Lunatic asylum

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The lunatic asylum, insane asylum or mental asylum was an institution where people with mental illness were confined. It was an early precursor of the modern psychiatric hospital.

Modern psychiatric hospitals evolved from and eventually replaced the older lunatic asylum. The treatment of inmates in early lunatic asylums was sometimes brutal and focused on containment and restraint.^[1][2] The discovery of anti-psychotic drugs and mood-stabilizing drugs resulted in a shift in focus from containment in lunatic asylums to treatment in psychiatric hospitals, and eventually led to the deinstitutionalization movement which focuses on treatment at home or in less isolated institutions.

History

Medieval era

In the Islamic world, the Bimaristans were described by European travellers, who wrote about their wonder at the care and kindness shown to lunatics. In 872, Ahmad ibn Tulun built a hospital in Cairo that provided care to the insane, which included music therapy.^[3] Nonetheless, British historian of medicine Roy Porter cautioned against idealising the role of hospitals generally in medieval Islam, stating that "They were a drop in the ocean for the vast population that they had to serve, and their true function lay in highlighting ideals of compassion and bringing together the activities of the medical profession."^[4]: 105

In Europe during the medieval era, a small subsection of the population of those considered mad were housed in a variety of institutional settings. Mentally ill people were often held captive in cages or kept up within the city walls, or they were compelled to amuse members of courtly society.

The level of specialist institutional provision for the care and control of the insane remained extremely limited at the turn of the 18th century. Madness was seen principally as a domestic problem, with families and parish authorities in Europe and England central to regimens of care.^{[8]: 154 [9]: 439} Various forms of outdoor relief were extended by the parish authorities to families in these circumstances, including financial support, the provision of parish nurses and, where family care was not possible, lunatics might be 'boarded out' to other members of the local community or committed to private madhouses.^{[9]: 452–56 [10]: 299} Exceptionally, if those deemed mad were judged to be particularly disturbing or violent, parish authorities might meet the not inconsiderable costs of their confinement in charitable asylums such as Bethlem, in Houses of Correction or in workhouses.^{[11]: 30, 31–35, 39–43}

In the late 17th century, this model began to change, and privately run asylums for the insane began to proliferate and expand in size. Already in 1632 it was recorded that Bethlem Royal Hospital, London had "below stairs a parlor, a kitchen, two larders, a long entry throughout the house, and 21 rooms wherein the poor distracted people lie, and above the stairs eight rooms more for servants and the poor to lie in".^[12] Inmates who were deemed dangerous or disturbing were chained, but Bethlem was an otherwise open building. Its inhabitants could roam around its confines and possibly throughout the general neighborhood in which the hospital was situated.^[13] In 1676, Bethlem expanded into newly built premises at Moorfields with a capacity for 100 inmates.^{[8]: 155 [14]: 27}

A second public charitable institution was opened in 1713, the Bethel in

Due, perhaps, to the absence of a centralised state response to the social problem of madness until the 19th century, private madhouses proliferated in 18th century Britain on a scale unseen elsewhere.^[8]: 174 References to such institutions are limited for the 17th century but it is evident that by the start of the 18th century, the so-called 'trade in lunacy' was well established.^{[15]: 8–9} Daniel Defoe, an ardent critic of private madhouses,^[19]: 118 estimated in 1724 that there were fifteen then operating in the London area.^[20]: 9 Defoe may have exaggerated but exact figures for private metropolitan madhouses are available only from 1774, when licensing legislation was introduced: sixteen institutions were recorded.^{[20]: 9–10} At least two of these, Hoxton House and Wood's Close, Clerkenwell, had been in operation since the 17th century.^[20]: 10 By 1807, the number had increased to seventeen.^[20]: 9 This limited growth in the number of London madhouses is believed likely to reflect the fact that vested interests, especially the College of Physicians, exercised considerable control in preventing new entrants to the market.^{[20]: 10–11} Thus, rather than there being a proliferation of private madhouses in London, existing institutions tended to expand considerably in size.^[20]: 10 The establishments which increased most during the 18th century, such as Hoxton House, did so by accepting pauper patients rather than private, middle class, fee-paying patients.^[20]: 11 Significantly, pauper patients, unlike their private counterparts, were not subject to inspection under the 1774 legislation.^[20]: 11

Fragmentary evidence indicates that some provincial madhouses existed in Britain from at least the 17th century and possibly earlier.^{[8]: 175 [15]: 8} A madhouse at Kingsdown, Box, Wiltshire was opened during the 17th century.^{[8]: 176 [20]: 11} Further locales of early businesses include one at Guildford in Surrey which was accepting patients by 1700, one at Fonthill Gifford in Wiltshire from 1718, another at Hook Norton in Oxfordshire from about 1725, one at St Albans dating from around 1740, and a madhouse at Fishponds in Bristol from 1766.^{[8]: 176 [20]: 11} It is likely that many of these provincial madhouses, as was the case with the exclusive Ticehurst House, may have evolved from householders who were boarding lunatics on behalf of parochial authorities and later formalised this practice into a business venture.^[8]: 176 The vast majority were small in scale with only seven asylums outside London with in excess of thirty patients by 1800 and somewhere between ten and twenty institutions had fewer patients than this.^[8]: 178

Humanitarian reform

During the

In 1792, Pinel became the chief physician at the Bicêtre Hospital in Le Kremlin-Bicêtre, near Paris. Before his arrival, inmates were chained in cramped cell-like rooms where there was poor ventilation, led by a man named Jackson 'Brutis' Taylor. Taylor was then killed by the inmates leading to Pinel's leadership. In 1797, Jean-Baptiste Pussin, the "governor" of mental patients at Bicêtre, first freed patients of their chains and banned physical punishment, although straitjackets could be used instead.^[22][23] Patients were allowed to move freely about the hospital grounds, and eventually dark dungeons were replaced with sunny, well-ventilated rooms. Pinel argued that mental illness was the result of excessive exposure to social and psychological stresses, to heredity and physiological damage.^{[citation needed]}

Pussin and Pinel's approach was seen as remarkably successful, and they later brought similar reforms to a mental hospital in Paris for female patients,

The entire Tuke family became known as founders of moral treatment.[28] They created a family-style ethos, and patients performed chores to give them a sense of contribution. There was a daily routine of both work and leisure time. If patients behaved well, they were rewarded; if they behaved poorly, there was some minimal use of restraints or instilling of fear. The patients were told that treatment depended on their conduct. In this sense, the patient's moral autonomy was recognised. William Tuke's grandson, Samuel Tuke, published an influential work in the early 19th century on the methods of the retreat; Pinel's Treatise on Insanity had by then been published, and Samuel Tuke translated his term as "moral treatment". Tuke's Retreat became a model throughout the world for humane and moral treatment of patients with mental disorders.^[29]

The York Retreat inspired similar institutions in the United States, most notably the Brattleboro Retreat and the Hartford Retreat (now the Institute of Living). Benjamin Rush of Philadelphia also promoted humane treatment of the insane outside dungeons and without iron restraints, as well as sought their reintegration into society. In 1792, Rush successfully campaigned for a separate ward for the insane at the Pennsylvania Hospital. His talk-based approach could be considered as a rudimentary form of modern occupational therapy, although most of his physical approaches have long been discredited, such as bleeding and purging, hot and cold baths, mercury pills, a "tranquilizing chair" and gyroscope.

A similar reform was carried out in Italy by Vincenzo Chiarugi, who discontinued the use of chains on the inmates in the early 19th century. In the town of Interlaken, Johann Jakob Guggenbühl started a retreat for mentally disabled children in 1841.^[30]

Institutionalisation

The modern era of institutionalized provision for the care of the mentally ill, began in the early 19th century with a large state-led effort. Public mental asylums were established in Britain after the passing of the

In 1838, France enacted a law to regulate both the admissions into asylums and asylum services across the country. Édouard Séguin developed a systematic approach for training individuals with mental deficiencies,^[39] and, in 1839, he opened the first school for the "severely retarded". His method of treatment was based on the assumption that the "mentally deficient" did not suffer from disease.^[40]

In the United States, the erection of state asylums began with the first law for the creation of one in New York, passed in 1842. The

Looking into the late 19th and early 20th century history of the Homewood Retreat of Guelph, Ontario, and the context of commitments to asylums in North America and Great Britain, Cheryl Krasnick Warsh states that "the kin of asylum patients were, in fact, the major impetus behind commitment, but their motivations were based not so much upon greed as upon the internal dynamics of the family, and upon the economic structure of western society in the 19th and early 20th centuries."^[42]

Women in psychiatric institutions

Based on her study of cases from the Homewood Retreat, Cheryl Krasnick Warsh concludes that "the realities of the household in late Victorian and Edwardian middle class society rendered certain elements—socially redundant women in particular—more susceptible to institutionalization than others."^[42]

In the 18th to the early 20th century, women were sometimes institutionalised due to their opinions, their unruliness and their inability to be controlled properly by a primarily male-dominated culture.^[43] There were financial incentives too; before the passage of the Married Women's Property Act 1882, all of a wife's assets passed automatically to her husband.

The men who were in charge of these women, either a husband, father or brother, could send these women to mental institutions, stating that they believed that these women were mentally ill because of their strong opinions. "Between the years of 1850–1900, women were placed in mental institutions for behaving in ways the male society did not agree with."^[44] These men had the last say when it came to the mental health of these women, so if they believed that these women were mentally ill, or if they simply wanted to silence the voices and opinions of these women, they could easily send them to mental institutions. This was an easy way to render them vulnerable and submissive.^[45]

An early fictional example is

In 1887, journalist Nellie Bly had herself committed to the Blackwell's Island Insane Asylum in New York City, in order to investigate conditions there. Her account was published in the New York World newspaper, and in book form as Ten Days in a Mad-House.

In 1902,

In continental Europe, universities often played a part in the administration of the asylums.^[47] In Germany, many practising psychiatrists were educated in universities associated with particular asylums.^[47] However, because Germany remained a loosely bound conglomerate of individual states, it lacked a national regulatory framework for asylums.

Although Tuke, Pinel and others had tried to do away with physical restraint, it remained widespread in the 19th century. At the Lincoln Asylum in England, Robert Gardiner Hill, with the support of Edward Parker Charlesworth, pioneered a mode of treatment that suited "all types" of patients, so that mechanical restraints and coercion could be dispensed with—a situation he finally achieved in 1838. In 1839 Sergeant John Adams and Dr. John Conolly were impressed by the work of Hill, and introduced the method into their Hanwell Asylum, by then the largest in the country. Hill's system was adapted, since Conolly was unable to supervise each attendant as closely as Hill had done. By September 1839, mechanical restraint was no longer required for any patient.^[48][49]

William A. F. Browne (1805–1885) introduced activities for patients including writing, art, group activity and drama, pioneered early forms of occupational therapy and art therapy, and initiated one of the earliest collections of artistic work by patients, at Montrose Asylum.^[50]

Rapid expansion

By the end of the 19th century, national systems of regulated asylums for the mentally ill had been established in most

However, the hope that mental illness could be ameliorated through treatment during the mid-19th century was disappointed.[52] Instead, psychiatrists were pressured by an ever-increasing patient population.^[52] The average number of patients in asylums in the United States jumped 927%.^[52] Numbers were similar in Britain and Germany.^[52] Overcrowding was rampant in France, where asylums would commonly take in double their maximum capacity.^[53] Increases in asylum populations may have been a result of the transfer of care from families and poorhouses, but the specific reasons as to why the increase occurred are still debated today.^[54] No matter the cause, the pressure on asylums from the increase was taking its toll on the asylums and psychiatry as a specialty. Asylums were once again turning into custodial institutions^[55] and the reputation of psychiatry in the medical world had hit an extreme low.^[56]

In the 1800s, middle class facilities became more common, replacing private care for wealthier persons. However, facilities in this period were largely oversubscribed. Individuals were referred to facilities either by the community or by the criminal justice system. Dangerous or violent cases were usually given precedence for admission. A survey taken in 1891 in Cape Town, South Africa shows the distribution between different facilities. Out of 2046 persons surveyed, 1,281 were in private dwellings, 120 in jails and 645 in asylums, with men representing nearly two-thirds of the number surveyed.^[57]

Defining someone as insane was a necessary prerequisite for being admitted to a facility. A doctor was only called after someone was labelled insane on social terms and had become socially or economically problematic. Until the 1890s, little distinction existed between the lunatic and criminal lunatic. The term was often used to police

The use of psychosurgery was narrowed to a very small number of people for specific indications. Egas Moniz performed the first leucotomy, or lobotomy in Portugal in 1935, which targets the brain's frontal lobes.^[7] This was shortly thereafter adapted by Walter Freeman and James W. Watts in what is known as Freeman–Watts procedure or the standard prefrontal lobotomy. From 1946, Freeman developed the transorbital lobotomy, using a device akin to an ice-pick. This was an "office" procedure which did not have to be performed in a surgical theatre and took as little as fifteen minutes to complete. Freeman is credited with the popularisation of the technique in the United States. In 1949, 5,074 lobotomies were carried out in the United States and by 1951, 18,608 people had undergone the controversial procedure in that country.^[63] One of the most famous people to have a lobotomy was the sister of John F. Kennedy, Rosemary Kennedy, who was rendered profoundly intellectually disabled as a result of the surgery.^[64]

In modern times, insulin shock therapy and lobotomies are viewed as being almost as barbaric as the Bedlam "treatments", although the insulin shock therapy was still seen as the only option which produced any noticeable effect on patients. ECT is still used in the West in the 21st century, but it is seen as a last resort for treatment of mood disorders and is administered much more safely than in the past.^[65] Elsewhere, particularly in India, use of ECT is reportedly increasing, as a cost-effective alternative to drug treatment.^{[citation needed]} The effect of a shock on an overly excitable patient often allowed these patients to be discharged to their homes, which was seen by administrators (and often guardians) as a preferable solution to institutionalisation. Lobotomies were performed in the thousands from the 1930s to the 1950s, and were ultimately replaced with modern psychotropic drugs.

Eugenics movement

The eugenics movement of the early 20th century led to a number of countries enacting laws for the compulsory sterilization of the "feeble minded", which resulted in the forced sterilization of numerous psychiatric inmates.^[66] As late as the 1950s, laws in Japan allowed the forcible sterilization of patients with psychiatric illnesses.^[67]

Under Nazi Germany, the Aktion T4 euthanasia program resulted in the killings of thousands of the mentally ill housed in state institutions. In 1939, the Nazis secretly began to exterminate the mentally ill in a euthanasia campaign. Around 6,000 disabled babies, children and teenagers were murdered by starvation or lethal injection.^[68]

Psychiatric internment as a political device

Psychiatrists around the world have been involved in the suppression of individual rights by states wherein the definitions of mental disease had been expanded to include political disobedience.^[69]: 6 Nowadays, in many countries, political prisoners are sometimes confined to mental institutions and abused therein.^[70]: 3 Psychiatry possesses a built-in capacity for abuse which is greater than in other areas of medicine.^[71]: 65 The diagnosis of mental disease can serve as proxy for the designation of social dissidents, allowing the state to hold persons against their will and to insist upon therapies that work in favour of ideological conformity and in the broader interests of society.^[71]: 65

In a monolithic state, psychiatry can be used to bypass standard legal procedures for establishing guilt or innocence and allow political incarceration without the ordinary odium attaching to such political trials.^[71]: 65 In Nazi Germany in the 1940s, the 'duty to care' was violated on an enormous scale: A reported 300,000 individuals were sterilised and 100,000 killed in Germany alone, as were many thousands further afield, mainly in Eastern Europe.^[72]

From the 1960s up to 1986,

The new antipsychotics had an immense impact on the lives of psychiatrists and patients. For instance,

By the beginning of the 20th century, ever-increasing admissions had resulted in serious overcrowding. Funding was often cut, especially during periods of economic decline, and during wartime in particular many patients starved to death. Asylums became notorious for poor living conditions, lack of hygiene, overcrowding, and ill-treatment and

There was an argument that community services would be cheaper. It was suggested that new psychiatric medications made it more feasible to release people into the community.[80]

There were differing views on deinstitutionalization, however, in groups such as mental health professionals, public officials, families, advocacy groups, public citizens and unions.^[81]

Today

Africa

• Uganda has one psychiatric hospital.^[79]
• South Africa currently has 27 registered psychiatric hospitals. These hospitals are spread throughout the country. Some of the most well-known institutions are: Weskoppies Psychiatric Hospital, colloquially known as Groendakkies ("Little Green Roofs") and Denmar Psychiatric Hospital in Pretoria, TARA^[82] in Johannesburg, and Valkenberg Hospital in Cape Town.

Asia

In Japan, the number of hospital beds has risen steadily over the last few decades.^[79]

In Hong Kong, a number of residential care services such as half-way houses, long-stay care homes, and supported hostels are provided for the discharged patients. In addition, a number of community support services such as Community Rehabilitation Day Services, Community Mental Health Link, Community Mental Health Care, etc. have been launched to facilitate the re-integration of patients into the community.

Europe

Countries where deinstitutionalisation has happened may be experiencing a process of "re-institutionalisation" or relocation to different institutions, as evidenced by increases in the number of

There were some references to instances of helpful aspects or kindnesses despite the system. Participants were offered counselling to help them deal with their experiences, and advice on their rights, including access to records and legal redress.[84]

South America

In several

At the beginning of the 19th century, there were, perhaps, a few thousand "lunatics" housed in a variety of disparate institutions; but, by the beginning of the 20th century, that figure had grown to about 100,000. This growth coincided with the development of "alienism," now known as psychiatry, as a medical specialty.^[8]: 14

United States

The United States has experienced two waves of

• Deinstitutionalization
• History of mental disorders
• Kirkbride Plan
• Timeline of psychiatry
• History of psychiatric institutions in China
• List of asylums commissioned in England and Wales

References