History of mental hospitals

The history of psychiatric hospitals or asylums as they were known is linked heavily with social and scientific attitudes towards mentally ill people, which have changed greatly over the past centuries.

Cities
As the number of people living in cities increased, there became an increasingly large population of mentally ill people. Generally speaking, in rural areas the mentally ill had been able to rely on local support of the people around them, or managed to simply go unnoticed amongst the rest of the population. However, under the demands of larger cities they faced a higher degree of difficulty and had a much greater chance of causing disruption or simply being a nuisance. This led to the building of the early asylums.

In England the Middlesex County Court Judges pressured the UK Government resulting in an act of parliament - The Madhouse Act 1828, allowing the building of purpose-built asylums, the first of which the 1st Middlesex County Asylum was at Hanwell in West London and opened its doors in late 1831. (Src. Museums of Madness, Andrew T. Scull, Penguin 1979)

Initially these early asylums were little more than repositories for the mentally ill – removing them from mainstream society in the same manner as a jail would for criminals. Conditions were often extremely poor and serious treatment was not yet an option.

Early psychiatric hospitals
The first psychiatric hospitals and insane asylums were built in the medieval Islamic world as early as the 8th century. Muslim physicians and psychologists built the first ones in Baghdad from 705, followed by Fes in the early 8th century, and Cairo in 800. Other famous psychiatric hospitals were built in Damascus and Aleppo in 1270.

Bethlem Royal Hospital


Bethlem Royal Hospital (Bedlam) was the first known psychiatric hospital in Europe, founded in London in 1247 and by 1403, had begun accepting social outcasts, the "crazy people", "lunatics" and those who just couldn't stay hidden in society anymore. It soon became infamous for its cruel treatment of the insane, and in the 18th century would have outsiders pay a penny to come and watch their patients as a form of torturous entertainment. In 1700 it is recorded that the "lunatics" were called "patients" for the first time, and within twenty years separate wards for the "curable" and "incurable" patients had been established. Mental illness was now no longer an affliction, but a disease, to be diagnosed and potentially cured.

Humane treatment
The physician Plato was the one who followed Hippocrates search and believed that the treatment for people that had mental illness had to be more humane and gentle rather than cruel.

Middle East
Unlike medieval Christian physicians who relied on demonological explanations for mental illness, medieval Muslim physicians and psychologists relied mostly on clinical observations. They made significant advances to psychiatry and were the first to provide psychotherapy and moral treatment for mentally ill patients, in addition to other forms of treatment such as baths, drug medication, music therapy and occupational therapy. In the 10th century, the Persian physician Muhammad ibn Zakarīya Rāzi (Rhazes) combined psychological methods and physiological explanations to provide treatment to mentally ill patients. His contemporary, the Arab physician Najab ud-din Muhammad, first described a number of mental illnesses such as agitated depression, neurosis, priapism and sexual impotence (Nafkhae Malikholia), psychosis (Kutrib), and mania (Dual-Kulb).

In the 11th century, another Persian physician Avicenna recognized 'physiological psychology' in the treatment of illnesses involving emotions, and developed a system for associating changes in the pulse rate with inner feelings, which is seen as a percursor to the word association test developed by Carl Jung in the 19th century. Avicenna was also an early pioneer of neuropsychiatry, and first described a number of neuropsychiatric conditions such as hallucination, insomnia, mania, nightmare, melancholia, dementia, epilepsy, paralysis, stroke, vertigo and tremor.

Continental Europe
Phillipe Pinel (1793) is often credited as being the first in Europe to introduce humane methods into the treatment of the mentally ill as the superintendent of the Asylum de Bicêtre in Paris. A hospital employee of Asylum de Bicêtre, Jean-Baptiste Pussin, was actually the first one to remove patient restraints. Pussin influenced Pinel and they both served to spread reforms such as categorising the disorders, as well as observing and talking to patients as methods of cure.

United States
Progress in treatment was also occurring in the United States, often ahead of similar advances in Europe. Due to its relative youth, the United States is the only major nation where psychiatric hospitals were first established for treatment, rather than punishment. This was especially true in tolerant New England and particularly one institution in Brattleboro, Vermont. In 1834, Anna Marsh established the prestigious Brattleboro Retreat to offer "merciful, ethical, and scientific care" to the mentally ill. Originally named the Vermont Asylum for the Insane, the hospital pioneered the application of "moral treatment" based on clean living, patient empowerment, and therapeutic farm work. The hospital grew into a large research facility complete with these world firsts: a patient-produced newspaper, hospital swimming pool, bowling alley, gymnasium, theater, chapel, patient choir, patient sports leagues, outing club, dairy farm, and patient-run companies. Marsh endowed the Brattleboro Retreat in memory of her late physician husband. The vision she expressed in her will would come to impact around the world. Today it stands as a member of the Ivy League Hospitals. The original hospital building was the Marsh home, which still stands among the large riverside campus.

The Hartford Retreat (now the Institute of Living at Hartford Hospital) and McLean Hospital also set the tone for the United States' history of relatively humane private psychiatric facilities. The Quakers of the mid-Atlantic states, particularly Pennsylvania, also offered dignified treatment that was among the most progressive in the world. The transition to state hospitals and "state schools", however, brought with them many abuses that shocked operators of private American psychiatric hospitals.

Reformers, such as American Dorothea Dix began to advocate a more humane and progressive attitude towards the mentally ill. Some were motivated by a so-called Christian Duty to mentally ill citizens. In the United States, for example, numerous states established state mental health systems paid for by taxpayer money (and often money from the relatives of those institutionalized inside them). These centralized institutions were often linked with loose governmental bodies, though oversight and quality consequently varied. They were generally geographically isolated as well, located away from urban areas because the land was cheap and there was less political opposition. Many state hospitals in the United States were built in the 1850s and 1860s on the Kirkbride Plan, an architectural style meant to have curative effect. States made large outlays on architecture that often resembled the palaces of Europe, although operating funding for ongoing programs was more scarce. Many patients objected to transfers from private hospitals to state facilities. Some Brattleboro Retreat patients tried to hide when state officials arrived to transfer them to the new Waterbury State Hospital. This decline in patient census led to the collapse of many private institutions, which still accepted indigent patients even when state reimbursement for private hospitals dropped in the face of rising state hospital costs.

United Kingdom
At much the same time William Tuke was also pioneering an enlightened approach to the treatment of the mentally ill in England at the Retreat in York, for which the Brattleboro Retreat and the former Hartford Retreat were named. This included not just humane treatment but moral therapy as well.

In 1817 a William Ellis was appointed as superintendent to the newly built West Riding Pauper Asylum at Wakefield. A Methodist, he too had strong religious convictions and with his wife as matron they put into action those things they had learn from the Sculcoates Refuge in Hull which was run on a similar model as the York Retreat. After 13 years their reputation had become such, that they were then invited to run the newly built first pauper asylum in Middlesex called the Hanwell Asylum. Accepting the posts, the asylum opened in May 1831. Here the Ellis's introduced their own brand of humane treatment and 'moral therapy' combined with 'therapeutic employment'. As its initial capacity was for 450 patients it was already the largest asylum in the country and subject to even more building soon after. Therefore, the immediate and continuing success of humane therapy working on such a large scale, encouraged its adoption at other asylums. In recognition of all this work he received a knighthood. He continued to development therapeutic treatments for mental disorders and always with moral treatment as the guiding principle.

In Lincoln, Lincolnshire, England, Robert Gardiner Hill with the support of Edward Parker Charlesworth,  develop a mode of treatment that suited 'all types' of patients, where by the reliance on mechanical restraint and coercion could be made obsolete altogether, a situation he finally achieved in 1838.

By the following year of 1839 Serjeant John Adams and Dr. John Conolly were so impressed by the work of Hill, that they immediately introduced the method into their Hanwell Asylum, which was by then the largest in the kingdom. The greater size required Hill's system to be developed and refined. This was necessary as it was beyond Conolly to be able to supervise each attendant as closely as Hill had had to do. Even so, he bid a pair of extra soft slippers made so that he could walk around the building at night without his foot falls warning the attendance of his imminent approach. By September 1839, mechanical restraint was no longer required for any patient. For years, this day was remembered at the Hanwell asylum by a celebration on its anniversary. Hanwell also was a very accomplished communicator and wrote and lectured widely about his work in mental health. Through all this progress Hanwell build great fame and his discoveries spread around the world.

By such means these and others, more effective treatment methods gradually took hold in different countries, and attitudes towards the treatment of the mentally ill began to drastically improve during the mid-19th century. Courts began to administer involuntary commitments with a greater eye towards medical justification.

Ineffective treatments
This provided a fruitful environment for the popularity of quick-fix solutions, like the eugenic compulsory sterilization programs undertaken in over 30 U.S. states (and, later, in Germany), which allowed institutions to discharge patients while still claiming to be serving the public interest. These new treatments of mental illness – which was now seen as a "defect", and likely a hereditary one – were seen less as therapeutic for the individual patient than as preventative for the society as a whole.

From 1942 to 1947, conscientious objectors in the US assigned to psychiatric hospitals under Civilian Public Service exposed abuses throughout the psychiatric care system and were instrumental in reforms of the 1940s and 1950s. The CPS reformers were especially active at the Byberry Hospital in Philadelphia where four Friends initiated The Attendant magazine as a way to communicate ideas and promote reform. This periodical later became the The Psychiatric Aide, a professional journal for mental health workers. On May 6, 1946, Life Magazine printed an exposé of the mental healthcare system based on the reports of COs. Another effort of CPS, namely the Mental Hygiene Project, became the National Mental Health Foundation. Initially sceptical about the value of Civilian Public Service, Eleanor Roosevelt, impressed by the changes introduced by COs in the mental health system, became a sponsor of the National Mental Health Foundation and actively inspired other prominent citizens including Owen J. Roberts, Pearl Buck and Harry Emerson Fosdick to join her in advancing the organization's objectives of reform and humane treatment of patients.

Radical medicine
By the mid-1940s, treatment of the mentally ill took a new turn, with the advent of electroconvulsive therapy (ECT) and insulin shock therapy, and the use of frontal lobotomy. In modern times, insulin shock therapy and lobotomies are viewed as being almost as barbaric as the Bedlam "treatments", though in their own context they were seen as the first options which produced any noticeable effect on their patients. ECT is still used in the West, but it is seen as a last resort for treatment of mood disorders, and is administered much more safely than in the past. Elsewhere, particularly in India, reports have surfaced that ECT is enjoying increased use, as a cost-effective alternative to drug treatment. The effect of a lobotomy on an overly excitable patient often allowed them to be discharged to their homes, which was seen by administrators (and often guardians) as a preferable solution than institutionalisation. Lobotomies were performed in great numbers from the 1930s to the 1950s.

Drugs
By the mid-1950s, the first psychiatric medications became available for the treatment of mental illness, such as chlorpromazine, which revolutionized psychiatric care and provided new ways for many of the severely mentally ill to return to normal society. Newly developed antidepressants were used to treat cases of depression, and the introduction of muscle relaxants allowed ECT to be used in a modified form for the treatment of severe depression and a few other disorders. The use of psychosurgery was narrowed to a very small number of people for specific indications. New treatments led to reductions in the number of patients in mental hospitals.

Political device
In some nations, mental hospitals were used as sites for the stifling of political dissidence or even genocide. In the Soviet Union, dissidents were often put into asylums and kept on a variety of destabilising medications, with the hope of not simply removing them from society, but making them unreliable in the eyes of others (see Psikhushka). In the case of Zhores Medvedev, the ire of officials was aroused by manuscripts that had been published (without his permission) in the West and a book, Biology and the Cult of Personality, which was an attack on Lysenkoism.

The attitudes in these cases – that the mentally ill were a scourge and needed to be eliminated, and that the line between 'patient' and 'prisoner' is incredibly blurry – have their precedents in the history of mental hospitals, though were taken to extremes by totalitarian regimes.