Moral Treatment

Moral treatment can be described in three ways: as an ideology, as a practice, and as a set of principles about the treatment of mental illness.

David Kennard, 1998, Introduction to Therapeutic Communities[1]

The Sanctuary Model

In 1813, Samuel Tuke, grandson of William, published a book titled Description of the Retreat, an institution near York for insane persons of the Society of Friends. In his book, he gave an account of “Moral Treatment". Physical coercion and restraint were deplored and were replaced with relationships with attendants who were carefully selected to offer inmates guidance and treat them humanely. Patients were to be treated with respect, as adults, not as children, and were to be urged in the direction of self-restraint and self-control [2]. The violent were separated from the nonviolent. Environmental factors were seen as playing an important role in the etiology of the mental problems. Attention to the social milieu largely replaced physical methods of treatment.

The mad were not seen as animals, but as suffering humans who had gone astray and who could be led back to the right path through kindness, compassion, and rational conversation. Moral treatment was a profoundly social form of treatment. The experience of madness was to be corrected by placing people in humane and caring social environments that emphasized social interaction and the cultivation of latent faculties and healing processes. Moral Treatment had far-ranging effects on the face of institutionalization in Europe and in America. The book that Samuel Tuke wrote about the York Retreat spurred the investigation and reform of madhouses throughout the Continent [3].

Moral Treatment spread rapidly to the United States. Benjamin Rush, considered the founder of American psychiatry, believed that disease, political institutions, and economic organization were so interrelated that any general social change produced accompanying changes in health. For him, proper political stimuli and a stable and ordered society were required for health. “Mental health implied a society which would provide the proper stimuli and necessary conditions for well-being” [4].

As a result of the influence of the Tukes, Pinel, and others, the asylum movement grew rapidly, and soon every population center in America had a beautifully constructed asylum created to provide the mentally ill with the most modern forms of social treatment in a safe and humane environment. By 1844, American proponents of Moral Treatment "Moral treatment" had amassed an impressive body of evidence to support their belief that mental illnesses were treatable and that asylum treatment could restore patients to health. By 1837, Eli Todd at the Hartford Retreat had cured 91.3 percent of his recent cases, and Woodward at Worcester had discharged more than 82 percent as recovered. They proposed that the mentally ill had as much chance for recovery as a person who was ill with any other acute disease of equal severity [5].The Sanctuary Model

But Moral Treatment required the intensive involvement of many staff members with small groups of patients, and this kind of treatment was more expensive than domiciliary care. As the asylums became available, they were seen as the last resort for many different kinds of problem populations - the senile, syphilitics suffering from the tertiary stage of the disease, the mentally retarded, alcoholics, opium addicts, impoverished immigrants, and other patients suffering from chronic disorders for which little treatment existed. The resultant increase in the chronic population reduced the rates of cures, making it harder for the asylums to justify the increasing level of funding required from state legislatures [5].

The Sanctuary ModelMeanwhile, the sheer numbers of patients demanding care resulted in the massive growth of mental institutions, thus defeating the original premises of Moral Treatment. Hospitals designed to accommodate small patient populations were faced with demands for admissions of anyone considered deviant or unmanageable. As the management of these unwieldy institutions became more and more bureaucratized, the care became more impersonal, controlling, neglectful, and harsh. The funding of asylums became a hot political potato. Legislatures grew increasingly unwilling to fund the asylums. Charismatic and inspired asylum directors gave way to men with the political savvy to attempt political bargaining with state legislatures but who did not necessarily understand the initial goals of Moral Treatment "Moral treatment" [5-7]. Administrations became increasingly corrupt, until by 1891, Burdett, an English physician surveying American institutions, depicted “overcrowding, deteriorated physical facilities, extensive use of physical restraint and manipulation, and only occasionally a hospital with a therapeutic orientation” [8]. These asylums were the huge and impersonal institutions that we have been busy disassembling for over twenty years.

Excerpt from Creating Sanctuary: Toward the Evolution of Sane Societies. Bloom, S. L. 1997

Key Points: Moral Treatment as a Practice

  • Physical restraint is rarely needed
  • Insanity is curable
  • People need to have structured, ordered, regular work and socialization in an attractive, family-like environment.
  • Patients are normal, rational beings.
  • The curability of insanity
  • Reward rather than punishment
  • The importance of size and setting
  • The personal attributes of the staff

Moral treatment focused on the means by which “the power of the patient to control the disorder is strengthened and assisted”.
Samuel Tuke, Description of the Retreat, 1813 [9]

 

In contrast to the previous practice of the times, in which any form of restraint had been considered acceptable because the insane were not thought to be fully human, Tuke with his Quaker concept of personhood, argued for minimum restraint and for the acceptance of risk in the management of disturbed behavior..
David Kennard, 1998, An Introduction to Therapeutic Communities.

 

The use of social reinforcement was also clearly recognized: Tuke pointed out that providing a comfortable environment increased the patient’s ‘desire to restrain himself by exciting the wish not to forfeit his enjoyments’.
David Kennard, 1998, An Introduction to Therapeutic Communities.

 

Moral treatment . . . was aimed at recognizing and nurturing the intact part of the patient’s personality, through whatever methods were available..
David Kennard, 1998, An Introduction to Therapeutic Communities.

 

In America . . . moral treatment meant placing the victim of . . . social pressures in an environment designed to restore inner equilibrium. In their asylums they attempted to create a new, ideal mini-society in which the virtues of order, calm and productive work would replace the chaos and competitiveness of a burgeoning new world..
David Kennard, 1998. An Introduction to Therapeutic Communities.

 

  1. Kennard, D., Introduction to Therapeutic Communities. 1998, London: Jessica Kingsley.
  2. Busfield, J., Managing Madness: Changing Ideas and Practice. 1986, London: Unwin Hyman.
  3. Macalpine, I. and R. Hunter, George III and the Mad-Business. 1993, London: Pimlico.
  4. Rosen, G., social stress and mental diseases from the 18th century to the present: Some origins of social psychiatry. Milbank Memorial Fund Quarterly, 1959. 37: p. 5-32.
  5. McGovern, C.M., The Masters of Madness: Social Origins of the American Psychiatric Profession. 1985, Hanover Press: University Press of New England.
  6. Dwyer, E., Homes for the Mad: Life Inside Two Nineteenth-Century Asylums. 1987, New Brunswick: Rutgers University Press.
  7. Rothman, D.J., Conscience and Convenience: The Asylum and Its Alternatives in Progressive America. 1980, Glenview, IL: Scott, Foresman and Company.
  8. Almond, R., The Healing Community: Dynamics of the Therapeutic Milieu. 1974, New York: Jason Aronson.
  9. Tuke, S., Description of The Retreat: An Institution Near York for Insane Persons of the Society of Friends. 1996 (1964, 1813), London: Process Press.