Asylum — EWM

Summary

The asylum — an institution specifically designed to house, and eventually to treat, the mentally ill — emerged as a distinct social technology in Western Europe during the late eighteenth and early nineteenth centuries. Before that point, mentally ill people were kept at home under often brutal conditions, placed in poorhouses, or confined in workhouses. The idea that confinement itself could be curative, delivered through a structured environment, humane routine, and the physician’s authority, was new. It arrived through the moral treatment movement associated with Philippe Pinel in France, William Tuke’s York Retreat in England, and Vincenzio Chiarugi in Italy — all working largely independently in the 1790s. By 1900 the therapeutic optimism of that founding generation had collapsed under the pressure of overcrowding. By the 1950s, chlorpromazine made it pharmacologically possible to discharge patients who had been hospitalized for years. What followed — deinstitutionalization — resolved one set of problems and created several others that remained unresolved at the end of the twentieth century.

Origins: Pre-Asylum Confinement

Before the end of the eighteenth century, psychiatry did not exist as a discipline. Individual physicians had written about the insane since ancient Greece, but without common professional identity or therapeutic program.(Shorter, 1997) Medieval and early modern institutions — Bethlem (“Bedlam”) in London, the Bicêtre and Salpêtrière in Paris, the Narrenturm (“fools’ tower”) in Vienna — had solely custodial functions. Traditional society had no concept of delivering therapy to confined patients.(Shorter, 1997)

The therapeutic asylum failed due to overwhelming patient numbers, not because its underlying concept was flawed.(Shorter, 1997) The first biological psychiatry was a research movement in universities, distinct from the asylum system, aiming to lay bare the relationship between genetics, brain chemistry, and mental illness through systematic experiment.(Shorter, 1997)

Scull documents that hospitals for the insane existed under Islamic rule from the eighth century, and that by the twelfth century no large Islamic city lacked one.(Andrew Scull, 2015) The treatments administered in those institutions combined chains, beatings (which Avicenna considered therapeutic, as “a means of beating sense into the wildly irrational”), humoral diets intended to cool and moisten the body, bloodletting, purges, opium, and herbal preparations including lavender, chamomile, and hellebore.(Andrew Scull, 2015)

In medieval Europe, by contrast, specialized institutions for the mad were rare exceptions. Scull draws particular attention to the shrine of St Dymphna at Gheel in Belgium, which developed an unusual arrangement: lunatics were chained in the church for eighteen days of attempted exorcism, and when madness persisted, many moved in with local peasant families, creating what Scull calls “a curious sort of lunatic colony, the whole economy being based on the donations made by the relations of the mad.”(Andrew Scull, 2015) [GAP: The subsequent invocation of the Gheel arrangement by reformers as a prototype for community psychiatry is not supported by the cited card.] Bethlem Hospital in London followed a more typical trajectory: founded in 1247 as a general charitable institution, it acquired a reputation for the mad only gradually, holding just six documented lunatics in 1403.(Andrew Scull, 2015)

The broader medieval pattern, Scull argues, was that most mad individuals remained the responsibility of their families, confined by ad hoc domestic expedients if dangerous, or left to wander if not. Institutional confinement was the exception rather than the rule, and madness was understood as primarily a social and spiritual problem rather than a medical one.(Andrew Scull, 2015)

The dominant intervention on pre-asylum confinement is Michel Foucault’s “grand confinement” thesis, argued in Madness and Civilization (1961): that the mid-seventeenth century saw an administrative sweep that incarcerated the poor, the idle, the mad, and the deviant together into new disciplinary spaces, producing through institutional practice the social category of “the mad.” Foucault’s account is addressed more fully in the historiographical section below.

The Trade in Lunacy and Coercive Treatment

The eighteenth century saw the rise of private, profit-making madhouses across England, serving families wishing to remove disturbed relatives from domestic settings. Scull calls this “the trade in lunacy,” a structural consequence of growing commercial prosperity: as wealthier families could pay for “discreet aid, advice and reassurance,” an informal network of madhouses arose to provide confinement that shielded families from the stigma a visible lunatic imposed on their social standing.(Andrew Scull, 2015) The profits could be considerable. William Battie, author of the 1758 Treatise on Madness, grew rich and prominent enough from his private madhouse practice to earn a knighthood, become President of the Royal College of Physicians, and accumulate a fortune Scull estimates at between £100,000 and £200,000 — tens of millions in modern terms.(Andrew Scull, 2015)

Thomas Willis (1621–75) was explicit: “Furious Mad-men are sooner and more certainly cured by punishments and hard usage, in a strait-room, than by Physick, or Medicines.”(Andrew Scull, 2015) Even monarchs were not spared. When Francis Willis, a Lincolnshire madhouse keeper, was summoned to treat George III during his 1788 episode of madness, the king was subjected to beatings, chains, and intimidation.(Andrew Scull, 2015)

The era produced considerable mechanical ingenuity in the service of coercion. Benjamin Rush (1746–1813) invented a device he called “The Tranquillizer,” a chair that “binds and confines every part of the body” and claimed to reduce blood flow to the brain, whose effects Rush described as “truly delightful to me.”(Andrew Scull, 2015) Joseph Mason Cox adapted Erasmus Darwin’s suggestion of spinning motion as therapy into a swinging chair that induced nausea, vertigo, and terror, spread widely across Europe, and was not banned at the Berlin Charité until the 1820s.(Andrew Scull, 2015)

Moral Treatment and the Reform Era

The therapeutic asylum — an institution in which confinement itself was designed to be curative — was invented in the late eighteenth century, with several independent originators.

In Florence, Vincenzio Chiarugi (working from 1785) established the basics of running a therapeutic asylum before Pinel, publishing a three-volume work On Insanity in 1793–94 arguing that asylums were not merely for segregation but for healing.(Shorter, 1997)

In Britain, William Battie’s 1758 Treatise on Madness was the first influential statement attributing therapeutic virtues to the asylum, quoting an anonymous colleague that “management did much more than medicine.”(Shorter, 1997)

In France, Philippe Pinel reorganized the Bicêtre from 1793 onward, arguing that the mad behaved like animals because that was how they were treated. His 1801 textbook positioned the asylum as a place for psychological treatment — through the structure of institutional life and the doctor-patient relationship rather than explicit psychotherapy.(Shorter, 1997) Porter notes that the celebrated image of Pinel dramatically striking chains off patients at the Bicêtre belongs to legend rather than documented history.(Porter, 1997) Scull elaborates: the actual reforms at the Bicêtre and Salpêtrière were implemented by lay administrators Jean-Baptiste and Marguerite Pussin; Pinel learned from their practical experience and “theorized” the changes, providing the first systematic published account of the French version of moral treatment.(Andrew Scull, 2015) The French phrase le traitement moral — “moral treatment” — means “mental treatment” rather than ethical instruction; Pinel’s moral is what we would call psychological.(Shorter, 1997)

In England, reform proceeded along parallel lines. John Conolly at the Hanwell County Lunatic Asylum from 1839 onward took the nonrestraint principle to its logical limit: he abolished all physical restraints on agitated patients and replaced them with structured work routines, crafts, and therapeutic activity — a practical demonstration that the asylum could function without the mechanical devices that had seemed indispensable.(Shorter, 1997) William Tuke, a Quaker tea merchant, had founded the York Retreat in 1792.(Andrew Scull, 2015) The Retreat’s founders asserted that medicine achieved nothing for the insane.(Porter, 1997) Porter describes it as evolving “a therapeutics grounded on quiet, comfort and a supportive family atmosphere, in which the insane were treated like ill-disciplined children.”(Porter, 1997) At the Retreat, Scull notes, chains were dispensed with and all forms of physical violence forbidden, replaced by self-restraint cultivated through rewards, work, and therapeutic environment.(Andrew Scull, 2015)

In Germany, Maximilian Jacobi’s Siegburg asylum (opened 1825) became the beacon of German psychiatric reform, with Jacobi conceiving the asylum as a hospital organized to treat “organic illnesses associated with mental illness.”(Shorter, 1997) Social-constructionist accounts that attribute the asylum explosion solely to capitalism’s intolerance of deviance are dismissed by Shorter as having virtually no supporting historical evidence.(Shorter, 1997)

From the late nineteenth century onward, the demented elderly were increasingly transferred from family care to asylums, contributing significantly to the redistribution effect in asylum population growth.(Shorter, 1997) In France, politics destroyed virtually all efforts to launch university psychiatry until a government decree in 1877 created psychiatric clinics at the four main universities.(Shorter, 1997) Esquirol’s concept of monomania and his advocacy of the asylum as a “therapeutic instrument” shaped French psychiatric practice and classification through the mid-nineteenth century.(Porter, 1997)

Shorter notes that in France, the 1838 law regulating asylums focused on administrative mechanisms of admission rather than therapeutic goals, and many areas of France lacked public asylums well into the late nineteenth century.(Shorter, 1997)

Foucault famously characterized moral treatment as a form of “gigantic moral imprisonment,” and Scull finds at least a kernel of truth in the characterization. The Scottish alienist W. A. F. Browne acknowledged that “Moral Treatment consists in being kind and humane to the insane” was itself “a fallacy.” The new approach sought to transform the asylum into a “great moral machine” whose goal was to ensure that “the impress of authority is never withdrawn, but is stamped upon every transaction.” In his own practice, Browne boasted, he sought to continue “the discipline and inspection exercised during active pursuits into the night, and during silence and sleep. Control may thus penetrate into the very dreams of the insane.”(Andrew Scull, 2015)

The Great Age of the Asylum, 1850–1950

The first biological psychiatry, a research movement in universities distinct from the asylum system, aimed to uncover the relationship between genetics, brain chemistry, and mental illness through systematic experiment.(Shorter, 1997) A parallel ambition accompanied this research strand: the medicalization of mental illness — drawing it into the circle of general medical experience so that family doctors could identify and manage cases at an early stage — was a program running alongside the laboratory neuroscience.(Shorter, 1997) However, driven by a microscope craze in the 1880s, it reached a dead end due to its detachment from patients.(Shorter, 1997) By 1900 the therapeutic optimism with which the nineteenth century had opened had almost entirely collapsed; as a German asylum doctor put it in 1910: “We know a lot and can do little.”(Porter, 1997)

The construction of this system was not spontaneous. Scull traces it to a state-mandated building campaign driven by reformers documenting abusive conditions. Esquirol, in 1818, had secured a government commission to survey French institutions for the insane; his report was a catalogue of horrors: “I have seen them naked, clad in rags, having but straw to shield them from the cold humidity of the pavement where they lie… at the mercy of veritable jailers, victims of their brutal supervision.”(Andrew Scull, 2015) Esquirol subsequently devised the national asylum scheme enacted by French law in 1838. In the United States, Dorothea Dix conducted a comparable state-by-state campaign, “bludgeoning male politicians everywhere she went with the horrors the insane faced in confinement” — and when local examples were scarce, Scull notes, she “did not scruple to invent and to embroider.”(Andrew Scull, 2015) The result, across Europe and North America, was what Scull calls “a new geography of suffering”: the asylum “everywhere became the chosen solution to the problems posed by the Bedlam mad.”(Andrew Scull, 2015)

Who actually populated these new institutions did not match the reformers’ expectations. Early nineteenth-century alienists had framed insanity as a disease of civilization disproportionately afflicting the ambitious and refined; the actual patient population proved otherwise. As Scull documents, it was “from among the poor and the middling sort that the overwhelming bulk of the rapidly expanding numbers of certified lunatics immediately came.” The designation “pauper lunatic” was to some degree misleading — not all were drawn from the lowest economic stratum — but madness made earning a living virtually impossible, and to rely on the public purse was to be classified a pauper.(Andrew Scull, 2015)

Shorter argues that this failure reflected the tragedy of progressive intentions overwhelmed by patient numbers, not the bankruptcy of the therapeutic concept: “The reformers were defeated not by the faulty nature of their concept but by the pressure of numbers.”(Shorter, 1997)

The rise in admissions had two distinct components. The first was a redistribution effect: mentally ill people previously managed in families and poorhouses were transferred to asylums as changing patterns of family sentiment — the shift toward the family as an intimate emotional unit — made disruptive relatives increasingly intolerable at home.(Shorter, 1997) The demented elderly were a significant driver of this redistribution; an English medical writer noted in 1908 an increase in asylum admissions “due to the drafting into asylums of harmless old people, the subjects of senile dementia.”(Shorter, 1997) In France, the 1838 law regulating asylums focused on administrative mechanisms of admission rather than therapeutic goals, and many areas of France still lacked public asylums late in the nineteenth century.(Shorter, 1997) The second component was a genuine increase in certain illnesses — neurosyphilis, alcoholic psychosis, and (less certainly) schizophrenia — that social-constructionist accounts cannot address.(Shorter, 1997)

A third factor, which Scull identifies as “diagnostic creep,” was a steady broadening of criteria for calling someone mentally ill. What George Cheyne had profitably diagnosed among wealthy patients as “the English malady” became, through successive expansions, a wide enough category to sweep in borderline cases that previous generations had managed at home or in workhouses. Scull observes this pattern repeating in the late twentieth century with bipolar disorder and autism.(Andrew Scull, 2015)

The accumulation of chronic patients had its own arithmetic logic. Scull describes it plainly: “if only one-third or two-fifths of each year’s intake left ‘improved’ or ‘cured’, and only 10 per cent died (and these became the common sort of statistics at most institutions), then over time, cases inevitably accumulated, and the chronic formed a larger and larger portion of the asylum population.” Relentlessly, the average size of asylums grew alongside their number.(Andrew Scull, 2015)

The crisis of legitimacy this produced was made public in 1894, when the Philadelphia neurologist Silas Weir Mitchell addressed the assembled members of the American psychiatric profession on the fiftieth anniversary of their association — and chided them. They presided, he said, over a collection of “living corpses,” patients “who have lost even the memory of hope, [and] sit in rows, too dull to know despair, watched by attendants: silent, grewsome machines which eat and sleep, sleep and eat.”(Andrew Scull, 2015) The same period generated a literature of patient protest: John Perceval, son of the only British Prime Minister to be assassinated, published accounts of his own asylum treatment and helped found the Alleged Lunatics’ Friend Society; Elizabeth Packard in the United States publicized wrongful confinement; and novelists including Charles Reade satirized alienists’ diagnostic competence and motives in fiction such as Hard Cash.(Andrew Scull, 2015)

Running parallel to the custodial asylum was the first biological psychiatry, a research movement in German universities. Wilhelm Griesinger established modern university psychiatry at Berlin’s Charité in 1865, declaring that “patients with so-called mental illnesses are really individuals with illnesses of the nerves and brain.”(Shorter, 1997) Scull notes that the Germans had the same “barracks-asylums as everyone else,” but the appointment of Griesinger gave them additionally a set of smaller clinics attached to universities where intensive research could proceed — a model quite distinct from the custodial asylum dominant in Britain, France, and North America.(Andrew Scull, 2015) This tradition attempted to ground psychiatric illness in brain anatomy, but ended in a dead end when its focus on microscopic anatomy detached it too completely from patients: researchers such as Flechsig and Hitzig were celebrated scientists who were terrible clinicians.(Shorter, 1997) The first biological psychiatry was “a movement of ideas rather than an exercise in bricks and mortar,” distinct from the custodial asylum.(Shorter, 1997)

One finding from the biological tradition carried genuine evidential weight. In 1822, Antoine Bayle, a young assistant physician at Charenton, had conducted autopsies on some two hundred mental patients and identified in a subset a cluster of symptoms he called paralysie générale — progressive impairment of speech, loss of limb control, and psychiatric symptoms including delirium giving way to dementia. Post-mortem examination of these patients’ brains revealed consistent lesions: meningeal inflammation and cerebral atrophy. By the end of the nineteenth century, this condition — General Paralysis of the Insane, GPI — accounted for 20 percent or more of male asylum admissions across Europe and North America.(Andrew Scull, 2015) Scull later notes this as one of the genuine triumphs of the medicalization of madness: “The wager that handing madness over to the ministrations of medics will have a practical payoff has had some successes — most notably with respect to tertiary syphilis, a terrible disorder that accounted for perhaps 20 per cent of male admissions to asylums in the early twentieth century. For the most part, however, it is a bet we have yet to collect on.”(Andrew Scull, 2015)

Professional associations of alienists formed across Europe and North America in the 1840s–1860s, alongside specialty journals, marking the institutional consolidation of psychiatry as a medical specialty tied to asylum administration.(Andrew Scull, 2015) In Britain, the Association of Medical Officers of Asylums and Hospitals for the Insane met for the first time in 1841; in the United States, thirteen heads of asylums gathered in Philadelphia in 1844 to form their own Association of Medical Superintendents.(Andrew Scull, 2015)

As ideology, degeneration theory served the professional interests of alienists by explaining therapeutic failure as inevitable (not incompetence) and by grounding madness in physical pathology, thereby reinforcing medical authority while justifying permanent segregation in asylums.(Andrew Scull, 2015) Scull argues that the theory had “surpassing virtues” for alienists in this regard.(Andrew Scull, 2015) Wealthy Victorian families, motivated by social stigma and fears about hereditary taint, went to extraordinary lengths to avoid confining disturbed relatives in public asylums, using private confinement at home, nursing homes, sanatoriums, or sending them abroad; Victorian letters and diaries document elaborate strategies such as building cottage annexes on estates, placing the disturbed in private lodgings, or sending them abroad.(Andrew Scull, 2015)

The Nazi T-4 programme, launched in 1939, was the culmination of eugenic logic applied to the mentally ill.(Andrew Scull, 2015) In October 1939, Hitler issued a decree launching the so-called T-4 programme.(Andrew Scull, 2015) Psychiatrists enthusiastically joined in implementing the new policy.(Andrew Scull, 2015) The mentally ill were rounded up and sent to a number of mental hospitals, where they were “disinfected”.(Andrew Scull, 2015) More than 70,000 patients were exterminated within eighteen months.(Andrew Scull, 2015)

Emil Kraepelin’s prognosis-oriented, longitudinal classification of mental illness eventually superseded the anatomical approach. His threefold clinical classification — dementia praecox, paranoia, and manic-depressive psychosis — based on following the total disease picture over time rather than mapping symptoms to brain locations, is described by Ackerknecht as “more practical and closer to reality than any of the preceding classifications,” and by Porter as the forerunner of the modern DSM.(Ackerknecht, 1955)(Porter, 1997) Kraepelin’s institutional legacy extended beyond nosology: his German Research Institute for Psychiatry, founded in Munich in 1917, became the seedbed for genetic research that established brain-based etiologies for major psychiatric illness — the germination point of what would later be recognized as a second biological psychiatry, which burst into clinical practice only in the 1970s.(Shorter, 1997)

The asylum model did not remain confined to Western Europe and North America. Scull documents its spread through British imperialism, but notes the adoption was uneven and often served colonial purposes distinct from any therapeutic intent. In India, the British East India Company primarily dealt with insane employees by sending them back to London; as that expedient became impractical, the “presence of crazed Europeans was an obvious threat to the ideology of white superiority,” and asylums were established chiefly to remove insane Europeans from public view. In colonial Nigeria, by contrast, most “natives continued to be managed and dealt with by their families, with some assistance from traditional Yoruba healers, who sometimes had recourse to a form of herbal treatment derived from a species of the plant rauvolfia” — a plant whose alkaloid reserpine, ironically, Western psychiatrists would experiment with as an antipsychotic in the 1950s.(Andrew Scull, 2015)

Between the world wars, psychiatrists caught between the ineffective asylum and psychoanalysis’s irrelevance for serious illness experimented with physical therapies. Julius Wagner-Jauregg’s malarial fever treatment for neurosyphilis — first used in 1917 and awarded the Nobel Prize in 1927 — was the first successful physical therapy in psychiatry, breaking the therapeutic nihilism that had dominated previous generations.(Shorter, 1997) Manfred Sakel’s insulin coma therapy (1933) and Ladislas von Meduna’s convulsive therapy preceded the chlorpromazine revolution; electroconvulsive therapy, introduced by Cerletti and Bini in Rome in 1938, became the most enduring physical therapy of the pre-drug era.(Shorter, 1997)(Shorter, 1997)

Desperate Remedies

The interwar period of somatic experimentation extended to treatments that, in retrospect, amounted to experiments on captive patients. Henry Cotton, superintendent of Trenton State Hospital in New Jersey, announced that he had discovered the aetiology of madness: all mental illness, he argued, was caused by chronic bacterial infections in various parts of the body — teeth, tonsils, colons — whose toxins spread through the bloodstream to poison the brain. He removed teeth and tonsils “on a massive scale.” When mortality rates from the more extensive abdominal surgeries approached 45 percent, Cotton’s mentor Adolf Meyer, America’s most prominent psychiatrist, suppressed the findings of an inquiry he had himself supervised, “preferring to avoid a potential scandal rather than intervening to protect patient lives.”(Andrew Scull, 2015)

Manfred Sakel relocated to Vienna in 1933 and began experimenting with insulin shock therapy for schizophrenia. By 1937 he was claiming a 70 percent remission rate, with favorable reports from twenty-two countries; the treatment killed between 2 and 5 percent of those treated, and controlled studies eventually demonstrated it was useless.(Andrew Scull, 2015)

Scull’s assessment of this entire wave of somatic experimentation — from malaria therapy through lobotomy — is that it was driven not by evidence but by psychiatry’s crisis of professional legitimacy relative to germ-theory medicine, therapeutic desperation, and the captive status of patients:

All across Europe and North America, the 1920s and 1930s witnessed the introduction of a quite remarkable array of somatic treatments designed to root out madness and restore the lunatic to sanity. Everywhere, the desperation felt by the families of those whose minds were unhinged, the professional ambitions of psychiatrists eager to move beyond their assigned role as curators of museums of the mad, and the fiscal pressures that the burden of chronic madness visited upon the body politic, encouraged therapeutic experimentation, and no countervailing forces held it in check. Certainly, patients had little say in the matter.(Andrew Scull, 2015)

Historiographical Debates

The historiography of the asylum is unusually contested, with three major interpretive frameworks in direct conflict.

Foucault’s “grand confinement” thesis, from Madness and Civilization (1961), reads the asylum as a technology of social discipline: the incarceration of deviance in the name of reason, replacing physical chains with the controlling chains of individual conscience. Foucault treats the asylum as fundamentally about social control rather than medical care, and regards the moral treatment reformers as having advanced, rather than ameliorated, the exercise of power over the mad.

Shorter disputes Foucault’s grand confinement thesis by arguing that the rise in asylum admissions was partly due to genuine increases in organic psychiatric illnesses such as neurosyphilis and schizophrenia, which social-constructionist accounts cannot address.(Shorter, 1997) Scull similarly disputes the thesis, providing evidence from Montpellier where only a tiny number of the mad were confined, with most remaining with families.(Andrew Scull, 2015) Shorter also notes that Bayle’s 1822 discovery of neurosyphilis as an organic disease further supports the view that biological factors contributed to the asylum explosion.(Shorter, 1997)

Social-constructionist accounts — associated with Thomas Szasz, R.D. Laing, and a range of revisionist historians — hold that mental illness is a social category rather than a genuine disease, and that asylum psychiatry was primarily a mechanism for controlling deviance. Shorter’s counter-position is that neurosyphilis, alcoholic psychosis, and (less certainly) schizophrenia genuinely increased in frequency during the nineteenth century in ways that social labeling alone cannot explain.(Shorter, 1997)

Shorter’s own position is that psychiatry has always been a medical enterprise aimed at genuine biological illness, repeatedly impeded by insufficient knowledge and inadequate tools. Porter occupies a more agnostic middle position, framing psychiatry’s history as permanently “hostage to the mind-body problem, buffeted back and forth between psychological and physical definitions of its object and its techniques,” without endorsing either extreme.(Porter, 1997)

The “unchaining” narrative deserves specific attention as a mythologized reforming story. Both Porter and Shorter note that the image of Pinel dramatically striking chains from the mad belongs to legend rather than documented history.(Porter, 1997)

Deinstitutionalization

Chlorpromazine, synthesized by Rhône-Poulenc and first used psychiatrically in Paris in 1952, changed what was pharmacologically possible in the management of serious mental illness.(Shorter, 1997) Heinz Lehmann’s 1953 trials at Montreal’s Verdun Hospital showed that acute schizophrenic patients became symptom-free within weeks — a remission from schizophrenia in weeks — something without precedent.(Shorter, 1997) Psychopharmacology restored therapeutic optimism and accelerated deinstitutionalization by promising “a relatively safe, cost-effective method of alleviating mental suffering without recourse to lengthy hospital stays, psychoanalysis or irreversible surgery.”(Porter, 1997)

The political rhetoric of deinstitutionalization was stated plainly by Britain’s Minister of Health Enoch Powell in his 1961 “Water Tower” speech to the National Association for Mental Health. The great Victorian asylums were “doomed institutions,” Powell announced; he called for their elimination and set a target, to be achieved within fifteen years, of halving the numbers of patients confined in them.(Andrew Scull, 2015)

Scull argues that deinstitutionalization began before chlorpromazine was broadly distributed.(Andrew Scull, 2015) He notes that it “proceeded far more rapidly in some states than others for reasons that had nothing to do with the new medications.”(Andrew Scull, 2015) The primary motor, in his account, was fiscal: the 1965 introduction of Medicare and Medicaid in the United States created powerful incentives to transfer mental patients out of state hospitals, where costs had to be borne by individual states, into nursing homes and community facilities where federal money could be accessed.(Andrew Scull, 2015)

The mechanism of deinstitutionalization was primarily economic rather than ideological. Shorter argues that the antipsychiatry movement of the 1960s provided an intellectual climate hospitable to reducing hospital censuses, “but the main engine of deinstitutionalization was not ideology but economics.”(Shorter, 1997) State governments discovered that community placement was cheaper than hospital maintenance.

In Italy, the same period produced the only national legislative abolition of the public asylum system. Franco Basaglia, appointed director of the asylum at Gorizia in the early 1960s, began systematically dismantling traditional institutional structures. His work led to Law 180 of 1978, which prohibited new admissions to public mental hospitals and provided for their eventual closure — legislation Scull calls “a dramatic and remarkable legislative triumph.”(Andrew Scull, 2015)

The results of deinstitutionalization were uneven. Chlorpromazine’s extrapyramidal side effects — tardive dyskinesia, involuntary grimacing and movements — caused many discharged patients to stop taking medication to avoid them, producing revolving-door patterns of discharge and readmission.(Shorter, 1997) Scull’s account of the outcome for chronic patients is direct: “A substantial fraction of those who left the back wards — the chronic schizophrenics, manic-depressives and demented elderly who constituted the bulk of long-stay patients — ended up not in comfortable community facilities but homeless, wandering the streets of American cities, or cycling in and out of emergency rooms and jails. Prisons became the new asylums, and the seriously mentally ill were again deprived of liberty, this time in penal institutions with no therapeutic aspirations whatsoever.”(Andrew Scull, 2015)

[HUMAN NOTE]: None yet.

Sources

Shorter, Edward. A History of Psychiatry: From the Era of the Asylum to the Age of Prozac. New York: John Wiley, 1997. — Primary source. Chapters 2, 3, 4, 7, 8.
Porter, Roy. The Greatest Benefit to Mankind. London: HarperCollins, 1997. Chapter 16 (Psychiatry).
Ackerknecht, Erwin H. A Short History of Medicine. New York: Ronald Press, 1955. Chapter 18 (Kraepelin and psychiatric classification).
Scull, Andrew. Madness in Civilization: A Cultural History of Insanity. Princeton: Princeton University Press, 2015. Chapters 1, 3, 5, 7, 8, 9, 10, 12.

Summary

Origins: Pre-Asylum Confinement

The Trade in Lunacy and Coercive Treatment

Moral Treatment and the Reform Era

The Great Age of the Asylum, 1850–1950

Desperate Remedies

Historiographical Debates

Deinstitutionalization

See Also

Sources

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