Ethan Rhodes
The history of psychiatric hospitals is a long and complex one. In the Islamic world, Bimaristans were described by European travellers as places of care and kindness for the insane. In the Western world, the first institution specializing in the treatment of mental illness was founded in Valencia, Spain, in 1409. The arrival of institutionalization as a solution to madness was a 19th-century phenomenon in the West. Early lunatic asylums, the precursors of modern psychiatric hospitals, often employed brutal treatments focused on containment and restraint. With the discovery of anti-psychotic and mood-stabilizing drugs, the focus shifted from containment to treatment, leading to the development of modern psychiatric hospitals. The 1960s and 1970s saw a rise in the community health movement, advocating for the deinstitutionalization of individuals with mental illnesses and the integration of mental health care into community-based services.
| Characteristics | Values |
|---|---|
| First public hospital for the insane | Eastern State Hospital, incorporated in 1768 in Williamsburg, Virginia |
| First patients admitted | 1773 |
| First precursor to modern psychiatric hospitals | Bimaristans in the Islamic world |
| First institution specializing in treatment of mental illness | Founded in Valencia in 1409 by Juan Gilaberto Jofré |
| First public charitable institution in Britain | The Bethel in Norwich, opened in 1713 |
| First public mental asylum in Britain | Opened after the 1808 County Asylums Act |
| First public asylum in the US | Institute of the Pennsylvania Hospital, established in 1841 |
| First asylum in Philadelphia | Asylum for the Relief of Persons Deprived of the Use of Their Reason, opened under Quaker supervision |
| First mental institution west of the Appalachian Mountains | Eastern Lunatic Asylum in Lexington, Kentucky |
| First shift towards compassionate treatment | Advocated by Philippe Pinel at Bicêtre Hospital in France and William Tuke at York Retreat in England |
| First shift away from terms like "insanity" | Late 19th and early 20th centuries |
| First movement towards deinstitutionalization | 1960s and 1970s |
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What You'll Learn
- The first public hospital for the insane was the Eastern State Hospital in Virginia, incorporated in 1768
- The Kirkbride Plan: a blueprint for how hospitals for moral treatment should be built and organised
- Dorothea Dix: a prominent 19th-century social reformer and advocate for mental health
- St. Elizabeths Hospital: the first federally funded mental hospital in the US
- Early asylums: confinement of the insane in the 15th and 16th centuries
The first public hospital for the insane was the Eastern State Hospital in Virginia, incorporated in 1768
The first public hospital for the insane was the Eastern State Hospital in Williamsburg, Virginia, incorporated in 1768 and admitting its first patients in 1773. The hospital was constructed solely for the care and treatment of the mentally ill. Before this, the treatment of those with mental health issues was largely a domestic problem, with families and parish authorities in Europe and England central to regimens of care. In England, those deemed to be insane were judged by 12 citizens, similar to a jury, and classified as either criminal, lunatic, or idiot. Those classified as lunatics were often placed in the Public Gaol in Williamsburg.
The 18th century saw a shift in attitudes towards the mentally ill, with the rise of Enlightenment principles that encouraged sensitivity and the perception of mental illness as a treatable disease. This shift in attitudes influenced the establishment of the Eastern State Hospital, which was preceded by a speech from Francis Fauquier, the Royal Governor of the colony of Virginia, in 1766. In his speech, Fauquier expressed concern for the "poor unhappy set of people who are deprived of their senses and wander about the country, terrifying the rest of their fellow creatures". Unfortunately, Fauquier died in 1768, before the hospital was built.
The establishment of the Eastern State Hospital set a precedent for the development of public mental asylums. By 1890, every state in the US had built at least one publicly supported mental hospital. These institutions aimed to provide treatment and care for the mentally ill, marking a shift from the previous focus on containment and restraint. The treatment of inmates in early lunatic asylums was often brutal, with practices such as bleeding, purging, hot and cold baths, and the use of restraints. However, reformers in the 19th century advocated for "moral treatment," which emphasized kindness, peaceful settings, meaningful work, and gentler forms of restraint.
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The Kirkbride Plan: a blueprint for how hospitals for moral treatment should be built and organised
The Kirkbride Plan was a system of mental asylum design promoted by American psychiatrist Thomas Story Kirkbride (1809–1883) in the mid-19th century. The plan was a prototype for many future private and public insane asylums and was based on a philosophy of moral treatment and environmental determinism.
The typical floor plan of a Kirkbride building featured a central administrative structure with long, straight wings radiating outward from the centre, often referred to as a "bat wing" style. The wings were arranged en echelon, in a staggered fashion, so each connected wing received sunlight and fresh air, and patients could enjoy privacy and comfort. The building form itself was meant to have a curative effect, with the grounds "highly improved and tastefully ornamented". The idea of institutionalization was central to Kirkbride's plan, and these asylums tended to be large, imposing buildings with a "narrow, stepped, linear building footprint".
In addition to the intricate building design, Kirkbride advocated for the hospitals to be built on fertile and spacious landscapes, with views of nature and a minimum of 100 acres (40 hectares) of land. The foliage and farmlands were sometimes maintained by patients as part of physical exercise and therapy. The hospitals were to be entirely self-sufficient, providing patients with a range of stimulating mental and physical activities.
Kirkbride also outlined specific guidelines for staffing and daily operations. He suggested a total of 71 staff members, including a superintending physician, an assisting physician, nurses, supervisors, teachers, a chaplain, a matron, and a night watchman. He stressed the importance of proper selection and comfortable working conditions for attendants, who had extensive management responsibilities. Kirkbride also suggested that able-minded patients could help maintain the hospital grounds and assist in their respective wards.
The first hospital designed under the Kirkbride Plan was the Trenton State Hospital in Trenton, New Jersey, constructed in 1848. Throughout the remainder of the nineteenth century, numerous psychiatric hospitals were designed according to the Kirkbride Plan across the United States. By the twentieth century, the popularity of the design had waned due to economic pressures and contestation of Kirkbride's theories.
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Dorothea Dix: a prominent 19th-century social reformer and advocate for mental health
Dorothea Dix was an early 19th-century activist and progressive social reformer who transformed the medical field and dedicated her life to improving the welfare of the mentally ill. Born in Hampden, Maine, in 1802, Dix left her unhappy family home at the young age of 12 and moved to Boston to live with her grandmother. By the age of 14, she was already teaching at a school for young girls in Worcester, Massachusetts, where she implemented a curriculum of her own, emphasising natural sciences and ethical living.
Dix's passion for helping the mentally ill was sparked while she was teaching female prisoners in East Cambridge. She witnessed the inhumane conditions they were subjected to, locked up in dark, bare cells with stagnant air, labelled as "looney paupers", and treated similarly to violently deranged criminals. Outraged by this injustice, she began her lifelong journey as an advocate for mental health reform.
In the 1840s, Dix travelled extensively, documenting the conditions of the poor mentally ill. She visited almshouses, jails, penitentiaries, and hospitals across the United States, including in New Hampshire, Louisiana, and Illinois. Her investigations and reports led to the establishment of the first state mental hospital in Illinois. She also played a crucial role in the reform movement in North Carolina, where the Dix Hill Asylum, named in her honour, was opened in 1856.
Dix's influence extended beyond the United States. In 1836, she travelled to England and connected with the Rathbone family, prominent social reformers who believed in the government's active role in social welfare. She also encountered the British reform movement for the care of the mentally ill, known as lunacy reform. Later, in the 1850s, she returned to England and Europe, investigating Scotland's madhouses, which led to the formation of the Scottish Lunacy Commission to oversee reforms.
In addition to her advocacy for mental health, Dix made significant contributions to nursing during the Civil War. She helped recruit nurses for the Union Army and served as a superintendent of army nurses. Her legacy in the field of nursing is also noteworthy, as she challenged traditional notions of reform and illness, leaving a lasting impact on healthcare and social welfare.
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St. Elizabeths Hospital: the first federally funded mental hospital in the US
St. Elizabeths Hospital, formerly known as the Government Hospital for the Insane, was the first federally funded mental hospital in the United States. It was established in 1855 in Southeast Washington, D.C., as part of a larger asylum movement. The hospital was founded by Dorothea Dix, a prominent 19th-century social reformer and advocate for mental health. Dix lobbied for a public facility to care for mentally ill military personnel and local Washington, D.C., residents.
At its peak in the 1950s, St. Elizabeths Hospital housed over 8,000 patients annually and employed 4,000 people. The hospital was designed by Thomas U. Walter, the primary architect of the expansion of the U.S. Capitol, and was based on the principles of the Kirkbride Plan. The Kirkbride Plan advocated for the humane treatment of psychiatric patients and the philosophy of "moral treatment" based on compassion and respect. Each patient at St. Elizabeths was to have their own private room with views of nature, and the hospital was partially self-sustainable with drinking water from two springs on the grounds and fresh produce from the surrounding farmland.
However, despite its progressive design, St. Elizabeths Hospital was not immune to criticisms and controversies. Beginning in the 1950s, large institutions like St. Elizabeths were criticized for hindering patient treatment and abusing patients. The hospital also faced allegations of violating patient rights, and in the 1970s, it struggled with funding issues. The passing of the 1963 Community Mental Health Act led to deinstitutionalization, and the patient population of St. Elizabeths steadily declined as alternatives to inpatient treatment were sought.
Today, St. Elizabeths Hospital continues to operate but on a much smaller scale. The hospital functions have been limited to a portion of the East Campus, operated by the District of Columbia Department of Mental Health. The West Campus has been transferred to the United States Department of Homeland Security, and the remaining buildings on the campus serve as monuments to the pioneers of psychiatric medicine.
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Early asylums: confinement of the insane in the 15th and 16th centuries
In the 15th and 16th centuries, the confinement of the insane was largely a domestic affair, with families and parish authorities in Europe and England central to regimens of care. The majority of those with mental illnesses lived within their communities and were cared for by their families. However, some were homeless and begged on the streets, often receiving nicknames such as 'Tom o'Bedlams'.
During this time, the notion of mental illness as a medical issue began to emerge, with the appointment of the first medical 'keeper' of Bethlem Hospital in London in 1619. This marked a shift from viewing mental illness as a supernatural event to understanding it as a medical matter. The hospital, also known as Bedlam, was England's only asylum for the mentally ill at the time. Founded in 1247, it housed six insane men at the start of the 15th century.
In the 16th century, a variety of practitioners, including bone setters, 'wise women', 'cunning men', herbalists, and astrologers, offered treatments for mental illnesses. Richard Napier, a clergyman, medical practitioner, and astrologer, treated thousands of patients with mental health concerns between 1597 and 1634. His treatments incorporated religious, psychological, astrological, and traditional healing methods.
While the exact numbers are unclear, it is evident that private madhouses or 'fools' towers' existed in some cities during the 15th and 16th centuries. These institutions often confined the insane, with inmates deemed dangerous or disturbing being chained. However, some of these early asylums allowed their inhabitants to roam within their confines and possibly in the surrounding neighborhoods.
The development of mental health institutions during this period was influenced by cultural and religious contexts. For example, in Spain, several hospitals for the insane were established after the Christian Reconquista, including facilities in Valencia (1407), Zaragoza (1425), Seville (1436), Barcelona (1481), and Toledo (1483).
The early asylums of the 15th and 16th centuries laid the groundwork for the emergence of more formalized systems of confinement and treatment for the insane in the centuries that followed.
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Frequently asked questions
The Priory of Saint Mary of Bethlehem, later known as Bedlam, was founded in London, England, in 1247. It housed six insane men at the start of the 15th century.
The New York Hospital opened a ward for "curable" insane patients in 1808. A freestanding medical facility was built nearby for the humane treatment of the mentally ill.
Early lunatic asylums often featured harsh restraints and long periods of isolation. Patients were subjected to treatments such as bleeding, purging, hot and cold baths, mercury pills, and the use of a "tranquilizing chair". However, some asylums, like the Victorian Mental Asylum, were reportedly kinder places than commonly believed.
The treatment of the mentally ill evolved with the discovery of anti-psychotic and mood-stabilizing drugs, shifting the focus from containment to treatment. The introduction of effective evidence-based treatments and reforms led to modern psychiatric hospitals, which emphasize treatment and provide humane and efficient care. Deinstitutionalization efforts in the 1960s and 1970s further transitioned care from institutional settings to community-based services.
