MENTAL ILLNESS

The understanding and treatment of mental illness changed radically between 1754 and 1829. Two major, related trends can be discerned: a move towards a more benevolent, nontheological approach to persons considered insane and the establishment of the first institutions in British North America designed to treat mental illness.

1754–1790s

By the 1750s, colonists in British North America who were influenced by the European Enlightenment increasingly questioned Calvinist concepts of the innate evil of mankind and pessimism about human life, as well as age-old Christian beliefs that demonic possession and sinful natures caused insanity, for which the insane deserved punishment. On the European continent, optimistic Enlightenment views that human nature was malleable and that nature could be controlled by knowledge-based action fostered a secular approach to mental disorders. Although not new, the idea that mental afflictions were diseases, natural phenomena, and thus subject to medical treatment, became more common in British North America and began to be expressed institutionally. The colonists wanted to emulate Europe in establishing enlightened institutions in North America. Furthermore, population growth and urban development, especially in the northern colonies, produced fears of deranged persons wandering freely in the community.

The Pennsylvania Hospital, the first hospital in the colonies, established by Quakers in Philadelphia in 1754, accepted mental patients. In support of that policy, Benjamin Franklin—preeminent civic activist, creator of institutions, and promoter of the hospital—pointed to London's venerable Bethlem Royal Hospital ("Bedlam") for the mentally ill, where twothirds of patients reportedly recovered (an exaggerated claim). At the Pennsylvania Hospital more than a generation later, Dr. Benjamin Rush—scientist, reformer, and "father of American psychiatry"—advocated humanizing the care of mental patients. However, his heroic therapeutic techniques, most notably extensive bloodletting and dosing with chemicals, did not work. Rush and his contemporaries could accurately describe symptoms of mental illness, but they had limited scientific understanding of it, and their physical remedies were minimally effective.

Another early institutional model was the first publicly supported hospital exclusively for mental patients in the colonial capital of Williamsburg, Virginia. Opened in 1773 as a secular, humane institution, it demonstrated to the governor and other elite founders the advanced state of their civil society (slavery notwithstanding).

Throughout the colonies, though, most "insane" persons—often chained in basements or attics at home, languishing in almshouses and jails, or roaming about neighborhoods—remained untreated, and physicians, however enlightened, lacked verifiable knowledge of the etiology of mental disorders, the physiology of the brain, and the nature of the "mind" and its relationship to a soul assumed to be immortal.

1790s–1829

By the end of the eighteenth century new approaches to the nature and treatment of mental disorder emerged in Europe and found their way to the United States. In revolutionary France Dr. Philippe Pinel, famous for removing chains from insane patients, initially considered insanity to be a self-limiting disorder that could be ameliorated by physically shocking the patient. When this technique failed, he adopted a "moral" treatment, whereby patients were managed primarily with compassion and moral suasion.

In England the Quaker leader Samuel Tuke independently devised and introduced a somewhat similar system in 1792 in a small new sectarian asylum. Tuke's example influenced fellow Quakers in the United States to open the Friends Asylum outside Philadelphia in 1817. Subsequently, Friends elsewhere were involved in founding several well known nonsectarian hospitals following the same therapeutic philosophy. They stressed humane care and occupational therapy, in a comfortable, friendly setting in bucolic surroundings, with patients away from their families, the cares of ordinary life, and fire and brimstone religious sermons—all believed to contribute to, if not cause, mental illness. While physicians visiting the facilities continued dosing and bleeding patients, the emphasis at the new institutions was on trying to affect the psyche through a benevolent, communal environment and training in self-control. Exactly how these techniques affected the mind was not made clear: these early British and American lay reformers were motivated by pragmatic and humanitarian concerns rather than medical science.

American physicians—like Pinel, whose psychiatric writings became available in English translation in 1806—considered insanity to be an essentially somatic (physical) disease. They viewed moral treatment, however humane, as nonmedical in nature and therefore incapable of curing insanity, although they had little else to offer and were stymied by the traditional mind-body dichotomy.

By 1829 the high recovery rates reported in moral-treatment hospitals seemed to justify therapeutic claims for the system. But only a relatively few mentally ill persons could benefit from such hospitals, as these institutions tended to cater to (white) families able to pay the fees. Physicians and laypeople both assumed that the sensitive upper classes were most likely to succumb to insanity, while lowerclass white people were much less susceptible and blacks and Indians least so. In fact, there was no evidence for most contemporary notions about the prevalence or incidence of insanity. By the mid nineteenth century, when state mental hospitals for the public proliferated, views about susceptibility reversed: now poor people, immigrants, and nonwhites were considered more apt to become insane and harder to treat. As before, social and class prejudice, combined with unsophisticated and erroneous statistics, influenced "scientific" attitudes.

Still, some of the early hospitals, by gathering patients together in an optimistic hospital environment, gave local communities experience with the insane to counterpose against traditional pessimistic, superstitious, and theological lore about mental illness. This change, together with an American belief in progress and overoptimism about curability (spawned by the presumed effectiveness of moral treatment), would help to inspire the later full-scale movement (beginning in the mid-nineteenth century) to build state mental hospitals, many with moral treatment as a goal. To be sure, an additional major consideration was always the perceived need to protect society, and at lowest cost. The difficulty of sustaining moral treatment, an expensive therapy, plus the intractability of much of mental illness and the failure of physicians to discover a somatic basis for it, dimmed the early high hopes and eventually alienated most advocates of moral treatment from the medical establishment. Cycling between psychological and somatic theories—the old mind-body split—continued through the years and is still used today, in practice if not in theory. The moral-treatment movement faded from history until the mid-twentieth century, to be rediscovered in a new era of reform, serious historical study of psychiatry, and radical critiques of medical concepts of mental illness and its treatment. By the beginning of the twenty-first century, contrary to revisionist writers like Michel Foucault (1926–1984), who viewed all societal efforts to improve the lot of the mentally ill as inherently exploitive, most historians would agree that moral treatment, its limitations notwithstanding, was a social advance.

See alsoFranklin, Benjamin; Health and Disease; Hospitals; Professions: Physicians; Quakers .

bibliography

Dain, Norman. Concepts of Insanity in the United States, 1789–1865. New Brunswick, N.J.: Rutgers University Press, 1961.

Grob, Gerald N. The Mad among Us: A History of the Care of America's Mentally Ill. New York: Free Press, 1994.

Jimenez, Mary Ann. Changing Faces of Madness: Early American Attitudes and Treatment of the Insane. Hanover, N.H.: Published for Brandeis University Press by University Press of New England, 1987.

Micale, Mark S., and Roy Porter, eds. Discovering the History of Psychiatry. Parts 4–5. New York: Oxford University Press, 1994.

Scull, Andrew, ed. Madhouses, Mad-Doctors, and Madmen: The Social History of Psychiatry in the Victorian Era. Philadelphia: University of Pennsylvania Press, 1981.

Norman Dain