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Treatment of mental health patients has come a long way since the 18th century. The care for them is primarily considered both inhumane and immoral in the face of modern-day psychiatry. In those days, those who had mental illness were often kept out of public view in private homes, almshouses and even jails. These facilities offered little care and often used restrains as a means of managing a patient’s action.

A moral approach was first introduced in 1796 by William Tuke at the York Retreat in England and 1792 by Philippe Pinel at the Bicetre in Paris. Their efforts included sensitizing staff on compassion and limiting the use of restraints. They worked to keep patients occupied; taking them to a country environment that was believed to be conducive to health. From these early beginnings, the theory of “moral treatment/management” gave birth to the construction and maintenance of institutions providing psychiatric care for the mentally ill.

Psychiatry in the 1800s

In February 1811, Massachusetts General Hospital housed the first psychiatric hospital in New England. In this division of the hospital, McLean Asylum, they began accepting patients in 1818. This asylum rested on Pleasant Hill, Charlestown for 77 years. It was beautiful and quiet, designed to feel like a retreat as opposed to a hospital. That was before industrialization and pollution pushed them to relocate to Wellington Hill, Waverley. The hospital’s design factored in that patients get hospitalized for long periods of time. It functioned as a community that included nurses and physicians living on the grounds, water, its own steam, electrical supplies and a farm with livestock and fruit orchards. In 1892 the name was changed from ‘asylum’ to ‘hospital’ to commemorate the total shift in ethical treatment.

These weren’t the first steps to modernizing psychiatry.  In 1845, Great Britain passed the Lunacy Act to reflect the change in response to mental illness. The mentally ill were taken from the general population and medically managed in hospitals by physicians. Until Pinel introduced “moral treatment/management,” crude and painful methods were in use to treat patients. The misconception was that altering a patient’s physical state would rewire their brain.

An example is Benjamin Rush, viewed as the father of modern American psychiatry, thought excess blood in the brain was responsible for mental illness. As one would expect, he’d draw copious amounts of blood from his patients. Drowning to near death was thought of as a way to scare the ill back into sanity. Purging, vomiting and other bodily harm featured significantly in a lot of treatments.

Pinel changed the approach in Europe by treating people with a mental health condition like individuals suffering from a disease like any other (2). It entailed a differential diagnosis, prognosis, and therapy. It was also the beginning of civilized interactions between therapist and patients with a family set up used to enhance the effectiveness of psychotherapeutic treatment.

What is 'moral treatment'?

To understand the context in which mental illness functioned, we now have to define what ‘moral’ treatment means. The basic principle constituted respect for the person who’s unwell, with everyone upholding the Hippocratic imperative of ‘do no harm’ (3). Kindness and gentleness were some terms used to Samuel Tuke, William’s son who wrote a publication called Description of the Retreat (Tuke 1813), used as well as Pinel. That is not to say enforcement of discipline did not happen. Fear was a therapeutic instrument, though used within certain limits. Treatment involved a paternalistic approach. Pinel, in his publication, stated doctors ought to hold ‘moral ascendancy’ for successful treatment to occur.

To better understand moral ascendancy, one would look at the relationship between a parent and a child. Though an oversimplified way of looking at it, it helps shed light on the importance of restrictions of freedom and responsibility when using a paternalistic stance. The reason behind using that approach as opposed to stating the meaning of ‘moral’ is due to the broad interpretations of the word in both Pinel and Tuke works. It is especially tasking when looking at the word ‘moral’ in French.

Pinel’s use of ‘moral’ meant many things. It could refer to the psychological or mental state but not the physical, ethics, moral faculties, effective displays or even moral science. The multiple variations in his text made in impossible to pinpoint his use of the word ‘moral’ in a way that analysis can agree upon the meaning.

However, what many have agreed upon is “moral treatment” as mentioned earlier. It references the therapeutic changing of psychological variables. That could include environmental factors; the retreat-like facilities and the diet (livestock and fruit orchard). With regards to how we’ve come to understand the word moral in today’s approach to mental illness, the buck stops there.

Moral was not extended to a patient’s physical body. Treatments such as purgatives, bloodletting, administering of opiates and tonics, emetics and others did not fall under the ‘moral’ umbrella and were thus not used. This era began the psychological approach to mental health as opposed to taking physical routes to solve a mental problem. It got based on clinical observations of individuals before being diagnosed and treated accordingly. Daily logs documenting a patient’s life were used to gauge their response to treatment and using evidence from the data gathered to act accordingly.

20th Century psychiatry

The 20th century marked the beginning of modern-day medicine. Retreat like, and upgraded inpatient facilities, as well as technologically advanced and researched approaches to mental illness, have, for the most part, characterized this medical landscape. There, however, exceptions in some areas; wealth and affordability equally play a role in the quality of health care a person receives. 

A shift in the 1990s however affected psychiatric healthcare facilities. Medicare and Medicaid reimbursements and the rise of care placed substantial restrictions on how they operate. During this time, many institutions closed. That was due to shorter stays by patients, with long-term care left for severe cases. This system reduced the number of inpatient buildings required.

On the flip side, this reduction in healthcare facilities, even with the rise of patients, has left a significant population homeless or housed and receiving treatment in penal facilities such as prisons. There has been a rise in off-site and residential care for the wealthy community. It is only rational to conclude that shifting back to the humane and moral approach to psychiatry that William Tuke and Philippe Pinel began will drastically change how mentally ill patients receive care. That would especially help those with low or no income, saving them from homelessness or termed as criminals due to undergoing treatment in a penal institution.

Decline of moral treatment

As mentioned prior, there has been a decline in the ethical treatment of mentally ill patients in the centuries that followed. It began in the mid-19th century but to both increased patient numbers and diminishing resources. In an era with advanced technology and stores of information in psychiatry, it is regrettable for such a deterioration to take place in a ‘rich’ society. More than any other time, other industries have significantly expanded. In the medical field, there are now more holistic approaches to nutrition, like that of Chef Kanida Chey, and how cancer, diabetes, and other serious illnesses get treated. This deterioration is evident in the depiction of mentally ill persons in films. According to a research paper on the topic (4), one in four film characters kill someone while more than half harm another person. Mentally ill patients have come to be viewed as test subjects in these contexts.

Though therapists mostly claim that these stereotyping does not reflect the reality, they are yet to shed this image. These portrayals are primarily responsible for persons needing care opting out of visiting mental health care facilities. Policy makers are equally to blame for their hesitance in offering funding and support.

Bibliographic references

1. BRAGG, TERRY., M.A., M.S.L.S., COHEN BRUCE M., M.D., Ph.D. 2007, From Asylum to Hospital to Psychiatric Health Care System,

2. Carron, Michael A., Hanna Saad, 2012, Treatment of the Mentally Ill in the Pre-Moral and Moral Era: A Brief Report, Wayne State University School of Medicine.

3. Rudnick, Abraham, David Roe, William A. Anthony, 2011, Moral Treatment in the Eighteenth and Nineteenth Century in Serious Mental Illness: Person-Centered Approaches (Patient-Centered Care), 303864425_Moral_treatment_in_19th_and_18th_century_psychiatry

4. Beachum Lauren, fall 2010, The Psychopathology on Cinema: How Mental Illness and Psychotherapy are portrayed in Film.