How did mental health become so biomedical? The progressive erosion of social determinants in historical psychiatric admission registers

Abstract

This paper explores the historical developments of admission registers of psychiatric asylums and hospitals in England and Wales between 1845 and 1950, with illustrative examples (principally from the archives of the Rainhill Asylum, UK). Standardized admission registers have been mandatory elements of the mental health legislative framework since 1845, and procedural changes illustrate the development from what, today, we would characterize as a predominantly psychosocial understanding of mental health problems towards primarily biomedical explanations. Over time, emphasis shifts from the social determinants of admission to an asylum to the diagnosis of an illness requiring treatment in hospital. We discuss the implications of this progressive historical diminution of the social determinants of mental health for current debates in mental health care.

‘Picture imperfect’: the motives and uses of patient photography in the asylum

“…In fact, the findings of this paper parallel the findings of Handerer et al (2020), who explore the historical development of admission registers of asylums and point out how the 1845 reform focused on social circumstances, permitting empathy and a better consideration of the impact of life events on a person’s mental health – only to be progressively replaced by a biomedical focus. Similarly, the findings from the current study illustrate a change from a psychosocial understanding of mental health problems to primarily biological and genetic explanations.…”

“…Arguably, the most important provision of the 1845 Lunacy Act was the change in the status of people with mental health problems from lunatics to patients; this was a triumph of humanitarian reform that allied lay reformers with medical professionals, and resulted in a mass construction of lunatic asylums under the control of Medical Superintendents (Takabayashi, 2017). One detail of interest to historians was that it was now compulsory for all English asylums to keep a casebook containing notes about the individual patients (Handerer, Kinderman, Timmermann and Tai, 2020). In the following years, notes and comments focusing on the social circumstances in which an individual developed mental health problems (the 'causes' of insanity), emphasising psychosocial phenomena, were prominent in the casebooks (Handerer et al, 2020).…”

“…One detail of interest to historians was that it was now compulsory for all English asylums to keep a casebook containing notes about the individual patients (Handerer, Kinderman, Timmermann and Tai, 2020). In the following years, notes and comments focusing on the social circumstances in which an individual developed mental health problems (the 'causes' of insanity), emphasising psychosocial phenomena, were prominent in the casebooks (Handerer et al, 2020). Nothing in the legal reforms of 1845 discussed the practice of photographing patients in the asylums.…”

“…Patient photographs are first-hand sources of important historical materials that may be used to contextualise medical and social approaches to health care in contemporary society. For instance, this has been done with psychiatric admission registers from the same historical period, illustrating a shift from a predominantly psychosocial understanding of mental health problems towards primarily biomedical understandings (Handerer et al, 2020). Therefore, it is notable that so little research has explored the history and development of the patient photography practice.…”

“…They were usually close-ups, thus keeping the focus of the image on the diseased 'part or symptoms', which was visually isolated from the rest of the patient's body (see Figure 3). In fact, this period saw an increasing use of photographs in textbooks (Handerer et al, 2020).…”