Psychiatry & the AsylumPsychiatry & the Asylum

1750-19001750-1900

Basic Chronology of the Basic Chronology of the Transformation of the Care of the Transformation of the Care of the

InsaneInsane Prior to 1750, little institutional carePrior to 1750, little institutional care

Not part of orthodox medical practiceNot part of orthodox medical practice

Few people actually categorized as insaneFew people actually categorized as insane

1807, estimated 2,200 insane people in Britain1807, estimated 2,200 insane people in Britain

1890, 66 public mad houses1890, 66 public mad houses 90,000 people admitted to them90,000 people admitted to them

Population of the insane grew 4X faster than Population of the insane grew 4X faster than the population of Britain as a wholethe population of Britain as a whole

3 Social Transformations in Care of 3 Social Transformations in Care of the Insane after 1750the Insane after 1750

Prior to 1750, care of the insane was basically Prior to 1750, care of the insane was basically custodialcustodial

e.g.: Bethlem Hospitale.g.: Bethlem Hospital Founded 1247Founded 1247 1403: housed 6 men “deprived of reason”1403: housed 6 men “deprived of reason” 1632: 27 inmates1632: 27 inmates Moved to new site 1676: 150 inmatesMoved to new site 1676: 150 inmates

Little in way of medical therapyLittle in way of medical therapy

Many never saw a doctorMany never saw a doctor

Standard “treatments”Standard “treatments” DunkingDunking Physical restraintPhysical restraint BleedingBleeding Fear Fear

Benjamin Rush on bloodletting:Benjamin Rush on bloodletting:

It should be copious on the first attack . . . From It should be copious on the first attack . . . From 20 to 40 ounces of blood may be taken at once. 20 to 40 ounces of blood may be taken at once. The effects of this early and copious bleeding The effects of this early and copious bleeding are wonderful in calming mad people. (1812)are wonderful in calming mad people. (1812)

Appalling conditions in institutions for the Appalling conditions in institutions for the insaneinsane Incompetent doctors (or none at all)Incompetent doctors (or none at all) Abuse & neglect of patientsAbuse & neglect of patients Exploitation of patientsExploitation of patients

Prisons were no betterPrisons were no better Voluntary hospitals slightly betterVoluntary hospitals slightly better

Prison reform movementPrison reform movement John HowardJohn Howard

Resulted in more enlightened public opinion Resulted in more enlightened public opinion about institutional care generallyabout institutional care generally

1. Rise of the Moral Cure1. Rise of the Moral Cure

Defined itself in opposition to what had come Defined itself in opposition to what had come beforebefore

Samuel TukeSamuel Tuke Prominent tea merchant at YorkProminent tea merchant at York QuakerQuaker

Founded the Retreat in 1796Founded the Retreat in 1796

Initially tried standard medical therapiesInitially tried standard medical therapies

Rejected these as uselessRejected these as useless

Substituted “moral treatment”Substituted “moral treatment”

Believed that the insane had lost control of Believed that the insane had lost control of inhibitions that defined their humanityinhibitions that defined their humanity

Asylum an environment that emphasized the Asylum an environment that emphasized the self-discipline they had lostself-discipline they had lost

Distanced them from the environments that Distanced them from the environments that had made them insanehad made them insane

Run as a family environmentRun as a family environment

Superintendent took parental roleSuperintendent took parental role

Inmates treated like ill-disciplined childrenInmates treated like ill-disciplined children

Intended to change emotional or intellectual Intended to change emotional or intellectual disorder, not pathologydisorder, not pathology

Accomplished through behavioural means, not Accomplished through behavioural means, not physiologyphysiology

Used restraintsUsed restraints

Rejected physical or emotional abuseRejected physical or emotional abuse

Work therapyWork therapy

2. Medicalization of Insanity2. Medicalization of Insanity

Psychiatry one of most successful Psychiatry one of most successful medicalizations in medical historymedicalizations in medical history

Two aspectsTwo aspects Theoretical understanding of mental illnessTheoretical understanding of mental illness Management of mental illnessManagement of mental illness

1. Theoretical Medicalization1. Theoretical Medicalization

Accomplished by making diagnosing & Accomplished by making diagnosing & treating insanity exclusively medical in treating insanity exclusively medical in orientationorientation

Philippe PinelPhilippe Pinel 1745-18261745-1826

Worked at Bicetre & Worked at Bicetre & later the Salpetrierelater the Salpetriere

Appalled by callous Appalled by callous way mad people were way mad people were treatedtreated

I cannot here avoid giving my most decided I cannot here avoid giving my most decided sufferage in favour of the moral qualities of sufferage in favour of the moral qualities of maniacs. I have no where met, excepting in maniacs. I have no where met, excepting in romances, with fonder husbands, more romances, with fonder husbands, more affectionate parents, more impassioned . . . affectionate parents, more impassioned . . . than in the lunatic asylum, during their than in the lunatic asylum, during their intervals of calmness and reason." intervals of calmness and reason."

Rejected callous treatment of the insaneRejected callous treatment of the insane Ordered removal of chains Ordered removal of chains Wrote Wrote Medical-Philosophical Treatise on Mental Medical-Philosophical Treatise on Mental

Alienation or ManiaAlienation or Mania

Much more could be said about the rise of Much more could be said about the rise of psychiatry & influential physicians in this area psychiatry & influential physicians in this area of specializationof specialization

Why was medicalization of mental illness Why was medicalization of mental illness successful?successful?

Secularization of France supported more Secularization of France supported more materialist understanding of mental illnessmaterialist understanding of mental illness

Disease of the brain, not the mind/spiritDisease of the brain, not the mind/spirit

2. Medicalization of Treatment2. Medicalization of Treatment

In Britain, the state needed medical assistance In Britain, the state needed medical assistance in care of the insanein care of the insane

Only small number of patients in “public” Only small number of patients in “public” institutions, which were for the poorinstitutions, which were for the poor

Middle and upper classes dependent on private Middle and upper classes dependent on private institutionsinstitutions

Sites of considerable abuseSites of considerable abuse

People sent to asylums to get rid of themPeople sent to asylums to get rid of them

No registers of who was thereNo registers of who was there

No supervision of any sortNo supervision of any sort

Several House of Commons hearings in 18Several House of Commons hearings in 18 thth century related to reports of unethical century related to reports of unethical confinementconfinement

1774 Madhouses Act1774 Madhouses Act

No one could be admitted without medical No one could be admitted without medical certificatecertificate

Madhouses to be licensedMadhouses to be licensed

Must keep register of inmatesMust keep register of inmates

Did not define who was a physicianDid not define who was a physician

Royal College of Physicians unenthusiastic Royal College of Physicians unenthusiastic about supporting this legislationabout supporting this legislation

Rapid expansion of private madhousesRapid expansion of private madhouses

Onset of state-run madhousesOnset of state-run madhouses

Needed increased support from physiciansNeeded increased support from physicians

1828: all madhouses must have physician visit 1828: all madhouses must have physician visit once a weekonce a week

Proper medical records to be keptProper medical records to be kept

Increasing state surveillanceIncreasing state surveillance

Decrease in lay-established asylumsDecrease in lay-established asylums

1854: permanent commission to oversee all 1854: permanent commission to oversee all madhousesmadhouses 50% lay people50% lay people 50% physicians50% physicians

Legal definition of criminal insanityLegal definition of criminal insanity 1854 M’Naghten case1854 M’Naghten case Physicians asked to provide expert testimonyPhysicians asked to provide expert testimony

3. Pauperization of Insanity3. Pauperization of Insanity

Madhouse (asylum, mental hospital) became Madhouse (asylum, mental hospital) became institution of choice for mentally ill poorinstitution of choice for mentally ill poor

Growth in institutional care can be interpreted Growth in institutional care can be interpreted as indication of more humanitarian response to as indication of more humanitarian response to distressdistress

Can also be interpreted as increased interest in Can also be interpreted as increased interest in controlling deviant behaviourcontrolling deviant behaviour

Shifts in what constituted deviance over timeShifts in what constituted deviance over time

Leads to critique of psychiatry’s roleLeads to critique of psychiatry’s role

Is mental illness found or made?Is mental illness found or made?

Major critiques in 20Major critiques in 20thth century century ““One Flew Over the Cuckoo’s Nest”One Flew Over the Cuckoo’s Nest” ““Clockwork Orange”Clockwork Orange” Myth of Mental IllnessMyth of Mental Illness (Dr. Thomas Szasz) (Dr. Thomas Szasz) Madness and CivilizationMadness and Civilization (Michel Foucault) (Michel Foucault)

Most intensive period of asylum building in Most intensive period of asylum building in Britain between 1840 and 1880Britain between 1840 and 1880

Size of these institutions made effective Size of these institutions made effective patient care impossiblepatient care impossible

By end of 19By end of 19thth century, asylums had become century, asylums had become warehouses for the insanewarehouses for the insane

A Bit More About Moral A Bit More About Moral ArchitectureArchitecture

Mental institutions were generally designed to Mental institutions were generally designed to be highly visiblebe highly visible

Reminded people of consequences of deviant Reminded people of consequences of deviant behaviourbehaviour

Brandon Mental Hospital on north hill outside Brandon Mental Hospital on north hill outside of town; could be seen by everyone in the cityof town; could be seen by everyone in the city

Physical space laid out like a large Victorian Physical space laid out like a large Victorian househouse

Impressive entrance & foyers laid out in a Impressive entrance & foyers laid out in a large centre blocklarge centre block

Centre block often contained apartments of Centre block often contained apartments of medical superintendent & his familymedical superintendent & his family

Patient wings placed on each sidePatient wings placed on each side

Males & females separatedMales & females separated

Brandon Mental Health CentreBrandon Mental Health Centre

Based on unpublished masters thesis (UM) by Based on unpublished masters thesis (UM) by Christopher DooleyChristopher Dooley

““When Love and Skill Get Together:” Work, When Love and Skill Get Together:” Work, Skill and the Occupational Culture of Mental Skill and the Occupational Culture of Mental Nurses at the Brandon Hospital for Mental Nurses at the Brandon Hospital for Mental Diseases, 1919-1946”Diseases, 1919-1946”

Prior to 1880, no formal provision for mental Prior to 1880, no formal provision for mental health care in Manitobahealth care in Manitoba

At discretion of local officialsAt discretion of local officials FamilyFamily Fend for selfFend for self Incarcerated in jailsIncarcerated in jails DeportedDeported

18771877 Mental patients incarcerated in gaol at Lower Mental patients incarcerated in gaol at Lower

Fort GarryFort Garry Later, moved to Stony Mountain PenitentiaryLater, moved to Stony Mountain Penitentiary Housed in basementHoused in basement Condemned in 1884; had been contaminated Condemned in 1884; had been contaminated

by sewageby sewage

1883: 50 bed facility constructed at Selkirk1883: 50 bed facility constructed at Selkirk Patients under medical care for first timePatients under medical care for first time

1891: Conversion of Brandon Reformatory to 1891: Conversion of Brandon Reformatory to asylum for the insaneasylum for the insane

Named the Brandon AsylumNamed the Brandon Asylum 25 patients transferred from Selkirk25 patients transferred from Selkirk

1910: Asylum burned down1910: Asylum burned down 700 patients and staff housed in building on 700 patients and staff housed in building on

agricultural groundsagricultural grounds

1913: New asylum completed1913: New asylum completed 1000 bed capacity1000 bed capacity Renamed Brandon Hospital for the InsaneRenamed Brandon Hospital for the Insane

1919: Renamed Brandon Hospital for Mental 1919: Renamed Brandon Hospital for Mental DiseasesDiseases

http://timelinks.merlin.mb.ca/imageref/imagerhttp://timelinks.merlin.mb.ca/imageref/imager18.htm18.htm

http://members.tripod.com/hillmans2002/bmhchttp://members.tripod.com/hillmans2002/bmhctour.htmltour.html

Unexplored themes in the History of Unexplored themes in the History of PsychiatryPsychiatry

Patient’s LivesPatient’s Lives

Medicalization of mental illness had little Medicalization of mental illness had little impact on the experience of patientsimpact on the experience of patients

In 1920, Dr. C.A. Barager, Medical Sup’t of In 1920, Dr. C.A. Barager, Medical Sup’t of Brandon facility reported that only 19.7% of Brandon facility reported that only 19.7% of patients discharged considered curedpatients discharged considered cured

Patients suffered from a wide range of Patients suffered from a wide range of problems:problems: DevelopmentalDevelopmental PsychiatricPsychiatric Psychiatric consequences of physical illnessesPsychiatric consequences of physical illnesses Age related dementiasAge related dementias EpilepsyEpilepsy

Treatments were crude, often ineffectiveTreatments were crude, often ineffective

Institutional life could be:Institutional life could be: BoringBoring DangerousDangerous HumiliatingHumiliating

Three excellent Canadian studies of Three excellent Canadian studies of psychiatric care in the late 19psychiatric care in the late 19 thth – 20 – 20thth century century

Reaume, Geoffrey. Reaume, Geoffrey. Remembrance of Patients Remembrance of Patients Past: Patient Life at the Toronto Hospital for Past: Patient Life at the Toronto Hospital for the Insane 1870-1940.the Insane 1870-1940. Toronto: Oxford Toronto: Oxford University Press, 2000.University Press, 2000.

Warsh, Cheryl. Warsh, Cheryl. Moments of Unreason: The Moments of Unreason: The Practice of Canadian Psychiatry and the Practice of Canadian Psychiatry and the Homewood Retreat, 1883-1923.Homewood Retreat, 1883-1923. Montreal: Montreal: McGill-Queen’s University Press, 1989.McGill-Queen’s University Press, 1989.

Chunn, Dorothy E. and Robert Menzies. “Out Chunn, Dorothy E. and Robert Menzies. “Out of Mind, Out of Law: The Regulation of of Mind, Out of Law: The Regulation of Criminally Insane Women Inside British Criminally Insane Women Inside British Columbia’s Public Mental Hospitals, 1888-Columbia’s Public Mental Hospitals, 1888-1973.” 1973.” Canadian Journal of Women and the Canadian Journal of Women and the LawLaw, 10 (1998), 307-337., 10 (1998), 307-337.

Changes in Medical TreatmentChanges in Medical Treatment

Experience of Staff in Psychiatric Experience of Staff in Psychiatric FacilitiesFacilities

Dooley’s thesisDooley’s thesis

Tipliski’s doctoral dissertationTipliski’s doctoral dissertation