From 16th to 17th Century, mental illness was regarded to be as an influence of the devil. Mentally sick patients were believed to be possessed by the demons and the evil spirits.1 These patients attracted little sympathy from few people.
Patients were often treated harshly and people thought that by torturing them it would help drive out these evil spirits. During this period, the care for mentally ill patients was under family responsibility and a few people from the community who were involved in charity work.2
In situations where metal illness patients were not causing any threat to the community, they were ignored and left on their own. However, if they posed any threat they were put into confinements. Such confinement was the best option during this time to seclude patients from the society.
Treatment was rudimental and entailed more of mechanical restraint.3 By the start of mid 18th Century, the treatment for mentally ill patients took a different approach. It involved moral treatment that was anchored on kind treatment of the patients.4
In this approach, form of restraints such as ankle irons, handcuffs, and straightjacket were used.
As the time went by new inventions were made that had appropriate treatment such as psychotropic drugs and emergency of new health workers such as psychologists and this made the treatment of mentally ill patients improve greatly.5
Therefore, the purpose of this essay is to compare successfulness of moral treatments of mentally ill patients in 19th Century and that of 20th Century.
Before the 19th Century confinement and use of mechanical restraints was prevalent mode of treatment for the patients who were mentally ill in many parts of the world. Mentally ill patients were treated in either asylums or private madhouses. In Britain, private madhouses were common for particularly in 18th Century.6
They often managed by institutions, doctors and clergymen. This places offered accommodation for about hundred patients or more. Patients were exposed to harsh treatment and mechanical restraint.7
In United States of America, South Carolina Lunatic Asylum currently referred to as South State Hospital was the oldest public mental institution. This institution was founded during the time when creation of asylums for mentally ill patients was at climax.
As 19th Century began treatment models of these patients in public dilapidated houses and in private madhouses was unsatisfactory. This was due to increased pressure from urbanization, high population increase and expanding trade.8
Nevertheless, American asylums differed with those in Europe in that it federal governments lacked legislation that could mandate building of public asylums. For this reason, initiation and running of asylums depended on individual states.
By the fall of 19th Century, at least every state had one asylum with mental patients being treated there. Small groups of reformers were involved to promote state asylums and they were more like private charitable asylums for patients from affluent and poor backgrounds.9
In Britain, development of health facilities for mentally ill patients began around 18th Century. Before then, only the St. Mary of Bethlem in London City was inexistence for several centuries. Before 1812, most of asylums belonged to private or royal benevolence.10
Individuals who were mentally challenged and patients who were mentally ill were taken care of by their family members and were kept in poor houses and prisons. Due to horrible conditions in which many mentally ill patients were kept in it provoked formation of Act of Parliament of 1774.11
Through mandate of this Act, five commissioners from Royal College of Physicians to set out and inspect all private madhouses in London and licensed those that were in good condition to avoid further abuse subjected to the patients12.
However, even though this bill was meant to regulate madhouses it was not effective because any person could have acquired license to operate asylum. Wynn’s Act, which was introduced in 1809 for the welfare of mentally ill persons in England.
This bill enabled magistrate to come up with asylums in every county that were rate supported. These asylums were meant to address the increased number of mentally ill persons from poor families. This bill led to a Parliamentary Select Committee of Inquiry in the year 1815-1816.
This inquiry observed evidence of abuses in mentally ill institutions and private madhouses and dismissal of the officers in charge. These necessitate a better system of inspection of mentally ill patients’ rehabilitation centers by use of a national body.13
The development of Retreat in 1796 by William Tuke in Britain brought about a significant change in managing mentally ill patients. The situation further was improved by development of the concept of ‘moral development’.14 The concept of Moral treatment was advanced by a French psychiatrist know as Philippe Pine.
This term referred to a new approach of managing mentally ill patients. He maintained that if a physician had confidence and install hope to the mentally ill patients, this could significantly improve their behavior and their quality of life.15
The reason behind this was that the former approach used was based on “principle of fear to govern the mentally ill patients”. Moral treatment encouraged health workers to relate to patients with some form of personal strength because force was deemed as the best method of achieving control.16
This approach advocated on individualized care for each mentally ill patient. It also considered integration of activities such as religious support and occupational therapy as part of treatment. Those who supported this concept urged that mentally ill patients required confinement within mental health institutions.
They maintained that if these patients were given freedom their lives together with their family members and friends might be stressful or affect the efficacy of the treatment. This led to providing limited freedom to such patients in case they were to be granted freedom.17
Towards the end of 18th Century, interest in legal, clinical, diagnostic, therapeutic and aspects of mentally ill started gaining momentum. During this time, medical literature for mentally ill patients started increasing as well as medically operated centers.
There was also an understanding mental illness was just like any other kind of diseases human beings suffer from. It is during this period the concept of moral treatment started fading away as new approaches based on physical treatment and new biological understanding came to be embraced.
According to the writings of Kraepelin, a psychiatrist, most of the mental illness patients were seen to leave their homes with little hopes of regaining their normal lives.18
As such, these new treatment approaches focused on managing mental related disorders and symptoms in the mentally ill patients. These treatment modalities by the current standards, they would be considered inhuman. For example, hydrotherapy was one of the physical treatment done to mentally ill patients.
Hydrotherapy was in form of different types of baths such as ‘surprise bath’ where a patient was dipped while standing in a water reservoir. There was also wrapping of the patients in wet packs for long duration of time.19
Other treatments included use of physical shocks induced by electricity or use of insulin and sedative drugs. The common sedative drug used by then was laudanum, which could be administered orally. These drugs were only administered to the patients with their consent.
However, invention of hypodermic syringe made it possible to provide medication even without patients consent.
The end of 18th Century and beginning of 19th Century marked the beginning of kind approach to mentally ill patients and establishments of bodies that represented workers operating in hospitals and asylums.20
Treatment of mentally ill in the 20th Century also used physical therapies such as sedatives, insulin shock and psychosurgery but in better application due to use of medical model which was not there in 19th Century.21
Most of these treatments resulted in suppression of the symptoms. Patients who were receiving these treatments did not get back to their normal lives.
This led psychiatric professional see a need for a better treatment. Such a need was anticipated as expressed by a one of the psychiatric nurse who wrote a letter in 1949 to Earl Warren, a governor of California expressing that better treatments were needed because popular treatments by then had failed22
In early 20th Century, physical treatments such as lobotomies and shock treatment they were not effective in managing patients’ conditions. This triggered advocacy of more effective treatment methods that could not only target on suppression of symptoms but also improve the quality of lives among mentally ill patients.
During a meeting held by the America Psychiatric Association, it was recognized that primary objective in psychiatric treatment is to help the ailing person be integrated in the community in away he or she can use community resources in his personal and social good.
However, such objective was not in line with the treatment offered by then. Between 1950s and 1960s developments in therapeutic approaches for mentally ill persons made great improvements. Use of therapeutic communities was a great breakthrough. It proved more effective compared to traditional methods.
Patients’ rights were respected and were embedded in therapeutic practices. New medications which were more effective like chlorpromazine helped manage patients symptoms better with little clinical monitoring.23
In both 19th Century and 20th Century treatments for mentally ill patients, use of coercion formed key part of the treatment. For instance, coercive measures were used to prevent patient regain control over psychiatric symptoms and prevent possibility committing suicide.
Coercive measures are often used among the patients who are violent or with threatening behaviors that posies risk to others.
Use of coercive measures in mental rehabilitation centers was justified through paternalism and due to the nature of the mental sickness. Mentally ill patients lack autonomy and are incompetent to make their own decisions. 24
For this reason, medical paternalism where health care worker is supposed to intervene in behalf of the patients’ interest is necessary. Where the interest is for the members of the society who may be harmed by the patients’ acts social paternalism is applied.
In overall, coercion was used as part of the treatment even in 20th Century because it was considered that it is likely to enhance long-term autonomy of the patients. In addition, mentally ill patients’ irrational preferences are likely to be different from long-term rational preferences.25
In order to protect human rights, dignity and fundamental freedom among mentally ill patients the United Nations passed a resolution meant to protect individuals who have been detained on mental health grounds.
Similarly, the European Council has also made a recommendation that acknowledges legal requirement for mentally ill persons.26
Therefore, treatment of mentally ill persons has evolved through time. Initially, mental illness was considered to be caused by evil spirits. Those who suffered mental illness were treated harshly because it was believed that by so doing the evil spirit would be cast way.
Often, mentally ill patients were caged in poor conditions and their care was left to family members. The 19th Century treatment of mentally ill persons was an improvement from previous mode of treatment. However, its approach still did not meet the needs for mentally ill persons in that patient’s rights were not highly regarded.
In addition, treatment focused on alleviation of symptoms. The 20th Century treatment of mentally ill persons involved therapeutic community approach. Patient’s nature of illness was regarded as any other kind of illness that affects the body.
Treatment did not only focus on reducing symptoms but also improving the quality of life of the patients. However, in both 19th Century and 20th Century treatment coercive measures were used to protect and treat the patients.
Alice, Keski-valkama. The use of seclusion and mechanical restraint in psychiatry: a persistent challenge over time, Accessed from www.ps.psychiatryonline.org/data/Journals/PSS/3651/1115.pdf, p1
Andrew, Scull. Social Order/Mental Disorder: Anglo-American Psychiatry in Historical Perspective, California: University of California Press, 1989
Freeman, Harrison. Mental Health Policy and Practice in the NHS: 1948-79, Journal of Mental Health, 7, 3, June, 1998
Hellen, Keller. Recovery: A conspiracy of Hope, Accessed from www.pendari.com/DMH/Books/recovery/files/recovery.pdf
Hospital Library Program. From custody to cure: mental Health Care in the North Country, Accessed from www.samaritanhealth.com/library/images/…/smcnewsletter43.pdf ,p1 2008,p1
Peterson, Bracken and Patrick, Thomas. Post psychiatry: A New Direction in Mental Health, British Medical Journal, 322, 2001
Roy, Bewley and David, Wright. The Confinement of the Insane: International Perspectives. 1800-1965, New York: Cambridge University Press , 2003
Thomas, Bewley. Madness to mental illness; History of the Royal College of psychiatrists, Accessed from www.rcpsych.ac.uk/files/samplechapter/MadnesstoMIllnessSChap.pdf, p4
1 Keski-valkama Alice, The use of seclusion and mechanical restraint in psychiatry: a persistent challenge over time. Accessed from www.ps.psychiatryonline.org/data/Journals/PSS/3651/1115.pdf, p1
3 Bewley Thomas, Madness to mental illness; History of the Royal College of psychiatrists, Accessed from www.rcpsych.ac.uk/files/samplechapter/MadnesstoMIllnessSChap.pdf, p4
4 Hospital Library Program, From custody to cure: mental Health Care in the North Country, Accessed from www.samaritanhealth.com/library/images/…/smcnewsletter43.pdf ,p1 2008,p1
5 Hospital Library Program.,”From custody to cure: mental Health Care in the North Country, “Accessed from www.samaritanhealth.com/library/images/…/smcnewsletter43.pdf P1 2008,p1
6 Porter Roy and Wright David, The Confinement of the Insane: International Perspectives. 1800-1965, (New York: Cambridge University Press , 2003) , p 334
7 Bewley Thomas, Madness to mental illness; History of the Royal College of psychiatrists, Accessed from www.rcpsych.ac.uk/files/samplechapter/MadnesstoMIllnessSChap.pdf p4
8 Porter Roy and Wright David, The Confinement of the Insane: International Perspectives. 1800-1965, (New York: Cambridge University Press, 2003), p 172
9 Porter Roy and Wright David, The Confinement of the Insane: International Perspectives.,1800-1965, (New York: Cambridge University Press ,2003 ), p 172
10 Bewley Thomas, Madness to mental illness; History of the Royal College of psychiatrists. Accessed from www.rcpsych.ac.uk/files/samplechapter/MadnesstoMIllnessSChap.pdf, p4
13 Bewley Thomas, Madness to mental illness; History of the Royal College of psychiatrists. Accessed from www.rcpsych.ac.uk/files/samplechapter/MadnesstoMIllnessSChap.pdf, p4
14 Scull Andrew, Social Order/Mental Disorder: Anglo-American Psychiatry in Historical Perspective, (California: University of California Press, 1989), p83
16 Bewley Thomas, Madness to mental illness; History of the Royal College of psychiatrists. Accessed from www.rcpsych.ac.uk/files/samplechapter/MadnesstoMIllnessSChap.pdf, p4
17 Scull Andrew, Social Order/Mental Disorder: Anglo-American Psychiatry in Historical Perspective, (California: University of California Press, 1989), p83
18 Peterson Bracken and Patrick Thomas, Post psychiatry: A New Direction in Mental Health, British Medical Journal, 322, 2001, p 725.
19 Bewley Thomas, Madness to mental illness; History of the Royal College of psychiatrists, Accessed from www.rcpsych.ac.uk/files/samplechapter/MadnesstoMIllnessSChap.pdf, p6
21 Peterson Bracken and Patrick Thomas, Post psychiatry: A New Direction in Mental Health, British Medical Journal, 322, 2001, p p726
22 Keller Hellen, Recovery: A conspiracy of Hope, Accessed from www.pendari.com/DMH/Books/recovery/files/recovery.pdf , p3
24 Harrison Freeman, Mental Health Policy and Practice in the NHS: 1948-79’, Journal of Mental Health, 7, 3, 1998, pp 233.
25 Keller Hellen, Recovery: A conspiracy of Hope, Accessed from www.pendari.com/DMH/Books/recovery/files/recovery.pdf , p5
26 Harrison, p230