The Royal College of Psychiatrists was founded in 1971 and is responsible for training and supporting psychiatrists throughout their careers. It sets and monitors the examinations to become members of the college and without this qualification it would be very unusual for any doctor to be employed by the NHS as a psychiatrist. The college is responsible for setting and raising standards of clinical practice. They also work with patients, carers and other organisations to deliver high quality services.
The college produces a large number of patient leaflets, podcasts and even runs its own YouTube channel to produce high quality accurate information for the public about mental health. The college also produces and reviews a large number of research papers ranging from the use of corporal punishment for children to attempts to define safe drinking limits for alcohol.
One might wonder why a Royal College was only established in 1971 when ‘madness’ has been part of the human condition for millennia. Before the 19th century the treatment of the mad did not constitute a specialised branch of medicine. General physicians would handle the mad as part of their general caseload and a few gained a reputation for expertise. Francis Willis was called upon the treat George III in 1788 when the court physicians failed to cure him. Willis was also a clergyman. But unlike other medical conditions it was the community who decided who was mentally unwell and the community that ordered treatment. Mad people were a family responsibility, failing that the parish would provide a carer or the patient would be put in safe keeping in jails, religious institutions or private madhouses. Most madhouses, of which Bedlam was an example, were not medical institutions and had their origins as religious or charitable organisations. Theories of mental illness began to change in the latter part of the 18th century. Ideas of possession by devils and moral failing began to be replaced with ideas about the human mind from the developing science of neurology and ideas from the Scottish and French Renaissance philosophers. Physical treatments such as beating, purging and bloodletting were replaced with ideas of moral management. Patients were treated like children or in very quiet calm self sustaining communities. The York Quakers led by William Tuke, a tea merchant, founded the York Retreat where patients led a simple structured life with plenty of walking, fresh air and kindness. Unfortunately many madhouses were awful places of filth and cruelty able to flourish without regulation or supervision.
Concern for the well being of those suffering from mental illness gradually increased and was particularly embraced in the charitable social and political policy of the Victorians. County asylums were the recommendation of a House of Commons select committee, which had been set up in 1807 to ‘enquire into the state of lunatics’. Legislation in support of the establishment of asylums followed, including Wynn’s Act of 1808 ‘for the better care and maintenance of lunatics, being paupers or criminals’ and the Shaftesbury Acts of 1845 ‘for the regulation of the care and treatment of lunatics’. The Association of Medical Officers of Asylums was founded in 1841 and there was increasing acceptance that doctors had a role in diagnosis and treatment of mental illness. Doctors also had a role in the criminal justice system. In 1799 the trial of James Haslam was halted by the judge when he ruled that his attempt to shoot George III was due to a delusion and a verdict of ‘not guilty by insanity’ was given. Trying to differentiate the ‘bad from the mad’ remains an important part of many trials.
Most asylums were built on the outskirts of major cities, in order to provide a rural retreat for patients. Most operated as self-sufficient communities with their own water supplies, farms, laundries and factories. They were therefore isolated from the local community and psychiatrists working with them were isolated from their colleagues in other medical specialties. Admission to an asylum could be abused by husbands or other family members to exploit their relatives financially (forms an essential part of the plot of the Wilkie Collin’s novel ‘The Woman in White’. The early asylums made no differentiation between mental handicap and acquired mental illness. The Lunacy Act of 1890 set the parameters for admission, providing a legal system in which a patient had to be certified as insane in order to be admitted to the asylum. Under the Act, asylums became ‘a last resort for the insane rather than a means to their recovery’.3 No psychiatric opinion was sought prior to admission. The parish doctor declared patients insane and they were then placed on a compulsory reception order by a local magistrate and taken to the asylum
These differences in admission criteria contributed to an exponential rise in the asylum population. The rising population was due to a number of factors including the admission of many severely disabled patients who could never be discharged. There were also a large number of poorly understood and untreatable conditions presenting with psychiatric symptoms such as metabolic disorders, lead poisoning, syphilis and intracranial tumours. Once admitted to the asylum, medical officers’ duties included classifying patients as ‘curable’ or ‘incurable’ according to the duration of their illness and the presence of complications such as epilepsy and paralysis.2
In order to address the ever increasing asylum population, the Mental Treatment Act of 1930 extended the voluntary admission procedure to asylums, which encouraged them to establish outpatient departments ‘for the examination of applicants as to their fitness for reception as voluntary patients into asylums’. In 1925, there were 25 psychiatric outpatient departments in the UK and by 1935; this figure had increased to 162. These clinics were the origins of community psychiatric services.
By the 1970s the old asylums were underfunded, rundown and out of tune with modern treatments. In the 1950s effective drugs for the treatment of schizophrenia transformed life for many patients.
Modern psychiatry perhaps more than any other speciality continues to generate controversy. New illnesses such as ‘conduct disorder’ social phobia’ and various new addictions continue to spark heated debate. The rights of the mentally ill and the general population are often perceived as being in conflict and an often fierce debate about medication versus talking therapies never goes away.
The Greatest benefit to Mankind by Roy Porter 1999, Mind-Forged Manacles by Roy Porter 1987, https://doi.org/10.1093/bmb/ldl017
From the asylum to community care: learning from experience by Helen Killaspy,