MENTAL ILLNESS AND ASYLUMS.

By 1914 the new discipline of psychiatry was firmly established in Europe. The Continent was covered by a network of asylums and clinics that stretched from the west coast of Ireland to Russia's eastern provinces. Specialists in mental disease had formed professional organizations, publishing journals (such as Germany's Archiv für Psychiatrie und Nervenkrankheiten) that articulated a clear vision of the direction and purpose of the new science. Public policy and popular culture were informed by concepts such as degeneration, suggestion, and addiction that had been first articulated in psychiatric practice. It was a remarkable achievement, for the discipline of psychiatry had only emerged in the previous century as an ad hoc response to problems of legal process and welfare administration. Indeed, the subject matter of psychiatry had long been under dispute, and it was to be further confused by new political and economic demands and as novel therapies became available.

THE RISE OF THE ASYLUM

The changing subject and mission of psychiatry is demonstrated by the rise and decline of the great asylums of industrialized Europe. Upon their foundation in the early nineteenth century, they had been seen as curative institutions providing a therapeutic environment in which the deranged individual could recover his or her lost faculties. By the end of the century the massive growth in the asylums' population led many psychiatrists to reconceptualize their task. They no longer saw themselves curing individual patients; rather, they were working to preserve the health of the race and nation by isolating diseased individuals. This policy, which reflected a growing psychiatric pessimism, was underwritten by a new biological rationale: the theory of degeneration. Developed in the 1850s by the French alienists Benedict Augustin Morel (1809–1873) and Joseph Moreau de Tours (1808–1888), the theory was soon adopted by doctors and psychiatrists across Europe. Supporters such as Henry Maudsley (1835–1918) in England, Cesare Lombroso (1836–1909) in Italy, and Paul Mobius (1854–1907) and Max Nordau (1849–1923) in Germany argued that mental disorder resulted from the accumulation of inherited toxins that progressively weakened the diseased pedigrees of the race. Their position was reinforced by an increase in the asylum population, alarmist reports on the growth of crime and drunkenness in Europe's towns and cities, and new data on the failing health of potential military recruits. As the Edinburgh asylum keeper Thomas Coulston (1840–1915) argued, the threat of racial decay created a situation in which psychiatrists would have to become "the priests of the body and guardians of the physical and mental qualities of the race."

NEW CATEGORIES, NEW TREATMENTS

Given the therapeutic pessimism inherent in the doctrine of degeneration, it was unsurprising that much of the intellectual effort of European psychiatry was devoted to questions of "nosology," or the classification of disease rather than cure. The identification of different forms of mental and sexual abnormality, notably in the sexological work of Richard von Krafft-Ebing (1840–1902), created a set of intellectual categories that still inform the contemporary sense of identity. Yet this new emphasis on nosology created a plethora of competing diagnostic labels, which undermined the possibility of a unified psychiatric science. The Heidelberg psychiatrist Emil Kraepelin (1856–1926) tried to meet this confusion by arguing for a simplified model based on the long-term study of clinical outcomes rather than catalogs of mental symptoms or neurological anomalies. He reduced the nonorganic psychoses to two illnesses: manic-depressive insanity and dementia praecox. This latter category would in turn be redefined by Eugen Bleuler (1857–1939) as schizophrenia.

Kraepelin's work prioritized the patient's biography, rather than his or her pathological anatomy, as a source of clinical and diagnostic insight. And this turn to historical knowledge as the key to psychiatric practice was also reflected in contemporary developments in psychotherapy and psycho-dynamic psychiatry. In France, an active program of investigation into hypnosis and the generation of hysterical affects led Pierre Janet (1859–1947) to posit a dissociation (or splitting of consciousness) in response to psychological trauma. His approach was adopted and modified by psychotherapists and spiritual healers across Europe. In Vienna, Sigmund Freud (1856–1939) and Josef Breuer (1842–1945) experimented with the hypnotic recall of apparently repressed memories as a way of removing hysterical symptoms. This was to provide the foundation for Freud's later development of psychonalytic treatment. He abandoned hypnosis and instead developed the technique of free association to elicit unconscious material, arguing in The Interpretation of Dreams (1900) and The Psychopathology of Everyday Life (1901) that even the most capricious statement or action could be read as a meaningful symbol granting insight into the activities of the unconscious.

THERAPEUTIC ECLECTICISM

This mixture of clinical and literary approaches earned a wide, if sometimes critical, audience for psychoanalysis. The speculative nature of the structure imputed to the unconscious meant that Freud and his followers had to rigorously police the language and theories of the new psychotherapy. By 1914 conflicts over the sexual etiology of the neuroses had led pioneer psychoanalysts such as Alfred Adler (1870–1937) and Carl Gustav Jung (1875–1961) to break away from the Freudian movement and launch their own eclectic therapies. This flowering of new psychodynamic approaches was to continue throughout the twentieth century, although their impact on asylum psychiatry was marginal. Despite the claim that the epidemic of war neuroses in World War I helped to establish the legitimacy of psychoanalysis, it remained for the most part an elite preserve restricted to those who could enjoy the benefits of extended private consultation. When European asylum workers had the resources to deploy analytic methods, it was usually accompanied by a mixture of physical and suggestive therapies.

Such therapeutic eclecticism was to remain characteristic of European psychiatry throughout the interwar years. The identification in 1913 of the syphilis spirochete as the infective agent in general paralysis of the insane led to a period of open-ended experimentation in which many new therapies and models of illness were developed. In 1917 the Austrian psychiatrist Julius Wagner-Jauregg (1857–1940) announced the successful treatment of neurosyphilis through the induction of malarial fever. In 1920 Jakob Klaesi (1883–1980) in Zurich used the newly developed barbiturate drugs to induce episodes of prolonged sleep to treat psychotic patients. The risks associated with this technique led the Polish neurophysiologist Manfred Sakel (1900–1957) to experiment with insulin comas, a practice that was widely imitated, particularly in Britain and Switzerland.

There was no shared theoretical basis underpinning these treatments. In 1935 the Portuguese neurologist Egas Moniz (1874–1955) claimed to have sucessfully treated obsessions and emotional disorders by surgically altering the brain's frontal lobes. In Hungary, Ladislaus Meduna (1896–1965) proposed that a biological antagonism existed between epilepsy and schizophrenia and that presence of one would lead to the elimination of the other. He used camphor (and later cardiac drugs) to induce therapeutic fits in schizophrenic patients. The apparent success of this approach was tempered by the high risk of injury experienced by the patient. In an attempt to control the severity of the fit, two Italian doctors, Ugo Cerletti (1877–1963) and Lucio Bini (1908–1964), experimented with a new technique of electrically induced convulsions (ECT). First trialed on humans in 1938, the technique has remained in use across Europe as a treatment for manic-depressive illness and depression.

PSYCHIATRIC POLITICS

The sheer variety of experimental treatments developed in interwar Europe was a reflection of some unhappy truths. Such open-ended experimentation was made possible by the lack of a widely accepted theoretical model of mental disorder and the absence of any clear agreement on the political status or rights of the patient. Indeed, illness models and patients' rights were inextricably linked. Hereditarian models of mental disorder arising out of the old doctrine of degeneration had encouraged the idea that the mentally ill were "a race apart" and as such could be subjected to new forms of control and intervention. In Germany in 1933, the Nazis passed a sterilization law, partauthored by Ernst Rudin (1874–1952), a Swiss expert in psychiatric genetics. By 1937 two hundred thousand had been sterilized. Similar laws were passed in Norway, Sweden, Denmark, Switzerland, Estonia, and Iceland and remained in place long after the end of World War II. This politicization of psychiatry and the implementation of racial employment laws encouraged a large-scale emigration of German and Austrian psychiatrists to western Europe and America. Supported, in part, by the Rockefeller Foundation, these émigrés helped to propagate new forms of phenomenological psychiatry, in which close attention was paid to the subjective experience of the patient.

During World War II, the Soviet security services (the NKVD) opened their own psychiatric hospital in Kazan, and after the war there was increased recourse to psychiatric diagnoses (in particular, "sluggish schizophrenia") as a means of controlling poltical dissent. These obvious examples of the political abuse of psychiatry raised large questions about the underlying rationale of the medical project. New forms of wartime treatment, such as the group therapies developed by British military psychiatrists, encouraged this debate. The idea that psychiatric diagnoses and treatments might help sustain mental illnesses was taken up by radical commentators across western Europe. In Italy, Francisco Basaglia (1924–1980) experimented with open communities as a means that would allow patients to escape the oppressive effects of labels and institutions. In Britain, R. D. Laing (1927–1989) and David Cooper (1931–1986) achieved considerable fame during the 1960s by arguing that mental illness was sustained by opressive social relations. This idea that society excluded the insight of the psychotic was taken up by the Dutch psychiatrist Jan Foudraine (b. 1929) and the French philosopher Michel Foucault (1926–1984), but its influence on contemporary policy and practice was limited.

Across western Europe, mental hospital populations began to fall in the early 1950s, due in part to the emergence of a new class of phenothiazine drugs and the right-wing critique of the financial costs of the welfare states. The discovery in 1952 of chlorpromazine, an antipsychotic developed by the French pharmaceutical company Rhone-Poulenc, encouraged a period of intense psychopharmocological experimentation. In 1958 the Swiss firm Geigy released imipramime, the first of the tricyclic antidepressants, onto the market. The antidepressants made possible new regimes of patient management, but they also encouraged a reconceptualization of mental illness. No longer seen as an intricate biographical problem requiring careful investigation, mental illness was presented as a chemical imbalance that could be corrected through pharmaceutical intervention. This simple model of psychopathology undermined much of the mental hospital's rationale. It was no longer needed, either as a therapeutic refuge or a eugenic solution, and mental health care began to be devolved to a number of frontline agencies: general practitioners, community psychiatrists, and psychiatric social workers. This system, pioneered in southern France during the interwar period, became dominant in Britain, France, and northern Europe during the 1960s and was taken up in Spain in the 1980s. In eastern Europe patterns of care remained more varied, with use of crib-beds and incarceration persisting long after the fall of the communist governments in Hungary, Slovakia, Estonia, and the Czech Republic.

THE END OF THE ASYLUM

The impetus for the ongoing transformation of mental health care services across Europe comes in part from the rationalizing demands of market economics, and countries such as England and Portugal have increasingly relied on the private sector in the provision of care. Yet a growing patient's advocacy movement, inspired by the examples of aid charities, has developed more global aspirations. Transnational institutions such as the European Union, media organizations, and pharmaceutical companies have created a new set of expectations that are changing the organization of European psychiatry. And these changes in psychiatric practice themselves encourage new theories and cultures of of mental health. Western Europe is beginning to emulate the American enthusiasm for antidepressant drugs, particularly the new generation of selective serotonin reuptake inhibitors—an enthusiasm that raises larger questions over the mission of psychiatry as it moves from being a remedial therapy to a technique for individual self-improvement.

See alsoPsychiatry; Psychoanalysis; War Neuroses.

BIBLIOGRAPHY

Angel, Katherine, Edgar Jones, and Michael Neve. European Psychiatry on the Eve of War: Aubrey Lewis, the Maudsley Hospital, and the Rockefeller Foundation in the 1930s. London, 2003. An edited version of the 1930s reports of the Anglo-Australian psychiatrist Aubrey Lewis on the state of European psychiatry.

Berrios, German E., and Roy Porter, eds. A History of Clinical Psychiatry. London, 1995. A useful collection on the history of individual mental illnesses.

Castel, Robert, Françoise Castel, and Anne Lovell. The Psychiatric Society. Translated by Arthur Goldhammer. New York, 1982. A political account of the rise of French psychiatry.

Finzsch, Norbert, and Robert Jütte. Institutions of Confinement: Hospitals, Asylums, and Prisons in Western Europe and North America, 1500–1950. Washington, D.C., 1996. A collection examining the disciplinary role of asylums.

Freeman, Hugh. A Century of Psychiatry. London, 1999. Useful collection of short essays on most aspects of twentieth-century psychiatry.

Healy, David. The Antidepressant Era. Cambridge, Mass., 1997. One of the best accounts of the rise of psychopharmocology.

Micale, Mark S. "The Psychiatric Body." In Medicine in the Twentieth Century, edited by Roger Cooter and John Pickstone, 323–346. Amsterdam, 2000. A good analysis of the main forces driving contemporary psychiatry.

Micale, Mark S., and Roy Porter, eds. Discovering the History of Psychiatry. Oxford, U.K., 1994. Includes useful essays on the historiography of psychiatry in Britain, France, Russia, and Germany.

Neve, Michael. "Medicine and the Mind." In Western Medecine: An Illustrated History, edited by Irvine Loudon, 232–263. Oxford, U.K., 1997. A fine introduction to the main themes.

Pressman, Jack. "Concepts of Mental Illness in the West." In The Cambridge World History of Human Diseases, edited by Kenneth F. Kiple, 59–84. Cambridge, U.K., 1993. A rich global history of the rise of psychiatry.

Shorter, Edward. A History of Psychiatry: From the Age of the Asylum to the Age of Prozac. New York, 1997. The most thorough historical overview available.

Weindling, Paul. Health, Race, and German Politics between National Unification and Nazism, 1870–1945. Cambridge, U.K., 1989.

Rhodri Hayward