Social Class and Mental Illness in Northern Europe

Petteri Pietikäinen, Jesper Kragh, Petteri Pietikäinen, Jesper Vaczy Kragh

• Editorial: Routledge
• Año: 2019
• ISBN:
  9780429779336
• Edición: 1
• Categoría: Historia
• Categoría: Historia del mundo

This book examines the relationship between social class and mental illness in Northern Europe during the 20th century. Contributors explore the socioeconomic status of mental patients, the possible influence of social class on the diagnoses and treatment they received in psychiatric institutions, and how social class affected the ways in which the problems of minorities, children and various 'deviants' and 'misfits' were evaluated and managed by mental health professionals. The basic message of the book is that, even in developing welfare states founded on social equality, social class has been a significant factor that has affected mental health in many different ways – and still does.

Part I

Social class and mental health care

1 Pity the poor patient

The indigent mentally ill in late 19th- and early 20th-century Finland

Petteri Pietikäinen

When we discuss social class and mental illness in Finland from the historical perspective, we need to keep in mind that the country was a latecomer to the family of modern industrial nations. Up until the post-World War II era, Finland was a predominantly agrarian country, with the forest industry leading the industrial sector and forming the backbone of the export-driven economy. In 1860, at the threshold of industrialisation, 80 per cent of the adult population were employed or made a living in primary production.¹ During the next 100 years, industrialisation affected not only workers, but also the growing number of educated middle class who often had their roots in the countryside and traditional ways of living. Even in 1940, half of the population made their living in farming; by 1961, this had dropped to 31 per cent, and in 1980 only 11 per cent of the population were farmers.² Finland changed very quickly from an agrarian to industrial society, and then to a ‘post-industrial’ knowledge society.

Until 1809, Finland was part of Sweden, and between 1809 and 1917, it was part of the Russian Empire as a Grand Duchy. In late 1917, following the Russian Revolution, Finland gained independence, but only a few months later, the young nation experienced a brutal civil war. The civil war was in many ways a ‘class war’ in the sense that the socialist Red guards fought against the bourgeois White troops – and lost. There were many casualties (38,000 people), most of whom were ordinary folk who died on the front line or, if they were Reds, faced execution or fatal imprisonment after the war. The war left an open wound in the nation’s collective mindset and created an atmosphere of mutual distrust between the supporters of the Whites and the Reds. What it also meant was that, until the last years before the war, Finland was a semi-democratic ‘white republic’ with only relative freedom of expression. Socialist parties, representing the losing side in the civil war, were only partially tolerated, and, as the legal historian Lars Björne has demonstrated, between 1919 and 1944, approximately 4,000 people were sentenced on political grounds in the so-called communist trials.³

In a developing country such as Finland until the early decades of the 20th century, access to health care was very much dependent on one’s wealth: if you had money, you or your family members could go to a hospital or sanatorium. If you were poor, your chances of receiving medical treatment were much smaller. Therefore, only a small minority of the mentally ill from the disadvantaged classes were treated in a proper hospital; the great majority lived in their community, either with their family or as objects of a very rudimentary form of municipal poor relief, which included selling the poor in auctions, moving them from one house to another in the local community, or, from the late 19th century onwards, incarcerating them in poor houses.⁴ In short, the management of mental illness was very tightly linked with social class.

In this chapter, I will examine the early development of mental health care in late 19th- and early 20th-century Finland, and focus on the history of confining the indigent mentally ill during this period. I describe developments in mental health care as well as patient cases in one mental hospital in Northern Finland and the use of work as a form of therapy. My main argument is that, right from the start, social class was a determining force in the development of mental health care. In other words, class was not just one factor among other significant determinants shaping mental health care in Finland; it was intrinsic to the very establishment of certain institutional forms of confinement. What this meant in practice was that, until the post-war era, the great majority of mental patients were from the disadvantaged classes. Why this was the case is the principal question I will address in this chapter.

Mental illness, class, and poverty

One consequence of the late modernisation of Finland was a lingering understanding of mental illness as a social and moral problem rather than something medical. Those considered ‘crazy’, mad, or insane, lived in their local communities and were taken care of by their family, community, and the local authorities – usually the more affluent farmers and the clergy.⁵ In a developing country that was still almost wholly dependent on primary production, the social value and material security of individuals correlated very strongly with their ability to make a living and take care of themselves. Obviously, the mentally ill lacked this highly valued capacity for self-sufficiency and independent living.

An insane person was one more mouth to feed, so the first question in Finnish mental health care was, up until the 20th century, who will pay for the care of the mentally ill and who will provide them with shelter? The popular answer to this was ‘the family’, but it was also the official stance, as according to the Church Law of 1686, ‘the insane were first and foremost the responsibility of their family, in other words, the head of the household’.⁶ The family and the local community’s role in taking care of the insane has a long history in Nordic countries, that goes right back to the Middle Ages. If the family lived in abject poverty, the local congregation or, (towards the end of the 19th century) the local municipal social board, was in charge of these indigent mentally ill. Municipal social care was supervised, at least in principle, by representatives of the state – usually the Board of Health and governors of the provinces. The novel idea that the insane should be treated in an institution only established itself around the turn of the 20th century, and in more peripheral regions of the country the insane often remained in their local community until well into the 20th century – especially if they were only mildly deranged.⁷

In 1840, the Mental Health Care Act may have inaugurated the era of modern mental health care in Finland; but the 1889 version divided mental health care into two different spheres. It stipulated that the mentally ill should be treated in state mental hospitals and asylums for the chronically ill, as might be expected, but it also stipulated that municipalities have beds reserved for the ‘indigent mentally ill’ in their poor houses.⁸ In practice, this ‘mental health care’ was therefore nothing of the sort; it was rather a means of social control on the municipal level. This act, which laid the guidelines for Finnish mental health care for the next half a century, had been drawn up by the government’s Board of Health and MPs from each of the four estates in Parliament – or Diet (as it was summoned every three years or so) – then approved by the Tsar who, as the Grand Duke of Finland, had ultimate legislative power.

Prior to 1889, and in some places for decades later, the indigent mentally ill – elderly paupers, orphans, destitute children, and the feebleminded – were often sold at auction in the municipal halls to local farmers and tenant farmers (or crofters). In these ‘slave markets’, as the famous novelist Juhani Aho and other critics referred to this form of social care, the person who agreed to take care of a mentally ill person for the lowest fee usually won the bidding, and would take care of the insane person for that year in his house.⁹ Every year there would be a new auction, and the dependent would be put up ‘for sale’ again. Another more traditional form of social care in the countryside was to move the paupers, destitute, and homeless – including the mentally ill – from one house to another in turns. The more affluent the household (estimated by the taxes it paid), the longer they were assigned to look after these underprivileged people before they were sent on to the next house, and then the next, and the next. In some poorer households, these dependents stayed for only a day or two, while the better-off families provided them with basic security for months. As can be imagined, these two forms of ‘social welfare’ made these mostly helpless people vulnerable to neglect, abuse, and exploitation – especially in municipalities where supervision was lax. Yet, there are lots of anecdotes about pauper lunatics and other dependents avoiding and resisting custodial care in the poor house, because they feared (often with justification) that incarceration there would amount to a jail sentence.¹⁰

Following the 1889 Act, the indigent mentally ill were admitted to either the few public mental hospitals or their local municipal poor house. Quite often they would find themselves in the poor house first, and then they were taken to the mental hospital, provided that these overcrowded and understaffed institutions could admit new patients – which was not necessarily the case. What was also quite usual was that mental patients returned to the poor house from the hospital, if their mental state improved, or if the hospital physicians judged them to be chronically ill and (predominantly) non-violent. Sometimes the patient moved several times between poor house and hospital. At the same time as the number of poor houses grew, bigger towns – such as Helsinki, Turku, and Tampere – established their own municipal mental hospitals. Patients in these ‘urban’ institutions came from all walks of life: including industrial workers, domestic servants, merchants, and the urban educated middle class (Bildungsbürgertum).¹¹

The 1889 Act linked mental health care firmly to social care for the poor and needy. Thus, inadvertently or not, the act strengthened the association between mental illness and poverty. Moreover, it forced municipalities to organise mental health care in their region, an obligation for which they were ill-equipped, simply because they lacked resources and sometimes also the motivation, it seems, to truly develop medical care for the mentally ill in the community.

For middle- and upper-class Finns, there were a couple of small private mental hospitals in the country. In reality, the number of private institutions was much larger, it was just that, rather than calling themselves mental hospitals, they advertised themselves as sanatoria or ‘nerve sanatoria’. They provided care to patients who variously suffered from ‘weak nerves’, ‘exhaustion’, and a number of psychosomatic ailments, and who were in need of peace and quiet. These private sana...