The Most Solitary of Afflictions: Madness and Society in Britain, 1700-1900.

For nearly two decades Andrew Scull, a sociologist who is equally at home in the discipline of history, has been an active participant in the debate dealing with the history of the care and treatment of the severely and persistently mentally ill. In three earlier provocative works he elaborated his views and criticized--often in a shrill manner--virtually every other scholar dealing with the subject. The Most Solitary of Afflictions expands but does not significantly alter the views first presented in his doctoral dissertation and published in revised form in 1979.(1)

Like Michel Foucault and David Rothman, Scull is preoccupied with explaining the profound shifts in perceptions of madness and the thrust toward reliance on institutions. In mid-eighteenth-century England the mentally disturbed resided in the community and were part of a larger homogeneous group composed of dependent and deviant persons. A century later insanity had become "exclusively defined as an illness", mad doctors had assumed sole jurisdiction over "treatment," and the mad had acquired an identity of their own and were "incarcerated in a specialized, bureaucratically organized, state-supported asylum system which isolated them both physically and symbolically from the larger society."

The driving force behind these momentous changes, according to Scull, was the emergence of a mature capitalist market economy and the ensuing commercialization of life. The traditional master-servant relationship presupposed that the former retained responsibilities toward the latter. The rise of market capitalism broke the bond of reciprocal duties and responsibilities; class became the means by which power and authority were legitimated. Confronted with an increase in the ranks of the poor, the dominant elite became attracted to the alleged virtues of institutions to care for dependent and deviant populations. At the same time the mad--precisely because they threatened the regimented order of the workhouse--were separated and placed in segregated and specialized asylums. The very existence of such institutions helped to create a new class of professional managers (i.e., psychiatrists) whose preoccupation with order, rationality, and self-control appealed to the upper class.

The transition to institutional care mirrored a fundamental transformation in human perceptions. In accepting the possibility that nature itself could be changed by conscious and purposive actions, the groundwork was laid for a new interpretation of madness. The traditional image of mad people as beasts gave way to a new belief that they were simply defective mechanisms that could be remade. Under such circumstances the use of brute force to secure compliance fell into disrepute. The image of the curative asylum took its place. In such an institution rational techniques would be brought to bear to reclaim the insane and thus restore their ability to compete in the marketplace. Moral treatment was the means by which reason would be restored to mad people. Despite fundamental flaws in their arguments, mad doctors succeeded in making mental illness their private monopoly.

The ideology of English asylum reform, insists Scull, disguised an awkward and embarrassing reality. The fact of the matter was that asylums did not cure. Instead they functioned as receptacles for the confinement of the "impossible, the inconvenient, and the inept." (370) They also decreased family and community tolerance by broadening the definition of madness and offering a culturally legitimate alternative to home care. Indeed, the value of psychiatry was its role "in legitimizing and depoliticizing efforts to regulate social life and to keep the recalcitrant and socially disruptive in line." (392-393)

The Most Solitary of Afflictions is based on wide research; Scull has examined all relevant parliamentary records, books, pamphlets, and innumerable periodicals. The lengthy footnotes attest to his diligence, and future scholars will be indebted to him. Yet when all is said and done, his contribution to the history of the care and treatment of the mentally ill and psychiatry remains problematic. The reason is that his ideological commitments--made up of a peculiar melange of Marxian and Weberian concepts and a simplistic radicalism that was in vogue in the late 1960s and early 1970s--lead him to offer analyses and interpretations that are largely divorced from or irrelevant to his data. Indeed, ideology in his hands becomes not a tool that fosters understanding, but a weapon with which to bludgeon both the past and present. To put the issue very bluntly, Scull despises psychiatry and psychiatrists. Their role is one of control; their thinking is disingenuous and faulty; their goal is professional hegemony; and they merely serve the interests of market capitalism. That psychiatrists are not angels is surely true; that they are the villains that Scull makes them out to be does not follow. Indeed, Scull's analytic framework can easily be applied to any individual or occupational group (including historians and sociologists) in order to reduce them to mere caricatures.

Aside from a work of ideology, Scull's use of data leaves a great deal to be desired. Modern social historians have gone to great lengths to demonstrate that inarticulate and lower-class groups exercise agency; hegemonic control by elites is rarely complete or absolute. Yet in this volume the mentally ill are presented as objects that are acted upon by an impersonal social system and its agents of control. Aside from drawing a portrait of the mentally ill as completely passive, Scull ignores the fact that at any given time only a small proportion of severely mentally ill persons (which I do not equate, as he implies, simply with deviancy) were not in asylums. Nor were patient outcomes as bleak as he suggests; English (as well as American) data demonstrate that many patients passed through institutions after relatively brief stays, and that prolonged confinement was only one part of the story.

I am sorry to be so harsh on a work that could have been a substantial contribution to scholarship. Unfortunately Scull is possessed of an idee fixe, and hence ignores or disregards all evidence to the contrary.(2) The portrait that he draws is simultaneously depressing, grim, and one-sided. The world, at least in his tunnel vision, is dominated by a hegemonic upper class, and their need for social control explains anything and everything. Would that reality be as simple and clear as this vision suggests!

Gerald N. Grob Rutgers University 

ENDNOTES

1. Andrew Scull, Museum of Madness: The Social Organization of Insanity in Nineteenth Century England (New York, 1979). His other books include Decarceration: Community Treatment and the Deviant--A Radical View (Englewood Cliffs, NJ, 1997), and Social Order/Mental Disorder: Anglo-American Psychiatry in Historical Perspective (Berkeley, 1989).

2. In other works Scull follows a similar line of thought. Just as institutionalization grew out of economic change, so deinstitutionalization was based on the recognition that a segregative social control policy was too expensive and that an inexpensive (and equally ineffectual) alternative was available. See especially Decarceration and "Psychiatry and Social Control in the Nineteenth and Twentieth Centuries," History of Psychiatry, 2 (June, 1991): 149-169.