A new Wellcome Collection exhibition, Bedlam: the asylum and beyond, which I co-curated with Bárbara Rodriguez Muñoz, uses the story of Royal Bethlem hospital to trace the rise and fall of the mental asylum. Although the asylum’s era of mass confinement has been consigned to history, the ideas that animated it still shape the mental health landscape. And some of its long-forgotten aspirations are now being reclaimed to imagine and create new approaches to mental healthcare.
Bethlem hospital – known for centuries in popular slang as Bedlam – has occupied three different sites over the last three centuries. Each illuminates the attitudes to mental health of its day. During the 18th century it was a grand edifice in Moorfields, north of the City of London, whose baroque façade concealed the bleak galleries in which patients were confined. This contrast expressed the dual function of the “madhouse”, as it was then known: a worthy charitable initiative for the benefit of those who would otherwise be on the streets, but also keeping them securely segregated from the population at large.
In 1815 Bethlem relocated south of the Thames to the building in Southwark that now houses the Imperial War Museum. The ambitions of the 19th-century asylum were far greater than its predecessor’s. They were formed by inspiring examples such as the Retreat at York where the local Quaker community cared for their mentally unwell members in spacious, comfortable surroundings more like a home than a prison. The asylum became an emblem of social progress: a therapeutic community in which patients were to be treated with kindness, healed and reintegrated into society. But recovery rates remained stubbornly low, and as the century progressed the asylums filled and overflowed. Care was stretched thin and their humane intentions were lost in the crowded wards, where ever more patients were “put away” for life.
In 1930 Bethlem moved once more, to its current site: a villa complex in Beckenham, in what was then London’s leafy fringes. That year the Mental Treatment Act officially replaced the term “asylum” with “mental hospital” and reconceived insanity as mental disease, to be treated with the latest developments in medical science. Yet despite their early therapeutic optimism, the mental hospitals filled up just as the asylums had, and for similar reasons. By the 1980s they were being closed at an astonishing rate, replaced wherever possible with medication-led treatments and “care in the community”.
Each incarnation of the asylum failed to live up to its early promise, yet each lives on in the post-asylum world. The need for custodial and residential institutions has not gone away, and the biomedical approach developed in mental hospitals remains the primary focus of clinical treatment.
Over the past half century, however, attitudes to mental health have shifted once more. In the wake of the asylum, mental ill-health is no longer seen as something that can be segregated from society, but something that affects us all. With a growing tolerance to mental diversity, some of the more far-reaching dreams of the asylum are being reimagined. Throughout its history, progressive voices observed that the potential of patients living together to help one another was rarely tapped and often actively suppressed. Under some enlightened regimes they were encouraged to manage their own affairs: staffing the sickrooms, growing their own food and organising creative activities.
Could the asylum be reconceived entirely as a grassroots project, not controlled from the top down but evolved from the ground up? This is the premise of MadLove, a crowdsourced “designer asylum” whose latest iteration concludes the Wellcome exhibition. Over several years the collective has enlisted more than 400 service users in designing “a desirable and playful space to ‘go mad’”, in which mental difference is welcomed and mutual care allowed to blossom. MadLove is unashamedly utopian in scope, but it’s now been workshopped in Broadmoor as well as cultural venues, received awards from Design in Mental Health as well as the Arts Council, and is engaging closely with psychiatrists and hospital architects.
Comparable patient initiatives are starting to fill the social spaces vacated by shrinking mental health services. Re:Create Psychiatry is one such project where clinicians and patients explore new directions for therapy together. It’s one of many offshoots of the Dragon Cafe, a weekly event in Southwark, run by service users and open to all. Every Monday its members gather for debates, therapy, food and entertainment, and for a few hours the original vision of the asylum – a place of sanctuary, a world outside the world – materialises in the crowded City district where old Bedlam once stood.