Abandoning the Psyche to Secular Treatment: Of Mental Health, Medicine, and Morals

Most peopleare surprised to find that treatment of mental illness using moral treatment was very effective 150 years ago. This fact is no secret among mental health professionals, but it is not widely discussed among the laity. When moral treatment is mentioned even in textbooks, it is looked upon as a prescientific curiosity in the history of therapy, and its recovery rates are seldom compared to those of contemporary therapies. It is the forgotten success in the history of treating the disturbed. Christians were highly involved in the development and use of moral treatment, but abandoned it when everyone else did.

Moral treatment began at the end of the eighteenth century with the French physician Philippe Pinel, who held the radical view that the “insane” should be treated with kindness and consideration rather than as animals or criminals. In 1793 he received permission to unchain the patients at his hospital. He moved people out of dungeons, permitted exercise, and treated the patients with kindness. The effect was astounding. Noise, filth, and abuse were replaced by order and peace. People began to recover and leave the hospital.

At about the same time an English Quaker, William Tuke, established the “York Retreat,” a pleasant place where patients lived in a kindly, religious atmosphere. Tuke also faced resistance, some of it from the church. As word of Pinel’s success spread to England, Tuke’s small band of Quakers gradually gained support. Success in France and England revolutionized treatment of the maladjusted throughout the civilized world, including the United States. Friends Asylum was built in Pennsylvania by the Quakers.

American society of the early nineteenth century was an ideal place for the development of moral treatment. Most communities were small, close-knit communities where people were united by religious ties. Moral treatment was never clearly defined because its meaning was then self-evident. It included compassionate and understanding treatment of innocent sufferers, and even those not so innocent. Hospitals were cheerful, homelike, and not monotonous. Cruel punishments and almost all “shock” treatments were forbidden. Emphasis was placed on the relationship between physician and patient. The term “moral” carried connotations of zeal, hope, spirit, and confidence. Therapists kept in mind that the patients were sensitive to their interest and good will, and they limited their number of patients to those they could know personally.

In 1842 Charles Dickens described his visit to what is now Boston State Hospital. Patients were working, reading, or playing games. Every patient sat down to dinner with a knife and fork, and the superintendent ate with them. Every patient was trusted with the tools of his trade. Patients walked, ran, fished, painted, and rode in carriages. Once a week they had a ball in which the doctor, his family, all the nurses, and all the attendants took an active part. “Immense politeness and good breeding” were observed everywhere. The superintendent and his family lived and ate with the patients, who were considered part of his family.

In 1873 Isaac Ray wrote about the role of the mental hospital superintendent of that era. The superintendent was a man of distinction and highly regarded. He knew every patient in his care because hospitals rarely had more than 200 patients. He did not boast about the number of patients he had, but about the many whose experiences he discovered, whose needs he supplied, whose moods and fancies he had watched. A formal walk through the wards and the ordering of drugs was only a small part of his means of restoration.

This treatment was most effective, though “unscientific.” During the first half of the nineteenth century, when moral treatment was at its peak, at least 70 percent of the patients who had been ill for a year or less were released as recovered or improved. Some hospitals had recovery rates of 80 or 90 percent—higher than at previous or subsequent times. Moral treatment did all this without tranquilizers, antidepressants, shock treatment, psychosurgery, psychoanalysis, or any other kind of psychotherapy. Kindness, patience, attention to needs, opportunities for expression of creativity, trust, and the maintenance of self-respect were very effective.

Nonetheless, the use of moral treatment declined during the second half of the nineteenth century. The results were disastrous. Recovery and discharge rates went down as moral treatment gave way to the medical approach. Mental hospital directors often tried to obscure this fact and continued to contend that insanity was curable—curable as a physical disease of unknown origin. Definitions of “mental illness” also changed, as they continue to do today. Between 1833 and 1846, the discharge rate at Worcester State Hospital was 70 percent, using moral treatment. By 1893 it had declined to only 5 percent—once committed, chances were nineteen out of twenty that a person would never get out. Some psychiatrists claimed that mental illness was changing its form and becoming increasingly malignant.

Why was moral treatment abandoned? Many reasons have been proposed. The industrial revolution brought many changes in our culture. With the emphasis on mass production and desire to run expensive mental hospitals at a profit, hospitals grew from handling less than two hundred patients to handling several thousand. Large, centralized state hospitals were more efficient. To some people, Dorothea Dix is the Florence Nightingale of psychiatric treatment. A resolution by Congress in 1901 characterized her as “among the noblest examples of humanity in all history.” Although no one questions her motivation or effectiveness, the net results of her efforts may have actually set treatment back. While teaching a Sunday school class in a New England jail, she became enraged at the confinement of the mentally ill there under such deplorable conditions. As a direct result of her personal efforts more than thirty state institutions were built or enlarged. She also had an influence in fourteen countries other than the United States. She lived to see her goal of placing all mentally ill in mental hospitals rather than in jails, almshouses, cellars, and attics. Unfortunately, automatic increases in staff and number of hospitals did not accompany increases in patients. Overcrowded and understaffed, moral treatment simply could not function. Recovery rates began to decline.

Another reason for the decline of moral treatment was the emergence of the disease model of mental “illness.” The success of medicine in the nineteenth century led to its adoption as the model for psychiatric treatment and research. Dr. John Gray, appointed superintendent of the largest state hospital in America in 1854 and made editor of The American Journal of Insanity in 1855, held that insanity was always due to a physical lesion and treated patients accordingly, emphasizing rest, diet, fresh air, and so forth. Replacing the optimistic enthusiasm of the moral therapist was the restrictive watchfulness of an administrative custodian waiting for a cure to be discovered. Rather than seeing the patient as competent to meet expectations, carry out tasks, and make decisions, therapists assumed that they were helpless. The superintendency of mental hospitals was taken out of the hands of stewards or wardens and given to medical men. Neuropathologists were added to psychiatric staffs to search for the relationships between mental symptoms and brain pathology.

A final reason for the decline of moral treatment was that none of the early moral therapists developed theoretical conceptualizations of their principles. They considered this unnecessary since the principles were a part of the everyday life of the early American settler. Cultural changes, however, undermined the entire philosophy of moral treatment.

A more difficult question is, why not return to the use of moral treatment? It seems unlikely that therapists have not heard about it: a book on the subject appeared fifteen years ago, journal articles are available, and it is briefly presented in most abnormal psychology textbooks and handbooks. A more logical reason is found in the dominance of the medical model and the fear of being called unscientific if “moral treatment” were seriously proposed. When psychologist O. H. Mowrer used the terms “sin” and “morality” in his writing, other psychologists did not take him seriously. They pointed to his own past mental illness. Another reason is more philosophical. Although they are really not value-free, many scientists at least strive to be so. Then if scientists are to be value-free, and are not to impose their own morality on anyone else, how can they use something called “moral treatment”? The very concept of “moral” seems to conflict with the whole approach of modern secular psychology and psychiatry.

A final important question is this: what will Christians do? During the Middle Ages, treatment of the disturbed was left largely to the clergy, and the mentally ill were usually treated with considerable kindness. However, as theological beliefs about demonic influence on such behavior became more widely accepted by the secular world, treatment was taken over by the secular world and became more harsh. People were whipped, starved, chained, and immersed in hot water to make the body such an unpleasant residence that the demon would leave. This happened with the consent of the church. Then people like William Tuke and his group of Quakers revived kindness and consideration in treatment. Again the secular world took over. Again the church withdrew.

Compared to the physically ill, the church has largely ignored the mentally ill for the last hundred years. Hundreds of hospitals have been built to care for the physically ill, but only a very few to care for the mentally ill. Of course, this is not to say that the church should have built large hospitals modeled after those being built by others, but it did not continue to build effective centers for treatment, such as the York Retreat or Friends Asylum mentioned earlier. The church, like the secular world, abandoned moral treatment for the medical model.

The church has also watched the rise and decline of psychoanalysis. Although there are some Christian psychiatrists and psychologists, there are not enough. Too often we send our seriously disturbed church members to secular therapists. We give pastoral counseling to the less serious cases, then send them to the secular world if they are too difficult for us and we do not have ready access to a Christian therapist willing to handle difficult cases. Jesus did not avoid the “lunatic,” as the King James English puts it (Matt. 4:24).

What we need is a Christian approach to the treatment of the mentally ill, one that organizes the truths found in these secular approaches around a central Christian world view. In some cases physical disorders may cause mental disorders, and in these cases physical methods of therapy can be very effective. If a person has an undersecretion of thyroxin by the thyroid gland it will bring about retardation, both physical and mental. This can be prevented or, in some adult cases, reversed by taking thyroxin. General paresis may be prevented if syphilis is treated early. Although drugs are useful in some cases, they are not the answer to all disorders. Sometimes people simply learn inappropriate responses, in which cases behavior therapy may be effective. The person who has a phobia about dogs can learn not to fear them, through the methods of behavior therapy. Individuals who have underlying conflicts may be helped through traditional methods of psychotherapy.

As Christians, we must go beyond simply integrating these secular therapies. Sin and its resulting guilt feelings may be at the root of the person’s problem. In these cases we must bring the person to the point of seeking God’s forgiveness. Demon possession may cause psychotic-like behavior. We must learn to distinguish between demon possession and psychotic behavior, and to study Jesus’ methods for dealing with each. We must also not be content with merely making “sick” individuals “normal,” but with taking “normal” people and making them Christlike. As we consider developing a Christian approach, we must consider not only contemporary secular approaches, but also the old (and successful) approach to the treatment of the mentally ill. Why not the methods of moral treatment?

Anchored Heart