Perceval's psychosis

The onset of Perceval's illness was marked by religious experiences. He saw visions, felt a sense of peace and confidence of mind which he described as ‘a new and wonderful sensation [ … ] from my head downwards through my whole frame’, saying ‘I felt a spirit or a humour shedding its benign influence, the effect of which was that of the most cheerful, mild and grateful peace and quiet’ (italics in the original) (Bateson Reference Bateson1962: p. 17). There are descriptions of the power of God coming upon him and opening his mouth and compelling him to sing in ‘beautiful tones words of purity, kindness, and consolation’ (p. 19). Perceval commented that these actions were not his own doing and that the words ‘were wholly unthought of by me’ (p. 19). There were also embarrassing behaviours such as speaking or singing out of turn during church services. For example, ‘At morning service in Mr. Campbell's church, one Sunday, I was led to open my mouth, and sing a part of a psalm, at a time when the rest of the congregation were at peace, and whilst Mr Campbell was preparing to preach’ (p. 20). These behaviours were recognised by other members of the congregation as egregious and probably indicating mental illness and Perceval himself acknowledged that his insight fluctuated, sometimes he was aware that his behaviour transgressed the ordinances of the church but at other times he was not able to resist the ‘singular inspiration’ that moved him. Perceval reached a crisis point when he responded to command hallucinations and took up postures that seem catatonic in nature. He describes how he was guided to lie on his back and commanded to take on postures and movements that were exhausting and potentially dangerous. He complied with these commands because his postures demonstrated that the work of God was perfected. Many more of these behaviours that Perceval was compelled to undertake potentially posed grave risk to his life. He was tempted to throw himself on the top of his head backwards and to then rest on his head and on his feet alone, turning on his head from side to side until he had broken his neck.

The range and extent of the symptoms and signs of psychosis, including visual and auditory verbal hallucinations, delusional beliefs, and transgressive behaviours and utterances, were such that it was apparent to all concerned that he was unwell. Perceval was staying in Ireland, with an army officer who was a family acquaintance, at this time. His host Captain H. took him to Dublin, where he was seen by two doctors, one of whom was ‘a lunatic doctor’. He was subsequently confined at the home of Captain H. in Dublin, until his brother arrived from England. The confinement involved being ‘tied hand and foot in a straight waistcoat, in a small and close room’ (p. 38).

Perceval's incarceration at Dr Fox's private madhouse

Perceval was admitted to Dr Fox's madhouse in 1830. In this section, I will concentrate on the living arrangements, the management of Perceval's illness and his description of his treatment by the attendants.

Perceval describes his first room as:

This description allows us to have a sense of what the amenities were like in a private madhouse at the time, and this was evidently a much better prospect compared with the crowded and materially impoverished environment of the county asylums and workhouses. Nonetheless, Perceval was still kept in bed with his arms fastened in heavy leathern cases and when these were taken off and replaced by a straight waistcoat, he felt a sense of great relief. Initially, after breakfast he was dressed and taken down to ‘a small square parlour, with two windows opposite the entrance, looking over some leads into a court, then over a garden to a flat country terminated by hills’ (p. 61). This was Brislington, on the edge of Bristol. Perceval writes that ‘my dinner in this room was served on a tray, with a napkin, silver forks, decanters, &c. &c., and in these respects, such as was fitting for a gentleman’ (p. 63).

This honeymoon period was, however, short-lived. Perceval described the following period as ‘my second ruin’, characterised as it was by cruelty and suffering as he experienced psychotic episodes and ‘became again lunatic’ (p. 63). On his eventual recovery, in a sound state of mind he remained confined at Dr Fox's madhouse for almost 2 years, owing, he says, to a dispute with his family.

The social environment of the madhouse was bleak and grim. Perceval's descriptions will be recognisable to people who provide care to old people's homes and old age wards:

Perceval describes violence meted out to him by the attendants: severe blows to his face, head, ears and arms, rough handling and blows to the abdomen, and he recognised these events sometimes as punishments and at other times as unprovoked and inexplicable, amounting to sadism. On one occasion he was sent to solitary confinement, in ‘a kind of outhouse’ at the back of Dr Fox's garden. These were cells with bare walls, lit by a skylight and equipped with a bed furnished with straps and chains. In Perceval's case he was put in the innermost cell, which contained a straw mattress and pillow that stank of cow dung, on which he was strapped down with a broad strap over his chest and his right arm was manacled to a chain in the wall. No explanation was given to him for this punishment, which he saw as torture. Paradoxically, Perceval says that he was happy in this situation because there was comparative peace in the seclusion, and a much-needed freedom from intrusion. He spent a fortnight in this solitary confinement.

How are we to regard these punitive regimes? For Perceval, he saw them as designed to insult and degrade the patient under the pretext of managing his illness and behaviour. But he also saw and interpreted the strict and neglectful treatment as a reflection of the economy of running a madhouse. There was a way in which the maltreatment was rooted in the unfounded belief that ‘lunacy cannot be subdued, except by harsh treatment’ (p. 100). But, in reality, ill treatment did exactly the opposite. It inspired hatred against the attendants, it fortified the spirit of the residents to resist and endure. There is a lesson to be learned here. Perceval makes the point that the justification to treat him contrary to reason seemed to emanate from the idea that he was, himself, incapable of reason and deranged in his understanding. Next, that since in his illness he was liable to physically attack others, somehow this seemed to justify the licence to mistreat him; and finally that the requirement to deprive him of his liberty and privileges meant that there were no scruples in infringing virtually all his rights. This last idea speaks to the question whether deprivation of liberty ought to be restricted to discrete areas of living rather than regarded as global in its reach and effects.

Perceval describes how his behaviours were moderated in situations where he was treated with dignity and respect and how these situations persuaded and encouraged him to work hard to ensure that no extraordinary actions or expressions occurred when he was in respectable company. This happened, for example, when he was invited to dine with Dr Fox and family.

The debasement and mistreatment of vulnerable people who live under the care and supervision of others, be this in care homes, psychiatric hospitals or prisons, remains relevant in our own times. The dehumanising processes that both objectify the person and render the carers callous and inhumane are still very present in society.

In our own times, the complaint is often of overmedication with antipsychotics, whereas in Perceval's time, one of his complaints was the absence of any form of treatment:

We could, of course, argue that in 1830, there were no effective medical treatments and that what was truly on offer was care and compassion but these too were scarcely available. Despite the rarity of compassion, it did exist and Perceval describes three attendants who had humane dispositions and did not strike him or rarely did.

Perceval's advocacy

Perceval made cogent and powerful calls to the public in his writings, drawing attention to conditions in asylums, emphasising the lack of meaningful occupation, the use of restraints, the absence of real medical treatment and the imposition of regimes that forbad conversation and communication with others. And he correctly identified the maleficent effects of these on self-respect and self-reflection, which in their turn provoked appalling behaviour in patients. Perceval's writing at its best forcefully marshalled arguments, making a passionate case for better treatment of the mentally ill. Hunter & Macalpine (Reference Hunter and Macalpine1962) make the point that Perceval's contributions to psychiatry were not confined to his books. Perceval became involved in agitating for the reform of asylums and lunacy legislation from 1835 onwards. He was involved in private philanthropy to individual patients, for example Richard Paternoster, who believed himself to be wrongfully confined. And, in 1842, in concert with others unsuccessfully attempted to introduce an amendment to the laws of lunacy at the House of Commons.

Perceval, in 1845, worked to form the Alleged Lunatics’ Friend Society, whose purpose was to campaign for changes to the lunacy laws, thereby reducing the likelihood of illegal incarceration and improving the conditions of asylums (Hervey Reference Hervey1986). He became the honorary secretary in 1846. The Society was instrumental in bringing to public attention the abuses at Bethlem Hospital, which then gave the Lunacy Commissioners good reason for their inquiry in 1852. The highlight of his campaigning career was in 1859, when the Society was successful in the appointment of a Select Committee of the House of Commons to inquire into the Operations of Acts of Parliament and Regulations for the Care and Treatment of Lunatics and their Property. Perceval's advocating activities, understandably, were not always to the liking of members of the medical establishment, as they threatened the authority of the medical officers of asylums and hospitals.

Perceval was well aware of his influence. He referred to himself as the ‘attorney general of all Her Majesty's madmen’. He told the Select Committee ‘I believe I am the only person, and, as far as I can see, my pamphlet is the only work that is published on the subject of maintaining the rights of lunatics’ (quoted in Hunter Reference Hunter and Macalpine1962: p. 394). He wrote in a letter to Sir James Graham, in 1845, that it was important to nurture the sense of independence and self-respect of individual patients as this was likely to lead to cure (Hunter Reference Hunter and Macalpine1962).

This belief in the humane treatment of the mentally ill, drawing on his own experiences, with emphasis on the humanity of the patients and focusing on the need to foster their self-worth and freedom, is probably his most enduring accomplishment.