Mental Health and Civic Virtue: Psychiatry, Self-Development and Citizenship in the Netherlands, 1870-2005

As a product of nineteenth-century bourgeois society, psychiatry developed in a dynamic between social-political integration and exclusion. Into the twentieth century, institutional psychiatry fulfilled two functions: a medical one (care and cure), which gave priority to the interests of patients, and a social-political one (segregation), which was geared toward freeing society of the nuisance and danger associated with the insane. Which function was most prominent varied with a country’s political constellation. From around 1840 various West-European countries adopted legal regulations for the institutionalisation of the insane. Within the margins of the constitutional state, they served to protect citizens against random deprivation of freedom and to allow for effective admission procedures to ensure public order as well as medical treatment for mental patients. The hospitalised insane fell under special jurisdiction and state supervision, which implied a suspension of their civic rights. The liberal contract society assumed autonomous individuals who were capable of serving their own rights and interests while respecting those of others. Liberalism linked citizenship to rationality, autonomy, and responsibility, which were precisely the qualities mental patients had to do without. Mental incapacity counted in fact as the opposite of citizenship as it had been articulated on the basis of the ideals of freedom and equality since the American and French Revolutions.
The relationship between institutional psychiatry and liberal-democratic citizenship was ‘negative’ or ‘exclusive’ in the sense that hospitalisation in an asylum generally required legal certification and therefore the loss of basic civil rights. In the course of the twentieth century, however, a more ‘positive’ or ‘inclusive’ connection between psychiatry and citizenship was established in two ways. Firstly, the last three decades of the last century saw a growing recognition of the civil rights of the mentally ill, reflecting a shift from values associated with maintaining law and order to values associated with mental patients’ autonomy and consent. Secondly, from the early twentieth century on, in psychiatry as well as in the broader field of mental health care, psychological definitions of citizenship were advanced. Expressing views about the position of individuals in modern society and their possibilities for self-development, psychiatrists and other mental health workers connected mental health to ideals of democratic citizenship. Thus, they were clearly involved in the liberal-democratic project of promoting not only productive, responsible and adaptive citizens, but also autonomous, self-conscious, and emancipated individuals.
In this article I focus on the development of mental health care in the Netherlands from the late nineteenth to the early twenty-first century in order to explore its relation to socio-political modernisation in general and changing meanings of citizenship in particular. Citizenship took on a broad meaning, not just in terms of political rights and duties, but also in the context of material, social, psychological, and moral conditions that individuals should meet in order to develop themselves and be able to act according to those rights and duties in a responsible way. On the basis of the four different ideals of self-development that I identify, my account is divided into four periods: 1870-1945 (self-development through social adaptation), 1945-1965 (guided self-development), 1965-1985 (spontaneous self-development), and 1985-2005 (autonomous self-development). In the last section I will elaborate some more general characteristics of Dutch mental health care in its socio-political context.