Progress and Power: Exploring the Disciplinary Connections between Moral Treatment and Psychiatric Rehabilitation

Abstract

For much of the 20th century, scholars of American and European applied psychology and psychiatry have concerned themselves with the concepts of progress and power. In an effort to revisit the character of 19th-century psychiatry and to use the results as a means of evaluating 21st-century practice, this paper explores the relationship between power and progress in two popular but chronologically distinct approaches to caring for the mad: 19th-century moral treatment and late 20th-century psychiatric rehabilitation. Using the theoretical framework of Foucault (1979), moral treatment (as developed by Thomas Story Kirkbride, for example, [1854] 1973) and psychiatric rehabilitation (as developed by William A. Anthony and colleagues, for example, Anthony, Cohen, and Farkas 1990) are compared for the degree to which each is structured by disciplinary interests and technologies. Based on this textual analysis, important differences emerge. Not only do these differences cast moral treatment in a new, and perhaps more positive light, but they also shed light on how disciplinary structures might affect a psychiatric approach's ability to carry out expressly humanitarian goals. To the extent that both propositions are accurate, the traditional view equating psychology and psychiatry's progress with a diminished reliance on power is brought into question.

Languages of suffering

“…Although the psychiatric understanding of mental problems has become hugely influential, building on a biomedical narrative, it is significant that there used to be much more openness to the moral understanding in particular, and its associated treatments, in our culture. Early forms of mental treatment were significantly called moral treatment , and were particularly associated with the names of Tuke (England), Pinel (France), and Chiarugi (Italy) in the first half of the 19th century (Lilleleht, 2003). The term “moral” then signified something much broader than our contemporary understanding of morality (as the human and social sciences were seen as belonging to “the moral sciences”), but moral treatment was nonetheless based on explicit moral values, and “involved the creation and administration of corrective experience within a specialized setting” (Lilleleht, 2003, p. 169).…”

“…Early forms of mental treatment were significantly called moral treatment , and were particularly associated with the names of Tuke (England), Pinel (France), and Chiarugi (Italy) in the first half of the 19th century (Lilleleht, 2003). The term “moral” then signified something much broader than our contemporary understanding of morality (as the human and social sciences were seen as belonging to “the moral sciences”), but moral treatment was nonetheless based on explicit moral values, and “involved the creation and administration of corrective experience within a specialized setting” (Lilleleht, 2003, p. 169). Pioneers of psychiatric treatment practiced a kind of moral cure, which involved work and occupational therapy, general encouragement, and a gradual moral edification of the patients’ characters.…”

`Recovery' and current mental health policy

“…Patients are thereby brought back into the fold of society by a recent analogue of moral treatment. 34 As Lillehet notes, this leads to a 'Catch 22' because although patients are being trained to be independent, they must remain compliant and dependent on a new body of psychiatric knowledge in order to be defined as 'recovered'. Thus recovery becomes defined by successful professional interventions and the willingness of patients to 'remain engaged' with services.…”

“…As Lillehet notes, the challenge then for social psychiatry is about the pragmatics of rehabilitation. 34 The emphasis on survival from user critics suggests that citizenship has been eroded by serial invalidation within the patient's life leading to an oppressed identity. It starts with the personal invalidation of trauma and the disruption of attachments in childhood.…”

Crackpots and basket-cases: a history of therapeutic work and occupation

“…Before going further, two preliminary peculiarities should be addressed in the existing literature on the subject. For 40 years since the publication of Madness and Civilisation, references to work-based therapies in critical scholarship have rested almost exclusively on a Foucauldian account of institutionalized work as a form of disciplining unruly selves (what, in later writings, would become known as Foucault's 'governmentality' thesis -see Bracken [1995] and Lilleleht [2002] for examples). While these insights undoubtedly hold value, it is my belief that such frameworks have subsumed other equally interesting points of critique in the history of therapeutic work.…”