Moral treatment
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| - | :''see [[French psychiatry]]'' | ||
| - | '''Philippe Pinel''' ([[April 20]], [[1745]] - [[October 25]], [[1826]]) was a French physician who was instrumental in the development of a more humane approach to the custody and care of [[psychiatric hospital|psychiatric patients]], referred to today as [[moral treatment]]. He also made notable contributions to the [[classification of mental disorders]] and has been described by some as "the father of modern psychiatry". In modern commentary, [[Michel Foucault|Foucault]]'s influential book, ''[[Madness and Civilization|Madness and Civilization]]'' focuses on Pinel, along with [[William Tuke|Tuke]], as the driving force behind the shift from physical to mental oppression. | ||
| - | == Biography == | + | '''Moral treatment''' was an approach to [[mental disorder]] based on humane [[psychosocial]] care or [[moral]] discipline that emerged in the 18th century and came to the fore for much of the 19th century, deriving partly from [[psychiatry]] or [[psychology]] and partly from [[religious]] or [[moral]] concerns. The movement is particularly associated with reform and development of the [[psychiatric hospital|asylum]] system in Western Europe at that time. It fell into decline as a distinct method by the 20th century, however, due to overcrowding and misuse of asylums and the predominance of biomedical methods. The movement is widely seen as influencing certain areas of psychiatric practice up to the present day. There has been criticism that the approach blamed or oppressed patients according to the standards of a particular [[social class]] or [[religion]]. |
| - | He was born in [[Saint-André]], [[Tarn]] the son and nephew of physicians. After receiving a degree from the faculty of medicine in [[Toulouse]], he studied an additional four years at the Faculty of Medicine of [[Montpellier]]. He arrived in Paris in [[1778]]. | + | ==Context== |
| + | Moral treatment developed in the context of the [[Age of Enlightenment|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 tortuous "treatments" including whipping, beating, bloodletting, shocking, starvation, irritant chemicals, and isolation. There were some attempts to argue for more psychological understandings and curative 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 understanding, but conditions generally remained poor. The treatment of King [[George III]] also led to increased optimism about the possibility of therapeutic interventions. | ||
| - | He spent fifteen years earning his living as a writer, translator, and editor because the restrictive regulations of the old regime prevented him from practicing medicine. The Paris faculty did not recognize a degree from a provincial university like Toulouse. He failed twice in a competition which would have awarded him funds to continue his studies. In the second competition the jury stressed his ‘painful’ mediocrity in all areas of medical knowledge, an assessment seemingly so grossly incompatible with his later intellectual accomplishments that political motives have been suggested. Discouraged, Pinel considered emigrating to America. In 1784 he became editor of the not very prestigious ''[[Gazette de santé]],'' a four-page weekly.<br><br> | + | ==Early development== |
| - | At about this time he began to develop an intense interest in the study of [[mental illness]]. The incentive was a personal one. A friend had developed a ‘nervous melancholy’ that had ‘degenerated into mania’ and resulted in [[suicide]]. What Pinel regarded as an unnecessary tragedy due to gross mismanagement seems to have haunted him. It led him to seek employment at one of the best-known private sanatoria for the treatment of insanity in Paris. He remained there for five years prior to the Revolution, gathering observations on [[insanity]] and beginning to formulate his views on its nature and treatment. | + | ===Italy=== |
| + | Under the Enlightened concern of [[Leopold II, Holy Roman Emperor|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. | ||
| - | Pinel was an Ideologue, a disciple of the [[Étienne Bonnot de Condillac|abbé de Condillac]]. He was also a clinician who believed that medical truth was derived from clinical experience. [[Hippocrates]] was his model. | + | ===France=== |
| + | The ex-patient [[Jean-Baptiste Pussin]] and his wife Margueritte, and the physician [[Philippe Pinel]] (1745–1826), are also recognized as the first instigators of more humane conditions in asylums. From the early 1780s, Pussin had been in charge of the mental hospital division of the [[Bicêtre Hospital|La Bicêtre]], an asylum in [[Paris]] for male patients. From the mid 1780s, Pinel was publishing articles on links between emotions, social conditions and insanity. In 1792 (formally recorded in 1793), Pinel became the chief physician at the Bicetre. Pussin showed Pinel how really knowing the patients meant they could be managed with sympathy and kindness as well as authority and control. In 1797, Pussin first freed patients of their chains and banned physical punishment, although straitjackets could be used instead. Patients were allowed to move freely about the hospital grounds, and eventually dark dungeons were replaced with sunny, well-ventilated rooms. 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, [[Pitié-Salpêtrière Hospital|La Salpetrière]]. Pinel's student and successor, [[Jean Esquirol]] (1772–1840), went on to help establish 10 new mental hospitals that operated on the same principles. There was an emphasis on the selection and supervision of attendants in order to establish a suitable setting to facilitate psychological work, and particularly on the employment of ex-patients as they were thought most likely to refrain from inhumane treatment while being able to stand up to pleading, menaces, or complaining. | ||
| - | During the 1780s Pinel was invited to join the salon of [[Madame Helvétius]]. Pinel was in sympathy with the Revolution. After the revolution, friends he had met at Madame Helvétius’ salon came to power. In August 1793 Pinel was appointed "physician of the infirmeries" at [[Bicêtre Hospital]]. At the time it housed about four thousand imprisoned men--criminals, petty offenders, syphilitics, pensioners and about two hundred mental patients. Pinel’s patrons hoped that his appointment would lead to therapeutic initiatives. His experience at the private sanatoria made him a good candidate for the job. | + | Pinel used the term "traitement moral" for the new approach. "Moral" in French had a mixed meaning of both psychological/emotional and moral. |
| - | Soon after his appointment to Bicêtre Pinel became interested in the seventh ward where 200 mentally ill men were housed. He asked for a report on these inmates. A few days later he received a table with comments from the "governor" [[Jean-Baptiste Pussin]] ([[1745]]-[[1811]]). In the 1770s Pussin had been successfully treated for [[scrofula]] at Bicêtre; and, following a familiar pattern, he was eventually recruited, along with his wife, [[Marguerite Jubline]], onto the staff of the hospice. | + | ===England=== |
| + | An English [[Quaker]] named [[William Tuke]] (1732–1819) independently led the development of a radical new type of institution in northern [[England]], following the death of a fellow Quaker in a local asylum in 1790. In 1796, with the help of fellow Quakers and others, he founded the [[The Retreat|York Retreat]], where eventually about 30 patients lived as part of a small community in a quiet country house and engaged in a combination of rest, talk, and manual work. Rejecting medical theories and techniques, the efforts of the York Retreat centered around minimizing restraints and cultivating rationality and moral strength. The entire Tuke family became known as some of the founders of moral treatment. 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 recognized. William Tuke's grandson, [[Samuel Tuke (reformer)|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". | ||
| - | Appreciating Pussin’s outstanding talent, Pinel virtually apprenticed himself to that unschooled but experienced custodian of the insane. His purpose in doing this was to "enrich the medical theory of mental illness with all the insights that the empirical approach affords. What he observed was a strict nonviolent, nonmedical management of mental patients came to be called [[moral treatment]], though psychological might be a more accurate translation of the French ‘moral’. | + | ===United States=== |
| + | The person most responsible for the early spread of moral treatment{{Citation needed|date=September 2008}} in the [[United States]] was [[Benjamin Rush]] (1745–1813), 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.[http://www.nlm.nih.gov/hmd/diseases/benjamin.html] | ||
| - | Although Pinel always gave Pussin the credit he deserved, a legend grew up about Pinel single-handedly liberating the insane from their chains. This legend has been commemorated in paintings and prints. In fact Pinel condoned the use of threats and chains when other means failed. It was Pussin who replaced iron shackles with straitjackets at Bicêtre in 1797, after Pinel had left for the Salpêtrière. Pinel followed Pussin's example three years later, after bringing Pussin to the Salpêtrière. | + | A [[Boston]] [[schoolteacher]], [[Dorothea Dix]] (1802–1887), made humane care a public and a political concern in the US. In 1841 Dix visited a local prison to teach [[Sunday school]] and was shocked at the conditions for the inmates. She subsequently became very interested in prison conditions and later expanded her crusade to include the poor and mentally ill people all over the country. 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 hospital]]s that were to offer moral treatment. Many asylums were built on the so-called [[Kirkbride Plan]]. |
| - | While at Bicêtre Pinel did away with bleeding, purging, and blistering in favor of a therapy that involved close contact with and careful observation of patients. Pinel visited each patient, often several times a day, and took careful notes over two years. He engaged them in lengthy conversations. His objective was to assemble a detailed case history and a natural history of the patient's illness. In his book ''Traité médico-philosophique sur l'aleniation mentale; ou la manie'', published in [[1801]], Pinel discusses his psychologically oriented approach. This book was translated into English by [[David Daniel Davis|D. D. Davis]] as a ''Treatise on Insanity'' in [[1806]]. It had an enormous influence on both French and Anglo-American psychiatrists during the [[nineteenth century]]. | + | ==Consequences== |
| + | The moral treatment movement was initially opposed by many madhouse keepers and medics, the latter partly because it cast doubt on their own approach. By the mid-19th century, however, many medics had changed 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". | ||
| - | In 1795, he became chief physician of the [[Hospice de la Salpêtrière]], a post that he retained for the rest of his life. The Salpêtrière was, at the time, like a large village, with seven thousand elderly indigent and ailing women, an entrenched bureaucracy, a teeming market and huge infirmaries. Pinel missed Pussin, and in 1802 secured his transfer to the Salpêtrière. Pinel created an inoculation clinic in his service at the Salpêtrière in 1799 and the first vaccination in Paris was given there in April 1800. A statue in his honour stands outside the Salpêtrière. | + | 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. |
| - | In [[1795]] Pinel was also appointed as a professor of medical pathology, a chair that he held for twenty years. He was briefly dismissed from this position in 1822, with ten other professors, suspected of political liberalism, but reinstated as an honorary professor shortly thereafter. | + | There was also criticism from some [[Consumer/Survivor/Ex-Patient Movement|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. |
| - | In 1798 Pinel published an authoritative classification of diseases in his ''Nosographie philosophique ou méthode de l'analyse appliquée à la médecine''. Although he is properly considered one of the founders of psychiatry, this book establishes him as the last great [[nosology|nosologist]] of the [[eighteenth century]]. While the ''Nosographie'' appears completely dated today, it was so popular in its time that it went through six editions between its initial publication and [[1818]]. | + | In the context of [[industrialization]], public asylums expanded in size and number. Bound up in this was the development of the profession of [[psychiatry]], able to expand with large numbers of inmates collected together. By the end of the 19th century and into the 20th, these large out-of-town asylums had become overcrowded, misused, isolated and run-down. The therapeutic principles had often been neglected along with the patients. Moral management techniques had turned into mindless institutional routines within an authoritarian structure. Consideration of costs quickly overrode ideals. There was compromise over decoration—no longer a homey, family atmosphere but drab and minimalist. There was an emphasis on security, custody, high walls, closed doors, shutting people off from society, and physical restraint was often used. It is well documented that there was very little therapeutic activity, and medics were little more than administrators who seldom attended to patients and mainly then for other, somatic, problems. Any hope of moral treatment or a family atmosphere was "obliterated". In 1827 the average number of asylum inmates in Britain was 166; by 1930 it was 1221. The relative proportion of the public officially diagnosed as insane grew. |
| - | In 1802 Pinel published ''La Médecine Clinique'' which was based on his experiences at the Salpêtrière and in which he extended his previous book on classification and disease. | + | 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 [[holistic health|holistic care]], were often scapegoated for the failures of the system. Towards the end of the 19th century, somatic theories, pessimism in [[prognosis]], and custodialism had returned. Theories of hereditary degeneracy and [[eugenics]] took over, and in the 20th century the concepts of mental hygiene and [[mental health]] developed. From the mid 20th century, however, a process of [[antipsychiatry]] and [[deinstitutionalization]] occurred in many countries in the West, and asylums in many areas were gradually replaced with more local [[community mental health services]]. |
| - | Pinel was elected to the Académie des Sciences in 1804 and was a member of the Académie de Médecine from its founding in [[1820]]. He died in [[Paris]] in [[1826]]. | + | In the 1960s, [[Michel Foucault]] renewed the argument that moral treatment had really been a new form of moral oppression, replacing physical oppression, and his arguments were widely adopted within the [[History of anti-psychiatry|antipsychiatry]] movement. Foucault was interested in ideas of "[[other|the other]]" and how society defines normalcy by defining the [[abnormality|abnormal]] and its relationship to the normal. A patient in the asylum had to go through four moral syntheses: silence, recognition in the mirror, perpetual judgment, and the apotheosis of the medical personage. The mad were ignored and verbally isolated. They were made to see madness in others and then in themselves until they felt guilt and remorse. The doctor, despite his lack of medical knowledge about the underlying processes, had all powers of authority and defined insanity. Thus Foucault argues that the "moral" asylum is "not a free realm of observation, diagnosis, and therapeutics; it is a juridical space where one is accused, judged, and condemned." Foucault's reassessment was succeeded by a more balanced view, recognizing that the manipulation and ambiguous "kindness" of Tuke and Pinel may have been preferable to the harsh coercion and physical "treatments" of previous generations, while aware of moral treatment's less benevolent aspects and its potential to deteriorate into repression. |
| + | |||
| + | The moral treatment movement is widely seen as influencing psychiatric practice up to the present day, including specifically [[therapeutic communities]] (although they were intended to be less repressive); [[occupational therapy]] and [[Soteria]] houses. The [[Recovery model]] is said to have echoes of the concept of moral treatment. | ||
| + | |||
| + | ==See also== | ||
| + | * [[Deinstitutionalisation]] | ||
| + | * [[Moral insanity]] | ||
| {{GFDL}} | {{GFDL}} | ||
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Moral treatment was an approach to mental disorder based on humane psychosocial care or moral discipline that emerged in the 18th century and came to the fore for much of the 19th century, deriving partly from psychiatry or psychology and partly from religious or moral concerns. The movement is particularly associated with reform and development of the asylum system in Western Europe at that time. It fell into decline as a distinct method by the 20th century, however, due to overcrowding and misuse of asylums and the predominance of biomedical methods. The movement is widely seen as influencing certain areas of psychiatric practice up to the present day. There has been criticism that the approach blamed or oppressed patients according to the standards of a particular social class or religion.
Contents |
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 tortuous "treatments" including whipping, beating, bloodletting, shocking, starvation, irritant chemicals, and isolation. There were some attempts to argue for more psychological understandings and curative 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 understanding, but conditions generally remained poor. 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.
France
The ex-patient Jean-Baptiste Pussin and his wife Margueritte, and the physician Philippe Pinel (1745–1826), are also recognized as the first instigators of more humane conditions in asylums. From the early 1780s, Pussin had been in charge of the mental hospital division of the La Bicêtre, an asylum in Paris for male patients. From the mid 1780s, Pinel was publishing articles on links between emotions, social conditions and insanity. In 1792 (formally recorded in 1793), Pinel became the chief physician at the Bicetre. Pussin showed Pinel how really knowing the patients meant they could be managed with sympathy and kindness as well as authority and control. In 1797, Pussin first freed patients of their chains and banned physical punishment, although straitjackets could be used instead. Patients were allowed to move freely about the hospital grounds, and eventually dark dungeons were replaced with sunny, well-ventilated rooms. 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, La Salpetrière. Pinel's student and successor, Jean Esquirol (1772–1840), went on to help establish 10 new mental hospitals that operated on the same principles. There was an emphasis on the selection and supervision of attendants in order to establish a suitable setting to facilitate psychological work, and particularly on the employment of ex-patients as they were thought most likely to refrain from inhumane treatment while being able to stand up to pleading, menaces, or complaining.
Pinel used the term "traitement moral" for the new approach. "Moral" in French had a mixed meaning of both psychological/emotional and moral.
England
An English Quaker named William Tuke (1732–1819) independently led the development of a radical new type of institution in northern England, following the death of a fellow Quaker in a local asylum in 1790. In 1796, with the help of fellow Quakers and others, he founded the York Retreat, where eventually about 30 patients lived as part of a small community in a quiet country house and engaged in a combination of rest, talk, and manual work. Rejecting medical theories and techniques, the efforts of the York Retreat centered around minimizing restraints and cultivating rationality and moral strength. The entire Tuke family became known as some of the founders of moral treatment. 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 recognized. 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".
United States
The person most responsible for the early spread of moral treatmentTemplate:Citation needed in the United States was Benjamin Rush (1745–1813), 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.[1]
A Boston schoolteacher, Dorothea Dix (1802–1887), made humane care a public and a political concern in the US. In 1841 Dix visited a local prison to teach Sunday school and was shocked at the conditions for the inmates. She subsequently became very interested in prison conditions and later expanded her crusade to include the poor and mentally ill people all over the country. 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 on the so-called Kirkbride Plan.
Consequences
The moral treatment movement was initially opposed by many madhouse keepers and medics, the latter partly because it cast doubt on their own approach. By the mid-19th century, however, many medics had changed 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".
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.
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.
In the context of industrialization, public asylums expanded in size and number. Bound up in this was the development of the profession of psychiatry, able to expand with large numbers of inmates collected together. By the end of the 19th century and into the 20th, these large out-of-town asylums had become overcrowded, misused, isolated and run-down. The therapeutic principles had often been neglected along with the patients. Moral management techniques had turned into mindless institutional routines within an authoritarian structure. Consideration of costs quickly overrode ideals. There was compromise over decoration—no longer a homey, family atmosphere but drab and minimalist. There was an emphasis on security, custody, high walls, closed doors, shutting people off from society, and physical restraint was often used. It is well documented that there was very little therapeutic activity, and medics were little more than administrators who seldom attended to patients and mainly then for other, somatic, problems. Any hope of moral treatment or a family atmosphere was "obliterated". In 1827 the average number of asylum inmates in Britain was 166; by 1930 it was 1221. The relative proportion of the public officially diagnosed as insane grew.
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 holistic care, were often scapegoated for the failures of the system. Towards the end of the 19th century, somatic theories, pessimism in prognosis, and custodialism had returned. Theories of hereditary degeneracy and eugenics took over, and in the 20th century the concepts of mental hygiene and mental health developed. From the mid 20th century, however, a process of antipsychiatry and deinstitutionalization occurred in many countries in the West, and asylums in many areas were gradually replaced with more local community mental health services.
In the 1960s, Michel Foucault renewed the argument that moral treatment had really been a new form of moral oppression, replacing physical oppression, and his arguments were widely adopted within the antipsychiatry movement. Foucault was interested in ideas of "the other" and how society defines normalcy by defining the abnormal and its relationship to the normal. A patient in the asylum had to go through four moral syntheses: silence, recognition in the mirror, perpetual judgment, and the apotheosis of the medical personage. The mad were ignored and verbally isolated. They were made to see madness in others and then in themselves until they felt guilt and remorse. The doctor, despite his lack of medical knowledge about the underlying processes, had all powers of authority and defined insanity. Thus Foucault argues that the "moral" asylum is "not a free realm of observation, diagnosis, and therapeutics; it is a juridical space where one is accused, judged, and condemned." Foucault's reassessment was succeeded by a more balanced view, recognizing that the manipulation and ambiguous "kindness" of Tuke and Pinel may have been preferable to the harsh coercion and physical "treatments" of previous generations, while aware of moral treatment's less benevolent aspects and its potential to deteriorate into repression.
The moral treatment movement is widely seen as influencing psychiatric practice up to the present day, including specifically therapeutic communities (although they were intended to be less repressive); occupational therapy and Soteria houses. The Recovery model is said to have echoes of the concept of moral treatment.
See also
