Chapter 2 Asylums and the origins of psychiatry

  Psychiatry’s history is manageably short – barely 200 years. The mentally deranged have always been recognized and where they could not be cared for within the family some makeshift provision was made – private madhouses and spas for the rich and workhouses for the poor. Workhouses contained everyone who could not care for themselves – the feeble-minded, the sick, the feckless, and the unemployed. Conditions were grim (deliberately so to discourage the burden on the public purse) and the mentally ill often fared badly from other inmates who were impatient with them or took advantage of them. Private madhouses were hardly that much better. There was no training required to own or run them. Their main purpose seemed to be to hide mad members of rich families from view, either to protect the family’s reputation or to appropriate their fortunes. The harsh treatment of the much loved King George III generated powerful antipathy towards them in late 18th-century England.

  Bedlam was the first major public madhouse, opened in London in 1685 and still in existence as the much-reformed Bethlem Royal Hospital. The exhibition of the inmates was a popular public pastime in the early 18th century and generated revulsion in more educated quarters. France had established its Hotel Dieu and Hôpital Général in 1656 (the Bicêtre for men and Salpêtrière for women) which, despite their names, were not hospitals, but general establishments for custodial care more akin to workhouses. Tollhäuser (fools’ houses) had been established in medieval Europe. The first US insane ward was established in a Boston Almshouse in 1729 and the first US Psychiatric Hospital in 1773 in Williamsburg, Virginia.

The York retreat

  The impetus to separate the mentally ill and provide more appropriate care came not from doctors but from social reformers and reflected an emerging concern with the dignity of man. In our risk-obsessed days it is sobering to realize that asylums were proposed more to protect the deranged individual from society than vice versa. In France in 1792, Pinel dramatically and symbolically removed the chains from inmates in the Bicêtre and in England a Quaker family, the Tukes, proposed and built the first Asylum in York. The Tukes were convinced by the writings of Pinel and Esquirol that a calm and harmonious environment, close to nature and with kindness and predictable routines (‘moral therapy’), would bring peace to a troubled mind. The York retreat was built to contain 30 patients; opened in 1796 it achieved remarkable results – many early patients were discharged home improved or even cured. It attracted attention from all over the world and visitors came from the US and throughout Europe to study and replicate it. The UK developed early a liberal regime, reluctant to use mechanical restraints such as chains or belts (later championed by John Connelly in the ‘non-restraint movement’).

The asylum movement

  In the 1820s the asylum movement began and over the next 70 years hundreds were built for the reception of indigent ‘lunatics’ in each county in England, in most European countries, and across America. The scale of investment is hard to conceive of now, with enormous, well appointed buildings to house several hundred patients each. The physical conditions within the asylum (space, heating, food, recreation) would have been significantly better than most patients could have expected at home with their families. The principles of moral therapy dictated that asylums should be spacious, away from busy towns, placed in the countryside with extensive grounds. High airy locations were selected because of current theories implicating mists and ‘miasmas’ in disease.