This Way Madness Lies review from Bedlam to ECT, the story of psychiatry

Mike Jay’s beautifully designed book is a fascinating tour d’horizon of the treatment – and mistreatment – of mentally ill people, seen mostly through the lens of London’s Bethlem royal hospital. Founded in 1247 and now merged with the much younger Maudsley, this ancient institution has been by turns the archetypal “madhouse”, an asylum and a mental hospital. Along the way, “Bedlam”, as it was once widely known, has often promised more than it could deliver. In 1676, when the hospital moved from its original overcrowded and unsanitary site in Bishopsgate to nearby Moorfields, Robert Hooke’s grand new building turned out to have no foundations, while the elegant baroque facade was in fact a sham. The symbolism was clear: here, as Jay puts it, was “a facade of care concealing a black hole of neglect”.

Fittingly, This Way Madness Lies is rich with architectural metaphors. Writing about the infamous public visits that led to the creation of a tourist trail (surgery and autopsies were also on offer), Jay describes the building as “the perfect proscenium for the continuous drama that played inside”. Later, he says, the “warehousing” of the old asylums was replaced by the “revolving door”, when the 1980s ushered in “care in the community”.

Published to accompany the Wellcome Collection exhibition Bedlam: The Asylum and Beyond, the book is packed with telling details and fascinating anecdotes. A visit to a pig abattoir in Rome supposedly inspired the Italian neurologist Ugo Cerletti to develop what is now known as electroconvulsive therapy (ECT), in which a high-voltage current induces epileptic seizures. Though Jay refers to the misleading scene in One Flew Over the Cuckoo’s Nest (1975) in which “troublemaker” Randle McMurphy has ECT without anaesthetics or muscle relaxants (the practice, as Jay notes, had been abandoned in the 50s), he doesn’t take the opportunity to correct the still widely held belief that ECT is a brutal and ineffective treatment. While not risk-free (it has about the same probability of death as general anaesthetic), it can in fact be helpful as a treatment for severe depression, albeit usually as a last resort.

Jay also repeats the persistent myth that in the 50s, Walter Freeman – who charged $25 to perform frontal lobotomies using an ice pick under the eyelid – called the van in which he toured the mental hospitals of the US his “lobotomobile”, this being in fact a retrospective label used by others.

In the 50s, hopes for a “penicillin of the mind” were finally realised with the development of drugs to treat depression, mania and psychosis such as chlorpromazine and imipramine. “The long-promised medical breakthrough had arrived,” writes Jay, “but it made mental hospital wards uncomfortably reminiscent of the old asylums”, with patients becoming withdrawn and passive (and easy to control once more).

It’s not just the structures of mental health that reveal attitudes, but the language too. In 1930 the term “asylum” was legally replaced in Britain by “mental hospital”. Shell shock became combat stress, which in turn became post-traumatic stress disorder.

Jay doesn’t confine his history of mental healthcare to the UK, but looks at the US and the rest of Europe for alternatives – especially Geel in Belgium, which has been a beacon of best practice for genuine care in the community for over a hundred years, with the mentally ill seen as guests or boarders, and living with local families.

Jay offers a strong critique of the asylum system, drawing on Erving Goffman’s study Asylums (1961), which painted a picture of “total institutions” isolated from the world and run for the benefit of staff rather than patients. However, he is just as critical of the opposite approach. For example, for all its noble aims, RD Laing’s 1965-70 experimental community of Kingsley Hall in east London was “hugely successful as public theatre” but less so as therapy – in some ways bringing us back to the spectacle of Bedlam.

The book does much to counter the stigma of mental illness by humanising the patients, and denouncing the lurid media coverage focused on exceptional stories of violent acts perpetrated by mentally ill people. As Jay notes, those with mental health problems are far more likely to be the victims of violence than to be violent themselves.

The most pressing issue in This Way Madness Lies, however, is whether the original ideal of the asylum (Latin for “sanctuary”) could or should be recovered. Are the mentally ill to be placed in safe havens away from society or integrated within it? With one in four of us experiencing some form of mental illness in our lifetime, and the growing incidence of dementia, it’s a question that demands closer attention.

To order This Way Madness Lies for £20.46 (RRP £24.95) go to bookshop.theguardian.com or call 0330 333 6846. Free UK p&p over £10, online orders only. Phone orders min p&p of £1.99.

ncG1vNJzZmivp6x7tbTEoKyaqpSerq96wqikaJqfpLi0e5FpaG9nnqTDcH2QaKuhoaNixKLFjKaYnaaVqMBuuMieqmalmaCybrbAsmSrnaaesrh5wKywpa2d