Basic Chronology of the Transformation of the Care of the Insane Prior to 1750, little institutional care

Psychiatry & the Asylum

• 1750-1900

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

• http://timelinks.merlin.mb.ca/imageref/imager18.htm

• http://members.tripod.com/hillmans2002/bmhctour.html

Unexplored themes in the History of Psychiatry

Patient’s Lives

• 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.

Changes in Medical Treatment

Experience of Staff in Psychiatric Facilities

• Dooley’s thesis

• Tipliski’s doctoral dissertation