Moral treatment
Moral treatment was an approach to
Context
Moral treatment developed in the context of the Enlightenment and its focus on social welfare and individual rights. At the start of the 18th century, the "insane" were typically viewed as wild animals who had lost their reason. They were not held morally responsible but were subject to scorn and ridicule by the public, sometimes kept in madhouses in appalling conditions, often in chains and neglected for years or subject to numerous torturous "treatments" including whipping, beating, bloodletting, shocking, starvation, irritant chemicals, and isolation. There were some attempts to argue for more psychological understanding and therapeutic environments. For example, in England John Locke popularized the idea that there is a degree of madness in most people because emotions can cause people to incorrectly associate ideas and perceptions, and William Battie suggested a more psychological approach, but conditions generally remained poor.[1] The treatment of King George III also led to increased optimism about the possibility of therapeutic interventions.
Early development
Italy
Under the Enlightened concern of Grand Duke Pietro Leopoldo in Florence, Italian physician Vincenzo Chiarugi instituted humanitarian reforms. Between 1785 and 1788 he managed to outlaw chains as a means of restraint at the Santa Dorotea hospital, building on prior attempts made there since the 1750s. From 1788 at the newly renovated St. Bonifacio Hospital he did the same, and led the development of new rules establishing a more humane regime.[2]
France
The ex-patient
Pinel used the term "traitement moral" for the new approach. At that time "moral", in French and internationally, had a mixed meaning of either psychological/emotional (mental) or moral (ethical). Pinel distanced himself from the more religious work that was developed by the Tukes, and in fact considered that excessive religiosity could be harmful. He sometimes took a moral stance himself, however, as to what he considered to be mentally healthy and socially appropriate.[7]
England
English
Scotland
A very different background to the moral approach may be discerned in Scotland. Interest in mental illness was a feature of the
This tradition of medical materialism found a ready partner in the Lamarckian biology purveyed by the naturalist Robert Edmond Grant (1793–1874) who exercised a striking influence on the young Charles Darwin during his time as a medical student in Edinburgh in 1826/1827. William Browne advanced his own versions of evolutionary phrenology at influential meetings of the Edinburgh Phrenological Society, the Royal Medical Society and the Plinian Society. Later, as superintendent of Sunnyside Royal Hospital (the Montrose Asylum) from 1834 to 1838, and, more extravagantly, at the Crichton Royal in Dumfries from 1838 to 1859, Browne implemented his general approach of moral management, indicating a clinical sensitivity to the social groupings, shifting symptom patterns, dreams and art-works of the patients in his care. Browne summarised his moral approach to asylum management in his book (actually the transcripts of five public lectures) which he entitled What Asylums Were, Are, and Ought To Be. His achievements with this style of psychiatric practice were rewarded with his appointment as a Commissioner in Lunacy for Scotland, and by his election to the Presidency of the Medico-Psychological Association in 1866. Browne's eldest surviving son, James Crichton-Browne (1840–1938), did much to extend his father's work in psychiatry, and, on 29 February 1924, he delivered a remarkable lecture The Story of the Brain, in which he recorded a generous appreciation of the role of the phrenologists in the early foundations of psychiatric thought and practice.
United States
A key figure in the early spread of moral treatment in the United States was Benjamin Rush (1745–1813),[9] an eminent physician at Pennsylvania Hospital. He limited his practice to mental illness and developed innovative, humane approaches to treatment. He required that the hospital hire intelligent and sensitive attendants to work closely with patients, reading and talking to them and taking them on regular walks. He also suggested that it would be therapeutic for doctors to give small gifts to their patients every so often. However, Rush's treatment methods included bloodletting (bleeding), purging, hot and cold baths, mercury, and strapping patients to spinning boards and "tranquilizer" chairs.[10]
A Boston schoolteacher, Dorothea Dix (1802–1887), also helped make humane care a public and a political concern in the US. On a restorative trip to England for a year, she met Samuel Tuke. In 1841 she visited a local prison to teach Sunday school and was shocked at the conditions for the inmates and the treatment of those with mental illnesses. She began to investigate and crusaded on the issue in Massachusetts and all over the country. She supported the moral treatment model of care.[11] She spoke to many state legislatures about the horrible sights she had witnessed at the prisons and called for reform. Dix fought for new laws and greater government funding to improve the treatment of people with mental disorders from 1841 until 1881, and personally helped establish 32 state hospitals that were to offer moral treatment. Many asylums were built according to the so-called Kirkbride Plan.
Consequences
The moral treatment movement was initially opposed by those in the mental health profession. By the mid-19th century, however, many psychologists had adopted the strategy. They became advocates of moral treatment, but argued that since the mentally ill often had separate physical/organic problems, medical approaches were also necessary. Making this argument stick has been described as an important step in the profession's eventual success at securing a monopoly on the treatment of "lunacy".[12]
The moral treatment movement had a huge influence on asylum construction and practice. Many countries were introducing legislation requiring local authorities to provide asylums for the local population, and they were increasingly designed and run along moral treatment lines. Additional "non-restraint movements" also developed. There was great belief in the curability of mental disorders, particularly in the US, and statistics were reported showing high recovery rates. They were later much criticized, particularly for not differentiating between new admissions and re-admissions (i.e. those who hadn't really achieved a sustained recovery). It has been noted, however, that the cure statistics showed a decline from the 1830s onwards, particularly sharply in the second half of the century, which has been linked to the dream of small, curative asylums giving way to large, centralized, overcrowded asylums.[13]
There was also criticism from some ex-patients and their allies. By the mid-19th century in England, the Alleged Lunatics' Friend Society was proclaiming that the new moral treatment was a form of social repression achieved "by mildness and coaxing, and by solitary confinement"; that its implication that the "alleged lunatics" needed re-educating meant it treated them as if they were children incapable of making their own decisions; and that it failed to properly inform people of their rights or involve them in discussion about their treatment. The Society was suspicious of the tranquility of the asylums, suggesting that patients were simply being crushed and then discharged to live a "milk sop" (meek) existence in society.[14]
In the context of
Although the Retreat had been based on a non-medical approach and environment, medically based reformers emulating it spoke of "patients" and "hospitals". Asylum "nurses" and attendants, once valued as a core part of providing good
In the 1960s,
The moral treatment movement is widely seen as influencing psychiatric practice up to the present day, including specifically
See also
- Erwadi fire incident
- Humane treatment of the mentally ill
- Moral insanity
- The Retreat (First institution to implement moral treatment)
- Testimony of equality describing actions of the Quakers towards equality
References
- S2CID 13162025.
- ^ Mora, G. (1959) Vincenzo Chiarugi (1759–1820) and his psychiatric reform in Florence in the late 18th century (on the occasion of the bi-centenary of his birth) J Hist Med. Oct;14:424-33.
- PMID 382877.
- PMID 14071960.
- PMID 382874.
- ]
- ^ Louis C Charland (2008) A moral line in the sand: Alexander Chrichton and Philippe Pinel on the psychopathology of the passions. In Fact and value in emotion By Louis C. Charland, Peter Zachar
- S2CID 218906106.)
{{cite journal}}
: CS1 maint: multiple names: authors list (link - ^ Ackerson, BJ. & Korr, WS. (2007) Mental Health Policy and Social Justice in [ Advancing social justice through clinical practice Etiony Aldarondo
- ^ Benjamin Rush, M.D. (1749–1813): “The Father of American Psychiatry”
- PMC 1470530.
- ^ ISBN 0-415-35417-X.
- ^ a b Martin Terre Blanche (1999) Readmission and the social construction of mental disturbance Chapter 2: An archaeology of psychiatric readmission. University of South Africa
- PMID 3523075.
- PMID 8376657. Archived from the originalon 2013-01-05.
- ^ Foucault, Michel. Madness and Civilization, p. 158
- ^ Scull, A. (1989) Social Order/Mental Disorder: Anglo-American Psychiatry in Historical Perspective Chapter Four: Moral Treatment Reconsidered. Berkeley: University of California Press
- S2CID 21451994.
- PMID 2672822.
- ^ Shepherd, G., Boardman, J., Slade, M. (2008) Making Recovery a Reality. Archived 2008-08-28 at the Wayback Machine Sainsbury Centre for Mental Health