by Dr. James W. Trent, Jr., Gordon College
Moral treatment was a product of the Enlightenment of the late eighteenth century. Before then people with psychiatric conditions, referred to as the insane, were usually treated in inhumane and brutal ways. In France, England, and the United States, people who cared for the insane began to advocate for more kindly treatment. In France Philippe Pinel instituted what he called traitement moral at the Bicêtre hospital in Paris. According to Pinel, insane people did not need to be chained, beaten, or otherwise physically abused. Instead, he called for kindness and patience, along with recreation, walks, and pleasant conversation. Around the same time that Pinel called for his reforms, William Tuke, an English Quaker, founded the York Retreat for the care of the insane. Rejecting traditional medical intervention, Tuke emphasized the rural quiet retreat where insane people could engage in reading, light manual labor, and conversation. Never having more than thirty residents, the York Retreat remained small and hence able to focus on the individual needs of its residents.
In the United States, the first proponent of moral treatment was Benjamin Rush. A Philadelphia physician, Rush had been one of the signers of the American Declaration of Independence. For Rush, the hustle and bustle of modern life contributed to mental diseases. Such diseases could best be treated in a hospital setting away from the stresses of modern life. Rush employed blood-letting for some conditions and invented the “tranquilizer chair” as a restrain for agitated patients. Several decades after Rush’s death, Dorothea Dix in 1841 began her quest to bring humane treatment to the insane. Dix insisted that hospitals for the insane be spacious, well ventilated, and have beautiful grounds. In such settings, Dix envisioned troubled people regaining their sanity. In the 1840s and 1850s there was much optimism for the cure of insanity through kind treatment without restraints. This perspective held that a highly structured, highly regimented environment that was also bucolic and peaceful would help to facilitate cure.
During the second half of the nineteenth century, the optimism surrounding moral treatment began to wane. With the advent of industrialization along with the growth of immigration into the United States, pressures were placed on mental hospitals to admit more and more clientele. Soon the visions of small facilities where mentally ill people would receive individual treatment degenerated into large facilities where little attention was given to the individual. Soon also the mere upkeep of buildings and expansion of buildings took up increasingly more of the time of hospital administrators.
Added to the demise of concern for the individual mentally ill person were changes in philosophy that would undermine moral treatment. By the beginning of the twentieth century both the eugenics movement and the popularity in the United States of the theories of Sigmund Freud would serve to redirect the concerns of asylum keepers. The eugenics movement held that the social fabric was threatened by the “breeding of inferior stock.” People were “insane” (and “feeble minded”) because of this inferior breeding. If authorities wanted to stop insanity the most effective thing they could do would be to segregate people in public facilities where they could not give birth to what some authorities believed would be insane children. Quite suddenly the retreat for cure was replaced by the holding facility for hereditarily inferior people. The public residential institution grew in size and number from the 1880s until the 1970s.
Around the same time as the eugenics movement, Freudian psychodynamic practice began to influence American psychiatry. As such, a new breed of psychiatrists influenced by the psycho-sexual developmental theories of Freud would have a new model of cure. Not in the environment of the rural retreat or asylum, but now on the couch in the psychiatrist’s office, patients could free associate about phobias and developmental blockages. Through personal insight guided by the psychiatrist, the patient became better. For Freud, ironically people who had unresolved developmental matters in the youngest years of life were the people who had the most severe forms of psychopathology, like schizophrenia. Because these patients were not amenable to insight therapy, they were not curable. They had best remain in the institution. The dream of moral treatment died because of a combination of overcrowded hospitals along with the advent of eugenics and Freud around the turn of the twentieth century.
Source: James W. Trent, Jr., “Moral Treatment,” Disability History Museum, http://www.disabilitymuseum.org/dhm/edu/essay.html?id=19 (January 24, 2014).