Mike Jay, This Way Madness Lies: The Asylum and Beyond (London: Thames and Hudson, 2016), pp. 255, £24.95, hardback, ISBN: 978-0-500-51897-7.

The Wellcome Collection’s current exhibition Bedlam: The Asylum and Beyond, examines the institutional treatment of mentally ill people in Western culture, taking the metaphor of the asylum as its central motif. The asylum is all but synonymous with Bethlem Royal Hospital, colloquially known as ‘Bedlam’, the first institution devoted to the treatment of those suffering from mental illness. Bedlam, in both its literal and metaphorical manifestations, functions as the contextual backbone of the exhibition. Its changing material and spatial dimensions (the hospital has occupied four different sites over the course of its history, and still provides mental health care today) are represented though a range of architectural imagery. These reflect shifts in the institution’s function, which in turn mirror changing attitudes towards the understanding, care and treatment of mentally unwell people within a broader cultural and historical context.

The vagrancy acts of the eighteenth century formalised the institutionalisation of people deemed ‘insane’ for the first time. Indeed, the primary role of the asylum was to manage and contain the troublesome presence of mentally unwell people in the interests of maintaining civic order. As historical documents testify, these inmates were often subjected to various forms of inhumane treatment. Remedies for mental illness were restricted to purging and bloodletting, and patients were often physically restrained with a range of instruments such as wrist chains and collars. One image on display in the exhibition depicts an individual by the name of James Norris who had been shackled to the wall for ten years.

Over the course of the seventeenth and eighteenth century Bedlam became infamous as the quintessential ‘madhouse’, and took hold within the contemporary cultural imagination as the locus of intense fear and fascination. This is borne out by numerous artistic and literary representations of the period, which depict Bedlam as a vision of hell on earth, including an engraving of William Hogarth’s ‘A Scene in Bedlam’ from The Rake’s Progress. The hospital was also regularly open to the public who would queue up to ogle at the inmates, and situations of mutual provocation were not uncommon.

The ‘madman’, as a figure subjected to institutional control and repression, forms the basis of Michel Foucault’s 1961 critique of the asylum in Madness and Civilisation, and it is an enduring image that remains largely prevalent today. While this is, for the most part, entirely justified, the exhibition also provides a space for an alternative perspective in which the asylum is seen as a place of care and protection, a function closer to the etymological origins of the term; in Latin asylum means place of refuge. The metaphorical complexities and contradictions of the asylum are brought to the fore in the work of contemporary artist Jane Fradgley who has photographed the straightjackets and clothing worn by Bedlam inpatients (some of which bear the name of the hospital sewn in red thread). Her starkly lit images, provided with evocative titles such as Cocoon and Within, imply how these garments of restraint might also be seen as a form of protection (however crude) – mentally unwell people in times of crisis often pose a significant threat to themselves in terms of self-harm.

The second part of the exhibition charts the changes in psychiatric provision that took place over the course of the latter part of the nineteenth century, a period when more humane models of care were inaugurated. A pioneer in this respect was the Retreat, a facility in York set up by the Quakers. The use of physical restraints here was minimised, and the emphasis shifted towards engaging patients in productive forms of activity within the context of pleasurable outdoor surroundings. One of the most poignant images in the exhibition is by George Isaac Sidebottom, a long-term inpatient at the Retreat. His modestly sized oil on canvas depicts a group of smartly dressed male and female figures engaged in a variety of gentle exercises including croquet, tennis and cycling. Only the presence of a bed in the midst of the lawn indicates that this is not a picturesque depiction of weekend leisure on an upper-class country estate.

This painting is one of numerous examples of ‘patient art’ dispersed throughout the exhibition, ranging from poems and drawings produced in Bethlem’s own publication Under the Dome, nineteenth-century embroidery, a drawing made with charred matchsticks on rough institutional lavatory paper and the work of ‘Mr X’, a current Bethlem inpatient who makes mobile vehicles from cardboard boxes and drives them around the hospital grounds. Also on show is a short film about Edward Adamson, who set up an artist’s studio at a psychiatric hospital in Surrey after the Second World War and encouraged patients to use art as a therapeutic tool to explore the impact of their illness and articulate their personal experiences of institutionalisation. These works have been marginalised by conventional art historical narratives and remain for the most part in archives. The Wellcome exhibition provides a unique opportunity for these works to be seen by a wide audience, thereby giving a degree of visibility to the unseen and unheard histories of individuals suffering from mental illness whose voices have so often been silenced.

The accompanying publication to the Wellcome exhibition is entitled This Way Madness Lies by Mike Jay, who also acted as the show’s guest curator. The book traces the evolution of understandings of mental illness in Western culture though an analysis of the institutions in which the treatment and care of such patients took place, and is therefore based on a very similar premise to the exhibition. The book is meticulously researched and also provides an astute critical commentary on the various treatments to which mentally ill people have been subjected over the centuries. The language is scholarly, appealing to a specialised historical or medical audience, but written in a style that is accessible enough not to alienate the interested general reader. The book is beautifully designed and contains a wealth of fascinating imagery from a range of archives, serving to animate Jay’s lively commentary even further.

Of course, the book is able to present a more nuanced argument than the exhibition. This is most clear in the sections dealing with the transformations in understandings of psychiatric illness and approaches to treatment that have taken place from the twentieth century to the present. These include medical interventions such as ECT, the advent of pharmacological treatments and the anti-psychiatry movement. Granted, it is extremely difficult to convey the complexities of this discourse in an exhibition appealing primarily to the visual, without being overly didactic and risk losing the viewer’s interest and attention. Many of the objects on display here are reproduced in the book. But while they are here embedded within a detailed historical analysis, objects such as a bottle of Largactil syrup (the first mass market anti-psychotic drug) and ground-breaking texts such as R.D. Laing’s The Divided Self (1960) need to be situated within a more meaningful context than the exhibition provides.

The final part of the exhibition is, I would argue, the least successful element of the show. The text introducing this display states that today’s post-asylum world represents ‘a chaotic marketplace of therapies’. This is certainly how modern mental health care is represented in the mishmash of objects on display, but it is very far from psychiatric provision in the NHS today which, although underfunded, is based on NICE guidelines, themselves founded on a secure evidence base and the product of rigorous research and discussion by highly qualified health professionals. As well as pharmacological therapy, there are a range of services that people with a mental health condition may access including specialised outpatient clinics, home treatment and crisis intervention teams (designed to avoid hospital admission wherever possible) as well as psychological therapies, addiction support, mindfulness-based cognitive therapy and referrals for social support. A few out-dated leaflets on ‘alternative therapies’ displayed in a glass case do not do justice to modern mental health care today, and to imply that that service provision in this area is a chaotic medical marketplace is extremely misleading to say the least.

This is a shame as overall the exhibition is informative, well curated, and demonstrates how understandings of mental illness have changed over the centuries, from a time when afflicted people were thought to be possessed by demons, or suffering from an imbalance of humours, to the contemporary understanding of psychiatric illness according to a ‘biopsychosocial’ model, in which the individual and his or her disease are understood as the product of a complex interplay between these various factors.

The exhibition and book both close with the theme ‘Beyond the Asylum’, a concept with which the spectator is also invited to engage by designing their own ‘ideal’ asylum. Also included here are a series of haunting photographic images entitled Faces of Geel by the Belgian photographer Hugo Minnen. Since the Middle Ages the city of Geel in Belgium has looked after mentally unwell people according to an integrated model of care where they live with local families and participate in the life and work of the community. Throughout the book and exhibition Geel runs as a counter-narrative to the institutional model of care epitomised by Beldam and is offered here as a possible way forwards for future models of psychiatric care.