A history of stigma

I have struggled with mental health for many years: the fear of being labeled defective or crazy kept me from reaching out and getting help. Understanding that stigma from a philosophical and historical perspective helped me to make a conscious and much-needed shift from a moral and individual problem that I needed to keep under control (or else) to enlisting the help of others…

Any student of Shakespeare will tell you of the thematic importance of madness in his tragedies. From the melancholy of Hamlet to the rage of King Lear, madness is often portrayed as a form of insight. Even in the comedies, the fools are often bestowed with greater wisdom than the principal characters. This is not entirely by coincidence. In Renaissance Europe, the public view of mental illness did not carry the same stigma as it does today; in fact 'madmen' were often viewed as harmless transients who wandered across Europe. According to philosopher Michel Foucault, the criminalisation of madness was a relatively modern invention, the Age of Reason as the culprit with rationality as its heralding virtue. But how and why did this happen? And could this shed some light on the current stigma against the mentally ill?

The turn towards a social critique of madness

Michel Foucault was born in 1924 into an upper-middle class French family and educated at the École Normale Supériere, where he studied under Marxist philosophers Louis Althusser and Jean Hippolyte. This is perhaps where Foucault learned to be suspicious of institutional authority and to understand the importance of historical materialism, in which power relations are revealed through an analysis of events. Hippolyte is best known for his scholarship on Hegel and Logique et existence, which would have a serious impact on postmodern thought. Althusser was an active (although at times a strong critic) of the French Communist Party who was a structuralist Marxist, meaning that Marxism was a science that examined objective structures, in contrast to humanistic Marxism.

On a personal level, the turn towards a social critique of madness is not surprising, given that Foucault was gay and struggled with homophobia his entire life. Besides being later forced to leave France and Poland for his orientation, Foucault appeared to have turned most of that hatred on himself. He was prone to self-harm, leading his father to take him to psychiatrist Jean Delay at the Saint-Anne Hospital Center in 1948 after a suicide attempt. Delay was credited with being among to discover chlorpromazine, an antipsychotic used in treating schizophrenia. But despite the psychiatrist and his father's best efforts, Foucault remained fascinated with the idea of self-mutilation and suicide. This manifested in his later drug use and sadomasochistic sexual activity.

The structuralist, Hegelian, and Marxist influence is palpable throughout Madness and Civilization. A great deal of the book was inspired by Foucault's experience working in a mental hospital and from his own difficult history with mental health. In Madness and Civilization, Foucault traces how economics and the power of the state influenced the development of the asylum in the 19th century. But the book is also a good example of how Foucault broke with the strict ideology of his teachers, eventually finding his own way through historicism and what eventually became post-structuralism.

When Madness and Civilization was finally published in 1961, it received mixed reviews, praised on one hand for being an insightful critique of the asylum, but also largely ignored by the leftists Foucault was inspired by. Fellow post-structuralist Jacques Derrida critiqued the work for its supposed metaphysical bent, and others were concerned about the specificity of Foucault's use of data. Sociologist José Guilherme Merquior stated that there were many counterexamples to his claims of uniform abuse in mental hospitals, and that his use of data was riddled with errors. While the book was well intentioned, Merquior insisted that it should not be regarded as a factual analysis.

Confinement or stigma?

Whether or not the 'evidence' Foucault put forth in Madness and Civilization is entirely correct, I agree with Merquior that the spirit of the original work is worthy of discussion. There have been prominent examples throughout history of the conditions of various institutions, with empirical analysis to suggest that the process of confinement has done more harm than good in terms of treating mental illness, for example through largely unchecked monitoring by staff, treating patients like prisoners, or rampant sexual abuse.

But the book also raises important questions as to whether the process of confinement itself led to these problems, or whether shifting negative attitudes towards the mentally ill were to blame. To answer these questions, Foucault notes that process of confinement in Europe began with the monarchy as a means of control, not relief. He writes, 'From the very start, one thing is clear: the [asylum] is not a medical establishment… It was an instance of order, of the monarchial and bourgeois order being organized in France during this period. It was directly linked with the royal power which placed it under the authority of the civil government alone.'

Therefore, the asylum could be articulated along the same lines as the prison system, intending to keep its inhabitants away from society and under the thumb of royal authority. Requirements for confinement were not always limited to outward signs of mental illness either: the poor, unemployed, and prisoners were also lumped into this category: 'It is common knowledge that the seventeenth century created enormous houses of confinement; it is less commonly known that more than one out of every hundred inhabitants of the city of Paris found themselves confined there, within several months.' Absolutism in France and other countries in Europe made the conditions for imprisonment arbitrary, hence the large numbers of people confined during this period.

As Foucault later explains, with such large numbers 'confinement acquired another meaning. Its repressive function was combined with a new use.' That 'new use' was the cheap labour from 'those who had been confined and thus making them contribute to the prosperity of all'. Since many of the newly confined were the unemployed, putting them to work achieved a dual purpose: it kept the poor from growing restless and prone to uprising, and provided the state with cheap manpower in which they could justify the low wages. This is a direct echo of Marx and Engels' theory of the 'reserve army of labor', in which times of overproduction created periods of unemployment and thus a vulnerable workforce.

There was a moral component to justifying confinement as well: unemployment or idleness became synonymous with the idea of sin. Workhouses became 'houses of correction' in which the soul of the individual would be saved through a strong work ethic. Rather than being perceived as victims of circumstances beyond their control, this harsh treatment of the poor and mentally ill seemed justified from the 16th to the 19th centuries, as the Enlightenment added yet another reason for confinement: contamination.

Becoming tainted

Foucault suggests that the fear of becoming mad oneself magnified once the idea of confinement and madness became synonymous: 'Suddenly, in a few years in the middle of the eighteenth century, a fear arose…animated, basically, by a moral myth.' The fear in question was becoming tainted by madness through exposure. Confinement was now justified as a moral means of keeping undesirables away from the rest of society, but also, ironically, became a breeding ground for irrational fears about the mentally ill. When combined with fears leftover from the plagues of the Middle Ages about the spread of disease and contamination, these fears took on a new quality. 'The great reform movement that developed in the second half of the eighteenth century originated in the effort to reduce contamination… preventing evil and disease from tainting the air and spreading their contagion in the atmosphere of the cities.'

Like the prison system he would later undertake in Discipline and Punish, the need for reform or treatment came much later and failed to change confinement's initial purpose of controlling a poor or restless workforce. With these structures in place, it is no wonder that stigma of the mentally ill evolved, as illness often restricted further mobility and cast them in the public view as 'sinners'. Foucault later referred to this association as the 'immorality of the unreasonable', adding that there was also a long history of associating the mad with animals before the Great Confinement. The baseness of animality within the 'great chain of being' had also previously justified this distinction.

Therefore, the Great Confinement, once a tool of absolutist monarchies for controlling the poor, became a medical and moral dilemma that constituted failure on behalf on the individual. In the 19th century, when efforts to reform the system surfaced, the idea of rehabilitation grew out of religious sentiment and moral outrage at the conditions in which the mentally ill were kept. A distinction was now made between prisoners and those subject to madness, and the harsh punitive gestures of chaining the confined were lifted. However, despite liberation from outward methods of control, the discourse of the 19th century was now dominated by a literature of self-control, turning those punitive treatments inward:
'Religion was part of the movement which indicated in spite of everything the presence of reason in madness, and which led from insanity to health…to place the insane individual within a moral element where he will be in debate with himself and his surroundings: to constitute for him a milieu where, far from being protected, he will be kept in a perpetual anxiety, ceaselessly threatened by Law and Transgression.' (Madness and Civilization, pp. 244)

What better way to control a vulnerable population than by having them control themselves? By encouraging patients to become responsible for their own treatment and failure when they were unable to control it lifted the onus and responsibility from the general public (and more importantly, the state). Furthermore, the notion of 'curing' mental illness also falls under scrutiny here. Electro-shock therapy, the transorbital lobotomy, and the development of drugs like Thorazine were originally developed as cures, but their effectiveness was measured based on how well doctors were able to control their patients as a result. Like the previous association between sin and idleness, the discourse of the 19th century became one in which the individual's sheer willpower had to be exhausted lest they relapse. We see this even now in public discourse of mental health, where individuals are blamed for not seeking help when there is a lack of available public resources. Rather than being treated as a social problem that affects all of us, 'madness' remains an individual, private issue.

A long way to go

What can we learn from Foucault's analysis of the history of confinement and the birth of the asylum? For one thing, we can understand how the stigma of mental illness evolved from the fear of confinement and the moral and individual failing that accompanied it. Even though mental health institutions are changing and conditions have improved dramatically in the past 200 years, we still have a long way forward as far as complete public acceptance of mental illness. But if we keep in mind that the social structures that influenced this idea came from five-hundred-year-old external fears of social unrest, maybe that would lessen the burden of mental illness as a moral or individual failure. Perhaps instead people will be encouraged to unburden themselves or seek help.

Mental health is a precarious thing for all of us. Just like our bodies have the capacity to become sick, so too our thoughts and feelings have the potential to consume us or keep us locked into unhealthy behaviours. Whether or not you agree with Foucault's revisionist historical reading of mental illness in Europe, I think he is right to identify that it takes more than sheer willpower to change the situation of mental health in Western healthcare.

- Kellye McBride received her Master's degree from Kingston University London and Université Paris 8 Vincennes-St. Denis in contemporary European philosophy.
Twitter @kellyemmcbride.
Email: [email protected]