Atlas›Domain XVI · Historical, discredited & harmful›Guide 018
Guide XVI-018

Custodial madhouses with chains and cages (Bethlem)

1247London
A 30 · L 54 · M 1620 interventions in the Trinity explorer
Client cardCompare
[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: the history of Bethlem Hospital ("Bedlam") in London and the English private madhouses of the 18th and early 19th centuries, as told by Bethlem Museum of the Mind and its archivist, by Andrews, Briggs, Porter, Tucker and Waddington's The History of Bethlem (Routledge), by Parry-Jones (1973) on private madhouses, and by the 1815 House of Commons Select Committee on Madhouses as the Museum and the Wellcome Collection record it. Present-day chaining follows Human Rights Watch's 2020 report Living in Chains. [source: Bethlem Museum of the Mind; Gale 2012; Parry-Jones 1973; HRW 2020]

This is a historical institution and a custodial regime, not a therapy. Bethlem was founded in 1247 as the Priory of St Mary of Bethlem. It admitted the sick by 1403 and by the mid-15th century was known as a place for the care of the mad. [source: Tiao, Hektoen International] For much of its history its main job was to confine people, with treatment secondary. Patients were kept in bed for much of the week and chained, sometimes for years. Until 1770 the public could come in to look at them. [source: Museum of the Mind, "200 Years Ago Today 14"; Gale 2012] Private, profit-making madhouses grew up next to it. From 1774 they needed a licence and could be inspected. [source: Parry-Jones 1973] The "core idea of change" was confinement and control, not recovery. People who campaigned to expose these conditions in 1814–15, and the non-restraint movement after them, brought about the changes that history now records. [source: Mellby 2010; RSM, Committed]

What this looked like, as the sources record it. In May 1815 Bethlem's new matron told the Committee on Madhouses that patients had been got up only three days a week and left lying in bed the other four, and that a patient in a "fit of irritation" was chained at once to the bed or to the wall and left there for a long time. Of the women in her care, one long-stay patient had been "chained by the leg" for five or six years and a woman admitted two months earlier was kept chained by the hands; others were chained at times and unchained now and then to walk about. She dismissed a keeper who had struck a patient on the head with a key [source: Museum of the Mind, "200 Years Ago 6" and "200 Years Ago Today 14"]. In 1814 reformers circulated an image of a male patient whose wrists could slip ordinary manacles and who was therefore confined in an iron harness made for him; it became the emblem of Bethlem's conditions [source: Tromans 2010]. This guide does not say how chains or harnesses were fastened. Section 4 covers the psychotherapist's own work: historical literacy; clients whose families include people held in asylums; clients drawn to the history; clients with their own experience of coercive care; and recognising and reporting chaining that still happens today. Present-day chaining has its own guide (104 Chaining and shackling) and so do prayer camps (XI 069). Moral treatment and non-restraint are covered in this domain's "Asylum era and its reforms" guides (028, 029). [synthesis]

2. Framework

Historical phases (in outline). [source: Gale 2012; Museum of the Mind; Tiao; Parry-Jones 1973; Mellby 2010; RSM]

  • Priory to hospital (1247 to the 15th century). A religious house that came to care for the sick and then for the mad.
  • Bishopsgate to Moorfields (to 1676; 1676–1815). In 1676 the hospital moved into a purpose-built building at Moorfields designed by Robert Hooke. Caius Gabriel Cibber's figures of "Raving and Melancholy Madness" stood on the gateposts. A surveyor later judged the building to be in an "incurable" state. It was pulled down in 1815.
  • Public visiting (until 1770). The public could visit at set times, and poor boxes stood by the entrance. Over the 17th and 18th centuries the governors tightened the rules on visitors. From 1770 a visitor needed a ticket signed by a governor, which in effect ended open visiting.
  • The madhouse trade (1774 onward). The 1774 Act for Regulating Madhouses brought in licensing and inspection. It went unamended for 54 years and made no provision for paupers. The 1808 County Asylum Act allowed counties to build asylums but did not require it. The 1845 Lunatics Act made county pauper asylums compulsory. The 1890 Lunacy Act limited the further growth of madhouses.
  • Exposure (1814–16). In 1814 the philanthropist Edward Wakefield found a patient who had been kept under restraint for about ten years. A former American seaman, he had been admitted in 1800. Wakefield, William Hone and James Bevans campaigned for change, and the Select Committee on Madhouses was formed in 1815. A picture of the patient, etched by George Cruikshank after a sketch by George Arnald, was shown to the Committee. The patient was released from restraint and died within a few months. [source: Mellby 2010] The Committee heard evidence from Bethlem's new Matron, Elizabeth Forbes, and about abuses in private madhouses. [source: Museum of the Mind; RSM] The resident apothecary John Haslam and the physician Thomas Monro left office after the inquiry. [source: RSM, Committed]
  • Moves and reform (1815 onward). Bethlem moved to St George's Fields, Lambeth, in 1815 and to the Beckenham–Croydon border in 1930. [source: Gale 2012; Wellcome print 1814] Robert Gardiner Hill gave up mechanical restraint at Lincoln in 1838, and John Conolly did the same at Hanwell from 1839. [source: RSM, Committed] Bethlem is now an NHS psychiatric hospital within South London and Maudsley NHS Foundation Trust, and its records are held by Bethlem Museum of the Mind. [source: Museum of the Mind archives; Tiao]
  • After the asylums. Later critics of custodial institutions are often taken to include Erving Goffman's Asylums and Thomas Szasz (both 1961). The claim that deinstitutionalisation left many people homeless or in prison is [uncertain: secondary, unverified].

Phases of the psychotherapist's work. [synthesis]

  1. Preparation and historical literacy. Goal: know the history accurately, including where myth and fact part company. Move on once you can tell a client what is documented and what is legend.
  2. Recognition and assessment. Goal: find out how the subject reaches this client. It might be an ancestor in the records, an interest in heritage or fiction, the client's own experience of restraint or coercive care, or chaining happening now in their family or community. Move on once you have assessed risk and safeguarding needs.
  3. Safety and safeguarding. Goal: act on any current chaining, restraint abuse or risk to a child or adult at risk, and assess suicide risk. This phase comes first whenever a current risk appears.
  4. Processing, meaning-making and repair. Goal: work with grief, shame, inherited stigma, fears about heredity, and trauma from coercion. Move on when the client can hold the history without being overwhelmed or defined by it.
  5. Advocacy, commemoration and follow-up. Goal: memorial acts, rights-based advocacy and planning the ending.

Session number and length follow the client's needs and the setting. [synthesis]

3. Guiding principles

  • Never reproduce the practice. In practice: you discuss confinement and chaining only in terms of their effects and meaning, never how they were done. [synthesis]
  • Separate documented history from "Bedlam" myth. In practice: myth and record differ. The Routledge history says Bethlem became "a cultural and literary myth". Its archivist argues that visitors probably numbered in the thousands a year, not the often-quoted 96,000. [source: Routledge; Gale 2012]
  • Attribute and date every historical claim. In practice: you tell the client who says what (the Museum, a named historian, the 1815 evidence) and flag points that are disputed. [synthesis]
  • Dignity of the people confined. In practice: you never name or display patients as curiosities. The historical gaze of the visitor is something to examine, not repeat. The Museum still calls the display of patients' misery "a powerful metaphor". [source: Museum of the Mind, Visiting Bethlem; synthesis]
  • The client's history belongs to the client. In practice: the client decides what to research, what to read, and when. [synthesis]
  • Safety comes before the story. In practice: current chaining or restraint abuse and suicide risk come before historical exploration. [synthesis]
  • Trauma-informed, non-coercive stance. In practice: offer choice, never pressure, and recognise that a person who has been restrained may experience the therapy room as a place of power. [synthesis]
  • Reform came from making things visible. In practice: you take seriously what clients witness in services today, as the 1814–15 campaigners did. They used testimony and pictures. [source: Mellby 2010; synthesis]
  • Rights framing for present-day chaining. In practice: you treat shackling as a human-rights issue. The UN Special Rapporteur on Torture has said it can "unequivocally amount(s) to torture", and the CRPD prohibits deprivation of liberty on the basis of disability. [source: HRW 2020]
  • Cultural humility. In practice: families who chain a relative often see no alternative, and some explain the illness in spiritual terms. You explore their frame without contempt and keep firm boundaries on safety. [source: HRW 2020; synthesis]
  • Avoid stigmatising language. In practice: you do not use "bedlam" or "madhouse" for the client's experience unless the client chooses to. [synthesis]
  • Stay within your role. In practice: you are the therapist, not the client's genealogist, lawyer or campaign organiser (see APA Ethics Code Standard 3.05). [source: APA Ethics Code; synthesis]

4. Intervention inventory

The interventions below are the psychotherapist's own work; steps not drawn from a cited source are marked [synthesis].

4.1 Building your own historical literacy

  • Purpose / when: before working with any client whose life touches this history, and whenever you notice yourself relying on the "Bedlam" stereotype. [synthesis]
  • Steps: (1) Learn the outline in section 2: the dates, the sites, the 1774, 1808, 1845 and 1890 Acts, and the events of 1814–15. (2) Read one standard history, such as Andrews et al., The History of Bethlem, and one primary record, such as the 1815 Committee reports catalogued by the Wellcome Collection. (3) Note the points historians dispute, such as how many visitors came and when visiting first became a spectacle. (4) Note that reform followed public exposure, inspection and legislation, not changes in treatment theory alone. [source: Routledge; Wellcome; Gale 2012; Parry-Jones 1973; synthesis]
  • Example language (illustrative): "Historians still argue about how many people came to look at the patients. The hospital's own archivist thinks it was thousands a year, not the much larger figure you sometimes read."
  • Watch for: repeating lurid legends as fact, or swinging the other way and denying documented harms. It is working when you can answer a client's question with a dated, attributed fact, or say plainly that something is not known.

4.2 Myth-and-fact psychoeducation about "Bedlam"

  • Purpose / when: when a client's fear of psychiatric care, or their shame about it, is shaped by the image of "Bedlam". [synthesis]
  • Steps: (1) Ask what images come to mind when they think of hospitals or asylums. (2) Acknowledge what is true: patients were chained, some for years, and the public once came to look at them. (3) Separate that from today. Bethlem is now an NHS hospital, and inspection and mental-health law developed partly because of the abuses that were exposed. (4) Invite the client's own questions, and let them choose how much detail they want. [source: Museum of the Mind; Gale 2012; Tiao; synthesis]
  • Example language (illustrative): "What you've read about chains was real, and it's right to be appalled. It's also part of why there are now laws, inspections and rights in hospital. Which parts of that worry you most for yourself?"
  • Watch for: reassurance that dismisses a fear grounded in the client's own experience of coercive care. If that experience is present, move to 4.9. It is working when fear becomes specific and open to discussion.

4.3 Exploring a family history of asylum admission

  • Purpose / when: when a client discovers or mentions an ancestor or relative who was confined in an asylum or madhouse. [synthesis]
  • Steps: (1) Ask how they found out and what the family story is. (2) Map who knew, who kept it secret and why. (3) Explore what the discovery means to them now: grief, shame, curiosity, or fear about heredity. (4) Agree whether they want to research further (4.4) or simply to work with the meaning. [synthesis]
  • Example language (illustrative): "Finding a great-grandmother in a hospital register can stir up a lot. What did you feel when you first saw her name there?"
  • Watch for: the client taking on inherited shame ("we were the mad family"), and family conflict about "digging up the past". It is working when the ancestor becomes a person with a story rather than a stigma.

4.4 Supporting archival research on an ancestor

  • Purpose / when: when a client chooses to look for records. [synthesis]
  • Steps: (1) Explain the main routes, described in outline to the client. Bethlem Museum of the Mind holds records of Bethlem, the Maudsley and Warlingham Park, including Bethlem admission registers from 1683 to 1902. Many are indexed on Find My Past. The Museum asks enquirers to contact it first, with the ancestor's name, evidence of a link to the hospital, and dates. Recent records fall under data-protection and medical-confidentiality rules and go to South London and Maudsley's Freedom of Information team. For other hospitals there is The National Archives' hospital records database. (2) The client does the research themselves. You help them prepare emotionally. (3) Agree how they will look after themselves if a record is distressing. [source: Museum of the Mind archives; synthesis]
  • Example language (illustrative): "The museum's archive asks you to write to them first with her name and dates. Would it help to plan when you'll read whatever comes back, and who'll be with you?"
  • Watch for: blurred roles. Do not run the search for the client (APA Ethics Code Standard 3.05). Watch also for the client opening records alone at a vulnerable moment. It is working when the client feels in control of the pace.

4.5 Processing distressing record content

  • Purpose / when: after the client has read case notes, registers or committee evidence describing an ancestor's confinement. [synthesis]
  • Steps: (1) Ask what they read, but let them choose how much to say. (2) Name the reaction (horror, anger, grief) and explore it. (3) Put the record in its historical context: the language of the time, and the views of whoever wrote it. (4) Help the client separate the institution's description of the person from the person themselves. [synthesis]
  • Example language (illustrative): "The notes were written by people who saw her mainly as a problem to manage. What do you imagine she would have wanted said about her?"
  • Watch for: intrusive imagery and sleep disruption. Watch also for over-identification ("that'll be me"). It is working when the client can talk about the record without being flooded.

4.6 Addressing fears of heredity

  • Purpose / when: when a family history of asylum admission feeds a fear that the client or their children are "bound" to become ill. [synthesis]
  • Steps: (1) Draw out the fear and the beliefs underneath it. (2) Point out that old diagnoses do not translate reliably into modern ones. (3) Where the client wants factual information about their own risk, refer them to their GP or primary care physician, or to a genetic-counselling service. Do not offer risk estimates yourself. (4) Work on how the fear affects the client's choices now. [synthesis]
  • Example language (illustrative): "The word in that register meant something different in 1850. If you'd like proper information about your own risk, your GP can point you to the right service. Meanwhile, how is this fear shaping your plans?"
  • Watch for: avoidance of relationships or of having children because of the fear, and health anxiety. It is working when the client's decisions are made from information rather than dread.

4.7 Working with a client's interest in the history

  • Purpose / when: when a client is drawn to asylum history, "Bedlam" fiction, abandoned-asylum exploration, or heritage visits. [synthesis]
  • Steps: (1) Ask what draws them: scholarship, family, their own experience, or fascination with horror. (2) Point them to responsible routes, such as the Museum, its learning resources and peer-reviewed histories. (3) Gently explore any re-enactment of the spectator's gaze. The Museum and its archivist treat visitors' reactions as part of the history: visitors felt both amused and ashamed. (4) Link the interest to the client's own goals. [source: Museum of the Mind, Visiting Bethlem; Gale 2012; synthesis]
  • Example language (illustrative): "Even in the 1780s some visitors noticed they were both entertained and ashamed. What does looking at this history do for you?"
  • Watch for: retraumatisation in clients with their own experience of hospital, and trespass or safety risks in derelict sites. It is working when the interest supports meaning rather than distress.

4.8 Working with stigma and language

  • Purpose / when: when the client uses, or has had used against them, words like "bedlam", "madhouse" or "lunatic". [synthesis]
  • Steps: (1) Notice the word and ask where it comes from in their life. (2) Give its history briefly: "Bedlam" came from Bethlem, and the hospital's reputation turned its name into a byword. (3) Explore how the label has become part of the client's self-image. (4) Help them choose the language they want for their own experience. [source: Dyer, Victorian Web; synthesis]
  • Example language (illustrative): "'Bedlam' was the nickname of one London hospital and it became an insult. Which words do you want to use for what you've been through?"
  • Watch for: the client turning humour against themselves to hide shame. It is working when the client describes themselves in less stigmatising terms.

4.9 Assessing a client's own experience of restraint, seclusion or coercive care

  • Purpose / when: when the client has been restrained, secluded, detained or treated against their will in any setting, or when historical material reminds them of this. [synthesis]
  • Steps: (1) Ask open, non-leading questions about past care, and offer the choice not to go into detail. (2) Screen for trauma symptoms with a validated measure you are licensed to use. (3) Ask whether any of it is still going on. If it is, go to 4.12. (4) Ask about current suicidal thoughts (see 4.18). (5) Agree on what feels safe in the room, such as seating, the door and breaks. [synthesis]
  • Example language (illustrative): "Some people who have been held down or locked in feel uneasy in rooms like this one. Is there anything about where we sit, or the door, that would help?"
  • Watch for: dissociation, hypervigilance, and the client experiencing the therapist as another controlling authority. It is working when the client says they feel in charge of what they disclose.

4.10 Trauma-focused processing and referral

  • Purpose / when: when restraint-related or institutional trauma meets the threshold for a trauma disorder. [synthesis]
  • Steps: (1) Do the work in a phased way: stabilisation and safety first. (2) Offer, or refer the client for, an evidence-based trauma-focused therapy recommended in current guidelines [uncertain: not verified]. (3) Coordinate with the client's psychiatric team if they have one. Do not advise on their medication. (4) Keep checking consent, including the right to stop at any point. [synthesis]
  • Example language (illustrative): "We go at your pace, and you can stop any time. You decide whether and when we turn to the worst memories."
  • Watch for: symptoms getting worse between sessions, and the client feeling forced to tell their story. It is working when symptoms ease and the client feels in control of the process.

4.11 Recognising present-day chaining and shackling

  • Purpose / when: when a client describes a relative being kept in chains, locked in a shed or room, or held at a faith-healing centre. This may be in the client's home country or in their community. [source: HRW 2020]
  • Steps: (1) Know the pattern HRW documented in 2020. Shackling was found in 60 countries. Those affected include men, women and children as young as 10, often held for years and hidden from neighbours. It happens in family homes, in state and private institutions, and in traditional and faith-healing centres. (2) Ask gently and specifically whether the person can move freely and leave. (3) Find out where it is happening, who is involved and whether a child is affected. (4) Cross-refer to the chaining guide (104) and the prayer-camp guide (XI 069). [source: HRW 2020; synthesis]
  • Example language (illustrative): "You mentioned your uncle is 'kept at the centre'. Is he free to walk around and to leave if he wants to?"
  • Watch for: the client minimising it as "for his own good", and shame stopping them from disclosing. It is working when the facts are clear enough for you to decide what to do next.

4.12 Safeguarding and reporting current chaining or restraint abuse

  • Purpose / when: when a person is being chained, confined or abused now, or a child is involved. [synthesis]
  • Steps: (1) If a child is involved, follow your mandatory reporting and child-protection procedures without delay. (2) For an adult at risk in your own jurisdiction, use the adult safeguarding route or the police. Explain the limits of confidentiality to the client. (3) Where the abuse is abroad, explore with the client what routes exist locally, such as health services, human-rights organisations or embassies, and record what you advised. (4) Consult your supervisor and record your decisions. [synthesis] The routes HRW recommends at system level are bans in law, independent monitoring with unannounced visits, confidential complaint systems, and community-based services. [source: HRW 2020]
  • Example language (illustrative): "Because a child is involved I have to pass this on to child protection, and I'll tell you what I'm saying. I'd like us to do this together."
  • Watch for: delay while waiting for certainty, and the client's fear of the family's reaction. It is working when the referral has been made and the client is still engaged.

4.13 Duties when a colleague or institution uses abusive restraint or confinement

  • Purpose / when: when you witness, or are told about, restraint or seclusion used as punishment, for long periods, or in degrading conditions in a service. [synthesis]
  • Steps: (1) Make sure anyone in immediate danger is safe. (2) Record what you saw or heard: facts, dates and witnesses. (3) Raise it through the service's safeguarding lead and its whistleblowing or speaking-up route. (4) If nothing changes, take it to the external inspectorate or regulator and to your professional body, using the routes they publish. (5) Never take part in, supervise or endorse the practice. [synthesis] The 1815 inquiry is a historical precedent: evidence from inside the institution, including the new Matron's testimony, helped bring about change. [source: Museum of the Mind; RSM]
  • Example language (illustrative, to a manager): "I saw a patient secluded for most of yesterday with no review. I've written it down, and I'm raising it with the safeguarding lead today."
  • Watch for: pressure to stay quiet, and retaliation. It is working when the concern is logged, acknowledged and investigated.

4.14 Working with families who feel they have no alternative

  • Purpose / when: when the client is a family member who has confined a relative, or is under pressure to do so, because services are lacking or the family is exhausted. HRW names these as drivers of shackling, along with stigma and very low spending on mental health. [source: HRW 2020]
  • Steps: (1) Recognise the burden without excusing the confinement. (2) Make clear that chaining harms the person and that you have safeguarding duties (4.12). (3) Map the support available: community mental-health services, crisis teams and carers' support. (4) Plan concrete next steps for getting the relative into voluntary, community-based care. [source: HRW 2020; synthesis]
  • Example language (illustrative): "You've been caring for your brother on your own for a long time. Locking him in isn't safe for him, and I can't leave it there. Let's work out who can help today."
  • Watch for: the family withdrawing from you, and the person being moved or hidden. It is working when the family accepts help and the confinement stops.

4.15 Working within a religious or spiritual frame

  • Purpose / when: when chaining or confinement happens in a spiritual setting, or the family sees the illness in spiritual terms. HRW found that such beliefs often lead families to faith healers first. [source: HRW 2020]
  • Steps: (1) Use the DSM-5-TR Cultural Formulation Interview and its supplementary module on spirituality, religion and moral traditions [uncertain: DSM-5-TR wording not verified]. (2) Where it fits, record a Religious or Spiritual Problem, code Z65.8. (3) Explore which parts of the faith support care, for example leaders who speak against chaining. HRW urges faith-based organisations to oppose it publicly. (4) Keep a firm boundary on safety while respecting the faith itself. [source: ICD-10-CM Z65.8 (Unbound Medicine); HRW 2020; synthesis]
  • Example language (illustrative): "Your faith matters a great deal to your family. Are there people in your community who would back getting her medical care as well as prayer?"
  • Watch for: setting faith against medicine in a way that drives the family away. It is working when faith becomes a source of support for safe care.

4.16 Rights-based advocacy

  • Purpose / when: when a client, or the clinician, wants to act beyond the individual case. [synthesis]
  • Steps: (1) Learn the frameworks: the CRPD, WHO's QualityRights initiative, WHO's Chain-Free Initiative (which freed 1,700 people in Somalia between 2007 and 2010), and the UN Special Rapporteur on Torture's statements. (2) Support the client's own choices about advocacy, for example joining survivor-led groups as those groups describe themselves. (3) Keep your therapeutic role separate from campaigning (APA Ethics Code Standard 3.05). [source: HRW 2020; APA Ethics Code; synthesis]
  • Example language (illustrative): "Some people find it helps to speak out. Others don't. If you want to, we can think about what that would cost you and what it would give you."
  • Watch for: advocacy being used to avoid personal grief, and burnout. It is working when the advocacy feels chosen and sustainable.

4.17 Reflective audit of coercion in your own practice

  • Purpose / when: regular self-review for clinicians working in services that use detention, seclusion or restraint, drawing on what the field learned from the madhouse era. [synthesis]
  • Steps: (1) Review where coercion touches your own work. (2) Ask what someone visiting from outside would see. The 1774 Act's inspection regime and the 1815 inquiry rested on the idea that what is seen gets reformed. (3) Bring examples to supervision. (4) Note the non-restraint pioneers at Lincoln (1838) and Hanwell (1839) as proof that institutions can change their practice. [source: Parry-Jones 1973; RSM, Committed; synthesis]
  • Example language (illustrative, in supervision): "If an inspector watched that admission, what would they write down?"
  • Watch for: defensiveness, and coercion coming to seem normal. It is working when specific practices change.

4.18 Suicide-risk assessment and crisis resources

  • Purpose / when: whenever discussion of institutional abuse, family history or current confinement goes with hopelessness or suicidal thoughts. Abusive institutions are linked to suicide and suicide attempts. [synthesis]
  • Steps: (1) Ask directly and calmly about suicidal thoughts, intent and plans. (2) Assess risk and protective factors using your service's standard approach. (3) Make a safety plan with the client and their supports, including counselling on restricting access to means where needed. (4) Give crisis resources: 988 (US) and Samaritans 116 123 (UK and Ireland). (5) Talk about it safely: no method details and no glamorising. [synthesis]
  • Example language (illustrative): "When people learn things like this, they sometimes have thoughts of not wanting to be alive. Has that happened for you?"
  • Watch for: sudden calm after distress, and the client withdrawing from their supports. It is working when the client agrees to a plan and uses their supports.

4.19 Memorial and commemoration work

  • Purpose / when: when the client wants to honour an ancestor or a group of people who were confined. [synthesis]
  • Steps: (1) Offer options: writing a letter to the ancestor, visiting Bethlem Museum of the Mind, marking a grave, or telling the family story with the person's dignity restored. (2) Let the client choose the form. (3) Process the experience in the following session. [source: Museum of the Mind; synthesis]
  • Example language (illustrative): "If you wrote to him now, what would you want him to know about how the family remembers him?"
  • Watch for: unresolved anger at relatives who committed the ancestor. It is working when the client feels the person has been given their place back.

4.20 Ending and follow-up

  • Purpose / when: as the work closes. [synthesis]
  • Steps: (1) Review what the client now knows and what they feel. (2) Check that any safeguarding actions have been completed. (3) Agree how they will handle new findings from the records or new family disclosures. (4) Offer a review appointment. [synthesis]
  • Example language (illustrative): "If another record turns up next year, what would you like to do with it, and would you want to come back to talk it through?"
  • Watch for: the ending stirring up memories of abandonment by institutions. It is working when the client leaves with a plan.

5. Handling problems

The problems below are the psychotherapist's own synthesis [synthesis]; a source tag marks any point drawn from a cited source.

  • The client gets stuck in horror at the history. Slow down. Move from the details to their meaning ("what does this say about how the world treats people like her?"). Add grounding techniques, and pause research for a while. [synthesis]
  • The client wants lurid detail. Hold the dignity boundary. Talk about effects, not methods, and explore what the detail would do for them. Point them to the Museum and to peer-reviewed histories rather than sensational accounts. [synthesis]
  • The client dismisses the history ("that was centuries ago"). Respect their choice. Gently note the links to the present: HRW documented shackling in 60 countries in 2020. Still, do not push the topic. [source: HRW 2020; synthesis]
  • Resistance born of earlier coercive care. Treat mistrust as understandable. Offer more choice, ask for feedback openly, and never use leverage such as threats of detention to secure engagement. Explain the limits of confidentiality honestly, at the start. [synthesis]
  • Overwhelm after reading records. Use 4.5 and stabilisation. Agree not to open further material between sessions without a plan. Check for suicide risk (4.18). [synthesis]
  • Non-adherence (records left unread, tasks dropped). Treat this as information, not failure. The client may be pacing themselves sensibly. Agree goals again. [synthesis]
  • Ruptures over safeguarding reports. Be open in advance about what you must report. Afterwards, name the strain, acknowledge the client's feelings, explain your duty again, and keep the door open. [synthesis]
  • Family conflict over disclosure of an ancestor. Help the client decide what to share and with whom, and whether family sessions or a referral would help. [synthesis]
  • Disputed or uncertain facts. When a fact is contested, such as how many people visited, when the spectacle began, or a family legend, say so and attribute each position. Gale (2012) sets the archivist's estimate against Waddington's and Allderidge's views, and Neely's argument against his own. [source: Gale 2012]
  • Clinician vicarious distress or guilt for the profession's history. Take it to supervision. You can acknowledge the profession's history without carrying personal blame for it, and turn the feeling into better practice (4.17). [synthesis]
  • Present-day chaining overseas with no clear reporting route. Record what you know. Consult your supervisor and, where available, human-rights or international health organisations. Support the client to act safely. Keep your own role clear (APA Ethics Code Standard 3.05). [source: HRW 2020; APA Ethics Code; synthesis]
  • A client recreating confinement (self-isolation, or locking themselves away). Assess risk, including self-neglect and suicide. Explore the meaning, possibly a link to family history. Bring in medical or crisis services if needed. [synthesis]
  • Requests for medication advice in the context of past forced treatment. Do not advise starting, stopping or changing any medicine. Support the client to discuss it with their prescriber and to use advocacy services. [synthesis]

Sources

Online sources:

Books cited:

  • Andrews, J., Briggs, A., Porter, R., Tucker, P., & Waddington, K. The History of Bethlem. Routledge [uncertain: year, 1997 or 1998].
  • Goffman, E. Asylums (1961) and Szasz, T. (1961) [uncertain: not verified].
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