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00:00:00Hearts.
00:00:32There's something uncanny and rather perplexing about a building as large and as empty as
00:00:37this one, especially when it doesn't seem to be all that old, just over a hundred years
00:00:41in fact.
00:00:43And although it's a frightful mess now, it doesn't seem to have been abandoned all that
00:00:47long.
00:00:48It's not what you call a ruin, certainly not an archaeological one.
00:00:51So who is it meant for?
00:00:54And where have they all gone?
00:00:56And why?
00:01:09So who is it meant for?
00:01:33Well, while it may not be all that easy to tell from the inside, I'm sure that if you
00:01:37could see the exterior of this building, you'd recognize it at once as a lunatic asylum.
00:01:44And although it's not serving that function now, the memory of such places is still so
00:01:49vivid in the popular imagination that we all know the names which express or perhaps conceal
00:01:55our fear.
00:02:01The paradox is that although such institutions still loom rather threateningly in the public
00:02:12imagination, they're actually quite recent inventions.
00:02:16And after a comparatively short existence, they seem to be on their way out.
00:02:36And yet you only have to walk a few yards down this abandoned corridor to find that that's
00:02:41not quite the whole story.
00:02:43The custodial care of the insane is still a going concern.
00:02:48Here, as in mental hospitals throughout the Western world, the resident population, 600, is
00:02:56a small remnant of the 6,000 who once occupied these enormous premises.
00:03:01The patients who remain are the survivors of a therapeutic regime which has somehow lost confidence
00:03:07in itself.
00:03:09Unless one makes the unlikely assumption that the incidence of mental illness has fallen
00:03:14dramatically, one can only conclude that the reduction in asylum population is the result
00:03:20of changing attitudes to how we care for the mad.
00:03:25Basically, you had the advent of the psychotropic medication that had such a significant impact.
00:03:31Then you add to that the fact that you have the advent of the civil rights legislation which
00:03:37occurred under the Kennedy administration.
00:03:39And that legislation basically decreed that an individual has the right to be treated in
00:03:46the least restrictive environment.
00:03:48Now, by definition, inpatient hospitalization has to be the most restrictive environment.
00:03:54An individual is treated here, he's able to leave the hospital, he's discharged, okay?
00:04:00Well, in order to be readmitted, you've got to meet three critical criteria.
00:04:04If you don't meet all three, legally we're not permitted to admit you.
00:04:07The three criteria are, number one, you must be suffering from a mental illness as diagnosed
00:04:12by a physician, number two, that illness must be sufficiently severe that treatment in a
00:04:18less restrictive environment is not appropriate, least restrictive environment notion.
00:04:24And third, the individual must be dangerous to himself or other.
00:04:28If you fail to meet those three criteria, we cannot legally admit you.
00:04:34So in other words, the people on the streets are not necessarily a symptom of the heartlessness
00:04:39of a system which no longer cares for them.
00:04:41No, not at all.
00:04:42You're dealing with the notion of least restrictive environment.
00:04:46The paradox is that in yielding to the unprecedented demand for patients' rights and to the strict
00:04:52statutory limitations under which people may be admitted and held against their will, asylums
00:04:57throughout the Western world have made an unintended contribution to the growing throngs of the homeless.
00:05:02And yet confronted by the unrestricted environment of the streets, it's hard to visualize it
00:05:08as a liberty.
00:05:10And for those who would be quite unable to survive such liberation, the comforts of custody seem
00:05:16almost self-evident.
00:05:21So what do you do now?
00:05:23No, you can take that.
00:05:25Okay, can I do it?
00:05:25Yeah.
00:05:26Okay.
00:05:26Get your finger out of the way.
00:05:28That's good.
00:05:28How's that?
00:05:29Is that good?
00:05:29Like that.
00:05:31These are folks who are still symptomatology, their symptomatology still isn't really controlled.
00:05:39And the outlook is not particularly positive for most of them.
00:05:43And most of these couldn't live outside in the community?
00:05:45They haven't got families or they couldn't really survive?
00:05:48No, I wouldn't go so far as to say that.
00:05:51I think a number of them could make it if we can deal with some of the behaviors.
00:05:57I mean, the lady over there making the decorations that you see in the room, I mean, she'd be a
00:06:03delightful
00:06:03grandmother, you know, really.
00:06:10Now, in order to understand how things got to this point, you've really got to cast your
00:06:17mind back to the time when such institutions were completely unimaginable.
00:06:23That's to say, when the fate of the insane was perhaps even more uncertain than it is now.
00:06:29Well, as often happens, it's Shakespeare who provides some interesting evidence about the image of insanity in the early modern
00:06:40era.
00:06:42In his play, King Lear, Shakespeare shows us the tactics of a character, Edgar, who wishes to conceal his identity
00:06:50under the guise of madness.
00:06:53My face I'll grime with filth, blanket my loins, elf all my hairs in knots, and with presented nakedness out
00:07:01-face the winds and persecutions of the sky.
00:07:05The country gives me proof and precedent of bedlam beggars, who, with roaring voices, strike in their numbed and mortified
00:07:13bare arms,
00:07:13pins, pins, wooden pricks, nails, sprigs of rosemary, and with this horrible object from low farms, poor pelting villages, sheep
00:07:21coats and mills,
00:07:23sometime with lunatic bands, sometime with prayers enforce their charity.
00:07:26Poor Charlie, poor Charlie, poor Charlie, poor Charlie, poor Charlie, poor Charlie, poor Charlie.
00:07:31That's something yet.
00:07:33Edgar, I nothing am.
00:07:40Edgar, I nothing am.
00:07:44In a play which is preoccupied with the themes of madness and loss, Shakespeare constantly repeats the word nothing.
00:07:56So perhaps it's not surprising that much of the action happens in a place which once represented nowhere at all.
00:08:05The Heath.
00:08:13In the Middle Ages, and probably until the beginning of the 17th century,
00:08:19the image of lunacy was metaphorically associated with the kind of uninhabited desolation that spreads out as far as the
00:08:28eye can see on either side of this road.
00:08:32In an age when towns and industrialized agriculture have covered so much of the surface of our world,
00:08:38it's quite hard to recapture exactly what the word Heath once meant.
00:08:43and to realize that a now picturesque road like this was once seen as a perilous tightrope stretched across the
00:08:52no man's land
00:08:53that surrounded the towns, villages and low pelting farms of human habitation.
00:09:03In visualizing lunacy as a state of nothingness,
00:09:07our predecessors didn't think of it as a condition of no existence or of no longer being anything at all,
00:09:13but as something perhaps more terrible, of being alive but no longer human,
00:09:20no better than the wild beasts that once roamed these unowned and uninhabited stretches of Heath.
00:09:31Within the community, madness could be valued in different sorts of ways.
00:09:36Of course it could be seen as little better than being a wild beast,
00:09:39but within the traditional culture, madness could also be esteemed.
00:09:44It could be seen as a form of innocence, a kind of child-likeness that was virtuous in itself.
00:09:50It could even be seen as a direct communication with God.
00:09:53There could be a kind of divine madness as well as a diabolical madness.
00:09:57And the madman, his hallucinations, her voices might be seen as, as it were,
00:10:03the supernatural directly communicating important messages.
00:10:08There's a romantic notion of the treatment of the mad in medieval period,
00:10:13according to which folly was a form of wisdom,
00:10:16the mad were left at liberty and indeed tolerated as part of society.
00:10:22I find this, in most respects, a very misleading set of notions.
00:10:36In fact, it seems to me, wherever the mad were troublesome,
00:10:40there wasn't the least compunction about whipping them, beating them, chaining them up,
00:10:45finding some way to dispose of them, get them out of harm's way.
00:10:50Where they were less troublesome, they might be left to roam the countryside, left, if need be, to rot.
00:11:01Now, you may have noticed that in his speech, Edgar uses the phrase, bedlam beggars.
00:11:08Now, apart from the fact that this implies an affinity between poverty and lunacy,
00:11:14and that'll turn out to be a vital issue in the whole history of the subject,
00:11:17the word bedlam, of course, indicates the existence, even at this time,
00:11:23of a specialized institution for dealing with insanity.
00:11:27The word bedlam is simply a corrupted version of Bethlehem,
00:11:31and it refers to a small establishment, St. Mary of Bethlehem,
00:11:36under monastic patronage that had devoted itself to housing the mad since the late Middle Ages.
00:11:43Now, in spite of the fact that this word is now virtually synonymous with custodial treatment of madness,
00:11:49the number of insane people who were housed in Bethlehem, at this time no more than 20 or 30,
00:11:55there were only a tiny fraction of those who were afflicted.
00:11:59The rest were almost invisible in the vast mass of rogues, vagabonds, rootless, unemployables and so forth,
00:12:07amongst whom Edgar hoped to hide himself.
00:12:10These people began to pose an acute problem to those who were responsible for the policing of parishes and local
00:12:18communities,
00:12:18as Europe began to emerge from the medieval feudal system.
00:12:31An aerial view of England today discloses few signs of that medieval world,
00:12:37and the grandiose layouts of the great estates that superseded it are themselves little more than relics.
00:12:47Nonetheless, this landscaped formality epitomizes a civilization that was increasingly intolerant of behavior which conflicted with order and reason.
00:12:59You could say that for centuries mad people were largely dealt with in the community, in the home, by the
00:13:07family.
00:13:07And that really changes during the course of the latter half of the 17th century, and then through the 18th
00:13:13and into the 19th centuries,
00:13:14where they become institutionalized in large numbers for the first time.
00:13:20Historians have debated at great length, and often with tremendous acrimony, as to why that sort of process took place.
00:13:26And some have said this was a response to capitalism.
00:13:30Other people have argued that the development of the nation-state, the powerful prince, was important.
00:13:35Some people say that it was a response to the Enlightenment, the way in which reason in the Enlightenment becomes
00:13:41so important.
00:13:42Those people who are unreasonable therefore cannot be accepted as citizens any longer.
00:13:47They have to be shunted out of society into institutions.
00:13:59Some of these were quite small, others grew to a considerable size, so that by the end of the 18th
00:14:05century,
00:14:06there were two or three in which conditions were quite appalling, running to perhaps two or three hundred inmates.
00:14:13Instruments of confinement were quite commonly used.
00:14:16Patients were kept in conditions that were quite terrible in many instances, with no glazing on the windows, for instance,
00:14:24with shackles tying them up to the walls, with straw on the floor, sometimes naked through the winter.
00:14:32As far as treatment is concerned, the profession relied on the traditional remedies of bleeding, purging and vomiting.
00:14:38In spite of the fact that the humoral theory on which they were all based had already retreated in favour
00:14:44of a growing interest in the role of the brain.
00:14:48Meanwhile, reformers were beginning to express misgivings about the physical conditions under which the mad were held.
00:14:53And one of the earliest reforming initiatives took place in France against a background of revolutionary enlightenment.
00:15:01Philippe Pinel, the medical superintendent at the Salpetriere, has become an almost mythical figure in the history of psychiatry.
00:15:11The famous picture of him striking the chains from the inmates of the asylum still hangs at the head of
00:15:17the stairs leading to the medical library.
00:15:20In fact, this event never actually took place.
00:15:23But Pinel did fundamentally change the whole therapeutic attitude to the insane.
00:15:29He addressed his treatments to the mind rather than to the body, preferring to view the deranged as being at
00:15:36one end of a human continuum
00:15:38in which there were imperceptible gradations between health and insanity.
00:15:43In England, where there had been no revolution, most of the reforming initiatives took place under the auspices of existing
00:15:51parliamentary institutions.
00:15:58You have before you drawings of Norris in his state of confinement.
00:16:03Do you admit they are a correct representation of the manner in which Norris was confined?
00:16:10I think the apparatus is all correct.
00:16:12In fact, one of the most significant events which set the stage for the great asylum building program which took
00:16:19place in the middle of the 19th century
00:16:21was the establishment of a series of parliamentary subcommittees appointed to take evidence from witnesses of some of the more
00:16:28outrageous excesses of the existing system.
00:16:31The recommendations of the 1815 subcommittee laid the foundations for far-reaching public legislation.
00:16:39I infer I did not approve it.
00:16:41Knowing the situation of Mr Crowther at the time, I paid no attention to it.
00:16:46Mr Crowther was generally insane and mostly drunk.
00:16:49He was so insane as to have a straight waistcoat.
00:16:56Mr Crowther was also consumed by his dad.
00:16:57In September 28th, 1814, I visited a private house at Box, about six miles from Bath.
00:17:05in it there were four women i saw lying on straw two of the women nearly naked
00:17:13the place in which they are confined is entirely dark and i think that in the course of my visiting
00:17:20i never recollect to have seen four living persons in so wretched a state
00:17:34i never smelt such a stench in my life it was so bad that the friend that went with us
00:17:41said he could
00:17:42not enter the other room i said i would go in for if the patients could survive the night i
00:17:49could at
00:17:49least inspect it the stench was so bad i almost suffocated and for hours afterwards if i ate
00:17:59anything i still remembered the same smell it was originally a pigsty it was built up high especially
00:18:11for her i have seen her confined there three weeks together was she ironed she was ironed there
00:18:19in the crib with wrist locks and leg locks and a chain two or three times across her body
00:18:28was there an iron bar placed between her legs in order to prevent her joining her feet together
00:18:35yes there was mr talbot had it made on purpose for her it was confined to each ankle with a
00:18:42chain going
00:18:42up between her legs which was attached to her handcuffs
00:18:50dr monroe what are the forms of treatment well in order to be bled the latter end of may
00:18:57in the following months we are administering medicines we don't do this in the winter season
00:19:04because the house is so excessively cold and after they've been bled they take vomit once a week for
00:19:10a number of weeks are you aware that many consider the practice of vomiting unfavorable yes i am but
00:19:19the practice continues notwithstanding yes people differ in their opinions i vomit my patients freely
00:19:28meanwhile in york a program of practical reform had already been inaugurated by a group of
00:19:35philanthropists who undertook improvements on their own behalf the instigator of this reform william tuke
00:19:43a quaker gave evidence to the parliamentary subcommittee you were the principal promoter of the retreat
00:19:49at york i was and i've always taken an active part in the attendance on committee meetings and everything
00:19:57that has been done respecting it from the beginning do you know enough of the medical treatment of the
00:20:02patients at the retreat to enable you to inform the committee whether the patients in the house
00:20:07have periodically physicked bled vomited and bathed no such thing with respect to bathing the bath is
00:20:17most frequently used and i think the warm bath rather than the other in fact very little medicine is used
00:20:24i do not mean to boast but i could find fifty or a hundred former patients well and happy within
00:20:33a
00:20:33morning's ride of my house if i know whips and chains at york why the men who behave amiss there
00:20:43are
00:20:43subject to no further punishment than to be put on the airing ground
00:20:49and they have named up bedlam thank you mr tukey in order to appreciate the significance of what had
00:20:58happened it's very important to understand the extent to which the medical profession had succeeded
00:21:04in gaining an almost exclusive monopoly over the custody and treatment of the mad and that this
00:21:10otherwise inevitable process had been interrupted though not permanently as we'll see
00:21:15by someone who resolutely refused to acknowledge the psychiatric authority of the doctor
00:21:27those are the case books but you also have the admissions register which is much more organized
00:21:34beginning in 1796 and there's your first patient uh margaret holt of bradford
00:21:42it is interesting that they actually do record it as unrequited love how soon did it acquire the
00:21:47reputation of being a good place to be in i mean quite evidently is now you walk into it and
00:21:51you would
00:21:51say well if i went mad i'd like to be here how soon do you think it had got that
00:21:56reputation in the
00:21:57community in york i think quite early on um for instance um we have a volume of reception orders which
00:22:04begin in 1796 they consist mostly of letters from physicians sending patients for treatment at the retreat
00:22:12um this particular one is comes from stockport i happen to know that the surgeon involved who has
00:22:17the wonderful name of john edgerton killer a very good name for surgeon um he's was not a quaker
00:22:24but he's using um the quaker establishment because he knows it's very good
00:22:31as with the other puritan sects which flourish during and after the great religious upheavals of
00:22:39the 17th century the theater in which the distinctive quaker virtues were practiced and perfected was the
00:22:46god-fearing household so that in the effort to restore and strengthen what had been weakened by insanity
00:22:53toke and his associates did everything they could to construct a convincing replica of the quaker home
00:23:00the theory was that by providing the patients with a persuasive reproduction of the decor in which they
00:23:07had lived they would automatically revert to the decorum from which they had lapsed
00:23:15infractions resulted in loss of privileges less comfortable rooms perhaps whereas good behavior was
00:23:22rewarded by approval and by full participation in the repertoire of daily activities but the most
00:23:29noticeable feature of the little household was the fact that the patient was addressed as a potentially
00:23:34reasonable person and not as an unreasonable brute so that what was once a menagerie had become a
00:23:42menage it was this more secular aspect of the tuke enterprise that was taken up and exploited elsewhere
00:23:58when mclean hospital was established in new england at the beginning of the 19th century it was one of
00:24:03a small group of asylums in fact there were only 500 patients in custody in the whole of the country
00:24:13in pennsylvania in pennsylvania in new york and also here in massachusetts the founders had been almost
00:24:21unanimously inspired by the model of the retreat at york and although rufus wyman who was the first
00:24:30medical superintendent appointed in 1816 was not himself a quaker there's no doubt that he too was
00:24:37inspired by tukes idea of moral treatment in fact this is his personal copy of tukes description of the
00:24:45york retreat
00:24:52well the odd thing is that tukes idea was received and adopted here in the united states with much greater
00:24:59enthusiasm than it had been in england and one reason i suspect is that there was not as there had
00:25:06been in england a sort of gulag archipelago of private and public mad houses whose medical
00:25:12superintendents fought a rearguard action against the encroachments of non-medical treatment but i think
00:25:20there's probably a more important positive reason and that i think is to do with the fact that this was
00:25:26a new country so that there weren't a lot of old ideas clogging the mind i think the point is
00:25:32that the
00:25:32founding fathers had recently established their new country on the enlightened principle that human
00:25:39beings were essentially perfectible individuals and that if only social arrangements could be fair and
00:25:46reasonable then happiness and prosperity would follow inevitably the assumption was that passion could
00:25:54somehow be reconciled with rational self-interest by appealing to right reason and it's easy to
00:26:01understand how tukes idea that one could address the residual rationality of the madman would have
00:26:08appealed to these socially optimistic americans the influence of the new humanitarianism meant that
00:26:17even in hospitals where restraint apparatus was still used to control patients it underwent a subtle change
00:26:25when you first cast your eyes over these early 19th century instruments of restraint it may be quite hard
00:26:34to see that they reflect and express a completely new attitude to insanity
00:26:48under the influence of the english philosopher john locke madness was regarded as the invasion of orderly
00:26:56thought by false ideas and the theory was that if only the mind could be curtained and quietened
00:27:03it might spontaneously revert to its natural orderliness and obey its normal tendency to associate ideas in a rational manner
00:27:16in fact even that revolving wheel or drum had a psychological rationale behind it once inside as long as you
00:27:23remain still
00:27:25you would avoid the vertiginous discomforts of rotation so the assumption was that by appealing to his
00:27:33residual reason the patient would be taught that there was nothing to be gained and in fact everything
00:27:39to be lost by his maniacal behavior as the inventor of the apparatus itself put it it would reawaken his
00:27:48sense of responsibility in this new age of therapeutic optimism the asylum was now regarded as the sovereign
00:27:56remedy for the social problem of lunacy it was to all intents and purposes a factory for reconstructing
00:28:03sanity like the great prisons which began to appear in the same period these custodial establishments for
00:28:11the mad were built in every state and county in america one of the most emblematic examples of the new
00:28:18initiative
00:28:18was the pennsylvania institute for the insane whose quaker superintendent thomas kirkbride wrote an
00:28:25influential treatise entitled the construction management and general arrangements of hospitals for the insane
00:28:32i think one of the hardest experiences to recapture for us in the late 20th century is the impact that
00:28:41a building like this would have had on a person in the 1860s i mean the scale now when we're
00:28:47used to such
00:28:47large buildings the scale of something like this seems relatively small but for its time this would
00:28:54have been an extremely impressive building and kirkbride played on that sense of as often happens when the
00:29:01excesses of a derelict regime are identified and overthrown the alternative plans visualized by the reformers
00:29:09assumed a recognizably utopian character the reformers designed establishments whose
00:29:17architectural format expressed intelligible regularity assuming that by living in premises
00:29:24which represented order and reason the inmates would repossess their own
00:29:30an image was created that here was not a prison but a healing institution that it had the capacity
00:29:37by the use of bricks and mortar by the use of therapeutic regimes to cure people and an enormous
00:29:44amount of energy was invested by early 19th century asylum keepers to try to i guess one could say
00:29:51improve the quality of life in the asylum not just to make it more humane but to create occupational
00:29:57opportunities work in the fields to improve the social interaction of lunatics to improve staff
00:30:05patient ratios to create harmony within the asylum and one of the sort of classic examples of that
00:30:12is the asylum ball it's very well documented by people like dickens that at christmas or new year
00:30:19there'd be a great party a celebration of coming together if you like of staff and patients and the
00:30:26outside world showing that recuperation was actually happening this is not a world of punishment this is
00:30:32the world of retraining people for outside life
00:30:55in some ways the 19th century asylum was the victim of its own success or at least its propaganda
00:31:01more and more of them were built more money was invested more public hopes were placed upon the
00:31:07asylum and of course these hopes were dashed
00:31:13moral treatment once it got into the state-sponsored asylums was rapidly diluted and transformed into
00:31:21something very different it became quite quickly a mechanism for repressively managing large numbers
00:31:28of patients juke's retreat had contained only 30 or 40 patients the new county asylums from the outset
00:31:37had one or 200 and very quickly that rose to 500 600 a thousand and then several thousand and under
00:31:44conditions of that sort what became of prime importance was simply managing the patients and
00:31:51developing techniques to keep them placid and from causing undue trouble
00:31:57like so many of the other reformers thomas kirkbride lived to see his utopian scheme on the edge of ruin
00:32:05i think he died not broken-hearted but aware that his his life's work was threatened and that the
00:32:15validity of his ideas was being questioned on all sides a younger generation young turks as they called
00:32:22themselves had come along and insisted that mental illness was strictly semantic in origin that it
00:32:28had to be dealt with from a semantic uh standpoint and in fact were very pessimistic about the power
00:32:35of medicine uh moral of medicine to cure the insane and so at the time that he died in 1883
00:32:41it was a full-scale um revolt against moral treatment in his hospital plan the kirkbride plan came to
00:32:48symbolize that that old-style uh blend of religion and science and the younger generation didn't want to
00:32:56have anything to do with it
00:32:57uh
00:33:14confronted by a growing population whose sheer size meant that moral treatment was inapplicable the
00:33:22incentive to find alternative methods of treatment proved almost irresistible now the point is that
00:33:29since there had always been a lurking suspicion that insanity was the result of an organic disease
00:33:36the treatments that were eventually seized upon especially in the middle years of the 20th century
00:33:41predictably assumed a drastic physical form
00:33:49medicine in the early 20th century had made great strides in both understanding and to some extent in
00:33:54treating disease and as a result had accrued considerably more social prestige than it had hitherto enjoyed
00:34:02by contrast psychiatrists presiding over a ramshackle empire of decaying asylums that really were seen as
00:34:10failing to cure completely uh felt very much left behind and one can see i think efforts on their part
00:34:18to catch up with the rest of medicine and to import some of the uh advances that seem to have
00:34:23had such
00:34:24dramatic effect there
00:34:29beginning in the early 20th century we see the emergence in institutional psychiatry of a range of
00:34:35treatments which in retrospect looked quite peculiar giving patients with tertiary syphilis malaria operating
00:34:43on them pulling teeth removing tonsils and perhaps going into the abdominal cavity and starting to
00:34:48remove stomachs and colons and so forth justified on the basis that these people were victims of an
00:34:54infectious illness that was poisoning their brains the use of insulin and of electroshock and metrazole
00:35:03as ways of shocking the system perhaps into some form of sanity
00:35:52as an almost inevitable consequence of the belief that lunacy was caused by something going
00:35:56wrong in the brain surgeons began to undertake direct assaults upon the cranial contents
00:36:04meanwhile in nazi germany an even more radical solution was proposed
00:36:17i don't think it takes a particularly vivid imagination to reconstruct and even relive the
00:36:23experience of the 10 000 mental patients who spent the last agonizing moments of their existence in
00:36:30this small tiled room in hadoma a few miles north of frankfurt
00:36:37perhaps the whole process took more than a few moments the carbon monoxide which was used to asphyxiate
00:36:44the victims 60 or 70 at a time wasn't all that efficient in any case there was the problem of
00:36:52disposal soiled with the vomit and excrement which would have been voided during the death throes
00:37:00the bodies which were not destined for dissection in the next room
00:37:04were loaded onto trolleys and transported down a short corridor to the incinerators
00:37:11it strikes me as a paradox that a people so obsessed with cleanliness and with beautiful sunlit bodies
00:37:18were prepared to wade through fathoms of obscene filth on their way to a teutonic millennium
00:37:25but then nazism always projected an image curiously comprised of edelweiss and excrement
00:37:38of the world by the time the invasion of the rest of europe was underway german doctors were violating
00:37:52the civil rights of their own citizens by rounding up epileptics mental defectives and indeed anyone whose
00:37:59mental disorder could be identified as a threat to the genetic purity of a nation which was otherwise
00:38:06destined for heroic precedence
00:38:13even at the outset there were misgivings about the social acceptability of the scheme
00:38:19and even about its moral propriety
00:38:23and although the records were kept with an almost pedantic accuracy much of the operation was conducted in
00:38:30somewhat underhand manner and more often than not the victims relatives were either misinformed or kept
00:38:38completely in the dark in any case for one reason or another the program came to an official conclusion
00:38:46by the end of 1941 although by that time 70 000 people had perished
00:38:58i think the question one once answered is not how did it come to an end but how on earth
00:39:04did it get
00:39:04started in the first place as we've already seen the management of the mentally ill had always posed a
00:39:12vexing problem so one can only suppose that the readiness to adopt such a lethal solution for it this time
00:39:20was that the problem was conceived in completely different terms
00:39:24not just as one of management and expense but in terms of something much more fundamental
00:39:30as to say in terms of the biological destiny of the human race
00:39:36i think in that sense what the nazis were prepared to do was an extension of a movement which was
00:39:43already underway at the turn of this unforgivable century that is to say a belief that biology
00:39:51offered a way of permanently rectifying the hereditary imperfections of the human race
00:40:11the human race
00:40:15what this had to do with marrying alice was that apparently some of her relatives had been residents
00:40:23here at the local asylum and that meant that alice had inherited and might even pass on this degenerate taint
00:40:40the theory of degeneration as applied to asylum inmates was simply one aspect of a biologically
00:40:50based suspicion which had begun to grow in the 19th century the idea was that even amongst ordinary
00:40:58people that's to say outside the asylum one could identify lower orders of humanity epileptics mental
00:41:05defectives of one sort or another cretins criminals and even some racial groups well behind all this lay
00:41:13the assumption that the human race was undergoing an hereditary change for the worse and whatever the
00:41:20reasons for this deterioration programs of artificial selection were recommended as a substitute for
00:41:28the frustrated force of natural selection
00:41:31and so if we want to maintain the race at a high level physically and mentally everybody sound in body
00:41:39and mind should marry and have enough children to perpetuate their stock and carry on the race
00:41:46in the race not all mental deficiency is hereditary but heredity accounts for more of the mild feeble-minded
00:41:52types these are children who are helpless in every way and need constant attention
00:41:59once such children have been born we must do the best we can for them but it would have been
00:42:04better
00:42:04by far for them and for the rest of the community if they had never been born
00:42:12well in the early years of the 20th century many intellectuals throughout the western world became
00:42:18enthusiastic exponents of these eugenic policies and although they were often vigorously opposed by
00:42:25politicians and scientists who suspected what this could lead to it was only under the auspices of
00:42:32nazism that the world was brought face to face with what would happen if these ideas were taken to
00:43:07their logical conclusion
00:43:07in 1946 not much more than a year after the allies had liberated the death camps of europe
00:43:17the american journalist albert deutsch undertook a nationwide investigation of american mental hospitals
00:43:26like the photographers who accompanied him on this dreadful odyssey deutsch was horrified to discover
00:43:32that the condition of the patients bore an unsettling resemblance to that of the survivors of belson buchenwald and dachau
00:43:43i entered buildings swarming with naked humans herded like cattle and treated with less concern
00:43:51i saw hundreds of patients living under leaking roofs surrounded by moldy decaying walls and sprawling on
00:43:58rotting floors on rotting floors for want of seats or benches many of the attendants i was told were vagrants
00:44:05recruited directly from courts and police stations where they were reportedly given the choice of a jail
00:44:11of a jail sentence or of going on the asylum payroll
00:44:25apart from the heart-rending spectacles themselves i think what disturbed deutsch as much as anything else
00:44:32was that whereas the conditions in the concentration camps were the expression of a deliberate policy to
00:44:39torment and exterminate the unwanted the atrocities which he witnessed in the american mental hospitals
00:44:45were quite unintentional far from being the expression of a policy they were the result of a conspicuous
00:44:51lack of policy made all the worst by political indifference and by an almost breathtaking economic
00:44:58stinginess on the part of those who were responsible for the welfare of the insane
00:45:02it was in deutsche's own words euthanasia by neglect well to be strictly fair the term euthanasia ought to be
00:45:12taken with a pinch of salt as there was no large-scale elimination of mental patients all the same there's
00:45:19no getting away from the fact that the rates of both morbidity and mortality were much higher than they
00:45:25should have been and that both of them were the result of neglect like the softly overgrown hummocks
00:45:33at auschwitz more than 40 years after the liberation the unalarming rusticity of this scene betrays almost no
00:45:41sign of the victims who lived and then died in these dreadful conditions but if you brush away the undergrowth
00:45:49here
00:45:50you soon become aware of the fact that you're standing here in a vast unmarked cemetery each of these
00:45:58numbered stakes represents a grave
00:46:08and if we go back to the hospital records it soon becomes apparent that in this hospital alone
00:46:13patients were dying at the rate of 10 a day now it's almost impossible to tell except by the number
00:46:19who
00:46:20this might be go back to the white males 394 it could have been someone called robert kebler
00:46:30look at colored males 394 and it could be moses smith and then we can go further and look at
00:46:39the colored
00:46:40females 394 it could be susan mckeastlin in fact we'll never know
00:46:49now as i say it would be both misleading and unjust to regard these deaths as an atrocity
00:46:57but there's no doubt that the lives of the victims were and it's quite hard to get one's mind around
00:47:03the idea that anyone let alone the afflicted should have had to endure such conditions especially in a
00:47:09country which prided itself on being the land of the free and the home of the brave
00:47:18in fact by the 1950s there were almost a million people incarcerated in asylums in the united states
00:47:31alone
00:47:32it's often been claimed that what reduced the asylum population from the 1950s onwards was the introduction
00:47:41of new treatments and indeed with the introduction of drugs such as chlorpromazine or thorazine there was
00:47:49yet another period of therapeutic optimism
00:47:55perhaps the most eloquent spokesman on behalf of this new optimism was the english psychiatrist william
00:48:01sergeant when i first walked into an asylum and had to work there i actually walked out i i just
00:48:06couldn't really bear it sergeant prophesied that organic medicine would eliminate insanity along with
00:48:12all the other scourges that had already yielded to drugs and surgery yes this is a lady with a six
00:48:18year history of abdominal pains and blackouts and um depression six years yes six years history and
00:48:25she's done very well with the combined drugs and five ect she's only been in just over a fortnight
00:48:29which is very much better indeed the point of these new treatments about which has been so much
00:48:33discussion is they've meant that these old asylum patients are now treated in general hospitals and you
00:48:42without these new treatments we we did have psychotherapy and psychoanalysis you know 30 years
00:48:46ago but we hadn't got these new treatments without these new treatments i think we would still be in
00:48:49the old mental hospital atmosphere this department here has 20 000 new and old attendances a year
00:48:57and i think that with the methods we've shown here if you really use them intensively you can treat the
00:49:02most acute schizophrenic the most severe depression in a general hospital atmosphere without any need for
00:49:08locked doors and and i i believe that we're just at the start of our revolution and that as i
00:49:15say
00:49:15eventually i hope in the next 20 years time the old mental hospitals will be things of the past
00:49:23as things turned out apart from the fact that the side effects of drugs threatened to create as many
00:49:30problems as they solved if one looks carefully at the timing of these events there's plenty of evidence
00:49:36to show that the process of decarceration was already recognizably underway
00:49:44well this can only mean that some other factor was at work and it's possible that this had something
00:49:50to do with a suspicion or a misgiving which had already been expressed by the english psychiatrist
00:49:57john connolly at the inception of the public asylum movement early in his career connolly had warned the
00:50:05profession that institutional confinement was a risky maneuver and that it might create as much
00:50:11insanity as it was intended to cure now for him this was nothing more than a prophetic intuition
00:50:18but in the 20th century sociological investigators such as irving goffman recognized that by assigning
00:50:25patients the role of lunatic launching them as it were on an irreversible career of lunacy the asylums were
00:50:33simply fulfilling their own expectations and thereby guaranteeing their own futility
00:50:40as it happens these convictions ran parallel to many other currents in favor of social liberty and
00:50:48liberal opinion at large identified a deep affinity between people who were imprisoned for insanity
00:50:54and other social groups whose freedom had been unfairly limited and that we are going to continue
00:51:02to stand up for what we know is right blacks and other minorities were not the only people who had
00:51:09their eyes
00:51:09on the prize throughout the 1960s and although the mad didn't have any charismatic spokesman amongst their own members
00:51:17men such as martin luther king who were able to convince their fellows that they had a dream
00:51:23there's no doubt that the spirit of civil rights in general had an important part to play
00:51:28but by the content of their character i have a dream
00:51:31it was all this as much as drugs that helped to alleviate the condition of the asylum inmate and
00:51:44put the asylum virtually on notice of dismissal and even if the institution was not exactly disestablished
00:51:51the conditions under which patients were now admitted and held were much stricter
00:51:59the irony is that the york retreat upon which so many of the subsequent institutions were modeled
00:52:05is one of the few which has remained an asylum in the best sense of the word
00:52:15but one is left with the suspicion that it has done so by continuing to limit its clientele
00:52:22not to the quakers for whom it was originally intended but to those who for one reason or another
00:52:27can afford the private fees
00:52:34however in hospitals that relied on public funds and which were therefore unable to resist the overcrowding
00:52:41that prevented them from fulfilling their early promise an exodus has already begun
00:52:50the inmates have increasingly in the somewhat euphemistic term used by the administrators
00:52:54been returned to the community
00:53:12it's almost 150 years since free and hospital was opened with all the high hopes that characterized an
00:53:20age that so often referred to itself as an era of improvement now as the 20th century draws to its
00:53:28close the function of such places no longer seems as clear as it must have done to its optimistic founders
00:53:36indeed it's quite hard to tell what somewhere like this should be for if anything the problem is that
00:53:43it's easy to read so many different arguments into a desolate spectacle like this
00:53:48the fact that the last patients moved out of this ward only a few weeks ago could be interpreted as
00:53:55yet another step towards the abolition of an institution that should never have existed in the first place
00:54:00and that its emptiness reflects the success of modern treatment and the realization that custody created
00:54:07as much mental disorder as it was intended to cure
00:54:13alternatively it could be seen as a catastrophe visited upon the insane by a society unwilling to bear
00:54:20the fiscal burdens which are necessary for the upkeep of such establishments
00:54:25because although the word asylum has acquired almost universally negative connotations
00:54:32there's no getting away from the fact that in spite of the advances in treatment there are still people
00:54:36for whom asylum spells refuge and sanctuary and many of the people who left here a few weeks ago
00:54:43would have very little chance of surviving in the outside world
00:54:53although the large public asylum has been tried and found wanting the liberty which is now inflicted on
00:55:00some of its former inmates is no solution either the homeless limbo into which so many ex-mental patients
00:55:10are now thrown is little more than a concrete version of the medieval heath upon which their predecessors are
00:55:17supposed to have roamed
00:55:50the
00:55:54the
00:55:56the
00:55:58the
00:55:58the
00:56:00the
00:56:00the
00:56:02the
00:56:03I reach for a star, good in my heart, good in my heart, but I only know here we are.
00:56:11Won't sing, won't sing, high in the clouds, drifting, dreaming, high in the clouds.
00:56:17So for a move, it must go away, while the world's through, it's still going away.
00:56:22And we go, won't sing, won't sing, just you and I, won't sing, you and I in the sky.
00:56:45The paradox is that in yielding to the unprecedented demand for patients' rights
00:56:51and to the strict statutory limitations under which people may be admitted and held against their will,
00:56:56asylums throughout the Western world have made an unintended contribution
00:57:00to the growing throngs of the homeless.
00:57:02And yet confronted by the unrestricted environment of the streets,
00:57:06it's hard to visualize it as a liberty.
00:57:10And for those who would be quite unable to survive such liberation,
00:57:13the comforts of custody seem almost self-evident.
00:57:20So what do you do now?
00:57:22No, you can take that.
00:57:24Can I do it?
00:57:24Yeah, I'll take it.
00:57:25Okay, get your finger out of the way.
00:57:27Okay.
00:57:27That's good.
00:57:28How's that?
00:57:28Is that good?
00:57:28I like that.
00:57:30These are folks who are still,
00:57:34symptomatology, their symptomatology still isn't really controlled.
00:57:38And the outlook is not particularly positive for most of them.
00:57:42And most of these couldn't live outside in the community?
00:57:44They haven't got families or they couldn't really survive?
00:57:47No, I wouldn't go so far as to say that.
00:57:50I think a number of them could make it
00:57:53if we can deal with some of the behaviors.
00:57:56I mean, the lady over there making the decorations that you see in the room,
00:58:01I mean, she'd be a delightful grandmother.
00:58:03You know, really.
00:58:10Now, in order to understand how things got to this point,
00:58:14you've really got to cast your mind back to the time when...
00:58:19Unless one makes the unlikely assumption
00:58:20that the incidence of mental illness has fallen dramatically,
00:58:24one can only conclude that the reduction in asylum population
00:58:28is the result of changing attitudes to how we care for the mad.
00:58:34Basically, you had the advent of the psychotropic penicillation.
00:58:38Yeah.
00:58:38That had such a significant impact.
00:58:41Then you add to that the fact that you have the advent of the civil rights legislation,
00:58:45which occurred under the Kennedy administration.
00:58:49And that legislation basically decreed that an individual has the right
00:58:54to be treated in the least restrictive environment.
00:58:58Now, by definition,
00:58:59inpatient hospitalization has to be the most restrictive environment.
00:59:03An individual is treated here,
00:59:06he's able to leave the hospital, he's discharged, okay?
00:59:09Well, in order to be readmitted,
00:59:11you've got to meet three critical criteria.
00:59:14If you don't meet all three,
00:59:15legally we're not permitted to admit you.
00:59:17The three criteria are,
00:59:18number one,
00:59:19you must be suffering from a mental illness
00:59:21as diagnosed by a physician.
00:59:23Number two,
00:59:24that illness must be sufficiently severe
00:59:26that treatment in a less restrictive environment
00:59:29is not appropriate,
00:59:31least restrictive environment notion.
00:59:33And third,
00:59:34the individual must be dangerous to himself or other.
00:59:37If you fail to meet those three criteria,
00:59:40we cannot legally admit you.
00:59:43So, in other words,
00:59:44the people on the streets
00:59:46are not necessarily a symptom
00:59:47of the heartlessness of a system
00:59:49which no longer cares for you.
00:59:51No, no, not at all.
00:59:51You're dealing with the notion
00:59:52of least restrictive environment.
00:59:56No, no, not at all.
00:59:57No, no.
01:00:08So,
01:00:10no, not at all.
01:00:27there's something uncanny and rather perplexing about a building as large and as empty as this
01:00:32one especially when it doesn't seem to be all that old just over a hundred years in fact
01:00:37and although it's a frightful mess now it doesn't seem to have been abandoned all that long
01:00:42it's not what you call a ruin certainly not an archaeological one so who is it meant for
01:00:47and where have they all gone and why
01:01:27well while it may not be such institutions were completely unimaginable that's to say
01:01:34when the fate of the insane was perhaps even more uncertain than it is now well as often happens
01:01:42it's Shakespeare who provides some interesting evidence about the image of insanity in the early
01:01:49modern era in his play King Lear Shakespeare shows us the tactics of a character Edgar who wishes to
01:01:58conceal his identity under the guise of madness my face I'll grime with filth blanket my loins elf all
01:02:07my hairs in knots and with presented nakedness out face the winds and persecutions of the sky
01:02:14the country gives me proven precedent of bedlam beggars who with roaring voices strike in their
01:02:21numbed and mortified bare arms pins wooden pricks nails sprigs of rosemary and with this horrible
01:02:28object from low farms poor pelting villages sheep coats and mills sometime with lunatic bands sometime
01:02:34with prayers enforce their charity poor telegard poor tom that's something yet Edgar I nothing am
01:02:50Edgar I nothing am in a play which is preoccupied with the themes of madness and loss
01:03:00Shakespeare constantly repeats the word nothing all that easy to tell from the inside I'm sure that
01:03:07if you could see the exterior of this building you'd recognize it at once as a lunatic asylum and although
01:03:14it's not serving that function now the memory of such places is still so vivid in the popular imagination
01:03:20we all know the names which express or perhaps conceal our fear it's a loony bin it's a crazy house
01:03:28a
01:03:29laughing academy a bug house or even a snake pit the paradox is that although such institutions still
01:03:39loom rather threateningly in the public imagination they're actually quite recent inventions and after a
01:03:47comparatively short existence they seem to be on their way out
01:04:05and yet you only have to walk a few yards down this abandoned corridor
01:04:09to find that that's not quite the whole story the custodial care of the insane is still a going concern
01:04:18here as in mental hospitals throughout the western world the resident population 600 is a small remnant of
01:04:26the 6,000 who once occupied these enormous premises the patients who remain are the survivors of a therapeutic
01:04:34regime which has somehow lost confidence in itself
01:04:37and
01:04:39you
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