Deviancy to Mental Illness: Nineteenth-Century Developments in the Care of the Mentally Ill
Deviancy to Mental Illness: Nineteenth-Century Developments in the Care of the Mentally Ill
At the opening of the nineteenth century the view of insanity was just beginning to shift from unacceptable deviancy to a form of treatable illness. During earlier periods those with mental illness were held in suspicion of demon possession and other unearthly states. Public mistrust and fear of the insane resulted in their confinement, perpetually shackled in miserable cells. In the spirit of the Enlightenment an objective assessment of insanity permitted social and medical efforts to examine the causes and possible cures of the afflicted. A leading goal in the care and treatment of mental illness was to shepherd sufferers back into to the fold of normal society in the interest of preserving social order. Though the causes of mental illness were not identified and few cures emerged, the new empirical approach to the care and treatment of the mentally ill punctuated the beginning of an era that witnessed vast improvements on their behalf. By the end of the nineteenth century medical science had devoted prodigious efforts towards the study of mental illness, and fervent social reformers sought improvements for the care of the mentally ill.
French physician Philippe Pinel (1745-1826) revolutionized the care of mentally ill. Pinel, while working in Paris at the turn of the nineteenth century, championed the notions that the environment, not intangible forces, was a causal factor for insanity and that mental illness was curable. Pinel's work set forth a novel trend in the treatment of the mentally ill, since he helped to disentangle the causes of mental illness from abstract deviancy. Since the environment was significant to mental health in Pinel's framework, he changed the asylum environment by releasing the mentally ill from their shackles. Pinel also introduced traitement moral (moral treatment), which established a social interaction-oriented approach to the treatment of mental illness for the newly released patients. With traitement moral Pinel practiced empirical observation of and interaction with patients, in a form of trial and error, to uncover patterns of lucidity and triggers for normal and abnormal states in his patients. Although Pinel denied the benefits of restraints and corporal punishment for the mentally ill, he did condone verbal chastisement and threats to maintain control over patients. Though most of Pinel's assertions were not original, his approach to and execution of treatment for the mentally ill opened the door for changes and improvements in the care of the mentally ill.
Along with Philippe Pinel, Italian physician Vincenzio Chiarugi (1759-1820) and American physician Benjamin Rush (1745-1813) worked in their respective countries to reform the care of the insane by treating the condition as an illness, rather than deviancy, during the early nineteenth century. The efforts of Quaker merchant William Tuke (1732-1822), however, proved more influential than the work of either Chiarugi or Rush. At England's York Retreat Tuke continued the Quaker tradition of moral reform for dependent groups by implementing new practices in the care of the mentally ill. Like Pinel, Tuke shirked the use of restraints and corporal punishment as a means to control inmates. Instead, the mentally ill were likened to children, and as such, the use of threats and intimidation produced the desired beneficial results. Tuke's model left open the possibility that patients would recover given the opportunity. The expenditure of patience and time-consuming observation paid off with patients released as cured. Asylums for the mentally ill garnered a fresh air of legitimacy as a result of Pinel and Tuke's work. With large asylums held in higher esteem, local authorities were offered a new respectable place to relocate the mentally ill.
Throughout the nineteenth century the proponents of various schools of thought investigated diagnostic models for mental illness. Swiss theologian Johann Kasper Lavater (1741-1801) advocated the classification of facial features to evaluate character and personality in the field of physiognomy. In the same vein Austrian anatomist Johann Spurzheim (1776-1832) advocated phrenology, the study of head shape, to diagnosis mental problems. Although physiognomy and phrenology were debunked by the close of the nineteenth century, the tangible aspects of both methods offered stiff competition to the emerging field of psychiatry, which did not link physical characteristics with mental, personal, or emotional states. Instead, early psychiatrists, who initially were physicians working in asylums, followed empirical observations of patient behavior and generally linked patients' conditions with physical (accident, brain lesion) or moral (excessive behaviors like greed or masturbation) phenomena. Unlike twentieth-century psychiatry, which generated a plethora of diagnostic terms for neuroses, nineteenth-century psychiatry was more conservative and held to only five categories of mental illness: mania, melancholia, monomania, dementia, and idiocy.
Despite the advances made by Pinel and his contemporaries, improvements for the majority of the mentally ill progressed slowly throughout the nineteenth century. Physical restraint of the mentally ill with muffs, shackles, collars, cribs, and strong chairs declined during the nineteenth century but never disappeared entirely. Physicians in the United States and England participated in lengthy debates on the value of restraint. Where American physicians believed temporary restraint was useful to calm excited patients, English physicians insisted all forms of restraint were unnecessary and associated the American use of restraints to its legacy of slavery. Other antiquated ideas persisted into but eventually perished during the nineteenth century. For example, the long-held myth that the insane did not suffer from the elements led to horrid conditions with inmates exposed to the extremes of weather conditions without the benefit of clothing or heat. Fortunately, that myth was put to rest by the midpoint of the century, due to the acceptance of mental illness as a treatable condition. While physical restraint declined and humane living conditions came into vogue, chemical restraint (ether, chloroform, etc.) emerged as a non-physical means to restrain excited patients. Chemical restraint, however, lost popularity almost as quickly as it came into fashion.
In the United States and Europe Pinel's traitement moral was adopted and implemented in the construction of asylums and the care of the mentally ill. Outside of France traitement moral was translated to "moral treatment," which included "morality" along with Pinel's empirical methods. By and large the incorporation of morality affected the design and atmosphere of nineteenth-century asylums. The basic structure of nineteenth-century asylums was modeled after the family unit. This system raised inmates to the status of children and the asylum superintendents to the role of caring parents. In this scheme the goal was for the parental superintendents to raise the childlike inmates to the plateau of the sound mind. In the family model labor therapy provided a handy diversion for inmates. Nearly ubiquitous in Europe and the United States by the mid-nineteenth century, labor therapy quickly gained popularity under the rubric of moral treatment since it set inmates to work, thereby modeling the productive activities of the outside world. Also in the effort re-create society, the cottage system in asylum design reflected small communities with clusters of cottages housing mentally ill patients under treatment.
In the United States Unitarian social reformer Dorothea L. Dix (1802-1887) proved to be the greatest advocate for improved conditions for the mentally ill. Dix was influenced by William Tuke's methods during her visits at the York Retreat in England. Upon her return to America Dix spearheaded a campaign to create federal asylums for the care of the mentally ill. To provide evidence of the need for federal responsibility, Dix systematically visited county poor-houses in several American states and reported the lamentable conditions to the U.S. Congress. Dix claimed the mentally ill suffered a variety of horrors and immoral conditions in local poor-houses throughout the country. And, while some houses were better than others, Dix insisted the range in quality was unacceptable. Dix argued the need for one standard of care that was defined by the national government. That standard, Dix hoped, would insure equal care to all the mentally ill in asylums. The plan for a federal system, however, was thwarted as too ambitious. Dix's next attempt was to lobby individual state legislatures with the intent of creating state level statutes. Dix was more successful on that front. In New York, for example, the legislature passed the Willard Act of 1865, which mandated state level care of insane paupers, which was later strengthened with the State Care Act of 1890.
A notable nineteenth-century advancement in the care of the mentally ill was the recognition of the possibility of recovery. By the mid-point of the nineteenth century, many asylums were built around the expectation that at least some patients would recover and others may not. The assignment of "acute" or "chronic" insanity to an inmate often dictated their life course. Acute insanity was generally an arbitrary one-to-two-year period in which a variety of treatments were attempted. If the patient recovered during that period, they were released from the asylum. If an inmate's mental illness extended beyond the arbitrary period, their condition was re-classed as chronic insanity, at which time chronic patients were transferred to an asylum for the chronically insane. Asylums for the chronically insane served a custodial role and offered limited forms of treatment. And, fulfilling caretaker's expectations, recovery rates at asylums for the chronically insane were very low. Institutions for the chronically insane drew negative attention since their inmate population was rather permanent, in comparison to acute asylums where inmates were in and out within two years whether they were cured or not. Thus, by the end of the nineteenth century, chronic institutions—with overcrowded wards filled with long-tenured inmates seemingly lost and forgotten in the fray—represented a dismal counterpoint to the otherwise positive developments in the treatment of the mentally ill during the century.
SHAWN M. PHILLIPS
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Grob, Gerald. The Mad Among Us: A History of the Care ofAmerica's Mentally Ill. Cambridge, MA: Harvard University Press, 1994.