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The General Superintendence of All Their Departments
In the United States, psychiatry was fortified not by a psychiatrist or the Association of Medical Superintendents of American Institutions for the Insane (AMSAII), but by an indefatigable former schoolteacher who traversed the eastern seaboard promoting the mental asylum. Insofar as the asylum ensured a place of prominence for psychiatrists in the management of madness, it is to Dorothea Dix that they owe a debt of gratitude. Dix did not invent the asylum. The model that underwrote her efforts, she got secondhand. But more than anyone else, she was responsible for the American system of publicly funded asylums. The institutions that she fought for would become strongholds of psychiatric authority and refuges to which psychiatrists could retreat during periods of crisis.
Dix's childhood was marred by sorrow and neglect. Her father was an abusive alcoholic. Her mother was likely mentally ill herself. Dix was forced to endure the wrath and fallouts of their troubles, essentially burdened with the responsibility of raising her younger brothers. The precariousness of her youth left a lasting mark; Dix would suffer bouts of anxiety and melancholy throughout her life. Still, her inner demons had their benefits; they begat a deep empathy for the insane. This empathy would propel her to become, in the words of her biographer, "the most productive woman in nineteenth century American politics." But if it was Dix's fate to become the voice of the mad, destiny had to wait.
Dix began her career as a schoolteacher, one of the few fields open to educated women of her day. She gained a measure of notoriety for her educational book for young girls, Conversations on Common Things. But her attempted move from the classroom to education reform was waylaid by a nervous collapse in 1836. Unable to work, Dix left the United States to convalesce in England at the estate of William Rathbone III, a wealthy reformer sympathetic to Dix's plight. There she encountered the ideas of English asylum reformers, specifically those of Samuel Tuke, a friend of the Rathbones and grandson of the founder of the famous York Retreat, William Tuke. The York Retreat was the model of moral treatment in the English-speaking world, and Dix "instinctively responded to the Retreat's therapeutic program." Moral treatment resonated with her Unitarian religious beliefs and paralleled with own recovery at the serene Rathbone estate. She would carry the message of moral treatment back to her home country.
Upon her return to Massachusetts in 1837, Dix found herself drawn to the plight of the insane. An inheritance from her grandmother's estate gave her financial security and freed her to pursue her reforming drive. In 1841, Dix departed on an eighteen-month tour to study the condition of the mentally ill in Massachusetts. This tour changed her life. It changed her country as well.
Compared to other states, Massachusetts was generous when it came to mental health. One of the first private hospitals for the insane, McLean Hospital, was founded in Charlestown in 1811. Two decades later, in 1833, the legislature established the state-run Worcester State Lunatic Hospital. When demand outpaced space at Worcester, in 1839, the legislature built a new hospital for the insane poor, Boston Lunatic Hospital, in the state's most populous city. Yet, despite the state's relative attentiveness to the mentally ill, Dix's tours revealed the inadequacies of the available services. Throughout the state, she witnessed abject suffering among the insane. With encouragement from friend and reformer Samuel Gridley Howe, Dix published her findings in her Memorial to the Legislature of Massachusetts in 1843.
The Memorial seethed with quiet indignation as Dix described the miserable situation of the mentally ill in Massachusetts. Claiming to only "tell what I have seen," she reported brutal tales of "the present state of Insane Persons confined within this Commonwealth, in cages, closets, cellars, stalls pens! Chained, naked, beaten with rods, and lashed into obedience." Some of her anecdotes were lengthy, with fleshy humanizing details. In Danvers, Dix discovered
... a young woman, exhibiting a condition of neglect and misery blotting out the faintest idea of comfort, and outraging every sentiment of decency. She had been, I learnt, "a respectable person"; industrious and worthy; disappointments and trials shook her mind, and finally laid prostrate reason and self-control ... She had passed from one degree of violence to another, in swift progress; there she stood clinging to, or beating upon, the bars of her caged apartment, the contracted size of which afforded space only for increasing accumulations of filth, a foul spectacle; there she stood with naked arms and disheveled hair; the unwashed frame invested with fragments of unclean garments, the air so extremely offensive, though ventilation was afforded on all sides save one, that it was not possible to remain beyond a few moments without retreating for recovery to the outward air. Irritation of body, produced by utter filth and exposure, incited her to the horrid process of tearing off her skin by inches; her face, neck and person, were thus disfigured to hideousness....
Other anecdotes drew their power from their jarring succinctness. In Lincoln, Dix found "a woman in a cage." In Medford, she encountered "one idiotic subject chained, and one in a close stall for 17 years," and in Bridgewater, "three idiots; never removed from one room." The Memorial linked quaint Massachusetts towns — Springfield, Northampton, Brookfield, Granville, Plymouth, Scituate — to stories of misery and suffering. In the process, Dix exposed the collective guilt of the state. When accumulated, these stories painted an overwhelmingly bleak picture of "human beings, reduced to the extremest states of degradation and misery." Such wretchedness was rendered all the more stark when juxtaposed with the figure of demure femininity that Dix struck. To exhort the legislature to act, she joined a moral appeal to their Christian humanity with an economic argument — it would be cheaper to humanely cure the insane than to house them in indefinite squalor — that spoke to legislators' more pragmatic instincts.
The response to Dix's Memorial was electric. Although some towns refuted her claims, the public firestorm she ignited forced the state legislature to act. And while the victory in Massachusetts was a modest additional $25,000 of funding for the mentally ill, it crystallized Dix's passion. She extended her investigations into New York, then New Jersey and Pennsylvania, before departing on a tour of the South. The southern tour was capped by a trip to Washington, DC, to convince the federal government to grant land for the treatment of the insane, a plan that was eventually vetoed by President Franklin Pierce. Wherever she went, Dix followed a similar course. She toured the state, recorded her observations of the woeful treatment of the insane, composed a memorial to the state legislature, and lobbied the legislature unrelentingly. In the end, she was responsible for founding, or enlarging, over thirty mental hospitals in the United States and abroad. Her work ended in a poetic manner rarely afforded by life's vicissitudes; she died as a guest in the New Jersey State Lunatic Hospital — an institution that she not only founded but designed, an institution that she called her firstborn child.
Despite her herculean efforts, Dix always had a complicated relationship with the very psychiatric superintendents whose interests she was advocating. For her part, Dix maintained a deep admiration of superintendents. She absorbed their reports, spread their understanding of mental distress, and translated their ideas into concrete policies. Her memorials articulated their concerns. In them, she parroted superintendents' inflated claims about the curability of the insane, for example writing to the Illinois state legislature:
Insanity is no longer regarded as the extinction of the mind; a disease hopeless and incurable; but proceeding from the physical causes, which disable the brain for a time from the correct exercise of those functions through which the mind is represented: And this malady is subject to successful physical treatment, as surely as a fever, or other common bodily disease.
Dix's unwavering (some might say naïve) support, however, was rewarded with indifference from superintendents. Despite the outsized role she played in establishing the institutional infrastructure for their profession, psychiatrists dedicated scant attention to Dix in their flagship journal, the American Journal of Insanity (AJI). When they did mention her, it was mostly to express misgivings about her tactics. They worried that she conflated asylums and prisons in her lobbying efforts and thereby tainted superintendents by associating them with prisoners and unscrupulous wardens. Such complaints were colored by prevailing gender ideologies and patriarchal dismissiveness; superintendents chafed at the fact that the most prominent voice for their profession was not just an outsider, but a woman.
Superintendents' wariness toward Dix reflected their concern that she was saddling them with unrealistic expectations. Dix won support for asylums through a hard sell that promised sweeping cures at low costs. This put superintendents on notice, and many of them pinned the responsibility for these unrealistic expectations on her. But this was unfair. After all, Dix, who had "no feel for numbers," reiterated the inflated curability rates, often upward of 90%, that superintendents themselves published. Dix might have been a convenient scapegoat when the stark realities of the asylums contradicted the optimistic hype used to justify their existence, but superintendents had no one to blame but themselves. They were the ones who published the misleading statistics that fostered an impression of success when there was little.
For a profession that would become so steeped in ignorance, psychiatry was reared in the warm glow of certainty. Superintendents created great expectations that they would cure insanity. These expectations would end in disappointment, but not before a new profession was born.
This chapter covers the asylum era of American psychiatry, from the establishment of the profession in the 1840s to its first crisis at the turn of the twentieth century. No other period of American psychiatry has received as much scholarly attention. And perhaps no other period has elicited as much controversy. For some, the asylum, with its grand facades, serene grounds, rich programming, and benevolent care, marked a period of all-too-rare kindness in the history of psychiatry. Freed of the fetters of religious strictures, psychiatry loosened the fetters binding the insane and embraced a gentler approach to treatment, the effect of which, while never obtaining the hype, was positive nonetheless. Other scholars counter that the asylum is better characterized as a technique of social control par excellence; moral treatment replaced ineffectual external constraints with a more effective and insidious form of control that operated on the soul. Through "great confinement" of the insane in asylums, psychiatrists "domesticated" madness, transforming nonconforming deviants into docile, tractable, and even productive members of society.
Despite the controversy regarding the essential character of the asylum, consensus has emerged as to the details of its history, including the factors leading to its establishment, the philosophical foundations of its operation, and the causes of its decline. Building on this consensus, this chapter recounts the birth of psychiatric ignorance as a professional problem, thus establishing the dynamics for the subsequent politics of psychiatry, dynamics that endure to this day. Superintendents built their profession upon a foundation of deep certitude. Confident in the asylum and moral treatment, they made grand promises to state legislators, raising expectations that they could cure insanity and do so affordably. On the basis of these promises, they generated support and mobilized resources from legislatures to build up a network of asylums over which they maintained unencumbered authority. For a time, superintendents' inflated statistics of cure rates obscured their ignorance and masked the daily difficulties they encountered. However, the exposure of these statistics as fraudulent revealed the superintendents' promises as empty. Accused of bad faith and, worse, ignorance, psychiatrists succumbed to crisis when finally forced to confront all that they did not know.
The asylum era may have yielded psychiatry's first crisis, but it would not be its last. Its hype/disappointment trajectory would become the cyclical template that all subsequent reinventions would play out. To this fraught future, the asylum left two legacies that would shape psychiatry for the next century. The failure of the asylum raised the specter of ignorance with which psychiatrists still struggle and for which reinvention would become the solution. But it also created its organizational foundation and infrastructure from which subsequent generations of reformers launched their reinventions. The network of asylums that dotted the countryside became fortresses of psychiatric authority that, for a century, helped psychiatrists weather ignorance's assaults. Psychiatry can thank the asylum system for both its existence and the existential crisis that it is still negotiating.
The Rise of the Asylum
That Dix was the catalyst for the expansion of the asylum system in the United States was an anomaly only in the fact of her gender. Her nonmedical background would not have struck contemporaries as strange. Indeed, the initial momentum for the asylums was driven primarily by lay reformers.
Asylum reforms were part of a larger response to the bewildering social changes of the early 1800s and the problems that followed in their wake. During the Jacksonian period, Americans experienced profound upheaval resulting from population growth, urbanization, capitalism, industrialization, and democratization. The effects of these disruptions on the problems posed by the mentally ill were manifold. Madness, long interpreted through a religious lens, came to be viewed as an unfortunate side effect of modernization, or "part of the compensation for our progress and refinement," as the famous neurologist George Miller Beard put it. The frenzied pace of social change produced what the astute American observer Alexis de Tocqueville described as a kind of mental agitation. Urbanization and revolutions in transportation increased mobility and social dislocation that exacerbated this agitation. As people migrated from isolated communities to the city, they came into more regular contact with strangers. The increased anonymity made daily interactions more fraught, uncertain, and possibly treacherous. Disruptions caused by the insane threatened an already fragile social cohesion. Modernization, it seemed, produced more madness, while eroding the communal bonds that traditionally handled the problems of the insane.
In response to these changes, reformers began to lobby state legislatures to take control of madness. Early reformers were inspired by an activist model of religious life, born of the Second Great Awakening that emphasized good works. The philosophy undergirding the asylum — moral treatment — resonated with these beliefs. More than isolated buildings with walls to contain, the modern asylum's true innovation lay in its humane, psychosocial approach to treating mental illness. This approach eschewed the use of force and violent "heroic" medical therapies for a calming therapeutic milieu and a retreat-like atmosphere. The new institutions would not just confine the insane; they would cure them by means that resonated with reformers' Christianity.
Moral treatment was not an American creation. Instead, two international figures provided much of the inspiration for the early American asylum movement. The first was William Tuke, grandfather to Samuel Tuke, under whose spell Dix had fallen. Tuke's concern for the mentally disturbed was driven by his religious convictions. The deprivation and squalor of Bethlehem Hospital (aka "Bedlam") in London offended Tuke's Quaker sensibilities. He condemned the imprisonment of the insane as well as their physicians, who performed violent, depletive treatments, like blistering and bleeding, on those with mental illness. While such treatments were consistent with medical practice of the day, they were applied with particular aggression to the mentally ill, who were perceived as uncivilized and thus less sensitive to physical pain. Marrying his Quaker beliefs with his business acumen, Tuke developed a more humane alternative, opening the York Retreat in 1796. He promised York would be a place where "neither chains nor corporeal punishment are tolerated." Here the insane were to be treated with dignity. Kindness replaced violence. The influence of the Retreat on American asylum reformers was direct. It served as the model for the Friends' Hospital in Philadelphia, founded in 1813, one of the first institutions in the United States dedicated to the treatment of the mentally ill. Tuke's gentler approach was promoted by his American adherents as an effective means of cure.(Continues…)
Excerpted from "On the Heels of Ignorance"
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Table of ContentsAcknowledgments
Chapter 1: The General Superintendence of All Their Departments
Chapter 2: Unruly Ignorance and Pragmatic Eclecticism
Chapter 3: Ignorance Repressed
Chapter 4: It Takes a Community to Raise a Profession
Chapter 5: Profession of the Book