Thursday, January 1, 2009

Review: Nancy Tomes, A Generous Confidence: Thomas Story Kirkbride and the Art of Asylum-Keeping, 1840-1883

Writing about the history of psychiatry has often resembled a battle of ideologies. While early historians of the field were content to trace the advance of science and civilization in the treatment of the menally ill, revisionists, who have seen psychiatry as a nexus of social, political and economic issues, attempted to turn these earlier ' whig' interpretations on their head. Michel Foucault, perhaps the most prominent revisionist, candidly expressed his motives for entering into the fray: For me, it was a matter of this: if, concerning a science like theoretical physics or organic chemistry one poses the problem of its relations with the political and economic structures of society, isn't one posing an excessively complicated question" Doesn't it set the threshold of possible explanations impossimbly high? But on the
other hand, if one takes a form of knowledge [savoir] like psychiatry, won't the
question be much easier to relolve, since the epistemological profile of psychiatry
is a low one and psychiatric practice is inked with a whole range of institutions,
economic requirements and political issues of social regulation? Couldn't the
interweaving of the effects of poewr and knowledge be grasped with greater certainty
in the case of a science as 'dubious' as psychiatry.* Animated by views such as this, revisionists fashioned an image of psychiatry which focused on the relationship of psychiatry to society-at-large and emphasized its social control functions over its therapeutic pretentions.
At one time, anyone attempting to write about the history of psychiatry was tempted to be drawn into the battle between the whigs and the revisionists. As Nancy Tomes wisely noted at the beginning of her book, however, both of these views tend to reduce psychiatry to one sterotype or another. What was missing from both whig and revisionist interpretations was a careful study of the daily practice of psychiatry and not simply what the published record showed that psychiatrists and others may have said. It was precisely Professor Tomes' intellient effort to look at the daily life of psychiatrists and patients at the Pennsylvania Hospital for the Insane during the nineteenth century that made A Generous Confidence one of the most enriching works in the history of psychiatry at the time it was published. Many books have since been published in a similar spirit, but Tomes' book was certainly one of those that pointed the way.
By taking a close look at the life of Thomas Story Kirkbride, who was the superintendent of the Pennsylvania Hospital for the Insane from its founding in 1841 until his death in 1883, she was able to open a window on the treatment of the mentally ill which made simple stereotypes more difficult to maintain. In doing this she was fortunate that the records of the hospital were unusually well preserved, but her resourcefulness in using these records cannot be overstated.
We are also fortunate that in choosing to write about Kirkbride, Tomes selected one of the most influential American psychiatrists of the period. This choice allows a study of one man and his institution to reflect, quite convincingly, the rise and decline of asylum treatment of the insane. In addition to managing his asylum, Kirkbride was also a founder and leading member of the Association of American Superintendents of Asylums for the Insane [the forerunner of the American Psychiatric Association]. His writings about asylum architecture were highly influential in an ear that took the moral influences of asylum design very seriously. His biography is also of interest because, as a leading advocate of 'moral treatment' who remained professionally active into the 1880s, he lived to see and struggle against the severe criticism which this treatment received in the 1870s. Because of Tomes' approach, however, the reader is not only able to form a picture of the controversies which swirled around asylum practice but also of tensions within the asylum. Especially interesting are her discussions of the various ways patients resisted Kirkbride's efforts and her portrayals of particular patients such as Wiley Williams, who shot kirkbride in the head, and Ebenezer Haskell, who made a cause celebre of his contention that he had been unjustly committed.
Perhaps the most interesting feature of this book is Tomes'' discussion of Kirkbride's efforts to 'cultivate his patron's generous confidence' in asylum treatment. Arguing that the rise of the asylum corresponded with changes in families' willingness and ability to care for disturbed members, Tomes overcomes the dichotomy between views of the asylum as merely controlling disturbed members of society or simply providing care for patients. Families wanted both control and care for their relatives and Kirkbride attempted to convince them, in both his rhetoric and his practice, that his institution would provide them with what they wanted. Particularly illuminating in this regard is Tomes' discussion of Kirkbride's preoccupation with architectural details. while previous historians wrote off such preoccupations as reflecting merely managerial concerns, Tomes shows, quite convincingly, that Kirkbride was able to use his descriptions of thephysical structure of the asylum to convince families that it was an institution that they could trust. Through her use of asylum records and letters, she is also able to show that Kirkbride's practice was often quite effective in restoring patients to health. Tomes' ability to convey how it was that moral treatment healed is a particularly rewarding feature of this book.
Well indexed and annotated and complete with helpful photographs and an appendix with a statistical profile of the asylum, this is an eminently readable book. More than that it is a book which has been important in helping us transcend earlier battle lines and arrive at a more accurate picture of asylum treatment in the nineteenth century.
This is a revision of a review originally written in 1985. Edward M. Brown *Michel Foucault, Power/knowledge: Selected Interviews and other Writings 1972-1977,
edited by Colin Gordon [New York, 1980, p 108

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