Moral treatment

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Moral treatment was an approach to mental disorder based on humane psychosocial care or moral discipline that emerged in the 18th century and came to the fore for much of the 19th century, deriving partly from psychiatry or psychology and partly from religious or moral concerns. The movement is particularly associated with reform and development of the asylum 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. 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 social class or religion.

Contents

Context

Moral treatment developed in the context of the Enlightenment 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 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 John Locke 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 William Battie suggested a more psychological approach, but conditions generally remained poor. [1] The treatment of King George III also led to increased optimism about the possibility of therapeutic interventions.

Early development

Italy

Under the Enlightened concern of Grand Duke Pietro Leopoldo in Florence, Italian physician Vincenzo Chiarugi 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 rules establishing a more humane regime. [2]

France

The ex-patient Jean-Baptiste Pussin and his wife Margueritte, and the physician Philippe Pinel (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 La Bicêtre, an asylum in Paris for male patients. [3] From the mid-1780s, Pinel was publishing articles on links between emotions, social conditions and insanity. [4] 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 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. [5] 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, La Salpetrière. Pinel's student and successor, Jean Esquirol (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. [6]

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 the Tukes, 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. [7]

England

English Quaker William Tuke (1732–1822) independently led the development of a radical new type of institution in northern England, 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 York Retreat, 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. [8] 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, Samuel Tuke, published an influential work in the early 19th century on the methods of the retreat; Pinel's Treatise On Insanity had by then been published, and Samuel Tuke translated his term as "moral treatment".

Scotland

A very different background to the moral approach may be discerned in Scotland. Interest in mental illness was a feature of the Edinburgh medical school in the eighteenth century, with influential teachers including William Cullen (1710–1790) and Robert Whytt (1714–1766) emphasising the clinical importance of psychiatric disorders. In 1816, the phrenologist Johann Spurzheim (1776–1832) visited Edinburgh and lectured on his craniological and phrenological concepts, arousing considerable hostility, not least from the theologically doctrinaire Church of Scotland. Some of the medical students, however, notably William A.F. Browne (1805–1885), responded very positively to this materialist conception of the nervous system and, by implication, of mental disorder. George Combe (1788–1858), an Edinburgh solicitor, became an unrivalled exponent of phrenological thinking, and his brother, Andrew Combe (1797–1847), who was later appointed a physician to Queen Victoria, wrote a phrenological treatise entitled Observations on Mental Derangement (1831). George and Andrew Combe exerted a rather dictatorial authority over the Edinburgh Phrenological Society, and in the mid-1820s manipulated the de facto expulsion of the Christian phrenologists.

This tradition of medical materialism found a ready partner in the Lamarckian biology purveyed by the naturalist Robert Edmond Grant (1793–1874) who exercised a striking influence on the young Charles Darwin 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 Edinburgh Phrenological Society, the Royal Medical Society and the Plinian Society. Later, as superintendent of Sunnyside Royal Hospital (the Montrose Asylum) from 1834 to 1838, and, more extravagantly, at the Crichton Royal in Dumfries 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 transcripts of five public lectures) which he entitled What Asylums Were, Are, and Ought To Be. His achievements with this style of psychiatric practice were rewarded with his appointment as a Commissioner in Lunacy for Scotland, and by his election to the Presidency of the Medico-Psychological Association in 1866. Browne's eldest surviving son, James Crichton-Browne (1840–1938), did much to extend his father's work in psychiatry, and, on 29 February 1924, he delivered a remarkable lecture The Story of the Brain, in which he recorded a generous appreciation of the role of the phrenologists in the early foundations of psychiatric thought and practice.

United States

A key figure in the early spread of moral treatment in the United States was Benjamin Rush (1745–1813), [9] an eminent physician at Pennsylvania Hospital. 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. [10]

A Boston schoolteacher, Dorothea Dix (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 Samuel Tuke. In 1841 she visited a local prison to teach Sunday school 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 Massachusetts and all over the country. She supported the moral treatment model of care. [11] 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 disorders from 1841 until 1881, and personally helped establish 32 state hospitals that were to offer moral treatment. Many asylums were built according to the so-called Kirkbride Plan.

Consequences

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, 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". [12]

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 "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. [13]

There was also criticism from some ex-patients and their allies. By the mid-19th century in England, the Alleged Lunatics' Friend Society was proclaiming that the new moral treatment was a form of social repression achieved "by mildness and coaxing, and by solitary confinement"; 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. [14]

In the context of industrialization, 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. [12]

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 holistic care, were often scapegoated for the failures of the system. [15] Towards the end of the 19th century, somatic theories, pessimism in prognosis, and custodialism had returned. Theories of hereditary degeneracy and eugenics took over, and in the 20th century the concepts of mental hygiene and mental health developed. [13] From the mid 20th century, however, a process of antipsychiatry and deinstitutionalization occurred in many countries in the West, and asylums in many areas were gradually replaced with more local community mental health services.

In the 1960s, Michel Foucault 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 antipsychiatry movement[ citation needed ]. Foucault was interested in ideas of "the other" and how society defines normalcy by defining the abnormal 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 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." [16] 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. [17]

The moral treatment movement is widely seen as influencing psychiatric practice up to the present day, including specifically therapeutic communities [18] (although they were intended to be less repressive); occupational therapy [19] and Soteria houses. The Recovery model is said to have echoes of the concept of moral treatment. [20]

See also

Related Research Articles

<span class="mw-page-title-main">Psychiatric hospital</span> Hospital specializing in the treatment of serious mental disorders

Psychiatric hospitals, also known as mental health hospitals or behavioral health hospitals, are hospitals or wards specializing in the treatment of severe mental disorders, such as schizophrenia, bipolar disorder, eating disorders, dissociative identity disorder, major depressive disorder and many others. Psychiatric hospitals vary widely in their size and grading. Some hospitals may specialize only in short-term or outpatient therapy for low-risk patients. Others may specialize in the temporary or permanent confinement of patients who need routine assistance, treatment, or a specialized and controlled environment due to a psychiatric disorder. Patients often choose voluntary commitment, but those who psychiatrists believe pose significant danger to themselves or others may be subject to involuntary commitment and involuntary treatment. Psychiatric hospitals are sometimes referred to as psychiatric wards/units, psych, or wards/units when they are located as a unit within a hospital.

Anti-psychiatry, sometimes spelled antipsychiatry, is a movement based on the view that psychiatric treatment is often more damaging than helpful to patients, highlighting controversies about psychiatry. Objections include the reliability of psychiatric diagnosis, the questionable effectiveness and harm associated with psychiatric medications, the failure of psychiatry to demonstrate any disease treatment mechanism for psychiatric medication effects, and legal concerns about equal human rights and civil freedom being nullified by the presence of diagnosis. Historically critiques of psychiatry came to light after focus on the extreme harms associated with electroconvulsive treatment or insulin shock therapy. The term "anti-psychiatry" is in dispute and often used to dismiss all critics of psychiatry, many of whom agree that a specialized role of helper for people in emotional distress may at times be appropriate, and allow for individual choice around treatment decisions.

<span class="mw-page-title-main">Philippe Pinel</span> French psychiatrist

Philippe Pinel was a French physician, precursor of psychiatry and incidentally a zoologist. He was instrumental in the development of a more humane psychological approach to the custody and care of psychiatric patients, referred to today as moral therapy. He worked for the abolition of the shackling of mental patients by chains and, more generally, for the humanisation of their treatment. He also made notable contributions to the classification of mental disorders and has been described by some as "the father of modern psychiatry".

Historically, mental disorders have had three major explanations, namely, the supernatural, biological and psychological models. For much of recorded history, deviant behavior has been considered supernatural and a reflection of the battle between good and evil. When confronted with unexplainable, irrational behavior and by suffering and upheaval, people have perceived evil. In fact, in the Persian Empire from 550 to 330 B.C., all physical and mental disorders were considered the work of the devil. Physical causes of mental disorders have been sought in history. Hippocrates was important in this tradition as he identified syphilis as a disease and was, therefore, an early proponent of the idea that psychological disorders are biologically caused. This was a precursor to modern psycho-social treatment approaches to the causation of psychopathology, with the focus on psychological, social and cultural factors. Well known philosophers like Plato, Aristotle, etc., wrote about the importance of fantasies, dreams, and thus anticipated, to some extent, the fields of psychoanalytic thought and cognitive science that were later developed. They were also some of the first to advocate for humane and responsible care for individuals with psychological disturbances.

<span class="mw-page-title-main">William Tuke</span> English mental health reformer (1732–1822)

William Tuke, an English tradesman, philanthropist and Quaker, earned fame for promoting more humane custody and care for people with mental disorders, using what he called gentler methods that came to be known as moral treatment. He played a big part in founding The Retreat at Lamel Hill, York, for treating mental-health needs. He and his wife Esther Maud backed strict adherence to Quaker principles. He was an abolitionist, a patron of the Bible Society, and an opponent of the East India Company's inhumane practices.

This article is a compiled timeline of psychotherapy. A more general description of the development of the subject of psychology can be found in the History of psychology article. For related overviews see the Timeline of psychology and Timeline of psychiatry articles.

<span class="mw-page-title-main">The Retreat</span> Hospital in York, England

The Retreat, commonly known as the York Retreat, is a place in England for the treatment of people with mental health needs. Located in Lamel Hill in York, it operates as a not for profit charitable organisation.

Moral insanity referred to a type of mental disorder consisting of abnormal emotions and behaviours in the apparent absence of intellectual impairments, delusions, or hallucinations. It was an accepted diagnosis in Europe and America through the second half of the 19th century.

Therapeutic community is a participative, group-based approach to long-term mental illness, personality disorders and drug addiction. The approach was usually residential, with the clients and therapists living together, but increasingly residential units have been superseded by day units. It is based on milieu therapy principles, and includes group psychotherapy as well as practical activities.

<span class="mw-page-title-main">Deinstitutionalisation</span> Replacement of psychiatric hospitals

Deinstitutionalisation is the process of replacing long-stay psychiatric hospitals with less isolated community mental health services for those diagnosed with a mental disorder or developmental disability. In the late 20th century, it led to the closure of many psychiatric hospitals, as patients were increasingly cared for at home, in halfway houses and clinics, in regular hospitals, or not at all.

<span class="mw-page-title-main">Claybury Hospital</span> Hospital in England

Claybury Hospital was a psychiatric hospital in Woodford Bridge, London. It was built to a design by the English architect George Thomas Hine who was a prolific Victorian architect of hospital buildings. It was opened in 1893 making it the Fifth Middlesex County Asylum. Historic England identified the hospital as being "the most important asylum built in England after 1875".

<span class="mw-page-title-main">James Crichton-Browne</span> British psychiatrist, neurologist, and eugenicist (1840–1938)

Sir James Crichton-Browne MD FRS FRSE was a leading Scottish psychiatrist, neurologist and eugenicist. He is known for studies on the relationship of mental illness to brain injury and for the development of public health policies in relation to mental health. Crichton-Browne's father was the asylum reformer Dr William A.F. Browne, a prominent member of the Edinburgh Phrenological Society and, from 1838 until 1857, the superintendent of the Crichton Royal at Dumfries where Crichton-Browne spent much of his childhood.

Jean-Baptiste Pussin (1746–1811) was a French hospital superintendent who, along with his wife and colleague Marguerite, established more humane treatment of patients with mental disorders in 19th-century France. They helped physician Philippe Pinel appreciate and implement their approach which, together with similar initiatives in other countries, became known as moral treatment.

<span class="mw-page-title-main">William Charles Ellis</span> English pioneer in mental treatment, 1780–1839

Sir William Charles Ellis was the superintendent of the West Riding Pauper Lunatic Asylum. His ideas on the treatment of mental illness became widely influential.

<span class="mw-page-title-main">Asylum architecture in the United States</span> Building design of mental hospitals

Asylum architecture in the United States, including the architecture of psychiatric hospitals, affected the changing methods of treating the mentally ill in the nineteenth century: the architecture was considered part of the cure. Doctors believed that ninety percent of insanity cases were curable, but only if treated outside the home, in large-scale buildings. Nineteenth-century psychiatrists considered the architecture of asylums, especially their planning, to be one of the most powerful tools for the treatment of the insane, targeting social as well as biological factors to facilitate the treatment of mental illnesses. The construction and usage of these quasi-public buildings served to legitimize developing ideas in psychiatry. About 300 psychiatric hospitals, known at the time as insane asylums or colloquially as “loony bins” or “nuthouses,” were constructed in the United States before 1900. Asylum architecture is notable for the way similar floor plans were built in a wide range of architectural styles.

<span class="mw-page-title-main">Vincenzo Chiarugi</span>

Vincenzo Chiarugi (1759–1820) was an Italian physician who helped introduce humanitarian reforms to the psychiatric hospital care of people with mental disorders. His early part in a movement towards moral treatment was relatively overlooked until a gradual reassessment through the 20th century left his reforms described as a landmark in the history of psychiatry. He also specialized in dermatology and wrote on other subjects.

Psychiatry is the medical specialty devoted to the diagnosis, prevention, and treatment of deleterious mental conditions. These include various matters related to mood, behaviour, cognition, and perceptions.

<span class="mw-page-title-main">William A. F. Browne</span>

Dr William Alexander Francis Browne (1805–1885) was one of the most significant British asylum doctors of the nineteenth century. At Montrose Asylum (1834–1838) in Angus and at the Crichton Royal in Dumfries (1838–1857), Browne introduced activities for patients including writing, group activity and drama, pioneered early forms of occupational therapy and art therapy, and initiated one of the earliest collections of artistic work by patients in a psychiatric hospital. In an age which rewarded self-control, Browne encouraged self-expression and may therefore be counted alongside William Tuke, Vincenzo Chiarugi and John Conolly as one of the pioneers of the moral treatment of mental illness. Sociologist Andrew Scull has identified Browne's career with the institutional climax of nineteenth century psychiatry.

"Browne was one of the reformers of the asylum care of the insane whose improvements and innovations were chronicled in his annual reports from The Crichton Royal Institution, but who in addition published almost on the threshold of his career a sort of manifesto of what he wished to see accomplished...." Richard Hunter and Ida Macalpine (1963) Three Hundred Years of Psychiatry 1535–1860, page 865.

<span class="mw-page-title-main">Lunatic asylum</span> Place for housing the insane, an aspect of history

The lunatic asylum or insane asylum was an early precursor of the modern psychiatric hospital.

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