The Evolution of the American Insane Asylum

Above image: Greystone Park Psychiatric Hospital in Morris Plains, NJ, demolished 2015

Something I decided to add to the final draft of Shores of Chaos: Shipwrecked was the 19^th century insane asylum. For most of us when we think of the typical Victorian or Gilded Age insane asylum, we think of grim, filthy places where patients were abused and neglected by cruel hospital staff. While this image is sadly true for quite a few of the insane asylums, it isn’t the whole story. In fact, most insane asylums didn’t start out this way and for many hospitals it wasn’t until the 20^th century that our typical idea of the asylum became more and more common place. The truth is, the treatment of the mentally ill has tended to ebb and flow throughout the centuries and this article will explore that.

We will begin in the 18^th century as I discussed what the treatment of the mentally ill was like in the American colonies in the 17^th century in “The Puritans and Mental Illness.” In the early 18^th century, patients were generally treated within their own families unless they were deemed too violent, poor, or disruptive to continue to live in society and be cared for within their towns. These people were usually sent to public almshouses or hospitals where they were gawked at by visitors and often left chained in cells and not given much in terms of actual treatment.^4,5 But as Enlightenment ideals progressed in the late 17^th century through the 18^th century, people looked beyond religion and spirituality for the causes of mental illness. Philosophers like John Locke established that the mind is natural, not supernatural, and the moral causes of mental illness began to be superseded by physical causes.¹ One physician, Benjamin Rush, combined these two causes. He thought poor behaviors and vices could cause blood vessels in the brain to become inflamed or damaged resulting in mental illness. In order to stop the over activity that lead to madness, he would prescribe bloodletting and restricted diets to slow a patient’s pulse and activity. He further restrained their passions by having them bound to a chair and placing a box over their ears and eyes to dull sensations. Rush’s ideas were used in the Pennsylvania Hospital’s insane ward which previously had used methods now considered inhumane such as bleeding until the patient became unconscious, purgatives, restraints, and whipping when needed. Although Rush’s techniques were questionable, he did want to get rid of the stigma of mental illness and wanted patients treated with medicine. He also wanted to use occupational therapy, amusements, and recreation with the patients and even called them family.^5,7  

By the 19^th century, “moral treatment” began to take hold in the care of the mentally ill. With “moral treatment,” patients were to be treated with kindness that appealed to the rational parts of their mind. Instead of restraints and isolation in cells, patients would have secluded, but comfortable retreats to stay at in country settings. At these places occupational therapy, recreation, rewards, and privileges would help cure their illness.⁴ A New England school teacher named Dorothea Dix was a leading proponent of this treatment. She stayed in Europe when she suffered from depression and learned of kinder methods of treating the mentally ill while there. Upon her return, she petitioned the United States Congress and state legislatures from the 1840s to the 1860s to create new facilities to house the insane, believing the mental health of the citizens to be important to the health of the state.^2,3,4 Another reformer was Pennsylvania psychiatrist Thomas Kirkbride who believed that the proper environments could cure mental illness. He created the idea of asylums designed to maximize natural light and air circulation. These buildings would be located in scenic places with well tended grounds and comfortable furnishings and amenities for the patients.³ What came from his ideas are the large “kirkbride style” 19^th century asylums that we often think of, with their sprawling batwing like wards and large windows and rooms for socializing and occupational therapy. At these hospitals, the mentally ill could look forward to a calm, natural setting and exercise and work to temper the mind.² By the 1870s, nearly every state had at least one such publically funded hospital.⁴

Like most well intentioned plans, these morally-centered asylums quickly fell short of the ideals from which they were created. Kirkbride originally intended for no more than 250 patients to be hospitalized at each asylum. However, the numbers greatly increased beyond the hospitals’ original capacity when unexpected events occurred. First, the Civil War led many who had experienced the traumas of war to asylum doors, but it also led to underfunding by the government.² Secondly, newly arrived immigrants from countries like Ireland, Germany, and Italy who could not afford private hospitals drove up asylum populations.³ Finally, it was easy for families to place their undesirables into the asylums as all that was needed for commitment was a family member making a complaint and two doctors backing it up.² Likewise, the elderly were often confined to asylums by the state to cut costs.⁴ The problems of overcrowding, understaffing, and underfunding continued to plague asylums with some of them falling into a pattern of patient abuse and neglect. This was perhaps most infamously depicted in Nellie Bly’s 1887 expose Ten Days in a Mad-House which showcased the horrendous conditions of the Women’s Lunatic Asylum on Blackwell’s Island.⁶

This trend continued into the 20^th century. The Great Depression hurt state funding for asylums and the Second World War created both staffing shortages and an increased number of patients.⁴ After World War II, the asylum population peaked at over half a million patients. While doctors and neurologists started to understand the brain more, there was still little effective treatment. Many of the treatments used on patients such as hydrotherapy, fever therapy, insulin therapy, induced seizures and comas, and wet shock were experimental in nature. Sadly, when the field of eugenics gained traction, many people in asylums were subjected to sterilization, often without their knowledge, as a way to weed out the mentally ill from future generations. Two notorious treatments were also performed in asylums: the lobotomy and electroshock therapy. The first lobotomy in the United States was performed by Walter Freeman in 1936. Some lobotomies actually ended up more or less successful with few side effects and the patient was relatively free of their psychotic symptoms which allowed them to leave the asylums. Unfortunately, many lobotomies were disastrous and could leave the person unable to speak or walk, completely unaware or uninterested in their surroundings, or even dead.² Electroconvulsive therapy was also used, perhaps more than was necessary, but unlike the lobotomy, shock therapy is still used today for cases of severe depression albeit in a much safer manner.

By the 1950s, the deinstitutionalization movement began. The introduction of the first effective antipsychotic medication, Thorazine, allowed many patients to be released from asylums. In addition, there was a movement for more community based care and the Community Mental Health Act of 1963 helped to fund alternatives to the asylums. Patient rights were furthered when the Supreme Court ruled in 1975 that the mentally ill could not be committed to an institution unless they posed a significant risk to themselves or others. The down side to the deinstitutionalization movement is that severely mentally ill people often do not get the long term treatment they need.² Today, the large, complex 19^th century asylums have become obsolete as many patients now receive outpatient services or short-term stays in psychiatric wards of general hospitals.³  

I will end this post with a brief note about the asylum featured in my story: the Maine Insane Hospital. The hospital opened in 1840 in Augusta, Maine and almost immediately found itself at the center of controversy. In 1841, Isaac Ray was made superintendent of the hospital and was nearly sued by a former patient, Isaac Hunt, for malpractice in 1848. Hunt complained of forced medication, restraints, and assault, but it is unclear how much of his account is true or exaggerated. It should also be noted that at this time, the Maine Insane Hospital was taking in the mentally ill from places where they had previously been confined in cells and were so without social skills that they were unable to rejoin their community so there may have been a learning curve when dealing with patients.⁸ Several decades later, Bigelow T. Sanborn served as superintendent of the asylum from 1883 to 1910. Under his care, the hospital seems to haven taken a turn for the better. By 1900, the hospital was reported to be clean and gave much attention to the recreation of its patients. The patients were often taken on boat excursions to the Isle of Springs or taken to local theaters. There was also a band that played on the lawn, balls, church services, entertainers who would come perform for the patients, and a library. Of the over 700 patients, 110 that had fully or partially recovered were released in 1900 as well. The biggest complaints regarding the asylum, at least from what I could find, were the outdated wards, some insolent female staff members, and overcrowding. Some of the patients were transferred to the Eastern Maine Insane Hospital in Bangor when it opened in 1901.^{9, 10} The asylum, like many others of its kind, now stands mostly abandoned in Augusta after it closed in 2004, serving as a testament to a once promising treatment of the mentally ill.

Sources

1. “Evil or Illness.” Mysteries of Mental Illness documentary series by PBS
2. “The Rise of the Asylum.” Mysteries of Mental Illness documentary series by PBS
3. “The American Mental Asylum: A Remnant of History” by Mark L. Ruffalo for Psychology Today. July 13, 2018.
4. “History of Psychiatric Hospitals” by Patricia D’Antonio for the University of Pennsylvania
5. Health and Wellness in Colonia America by Rebecca Tannenbaum. Greenwood of ABC-CLIO, LLC., 2012.
6. “Mental Health” by Barbara Floyd for the University of Toledo.
7. “Turning Points: The Transition of the Treatment of the Mentally Ill from Late 18th Century to Early 20th Century” by Lauren Plested for Temple Univerity
8. “Issac Ray, Malpractice Defendant,” Kenneth Weiss. Journal of the American Academy of Psychiatry and the Law Online. September 2013, 41 (3) 382-390
9. ”Reports of the Trustees, Resident Officers, and Visiting Committee of the Maine Insane Hospital” Dec. 1, 1900.
10. “Perspectives of Bigelow T. Sanborn” from Maine.gov, About Riverview Psychiatric Center