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

Little in way of medical therapy 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

Worked at Bicetre & later the Salpetriere 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 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