A brief history of psychiatry

John Cookson, in Core Psychiatry (Third Edition), 2012

The asylum and moral therapy
The history of ‘psychiatry’ began with the custodial asylum – an
institution to confine raging individuals who were dangerous or
a nuisance. The discovery that the institution itself could have a
therapeutic function led to the birth of psychiatry as a medical
speciality. This notion can be traced to clinicians such as
William Battie (St Luke's, 1751), Chiarugi (Florence, 1785) and
Pinel (Paris, 1795), and lay people such as William Tuke
(1796), a Quaker tea merchant who founded the Retreat in
York. Such a development was in keeping with the style of
thinking of the Age of Enlightenment (that ended with the
French Revolution in 1789), with its religious scepticism and its
quest for understanding. Pinel (at the Salpêtrière for women
and the Bicêtre for men), in particular, anticipated several
trends, abolishing the use of restraining chains and recognizing
a group of ‘curable lunatics’ (mainly with melancholia or mania
without delusions), for whom a more humanitarian approach in
an ‘institution morale’ seemed to be therapeutic.
The term ‘psychiatry’ was first used in 1808 by Reil, a professor
of medicine in Germany, to describe the evolving discipline,
although its practitioners were known as alienists (those who
treated mental alienation) until the twentieth century.
During the eighteenth century, there had been a growing trade
in lunacy throughout Europe. In Britain, for example, the insane
were confined to private madhouses, to which physicians had
limited access and input. In 1788, King George III suffered a
bout of mental illness for which eventually he received attention
from Francis Willis, a ‘mad-doctor’ renowned for his piercing
stare. The constitutional implications were considerable, and
parliament subsequently instituted a committee to enquire into
this and into the care of the mentally ill in general.
The therapeutic asylums, which sprang up in the nineteenth
century, had in common a routine of work and activity and an
approach by the staff encompassed in the term ‘moral therapy’
and variously described as ‘a mildness of manner and
expression, an attention to their narrative and seeming
acquiescence in its truth’ (Haslam, Bedlam, 1809), ‘the soothing
voice of friendship’ (Burrows, London, 1828) and ‘encouraging
esteem … conducive to a salutary habit of self-restraint’
(Samuel Tuke, York, 1813). Uplifting architecture, as well as
access to sunlight and the opportunity to work in the open air,
were also valued.
Many of these institutions had charismatic directors and
employed attendants who could be trusted not to beat the
patients. Reil (1803) described the qualities of a good
psychiatrist as having ‘perspicacity, a talent for observation,
intelligence, goodwill, persistence, patience, experience, an
imposing physique and a countenance that commands respect’.
These are recognizable ingredients contributing to a placebo
effect, and most of the physical treatments at their disposal
were largely that: purgatives, enemas, blood letting (advocated,
e.g. for mania by Benjamin Rush, the founding father of
American psychiatry, 1812) and emetics, aimed to ‘draw out’
nervous irritants (‘catharsis’).
During the nineteenth century, the confining of patients to an
asylum passed from an unusual procedure born of grave
necessity to society's first response when dealing with psychotic
illness. Therapeutic asylums were built on a vast scale as
politicians responded to the claims of the early enthusiasts.
Unfortunately, while the doctors had no effective treatments, the
asylums were destined to accumulate more and more incurable
patients, leaving the staff overwhelmed, demoralized, and with
insufficient time or conviction to sustain their ‘moral’ approach.
The situation was exacerbated by an increase in the numbers
of mentally ill people, especially through neurosyphilis and
alcoholism, and by the increasing reluctance of families in
industrialized society to tolerate their mentally ill relatives.
In 1894, the American neurologist Silas Weir Mitchell told
asylum physicians that they had lost contact with the rest of
medicine, and that their treatments were ‘a sham’. In Britain,
apart from the Maudsley Hospital, which opened in 1923 for
teaching and research and for the treatment of recently ill
patients, asylum psychiatry remained virtually divorced from the
rest of medicine until the 1930s.