Lecture 3: The Asylum

Question 1

As a bit of a side note - what was it from Hans’ childhood that had profound influence on his later intellectual interests?

Answer 1

The fact that he grew up next to a mental hospital.

Question 2

Before 1970/1980, where did most of mental health take place?

Answer 2

In mental hospitals/asylums, (although a minority of practitioners practiced out-patient therapy - like Freud).

Question 3

What are two buildings in Sydney that used to be old mental hospitals?

Answer 3

The Sydney College of the Arts building (but it’s no longer that either) and the old parramatta female factory that is next to Westmead hospital.

Question 4

What is ‘urban archeology’?

Answer 4

The study of the old, enormous, abandoned buildings that used to be asylums (mostly in the US).

Question 5

The field of psychiatry originated in the care of the insane in the insane asylums, what were other names for the psychiatrists working in the hospitals?

Answer 5

Mad doctors, alienists.

Question 6

The terms “insane” or “insanity” are not a medical term but what kind of term?

And what is the definition?

Answer 6

“Insane” or “insanity” are legal terms meaning - ‘those who have been certified by the church on the advice of physicians on having lost his or her reason and therefore not competent of being in charge of their own affairs.’

Question 7

Until the 1930s did people enter the asylums voluntarily?

Answer 7

No, there was no such thing as voluntary admission. Physicians and church approval would put people into the asylums.

Question 8

How did it come to be that medicine and the insane “met” in the insane asylum?

Answer 8

Well, people were put in there involuntarily and eventually those taking care of them thought they would try and do something about their different conditions.

Question 9

Who ended up in asylums?

Answer 9

• people who broke social expectations.
• people who were violent in public.
• people who couldn’t be taken care of at home by their families.
• people suffering from dementia, other biological complaints, syphilis, etc.

Question 10

In later years (perhaps the 50s or so), what type of drugs created a tremendous change in the asylums?

Answer 10

Antipsychotic drugs, as the chaos in the asylums was less pronounced.

Question 11

Who decided on the admissions to the asylums?

Answer 11

The church.

Question 12

What made it really difficult to do doctoring, or any type of medical intervention in the asylums?

Answer 12

The fact that the physicians did not choose their patients & the patients did not choose to be there.

Question 13

There are two theories about the origin of the asylum, what are they called and who are they by?

Answer 13

1. The poor - Michel Foucault.

2. The wealthy - Thomas Szasz.

Question 14

What was Michel Foucault’s theory about the origin of the asylums?

Answer 14

The Poor - people in France who were not capable of working and the ‘idle poor’ were locked up because their behaviour violated standards of reason as defined by the Enlightenment period.

Question 15

What was Thomas Szasz’s theory about the origin of the asylums?

Answer 15

The Wealthy - he focused on England and said the asylums started with the wealthy, where troublesome family members were committed to a sanatorium.

Question 16

Hans talks about the theoretical framework for treatment, what four elements does it include?

Answer 16

1. Psychiatric theory.
2. Treatment methods.
3. Location of treatment.
4. Patient population.

Question 17

There have been three “configurations” [for treatment] in mental hospitals, what were they?

Answer 17

• Heroic Treatment (before 1800).
• Moral Treatment (1800-1850).
• Therapeutic pessimism (after 1860).

Question 18

What did the period of Heroic Treatment involve?

Answer 18

Period before 1800:

• it was believed the mad lacked reason (“irrational brutes”).
• restraints were often used.
• it was believed they did not feel the temperatures (so no need to control temperature in the asylum).
• it was believed they resisted disease.
• they were characterised by violence, chaos, and terror.
• mental illness/insanity was considered a state “more deplorable than death itself”.

Question 19

What was one of the first mental asylums ever?

Answer 19

The Bethlehem Hospital in the UK, established in 1676.

Question 20

What is the story of “The Rake’s Progress?”

Answer 20

Painted by William Hogarth in 1735, the 8 paintings depict a story about a nice country boy who moves to the city and is in involved with the wrong crowd. He is gambling, visiting prostitutes, contracts syphilis and ends up in a madhouse.

Question 21

“The Maniac” is a typical figure depicted in 16th - 17th century England. What is it?

Answer 21

“The Maniac” is a very strong, burley, even apish figure, chained up who would wreck havoc if unleashed. He is the epitome of insanity from that time.

Question 22

Thomas Willis treated King George III, in 1684 he is quoted to have said… ?
(In relation to “The Maniac”).

Answer 22

“Madmen… can break cords and chains, break down doors or walls, one easily overthrows many endeavouring to hold him.”

Question 23

During the period of “Heroic Treatment” what was considered to cause insanity?

Answer 23

John Locke’s ideas were influential. He argues that the ideas in our minds are impressions based on sensory observations.
This can lead to chains of false impressions, false ideas, and associations.
Melancholia is an example of one false association.
Mania is an example of many false associations.
BUT ALSO
Sin played a very important role.

Question 24

Sin was considered a way toward madness, how so?

Answer 24

By performing sin, internal balance could be destroyed and lead to terrible consequences.

Question 25

During the period of “Heroic Treatment” what treatments were given to the insane?

Answer 25

• the belief that absolute authority and control needed to be established (mad doctor is like a lion tamer).
• depletion (induce vomiting, diarrhoea, leeches & blood letting).
• attempt to eradicate false impressions, ideas, and associations.

Question 26

What was a popular treatment for mania, during the “Heroic Treatment” period?

Answer 26

The tranquillising chair, it was believed mania was caused by a sensory overload, so tying someone to a chair and putting a box over their head for a long period of time would (apparently) reduce the mania.

Question 27

What are four main ideas about insanity (including what insanity is and treatment) from the Heroic Treatment period?

Answer 27

• Madness is a loss of reason.
• The insane are like beasts.
• Absolute authority was established.
• Treatment was mostly by using shock.

Question 28

Who were the pioneers on the Moral Treatment period?

Answer 28

Philippe Pinel (Paris), 1793;
Samuel Tuke (York Retreat), 1796;
Thomas Kirkbride (Philedelphia), 1859

Question 29

What triggered the Moral Treatment period?

Answer 29

It was from 1800 to 1850, the time of the French Revolution, and became a counter-treatment to the Heroic Treatment period.

Question 30

What were the main four premises of the Moral Treatment period?

• (how were the insane characterised?)
• (what should mental hospitals be like?)
• (what was an important principle?)
• (where did it originate?)

Answer 30

• the insane are confused children in search of guidance, gentle care, and discipline.
• mental hospitals should be pleasant and restful.
• principle of non-restraint.
• religious origin: Quakers.

Question 31

What were the eight principles of treatment during the “Moral Treatment” period?

Answer 31

1. non-restraint.
2. sympathy, respect.
3. appeal to sense and self-esteem.
4. appeal to self-control, self-discipline.
5. reeducation.
6. family and domestic circles.
7. pleasant environment.
8. highly structured.

Question 32

During the “moral treatment” period, particularly at the Pennsylvania Hospital for the insane in 1842, what was a tactic for treatment?

Answer 32

Putting the patients to work. Men in the garden, women in kitchen or mending garments.
“Labour as therapy,” also earned a bit of money for the hospital.

Question 33

What did the “Moral Treatment” period look like in practice?

Answer 33

• a tightly controlled daily schedule.
• religious atmosphere.
• reward of compliant behaviour.
• graded wards (do well, enter a better ward).
• seclusion.
• restraint (hardly ever used) but as ultimate resource.
• occupational therapy (work).

Question 34

Were there any theories about the cause of mental illness in the “Moral Treatment” period?

Answer 34

Yes, mental illness was considered an outcome of the environmental stresses of modern life combined with the individual weakness of an individual.

Question 35

Why were islands often used as mental asylums?

Answer 35

Because you did not have to build a wall, they were confined by water.

Question 36

During the periods of “Heroic Treatment” and “Moral Treatment”, the image of madness was somewhat gendered. In what way?

Answer 36

During the “Heroic Treatment” period, the image of madness was male (brute’s, maniacs).
During the “Moral Treatment” period, the image of madness was female (confused, less threatening).

Question 37

During the period of “Moral Treatment”, the treatments seemed to work. Were they medical? Religious?
Why did the treatments work?

Answer 37

They were religious treatments.
The treatments worked:
- in small settings;
- with highly motivated staff;
- with a high attendant-patient ratio;
- with less severe forms of mental illness.

Question 38

The “Moral Treatment” period created a sense of… ?

Answer 38

Therapeutic optimism. People really thought they could cure the mentally ill.

Question 39

The good news from the “Moral Treatment” period didn’t last… why?

Answer 39

• severe overcrowding (number of people going in always exceeded the number of people leaving).
• little opportunity for treatment.
• management as only option for treatment.
• restraints return.

Question 40

After the good news from the “Moral Treatment” period faded, what new theories were coming in?

Answer 40

• therapeutic pessimism (mental illness is part of someones constitution and very little can be done).
• eugenics.

Question 41

What two innovations were thought of in the period of “therapeutic pessimism”? Why?

Answer 41

• the utica crib (put the patient in a cage-like crib).
• straight jackets.

They were created for patient management.

Question 42

What was the mentally ill population like during the period of “therapeutic pessimism”?

Answer 42

• had severe and persistent forms of mental illness (psychosis, schizophrenia, etc.)
• overpopulation.

Question 43

What were the two main theories of mental illness during the “therapeutic pessimism” period?

Answer 43

• somatic theories of mental illness.

- genetic theories of mental illness (hereditary & nothing could be done).

Question 44

When did neglect in mental health treatments start happening?

Answer 44

Neglect (along with overcrowding) characterised mental hospitals in the 1940s and the 1950s.

Question 45

What caused the protests against mental hospitals in the 1940s and 1950s?

And what happened?

Answer 45

Pictures and articles were being published that showed what was happening in mental hospitals at the time (basically just a lot of neglect).

There was increasing critique of mental hospitals (ties in with anti-psychiatry).

Question 46

Major critiques of mental hospitals were beginning to circulate, what was the major one in Australia?

Answer 46

The Richmond Report, which came out in 1983. It was a royal commission.

Question 47

Major critiques on mental hospitals did what? Why was this not necessarily a good thing?

Answer 47

The major critiques deinstitutionalised many mental hospitals but before alternative care or programs had been put into place.

Question 48

Today in Australia, were do a lot of people with mental illness tend to live?

Answer 48

On the streets.

Question 49

What has mental health care been like in NSW since the 1980s?

Answer 49

Not great. Doctors often quit over a lack of resources.
“Mental health care budgets are constantly being raided…”
Every 18 months or so since the 1980s there has been mental health reports published that better needs to be done… but that hardly ever happens.

Question 50

What is happening in Indonesia?

Answer 50

In Pasung, there are terrible mental health practices. People’s legs are put into wooden blocks - sometimes for decades. There are movements to try and change the cultural issues surrounding mental health issues.

Question 51

What happens to many mentally ill people in the US today?

Answer 51

A lot of the mentally ill end up in prisons. Mentally ill are treated very badly (tortured) because they are not compliant.