Tag Archives: moral treatment

The Need for Treatment

Professional Nurses Would Have Looked Reassuring

Professional Nurses Would Have Looked Reassuring

Before the advent of insane asylums, most families by necessity had to simply accommodate a person’s mental health problems as best they could, and then wait to see what the future held. Once asylums became both established and accepted, medical intervention became much more the norm. Though some doctors believed strongly that many patients might not benefit at all from a stay in an asylum (one said that forcible confinement in an institution “would tend strongly to cause the disease to pass into some more intense form”), most saw institutional care as far superior to home care.

Probable Causes of Insanity, Missouri State Lunatic Asylum, 1954, courtesy Missouri State Archives

Probable Causes of Insanity, Missouri State Lunatic Asylum, 1954, courtesy Missouri State Archives

Alienists had several reasons for feeling this way. Most believed that the home environment was almost always at least partly to blame for an individual’s problem. Either something was going on that directly fed the mental problem, or associations the patient couldn’t get away from wouldn’t allow recovery. Doctors believed that simply getting a patient away from the situation and into a calm environment that didn’t make demands on him, would go a long way toward nipping the problem in the bud. They also felt that patients’ families didn’t have the knowledge or skill to handle mental illnesses, and certainly couldn’t make instant judgments concerning medicine, restraints, and the like.

Patients in Kalamazoo, Michigan Asylum, circa 1870s

Patients in Kalamazoo, Michigan Asylum, circa 1870s

Alienists, themselves, had four basic forms of treatment: mechanical, moral, hygienic, and medicinal. My next few posts will explore these types of treatment.

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Reasonable Rehabilitation

Amariah Brigham was Utica Asylum's First Superintendent

Amariah Brigham was Utica Asylum’s First Superintendent

The change in attitude between the old-style treatment of the insane and the new moral treatment’s philosophy (introduced by Pinel and Tuke) cannot be emphasized enough. Though some of the worst cruelties and neglect had fallen out of favor by Benjamin Rush’s time (December 24, 1745 – April 19, 1813), the man considered the “Father of American Psychiatry” believed that any physician treating an insane person had to first dominate that individual–usually through fear. Hence, threats and coercion were considered perfectly acceptable ways to gain the necessary control and authority.

One of the pioneers in American psychiatry, Dr. Amariah Brigham (December 26, 1798 – September 8, 1849) urged a completely different style of treatment. He and others of like mind developed the (then) modern insane asylum, which was capable of putting their ideas into action. For instance, Brigham believed that mental occupation was useful in effecting a cure, and suggested engaging patients’ minds in learning. He urged every institution to have something of a school within it, containing books, maps, scientific apparatus, and so on. Patients could learn reading, writing, drawing, music, arithmetic, history, philosophy, etc. The instructors in these schools would engage with patients constantly: they would teach, of course, but would also eat with patients, join them in recreational activities, and generally become their comrades. This type of engagement was for patients who were curable.

Interior of Shoe Shop, Willard Asylum for the Insane

Interior of Shoe Shop, Willard Asylum for the Insane

Patients Making Rugs, Hammocks, etc. at Hudson River State Hospital, 1909

Patients Making Rugs, Hammocks, etc. at Hudson River State Hospital, 1909

For those who weren’t (the chronic insane), manual tasks such as farm work, basket-weaving, sewing and embroidery, painting, printing, shoe-making, etc. would go a long way toward engaging patients’ attention and re-directing their thoughts in a positive manner. The physical work would also preserve their health by keeping them active.

In either type of patient, this kind of moral management, with its regular schedule, mental diversions, and lack of coercion, could be expected to help patients much more than the fear-based management of preceding philosophies. If the public had provided enough money to implement these programs effectively, the early hopes of the new psychiatric profession might have been realized.

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Treatments of Long Standing

Asylum Patients With Various Disorders

Treatments for insanity were surprisingly consistent until the modern era. Bleeding, purging, forced vomiting, and other physical remedies were go-to procedures until the early 1800s. Purging (causing the bowels to evacuate) and vomiting continued into the nineteenth century. Physicians turned to opiates to sedate patients early in the seventeenth century, and they were still popular in the nineteenth.

Even “new” psychological treatments created in the nineteenth century had echoes of this earlier period. Alienists and asylum superintendents in the 1800s recommended a change of scenery and light amusements to divert the troubled mind, particularly for those who fell into depression or melancholy as it was popularly called. Robert Burton, an expert on melancholy who wrote almost 1,400 pages on the subject in 1620, called for those afflicted with the condition to “seek merry company, play at honest amusements, dress gaily, and haunt light and lovely places.” The two treatments are remarkably similar, even though the first was part of the newly emerging “moral treatment” pioneered in the early 1800s.

On a darker note, authorities in the 1600s often beat the insane in much the same way parents would discipline unruly children. Some of the beatings or other forceful remedies for “misbehavior” could be quite painful and dehumanizing. Moral treatment succeeded in reducing or stopping such punishment for the behaviors of the insane, and patients enjoyed much more humane treatment for several decades. Unfortunately, the more crowded insane asylums became, the more often attendants ended up resorting to these primitive methods for controlling behavior. Some of the worst ills of the asylum era ended up being physical abuse and the various restraining devises attendants used.

Robert Burton's Book on the Treatment of Melancholy

A German Book on Melancholy, Published in 1653

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Experimental Psychology

Women Working on Farm as Part of Moral Therapy

In a general sense, patients at asylums were always an experiment in progress. Most alienists didn’t understand why people became insane, and didn’t really know how to cure insanity. Moral therapy, a relatively benign treatment, relied on the idea that a disciplined, busy schedule with plenty of sympathetic conversation, would take patients’ minds off their troubles and help them synch back up with society. Except for the situation itself (being in an insane asylum), this therapy was a fairly gentle attempt to help patients. Many, who perhaps only needed a change of scenery or some diversion to break a melancholy train of thought, probably did benefit from this therapy.

Some twentieth century therapies were more extreme.  The last stages of syphilis produced symptoms of insanity, and the condition was usually called “syphilitic insanity.” Doctors infected patients with malaria, hoping the high fever would stop syphilis’s progress. Julius Wagner-Jauregg won a Nobel prize for this therapy. Another leading psychiatrist gave schizophrenic patients high doses of barbiturates to induce deep sleep as a treatment. Another treatment for schizophrenia was insulin shock, in which doctors injected patients with large doses of insulin to produce comas. This therapy was used until the 1950s.

Fever Therapy

Insulin Shock Therapy

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Insane Writers

The Opal, courtesy New York State Archives

The Opal, courtesy New York State Archives

When asylums first began moral treatment (a system of retraining the patient’s mind so he or she could re-enter society), asylum superintendents encouraged light activity and creative endeavors. In 1837, an inmate of the Hartford Retreat who had been a printer and editor created two issues of a short periodical called the Retreat Gazette.

Another former printer-patient launched a newspaper called the Asylum Journal at Vermont Asylum for the Insane in 1842. The paper ran for two years, and cost $1 per year to subscribe. It accepted writing from other inmates, though it was managed by the young man who founded it. The paper folded when the patient recovered and left the asylum.

Vermont Asylum for the Insane

Vermont Asylum for the Insane

Perhaps the most famous asylum periodical was the Opal, which began publishing at the State Asylum in Utica, NY in 1851. It was produced entirely by patients, and in 1857 earned over $600. This money was used to buy an oil painting of the former superintendent and a piano, though other profits had gone to books for the asylum’s library. The American Journal of Insanity also originated at Utica.

The Hartford Retreat (postcard)

The Hartford Retreat (postcard)

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Comparing Canton Asylum

O.S. Gifford

O.S. Gifford

The Canton Asylum for Insane Indians was too small to compare to the large institutions created by Kirkbride, and it wasn’t built with any particular treatment plan in mind. Its first superintendent, O.S. Gifford, (see 2/25/2010 post) was not even a medical man. He had to travel to Washington, D.C. to see an example (St. Elizabeths) of the kind of institution he was to run.

Canton Asylum was a two-story building with four wings, and had a seven-foot fence around it. In keeping with other government institutions of its kind, however, it was lushly landscaped with over 1,000 trees and bushes that in time looked lovely.

Because Gifford wasn’t an alienist, he defaulted to a type of moral treatment that consisted of giving patients chores to do, allowing them to fish and play games when possible, and even allowing them to act like Indians. He allowed native dancing except when it proved too much for excitable patients, and let women create beadwork. This was in direct contrast to most governmental attitudes toward Indians.

His laissez-faire approach both helped and hurt the patients at Canton Asylum. Though he had no pet psychological theories to impose, he also couldn’t be bothered with setting up real programs to enable cures. When patients ran away or became hard to handle, his staff just got out the shackles.

Beaded Vest (1890-1900), courtesy Western History/Genealogy Department, Denver Public Library

Beaded Vest (1890-1900), courtesy Western History/Genealogy Department, Denver Public Library

Tobacco Bags (1895) courtesy Western History/Genealogy Department, Denver Public Library

Tobacco Bags (1895) courtesy Western History/Genealogy Department, Denver Public Library

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Some Treatments Were Moral

Dr. Philippe Pinel

Dr. Philippe Pinel

Early treatment of insanity generally embraced a view that insane persons had lost their reason, and though not responsible for their actions, could only be housed until they either somehow got better or died. Such treatments as existed were typically physical: bleeding, whipping, spinning, chaining, isolating from others, etc.

In the early 1800s, reformers such as Dr.  Philippe Pinel began to view the insane as people who had lost their reason because of exposure to severe stress or shocks. Victorians had terms like brain fever and shattered nerves to describe this kind of condition. Patients were seen as needing protection from society for a time so they could recover, and many alienists began using fewer restraints and stressful physical treatments. They believed that patients could be helped by moral treatments. These included friendly discussions of the patients’ problems, chores or occupations to discipline their time, and guidance for their interactions with others.

Glore Patients Out For a Stroll, 1902, courtesy Glore Psychiatric Museum

Glore Patients Out For a Stroll, 1902, courtesy Glore Psychiatric Museum

Though popular for several decades, the movement lost favor as medicine became incorporated into treatments, asylums became overcrowded, and money to pay for moral treatment (which required more attendants because patients received more than custodial care) became issues.Depiction of Dr. Pinel Intervening to Unchain a Patient

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