The muffled voices of the insane child – tracing the small voices of early child and adolescent psychiatry
Trine Elisabeth Møbius Sørensen, Aarhus University
1 Introduction: What ever happened to the child Psychiatric Patient?
“Almost every psychiatric or psychological textbook appears obliged to include a historical chapter or review, however desultory of the topics under discussion. These texts repeatedly tell us a story of the development of the psychological sciences in similar terms: they have a long past but a short history”. (Rose, 1998, p. 41)
In 2002 the textbook, Child and Adolescent Psychiatry (Rutter & Taylor, 2002), was published and contained over 1200 pages with a breadth of topics regarding child and adolescent psychopathology, leaving room for one chapter dedicated to the ‘History of Child and Adolescent Psychiatry’. The chapter was fourteen pages in length and written by historical researcher Michael Neve and psychiatrist Trevor Turner (2002), but in the new 2012 version (Goodman & Goodman, 2012) this chapter about the historical development has been left out.
The disappearing interest in the history of child and adolescent psychiatry in the new edition edited by Goodman and Goodman (2012) marks a significant contrast to the current global picture of child and adolescent mental health. According to the World Health Organization, “childhood and adolescence are critical stages of life for mental health” and one in seven 10- to 19-year-olds will experience a mental disorder. The number accounts for 14% of the global burden of disease in this age group (World Health Organization, 2021). The number illustrates a still expanding number of children and adolescents who are being diagnosed with mental disorders (Social- og Indenrigsministeriet, 2020). The interest in mental health research with children and adolescents has a ‘scientific history’, typically dominated by biological and genetic areas of research. These areas often present mental illness as scientific facts employed through a positivistic lens, but this “reality it seeks to render intelligible” (Rose, 1998, p. 42) often evades the institutional history and discursive practices, all in their search for a desire to determine and predict outcomes.
While the growing body of knowledge that logically binds mental disorders to neurological dysfunction still ratifies their presence in the research of mental health (Peters, 2010), other scholars have provided critical and discursive analytical approaches to study the discussions concerning child and adolescent mental health (O’Rielly & Lester, 2015). However, the history of how we culturally, professionally and organizational came to measure and assess the pathological dysfunctioning of children remains an almost blind spot in history – especially in Danish context. One can wonder why the history of Danish child and adolescent psychiatry is a sparse field, especially when compared to the fairly extensive field of research that exists about general psychiatry (e.g., Møllerhøj, 2008, 2009; Røn & Hartby, 2006; Mellergård, 2000; Kragh, 2008; Bjerrum, 2005; Vestergaard, 2018; Kelstrup, 1983).
The limited body of research that concerns the history of child insanity might be due to how the institutionalization of child and adolescent psychiatry seems to infiltrate into multiple lines of historical traditions and different fields of disciplines, e.g., the history of childhood and the development of the disciplines, pediatrics, pedagogy, psychiatry and psychology (Shuttleworth, 2013; de Coninck-Smith, 2000; Kotowicz, 2011, Neve & Turner, 2002). According to Neve and Turner (2002), the development of child and adolescent psychiatry can be displayed in a three-fold movement that evolved just at the dawn of the 20th century. First, a change was made in the definition of childhood as a privileged and separated period. Second, legislative changes followed, led by educational optimism that sent all children to school and out of work. Finally, these two changes made it possible to use the schools as a space to observe and intervene with new psycho-technological methods that could measure and assess the psychological functioning of children – normal as well as pathological.
Over the last decade, historians such as Taylor (2014, 2016, 2017), Junghans (2012, 2021) and Hutchison (2011) have shown a growing interest in the emerging history of ‘child insanity’. Taylor examined the experience of insane children across the period of 1845 to 1907 in England, and in recent studies, Junghans (2012, 2021) presented historical findings that confirm that Danish children were admitted to insane asylums many years before the official establishment of child and adolescent psychiatry took place in Denmark. According to Junghans (2012, 2021), the general history of child and adolescent psychiatry is almost non-existent in a Danish context, and in the limited number of publications available, the focuses are often on child psychiatry as a medical specialty or as a practice within the hospital system (e.g., Persson, 2009; Smedegaard et al., 1993; Thomsen, 2004). However, even though Junghans (2012, 2021) traced the confinement of children before the official institutionalization of Danish child and adolescent psychiatry, most articles and reviews first began their historiography in 1935 after the first child and adolescent clinic opened at Rigshospitalet in Copenhagen.
Therefore, I aim to explore the experience of the Danish insane child across the period of 1900 to 1930 to unfold to the forms of knowledge that powerfully generalized the structure of thought about child insanity (Spivak, 1993; Rose, 1998) – before child psychiatry officially became a discipline in its own right in Denmark. I argue that it is important to discuss and examine the “struggles, displacements and processes of re-purposing out of which contemporary practices emerged and to show the historical conditions of existence upon which present-day practices depend” (Garland, 2014, p. 373). Through a historico-critical approach of combined poststructuralist thinking (Rose, 1998; Foucault & Howard, 2017) and post-colonial theory (Spivak, 1993), I argue that the child was ruled by a regime of representation that viewed the insane child as a ‘clinical subject’ that could not speak, except through a patchwork of clinical theories and techniques (Swarz, 2005). Through this combined theoretical lens on the cultural and social conditions of history, I examine historical case records, doctorial and educational publications and textbooks. The article, therefore, contributes to an extended perspective on child insanity that goes beyond the more classical history (e.g., Junghans, 2012, 2021) and medical description (e.g., Thomsen, 2004) that narrowly explore and reduce the child as a historical or natural biological being. However, before I begin this task, I invite the reader into a corner of history on the emerging understanding of the mind of the child that ruled just before the period of 1900 to 1930. I outline these parts of history because the history of childhood cannot be divorced from the revaluing of values, struggles, conflicts and alliances that later came to shape the understanding of the insane child.
2 Sharpening the focus: An emerging histography about the insane child
In this section, I outline the formation of the history. However, before I do so, it is necessary to emphasize that the amount of knowledge on insanity and children is almost nonexistent when it comes to Danish literature. Therefore, I find it vital to include other sources to center the understanding of insanity and childhood and to sharpen the focus of what kind of behavior the doctors constituted as ‘insanity’ in the period just before the 20th century.
2.1 Sharpening the focus: The mind of the child
The term ‘insanity’ might seem offensive to modern ears and contradictory to the post-critical view (Spivak, 1993; Rose, 1998; Foucault & Howard, 2017) that the article applies to the becoming of children’s mental illness. However, I use this term to avoid confusing the different terms otherwise used during the development of the concept of mental illness (e.g., ‘lunatic’, ‘mentally defective’, ‘mentally deficient’, ‘idiotic’ or ‘imbecile’).
The interest and occupation with child insanity can be dated back to before the turn of the 20th century, but the ideas about what kind of behavior was categorized as insane were often fluid and multilayered (Taylor, 2017). Around 1850, a shift occured in the perception of mental illness in Denmark. The former notion that insanity was caused by possession of evil spirits was replaced by a more bio-medical thought, where the “madman” was no longer categorized as a beast, but seen as suffering from an illness that required professional treatment (Petersen, 2006). This development led to a new outlook on insanity as a disease, and therefore, the responsibility developed into a matter for the state. As the state took on the care and treatment of those considered insane, five large asylums were built from 1852 to 1915, leading Denmark into the era of the ‘great confinement’ (Foucault & Howard, 2017) that separated the mad from the poor and criminal and placed them in specialized institutions (Petersen, 2006). Therefore, the care for the insane became a domain of medical science, driven by the medical explanation that insanity was a disease that caused a man to ‘lose his mind’. Before the 20th century, it was self-evident that children could not be affected by insanity, as children were portrayed as irrational individuals without a mind of their own – they could simply not lose a mind that they did not have (Shuttleworth, 2013).
As a result of this system of belief, there was a reluctance to admit children into asylums, not just in Denmark (Junghans, 2012) but also in other parts of Europe (Taylor, 2016, 2017; Gingell, 2001; Hutchison, 2011). If a child was admitted, there was a tendency to casually explain that the child’s behavior was caused by the child’s faulty upbringing and not a disorder of the mind (Hutchison, 2011). However, at the end of the 1800s, the assertions that children could not suffer from insanity were challenged by a growing number of cases around Europe. In the historical studies of the constitution of the insane child in England from 1845 to 1907, Taylor (2017) explains how the construction of childhood was ‘incorporated into a discourse of innocence’. This meant that the families and medical professionals were often forced to create polarized narratives of the sick child as a ‘threat’ to themselves or others to paint a picture that would guarantee the child’s admission and treatment in asylum care (Taylor, 2017). From Scotland, a study by Hutchinson (2011) describes how institutions specifically for children were founded in the mid-19th century based on the assumption that “improvement of the ‘defective’ mental state could be accomplished through regimes of education and training, but that this needed to begin at an early age, and therefore there needed to be a specific focus upon children” (p. 429). According to Shuttleworth (2013), the late 19th century marked a significant shift in ideas about childhood as medical scientists changed their understanding of the child from being irrational to a complex individual. In the United States, child insanity was first portrayed as a minor deficit, compared to adult insanity, which was considered much more invasive to the cognitive functions of the brain (Rutter & Taylor, 2002).
2.2 Sharpening the focus: Revaluing the mind of the child
As we approach the 20th century, history frames certain deviant and sexual behavior in childhood as a problem that society needed to contain and control, highly influenced by the ideas and theory of degeneration (Kirkebæk, 2006; Taylor, 2017). In Denmark, the turn of the 20th century marked a significant shift in the ideas of childhood, the development of public school and child welfare. The ‘Act of Higher Education’ in 1903 cast the intellect of the child into a public arena and debated eugenics, heredity and social equality. Two years later, the 1905 ‘Act of the Child’ made it illegal to imprison children, while also making it possible for the state to place children in mental deficiency units, halfway houses or reeducation homes (Bryderup, 2005). The general idea was to remove neglected, difficult or criminal children from their homes and help them back to proper citizenship through placement in foster care or reeducation at institutions managed by the welfare state (Kirkebæk, 2006). E.g., Larsen (2020) explored how reeducation homes, such as Vejstrup Home for ‘particularly problematic’ girls, collaborated with psychiatric doctors when certain individuals did not respond to the disciplinary treatment practiced in the reeducation homes. Larsen (2020) illustrated how mental evaluation performed by doctors was being used to develop a reformulation of incorrigibility into a diagnosis of deviance or psychopathy. The development became a convenient alternative to the reeducation homes in cases where the reeducation failed to work with certain disturbed individuals. Larsen (2020) argues that the societal need to pathologize and diagnose children’s psychological functioning was developed as a response to the lack of resources and political support in other child welfare institutions across the period of 1908 to 1940.
Larsen (2020) adds an important body of knowledge to the history of how child and adolescent psychiatry emerged and established itself as an independent field of medicine that the welfare state needed to evaluate and assess certain difficult subjects. Across Danish literature, one can find reviews of child psychiatry, but they often begin their historiography from 1935, when the first child and adolescent clinic opened (Rigshospitalet in Copenhagen) or 18 years later in 1953 when child psychiatry was established as a medical specialty and officially institutionalized itself in the field of medicine (Junghans, 2021). However, other reviews (e.g., Persson, 2009; Smedegaard et al., 1993; Thomsen, 2004) often describe child psychiatry through a prism of the medical domain or as a discipline practiced within the hospital system. The knowledge of child and adolescent psychiatry before 1935 is therefore like a blind spot in history, and the absence of the children’s voices often evades history when viewed through discourses of psychiatry and hospital management. Therefore, the article provides a critical view of historical, archival and theoretical material. I aim to trace the silent narratives of the confined children who were muted by the ‘epistemological acts of violence’ that were performed by the elite (doctors) of history (Rose, 1998; Spivak 1993). Before I begin this critical walk through the written footsteps of history, I will first unfold the combined methodological and theoretical lens that I used to trace the written voices of history.
3 Locating the past: Methodological perspectives and method
Spending time with dusty old documents, looking for information, answers and blind spots in history about particular children, professionals and events from the past, might be to some researchers a distancing approach, unlike ethnographic fieldwork at present that is based on engagement and interaction with people in specific environments (Mellemgaard & Olwig, 2018; Koivisto, Lähdesmäki & Ceginskas, 2021). However, according to Mellemgaard and Olwig (2018), archival research and fieldwork have many parallels to fieldwork ‘in situ’. Therefore, I point to a ‘historical ethnography’ as a critical way to trace and follow theories and beliefs of the past and to get a closer view of the lives of the children in the asylums. I have limited my search to the period of 1900 to 1930, as I would like to investigate what happened to the (voices of the) child psychiatric patient before the first child psychiatric clinic opened in Denmark in 1935.
3.1 Locating the past: Doing ethnographic fieldwork in documents
My research into the field has led me down two empirical-coherent lines of history: 1) the theoretical beliefs about insanity and childhood and 2) the management and organization practiced in the asylum. The theoretical descriptions of child insanity were located through advanced searches in national (The Danish Royal Library), Nordic (Diva and Oria) and international databases (PsykInfo, Educations Research Complete, Scopus and Web of Science). The advanced searches made it possible to broaden the search beyond historical journals and locate books, dissertations, collected works and other materials written by medical or school professionals dating back to the early 1900s. Even though most, if not all of the located material, was written through a gaze of the medical domain and discourse, the material represents the epistemological system of belief that justified the confinement of children, and therefore, these theoretical frames cannot be divorced from the local situation of everyday life in the asylums. The search for the organization and management practiced in the asylums was conducted at the National Archive of Denmark, which located the medical records and registries from the Middelfart State Asylum. The medical records were only available in physical form at the National Archive, with the child patient records hidden between the many records of adults admitted over the years. The child records were therefore located through a systematic search of several boxes containing patient records dated back to the period of 1900 to 1930. The majority of these medical records contain material produced by employees of the asylum. In some cases, the doctors quoted the children’s own descriptions of their state of mind, but these statements appear to be merely medical documentation rather than an actual interest in the children’s perspective and voice. The archives represent the written experience of the past and thus represent a part of the everyday life that emerged and was practice in the asylums.
4 Locating the past: A combined theoretical lens
My walks through the written footsteps of the past are driven by a combined theoretical concern for the small voices of history, and provide a critical lens to the becoming of the insane child through a genealogy of ‘technologies of subjectification’ (Rose, 1998; Foucault & Howard, 2017) combined with an investigation of the acts of violence (Spivak, 1993;1985).
4.1 Locating the past: A critical walk through the archives
In terms of child insanity, I do not wish to repeat or rewrite the ‘elite’-history of child insanity as an ‘absolute other’, as this quickly can become a ‘genealogy of the historian’ (Spivak, 1985, p. 251), and less about the lives and the death of the admitted children. Therefore, I add a critical perspective because the descriptions of the admitted children can be problematic to explore as a mere reality of truth when viewed through a prism of insanity. I argue for the use of a critical view, as I draw on a complementary-theoretical view to investigate history, not as ‘a true origin of things’ but more as a shift toward the events that outline the formation of fields of social practices (Rose, 1998; Spivak 1993, 1985; Foucault & Howard, 2017). I hereby outline that “the task for critical history … is to reverse the lines of inquiry” (Rose, 1998, p. 47) must be considered as a way to problematize the terms of history, because subjects and objects of knowledge are always submissive to the terms of history (Rose, 1998). I find that the task, construction of a “history”, quickly can devolve the analysis (Spivak, 1985) and become simplistic, generalizing and ignorant of the fine lines of history (Rose, 1998). To dissolve this, I explore the children as oppressed subjects, inspired by what Spivak remarks as ‘the subaltern’. Spivak argues that the subaltern is systematically excluded from powerful systems of representation, created by academics or other elitists, that through a system of epistemic violence, not just deprive the subalterns to speak for themselves, but impose a mode of “speaking” on them. I elaborate on this further in the analysis, where I look in detail for issues of meaning in the available evidence, e.g., doctors’ notes, patients records and medical textbooks, to show how the system of representation, established between the professional and the children, provided the conditions under which it was impossible for the child to take a position of a subject, that could speak, only through a patchwork of theoretical psychiatry and hospital management, leaving them to be ‘silenced subjects of history’ (Spivak, 1993). In the analysis, I explore how the language about the insane child is epistemic and provides the basis for the creation and maintenance of knowledge established as “truth”, that not just regulated whether the children were able to speak but also if they were able to be heard. By drawing on theoretical perspectives on subjugation represented by postcolonial historiography (Spivak, 1993), the article explores the admission and experience of children, labeled as ‘insane’, and questions who speaks, or rather writes, to what purpose and through which system of representation.
5 Tracing the voices of the insane child
On the surface, descriptions of the children may simply appear as written records, but archives are not objective, as they did not arise by themselves, and therefore they cannot be free from the “episteme that defines the conditions of possibility of all knowledge” (Foucault, 2018 p. 183). Rather one must drag these epistemological acts of written violence “from their sleep” (Foucault 2000a, p. 323), not to judge, but to explore why these children were placed in asylums, what type of behavior did they show, and why was this polarized as pathological.
5.1 Tracing voices: A walk through “a monologue” by reason
When one is walking through historical case records, texts and documents, the reader learns a great deal about the ‘medical personage’, the tools and the methods used to rationalize and reason the origin of insanity but learns almost nothing about the children whom they wrote. In this section, I outline a theoretical investigation of medical textbooks and materials and explore how these applied a ‘system of meaning’ for which it was made possible for certain “persons to take up the position as a speaking subject” (Rose, 1998, p. 53), while systematically excluding other voices from the powerful system of representation (Spivak, 1993).
According to Rose (1998), a critical history of ‘psy’ must be viewed through the multiple theories, explanations and experimentations that birthed the language of ‘psy’ as a discipline. In Denmark, the turn of the 20th century marked a significant shift in the ideas of childhood. The 1905 ‘Act of the Child’ made it illegal to imprison children and made it possible for the state to legally take children from their homes and into mental deficiency units, halfway houses or reeducation homes (Bryderup, 2005). The general idea that a child could suffer from insanity was slowly emerging, but these legislative changes did not concern children with symptoms of insanity, and therefore, the welfare responses to support these children and families had not yet been developed (Taylor, 2017). Subsequently, Danish lunatic asylums did not officially admit mentally ill children, leaving the majority of insane children to be treated at home or in workhouses (Junghans, 2021; Larsen, 2020). According to Taylor (2017), the failure to admit children was partly caused by the fact that there was “an unwillingness by professionals to deal with child insanity in the same manner as insanity among adults” (p. 14). Therefore, children did not form the majority in the asylums, and the ideas about what could be labeled as insane behavior for children were fluid. Some children were described as deviant, devil-like or manic, and some showed sexually inappropriate behavior (Wimmer, 1909; Taylor, 2017).
In the psychiatrist’s struggle to form a unified description of insanity, doctor Christian Geil insisted that insanity was comparable with disorders of the somatic kind, saying “insanity is always an illness in the brain, as pneumonia is an illness in the lungs” (Giel, 1899, p. 10, my translation).
Foucault explains that the doctors of the asylums used the medical domain strategically to conceptualize insanity as a disease and not just a ‘lack of reason’. However, the psychiatric field suffered when asked to provide a “justified ... body of objective knowledge” (Foucault & Howard, 2017, p. 257), leaving them with only uncertain knowledge about the origin of insanity and what caused it (Møllerhøj, 2008). In 1909, doctor August Wimmer published the monograph, Degenerated Children, where he addressed these particular difficulties:
“The facts about the forms and conditions of heredity, as biology has collected, can unfortunately not for the moment be used within the psychiatric definition of inheritance. For now, this is purely clinical: the findings of certain mental abnormalities in the child’s origin, and the presumption that we have here, for the reason of the child’s mental disorders” (Wimmer, 1909, p. 9, my translation).
Through the eyes of Foucault, it is possible to question the position of the Danish psychiatrists and how they continued to rule the birth and history of insanity, though they clearly struggled to prove a pathological picture of insanity. Foucault argues that the introduction of the doctors to the asylums created a modern relation between insanity and medicine, as the care for the insane became a part of the medical domain (Foucault & Howard, 2017). Through a system of objectivity and rationality, the doctors were able to profile psychiatry as a scientific enterprise and maintain their ‘elite’ position, not because they had any particular knowledge of insanity, but because they “mastered it, and what for positivism would be an image of objectivity was only the other side of domination” (Foucault & Howard, 2017, p. 258). According to Foucault, the psychiatric practice confided themselves to positivism in their desire (and disappointment) to discover the origin of insanity. Although they failed to prove scientific accountability, the doctors imposed insanity as a mental disorder and positioned themselves with a ‘new status of the medical personage’, who represent an ultimate realm of reasoning. Through this scientific system of objectivity, the doctors could offer salvation if the patient objectified and subordinated themselves to him, “when man entrusts himself to medicine, he escapes the law of labor that nature itself imposes on him” (Foucault & Howard, 2017, p. 182). The doctors were able to serve insanity as a biological abnormality because they had assembled a specialized knowledge – a system of objectivity and rational reasoning. Additionally, through consideration of ‘nature’, the doctors were able to emphasize the normal child and how children who deviated represented the abnormal or “sick” (Hendrick, 1992).
“‘vanity’, this consistent ‘laziness’, this cold-blooded ‘lying’, etc., etc. does not concern the normal psychological affections in the mind of the child, but it has a much deeper and a far stronger root in the basis of being and must often be understood as an innate state of abnormality caused by a sick nervous system in the child”. (Wimmer, 1909, p. 2, my translation)
As August Wimmer writes these theories of explanation in 1909, he becomes the first Danish psychiatrist to officially publish a collective work on mental illness in childhood. He distinguished between two categories of child psychiatric disorders, ‘real insanity’ and ’mental abnormal state’, with the two subgroups, ‘defective condition’ and ‘neurosis’. Wimmer (1909) was strongly inspired by ideas of degeneration, which combined with the scientific influence of Darwin’s Origin of the Species (1910) led to a more intense medical opinion about the need to classify hereditary conditions in childhood and how they could contribute to abnormality (Taylor, 2017). The ideas of degeneration helped the doctors to objectify the child(hood) as an entity that could only be understood in reference to medicine and the ‘realm of reasoning’ that it represented (Hendrick, 1992).
The increasing discussions about hereditary transmission led to a more intense focus on the child and mental disturbances, leading medical professionals to participate in the debate, “that marriage should not be contemplated if a taint of insanity were to be found in the family inherited curse” (Shuttleworth, 2013, p. 16). In 1900, neurologist Hermann Oppenheim published a book, Vore Nervøse Børn og Deres Opdragelse (Our nervous children and their upbringing), that emphasized the importance of the correct upbringing of the child. Oppenheim’s theories of belief explicitly explained that the correct upbringing must contain a proper diet, cold washes and daily walks in the open air and expose the child to sudden sensory impressions such as loud noises. His description speaks to a medical focus on the development of the child that was also clearly marked with the ideas of degeneration, as he emphasizes that “one can notice that the hysterical nature of a mother is easily transmitted to the children. Therefore, a child who at home cannot avoid witnessing a nervous unnaturalness should be brought up among strangers” (Oppenheim, 1900, p. 21, my translation). Oppenheim emphasizes that the correct upbringing cannot cure inherited nervousness, but that the right methods could, to some extent, suppress the hereditary predispositions.
Through a system of ideas of degeneration and scientific enterprise, the “truth” about child insanity was born, and it could only be understood through a “monologue about reasoning about madness”. This made it possible for the doctors to “take up the position as a speaking subject” (Rose, 1998, p. 53), creating a powerful system of representation that deprived the insane of their voice. Because insanity became a position of unreason and irrationality, the insane subject, therefore, could not speak in a meaningful way about their own condition.
5.2 Tracing voices: A walk through the archives
The theories and beliefs about insanity and how it took hold in childhood speak more to a ‘surface of emergence’ (Foucault, 2013, p. 45) of the rules and “truth” that governed – what could be counted as meaningful (statements), and who could take up a position as a speaking subject and be heard. The system of belief was in many aspects an institutional epistemology, with the institutional relations structuring the knowledge and beliefs about insanity which had taken shape in the asylums in the domain of scientific medicine. The system of belief and theories imposed a way of speaking about the insane children, framing the subject through a picture of unreason, and through these forms of representation “removed them from all lines of social mobility” (Spivak, 2005, p. 475). Therefore, a critical walk through the archival material does not allow one to recreate the “reality” that prevailed in the archives. It can, at best, provide us with insight into the structure, system and conditions that ruled the voices constituted and confined to the asylum.
According to historian Junghans (2012), 367 children were admitted to Middlefart State Asylum from 1891 to 1940. Therefore, hospitalized children only accounted for about 5% of the asylum patients across a period of five decades. When a child was admitted to the asylum, the doctor filled out a journal using prefabricated questions that primarily focused on hereditary facts about morals, physical state, appearance and behavior.
Have any of the patient’s relatives been diagnosed with insanity?
Or suffered from an illness of the brain or the nervous system?
Does suicide run in the family?
Does criminal behavior run in the family?
Does alcoholism run in the family?
Are father and mother related? (Pt. No. 4524, 1916)
The patient records represent a unified system of knowledge that made it easy for doctors and nurses to quickly overview the individual case of the child and last, but not least, provided a simple way to decide the fate of the child. From 1900 to 1930, the questions changed, to some extent, in the way the questions were formulated, but the theory of degeneration still ruled the overall system of representation. In one case about a young girl, Agnes, age 16, the doctor wrote in the section about hereditary disposition for insanity, “No, however, it should be mentioned that the mother is occasionally somewhat strange” (Patient no. 4465, 1912). According to Agnes’ family, there was no disposition of insanity, but the doctor still found it necessary to write down that the mother showed ‘occasionally strange behavior’. In several of the case records, the questions about hereditary disposition were often filled in with answers of “No”. Despite these struggles to determine the origin and disposition for insanity, the thoughts about degeneration continued to rule the prefabricated questions in the admission forms.
On the surface, the journals might be viewed as a simple way to systemize information, but the records also developed a system of judgment that made it possible to observe and classify the children’s symptoms across each case. Keeping Foucault (Foucault & Howard, 2017) in mind, it also became a repressive regime, as the clinical notes written by the doctors are clearly colored with clinical theories and techniques. When a child was admitted, the admission was often based on observations from the child’s family or guardian (Junghans, 2012). The majority of the information in the records was not spoken words from the children themselves but obtained from the child’s family or guardian (Junghans, 2012). In the case of Dagmar, the doctor wrote, “She has, according to the mother’s description, sometimes been visually hallucinating” (Pt. No. 4520, 1916). The information stored in the records can, therefore, be incorrect and questionable, as it was created first through the eyes of the family and then (re)written through a “monologue about reasoning about madness”. Consequently, it can be difficult to locate the voices of the children from the past, as history does not reflect mere “reality”.
In continuation, Spivak (1985) turns our focus to the subaltern, who has systematically been suppressed by the powerful system of the elite in society. The children were systematically denied an opportunity to have a voice and independent agency because their own experiences of insanity were often influenced by the polarized narratives that the family and medical professionals would create to guarantee the child’s admission (Taylor, 2017). In a few cases, the doctors would use direct quotes from the child, but these sentences often ran through a haze of psychiatric language. In the case of Inge, the doctor describes a course of events that had happened just before her admission.
“I first saw the patient on May 13th, 1916. She was then quite escalated and confused. She had called her mother who was occupied in the kitchen. The mother ran to find her (Inge) with two knives in her hands. One knife she would use to ‘fight her way through’; the other the mother would use to kill her. But she would not ‘follow the mother further into the blue’. She misinterprets the pictures on the walls, and she talks to them as if they were real people … Shows acts of confused and disturbed behavior”. (Pt. No. 4524, 1916)
Inge emerges through the records as she is described by the elite doctor as a delusional and confused girl. She fails to perform or act in a reasonable manner because she communicates with pictures on the walls and tells the doctor that her ‘mother has the intention to kill her’. Although Inges’ words are emphasized in quotes, they occur more as lines of events, appearing to be medical documentation more than an actual interest in the child’s perspective and voice. Through this psychiatric system of representation, the narrative of Inge and her insanity is placed in the shadows of discourses of psychiatry and hospital management. Her illness becomes an episode, a line of events, presented through a filter of psychiatric symptoms that form a structured history of illness, thus leaving Inge silenced with the symptoms speaking for her. Through the case of Inge, it becomes more visible how the institution of psychiatry emerges through a system of activities, language and techniques that altogether controlled, duplicated and maintained an implicit structure of power. This structure of power established what could be defined as the “truth” and who was allowed to position the others within the discourse. The psychiatric representation of power positioned the doctors as the professional elites who, through ‘a monologue of reason’, were able to judge the children with written and spoken words of violence (Spivak, 1993; Rose, 1998). In this sense, the position of power becomes the one who can speak – the “truth” – in the name of another person (Mohr, 1999).
This position of power becomes even more visible when one follows the written footsteps of the doctors across the case records, where the onset of puberty marks an area of interest. According to Wimmer (1909), the development of the child’s sexual maturity in close connection with the development of the child’s personality and cognitive functions was a complex period (Wimmer, 1909). Junghans (2012) describes in her research about the insane children that the transition from childhood to adulthood was a complex period, containing much potential danger that could disturb any healthy development of the child’s mind. The female sex was especially associated with insanity (Møllerhøj 2009), and according to Junghans, the doctors would often interpret the symptoms of disturbed or deviant behavior into a theory of the menstrual cycle. Tracing the voices of the children is therefore difficult when we are, as Spivak argues, “in the shadows of shadows” (1993, p. 265). Spivak argues that subaltern women are doubly marginalized – first as colonized by the elite and then again as women repressed by the patriarchy. “If in context of colonial production, the subaltern has no history and cannot speak, the subaltern as female is even more deeply in shadow” (Spivak, 1993, p. 11). Spivak turns our attention to the dark corners of history that appear in these practices of writing performed by the elite. Although these case records are informational speech, collected through the voices of the families and the children themselves, the reading of the case records tells us more about the institutionalized forms of representation and less about the diseased minds and bodies confined in the asylums.
In this article, I have examined the experiences of the Danish insane child through different types of historical material, part theoretical and part practical, across the period of 1900 to1930. The historical material mapped a complex struggle of power between the theoretical concerns of eugenics, heredity, and social disposition and the way this was understood in practice. The theoretical assumptions about the etiology of insanity described by Giel (1900) and Wimmer (1909) mark a clear discrepancy in the doctors’ notes and writing in the case records from Middelfart State Asylum. According to the historian Møllerhøj (2008), who researched Danish psychiatry in general, the discrepancy between the theories and practice was due to hereditary disposition being a rather open concept that framed “heredity in a narrow sense as well as theories of degeneration” (p. 326). The broad concept meant that the definition of what constituted hereditary disposition varied not just on the institutional level, but from one doctor to another.
Despite these struggles and difficulties to define disposition and symptoms into a system of classification, the need to admit and segregate ‘particularly difficult’ children to other institutions managed by the welfare state continued to grow from 1900 to 1930 (Larsen, 2020; Kirkebæk, 2006; Junghans, 2012). Consequently, when one walks through the written footsteps of the case records from the past, the reader learns a great deal about the voices of those who ruled within the powerful systems of representation – the (elite) doctors and almost nothing about those they wrote. The children admitted at Middlefart were described as salivating, with incoherent speech, excited or hallucinatory (Pt. No. 4520, 1916), disobedient (Pt. No. 4463, 1915) and crying (Pt. No. 4620, 1917). To what extent do these statements represent the “reality”, it is difficult to know, when the experiences of the children were often (re)presented, first through the eyes of the family and then when put into prescribed forms and questions structured by the very institutional relations where it had taken shape (Foucault & Howard, 2017).
Through archival material, I argue that it is possible to trace theoretical and practical knowledge about the insane child. However, the actual voice of the insane child is not easily located when it is viewed through a powerful “monologue” by reason” (Foucault & Howard, 2017). So, (how) can we use these voices of the past in the present?
The muffled voices of the children labeled with insanity can tell us a great deal more than just the progress of change that has played out in the field of psychiatry. The records and theories about insanity can reveal an underlying structure of thought that ruled within the asylums, shaped by the discourses and experiences in a particular era. The historical struggles and exercises of power that shaped the voices of the insane child should, however, not be used to (re)write a history of the past. Instead, I argue for distinguishing these historical epochs and tracing their differential technologies of power that shaped each particular era and “reveal something important – but hidden – in our contemporary experience” (Garland, 2014, p. 368). I find this interesting because if research only traced the progress of change in psychiatric treatment of the child, the analysis might only highlight that the psychiatric patient have a much more empowered and central role in contemporary care than the admitted children did at Middlefart State Asylum. Patients’ rights critically changed around the 1960s when anti-psychiatric movements around Europe challenged the authoritarian role and functioning of the asylums (Miller, 1986, p. 23). The movements led to reforms, and today,
“Patient participation is seen as something positive, which is substantiated by the fact that it improves quality of life and provides patients with an increased sense of ownership and management of their symptoms, their illness and their situation, giving them a sense of control and self-determination”. (Jørgensen & Rendtorff, 2018, p. 490)
The objective behind patient participation is to recognize the patient as a unique individual and create space for alternative forms of life, based on the ideal that the “good” life must be determined by the individual self and not forced into preconceived categories structured by the institutional framework. Although it can be difficult to disagree with a health policy that humbly assigns the patient authority, it seems that the resistance toward the system has given rise to a number of new technologies of power. Through ideals of ‘ownership’ and ‘management’, the patient is promised freedom, which only can be restrained by the patient’s self-perception. Therefore, the power to be liberated becomes an inner dialogue between the self and the self (Villadsen, 2007). Perhaps today the crucial question of power “becomes not so much a matter of ordering, controlling, commanding obedience and loyalty, but of improving the capacity of individuals to exercise authority over themselves” (Rose, 1998, pp. 63-64). The power of psychiatry today does not originate itself from mental medicine or the mental hospital; it has developed into techniques of social regulation (Rose, 1987). Through the promise of “ownership and management of their symptoms, their illness, their situation” (Jørgensen & Rendtorff, 2018, p. 490) treatment, is “requested, rather than imposed” (Foucault, 2016, p. 296), making the subject (not) able to speak only (and still) through a patchwork of new contemporary practices of subjectification, perhaps today because “the most powerful way of acting upon the action of others is to change the way in which they will govern themselves” (Rose, 1998, pp. 63-64).
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Trine Elisabeth Møbius Sørensen, PhD student
Aarhus University, DPU, Campus Emdrup
Tuborgvej 164, DK, 2400 Copenhagen NV