My historical study of the Essex asylum, just outside London, which was recently published in Psychological Medicine, finds that those who were admitted showed significant disturbances of behaviour or evidence of organic disease. Almost two thirds of those who had psychological, as opposed to organic, disorders were discharged recovered or improved (mostly recovered). The idea that asylums acted as places to incarcerate unmarried mothers and social deviants is not borne out by this or other asylum studies. The current research does suggest, however, that modern mental health services fulfil similar functions to the old asylums – providing care for those who are unable to care for themselves, and containment for those whose behaviour is disturbing to others.
I started training as a psychiatrist at the tail end of the asylum era. These huge institutions, once a looming presence in the suburbs of cities and towns, were reduced by the 1990s to a few scattered wards, and over the next decade or two most of them disappeared altogether. Looking back, they were both better and worse than the system that replaced them. The asylums provided a ready-made community for both patients and staff. They were often situated in beautiful rural settings, with gentle activities like gardening on hand to take part in, and regular social events. Today many patients live on their own and are isolated and lonely. Local amenities and activities may be far away, and many have little access to green space and countryside. Staff are dispersed and demoralised. Trade unions are smaller and weaker and collective activities are few and far between.
Nevertheless, my experience was that the community of the old asylums was a strange and insular one. Cut off from the rest of the world, it existed in its own bubble – a bit like a boarding school or reformatory.
While asylums existed, it seemed they were indispensable. Now they are gone, we realise they are not. So how did they arise and what purpose did they originally serve? How was it that 19th century society was persuaded to undertake one of the most expensive public building programmes ever to have taken place; and this at a time when the central state and national taxation were still relatively new? The asylum programme predates the formation of the psychiatric profession and the triumph of the medical approach to madness, so they were not intended for medical purposes, at least not as we would understand these today. What function did these places fulfil, therefore?
Scholars have answered this question in a number of ways. Some claim that the asylums were always intended to be therapeutic places where people could recuperate and shelter from the harsh demands of the outside world (Jones, 1993). Others claim they were covert prisons for social deviants, including unmarried mothers and political activists (Cohen, 2016; Russel, 1995; Eloise, 2017). Somewhere between these two positions, historian Andrew Scull, suggests that the asylums were part of a broader system of social welfare and control, under the umbrella of the Poor Law in England, and linked with the Workhouse (and its equivalent elsewhere). The Workhouse was designed to force the ‘able-bodied’ poor into work, and the asylums developed as a specialist alternative for people who were unfit for this plan (Scull, 1993).
I looked at the medical case notes of people who were admitted to the Essex asylum, situated just outside London, at the beginning of the 20th century. I was helped by Joseph Rehling, an MSc student at UCL. We also referred to a history of the asylum compiled in the 1950s (Nightingale 1953).
We looked at the notes of 100 men and 100 women admitted consecutively in 1904. Most people admitted were working class; wealthier people would have been admitted to private asylums or made other arrangements. All the people admitted showed significantly disturbed behaviour. People were frequently described as ‘raving’, ‘incoherent’, ‘delusional,’ some were singing, shouting or praying in unusual circumstances, and many were noted to be unable to care for themselves. People complained of hearing voices through the telephone, of having electricity in their heads, one woman thought her husband was Jack the Ripper and another that she was a steam engine. We classified the problems described in terms of modern concepts of mental disorder using broad categories (Table 1).
Table 1 Retrospective classification of presentations
|Male (N=100)||Female (N=100)||Combined (N=200) %|
|Other organic disorder (epilepsy, delirium, unspecified)||22||16||19%|
|Abnormal behaviour (unclassifiable)||1||4||2.5%|
|Personal crisis (‘adjustment disorder’)||2||2||2%|
|Perinatal mania or psychosis||5||2.5%|
A total of 44% had an ‘organic’ disorder, including dementia, delirium, epilepsy, learning disability, syphilis and alcohol-related conditions. 36% had a psychotic or manic episode, and 12.5% had some form of depressive episode, with or without psychotic symptoms. The presentations of five people were unclassifiable, but they all showed disturbed behaviour including a young man who took his clothes off and attacked staff at the Workhouse infirmary from which he was transferred, and a young woman who was constantly laughing and described as ‘apathetic’ and ‘unfit to manage herself’. Interestingly, the 100 women we included were admitted over a shorter period than the men, suggesting that women were more likely to be admitted. Women had a higher rate of psychosis or mania, and men showed a greater frequency of organic disorders.
There is no doubt that people were discharged from the asylum if this was possible. Overall, 45.5% of the sample were discharged ‘recovered’, ‘improved’ or, in rare cases, ‘not improved’ in the judgement of the medical author of the case notes. Just under 30% died in the asylum, usually shortly after admission. There was a marked (and statistically significant) difference in the outcomes of those classified as having an organic condition versus those with a non-organic or psychological problem (Figure). Among those with a psychological disorder (psychosis, mania, depression, perinatal conditions, behavioural crisis and ‘abnormal behaviour’), 62% were discharged either recovered or improved (52% recovered and 10% improved). A third remained in the asylum or were transferred elsewhere. For those with a diagnosis of psychosis, the rate of discharge either recovered or improved was 33%, with 62% remaining in the asylum. Among those with mania, 85% were discharged recovered or improved and 11% showed a chronic course and stayed in the asylum. Among those with an organic disorder, almost 60% died in the asylum, but 22% were discharged recovered or improved.
Figure: Outcome of organic and psychological disorders (%’s)
Unfortunately we could not look at people’s ultimate outcome, because people might have been readmitted to several other asylums in the vicinity. These figures only relate to the outcome of the current admission, therefore. Those who were eventually discharged remained in the asylum for an average of 6.4 months and women stayed longer than men (8 months vs 4 months).
Interestingly some female patients admitted with psychotic disorders showed evidence of recovery after protracted periods of disturbance. Agnes, for example, a 52-year old married woman, was admitted with psychotic depression and continued in an agitated state for almost two years but then improved and was discharged recovered. Chrissy, a 27 year old barmaid, was admitted with delusions and rambling and incoherent speech. Two years after admission she was still described as symptomatic, but after three years she was discharged recovered. Thirty year old Harriet was admitted with ‘melancholia’ and delusions and was later described as hearing voices and looking ‘perplexed’. Over subsequent years she became ‘excited and violent’ and required seclusion, yet she was discharged recovered five years after admission.
So what does this tell us about the nature and functions of the asylum system? We found no evidence that people were admitted for ‘social deviance’ such as having illegitimate children, political activity or petty crime. The only woman who was admitted pregnant and gave birth in the asylum had persistent psychotic symptoms and remained in the asylum for at least the next six years. Local rate-payers paid for the upkeep of asylum residents, so there was an incentive to discharge people, although the process was certainly not as speedy as it is today. Many patients seemed to be given a few weeks and sometimes months respite between being deemed ‘improved’ and being discharged.
On the other hand, asylums were clearly places where people who were unable to look after themselves or were disturbing the peace, for reasons of organic disease or psychological disturbance, were sequestered until such time as they recovered their health or their sanity. The fact that many of them did recover owed nothing, of course, to any medical intervention that would currently be considered to be therapeutic. In this sense it was not a medical enterprise by today’s standards. Nevertheless, it seems that psychiatrists, politicians and others at the time believed they were engaged in a therapeutic endeavour. The asylum system was founded on the belief that it could restore people to sanity, and regular inspections were designed to maintain these goals and ensure the quality of care.
I wonder if things are so different today? Although the mental health system is now firmly branded as ‘medical,’ the long hypothesised biological basis of ‘functional’ psychiatric disorders has failed to materialise, and psychiatry still has no treatments that target the supposed biological basis of symptoms as other specialties do. While it may not live up to its own self-image as a modern and sophisticated technical enterprise, the system does, however, provide care for those who are unable to care for themselves, and containment for those whose behaviour is disturbing to others. Such people still include a mixture of those with organic disorders and psychological problems.
Modern treatments can effectively suppress some symptoms, which may reduce the time people need to spend in an institution, but it is not clear that current recovery rates are any better than they were at the beginning of the 20th century. In fact, David Healy and colleagues found that people were more likely to be in institutional care of some sort in 1996 compared with 1896, but in 1996 the care was more diverse, including residential homes and supported housing (Healy et al, 2005). Recent research on recovery shows pretty dismal findings for people who have a psychotic episode or a diagnosis of schizophrenia. In a randomised trial comparing maintenance antipsychotic treatment to a supported reduction in people with a first episode of psychosis, only 29% of people recovered by 7-year follow-up overall, and less than 20% of those who were allocated to antipsychotic maintenance treatment (Wunderink et al, 2013). Another 15-year follow-up conducted in the 1990s found that over 80% of people diagnosed with schizophrenia showed significant social disability (Wiersma et al, 2000).
Maybe the function of a mental health system is, after all, to provide care or ‘asylum,’ while trying, at the same time, to foster people’s own abilities to recover.
Paper: Rehling J & Moncrieff J (2020) The functions of an asylum: an analysis of male and female admissions to the Essex County Asylum in 1904. Psychological Medicine DOI: https://doi.org/10.1017/S0033291719004021. Published online 15th January 2020.
Cohen BMZ (2016) Psychiatric Hegemony: A Marxist theory of mental illness. Palgrave Macmillan, London
Eloise M (2017) why women were put in asylums in the 19th century. Dazed, 24th March 2017 https://www.dazeddigital.com/artsandculture/article/35262/1/all-the-reasons-women-used-to-be-put-in-asylums. Accessed 22/08/2019
Healy D, Harris M, Michael P, Cattell D, Savage M, Chalasani P and Hirst D (2005). Service utilization in 1896 and 1996: morbidity and mortality data from North Wales. History of Psychiatry, 16(1): 27-41.
Jones K (1993) Asylums and After: A Revised History of the Mental Health Services: From the Early 18th Century to the 1990s. Athlone Press: London.
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Wunderink L, Nieboer RM, Wiersma D, Sytema S, Nienhuis FJ (2013). Recovery of first-episode psychosis at 7 years of follow-up of an early dose reduction/discontinuation or maintenance treatment strategy. JAMA Psychiatry 70: 913-20.