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Book Forum: History of Psychiatry   |    
The Discovery of the Asylum: Social Order and Disorder in the New Republic (1971)
ROBERT O. PASNAU, M.D.
Am J Psychiatry 2003;160:1016-1016. doi:10.1176/appi.ajp.160.5.1016
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By David J. Rothman. New York, Walter de Gruyter, 2002, 380 pp., $18.95 (paper).

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This book is a classic, originally published in 1971. It was reprinted unchanged with a new introduction in 1990 and is now reprinted again without changes as a volume in a series titled New Lines in Criminology under the editorial direction of Thomas G. Blomberg. I remember reading the book in the 1970s as I was preparing my lectures in the history of psychiatry for residents. I recall admiring the excellent historical scholarship and dismissing the underlying sociological premise as justifying what I felt was the antipsychiatric bias of the author. It was the 1970s, after all, and attacks on involuntary psychiatric hospitalization and the legal advocacy of patients’ rights were the popular rhetoric of the day. What a surprise to find that I like the book a great deal more 30 years later, and that I find myself agreeing with many of his conclusions. I also believe that I understand why it was not reviewed in the American Journal of Psychiatry before this time.

In Rothman’s view, the sociological category "asylum" includes penitentiaries, mental hospitals, orphanages, reform schools, and all other institutions that exist to imprison those deemed deviant and/or dependent as a means of social control. David Rothman, who is now Bernard Schoenberg Professor of Social Medicine, Director of the Center for the Study of Society and Medicine, and Professor of History at Columbia University, is the author of many books on medical ethics and human rights. In the foreword to the 1990 reprint, he noted the controversy he had generated 20 years earlier when he introduced some of the first historical literature on the subject:

Now, however, historians were making the history of the asylum something other than the history of generous philanthropy and, by implication, were raising the question of whether those who now administered and defended the asylum should be ranked among the benevolent and reform-minded. Thus, mental health professionals and their allies (more so than wardens or welfare workers) took as an affront and personal challenge what I wrote in the original introduction to this volume. By describing the innovation as a reform,…[historians] assume that the asylum was an inevitable and sure step in the progress of humanity. It was exactly the type of device that well-meaning and wise citizens should have supposed. But such a perspective is bad logic and bad history. Was an organization that would eventually turn into a snake pit a necessary step forward for mankind?

In this relatively compact volume, with extensive references and sources at the end, Rothman reveals great skill in painting the broad picture of the colonial society in which the concepts of punishment and isolation developed. He discusses charity, correction, insanity, and social order in the 18th century, including the invention of the penitentiary, the almshouse, and the orphan asylum. He notes the contributions of the founders of the Association of Medical Superintendents of American Institutions for the Insane, now APA, especially Isaac Ray. He acknowledges the role of Dorothea Dix. However, he continues to refer to the mentally ill as the "deviant and the dependent" and disparages the role of the psychiatrist as the depriver of human rights. In my view, he also dismisses the role that many psychiatrists have had over the years in fighting against the injustices and mistreatment. In the 1970s, however, there were too many who promised too much from our profession and our treatments. It is easier to read this book now, when the role of psychiatric hospitalization is more limited and we have more effective treatments. As the author admits in his final paragraph,

The history of the discovery of the asylum is not without a degree of relevance that may be more liberating than stifling for us. We still live with many of these institutions, accepting their presence as inevitable. Despite a personal revulsion, we think of them as always having been with us, and therefore as always to be with us. We tend to forget that they were the invention of one generation to serve very special needs, not the only possible reaction to social problems. We need not remain trapped in inherited answers. An awareness of the causes and implication of past choices should encourage us to a greater experimentation with our own solutions.

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