‘umbrella’ effect of all associated conditions and reactions as all being of the same ‘disease’ is wrong. The theory helps to de-stigmatise and offer ‘hope’ to the sufferer, which is fine. But
Meanwhile, if someone is, as you say, physically ill; why are they locked away for it?
But.. I gotta go on holiday…
Missus nabbed me! Later guys, catch ya in a week
This whole item is predicated on the assumption that social control, and being an agent of same, is undesirable. Without social control, would there be an society worth speaking of? Without social control, would we have systems of health, education, employment rights, welfare benefits and so on?
I’d also like to unpack this sentence a little: -
The purpose of “treatment” is not for the beneficence of the individual, who incidentally did not ask to be involuntarily admitted, but for the purposes of social and moral coercion to conduct themselves in manner more acceptable to society. Indeed, if they felt their actions needed redress, they are more likely to do so, or to seek support voluntarily
I don’t quite know how ‘conducting themselves in a manner more acceptable to society’ is necessarily an undesirable aim, nor how it fails to intertwine with ‘the beneficence of the individual’. Without being able to conduct oneself in a manner more acceptable to society, it is likely that your health and wellbeing will suffer. Socialising with others, getting into education, having a job - all are made infinitely more difficult if you are constantly preoccupied by hallucinations or tormented by paranoid delusions.
What is also not addressed here is detention for the purposes of preventing suicide, which is surely for the beneficence of the individual, said individual’s extinction being a definite threat to their ongoing well-being.
Personally, I tend to agree with Peter Morall who has said that nurses need to bite the bullet, realise they are agents of social control, acknowledge that there is nothing wrong with that and just get better at it.
Foucault, Szasz and Laing - pfft!
I think Mental touched on some of these issues before. Though not as well as here
Slightly off topic, but sorry Beakie, I can’t let your dismisal of RD pass without retort.
Yes, Laing was a depressed alcoholic whose abandonment [of his his first family] may have a contibuted to his own daughters mental health problems, but………he still remains an electrifying commentator.
Virtually every page he wrote contained axioms, that said more than a turgid 20,000 word dissertation, for example;
“the perfectly adjusted bomber pilot may be a greater threat to species survival than the hospitalised schizophrenic deluded that the bomb is inside him” [Politics of Exprience, p99].
30 years ago Laing claimed “there is no such condition as schizophrenia [as a PROVEN bio-genetic neurological event], but the label is a social fact, and the social fact a political event. This political event occuring in the civic order of society imposes definitions and consequences on the labelled person. It is a social prescription that rationalises a set of social actions whereby the labelled person is annexed by others, who are legally sanctioned, medically empowered, and morally obliged to become responsible for the person labelled”.
Mr Ian, rightly in my view, seems to be preoccupied with very similar questions ?
Mr Ian, your comparison between recreational drugs such as alcohol, and by implication cocaine, amphetamines, and opiates, and the drugs used in psychiatry to treat mental illness is a poor one. It is not a false dichotomy to separate recreational drugs on the one hand and pharmaceutical drugs on the other. Both may have therapeutic uses and effects but the way in which they are used or in the case of recreational drugs, “abused” makes the comparison invalid. People prescribed psychiatric drugs should not have their minds “mushed” and if they do then the drugs are being misused or over prescribed.
Your second point that psychiatric drugs do not alleviate the causality of a problem is, depending on your philosophical view point, based on a false premise. If mental illness is primarily a disorder of the brain then by seeking to alter the balance of an individual’s brain chemistry alleviating the causality of mental illness is exactly what we are doing. The social effects that follow from mental illness, social exclusion, homelessness, unemployment, relationship problems etc are often consequences of having a mental illness. In as far as the social effects follow on from having a disorder of the mind or brain they could be viewed as (secondary) symptoms of that illness. They are certainly a lot easier to address when an individual is receiving treatment for their core symptoms.
I would be the first to agree that prescribing psychiatric drugs is not an exact science and side effects, particularly from anti psychotic medication, sometimes mean that we do more harm than good. But this stems from an incomplete knowledge of how the brain works rather than from a philosophical objection to the nature of mental illness as argued by Szasz and Laing.
I have met too many patients whose lives have been made at the very least tolerable and who have been able to build some semblance of a normal life and who would otherwise be dead, for the views of Laing and Ssasz to hold much validity anymore.
On the other hand there is this;
http://www.furiousseasons.com/.....ealybp.pdf
I hate it when there are two sides to every argument
Regarding “incomplete knowledge of how the brain works” - I predict we will never fully explain or understand how the brain works, or how the mind works, or how the relationship between the brain and the mind works. Those who believe we can reduce the totality of human existence to a chemical equation remind of Roy Harper’s words (this is a man with some experience of MH incarceration) ” …who point with computer-stained fingers…. to the rules and the codes and the system that keeps them in chains, which is where they belong, with no poems, no love and no brains”.
Regarding whether workers in the field of Mental Health are somehow guardians of good for the rest of society, well of course you are dammit! I don’t propose to comment on whether this is desirable or not, but I will ask all of you to recognise how onerous this responsibility is and to
oops…….(continued) and to think very very carefully every time you make a decision which will effect someone’s life. This probably means every minute of every working day. Good luck with it.
It is predicted that in 25 years or so computers, which are doubling in computing power every 18 months and which have already gained the intellectual capacity of a five years old, will have equalled the computing power of the human brain. At about the same time some scientists are confidently predicting that they will have unravelled the secret of consciousness itself. The result thinking computers;
http://en.wikipedia.org/wiki/A.....sciousness
Think of the neuroses and personality disorders your average PC will have when loaded with the latest version of Microsoft when that happens!! I for one can’t wait.
Producing a machine which has the processing power equivalent to a human brain is not the same as producing a human mind. All this logical processing capacity is fine, but we are not, as humans, logical beings, we merely enjoy thinking we are (which sort of proves the point really). Part of what makes us human is our brains’ capacity to make illogical connections. We seem to get a big buzz out of believing that the 1.5kg of grey slop that inhabits our crania can fathom the secrets of an effectively infinite universe. Why???? There are some things we just aren’t meant to know/don’t have the capacity to know. I don’t believe this is a Law of God or any such, it’s just the way things are.
And will any of technological developments make us more compassionate?
There: we’ve leapt from MH law as social control to the menaing of life, the universe and everything. That’s beautiful in a way no logic could ever comprehend!
Jan
“Producing a machine which has the computing power equivalent to a human brain is not the same as producing a human brain”
I did not say it was, but couple something with the computing power of a human brain with an undferstanding of what conciousness is and you might have, if not a human brain, the computer equivalent. A fully concious artificial intelligence. It is science fiction now but then so were personal communicators of the “beam me up Scotty” a few years ago.
“We are not, as humans logical beings”
Speak for youself.
“Illogical connections”
= Fuzzy logic.
“We get a buzz out of beleiving ….(that we)…. can fathom the secrets of an effectively infinite (who says it is infinite, very large certainly but not infinite) universe”
Thats because we are. (See Stephen Hawkins and others). We cerrtainly don’t know all there is to know but we know a lot more than we did and are set to learn a whole lot more.
“There are some things we just aren’t meant to know”
Says who? I am not a computer scientist but I think you underestimate the ingenuity of the human imagination. Thinking/ concious computers it is not as unrealistic as you think. (Cue music for 2001 A space odissey)
“Will any technological deveopments make us more compassionate?”
I don’t see why not but that is up to us. Technology is not incompatable with a compassionate society it certainly makes for a more comfortable one. (See microcopes, MRI scanners, anti retro viral drugs, televisions, the light bulb, airbags for cars, glasses, hip replacements, The Bee Gees, no scap that last one.
)
Ah, this could run forever. I’m not logical, and I quite like that. I dislike eating certain foods that I know are nutritious. Where’s the logic there? I’ve also been known to imbibe large amounts of toxic liquids in the name of entertainment, in spite of knowing that this was a potentially dangerous. And no, I do not believe the universe to be infinite, just so large that to a mere speck-of-dust-in-the-grand-scheme-of-things-like-me it might as well be. These Stephen Hawking types talk of universal limits being 4-dimensional, therefore incomprehensible to us 3-d types. This is the type of limitation of understanding I mean, and I’m actually comfortable with it
Also “illogical connections” = intuition/instinct/inspiration/ah so that’s where I put the scissors!
Jan
Those “Stephen Hawking types” have forgotten more about cosmology than we will ever know. But to prove I am not a card carrying member of the psychiatric establishment but a thinking individual who takes time to examine both sides of the argument here are two articles with which we can all probably agree.
http://www.furiousseasons.com/.....nosed.html
http://theicarusproject.net/ar.....tal-health
“Nice that a medical specialty with soul as its root word is more interested in how we interact with the economy than with how we are in our souls.” Priceless.
Hey all. Holiday was great, thanks for asking.
Love the postings - especially E’s: “I hate it when there are two sides to every argument” - I totally agree!
My point (which heavily leans on the social control aspect) was being made to highlight the priorities of MH legislation as being social control first, beneficence of the individual second. Of course, this is only where someone breaches the morals of the given society at that time, which includes suicidality.
Re: treating schiz by medication. I personally maintain anti-psychotics are as effective as paracetamol for pain. They only mask the effect; not cure it. The action of slowing the dopamine business is, to me, as likened to a twighlight anasthesia - we’re kinda aware, but not quite all there, and it simply dulls the symptoms - sometimes to nothingness.
The implications for adopting this ‘angle’ are that psychiatric treatment for psychoses remains realistic in addressing the functional losses that are secondary to the ‘disease’ and leaves the causality issue to the neurologists. Once they find a ‘cure’ I’m happy for them to take the stage. Meanwhile, we continue to support harm minimisation for those who suffer.
I agree social control has a place in mental health as a necessary evil. There are some people I have nurses I would not like to see roaming my neighbourhood. These are generally psychopaths and there remains a need to protect the public from the harm they can do.
I repost tho that MH law is over-regulatory and, in 200 years, continues to be used to employ an unequal balance in justice. I nursed a man under detention for 4 months because he grabbed a security guard who pushed him along and was then charged with common assault. He ended up MHA detained when he refused to speak to anyone because he felt injusticed. He was also found to have a MH record and, due to his medical record alone, was further detained. He got returned to prison once he started talking again then got bail - He’s not been seen since. He wasn’t ‘mentally ill’, he was pissed off - and more so when MH services took hold of him.
I don’t think Szasz et al want to remove all recognition of MH issues altogether. I think they simply wish to redefine the specialist area of work and look at it in a realistic way that basically stops trying to con people that mental illness is something it isn’t (or in fact, anything at all other than an extension of personality), and so too, psychiatry is nothing to do with ‘medically curing people’. It is an art form, not a science.
Psychoses may well be curable. I’ve not met one person that exhibits psychotic behaviour that does not also have a clearly definitive reason for it (eg drugs, life trauma, ex-forces, genetic defect) which usually indicates a severe stress on the brain. Ergo, some reparative act may be available; or it may be broken beyond repair. We still don’t know, but I suggest anti-psychotics are not ‘the answer’; merely the ‘band-aid’ (or perhaps the tourniquet?).
People are people - the continuum of personality types runs from ‘genius’ [which is merely another form of 'mental illness' or 'personality disorder' but with something to offer society] - thru “normal” - to mental illnesses - [people outside the bell distribution curve on "personalities" with nothing to offer society - as in the 'poor laws']. The use of MH legislative as a social control is aimed to rightfully support those who need such and protect Jo Public from acts of harm.
However, the reality I see is it is used as a predictor of failure or demise without any real boundaries, science or humanistic compassion and opinion is formed on a balance of ‘probabilities’. This opinion then directs for someone’s incarceration and the only ‘cure’ to be free is to display social conformity which includes over-correctiveness and being asymptomatic.