Recovery From Schizophrenia: Psychiatry And Political Economy

MADNESS AND THE INDUSTRIAL REVOLUTION 109long working hours and poverty made it harder for families to support theirdisabled members at home. 42When outdoor relief expenditure was severely restricted in the mid-nineteenthcentury there was a commensurate increase in the outlay on lunatic asylums andworkhouses. 43 The proportion of the population of England and Wales officiallyidentified as insane (including those in workhouses and the community, butlargely comprising asylum inmates) grew dramatically during the moral treatmentera and the period of establishment of county asylums. In 1807, the official countwas 2.3 insane people per 10,000 population; by the time moral treatment hadfaded away in 1870, there were officially 24.3 per 10,000. Nearly all of theincrease (at least after 1844 when the available figures allow a distinction to bemade) is in the number of pauper lunatics; the number of private patientsremained remarkably small and constant throughout the nineteenth century. 44There was clearly a growth in the recognition and confinement of the insane,but did the Industrial Revolution also spawn an actual increase in the occurrenceof insanity? Contemporary opinion was divided on this question, the majorityarguing that the increase was more apparent than real. As we shall see inChapter 9, however, there is a distinct possibility that psychosis, and particularlyschizophrenia, was indeed becoming more prevalent as the nineteenth centuryadvanced.MORAL TREATMENT FOR THE POORThe treatment methods of the moral-management advocates and of the twentiethcenturypioneers of social psychiatry were very similar (see Table 5.1); so, too, wasthe political function of the movements they created. Just as the post-SecondWorld War social psychiatry revolution legitimized deinstitutionalization, somoral treatment legitimized the growth of institutional care in the nineteenthcentury. In each case, the ideology of a treatment approach, initially humane anddirected towards the patients’ benefit, became subtly distorted and was used toserve political ends that were not necessarily in the patients’ interests. After theSecond World War, the effort to rehabilitate patients to decent living conditionsand a useful role in the community became translated into a rush to dumppatients on the street and in nursing homes in order to save money. Similarly,Samuel Tuke’s Description of the Retreat, published in 1813, encouraged reformersin the belief that asylums could be curative and hastened the expansion of thecounty asylum system. Moral treatment, as it was offered to paupers in the publicasylums, however, bore relatively little resemblance to moral treatment as it wasdeveloped for the middle-class clientele of the York Retreat.At the Retreat, seven staff cared for thirty patients, and, in addition, personalservants lived on the premises. In the county asylums, the generally accepted ratiowas one keeper to thirty patients. 45 The early asylums were overcrowded andstaffed by unqualified and untrained keepers. Despite the superintendents’promises of improved cure rates, local authorities were unwilling to pay for a