Basic Chronology of the Transformation of the Care of the Insane
Prior to 1750, little institutional care
Not part of orthodox medical practice
Few people actually categorized as insane
1807, estimated 2,200 insane people in Britain
1890, 66 public mad houses
90,000 people admitted to them
Population of the insane grew 4X faster than the population of Britain as a whole
3 Social Transformations in Care of the Insane after 1750
Prior to 1750, care of the insane was basically custodial
e.g.: Bethlem Hospital
Founded 1247
1403: housed 6 men “deprived of reason”
1632: 27 inmates
Moved to new site 1676: 150 inmates
Little in way of medical therapy
Many never saw a doctor
Standard “treatments”
Dunking
Physical restraint
Bleeding
Fear
Benjamin Rush on bloodletting:
It should be copious on the first attack . . . From 20 to 40 ounces of blood may be taken at once. The effects of this early and copious bleeding are wonderful in calming mad people. (1812)
Appalling conditions in institutions for the insane
Incompetent doctors (or none at all)
Abuse & neglect of patients
Exploitation of patients
Prisons were no better
Voluntary hospitals slightly better
Prison reform movement
John Howard
Resulted in more enlightened public opinion about institutional care generally
1. Rise of the Moral Cure
Defined itself in opposition to what had come before
Samuel Tuke
Prominent tea merchant at York
Quaker
Founded the Retreat in 1796
Initially tried standard medical therapies
Rejected these as useless
Substituted “moral treatment”
Believed that the insane had lost control of inhibitions that defined their humanity
Asylum an environment that emphasized the self-discipline they had lost
Distanced them from the environments that had made them insane
Run as a family environment
Superintendent took parental role
Inmates treated like ill-disciplined children
Intended to change emotional or intellectual disorder, not pathology
Accomplished through behavioural means, not physiology
Used restraints
Rejected physical or emotional abuse
Work therapy
2. Medicalization of Insanity
Psychiatry one of most successful medicalizations in medical history
Two aspects
Theoretical understanding of mental illness
Management of mental illness
1. Theoretical Medicalization
Accomplished by making diagnosing & treating insanity exclusively medical in orientation
Philippe Pinel
1745-1826
Worked at Bicetre & later the Salpetriere
Appalled by callous way mad people were treated
I cannot here avoid giving my most decided sufferage in favour of the moral qualities of maniacs. I have no where met, excepting in romances, with fonder husbands, more affectionate parents, more impassioned . . . than in the lunatic asylum, during their intervals of calmness and reason."
Rejected callous treatment of the insane
Ordered removal of chains
Wrote Medical-Philosophical Treatise on Mental Alienation or Mania
Much more could be said about the rise of psychiatry & influential physicians in this area of specialization
Why was medicalization of mental illness successful?
Secularization of France supported more materialist understanding of mental illness
Disease of the brain, not the mind/spirit
2. Medicalization of Treatment
In Britain, the state needed medical assistance in care of the insane
Only small number of patients in “public” institutions, which were for the poor
Middle and upper classes dependent on private institutions
Sites of considerable abuse
People sent to asylums to get rid of them
No registers of who was there
No supervision of any sort
Several House of Commons hearings in 18th century related to reports of unethical confinement
1774 Madhouses Act
No one could be admitted without medical certificate
Madhouses to be licensed
Must keep register of inmates
Did not define who was a physician
Royal College of Physicians unenthusiastic about supporting this legislation
Rapid expansion of private madhouses
Onset of state-run madhouses
Needed increased support from physicians
1828: all madhouses must have physician visit once a week
Proper medical records to be kept
Increasing state surveillance
Decrease in lay-established asylums
1854: permanent commission to oversee all madhouses
50% lay people
50% physicians
Legal definition of criminal insanity
1854 M’Naghten case
Physicians asked to provide expert testimony
3. Pauperization of Insanity
Madhouse (asylum, mental hospital) became institution of choice for mentally ill poor
Growth in institutional care can be interpreted as indication of more humanitarian response to distress
Can also be interpreted as increased interest in controlling deviant behaviour
Shifts in what constituted deviance over time
Leads to critique of psychiatry’s role
Is mental illness found or made?
Major critiques in 20th century
“One Flew Over the Cuckoo’s Nest”
“Clockwork Orange”
Myth of Mental Illness (Dr. Thomas Szasz)
Madness and Civilization (Michel Foucault)
Most intensive period of asylum building in Britain between 1840 and 1880
Size of these institutions made effective patient care impossible
By end of 19th century, asylums had become warehouses for the insane
A Bit More About Moral Architecture
Mental institutions were generally designed to be highly visible
Reminded people of consequences of deviant behaviour
Brandon Mental Hospital on north hill outside of town; could be seen by everyone in the city
Physical space laid out like a large Victorian house
Impressive entrance & foyers laid out in a large centre block
Centre block often contained apartments of medical superintendent & his family
Patient wings placed on each side
Males & females separated
Brandon Mental Health Centre
Based on unpublished masters thesis (UM) by Christopher Dooley
“When Love and Skill Get Together:” Work, Skill and the Occupational Culture of Mental Nurses at the Brandon Hospital for Mental Diseases, 1919-1946”
Prior to 1880, no formal provision for mental health care in Manitoba
At discretion of local officials
Family
Fend for self
Incarcerated in jails
Deported
1877
Mental patients incarcerated in gaol at Lower Fort Garry
Later, moved to Stony Mountain Penitentiary
Housed in basement
Condemned in 1884; had been contaminated by sewage
1883: 50 bed facility constructed at Selkirk
Patients under medical care for first time
1891: Conversion of Brandon Reformatory to asylum for the insane
Named the Brandon Asylum
25 patients transferred from Selkirk
1910: Asylum burned down
700 patients and staff housed in building on agricultural grounds
1913: New asylum completed
1000 bed capacity
Renamed Brandon Hospital for the Insane
1919: Renamed Brandon Hospital for Mental Diseases
Medicalization of mental illness had little impact on the experience of patients
In 1920, Dr. C.A. Barager, Medical Sup’t of Brandon facility reported that only 19.7% of patients discharged considered cured
Patients suffered from a wide range of problems:
Developmental
Psychiatric
Psychiatric consequences of physical illnesses
Age related dementias
Epilepsy
Treatments were crude, often ineffective
Institutional life could be:
Boring
Dangerous
Humiliating
Three excellent Canadian studies of psychiatric care in the late 19th – 20th century
Reaume, Geoffrey. Remembrance of Patients Past: Patient Life at the Toronto Hospital for the Insane 1870-1940. Toronto: Oxford University Press, 2000.
Warsh, Cheryl. Moments of Unreason: The Practice of Canadian Psychiatry and the Homewood Retreat, 1883-1923. Montreal: McGill-Queen’s University Press, 1989.
Chunn, Dorothy E. and Robert Menzies. “Out of Mind, Out of Law: The Regulation of Criminally Insane Women Inside British Columbia’s Public Mental Hospitals, 1888-1973.” Canadian Journal of Women and the Law, 10 (1998), 307-337.
