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Madness at HomeReview - Madness at Home
The Psychiatrist, the Patient, and the Family in England, 1820-1860
by Akihito Suzuki
University of California Press, 2006
Review by Tony O'Brien RN, MPhil
May 2nd 2006 (Volume 10, Issue 18)

In this analysis of the role of families in 19th century psychiatry Akahito Suzuki provides a new perspective on a critical period in the history of madness. Arguing against the revisionist view that psychiatry aligned itself with social interests to build an empire based on asylums, Suzuki argues that between 1820 and 1860 families played a central role in the definition, policing and control of madness, a role that was only gradually usurped by medicine. The argument applies only to middle class and wealthy families, not to the large numbers from the working class incarcerated in asylums. And this new analysis is intended to nuance rather than supplant the revisionist view. But despite these limitations Madness at Home offers rich new insights into 19th century madness and psychiatry.

The book is structured to provide a background to the legal framework of the period, then explores psychiatric practice, the role of property interests in psychiatric decision making, and the place of psychiatry within the domestic sphere. Throughout the book the valorization of the Victorian family serves as the backcloth to Suzuki's thesis. Notions of the Victorian family as a warm and protective institution were supported by legal procedures that protected their status, and most importantly, their property. It is this emphasis on property that is crucial to understanding how families contributed to the legitimacy of psychiatry, lending it a conditional power; conditional on psychiatry's performance in protecting family financial interests. This is not merely a restatement of the argument that families played a coercive role in the asylum era, an argument that emphasizes families' emotional motivation for invoking psychiatric power. Suzuki departs from this understanding to stress the family's financial motivation for psychiatric coercion. He argues that psychiatry was heavily dependent on families to supply the patient's history, the fundamental element in judging an individual insane. Physicians could do little through their own history taking or examination to add to the accounts provided by families.

To properly understand Suzuki's argument it is necessary to understand two coexisting but distinct legal procedures in relation to lunacy, a distinction, according to Suzuki, that has eluded some historians. A commission of lunacy was a legal procedure aimed at protecting the property interests of family members by constraining the legal power of an family member to make important personal and financial decisions. By returning a verdict of lunacy a commission could annul marriages, dissolve contracts, and prevent a family member from signing checks, but there was no necessary confinement. A commission was a public hearing, often with theatrical and melodramatic overtones, with a jury determining whether the charge of lunacy was proved. A separate and distinct legal procedure, the certificate of lunacy, was necessary to confine and individual to his or her home, or to a madhouse or asylum. Most importantly, a commission of lunacy could declare an individual unfit to manage his of her affairs. Commissions of lunacy are sometimes confused with the Lunacy Commission, a quasi-judicial investigative body established 1845, with a variety of powers in the administration of asylums and the treatment of lunatics.

To establish the role of commissions of lunacy in the management of madness, Suzuki studied the available documentary evidence of their proceedings, as well as the often fulsome and lurid reports in the press. His meticulous attention to the written record, appropriately qualified by pointing out where it is incomplete or open to interpretation that makes this book both compelling and convincing. Besides documenting the numbers of commissions of lunacy over the period study, Suzuki makes extensive use of detailed case studies to illustrate the central role played by families. Any of these case studies would make a worthy publication by itself, especially given the way Suzuki contextualizes events, relating them to the prevailing political and social climate.

Chapter Two contains the intriguing story of the hubris and demise of Dr. Burrows, author of the Compendium, British psychiatry's definitive work at the time. Like many figures in the history of psychiatry, Burrows was something of a contradiction, espousing an uncompromising form of somaticism (he even claimed to be able to 'smell out' mania), while at the same time depending heavily on families' accounts of madness. Suzuki uses Burrows' case to provide a detailed analysis of the gap between the way psychiatry of the time was theorized, and the way it was practiced. He describes this as an epistemological contradiction: There was no evidence to support Burrows' somatic theory, and Burrows did not argue on that basis when presenting an opinion to a commission of lunacy. He argued on the basis of the history supplied by the family. Two cases of wrongful confinement, those of Davies and Anderdon, were established against Burrows, cases that Suzuki argues arose directly from the contradictions that underpinned his theory of psychiatry. The result was professional ruin for Burrows. In a further irony, psychiatry's resolution of this crisis was to incorporate the family history into the psychiatric examination, not to exclude it.

Suzuki returns to the Anderdon and Burrows cases in the following chapter, in which he explores the varying responses of eminent psychiatrists to the ensuing crisis. John Conolly, famous for his policy of non-restraint at the Hanwell asylum, took the view that eccentric behavior was not a sufficient condition for a finding of lunacy. Conolly's insistence on something like a dangerousness criteria has a modern feel to it. Charles Dunne, himself discharged from the army on grounds of insanity, held the more romantic view that insanity was a natural part of the human condition, lending some support to the notion that eccentricity might be a manifestation of insanity. The result of the Burrows crisis placed families at some risk by depriving them of a legal procedure aimed at protecting their wealth from the profligacy of one of their members.

To repair this breach the concept of moral insanity, something with clear connections to contemporary practice, was championed by J. C. Prichard. Moral insanity expanded the notion of insanity from a defect of reason alone. Now, the morality of behaviour (for these purposes defined in terms of responsibilities to the Victorian ideal of family) became grist to the psychiatric mill. Relating this development to the central argument of the book, Suzuki shows how the notion of moral insanity ensured the importance of the family narrative in psychiatric practice.

In chapter four Suzuki explores what he terms 'domestic psychiatry': household beliefs and practices in relation to madness. The case of Hastings Middleton is examined in detail, and provides a vivid illustration. Middleton's mother became mentally unwell late in life, and Middleton had well a developed framework for both understanding her madness and making decisions about its management. The widespread domestic belief in an interpersonal / environmental model saw some wealthy households employ physicians not for their medical skills, but as live in companions for mad family members. For the aristocrats, as always less romantic, an arranged marriage was a convenient means of containing madness and preserving property. The full explication of Suzuki's 'domestic psychiatry' leads to a revision of the theory of Foucault, Scull and others, that institutional psychiatry dictated public beliefs. Instead, Suzuki proposes that institutional psychiatry, and in particular moral treatment, represented the incorporation of practices long prevalent in families, and was thus consistent with, rather than supplanting domestic practices.

Although the domestic sphere exerted considerable power in the lunacy business, it also had its limitations, explored in chapter five. Here, Suzuki introduces further case studies showing examples of failure to contain lunacy. In these cases, outsiders intervened to bring commissions of lunacy, using as their standard the prevailing norms of family behavior, particularly that of patriarchs. In this chapter Suzuki offers a further challenge to historical orthodoxies, arguing that Showalter's notion of the 'female malady' is but one piece of the jigsaw of Victorian psychiatry. Men too, were subject to normative judgments based on gendered expectations, and Suzuki argues that women's madness should not be considered entirely located within the domestic sphere. By the middle of the 19th century the state claimed a greater role in the care of lunatics, diminishing the importance of the domestic sphere, and the power of middle and upper class families. But current practitioners will look with more than a little interest at this crucial period, and to the place of the family history in psychiatric assessment. As a footnote to this, in my own country the mental health legislation was amended in 1999, at the instigation of family advocates, to oblige clinicians to consult with families of those placed under civil commitment.

Madness at Home is a richly detailed and important contribution to our understanding of 19th century psychiatry. It is of interest to both professional historians and clinical practitioners with an interest in the history of their profession. Those teaching courses in the history of psychiatry will find it difficult to cover their topic without reference to this work, and as a result will be able to provide students with a more nuanced account of the rise of psychiatry and the role of families.

 

2006 Tony O'Brien

 

Tony O'Brien RN, MPhil, Senior Lecturer, Mental Health Nursing, University of Auckland, a.obrien@auckland.ac.nz


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