Cowles on Hewitt (2020)

In her book Institutionalizing Gender: Madness, the Family, and Psychiatric Power in Nineteenth-Century France, Jessie Hewitt explores the history of psychiatry and the institution of the asylum in nineteenth-century France through the lens of class and gender. In tracing the development of the so-called moral treatment, initiated in France primarily by Philippe Pinel, she focuses on the ways the institution of psychiatry defined madness largely in terms of bourgeois norms of class and gender roles. Throughout her study, she draws attention to the inconsistencies of those norms: if bourgeois family life was celebrated as the ideal, why did doctors remove the mentally ill from their families; if a woman’s role as mother and “angel in the house” was somehow “natural,” how did women’s natural processes (menstruation, pregnancy, menopause) make them susceptible to mental illness; and if gender itself was “natural,” how could problems with gender roles lead to madness? The promotion of bourgeois norms as an indicator of sanity by the psychiatric profession, she argues, contributed to the reification of those norms in society at large. 

Hewitt’s analysis begins by detailing the methods and assumptions of the moral treatment: founded on the belief that a cure was possible, the treatment largely eschewed physical restraint and punishment in the asylum. Alienists—as practitioners of mental medicine were then called (2)—recognized socially determined desires in men like ambition and honor, in addition to physical conditions, as possible sources of madness, but generally excluded those social causes in women patients. The treatment for male patients assumed their inherent rationality and capacity for self-restraint, with the doctor providing the model of a constraining, but usually benevolent paternal authority. Hewitt’s discussion of the ethics of early psychiatry, revolving around practices like the cold shower, reveals that doctors also shared with those patients, and manipulated in their treatment, a code of male honor, enabling many alienists to eliminate physical punishment. For Hewitt, “honor had come to function as a proxy for rationality and thus, for manliness itself” (65). 

One of the most original aspects of Hewitt’s study is her inclusion of women as practitioners. Although they largely conformed to gender norms, both Jubline Pussin, the wife of Pinel’s surveillant, and Athalie Brierre de Boismont, the wife of a prominent director of a private asylum, played important roles in the treatment of patients, especially Brierre de Boismont, whose talent for observation and ability to act as the bourgeois matron in the simulated family of the asylum proved especially effective. Even more exceptionally, her daughter Marie Rivet, who lacked a medical degree but had long experience with mental patients, became the director of her own maison de santé for women. Rivet succeeded overall in balancing the cultural expectations of womanhood with her role as authority and her legitimacy as a lay expert. 

As Hewitt demonstrates, despite its importance in the legitimization and professionalization of early psychiatry, ultimately the moral treatment counted few real cures. Further, critics of the asylum system increasingly accused doctors of conspiring with those who sought to institutionalize mentally healthy family members in order to control their finances or prevent a disadvantageous marriage.  Citing several cases, Hewitt notes that the unjustly institutionalized who were able to marshal family sentiment and rationality in their defense proved most successful in gaining their release. Although doctors’ insistence that rationality confers autonomy might imply that women deserve equal rights, the case of a feminist activist committed to an asylum by her father suggests that progress was still needed in fin-de-siècle attitudes. 

Use of the moral treatment declined in the second half of the century, especially after the Franco-Prussian war and the Commune. Emphasis on heredity as a cause of madness, coupled with concerns about national decadence in the wake of defeat and the turmoil of the Commune, began to overshadow belief in psychological causes; it also led, according to Hewitt, to the abandonment of a treatment based on gender norms. The Franco-Prussian war offered the opportunity for alienists to reaffirm their devotion to their patients, and she provides several examples of the “Doctor as National Hero” (127). The judgment by many doctors that the Communards were mad and the alienists’ quickness to rally in support of the Third Republic also served to enhance their status and authority. The notion of confinement, the very basis of the asylum system, proved inconsistent with the values of the Third Republic, however, and Hewitt’s final chapter examines the alternatives that were explored at the end of the century. Alienists studied models of community care such as in Gheel, Belgium, but deemed them impractical and lax in terms of medical supervision. The most promising innovation came from the proposed “open door” asylum at Ville-Évrard, where patients could have freedom of movement, participate in farm work and crafts, and receive regular visits from their families.

In her conclusion, Hewitt brings the underlying questions of gender and power in nineteenth-century psychiatry squarely into focus. Despite the abandonment of the gender-based moral treatment by the end of the century, Hewitt finds that gender-normative expectations, determined by bourgeois male medical power, held sway in practice even as women demanded greater rights, as gender ideology revealed itself as ideology, and as Charcot and Freud dethroned the image of the bourgeois family. Nonetheless, she affirms that in the context of nineteenth-century psychiatric power, the interconnectedness of medical and gender ideologies undermined the status quo by exposing how the “natural” is a construct. 

Hewitt’s program is ambitious and her enquiry is multi-faceted. Her thoroughness in tracing the pertinent developments in nineteenth-century French psychiatry sometimes obscures the central focus on gender and family. We might wonder, too, if the inability of the moral treatment to effect viable cures led to its demise more than the question of the performance of gender norms, even though the failed performance of those norms as a definition of madness was certainly part of the equation. Nonetheless, Hewitt’s study is insightful, her emphasis on gender in psychiatric treatments prior to Charcot compelling, and her inclusion of women practitioners, creating a space of authority within gender expectations, original and much-needed.