For centuries, societies have struggled to define mental illness, discover its causes and decide how best to address the needs of those who suffer from it. 

Definitions of mental illness historically have been based on what the majority considers acceptable behavior, with little tolerance for individual differences. Behavior thought to evidence mental illness in one era or society might be ignored or even considered normal in another time or place. Even in the early 21st century, definitions of mental illness remain unsettled. The American Psychiatric Association has just published the fifth — and surely not the last — edition of its Diagnostic and Statistical Manual of Mental Disorders. 

Theories of the causation of mental illness have included visitations of the gods, demons, witchcraft, brain injury, infectious diseases, unconscious responses to early life experiences, abnormal brain anatomy and physiology, and more recently, genetics. The current view of mental illness is trending toward epigenetics: the idea that behavior is shaped by a combination of inborn genetic propensities that get expressed as various mental illnesses when triggered by exposure to physical and emotional factors.  Yet although scientists and physicians firmly assert that mental illness represents actual pathological conditions, some still regard such illness as a matter of personal choice, something that people can “snap out of.”

As science has tried to define mental illness and determine its causes, society has faced the problem of what to do with people who suffer from these conditions. When should people exhibiting abnormal behavior be forced into treatment or confined against their will? Approaches have cycled between intervening when a person is in need of treatment (the parens patriae approach) or only when the person poses a risk of serious harm to him- or herself or others (the police powers approach).  

Interventions have included banishment, relegation to family care, long-term institutionalization, alternations between outpatient care and hospitalizations in public or private facilities, or simply allowing the mentally ill to live autonomously, fending for themselves except in the most extreme circumstances. In short, policies toward the mentally ill have ranged from abuse and neglect to extreme paternalism, and all points in between. At the heart of many of these approaches has been the stigmatization of the mentally ill and the distress that their behavior causes to families and society at large.

Sarah Wise’s Inconvenient People is a well written, carefully researched account of 19th-century England’s struggles to define, determine the causes of and treat mental illness.  It describes a complex mental-health system that included an array of confinement options, from single-patient care and private hospitals to large public asylums and hospitals for “criminal lunatics”— those who had been found not guilty by reason of mental illness.  

Wise does not focus on the notorious large mental institutions of the time, such as the Royal Bethlehem Hospital, known as Bedlam, where patients who had been adjudicated mentally ill and dangerous were confined. Rather, she painstakingly documents a system that included multiple categories of care based on wealth and class. Single-patient care in unlicensed private homes was available to the wealthiest patients. “Chancery lunatics” were private patients with sufficient funds to be housed in private asylums, having been deemed unable to care for themselves or manage their property and certified by the Masters in Lunacy, with control of their property given to relatives. The system provided many opportunities to abuse patients, large profits for private asylums and the alienists who ran them, and unnecessary confinement of individuals who were eccentric but whose family members wanted them out of the way, sometimes as a convenient excuse to seize their assets.  

Wise reveals that, contrary to popular notions, wealthier patients of higher social ranking, and men more than women, were more likely to be abducted and confined unnecessarily, because others would benefit. No one had anything to gain by illegally confining poor people or women, the first because they had no assets and the second because their assets were already controlled by husbands or other male family members.

Wise enlivens this lengthy work with case examples of abuse and detention, political and family intrigue, popular outcries against the treatment of certain patients and the movement to prevent unnecessary confinements. Famous Englishmen including Charles Dickens and John Stuart Mill make appearances, as Wise describes a society struggling with competing notions of class, proper behavior, autonomy and fair play. Starting with the story of Edward Davies, an eccentric tea merchant whose mother had him certified in order to take over his business, Wise dramatizes the abuses of the system, particularly the misdeeds of prominent alienists of the time. She includes the saga of John Perceval, whose mental illness developed after the assassination of his father, Prime Minister Spencer Perceval. There is no doubt that John Perceval was mentally ill. Wise notes his relapses over the years, but also points out the horrific nature of his confinement and his struggles for release. Perceval went on to found the Alleged Lunatics’ Friends Society and to push for reform. 

Inconvenient People is more than a history of psychiatry in the Victorian Age. It is a chronicle of the social institutions and emerging forces of individual freedom over the course of the 19th century. It contains important lessons for those who seek to understand where we have been and where we are going in the effort to balance personal autonomy with society’s obligations to help those who cannot help themselves protect the public — in other words, for all of us. 

Ronald Schouten is a clinical and forensic psychiatrist. He is an associate professor of psychiatry at Harvard Medical School, director of the Law & Psychiatry Service at Massachusetts General Hospital and co-author of Almost a Psychopath: Do I (or Does Someone I Know) Have a Problem with Manipulation and Lack of Empathy? (Hazelden 2012).

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