379:, public asylums expanded in size and number. Bound up in this was the development of the profession of psychiatry, able to expand with large numbers of inmates collected together. By the end of the 19th century and into the 20th, these large out-of-town asylums had become overcrowded, misused, isolated and run-down. The therapeutic principles had often been neglected along with the patients. Moral management techniques had turned into mindless institutional routines within an authoritarian structure. Consideration of costs quickly overrode ideals. There was compromise over decoration—no longer a homey, family atmosphere but drab and minimalist. There was an emphasis on security, custody, high walls, closed doors, shutting people off from society, and physical restraint was often used. It is well documented that there was very little therapeutic activity, and medics were little more than administrators who seldom attended to patients and mainly then for other, somatic, problems. Any hope of moral treatment or a family atmosphere was "obliterated". In 1827 the average number of asylum inmates in Britain was 166; by 1930 it was 1221. The relative proportion of the public officially diagnosed as insane grew.
184:, where eventually about 30 patients lived as part of a small community in a quiet country house and engaged in a combination of rest, talk, and manual work. Rejecting medical theories and techniques, the efforts of the York Retreat centered around minimizing restraints and cultivating rationality and moral strength. The entire Tuke family became known as founders of moral treatment. They created a family-style ethos and patients performed chores to give them a sense of contribution. There was a daily routine of both work and leisure time. If patients behaved well, they were rewarded; if they behaved poorly, there was some minimal use of restraints or instilling of fear. The patients were told that treatment depended on their conduct. In this sense, the patient's moral autonomy was recognized. William Tuke's grandson,
431:
themselves until they felt guilt and remorse. The doctor, despite his lack of medical knowledge about the underlying processes, had all powers of authority and defined insanity. Thus
Foucault argues that the "moral" asylum is "not a free realm of observation, diagnosis, and therapeutics; it is a juridical space where one is accused, judged, and condemned." Foucault's reassessment was succeeded by a more balanced view, recognizing that the manipulation and ambiguous "kindness" of Tuke and Pinel may have been preferable to the harsh coercion and physical "treatments" of previous generations, while aware of moral treatment's less benevolent aspects and its potential to deteriorate into repression.
357:"non-restraint movements" also developed. There was great belief in the curability of mental disorders, particularly in the US, and statistics were reported showing high recovery rates. They were later much criticized, particularly for not differentiating between new admissions and re-admissions (i.e. those who hadn't really achieved a sustained recovery). It has been noted, however, that the cure statistics showed a decline from the 1830s onwards, particularly sharply in the second half of the century, which has been linked to the dream of small, curative asylums giving way to large, centralized, overcrowded asylums.
316:. He limited his practice to mental illness and developed innovative, humane approaches to treatment. He required that the hospital hire intelligent and sensitive attendants to work closely with patients, reading and talking to them and taking them on regular walks. He also suggested that it would be therapeutic for doctors to give small gifts to their patients every so often. However, Rush's treatment methods included bloodletting (bleeding), purging, hot and cold baths, mercury, and strapping patients to spinning boards and "tranquilizer" chairs.
145:
sympathy and kindness as well as authority and control. In 1797, Pussin first freed patients of their chains and banned physical punishment, although straitjackets could be used instead. Patients were allowed to move freely about the hospital grounds, and eventually dark dungeons were replaced with sunny, well-ventilated rooms. Pussin and Pinel's approach was seen as remarkably successful and they later brought similar reforms to a mental hospital in Paris for female patients,
372:"; that its implication that the "alleged lunatics" needed re-educating meant it treated them as if they were children incapable of making their own decisions; and that it failed to properly inform people of their rights or involve them in discussion about their treatment. The Society was suspicious of the tranquility of the asylums, suggesting that patients were simply being crushed and then discharged to live a "milk sop" (meek) existence in society.
153:(1772–1840), went on to help establish 10 new mental hospitals that operated on the same principles. There was an emphasis on the selection and supervision of attendants in order to establish a suitable setting to facilitate psychological work, and particularly on the employment of ex-patients as they were thought most likely to refrain from inhumane treatment while being able to stand up to pleading, menaces, or complaining.
86:
conditions, often in chains and neglected for years or subject to numerous torturous "treatments" including whipping, beating, bloodletting, shocking, starvation, irritant chemicals, and isolation. There were some attempts to argue for more psychological understanding and therapeutic environments. For example, in
England
279:
from 1838 to 1859, Browne implemented his general approach of moral management, indicating a clinical sensitivity to the social groupings, shifting symptom patterns, dreams and art-works of the patients in his care. Browne summarised his moral approach to asylum management in his book (actually the
85:
and its focus on social welfare and individual rights. At the start of the 18th century, the "insane" were typically viewed as wild animals who had lost their reason. They were not held morally responsible but were subject to scorn and ridicule by the public, sometimes kept in madhouses in appalling
68:
system in
Western Europe at that time. It fell into decline as a distinct method by the 20th century, however, due to overcrowding and misuse of asylums and the predominance of biomedical methods. The movement is widely seen as influencing certain areas of psychiatric practice up to the present day.
352:
The moral treatment movement was initially opposed by those in the mental health profession. By the mid-19th century, however, many psychologists had adopted the strategy. They became advocates of moral treatment, but argued that since the mentally ill often had separate physical/organic problems,
144:
for male patients. From the mid-1780s, Pinel was publishing articles on links between emotions, social conditions and insanity. In 1792 (formally recorded in 1793), Pinel became the chief physician at the
Bicetre. Pussin showed Pinel how really knowing the patients meant they could be managed with
430:
and its relationship to the normal. A patient in the asylum had to go through four moral syntheses: silence, recognition in the mirror, perpetual judgment, and the apotheosis of the medical personage. The mad were ignored and verbally isolated. They were made to see madness in others and then in
119:
instituted humanitarian reforms. Between 1785 and 1788 he managed to outlaw chains as a means of restraint at the Santa
Dorotea hospital, building on prior attempts made there since the 1750s. From 1788 at the newly renovated St. Bonifacio Hospital he did the same, and led the development of new
335:
and all over the country. She supported the moral treatment model of care. She spoke to many state legislatures about the horrible sights she had witnessed at the prisons and called for reform. Dix fought for new laws and greater government funding to improve the treatment of people with mental
356:
The moral treatment movement had a huge influence on asylum construction and practice. Many countries were introducing legislation requiring local authorities to provide asylums for the local population, and they were increasingly designed and run along moral treatment lines. Additional
69:
The approach has been praised for freeing sufferers from shackles and barbaric physical treatments, instead considering such things as emotions and social interactions, but has also been criticised for blaming or oppressing individuals according to the standards of a particular
156:
Pinel used the term "traitement moral" for the new approach. At that time "moral", in French and internationally, had a mixed meaning of either psychological/emotional (mental) or moral (ethical). Pinel distanced himself from the more religious work that was developed by
382:
Although the
Retreat had been based on a non-medical approach and environment, medically based reformers emulating it spoke of "patients" and "hospitals". Asylum "nurses" and attendants, once valued as a core part of providing good
353:
medical approaches were also necessary. Making this argument stick has been described as an important step in the profession's eventual success at securing a monopoly on the treatment of "lunacy".
161:, and in fact considered that excessive religiosity could be harmful. He sometimes took a moral stance himself, however, as to what he considered to be mentally healthy and socially appropriate.
136:(1745–1826), are also recognized as the first instigators of more humane conditions in asylums. From the early 1780s, Pussin had been in charge of the mental hospital division of the
719:
Borthwick, Annie; Holman, Chris; Kennard, David; McFetridge, Mark; Messruther, Karen and Wilkes, Jenny (2001). "The relevance of moral treatment to contemporary mental health care".
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renewed the argument that moral treatment had really been a new form of moral oppression, replacing physical oppression, and his arguments were widely adopted within the
216:(1776–1832) visited Edinburgh and lectured on his craniological and phrenological concepts, arousing considerable hostility, not least from the theologically doctrinaire
754:
255:
during his time as a medical student in
Edinburgh in 1826/1827. William Browne advanced his own versions of evolutionary phrenology at influential meetings of the
90:
popularized the idea that there is a degree of madness in most people because emotions can cause people to incorrectly associate ideas and perceptions, and
331:
and was shocked at the conditions for the inmates and the treatment of those with mental illnesses. She began to investigate and crusaded on the issue in
544:
Vincenzo
Chiarugi (1759–1820) and his psychiatric reform in Florence in the late 18th century (on the occasion of the bi-centenary of his birth)
296:, in which he recorded a generous appreciation of the role of the phrenologists in the early foundations of psychiatric thought and practice.
543:
464:
323:(1802–1887), also helped make humane care a public and a political concern in the US. On a restorative trip to England for a year, she met
285:
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180:, following the death of a fellow Quaker in a local asylum in 1790. In 1796, with the help of fellow Quakers and others, he founded the
146:
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224:(1805–1885), responded very positively to this materialist conception of the nervous system and, by implication, of mental disorder.
1107:
847:
705:
Louis C Charland (2008) A moral line in the sand: Alexander
Chrichton and Philippe Pinel on the psychopathology of the passions. In
640:
Weiner DB (September 1979). "The apprenticeship of
Philippe Pinel: a new document, "observations of Citizen Pussin on the insane"".
408:
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200:
A very different background to the moral approach may be discerned in Scotland. Interest in mental illness was a feature of the
443:
256:
237:
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The moral treatment movement is widely seen as influencing psychiatric practice up to the present day, including specifically
1122:
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387:, were often scapegoated for the failures of the system. Towards the end of the 19th century, somatic theories, pessimism in
361:
292:(1840–1938), did much to extend his father's work in psychiatry, and, on 29 February 1924, he delivered a remarkable lecture
112:
1117:
288:, and by his election to the Presidency of the Medico-Psychological Association in 1866. Browne's eldest surviving son,
1102:
368:
was proclaiming that the new moral treatment was a form of social repression achieved "by mildness and coaxing, and by
52:
discipline that emerged in the 18th century and came to the fore for much of the 19th century, deriving partly from
419:
247:
This tradition of medical materialism found a ready partner in the Lamarckian biology purveyed by the naturalist
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268:
228:(1788–1858), an Edinburgh solicitor, became an unrivalled exponent of phrenological thinking, and his brother,
31:
768:
435:
232:(1797–1847), who was later appointed a physician to Queen Victoria, wrote a phrenological treatise entitled
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occurred in many countries in the West, and asylums in many areas were gradually replaced with more local
404:
324:
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suggested a more psychological approach, but conditions generally remained poor. The treatment of King
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212:(1714–1766) emphasising the clinical importance of psychiatric disorders. In 1816, the phrenologist
284:. His achievements with this style of psychiatric practice were rewarded with his appointment as a
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221:
137:
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217:
188:, published an influential work in the early 19th century on the methods of the retreat; Pinel's
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176:(1732–1822) independently led the development of a radical new type of institution in northern
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or moral concerns. The movement is particularly associated with reform and development of the
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that were to offer moral treatment. Many asylums were built according to the so-called
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252:
205:
133:
91:
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had by then been published, and Samuel Tuke translated his term as "moral treatment".
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Chapter Four: Moral Treatment Reconsidered. Berkeley: University of California Press
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also led to increased optimism about the possibility of therapeutic interventions.
70:
45:
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Ackerson, BJ. & Korr, WS. (2007) Mental Health Policy and Social Justice in [
427:
987:
Social Order/Mental Disorder: Anglo-American Psychiatry in Historical Perspective
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Chapter 2: An archaeology of psychiatric readmission. University of South Africa
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236:(1831). George and Andrew Combe exerted a rather dictatorial authority over the
181:
17:
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medical school in the eighteenth century, with influential teachers including
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30:"Moral therapy" redirects here. For the modern therapeutic technique, see
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10.1002/(SICI)1520-6696(199723)33:4<381::AID-JHBS3>3.0.CO;2-S
661:
577:
392:
276:
866:
1012:
391:, and custodialism had returned. Theories of hereditary degeneracy and
177:
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took over, and in the 20th century the concepts of mental hygiene and
999:
Hollander R (1981). "Moral treatment and the therapeutic community".
271:(the Montrose Asylum) from 1834 to 1838, and, more extravagantly, at
170:
781:
Benjamin Rush, M.D. (1749–1813): “The Father of American Psychiatry”
500:
Laffey P (October 2003). "Psychiatric therapy in Georgian Britain".
1042:
Peloquin SM (August 1989). "Moral treatment: contexts considered".
336:
disorders from 1841 until 1881, and personally helped establish 32
881:"Advocacy or folly: the Alleged Lunatics' Friend Society, 1845-63"
141:
49:
867:
Readmission and the social construction of mental disturbance
399:
developed. From the mid 20th century, however, a process of
251:(1793–1874) who exercised a striking influence on the young
677:"Chiarugi and Pinel considered: Soul's brain/person's mind"
304:
A key figure in the early spread of moral treatment in the
450:
is said to have echoes of the concept of moral treatment.
364:
and their allies. By the mid-19th century in England, the
839:
Contesting Psychiatry: Social movements in Mental Health
280:
transcripts of five public lectures) which he entitled
836:
Crossley, Nick (2006). "Contextualizing contention".
438:(although they were intended to be less repressive);
426:" and how society defines normalcy by defining the
769:Advancing social justice through clinical practice
483:describing actions of the Quakers towards equality
220:. Some of the medical students, however, notably
556:Nemiah JC (September 1979). "Pussin redivivus".
477:(First institution to implement moral treatment)
81:Moral treatment developed in the context of the
831:
829:
422:movement. Foucault was interested in ideas of "
861:
859:
327:. In 1841 she visited a local prison to teach
1076:Shepherd, G., Boardman, J., Slade, M. (2008)
8:
930:"A history of the training of asylum nurses"
753:: CS1 maint: multiple names: authors list (
132:and his wife Margueritte, and the physician
244:expulsion of the Christian phrenologists.
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120:rules establishing a more humane regime.
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282:What Asylums Were, Are, and Ought To Be
240:, and in the mid-1820s manipulated the
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312:(1745–1813), an eminent physician at
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465:Humane treatment of the mentally ill
946:10.1046/j.1365-2648.1993.18081193.x
360:There was also criticism from some
286:Commissioner in Lunacy for Scotland
1087:Sainsbury Centre for Mental Health
709:By Louis C. Charland, Peter Zachar
234:Observations on Mental Derangement
25:
798:American Journal of Public Health
149:. Pinel's student and successor,
111:Under the Enlightened concern of
792:Parry, Manon S. (1 April 2006).
409:community mental health services
366:Alleged Lunatics' Friend Society
257:Edinburgh Phrenological Society
238:Edinburgh Phrenological Society
115:in Florence, Italian physician
267:. Later, as superintendent of
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865:Martin Terre Blanche (1999)
27:Mental disorder intervention
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1078:Making Recovery a Reality.
794:"Dorothea Dix (1802–1887)"
591:Grange KM (October 1963).
546:J Hist Med. Oct;14:424-33.
113:Grand Duke Pietro Leopoldo
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897:10.1017/s0025727300045701
727:(4). Routledge: 427–439.
707:Fact and value in emotion
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514:10.1017/S0033291703008109
1108:History of mental health
973:Madness and Civilization
810:10.2105/AJPH.2005.079152
721:Journal of Mental Health
319:A Boston schoolteacher,
269:Sunnyside Royal Hospital
32:Moral reconation therapy
842:. New York: Routledge.
436:therapeutic communities
879:Hervey N (July 1986).
733:10.1080/09638230124277
654:10.1176/ajp.136.9.1128
570:10.1176/ajp.136.9.1175
405:deinstitutionalization
294:The Story of the Brain
1123:Psychiatric hospitals
1056:10.5014/ajot.43.8.537
481:Testimony of equality
314:Pennsylvania Hospital
290:James Crichton-Browne
261:Royal Medical Society
1118:Ethics in psychiatry
593:"Pinel or Chiarugi?"
460:Erwadi fire incident
440:occupational therapy
370:solitary confinement
190:Treatise On Insanity
130:Jean-Baptiste Pussin
1103:Abnormal psychology
249:Robert Edmond Grant
222:William A.F. Browne
40:was an approach to
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1013:10.1007/BF01064897
970:Foucault, Michel.
675:Gerard DL (1998).
375:In the context of
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928:Nolan PW (1992).
377:industrialization
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