Moral treatment

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Background

Moral Treatment, also known as Moral Therapy or Management, was an approach to mental disorder based on humane psychosocial care and moral discipline. It emerged in the late 18th century and came to the fore for much of the 19th century, deriving partly from psychiatry or psychology and partly from religion or moral concerns. The movement was particularly associated with reform of the asylum system. It fell in to decline as a distinct method by the 20th century, however, due to rising numbers of patients and the predominance of biomedical methods. There has also been criticism that it blamed or oppressed patients according to the morals of a particular social class or religion. The movement is commonly seen as influencing psychiatric practice up to the present day, including specifically therapeutic communities and occupational therapy

History

Moral Treatment developed in the context of the Enlightenment and an increasing focus on individuality and rights. It has been argued that there was a secularization of madness from around 1660 and a Georgian era 'classical moral treatment' that preceded the moral treatment movement. In addition, the influential work 'Treatise on Madness' published in 1758 by William Battie, argued for the need to treat as well as confine insanity, and to consider the changeability and individuality of people and their symptoms, challenging the general perception that madness was a single inexplicable disease. In addition, in his An Essay Concerning Human Understanding, John Locke popularized the idea that there is a degree of madness in most people, because emotions can cause people to incorrectly associate ideas and perceptions, which can be difficult to correct through reasoning.

Italy

In the 1780s, Italian physician Vincenzo Chiarugi instituted improvements at the St. Bonifacio Hospital in Florence, Italy, including ensuring the removal of mechanical restraints, although his reforms were not well publicised.

France

The ex-patient Jean-Baptiste Pussin and the psychiatrist Philippe Pinel (1745-1826) are generally recognized as the first instigators of more humane conditions in asylums, part of what later became known as the moral treatment movement. In 1793, Pinel became the chief physician at La Bicêtre, an asylum in Paris for male patients. Pinel, following the lead of Pussin, argued that the patients should be treated with sympathy and kindess rather than, for example, chains and beatings. Following Pussin, he unchained them and allowed them to move freely about the hospital grounds, replaced the dark dungeons with sunny, well-ventilated rooms, and offered support and advice.

Pinel's approach was seen as remarkably successful and he later brought similar reforms to a mental hospital in Paris for female patients, La Salpetrière. As he had done at Bicêtre, Pinel removed the chains and instituted reforms. Pinel's student and successor, Jean Esquirol (1772-1840), went on to help establish 10 new mental hospitals that operated on the same principles.

England

An English Quaker named William Tuke (1732-1819) independently brought similar reforms to northern England, following the death of a fellow Quaker in a local asylum in 1790. In 1796 he founded the York Retreat, where about 30 patients lived as part of a small community in quiet country houses and engaged in a combination of rest, talk, manual work. The efforts of the York Retreat centered around minimizing restraints and cultivating rationality and moral strength.

The entire Tuke family became known as some of the founders of moral treatment. They created a family-style ethos and patients performed chores to give them a sense of contribution. There was a daily routine of both work and leisure time. If patients behaved well, they were rewarded; if they behaved poorly, they were punished. The patients were told that treatment depended on their conduct. In this sense, the patient's moral autonomy was recognized.

United States

The person most responsible for the early spread of moral treatment in the United States was Benjamin Rush (1745-1813), an eminent physician at Pennsylvania Hospital. He limited his practice to mental illness and developed innovative, humane approaches to treatment. He required that the hospital hire intelligent and sensitive attendants to work closely with patients, reading and talking to them and taking them on regular walks. He also suggested that it would be therapeutic for doctors to give small gifts to their patients every so often.

A Boston schoolteacher, Dorothea Dix (1802-1887), made humane care a public and a political concern in the United States. In 1841 Dix visited a local prison to teach Sunday school and was shocked at the conditions for the inmates. She subsequently became very interested in prison conditions and later expanded her crusade to include the poor and mentally ill people all over the country. She spoke to many state legislatures about the horrible sights she had witnessed at the prisons and called for reform. Dix fought for new laws and greater government funding to improve the treatment of people with mental disorders from 1841 until 1881, and personally helped establish 32 state hospitals that were to offer moral treatment.

Criticism

In the 1960s, many criticized any perceived glorification of the history of psychiatry. Particularly, Michel Foucault argued that Pinel's moral treatment was really a new form of moral oppression, replacing physical oppression. Foucault was interested in ideas of “the other” and how society defines normalcy by defining the abnormal and its relationship to the normal. A patient in the asylum had to go through four moral syntheses: silence, recognition in the mirror, perpetual judgment, and the apotheosis of the medical personage. The mad were ignored and verbally isolated. They were made to see madness in others and then in themselves until they felt guilt and remorse. The doctor, despite his lack of medical knowledge about the underlying processes, had all powers of authority and defined insanity. Thus Foucault argues that the 'moral' asylum is "not a free realm of observation, diagnosis, and therapeutics; it is a juridical space where one is accused, judged, and condemned." (Madness and Civilization 158)