The Moral Treatment of the Insane
By Amariah Brigham, Published in “American Journal of Insanity,” March 1847
Introduction: Amariah Brigham was the first superintendent of the New York State Asylum for the Insane in Utica. A leader in the field of moral treatment and the editor of “The Journal of Insanity,” Brigham here outlines his vision of care for people with psychiatric disabilities. Under the instigation of Brigham, the patients at Utica launched The Opal, a literary journal which frequently described asylum life in glowing terms.
Brigham presents asylum life in domestic terms; the asylum becomes an ideal middle-class home in which people are nurtured back to mental health and where coercion, if not eliminated, is minimized. Note the unusual role played here by at least some of the attendants. He envisioned them as fulfilling a task that would later be done by psychotherapists. Brigham emphasized “rational” amusements as part of treatment. The Utica institution had an extensive library, and the patients took part in various theatrical and musical presentations. Brigham died in 1849, just before the first edition of The Opal was published.
The Article: The removal of the insane from home and former associations, with respectful and kind treatment under all circumstances, and in most cases manual labor, attendance on religious worship on Sunday, the establishment of regular habits and of self-control, diversion of the mind from morbid trains of thought, are now generally considered as essential in the Moral Treatment of the Insane.
We shall therefore, in this essay, confine ourselves mostly — lst, to a brief historical review of this subject, in order to do at least partial justice to our predecessors, and 2d, notice such new suggestions and new methods of treatment as have come to our knowledge.
Previous to the time of Pinel, the moral treatment of the Insane was fluctuating and unestablished. In some periods and in some countries, a portion of the insane at least, were treated with great kindness, while at the same time, others were neglected and abused. From the most remote periods, insanity was regarded for the most part as a sacred disease, as coming direct from heaven, and as a consequence of the possession of a spirit or demon. This was the belief of the Chaldeans and the Jews. Saul was troubled by an evil spirit, and Job by a demon. Hence recourse was had to various moral means of cure. Thus Saul was cured by the music of David. “And it came to pass when the evil spirit from God was upon Saul, that David took a harp and played with his hand so Saul was refreshed and was well, and the evil spirit departed from him.” 1 Sam. xvi. 16.
Similar methods of treatment prevailed in ancient Egypt and Greece; the priests of the former country amused insane persons, and diverted their minds by music, and by pleasant walks in groves and gardens, filled with perfumes and flowers; and Melampus cured the daughters of Pretus, king of Argos, not with Hellebore as some have stated, but by bodily exercise, and by mysterious ceremonies that acted powerfully on the imagination.
But all the insane were not treated in the same manner; while those who were gay, sociable and courageous, were treated with respect and kindness, and even idolized and worshipped as Oracles, many that were timid and melancholy, were considered objects of Heaven’s wrath, and driven forth as outcasts, and subjected to the greatest abuse.
The treatment of the insane, has ever varied with the philosophy and intelligence of the age. That they are treated better in modern times, more kindly and judiciously, is not owing to any increase of benevolence, but to an increase of knowledge. Benevolence has ever existed in the heart of man, and compassion for suffering, been manifested from the most remote period. But without knowledge, benevolence may prove to be as injurious as tyranny itself. Hence we find in the ignorant ages. the insane not merely neglected, but abused and persecuted, and in many cases put to death in the most inhuman manner, and not for want of pity and compassion in the human heart, but from ignorance of the nature of insanity, Those thus treated were not considered as diseased, insane or as deserving of pity, but as wicked beings, in league with evil spirits, and meriting punishment.
From the earliest period, some individuals had correct notions on insanity — Celsus who lived at the time of Christ, gave many excellent precepts relating to the moral treatment a the insane, and Caelius Aurelianus, who lived three centuries later, insisted in strong terms on the necessity of acquiring the confidence and esteem of the insane by frankness of manner and by kind treatment.
But the difficulty has ever been to determine who are insane.
Not to go back to times too remote for abundant and correct historical details, we know that from the fourteenth to the eighteenth century, very many thousands of insane persons were put to death, and most of them by order of Courts of Justice. Some were condemned to death or to imprisonment for life as heretics, some were hung for practising witchcraft, and vast numbers were burned as sorcerers, or for being in league with the devil.
These cruelties have for the most part passed away, yet still down even to the present time, there are we believe in most countries, some deranged persons confined with criminals in prisons, and not unfrequently some are put to death for acts committed by them when deprived of their reason.
The burning of Joan of Arc, and the thousands of supposed sorcerers, and which we now look upon with horror, was caused by the ignorance of the times. In fact, ignorance has ever been the worst of all diseases, and as relates to insanity much yet remains, and we should regard it among our highest duties to endeavor to dispel it, and to diffuse such a knowledge of insanity among all classes, as will prevent the recurrence of the enormities we have mentioned.
Owing to the spread of science, the insane towards the beginning of the last century, ceased to be regarded as witches or sorcerers. Still they continued to be abused and neglected. The most furious were confined in cells and dungeons, and when obstinate or mischievous, were cruelly whipped, and in all respects treated like wild beasts. For many years no other method of treatment was supposed practicable or useful. No one scorns to have thought of attempting to cure them.Undoubtedly there were exceptions, but this was generally the treatment of the insane previous to the time of Pinel, whom we must regard as the founder of the humane, rational, and now generally adopted system of moral treatment.
He had, to be sure, an active assistant, and to some degree a precursor in Pussin; still to Pinel seems fairly due the very great merit which we have mentioned.
He is most generally and popularly known in connection with the insane, by his bold act of unchaining above fifty maniacs at one time at the Bicetre Hospital, in 1792. But he had six years previous to this, reduced to practice his mild system of treatment elsewhere.
This system was not the result of an accident or an experiment, but was adopted by Pinel after much reading, observation and reflection. He thoroughly qualified himself for this great work by vast learning, — a knowledge of the languages of other countries, and a thorough acquaintance with all that had been written on the subject of insanity.
Thus prepared, he early matured his system, then tried it in practice on a great scale for several years, and finally published it to the world. His first work on insanity, Traite Medico-Philosophique, was published in 1801, and we do not hesitate to say, that we know not of any work on insanity superior to this, especially as improved by Pinel in the last edition; — none more worthy of our daily study. On perusing it, we almost lament to find that very little indeed has been added that may be called improvement in the moral treatment of the insane since his time. This work was early translated, and thus the views of Pinel respecting insanity and the proper treatment of the insane, were soon made known throughout the civilized world.
Not many years after this, the Retreat, near York in England, was established. It was suggested by Mr. William Tuke, who is generally considered its founder, and was mainly established for insane persons belonging to the Society of Friends, and for the purpose of separating them from the profane and profligate, and placing them under the care of the members of the society, and where they would be kindly treated. Great good resulted from the establishment of this Retreat, although it must be confessed, the original founders did not seem to have had very clear ideas respect the nature of insanity, or of its proper treatment. Benevolent feelings led them to wish the insane to be kindly treated, and they endeavored to carry their wishes into practice. At first there was no regular medical superintendent, though fortunately in George Jepson, whose name should be ever dear to the insane, and who acted as superintendent, they found a man of an original and vigorous mind, and who having some knowledge of medicine, and having visited other establishments for the insane, was well calculated to introduce and carry out useful reform. To him we consider the Retreat largely indebted for the success that attended its early administration.
This institution was opened in 1796, four years after Pinel had unchained the Maniacs of the Bicetre. For several years but few patients were admitted, but the success attending their kind treatment, and the notoriety given to the institution, by various publication, made it good impression, and together with the circulation of Pinel’s Treatise, translated by Dr. Davis, and published in 1806, had the effect to introduce a milder and better system of moral treatment into many of the institutions for the insane in England. But while we cheerfully admit that great credit is due to the founders of the York Retreat for their humane exertions in behalf of the insane, and freely acknowledge that vast good resulted to other institutions for their exertions, and particularly from the publication and general circulation of Mr. Tuke’s description of the Retreat, published in 1813: — historical accuracy will not allow us to say, that they originated what may be called the rational, humane and modem system of moral treatment of the insane.
In this country, the system of Pinel was early introduced, and among those who were most instrumental in establishing it here, we ought to mention Rush, Wyman and Todd.
Dr. Rush was a man of great benevolence as well as great intelligence, and in his published writings on insanity, we find many interesting and valuable facts, and also many useful suggestions respecting the moral treatment of the insane. He inculcates the necessity of mild treatment and kind usage; but still, Dr. Rush can not now be considered as a correct guide for us to follow, either as regards the moral or the medical treatment of the insane.
So great is the authority of his name, and so great the influence which his “Observations on Diseases of the Mind,” have exercised on the opinions and practice of medical men in this country, that we deem it not improper to briefly notice some suggestions of his respecting the moral treatment of the insane that we deem erroneous. A prevailing error found in his writings on insanity, is, that the insane are to be disciplined and governed, that those who have the care of them must obtain a dominion over them by fear or by other means that we think improper. Thus he says: “the first object of a physician, when he enters the cell or chamber of the deranged patient, should be, to catch his eye, and look him out of countenance.” Again he says, “The conduct of a physician to his patients should be uniformly dignified, if he wishes to acquire their obedience and respect. He should never descend to levity in conversing with them. He should hear with silence their rude or witty answers to his questions, and upon no account ever laugh at them, or with them.” After attending to various means for making insane persons obedient, he says, “If these prove ineffectual to establish a government over deranged patients, recourse should be had to certain modes of coercion.”
After mentioning a recourse to the strait waistcoat, the tranquilizing chair, (which is an invention of Dr. Rush,) the privation of customary pleasant food, and pouring cold water under the coat sleeves, so that it may descend to the arm pits, he adds, “if all these modes of punishment should fail of the intended effect, it will be proper to resort to the fear of death?”
I need but mention these remarks of Dr. Rush, to show that he was far behind not only the present age in the moral treatment of the insane, but in arrear of Pinel, whose treatise on insanity had been published several years when Dr. Rush wrote.
“Doct. Wyman, the first Physician and Superintendent of the McLean Asylum, though not extensively known by his published writings, was a man of superior qualifications, and admirably qualified for the station he held.
“He had much architectural and mechanical ingenuity, and to him we are indebted for some of our best arrangements for the care of the insane. His untiring industry, his constant devotedness to the welfare of those under his charge, his sterling integrity and exactness in everything belonging to the duties of his station, furnished an example that has been in the highest degree salutary.
“Having no similar institutions in this country to look to for guidance, he had to depend upon the resources of his own head and heart, and fortunately these were both good, and consequently, most that he devised and suggested, has stood the test of time and experience. Dr. Wyman had, we think, one fault, considering the station he held, and this was excessive modesty or disinclination to make known his improvements and the success that attended his labors. Owing to his extreme sensitiveness on this subject, he is less known, and probably accomplished less good than men of less real merit. That his views of both moral and medical treatment, wove what we now deem correct, is evident from the following note to his discourse on “Mental Philosophy as connected with Mental Disease,” delivered before the Massachusetts Medical Society. “In mental disorders,” he says, “without symptoms of organic disease, a judicious moral management is most successful. It should afford agreeab1e occupation. It should engage the mind, and exercise the body; as in riding, walking, sewing, embroidery, bowling, gardening, mechanic arts to which may be added, reading, writing, conversation, &c., the whole to be performed with order and regularity. Even the taking of food, retiring to bed, rising in the morning and at stated times, and conforming to stated rules in almost every thing, is a most salutary discipline. It requires, however, constant attention and vigilance, with the greatest kindness in the attendants upon a lunatic. Moral treatment is indispensable, even in cases arising from organic disease.
“In regard to medical treatment, I believe that purging, bleeding, low diet, &c., have been adopted with little discrimination. They are to be resorted to only when there is organic disease, which requires the reducing plan. But these remedies, especially in debilitated subjects, are seldom useful in relieving mental disease. They are usually injurious, and frequently fatal.”
Dr. Todd, of Hartford, we also recall with pleasing recollections. He possessed, as Spurzheim said after seeing him, to the writer of this article, “a mountain of benevolence,” to which were added a good education, fine personal appearance, most engaging manners, and very superior conversational powers, all of which eminently fitted him for the moral treatment of the insane, in which he particularly excelled. His great merit we conceive, is, his having zealously embraced, and practically introduced into this country, and made extensively known here the moral and medical treatment recommended by Pinel, Tuke and Willis. To use his own words found in his first Report, he made the “Law of kindness, the all pervading power of the moral discipline of the Retreat, and required unvaried gentleness and respect to be manifested towards the inmates of the institution, by every member belonging to it.”
He early discountenanced depletion, particularly bleeding in insanity, and insisted upon the necessity of generous diet, and recommended a frequent resort to tonics and narcotics in the medical treatment of the insane.
This course of treatment, though it had been recommended by the best writers on insanity in Europe, had not to much extent been resorted to in this country, previous to the time of Dr. Todd. and it was so contrary to that recommended by Dr. Rush, that it required considerable boldness, and much address and management to introduce it, and make it popular in this country, and this, Dr. Todd accomplished.
As already stated, but few improvements in the moral treatment of the insane have been made, since the time of Pinel and Tuke. In their writings, all those methods that we now deem most essential, are clearly pointed out and insisted upon. Still these methods have by the labors of others, become more generally known and established, and in some respects improved.
M. Leuret, the distinguished Physician of the Bicetre Hospital at Paris, in his valuable work, “Du Traitement Moral de la folie,” has made many very useful suggestions, and done much good in calling attention to the vast importance of moral treatment in insanity. Most writers previous to Leuret, had considered the moral treatment as auxiliary to the medical, but Leuret considers the latter as of trivial importance compared with the former. He proposes to cure all cases of uncomplicated insanity, solely by moral means. For this purpose, he often excites pain or unpleasant sensations and ideas, in order to prevent and dispel those still more unpleasant.
Unfortunately for the establishment of the many excellent precepts contained in this profound work of M. Leuret, he has created a prejudice against himself and his writings by some of his recommendations, particularly by that of the Douche, which, however valuable it may be in some cases, is, we believe, liable to great abuse. In some of the prisons in this country, where it has been used extensively with refractory criminals, we have been informed on good authority, the use of it has occasionally proved dangerous, and in a few cases, fatal. But apart from this, and this is only one of a great variety of measures which he recommends for exciting the hopes and fears of his patients, dispelling their morbid fancies and teaching them habits of self-control, his work abounds with useful suggestions, and is well worthy of our careful study. He recommends resorting to a great variety of means to direct and engage the attention of patients. He insists on the importance of out door exercise and bodily labor, walking, riding, engaging in active sports, and more particularly on the value of mental labor, such as reading, committing pieces to memory and reciting them, add other school exercises, acting plays, attention to music, &c.
On all these subjects and many others relating to the mental treatment of the insane, more full and useful details will be found in the work of Leuret, than in any other with which we are acquainted.
In the main we coincide with him, that in a majority of cases of insanity, the moral treatment is of more importance than the medical, and we fear we shall never avail ourselves of the full value of the former, nor cease to do injury to some patients by administering too much medicine, until we heartily embrace this view of the subject.
That some cases of insanity require medical treatment we believe, but we also believe that a large majority of the patients in Lunatic Asylums do not. There is much analogy between many of the patients found in all such institutions, and the passionate, mischievous, and what are called bad boys in a school, and there is about as much propriety in following the example of Mrs. Squeers, and physicing and medicating the latter as the former, in order to cure them or to change their propensities. Rational hopes for the improvement of either, should we believe, be founded on moral management alone.
Bodily labor as a measure for benefiting and curing the insane is generally recommended, and we allude to it now, but to express the hope that better arrangements for this purpose will be made in institutions for the insane, than have hitherto been. Some have an insufficient quantity of land, and are destitute of work shops. We think every such institution should have a good farm attached to it; but still, a farm is not sufficient, as it can afford employment but to comparatively few, and only for part of the year. We think several work shops should be connected with every large establishment for the insane, and be so connected, that the patients of each class can go to them without risk or exposure. One or more rooms in connection with each hall for patients, is needed in order to afford employment to all that would be benefited by it. In such rooms, dress-making and tailoring, cabinet work, the manufacture of toys, basket-making, shoe-making, painting, printing, book-binding, and various other employments may be carried on to the advantage of many patients, some of whom can not be employed on the farm or in shops disconnected with the asylum. In the construction of asylums for the insane, we think there should more care be taken to provide convenient rooms for the purposes mentioned.
But however useful bodily labor may be to some, we regard it as less so generally as a curative measure, and less applicable in many cases, than mental occupation or the regular and rational employment of the mind.
In fact, manual labor, we believe, proves more beneficial by producing this result, that is, by engaging the attention and directing the mind to new subjects of thought, than by its direct effect upon the body. Not unfrequently manual labor appears to be injurious, especially in recent cases; it accelerates the circulation, and sometimes reproduces excitement of mind in those that have become quiet and convalescent.
We apprehend many have erroneous views on the subject of manual labor as a remedy for insanity. It. is undoubtedly useful of itself in some cases, but it rarely cures. The large majority of patients that recover are restored without it, and most of the work performed by those of this class in lunatic asylums is after convalescence is well established.
It is true, that in many institutions for the insane in this country, and to a greater extent in Europe, a vast amount of manual labor is performed by the patients; but the principal part of this, according to our observation, is done by those that belong to the incurable class; and to these, who constitute the majority in most establishments, manual labor is highly useful, and sometimes necessary for the preservation of the health, and of what mind is still possessed.
But as we have said, the curable class are more benefited by the regular and rational employment of the mind, by pursuits that engage the attention, and tend to the enlargement and the improvement of the mental and moral powers.
For this purpose, asylums should be well supplied with books, maps and apparatus illustrative of different sciences. and also collections in natural history, &c. Schools should be established in every institution for the insane, where patients could engage in reading, writing, drawing, music, arithmetic, geography, history, and also study some of the sciences, as chemistry, mineralogy, conchology, physiology, &c.
To these schools should be attached intelligent instructors, who should spend all their time with the patients, eat at the same table with them, but have no labor or other duty to attend to, than to interest the patients and contribute all they can by their presence and conversation to their contentment and enjoyment. They should join them in their amusements and walks, and be their constant companions.
We are satisfied that an establishment for the insane can be better managed, and with equal economy, by having an arrangement by which some attendants devote their time to the ordinary duties and labors of the halls, while others have nothing to do but to accompany the patients and endeavor to instruct and amuse them. The latter having nothing to do with any coercive measures, the patients do not become prejudiced against, and will readily hearken to their suggestions. Thus they serve as a constant guard, and by their presence and management, prevent outbreaks and disorder and make coercive measures, restraint and seclusion, rarely necessary.
They also by their presence and conversation quiet the timid, console the desponding, and by attention to all, contribute to the contentment and cheerfulness of the patients, and as we believe, essentially aid in curing them. Many cases, we believe, cannot be cured or improved, but by arousing and calling into exercise the dormant faculties of the mind. Hence schools are beneficial, not merely to the curable class of patients, but to the demented and those approaching this condition.
In such, the active state of the disease, which originated the mental disturbance, has passed, and left the brain and faculties of the mind in a torpid state. In these cues, medicine is generally of no use, and they cannot often be much improved, but by exercising the faculties of the mind.
But others are also benefited by devoting a portion of every day to mental improvement. To those who are nearly or quite well, and who remain in an asylum for fear of relapsing at home, or for other reasons, schools afford enjoyment and often means for improvement which are highly valued by the patients themselves.
The melancholy and despairing, and to all those suffering from delusions of mind, and those that are uneasy and nervous, that are constantly restless and disposed to find fault and to annoy the attendants, and quarrel with all about them, because they have nothing else to occupy their minds, are frequently cured by mental occupation and the exercises of a school, by attending to composition, declamation, the writing and acting of dialogues and plays.
Our observations for many years in various lunatic asylums, led us a long time since to regard the want of mental occupation as the greatest want in modern institutions for the insane. Go into any such establishment, and you will find some few, in winter a very few, at work, some playing cards or other games; yet a still larger number will be found sitting about, listless, inactive, doing nothing, saying nothing, taking no interest in anything going on around them; gathered around the stove or place that is heated, looking forward to nothing but the hour for eating and retiring to sleep. For a short time each day, when the physician passes around, they will exhibit a little animation and say a few words, and then relapse into their former condition.
When the weather is pleasant, some of them walk or ride out occasionally for a short time, but this, to many of the class we are describing, after a few times, seems to be a mechanical kind of business and confers but little enjoyment, they notice but little and say but little during the walk or ride, or after it. These patients make no especial trouble in an asylum, and are very apt to be overlooked and neglected, and if not already demented soon become so, They are thought not to require much attention, as they have good bodily health, and are quiet, consequently they generally receive but little notice.
But those belonging to this class require great attention they need mental exercise; they should attend school and have their minds awakened into activity, for an hour or two every day. Soon, by this course, their memories will improve; they will become interested in singing or in some particular study, and by perseverance a considerable number will be cured, and many, very many, rendered capable of much enjoyment, and be kept from sinking into a state of hopeless dementia,
Various are the methods that may be adopted to awaken into activity the dormant faculties of the mind and to dispel delusions and melancholy trains of thought. A museum or collection of minerals, shells, pictures, specimens of ancient and modern art and curiosities of all sorts, should be connected with institutions for the insane. The opportunities are abundant for making interesting and valuable collections of this kind by the aid of the patients that have recovered and their friends.
By means thus indicated Institutions for the care and cure of those affected by mental disorder will be made to resemble those for education, rather than Hospitals for the sick, or prisons for criminals; and when we call to mind that the greater part of those committed to such establishments are not actually sick, and do not require medical treatment, but are suffering from deranged intellect, feelings and passions, it is evident that a judicious course of mental and moral discipline is most essential for their comfort and restoration.
By these remarks we do not however mean to disparage medical treatment as it is in some cases very essential, but we mean to insist upon what we believe to be the fact, that moral treatment including religious instruction and medical advice as to the means of preventing re-attacks, is the most important, and as yet too much neglected; — that institutions in general have not been constructed and arranged in a manner best adapted for carrying into successful operation a complete system of moral treatment.
In conclusion we wish to express the hope that increased attention will be given to this subject, and are confident great good will result. When such system as we have briefly indicated or rather hinted at, is judiciously introduced into Asylums with convenient rooms and suitable books and apparatus. We apprehend that trivial and objectionable amusements will be abandoned by the inmates themselves for more rational enjoyments — enjoyments which while they serve to dispel the darkness and delusions that affect many, will at the same time have the effect to improve their minds and enable them to leave the institution not only rational, but better qualified by increased intelligence and power of self-control for encountering the troubles and performing the duties of life.
How to Cite this Article (APA Format): July, A.B. (1847, March). The moral treatment of the insane. American Journal of Insanity. Retrieved [date accessed] from /?p=10442.
Source: Disability History Museum, http://www.disabilitymuseum.org/dhm/edu/article