{{Short description|Historical confinement for mentally ill people}} {{Use dmy dates|date=November 2020}} [[Image:Francisco de Goya - La casa de locos - Google Art Project.jpg|thumb|[[Social alienation]] was one of the main themes in [[Francisco Goya]]'s masterpieces, such as ''[[The Madhouse]]'' (above).|332x332px]] The '''lunatic asylum''', '''insane asylum''' or '''mental asylum''' was an institution where people with [[mental illness]] were confined. It was an early precursor of the modern [[psychiatric hospital]].
Modern psychiatric hospitals evolved from and eventually replaced the older lunatic asylum. The treatment of inmates in early lunatic asylums was sometimes brutal and focused on containment and restraint.<ref name="Life Magazine">{{Cite web |title=Life Magazine |url=http://www.mnddc.org/parallels2/prologue/6a-bedlam/6a-bedlam.html |url-status=dead |archive-url=https://web.archive.org/web/20121130223053/http://www.mnddc.org/parallels2/prologue/6a-bedlam/6a-bedlam.html |archive-date=2012-11-30 |access-date=2011-01-18}}</ref><ref name="mnddc.org">{{Cite web |title=Life Magazine |url=http://www.mnddc.org/parallels2/prologue/6a-bedlam/bedlam-life1946.pdf |url-status=live |archive-url=https://ghostarchive.org/archive/20221009/http://www.mnddc.org/parallels2/prologue/6a-bedlam/bedlam-life1946.pdf |archive-date=9 October 2022}}</ref> The discovery of [[Antipsychotic|anti-psychotic]] drugs and [[Mood stabilizer|mood-stabilizing]] drugs resulted in a shift in focus from containment in lunatic asylums to treatment in psychiatric hospitals. Later, there was further and more thorough critique in the form of the [[Deinstitutionalisation|deinstitutionalization]] movement which focuses on treatment at home or in less isolated institutions.
Whilst it was used in the past, modern and more [[humane]] areas have been developed as opposed to the unorthodox methods of [[Social isolation|isolation]] and questionable [[Therapy|therapies]] used in lunatic (insane) asylums.
==History==
===Medieval era=== In the Islamic world, the ''[[Bimaristan]]s'' were described by European travellers, who wrote about their wonder at the care and kindness shown to lunatics. In 872, [[Ahmad ibn Tulun]] built a hospital in [[Cairo]] that provided care to the insane, which included music therapy.<ref name=Koenig>{{cite book|last=Koenig|first=Harold George|title=Faith and mental health: religious resources for healing|year=2005|publisher=Templeton Foundation Press|isbn=978-1-932031-91-1}}</ref> Nonetheless, British historian of medicine [[Roy Porter]] cautioned against idealising the role of hospitals generally in medieval Islam, stating that "They were a drop in the ocean for the vast population that they had to serve, and their true function lay in highlighting ideals of compassion and bringing together the activities of the medical profession."<ref name="GreatestBenefit">{{cite book|last=Porter|first=Roy|year=1997|title=The Greatest Benefit to Mankind: A Medical History of Humanity from Antiquity to the Present|publisher=Fontana Press|location=London|isbn=978-0006374541}}</ref>{{rp|105}}
In Europe during the medieval era, a small subsection of the population of those considered mad were housed in a variety of institutional settings. Mentally ill people were often held captive in cages or kept up within the city walls, or they were compelled to amuse members of courtly society.<ref>{{Cite journal |last=Tillack-Graf |first=Anne-Kathleen |date=2015 |title=Book Review: Thomas R. Müller, Wahn und Sinn. Patienten, Ärzte, Personal und Institutionen der Psychiatrie in Sachsen vom Mittelalter bis zum Ende des 20. Jahrhunderts |url=http://journals.sagepub.com/doi/10.1177/0957154X15605782d |journal=History of Psychiatry |language=en |volume=26 |issue=4 |pages=498–499 |doi=10.1177/0957154X15605782d |s2cid=20151680 |issn=0957-154X|url-access=subscription }}</ref> Porter gives examples of such locales where some of the insane were cared for, such as in monasteries. A few towns had towers where madmen were kept (called ''[[Narrenturm (hospital)|Narrentürme]]'' in German, or "fools' towers").{{Citation needed|reason=Unclear which towns; what is the source of this information? Does it simply refer to the one Narrenturm in Vienna?|date=February 2017}} The ancient Parisian hospital [[Hôtel-Dieu de Paris|''Hôtel-Dieu'']] also had a small number of cells set aside for lunatics, whilst the town of [[Elbing]] boasted a madhouse, the ''[[wiktionary:Tollhaus|Tollhaus]],'' attached to the Teutonic Knights' hospital.<ref>Gary D. Albrecht, Katherine D. Seelman, Michael Bury: ''Handbook of Disability Studies,'' p.20 [https://books.google.com/books?id=vAKSZPR-hk0C&pg=PA20&q=granada]</ref> Dave Sheppard's ''Development of Mental Health Law and Practice'' begins in 1285 with a case that linked "the instigation of the devil" with being "frantic and mad".<ref name="studymore.org.uk">{{cite web|url=http://studymore.org.uk/mhhtim.htm |title=Mental Health History Timeline |publisher=Studymore.org.uk |access-date=2014-04-15}}</ref>
In Spain, other such institutions for the insane were established after the Christian [[Reconquista]]; facilities included hospitals in [[Valencia]] (1407), [[Zaragoza]] (1425), [[Seville]] (1436), [[Barcelona]] (1481) and [[Toledo, Spain|Toledo]] (1483).<ref name="GreatestBenefit"/>{{rp|127}} In [[London]], England, the [[Bethlem Royal Hospital|Priory of Saint Mary of Bethlehem]], which later became known more notoriously as [[Bethlem Royal Hospital|Bedlam]], was founded in 1247. At the start of the 15th{{nbs}}century, it housed six insane men.<ref name="GreatestBenefit"/>{{rp|127}} The former lunatic asylum, [[Het Dolhuys]], established in the 16th{{nbs}}century in [[Haarlem|Haarlem, the Netherlands]], has been adapted as a museum of psychiatry, with an overview of treatments from the origins of the building up to the 1990s.
===Emergence of public lunatic asylums=== [[File:Plan of the first Bethlem Hospital.png|thumb|Plan of the [[Bethlem Royal Hospital]], an early public asylum for the mentally ill|alt=A map of the original Bethlem Hospital site]]
The level of specialist institutional provision for the care and control of the insane remained extremely limited at the turn of the 18th{{nbs}}century. Madness was seen principally as a domestic problem, with families and parish authorities in Europe and England central to regimens of care.<ref name="PorterMadmen"/>{{rp|154}}<ref name="Suzuki1991Part1">{{Cite journal| volume = 2| issue = 8| pages = 437–56| last = Suzuki| first = Akihito| title = Lunacy, in Seventeenth- and Eighteenth-Century England: Analysis of Quarter Sessions Records Part I| journal = History of Psychiatry| year = 1991| doi=10.1177/0957154X9100200807| pmid=11612606| s2cid = 2250614}}</ref>{{rp|439}} Various forms of outdoor relief were extended by the parish authorities to families in these circumstances, including financial support, the provision of parish nurses and, where family care was not possible, lunatics might be 'boarded out' to other members of the local community or committed to private madhouses.<ref name="Suzuki1991Part1"/>{{rp|452–56}}<ref name=AndrewsRise>{{Cite book|first=Jonathan|last=Andrews|chapter=The Rise of the Asylum|publisher=The Open University|isbn=978-0719067358|location=Manchester|year=2004|title=Medicine Transformed: Health, Disease & Society in Europe, 1800–1930 |editor=Deborah Brunton|pages=298–330}}</ref>{{rp|299}} Exceptionally, if those deemed mad were judged to be particularly disturbing or violent, parish authorities might meet the considerable costs of their confinement in charitable asylums such as [[Bethlem Royal Hospital|Bethlem]], in Houses of Correction or in workhouses.<ref name="Suzuki1991Part2">{{Cite journal| volume = 3| issue = 8| pages = 29–44| last = Suzuki| first = Akihito| title = Lunacy, in Seventeenth- and Eighteenth-Century England: Analysis of Quarter Sessions Records Part II| journal = History of Psychiatry| year = 1992| doi=10.1177/0957154x9200300903| pmid=11612665| s2cid = 28734153}}</ref>{{rp|30, 31–35, 39–43}}
In the late 17th{{nbs}}century, this model began to change, and privately run asylums for the insane began to proliferate and expand in size. Already in 1632 it was recorded that [[Bethlem Royal Hospital]], London had "below stairs a parlor, a kitchen, two larders, a long entry throughout the house, and 21 rooms wherein the poor distracted people lie, and above the stairs eight rooms more for servants and the poor to lie in".<ref>{{cite book|author=Allderidge, Patricia |chapter=Management and Mismanagement at Bedlam, 1547–1633|editor=Webster, Charles|title=Health, Medicine and Mortality in the Sixteenth Century|year=1979|location=Cambridge|publisher=Cambridge University Press|page=145|isbn=9780521226431|chapter-url=https://books.google.com/books?id=g588AAAAIAAJ&pg=PA141}}</ref> Inmates who were deemed dangerous or disturbing were chained, but Bethlem was an otherwise open building. Its inhabitants could roam around its confines and possibly throughout the general neighborhood in which the hospital was situated.<ref>{{cite book|author=Stevenson, Christine |chapter=The Architecture of Bethlem at Moorfields |author2=Jonathan Andrews |author3=Asa Briggs |author4=Roy Porter |author5=Penny Tucker |author6=Keir Waddington|title=History of Bethlem|year=1997|publisher=Routledge|location=London & New York|isbn=978-0415017732|chapter-url=https://books.google.com/books?id=NdIypYX6KIwC|page=51}}</ref> In 1676, Bethlem expanded into newly built premises at [[Moorfields]] with a capacity for 100 inmates.<ref name="PorterMadmen">{{Cite book| edition = Ill. ed. [originally published 1987]| publisher = Tempus| isbn = 9780752437309| last = Porter| first = Roy| title = Madmen: A Social History of Madhouses, Mad-Doctors & Lunatics| location = Stroud| year = 2006}}</ref>{{rp|155}}<ref name="Bethel">{{Cite journal| volume = 38| issue = 1| pages = 27–51| last = Winston| first = Mark| title = The Bethel at Norwich: An Eighteenth-Century Hospital for Lunatics| journal = Medical History| year = 1994| doi=10.1017/s0025727300056039| pmid = 8145607| pmc = 1036809}}</ref>{{rp|27}}
[[File:Eastern state hospital 1.jpg|thumb|left|[[Eastern State Hospital (Virginia)|Eastern State Hospital]] was the first psychiatric institution to be founded in the United States.]] A second public charitable institution was opened in 1713. Known as the Bethel in [[Norwich]], it was a small facility which generally housed between twenty and thirty inmates.<ref name="PorterMadmen"/>{{rp|166}} In 1728 at [[Guy's Hospital]], London, wards were established for chronic lunatics.<ref name="ParryJones"/>{{rp|11}} From the mid-eighteenth century the number of public charitably funded asylums expanded moderately with the opening of [[St Luke's Hospital for Lunatics|St Luke's Hospital]] in 1751 in Upper Moorfields, London; the establishment in 1765 of the Hospital for Lunatics at [[Newcastle upon Tyne]]; the Manchester Lunatic Hospital, which opened in 1766; the [[York]] Asylum in 1777 (not to be confused with the [[York Retreat]]); the [[Leicester]] Lunatic Asylum (1794), and the [[Liverpool]] Lunatic Asylum (1797).<ref name="Bethel"/>{{rp|27}}
A similar expansion took place in the British American colonies. The [[Pennsylvania Hospital]] was founded in [[Philadelphia]] in 1751 as a result of work begun in 1709 by the [[Religious Society of Friends]]. A portion of this hospital was set apart for the mentally ill, and the first patients were admitted in 1752.<ref name=ea>{{Cite Americana|wstitle=Insane, Institutional Care of the, in the United States|author=[[William Alanson White|William A. White]]}}</ref> [[Virginia]] is recognized as the first state to establish an institution for the mentally ill.<ref name="NYT1900">{{cite news|url=https://query.nytimes.com/gst/abstract.html?res=9F00E1D6163FE433A25755C1A9619C946197D6CF|title=THE FIRST INSANE ASYLUM.; To Virginia Belongs the Credit in This Country.|date=16 July 1900|newspaper=The New York Times|access-date=2009-11-01}}</ref> [[Eastern State Hospital (Virginia)|Eastern State Hospital]], located in [[Williamsburg, Virginia]], was incorporated in 1768 under the name of the "Public Hospital for Persons of Insane and Disordered Minds" and its first patients were admitted in 1773.<ref name=ea/><ref name=ce>{{CathEncy|wstitle=Asylums and Care for the Insane|author=[[James Joseph Walsh|James J. Walsh]]}}</ref> {{anchor|Trade in lunacy}}
====Trade in lunacy==== There was no centralised state response to “madness” in society in century Britain until the 19th{{nbs}}century, however private madhouses proliferated there in the 18th{{nbs}}century on a scale unseen elsewhere.<ref name="PorterMadmen"/>{{rp|174}} References to such institutions are limited for the 17th{{nbs}}century but it is evident that by the start of the 18th{{nbs}}century, the so-called 'trade in lunacy' was well established.<ref name="ParryJones">{{cite book|last=Parry-Jones|first=William Ll.|title=The Trade in Lunacy: A Study of Private Madhouses in England in the Eighteenth and Nineteenth Centuries|url=https://archive.org/details/tradeinlunacystu0000parr|url-access=registration|location=London|publisher=Routledge|year=1972|isbn=9780710070517}}</ref>{{rp|8–9}} [[Daniel Defoe]], an ardent critic of private madhouses,<ref name="NollEncyclopedia">{{cite book|last=Noll|first=Richard|title=The Encyclopedia of Schizophrenia and Other Psychotic Disorders|edition=3rd|year=2007|publisher=Facts on File|location=New York|isbn=978-0816064052|url-access=registration|url=https://archive.org/details/isbn_9780816064052}}</ref>{{rp|118}} estimated in 1724 that there were fifteen then operating in the London area.<ref name="MacKenzie">{{cite book | title=Psychiatry for the Rich: A History of Ticehurst Private Asylum | publisher=Routledge | author=MacKenzie, Charlotte | year=1992 | location=London | isbn=978-0415088916}}</ref>{{rp|9}} Defoe may have exaggerated but exact figures for private metropolitan madhouses are available only from 1774, when [[Madhouses Act 1774|licensing legislation]] was introduced: sixteen institutions were recorded.<ref name="MacKenzie"/>{{rp|9–10}} At least two of these, [[Hoxton#Almshouses and madhouses|Hoxton House]] and Wood's Close, [[Clerkenwell]], had been in operation since the 17th{{nbs}}century.<ref name="MacKenzie"/>{{rp|10}} By 1807, the number had increased to seventeen.<ref name="MacKenzie"/>{{rp|9}} This limited growth in the number of London madhouses is believed likely to reflect the fact that vested interests, especially the [[Royal College of Physicians|College of Physicians]], exercised considerable control in preventing new entrants to the market.<ref name="MacKenzie"/>{{rp|10–11}} Thus, rather than there being a proliferation of private madhouses in London, existing institutions tended to expand considerably in size.<ref name="MacKenzie"/>{{rp|10}} The establishments which increased most during the 18th{{nbs}}century, such as Hoxton House, did so by accepting [[pauperism|pauper]] patients rather than private, middle class, fee-paying patients.<ref name="MacKenzie"/>{{rp|11}} Significantly, pauper patients, unlike their private counterparts, were not subject to inspection under the [[Madhouses Act 1774|1774 legislation]].<ref name="MacKenzie"/>{{rp|11}}
Fragmentary evidence indicates that some provincial madhouses existed in Britain from at least the 17th{{nbs}}century and possibly earlier.<ref name="PorterMadmen"/>{{rp|175}}<ref name="ParryJones"/>{{rp|8}} A madhouse at [[Kingsdown, Box|Kingsdown]], Box, Wiltshire was opened during the 17th{{nbs}}century.<ref name="PorterMadmen"/>{{rp|176}}<ref name="MacKenzie"/>{{rp|11}} Further locales of early businesses include one at [[Guildford]] in Surrey which was accepting patients by 1700, one at [[Fonthill Gifford]] in Wiltshire from 1718, another at [[Hook Norton]] in Oxfordshire from about 1725, one at [[St Albans]] dating from around 1740, and a madhouse at [[Fishponds]] in Bristol from 1766.<ref name="PorterMadmen"/>{{rp|176}}<ref name="MacKenzie"/>{{rp|11}} It is likely that many of these provincial madhouses, as was the case with the exclusive [[Ticehurst House Hospital|Ticehurst House]], may have evolved from householders who were boarding lunatics on behalf of parochial authorities and later formalised this practice into a business venture.<ref name="PorterMadmen"/>{{rp|176}} The vast majority were small in scale with only seven asylums outside London with in excess of thirty patients by 1800 and somewhere between ten and twenty institutions had fewer patients than this.<ref name="PorterMadmen"/>{{rp|178}}
===Humanitarian reform=== {{Main|Moral treatment}} [[File:Philippe Pinel à la Salpêtrière .jpg|thumb|Dr. Philippe Pinel at the [[Salpêtrière]], 1795 by [[Tony Robert-Fleury]]. Pinel ordering the removal of chains from patients at the Paris asylum for insane women.]] [[File:The Joint Counties' Lunatic Asylum, Erected at Abergavenny.jpeg|thumb|The joint counties' lunatic asylum, erected at [[Abergavenny]], 1850]]
During the [[Age of Enlightenment]], attitudes began to change, in particular among the educated classes in Western Europe. “Mental illness” came to be viewed as a disorder that required some form of compassionate but clinical, “rational” treatment that would aid in the rehabilitation of the patient into a rational being. When the ruling monarch of the United Kingdom, [[George III of the United Kingdom|George III]], who had a mental disorder, experienced a [[remission (medicine)|remission]] in 1789, mental illness came to be seen as something which could be treated and cured. The introduction of moral treatment was initiated independently by the French doctor [[Philippe Pinel]] and the English [[Quaker]] [[William Tuke]].<ref name=Elkes13>Elkes, A. & Thorpe, J.G. (1967). ''A Summary of Psychiatry''. London: Faber & Faber, p. 13.</ref>
In 1792, Pinel became the chief physician at the [[Bicêtre Hospital]] in [[Le Kremlin-Bicêtre]], near Paris. Before his arrival, inmates were chained in cramped cell-like rooms where there was poor ventilation, led by a man named Jackson 'Brutis' Taylor. Taylor was then killed by the inmates leading to Pinel's leadership. In 1797, Jean-Baptiste Pussin, the "governor" of mental patients at Bicêtre, first freed patients of their chains and banned physical punishment, although straitjackets could be used instead.<ref>{{cite journal |author=Weiner DB |title=The apprenticeship of Philippe Pinel: a new document, "observations of Citizen Pussin on the insane" |journal=Am J Psychiatry |volume=136 |issue=9 |pages=1128–34 |date=September 1979 |pmid=382874 |doi=10.1176/ajp.136.9.1128}}</ref><ref name="bukelic">{{cite book|last=Bukelic |first=Jovan|title=Neuropsihijatrija za III razred medicinske skole|editor=Mirjana Jovanovic|publisher=Zavod za udzbenike i nastavna sredstva|location=Belgrade |year=1995|edition=7th|page=7|chapter=2|isbn=978-86-17-03418-2|language=sr}}</ref> Patients were allowed to move freely about the hospital grounds, and eventually dark dungeons were replaced with sunny, well-ventilated rooms. Pinel argued that mental illness was the result of excessive exposure to social and [[psychological trauma|psychological stresses]], to [[heredity]] and physiological damage.{{cn|date=August 2022}}
Pussin and Pinel's approach was seen as remarkably successful, and they later brought similar reforms to a mental hospital in Paris for female patients, [[Pitié-Salpêtrière Hospital|La Salpetrière]]. Pinel's student and successor, [[Jean Esquirol]], went on to help establish 10 new mental hospitals that operated on the same principles. There was an emphasis on the selection and supervision of attendants in order to establish a suitable setting to facilitate psychological work, and particularly on the employment of ex-patients as they were thought most likely to refrain from inhumane treatment while being able to stand up to patients' pleas, menaces, or complaints.<ref>{{cite journal |author=Gerard DL |title=Chiarugi and Pinel considered: Soul's brain/person's mind |journal=J Hist Behav Sci |volume=33 |issue=4 |pages=381–403 |year=1998 |url=http://www3.interscience.wiley.com/journal/45798/abstract |doi=10.1002/(SICI)1520-6696(199723)33:4<381::AID-JHBS3>3.0.CO;2-S|url-access=subscription }}{{dead link|date=February 2019|bot=medic}}{{cbignore|bot=medic}}</ref>
[[File:RetreatOriginalBuildingssm.jpg|thumb|left|The [[York Retreat]] ({{Circa|1796}}) was built by [[William Tuke]], a pioneer of moral treatment for the insane.]] [[William Tuke]] led the development of a radical new type of institution in [[Northern England]], following the death of a fellow Quaker in a local asylum in 1790.<ref name="Cherry">{{citation|last=Cherry|first=Charles L.|title=A Quiet Haven: Quakers, Moral Treatment, and Asylum Reform|location=London & Toronto|publisher=Associated University Presses|year=1989}}</ref>{{rp|84–85|}}<ref name="Digby">{{citation|last=Digby|first=Anne|title=Madness, Morality and Medicine: A Study of the York Retreat|location=Cambridge|publisher=Cambridge University Press|year=1983}}</ref>{{rp|30}}<ref name="Glover">{{citation|last=Glover|first=Mary R.|title=The Retreat, York: An Early Experiment in the Treatment of Mental Illness|location=York|publisher=Ebor Press|year=1984}}</ref> In 1796, with the help of fellow Quakers and others, he founded the [[York Retreat]], where eventually about 30 patients lived as part of a small community in a quiet country house and engaged in a combination of rest, talk, and manual work. Rejecting medical theories and techniques, the efforts of the York Retreat centred around minimising restraints and cultivating rationality and moral strength.
The entire Tuke family became known as founders of moral treatment.<ref>{{cite journal |last=Borthwick |first=Annie |author2=Holman, Chris |author3=Kennard, David |author4=McFetridge, Mark |author5= Messruther, Karen |author6=Wilkes, Jenny |title=The relevance of moral treatment to contemporary mental health care |journal=Journal of Mental Health |volume=10 |issue=4 |pages=427–439 |year=2001 |doi=10.1080/09638230124277|s2cid=218906106 }}</ref> They created a family-style ethos, and patients performed chores to give them a sense of contribution. There was a daily routine of both work and leisure time. If patients behaved well, they were rewarded; if they behaved poorly, there was some minimal use of restraints or instilling of fear. The patients were told that treatment depended on their conduct. In this sense, the patient's moral autonomy was recognised. William Tuke's grandson, [[Samuel Tuke (reformer)|Samuel Tuke]], published an influential work in the early 19th{{nbs}}century on the methods of the retreat; Pinel's ''Treatise on Insanity'' had by then been published, and Samuel Tuke translated his term as "moral treatment". Tuke's Retreat became a model throughout the world for humane and moral treatment of patients with mental disorders.<ref name=Borthwick>{{cite journal|author1=Borthwick A. |author2=Holman C. |author3=Kennard D. |author4=McFetridge M. |author5=Messruther K. |author6=Wilkes J. |year=2001|title=The relevance of moral treatment to contemporary mental health care|journal=Journal of Mental Health|volume=10|issue=4|pages=427–439|doi=10.1080/09638230124277|s2cid=218906106 }}</ref>
The York Retreat inspired similar institutions in the United States, most notably the [[Brattleboro Retreat]] and the Hartford Retreat (now [[the Institute of Living]]). [[Benjamin Rush]] of [[Philadelphia]] also promoted humane treatment of the insane outside dungeons and without iron restraints, as well as sought their reintegration into society. In 1792, Rush successfully campaigned for a separate ward for the insane at the Pennsylvania Hospital. His talk-based approach could be considered as a rudimentary form of modern occupational therapy, although most of his physical approaches have long been discredited, such as bleeding and purging, hot and cold baths, mercury pills, a "tranquilizing chair" and gyroscope.
A similar reform was carried out in Italy by [[Vincenzo Chiarugi]], who discontinued the use of chains on the inmates in the early 19th{{nbs}}century. In the town of [[Interlaken]], [[Johann Jakob Guggenbühl]] started a retreat for mentally disabled children in 1841.<ref>{{cite web|last1=Müller|first1=Christian|title=Guggenbühl, Johann Jakob|url=http://www.hls-dhs-dss.ch/textes/d/D14393.php|website=www.hls-dhs-dss.ch|access-date=23 June 2016|ref=Historical Dictionary of Switzerland|language=de}}</ref>
====Institutionalisation==== [[File:Anthony Ashley-Cooper, 7th Earl of Shaftesbury by John Collier.jpg|thumb|[[Anthony Ashley-Cooper, 7th Earl of Shaftesbury]], a vigorous campaigner for the reform of lunacy law in England, and the Head of the [[Lunacy Commission]] for 40 years]] The modern era of institutionalized provision for the care of the mentally ill, began in the early 19th{{nbs}}century with a large state-led effort. Public mental asylums were established in Britain after the passing of the [[County Asylums Act 1808|1808 County Asylums Act]].<ref>{{cite web|last1=Roberts|first1=Andrew|title=Mental Health History Timeline;1808|url=http://studymore.org.uk/mhhtim.htm|website=studymore.org.uk|access-date=24 June 2016}}</ref> This empowered [[magistrate]]s to build rate-supported asylums in every [[county]] to house the many 'pauper lunatics'. Nine counties first applied, and the first public asylum opened in 1811 in [[Nottinghamshire]].<ref>{{cite web|last1=Roberts|first1=Andrew|title=Mental Health History Timeline;1811|url=http://studymore.org.uk/mhhtim.htm#1811|website=studymore.org.uk|access-date=24 June 2016}}</ref> [[Parliamentary Committee]]s were established to investigate abuses at private madhouses like [[Bethlem Hospital]] – its officers were eventually dismissed and national attention was focused on the routine use of bars, chains and handcuffs and the filthy conditions the inmates lived in.<ref>{{cite web|last1=Roberts|first1=Andrew|title=Index of Lunatic Asylums and Mental Hospitals;1815|url=http://studymore.org.uk/4_13_ta.htm#Bethlem|website=studymore.org.uk|access-date=24 June 2016}}</ref> However, it was not until 1828 that the newly appointed [[Commissioners in Lunacy]] were empowered to license and supervise private asylums.<ref>{{cite web|last1=Roberts|first1=Andrew|title=The Lunacy Commission, A Study of its Origin, Emergence and Character;Chap.3.1.1|url=http://studymore.org.uk/1.htm#1.2.3|website=studymore.org.uk|access-date=24 June 2016}}</ref>
The [[Lunacy Act 1845]] was an important landmark in the treatment of the mentally ill, as it explicitly changed the status of [[mental illness|mentally ill]] people to [[patients]] who required treatment. The Act created the [[Lunacy Commission]], headed by [[Anthony Ashley-Cooper, 7th Earl of Shaftesbury|Lord Shaftesbury]], to focus on lunacy legislation reform.<ref>Unsworth, Clive."Law and Lunacy in Psychiatry's 'Golden Age'", Oxford Journal of Legal Studies. Vol. 13, No. 4. (Winter, 1993), pp. 482.</ref> The commission was made up of eleven Metropolitan Commissioners who were required to carry out the provisions of the Act:<ref>{{cite web|last1=Roberts|first1=Andrew|title=The Lunacy Commission, A Study of its Origin, Emergence and Character;Chap.5.1.3|url=http://studymore.org.uk/5s.htm|website=studymore.org.uk|access-date=24 June 2016}}</ref> the compulsory construction of asylums in every county, with regular inspections on behalf of the [[Home Secretary]]. All asylums were required to have written regulations and to have a resident qualified [[physician]].<ref>{{cite web|last1=Roberts|first1=Andrew|title=The Lunacy Commission as a government department|url=http://studymore.org.uk/5_2.htm#5.2.2|website=studymore.org.uk|access-date=24 June 2016}}</ref> A national body for asylum superintendents – the ''Medico-Psychological Association'' – was established in 1866 under the Presidency of [[William A. F. Browne]], although the body appeared in an earlier form in 1841.{{sfn|Shorter|1997|p=34, 41}}
In 1838, France enacted a law to regulate both the admissions into asylums and asylum services across the country. [[Édouard Séguin]] developed a systematic approach for training individuals with mental deficiencies,<ref>King. ''A History of Psychology'' p.214. {{ISBN|9780205512133}}</ref> and, in 1839, he opened the first school for the "severely retarded". His method of treatment was based on the assumption that the "mentally deficient" did not suffer from disease.<ref>{{cite encyclopedia|url=https://www.britannica.com/EBchecked/topic/532753/Edouard-Seguin |title=Edouard Seguin (American psychiatrist) | encyclopedia= Encyclopædia Britannica |date=2013-12-06 |access-date=2014-04-15}}</ref>
In the United States, the erection of state asylums began with the first law for the creation of one in New York, passed in 1842. The [[Utica State Hospital]] was opened approximately in 1850. The creation of this hospital, as of many others, was largely the work of [[Dorothea Lynde Dix]], whose philanthropic efforts extended over many states, and in Europe as far as [[Constantinople]]. Many state hospitals in the United States were built in the 1850s and 1860s on the [[Kirkbride Plan]], an architectural style meant to have curative effect.<ref>{{cite book|last=Yanni|first=Carla|title=The Architecture of Madness: Insane Asylums in the United States|publisher=Minnesota University Press|location=Minneapolis|year=2007|url=https://books.google.com/books?id=fJOC_rSW1kgC&pg=PP1 | isbn=978-0-8166-4939-6}}</ref>
Looking into the late 19th{{nbs}}and early 20th{{nbs}}century history of the Homewood Retreat of Guelph, Ontario, and the context of commitments to asylums in North America and Great Britain, [[Cheryl Krasnick Warsh]] states that "the kin of asylum patients were, in fact, the major impetus behind commitment, but their motivations were based not so much upon greed as upon the internal dynamics of the family, and upon the economic structure of western society in the 19th and early 20th{{nbs}}centuries."<ref name=":0">{{Cite journal|last=Warsh|first=Cheryl Krasnick|date=1988|title=The First Mrs. Rochester: Wrongful Confinement, Social Redundancy, and Commitment to the Private Asylum, 1883‑1923|author-link=Cheryl Krasnick Warsh|journal=Historical Papers|language=en|volume=23|issue=1|pages=145–167|doi=10.7202/030985ar|hdl=10613/3065|hdl-access=free}}</ref>
====Women in psychiatric institutions==== Based on her study of cases from the Homewood Retreat, Cheryl Krasnick Warsh concludes that "the realities of the household in late Victorian and Edwardian middle class society rendered certain elements—socially redundant women in particular—more susceptible to institutionalization than others."<ref name=":0" />
In the 18th to the early 20th{{nbs}}century, women were sometimes institutionalised due to their opinions, their unruliness and their inability to be controlled properly by a primarily male-dominated culture.<ref>{{cite web |title=Women and Psychiatry – Hysteria, Feminism, and Psychoanalysis |url=http://www.sciencemuseum.org.uk/broughttolife/themes/menalhealthandillness/womanandpsychiatry |access-date=9 July 2016 |archive-date=7 July 2016 |archive-url=https://web.archive.org/web/20160707173010/http://www.sciencemuseum.org.uk/broughttolife/themes/menalhealthandillness/womanandpsychiatry |url-status=dead }}</ref> There were financial incentives too; before the passage of the [[Married Women's Property Act 1882]], all of a wife's assets passed automatically to her husband.
The men who were in charge of these women, either a husband, father or brother, could send these women to mental institutions, stating that they believed that these women were mentally ill because of their strong opinions. "Between the years of 1850–1900, women were placed in mental institutions for behaving in ways the male society did not agree with."<ref>{{Cite book |title=Modern persecution, or, Insane asylums unveiled as demonstrated by the report of the Investigating Committee of the Legislature of Illinois |last = Packard |first = E.P.|publisher = Investigating Committee of the Legislature of Illinois|year = 1873|location = Hartford}}</ref> These men had the last say when it came to the mental health of these women, so if they believed that these women were mentally ill, or if they simply wanted to silence the voices and opinions of these women, they could easily send them to mental institutions. This was an easy way to render them vulnerable and submissive.<ref>{{Cite book|title = Women of the Asylum: Voices from Behind the Walls, 1840–1945|last = Geller|first = Jeffrey F.|publisher = Anchor Books|year = 1994}}</ref>
An early fictional example is [[Mary Wollstonecraft]]'s posthumously published novel ''[[Maria: or, The Wrongs of Woman]]'' (1798), in which the title character is confined to an insane asylum when she becomes inconvenient to her husband. Real women's stories reached the public through court cases: [[Louisa Nottidge]] was abducted by male relatives to prevent her committing her inheritance and her life to live in a revivalist clergyman's [[intentional community]]. [[Wilkie Collins]] based his 1859 novel ''[[The Woman in White (novel)|The Woman in White]]'' on this case, dedicating it to [[Bryan Procter]], the Commissioner for Lunacy. A generation later, [[Rosina Bulwer Lytton]], daughter of the women's rights advocate [[Anna Wheeler (author)|Anna Wheeler]], was locked up by her husband [[Edward Bulwer-Lytton]] and subsequently wrote of this in ''[[A Blighted Life]]'' (1880).
In 1887, journalist [[Nellie Bly]] had herself committed to the [[Blackwell's Island Insane Asylum]] in New York City, in order to investigate conditions there. Her account was published in the ''[[New York World]]'' newspaper, and in book form as ''[[Ten Days in a Mad-House]]''.
In 1902, [[Margarethe Krupp|Margarethe von Ende]], wife of the German arms manufacturer [[Friedrich Alfred Krupp]], was consigned to an insane asylum by [[Kaiser Wilhelm II]], a family friend, when she asked him to respond to reports of her husband's gay orgies on Capri.<ref name="giovannidallorto.com">{{cite web|url=http://www.giovannidallorto.com/krupp/krupp.html#grotta|title=Storia gay - Friedrich Alfred Krupp (1854-1902), l'omosessualità e lo scandalo di Capri|website=www.giovannidallorto.com}}</ref>
====New practices==== In [[continental Europe]], universities often played a part in the administration of the asylums.{{sfn|Shorter|1997|p=35}} In Germany, many practising psychiatrists were educated in universities associated with particular asylums.{{sfn|Shorter|1997|p=35}} However, because Germany remained a loosely bound conglomerate of individual states, it lacked a national regulatory framework for asylums.
[[File:Phrenologie1-157k.png|thumb|upright|[[William A. F. Browne]] was an influential reformer of the lunatic asylum in the mid-19th{{nbs}}century, and an advocate of the new 'science' of [[phrenology]].]] Although Tuke, Pinel and others had tried to do away with physical restraint, it remained widespread in the 19th{{nbs}}century. At the [[The Lawn, Lincoln|Lincoln Asylum]] in England, [[Robert Gardiner Hill]], with the support of [[Edward Parker Charlesworth]], pioneered a mode of treatment that suited "all types" of patients, so that mechanical restraints and coercion could be dispensed with—a situation he finally achieved in 1838. In 1839 Sergeant John Adams and Dr. [[John Conolly]] were impressed by the work of Hill, and introduced the method into their [[St Bernard's Hospital, Hanwell|Hanwell Asylum]], by then the largest in the country. Hill's system was adapted, since Conolly was unable to supervise each attendant as closely as Hill had done. By September 1839, mechanical restraint was no longer required for any patient.<ref name="Suzuki">{{Cite journal|last=Suzuki|first=Akihto|title=The politics and ideology of non-restraint: the case of the Hanwell Asylum.|journal=Medical History|volume=39|issue=1|pages=1–17|date=January 1995|doi=10.1017/s0025727300059457|pmid=7877402|pmc=1036935}}</ref><ref name="taom">Edited by: Bynum, W. F; Porter, Roy; Shepherd, Michael (1988) ''The Anatomy of Madness: Essays in the history of psychiatry''. Vol.3. The Asylum and its psychiatry. Routledge. London EC4</ref>
[[William A. F. Browne]] (1805–1885) introduced activities for patients including writing, art, group activity and drama, pioneered early forms of [[occupational therapy]] and [[art therapy]], and initiated one of the earliest collections of artistic work by patients, at [[Sunnyside Royal Hospital|Montrose Asylum]].<ref name=OutsiderArt>{{cite web |url=http://www.britishoutsiderart.com/exhibitions.aspx |title=British Outsider Art Exhibitions, John Joseph Sheehy London and Group Show in Paris 2008 |access-date=2009-01-15}}</ref>
====Rapid expansion==== By the end of the 19th{{nbs}}century, national systems of regulated asylums for the mentally ill had been established in most [[industrialization|industrialized countries]]. At the turn of the century, Britain and France combined had only a few hundred people in asylums,{{sfn|Shorter|1997|p=34}} but by the end of the century this number had risen to the hundreds of thousands. The United States housed 150,000 patients in mental hospitals by 1904. Germany housed more than 400 public and private sector asylums.{{sfn|Shorter|1997|p=34}} These asylums were critical to the evolution of psychiatry as they provided places of practice throughout the world.{{sfn|Shorter|1997|p=34}}
However, the hope that mental illness could be ameliorated through treatment during the mid-19th{{nbs}}century was disappointed.{{sfn|Shorter|1997|p=46}} Instead, psychiatrists were pressured by an ever-increasing patient population.{{sfn|Shorter|1997|p=46}} The average number of patients in asylums in the United States jumped 927%.{{sfn|Shorter|1997|p=46}} Numbers were similar in Britain and Germany.{{sfn|Shorter|1997|p=46}} Overcrowding was rampant in France, where asylums would commonly take in double their maximum capacity.{{sfn|Shorter|1997|p=47}} Increases in asylum populations may have been a result of the transfer of care from families and [[poorhouse]]s, but the specific reasons as to why the increase occurred are still debated today.{{sfn|Shorter|1997|p=48-49}} No matter the cause, the pressure on asylums from the increase was taking its toll on the asylums and psychiatry as a specialty. Asylums were once again turning into custodial institutions<ref name=Rothman>Rothman, D.J. (1990). ''The Discovery of the Asylum: Social Order and Disorder in the New Republic''. Boston: Little Brown, p. 239. {{ISBN|978-0-316-75745-4}}</ref> and the reputation of psychiatry in the medical world had hit an extreme low.{{sfn|Shorter|1997|p=65}}
In the 1800s, middle class facilities became more common, replacing private care for wealthier persons. However, facilities in this period were largely oversubscribed. Individuals were referred to facilities either by the community or by the criminal justice system. Dangerous or violent cases were usually given precedence for admission. A survey taken in 1891 in [[Cape Town]], South Africa shows the distribution between different facilities. Out of 2046 persons surveyed, 1,281 were in private dwellings, 120 in jails and 645 in asylums, with men representing nearly two-thirds of the number surveyed.<ref name="PorterWright2003">{{cite book|author1=Roy Porter|author2=David Wright|title=The Confinement of the Insane: International Perspectives, 1800–1965|url=https://books.google.com/books?id=i7ktMJZC_HsC|year=2003|publisher=Cambridge University Press|isbn=978-0-521-80206-2}}</ref>
Defining someone as insane was a necessary prerequisite for being admitted to a facility. A doctor was only called after someone was labelled insane on social terms and had become socially or economically problematic. Until the 1890s, little distinction existed between the lunatic and criminal lunatic. The term was often used to police [[vagrancy (people)|vagrancy]] as well as paupers and the insane. In the 1850s, lurid rumours that medical doctors were declaring normal people "insane" in Britain, were spread by the press causing widespread public anxiety. The fear was that people who were a source of embarrassment to their families were conveniently disposed of into asylums with the willing connivance of the psychiatric profession. This [[sensationalism]] appeared in widely read [[novel]]s of the time, including ''[[The Woman in White (novel)|The Woman in White]]''.<ref name="PorterWright2003" /><ref>{{cite web|url=http://bythebrooke.blogspot.com/2008/11/lunacy-panic.html |title=by the brooke: lunacy panic |publisher=Bythebrooke.blogspot.com |date=2008-11-12 |access-date=2014-04-15}}</ref>
===20th century===
====Physical therapies==== A series of radical physical therapies were developed in central and continental Europe in the late 1910s, the 1920s and most particularly, the 1930s. Among these, we may note the Austrian psychiatrist [[Julius Wagner-Jauregg]]'s [[malarial therapy]] for [[general paresis of the insane]] (or [[neurosyphilis]]) first used in 1917, and for which he won a Nobel Prize in 1927.<ref>{{cite journal | doi = 10.1177/0957154X0001104403 | author = Brown Edward M | year = 2000 | title = Why Wagner-Jauregg won the Nobel Prize for discovering malaria therapy for General Paresis of the Insane | journal = History of Psychiatry | volume = 11 | issue = 44| pages = 371–382 | s2cid = 71299293 }}</ref> This treatment heralded the beginning of a radical and experimental era in psychiatric medicine that increasingly broke with an asylum-based culture of therapeutic nihilism in the treatment of chronic [[psychiatric disorders]],<ref>Ugo Cerletti, for instance, described psychiatry during the inter-war period as a "funereal science". Quoted in {{harvnb|Shorter|1997|p=218}}</ref> most particularly [[dementia praecox]] (increasingly known as [[schizophrenia]] from the 1910s, although the two terms were used more or less interchangeably until at least the end of the 1930s), which were typically regarded as [[hereditary]] degenerative disorders and therefore unamenable to any therapeutic intervention.<ref>{{cite journal | author = Hoenig J | year = 1995 | title = Schizophrenia. In Berrios, German and Porter, Roy (Eds.), ''A History of Clinical Psychiatry''. Athlone: p. 337; Meduna, L. J. (1985). Autobiography of L.J. Meduna | journal = Convulsive Therapy | volume = 1 | issue = 1| page = 53 }}</ref> Malarial therapy was followed in 1920 by [[barbiturate]]-induced [[deep sleep therapy]] to treat dementia praecox, which was popularised by the Swiss psychiatrist [[Jakob Klaesi]]. In 1933 the [[Vienna]]-based psychiatrist [[Manfred Sakel]] introduced [[insulin shock therapy]], and in August 1934 [[Ladislas J. Meduna]], a Hungarian neuropathologist and psychiatrist working in [[Budapest]], introduced [[cardiazol]] shock therapy (cardiazol is the tradename of the chemical compound [[pentylenetetrazol]], known by the tradename [[metrazol]] in the United States), which was the first convulsive or seizure therapy for a psychiatric disorder. Again, both of these therapies were initially targeted at curing dementia praecox. Cardiazol shock therapy, founded on the theoretical notion that there existed a biological antagonism between [[schizophrenia]] and [[epilepsy]] and that therefore inducing epileptiform fits in schizophrenic patients might effect a cure, was superseded by [[electroconvulsive therapy]] (ECT), invented by the Italian neurologist [[Ugo Cerletti]] in 1938.{{sfn|Shorter|1997|p=190–225}}
[[File:Moniz.jpg|thumb|upright|[[António Egas Moniz|Egas Moniz]] pioneered the field of [[psychosurgery]] with the lobotomy of a patient's frontal lobes in 1935.]] The use of [[psychosurgery]] was narrowed to a very small number of people for specific indications. [[António Egas Moniz|Egas Moniz]] performed the first leucotomy, or [[lobotomy]] in Portugal in 1935, which targets the brain's frontal lobes.<ref name="studymore.org.uk"/> This was shortly thereafter adapted by [[Walter Jackson Freeman II|Walter Freeman]] and James W. Watts in what is known as Freeman–Watts procedure or the standard prefrontal lobotomy. From 1946, Freeman developed the transorbital lobotomy, using a device akin to an ice-pick. This was an "office" procedure which did not have to be performed in a surgical theatre and took as little as fifteen minutes to complete. Freeman is credited with the popularisation of the technique in the United States. In 1949, 5,074 lobotomies were carried out in the United States and by 1951, 18,608 people had undergone the controversial procedure in that country.{{sfn|Shorter|1997|p=226–229}} One of the most famous people to have a lobotomy was [[Rosemary Kennedy]], who was rendered profoundly intellectually disabled as a result of the surgery.<ref>{{cite web|last=Henley|first=Jon|title=The Forgotten Kennedy|url=https://www.theguardian.com/world/2009/aug/13/eunice-kennedy-shriver-rosemary-kennedy|newspaper=[[The Guardian]]|date=August 12, 2009}}</ref>
In modern times, insulin shock therapy and lobotomies are viewed as being almost as barbaric as the Bedlam "treatments", although the insulin shock therapy was still seen as the only option which produced any noticeable effect on patients. ECT is still used in the West in the 21st{{nbs}}century, but it is seen as a last resort for treatment of mood disorders and is administered much more safely than in the past.<ref>{{cite book|author=Yanni, Carla. |title=The Architecture of Madness: Insane Asylums in the United States (Architecture, Landscape and Amer Culture) |publisher=[[University of Minnesota Press]] |date=12 April 2007 |isbn=978-0-8166-4940-2 |edition=1 |pages=53–62 |url=https://books.google.com/books?id=fJOC_rSW1kgC&pg=PP1}}</ref> Elsewhere, particularly in India, use of ECT is reportedly increasing, as a cost-effective alternative to drug treatment.{{citation needed|date=November 2020}} The effect of a shock on an overly excitable patient often allowed these patients to be discharged to their homes, which was seen by administrators (and often guardians) as a preferable solution to institutionalisation. Lobotomies were performed in the thousands from the 1930s to the 1950s, and were ultimately replaced with modern [[Psychoactive drug|psychotropic drugs]].
====Eugenics movement==== {{Main|Eugenics|Compulsory sterilization}}
The [[eugenics]] movement of the early 20th{{nbs}}century led to a number of countries enacting laws for the compulsory sterilization of the "feeble minded", which resulted in the forced sterilization of numerous psychiatric inmates.<ref>{{cite web|last1=World Health Organization|title=Eliminating forced, coercive and otherwise involuntary sterilization: an interagency statement|url=http://www.unaids.org/sites/default/files/media_asset/201405_sterilization_en.pdf|website=unaids.org|access-date=23 June 2016}}</ref> As late as the 1950s, laws in Japan allowed the forcible sterilization of patients with psychiatric illnesses.<ref>{{cite web|last1=TSUCHIYA|first1=Takashi|title=Japanese Eugenic Sterilization, Newsletter of the Network on Ethics and Intellectual Disability, Vol.3, No.1 [Fall 1997], pp.1–4.|url=http://www.lit.osaka-cu.ac.jp/user/tsuchiya/gyoseki/paper/JPN_Eugenics.html|website=www.lit.osaka-cu.ac.jp|access-date=23 June 2016}}</ref>
Under Nazi Germany, the [[Aktion T4]] [[euthanasia]] program resulted in the killings of thousands of the mentally ill housed in state institutions. In 1939, the Nazis secretly began to exterminate the mentally ill in a euthanasia campaign. Around 6,000 disabled babies, children and teenagers were murdered by starvation or lethal injection.<ref name="Genocide">{{cite journal |author1=Torrey E.F. |author2=Yolken R.H. |title=Psychiatric Genocide: Nazi Attempts to Eradicate Schizophrenia |journal=[[Schizophrenia Bulletin]] |volume=36 |issue=1 |pages=26–32 |date=16 September 2009 |pmid=19759092 |pmc=2800142 |doi=10.1093/schbul/sbp097 |url=http://www.schizophreniaforum.org/images/livedisc/PsychiatricGenocide.pdf |url-status=dead |archive-url=https://web.archive.org/web/20120803052644/http://www.schizophreniaforum.org/images/livedisc/PsychiatricGenocide.pdf |archive-date=3 August 2012}}</ref>
====Psychiatric internment as a political device==== {{Main|Political abuse of psychiatry|Political abuse of psychiatry in the Soviet Union}} Psychiatrists around the world have been involved in the suppression of individual rights by states wherein the definitions of mental disease had been expanded to include political disobedience.<ref name=Semple>{{cite book|last1=Semple|first1=David|last2=Smyth|first2=Roger|last3=Burns|first3=Jonathan|title=Oxford handbook of psychiatry|year=2005|publisher=Oxford University Press|location=Oxford|isbn=978-0-19-852783-1|page=6|url=https://books.google.com/books?id=1MeRuoTs0loC&pg=PA6}}</ref>{{rp|6}} Nowadays, in many countries, political prisoners are sometimes confined to mental institutions and abused therein.<ref name="Noll">{{cite book|last=Noll|first=Richard|title=The encyclopedia of schizophrenia and other psychotic disorders|year=2007|publisher=Infobase Publishing|isbn=978-0-8160-6405-2|page=3|url=https://books.google.com/books?id=jzoJxps189IC&pg=PA3}}</ref>{{rp|3}} Psychiatry possesses a built-in capacity for abuse which is greater than in other areas of medicine.<ref name="Medicine betrayed">{{cite book|title=Medicine betrayed: the participation of doctors in human rights abuses|year=1992|publisher=Zed Books|isbn=978-1-85649-104-4|page=65|url=https://books.google.com/books?id=bMTu_oIfVsIC&pg=PA65}}</ref>{{rp|65}} The diagnosis of mental disease can serve as proxy for the designation of social dissidents, allowing the state to hold persons against their will and to insist upon therapies that work in favour of ideological [[conformity]] and in the broader interests of society.<ref name="Medicine betrayed"/>{{rp|65}}
[[File:St Petersburg Psychiatric Hospital of Specialized Type with Intense Observation.JPG|thumb|[[Leningrad Special Psychiatric Hospital of Prison Type of the USSR Ministry of Internal Affairs]] was a psychiatric institution used by the Soviet authorities to suppress dissent.]] In a monolithic state, psychiatry can be used to bypass standard legal procedures for establishing guilt or innocence and allow political incarceration without the ordinary odium attaching to such political trials.<ref name="Medicine betrayed"/>{{rp|65}} In Nazi Germany in the 1940s, the 'duty to care' was violated on an enormous scale: A reported 300,000 individuals were sterilised and 100,000 killed in Germany alone, as were many thousands further afield, mainly in Eastern Europe.<ref name="Birley">{{Cite journal | last1 = Birley | first1 = J. L. T. | title = Political abuse of psychiatry | doi = 10.1111/j.0902-4441.2000.007s020[dash]3.x | journal = [[Acta Psychiatrica Scandinavica]] | volume = 101 | issue = 399 | pages = 13–15 | date=January 2000 | pmid = 10794019}}</ref>
From the 1960s up to 1986, [[political abuse of psychiatry]] was reported to be systematic in the Soviet Union, and to surface on occasion in other Eastern European countries such as Romania, Hungary, Czechoslovakia and Yugoslavia.<ref name="Medicine betrayed"/>{{rp|66}} A "mental health genocide" reminiscent of the Nazi aberrations has been located in the history of South African oppression during the [[apartheid]] era.<ref name="Press conference">{{cite web|title=Press conference exposes mental health genocide during apartheid, 14 June 1997|url=http://www.info.gov.za/speeches/1997/06160x76497.htm|publisher=South African Government Information|access-date=16 January 2012}}</ref> A continued misappropriation of the discipline was subsequently attributed to the People's Republic of China.<ref name="van Voren 2010">{{cite journal|last=van Voren|first=Robert|title=Political Abuse of Psychiatry—An Historical Overview|journal=[[Schizophrenia Bulletin]]|date=January 2010|volume=36|issue=1|pages=33–35|pmid=19892821|pmc=2800147|doi=10.1093/schbul/sbp119}}</ref>
====Drugs==== The 20th{{nbs}}century saw the development of the first effective [[psychiatric drug]]s.
The first [[Antipsychotic|anti-psychotic drug]], [[chlorpromazine]] (known under the trade name [[Largactil]] in Europe and [[Thorazine]] in the United States), was first synthesized in France in 1950. [[Pierre Deniker]], a psychiatrist of the Saint-Anne Psychiatric Center in Paris, is credited with first recognising the specificity of action of the drug in psychosis in 1952. Deniker traveled with a colleague to the [[North America|United States and Canada]] promoting the drug at medical conferences in 1954. The first publication regarding its use in North America was made in the same year by the Canadian psychiatrist [[Heinz Lehmann]], who was based in [[Montreal]]. Also in 1954 another antipsychotic, [[reserpine]], was first used by an American psychiatrist based in [[New York City|New York]], Nathan S. Kline. At a Paris-based colloquium on [[neuroleptics]] (antipsychotics) in 1955 a series of psychiatric studies were presented by, among others, [[Hans Hoff (psychiatrist)|Hans Hoff]] (Vienna), Dr. Ihsan Aksel (Istanbul), Felix Labarth (Basle), [[Linford Rees]] (London), Sarro (Barcelona), [[Manfred Bleuler]] (Zurich), Willi Mayer-Gross (Birmingham), Winford (Washington) and Denber (New York) attesting to the effective and concordant action of the new drugs in the treatment of psychosis.{{Citation needed|date=January 2010}}
[[File:Thorazine advert.jpg|thumb|upright|Advertisement for Thorazine (chlorpromazine) from the early 1960s<ref>The text reads: ''When the patient lashes out against "them" – THORAZINE (brand of chlorpromazine) quickly puts an end to his violent outburst. 'Thorazine' is especially effective when the psychotic episode is triggered by delusions or [[hallucination]]s. At the outset of treatment, Thorazine's combination of antipsychotic and sedative effects provides both emotional and physical calming. Assaultive or destructive behavior is rapidly controlled. As therapy continues, the initial sedative effect gradually disappears. But the antipsychotic effect continues, helping to dispel or modify delusions, hallucinations and confusion, while keeping the patient calm and approachable. SMITH KLINE AND FRENCH LABORATORIES leaders in psychopharmaceutical research.''</ref>]] The new antipsychotics had an immense impact on the lives of psychiatrists and patients. For instance, [[Henri Ey]], a French psychiatrist at Bonneval, related that between 1921 and 1937 only 6% of patients with schizophrenia and chronic delirium were discharged from his institution. The comparable figure for the period from 1955 to 1967, after the introduction of chlorpromazine, was 67%. Between 1955 and 1968 the residential psychiatric population in the United States dropped by 30%.<ref>Thuillier, Jean (1999). ''Ten Years that Changed the Face of Mental Illness''. Trans. Gordon Hickish. Martin Dunitz: pp. 110,114, 121–123, 130. {{ISBN|1-85317-886-1}}</ref> Newly developed [[antidepressants]] were used to treat cases of [[clinical depression|depression]], and the introduction of [[muscle relaxants]] allowed [[Electroconvulsive therapy|ECT]] to be used in a modified form for the treatment of severe depression and a few other disorders.<ref name="studymore.org.uk"/>
The discovery of the [[mood stabilizing]] effect of [[lithium carbonate]] by [[John Cade]] in 1948 would eventually revolutionise the treatment of [[bipolar disorder]], although its use was banned in the United States until the 1970s.<ref>{{cite journal|last1=Shorter|first1=Edward|title=The history of lithium therapy|journal=Bipolar Disorders|pages=4–9|doi=10.1111/j.1399-5618.2009.00706.x|date=1 June 2009|pmid=19538681|pmc=3712976|volume=11|issue=Suppl 2 }}</ref>
====United States: reform in the 1940s==== From 1942 to 1947, [[conscientious objectors]] in the US assigned to psychiatric hospitals under [[Civilian Public Service]] exposed abuses throughout the psychiatric care system and were instrumental in reforms of the 1940s and 1950s. The CPS reformers were especially active at the [[Philadelphia State Hospital]] where four [[Society of Friends|Quakers]] initiated ''The Attendant'' magazine as a way to communicate ideas and promote reform. This periodical later became ''The Psychiatric Aide'', a professional journal for mental health workers. On 6 May 1946, ''[[Life Magazine|Life]]'' magazine printed an exposé of the psychiatric system by Albert Q. Maisel based on the reports of COs.<ref>{{cite book|url=https://books.google.com/books?id=BlUEAAAAMBAJ&pg=PA102|title=Bedlam 1946|author=Albert Q. Maisel|publisher=LIFE magazine|page=102|date=6 May 1946}}</ref> Another effort of CPS, namely the ''Mental Hygiene Project'', became the national [[Mental Health Foundation]]. Initially skeptical about the value of Civilian Public Service, [[Eleanor Roosevelt]], impressed by the changes introduced by COs in the mental health system, became a sponsor of ''the National Mental Health Foundation'' and actively inspired other prominent citizens including [[Owen J. Roberts]], [[Pearl Buck]] and [[Harry Emerson Fosdick]] to join her in advancing the organization's objectives of reform and humane treatment of patients.{{Citation needed|date=November 2009}}
====Deinstitutionalisation==== {{Main|Deinstitutionalisation}} By the beginning of the 20th{{nbs}}century, ever-increasing admissions had resulted in serious overcrowding. Funding was often cut, especially during periods of economic decline, and during wartime in particular many patients starved to death. Asylums became notorious for poor living conditions, lack of hygiene, overcrowding, and ill-treatment and [[abuse of patients]].<ref name=Fakhourya07>{{cite journal |vauthors=Fakhourya W, Priebea S |title=Deinstitutionalization and reinstitutionalization: major changes in the provision of mental healthcare |journal=Psychiatry |volume=6 |pages=313–316 |date=August 2007 |doi=10.1016/j.mppsy.2007.05.008 |issue=8}}</ref>
The first community-based alternatives were suggested and tentatively implemented in the 1920s and 1930s, although asylum numbers continued to increase up to the 1950s. The movement for deinstitutionalisation came to the fore in various Western countries in the 1950s and 1960s.
The prevailing public arguments, time of onset, and pace of reforms varied by country.<ref name=Fakhourya07/> [[Class action lawsuit]]s in the United States, and the scrutiny of institutions through [[disability activism]] and [[antipsychiatry]], helped expose the poor conditions and treatment. Sociologists and others argued that such institutions maintained or created dependency, passivity, exclusion and disability, causing people to be [[institutional syndrome|institutionalised]].
There was an argument that community services would be cheaper. It was suggested that new psychiatric medications made it more feasible to release people into the community.<ref>{{cite journal |author=Rochefort DA |title=Origins of the "Third psychiatric revolution": the Community Mental Health Centers Act of 1963 |journal=J Health Polit Policy Law |volume=9 |issue=1 |pages=1–30 |date=Spring 1984 |pmid=6736594 |url=http://jhppl.dukejournals.org/cgi/pmidlookup?view=long&pmid=6736594 |doi=10.1215/03616878-9-1-1 |access-date=29 November 2009 |archive-url=https://archive.today/20120709153258/http://jhppl.dukejournals.org/cgi/pmidlookup?view=long&pmid=6736594 |archive-date=9 July 2012 |url-status=dead|url-access=subscription }}</ref>
There were differing views on deinstitutionalization, however, in groups such as mental health professionals, public officials, families, advocacy groups, public citizens and unions.<ref>{{cite journal|vauthors=Scherl DJ, Macht LB |title=Deinstitutionalization in the absence of consensus |journal=Hosp Community Psychiatry |volume=30 |issue=9 |pages=599–604 |date=September 1979 |pmid=223959 |url=http://ps.psychiatryonline.org/cgi/pmidlookup?view=long&pmid=223959 |archive-url=https://web.archive.org/web/20120106115504/http://ps.psychiatryonline.org/cgi/pmidlookup?view=long&pmid=223959 |url-status=dead |archive-date=2012-01-06 |doi=10.1176/ps.30.9.599 |url-access=subscription }}</ref>
==Today== ===Africa=== * Uganda had one psychiatric hospital as of 2007.<ref name=Fakhourya07/> * South Africa had 27 registered psychiatric hospitals as of 2018. These hospitals are spread throughout the country. Some of the most well-known institutions are: [[Weskoppies Psychiatric Hospital]], colloquially known as Groendakkies ("Little Green Roofs") and [[Denmar Psychiatric Hospital]] in Pretoria, TARA<ref>{{cite web|url=http://www.medpages.co.za/sf/index.php?page=organisation&orgcode=241845|title= Tara H Moross Centre Hospital – Psychiatric Ward (Ward 8)|publisher=Medpages|access-date=28 May 2018}}</ref> in Johannesburg, and [[Valkenberg Hospital]] in Cape Town.
===Asia=== In Japan, the number of hospital beds has risen steadily over the last few decades.<ref name=Fakhourya07/>
In Hong Kong, a number of residential care services such as half-way houses, long-stay care homes, and supported hostels are provided for the discharged patients. In addition, a number of community support services such as Community Rehabilitation Day Services, Community Mental Health Link, Community Mental Health Care, etc. have been launched to facilitate the re-integration of patients into the community.
===Europe=== Countries where deinstitutionalisation has happened may be experiencing a process of "re-institutionalisation" or relocation to different institutions, as evidenced by increases in the number of [[supported housing]] facilities, [[forensic psychiatry|forensic psychiatric]] beds and rising numbers in the prison population.<ref>{{cite journal |author=Priebe S |title=Reinstitutionalisation in mental health care: comparison of data on service provision from six European countries |journal=BMJ |volume=330 |issue=7483 |pages=123–6 |date=January 2005 |pmid=15567803 |pmc=544427 |doi=10.1136/bmj.38296.611215.AE |name-list-style=vanc|author2=Badesconyi A |author3=Fioritti A |display-authors=3 |last4=Hansson |first4=L |last5=Kilian |first5=R |last6=Torres-Gonzales |first6=F |last7=Turner |first7=T |last8=Wiersma |first8=D}}</ref>
===New Zealand=== New Zealand established a [[Truth and reconciliation commission|reconciliation]] initiative in 2005 in the context of ongoing [[damages|compensation]] payouts to ex-patients of state-run mental institutions in the 1970s to 1990s. The forum heard of poor reasons for admissions; unsanitary and overcrowded conditions; lack of communication to patients and family members; physical violence and sexual misconduct and abuse; inadequate complaints mechanisms; pressures and difficulties for staff, within an [[authoritarian]] [[psychiatric]] hierarchy based on containment; fear and humiliation in the misuse of [[seclusion]]; over-use and abuse of [[Electroconvulsive therapy|ECT]], [[psychiatric medication]] and other treatments/punishments, including [[group therapy]], with continued [[adverse effects]]; lack of support on discharge; interrupted lives and lost potential; and continued stigma, prejudice and emotional distress and trauma.
There were some references to instances of helpful aspects or kindnesses despite the system. Participants were offered counselling to help them deal with their experiences, and advice on their rights, including access to records and legal redress.<ref>Dept of Internal Affairs, New Zealand Government. [http://www.confidentialforum.govt.nz/ Te Āiotanga: Report of the Confidential Forum for Former In-Patients of Psychiatric Hospitals] June 2007</ref>
===South America=== In several [[South American]] countries,{{which|date=January 2022}} the total number of beds in asylum-type institutions has decreased, replaced by psychiatric inpatient units in general hospitals and other local settings.<ref name=Fakhourya07/>
===United Kingdom=== At the beginning of the 19th{{nbs}}century, there were, perhaps, a few thousand "[[lunatic]]s" housed in a variety of disparate institutions; but, by the beginning of the 20th{{nbs}}century, that figure had grown to about 100,000. This growth coincided with the development of "[[Psychiatrist|alienism]]," now known as psychiatry, as a medical specialty.<ref name="PorterMadmen" />{{rp|14}}
===United States=== [[File:Art work of Toledo, Ohio - DPLA - 0a107364e8d8eb430ebc183d28c46463 (page 29) (cropped).jpg|thumb|right|Views of Toledo State Hospital for the Insane]]
The United States has experienced two waves of [[deinstitutionalization]]. Wave one began in the 1950s and targeted people with mental illness.<ref name="Stroman">Stroman, Duane. 2003. "The Disability Rights Movement: From Deinstitutionalization to Self-determination.'' University Press of America.''</ref> The second wave began roughly fifteen years after and focused on individuals who had been diagnosed with a [[developmental disability]] (e.g. intellectual disability).<ref name="Stroman"/>
A process of indirect [[cost-shifting]] may have led to a form of "re-institutionalization" through the increased use of jail detention for those with mental disorders deemed unmanageable and noncompliant.<ref>{{cite journal |vauthors=Domino ME, Norton EC, Morrissey JP, Thakur N |title=Cost shifting to jails after a change to managed mental health care |journal=Health Serv Res |volume=39 |issue=5 |pages=1379–401 |date=October 2004 |pmid=15333114 |pmc=1361075 |doi=10.1111/j.1475-6773.2004.00295.x }}</ref> In summer 2009, author and columnist [[Heather Mac Donald]] stated in ''[[City Journal (New York)|City Journal]]'', "jails have become society's primary mental institutions, though few have the funding or expertise to carry out that role properly... at [[Rikers]], 28% of the inmates require mental health services, a number that rises each year."<ref>{{cite magazine|title=The Jail Inferno|first=Heather|last=Mac Donald|url=http://www.city-journal.org/2009/19_3_jails.html|magazine=[[City Journal (New York)|City Journal]]|access-date=27 July 2009|author-link=Heather Mac Donald|archive-date=28 May 2010|archive-url=https://web.archive.org/web/20100528002312/http://www.city-journal.org/2009/19_3_jails.html|url-status=dead}}</ref>
==See also== * [[Deinstitutionalization]] * [[History of mental disorders]] * [[Kirkbride Plan]] * [[Timeline of psychiatry]] * [[Clifford W. Beers]] * [[History of psychiatric institutions in China]] * [[Commissioners in Lunacy#Asylums commissioned|List of asylums commissioned in England and Wales]] * [[Ann Pratt]]
==References== {{Reflist}}
== Further reading == * {{cite book|last=Yanni|first=Carla|title=The architecture of madness: insane asylums in the United States|year=2007|publisher=U of Minnesota Press|isbn=978-0-8166-4939-6|url=https://books.google.com/books?id=xnlERgg2fcoC}} * {{in lang|fr}} [[Michel Foucault]], ''[[Histoire de la folie à l'âge classique]]'', 1961, Gallimard, Tel, 688 p. {{ISBN|978-2070295821}} * {{in lang|fr}} [[Claude Quétel]], ''Histoire de la folie : De l'Antiquité à nos jours'', 2009, Editions Tallandier, Texto, 618 pages. {{ISBN|978-2847349276}} * {{citation|last=Shorter|first=E|date=1997|title=A History of Psychiatry: From the Era of the Asylum to the Age of Prozac|location=New York: John Wiley & Sons, Inc.|isbn=978-0-471-24531-5}}
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[[Category:Former psychiatric hospitals|*]] [[Category:Total institutions]]