2 Institutions: an outline history
2.1 Institutions and segregation
In this section I'll be compressing most of the history of legislation and provision which came to form the basis of health and social care over the last two centuries into quite a small space! You may want to find out more about particular aspects and developments. If you do, then you'll find the list of references to books and articles at the end of the course useful.
At one time, poverty, madness, disability and criminality were thought of as unchangeable God-given or demonic states. In the late eighteenth and early nineteenth centuries institutional care emerged as these conditions came to be viewed as treatable. Because it was believed that people could be improved in some way by being set apart from influences which were seen as damaging (like poor families, disease and lack of education) prisons, hospitals and asylums were designed with highly regimented and controlling regimes. Indeed earlier provision for adults and children with learning difficulties focused specifically on education and training programmes. An ethic of work was fundamental to many of these systems of care–work was seen as improving and at the same time providing for inmates’ and patients’ keep. Institutions also had the function of protecting other people whom, it was thought, might be at risk from contact with poor, mad, disabled or law-breaking members of society.
Previously, people with mental illness had been subjected to degrading practices, often being treated as public spectacles to be ridiculed and terrorised. Many of the nineteenth century reformers wanted to offer more humane treatment yet at the same time they were keen to provide opportunities for the medical profession to experiment with and treat more cases. Charles Dickens, writing in 1841, portrays Barnaby Rudge as someone with learning difficulties. His words are uncritical, but at the same time serve to distance his readers from his main character's humanity. They illustrate the dilemma he faced in writing about such a subject at that time:
Startling as his aspect was, the features were good, and there was something even plaintive in his wan and haggard aspect. But the absence of a soul is far more terrible in a living man than a dead one, and in this unfortunate being its noblest powers were wanting.
(Dickens, 1841, p. 28)
Reformers like Lord Shaftesbury supported those doctors who believed in removing chains and adopting a more caring regime, such as that developed at the Retreat in York which had been opened by Quakers as early as 1796. However while Shaftesbury was arguing for a more enlightened philosophy of care he also referred to ‘patients’, ‘hospitals’ and ‘doctors’. A new language designating conditions which had been thought of in ‘moral’ terms emerged as people came to be classified as ‘insane’, ‘imbeciles’ and ‘idiots’ which at the time were seen as scientific terms. With the new language came new courses of treatment, including bathing, mild sedative drugs, poultices and enemas. One system and language of care was thus substituted by another, more medical one (Nolan, 1993, pp. 33–5). This change in the words used to describe different conditions and disabilities marks a shift in attitudes and care practice.
The 1845 Lunacy Act and the Lunacy (Scotland) Act of 1857 required the counties or local authorities to build and maintain asylums. These new environments were seen as providing the basis for reforming difficult behaviours or treating illnesses. They provided a total environment of treatment, support and work for their inmates. The institutions, the treatment regimes and the segregation, it was believed, would contribute to some kind of cure. And of course, because they were so segregated, the general public had little opportunity to witness what went on within. This encouraged a belief that they were curative or at least therapeutic in some way.
Within the asylums, doctors’ powers tended to be unquestioned and were supported by public fears whipped up by contemporary newspaper reports. Indeed, in England and Wales the number of people certified as ‘lunatics’ doubled between 1844 and 1860, leading some people at the time to question the reliability of such assessments. Were publicity and social panic having an effect on judgements (Nolan, 1993, p. 33)? The growth in the numbers also had its effect on the operation of care within the institution as ‘cure and treatment’ could easily become ‘control and punishment’.
A distinctive feature of the asylums was their size. Many asylum buildings were remarkable in terms of architecture and layout. While the first asylums, like the Retreat at York, were meant for only 30 patients, by 1900 buildings came to average over 800. Colney Hatch, the Middlesex asylum which opened in 1851, was from the start designed for 1,000 patients. Its frontage was nearly one-third of a mile long (Alaszewski, 1986, p. 8).
These early institutions developed out of Elizabethan Poor Law provision where those whose families could not care for them or who were unable to provide for themselves were supported out of local parish funds in workhouses and small institutions.