Nineteenth Century Moral Treatment of Mental Illness Wore Many Hats Moral Therapy in Practice

Main Article Content

David Evers


coercion, Conolly, custodialism, inequality, Pinel and Tuke.


While its lessons are some two centuries old, moral treatment remains the greatest advance in the history of inpatient treatment of mental illness. Recent books and reviews have generally shaped our understanding of moral treatment into an early 19th century enclave in humanitarian psychological care for those suffering from insanity that was preceded by violence and banishment and followed by custodialism and therapeutic nihilism. This paper uses literature both from the era in question and previous to our generation to present a new picture of its contributions and limitations. A multi-fold definition is proposed for moral treatment. Its components are asylum sequestration, authoritarianism, compassion, early psychology, occupational treatment, self-control, and therapeutic optimism. A number of previously under-described features stand out when examined through this lens. Rather than uniquely charitable, it was best suited to wealthy patients. Impractical for average or severe patients, moral treatment was most applicable to those who were convalescent and suitably intimidated. Early psychological treatments were only a minor armament in its therapeutic arsenal. The heralded restraint-free conditions were an exaggeration. The anticipation that high rates of patient cures was limited to the moral treatment era (cult of curability) is likewise mistaken. Pessimistic cure rates in the era of custodialism failed to merit the title nihilistic. These limitations are frequently unknown or ignored by scholars and lend some context to the praise of moral treatment, which is no less praiseworthy, just a bit more seasoned and nuanced.

Abstract 926 | PDF Downloads 1285


1. Messias E. Standing on the shoulders of Pinel, Freud, and Kraepelin: a historiometric inquiry into the histories of psychiatry. J Nerv Ment Dis 2014; 202:788-92.
2. Poirier J, Clarac F, Barbara JG, Broussolle E. Figures and institutions of the neurological sciences in Paris from 1800 to 1950. Part IV: Psychiatry and Psychology. Revue Neurologique (Paris) 2012; 168:389-402.
3. Tripathi, Messias E, Spollen J, Salomon RM. Modern-day relics of psychiatry. J Nerv Ment Dis 2019; 207:701-4.
4. Bucknill JC, Tuke DH. A Manual of Psychological Medicine, 3rd Ed. London: J. Churchill; 1874.
5. Luchins AS. Moral treatment in asylums and general hospitals in 19th-century America. J Psychol 1989; 123(6):585-601.
6. Burtinshaw K, Burt JRF. Lunatics, imbeciles and idiots: a history of insanity in nineteenth-century Britain and Ireland. Pen and Sword; 2017.
7. Bynum WF. Rationales for therapy in British psychiatry: 1780-1835. Med Hist 1964; 18(4):317-34.
8. Plumed Domingo JJ, Rojo Moreno LM. The treatment of madness in the nineteenth and twentieth centuries: discourses about curability in Spanish mental health care, 1890-1917. História, Ciências, Saúde—Manguinhos 2016; 23:985-1002.
9. Charland LC. Science and morals in the affective psychopathology of Philippe Pinel. Hist Psychiatry 2010; 21(81 Pt 1):38-53.
10. Klaf FS, Hamilton JG. Schizophrenia--a hundred years ago and today. J Ment Sci 1961; 107:819-27.
11. Bockoven JS. Occupational therapy--a historical perspective. Legacy of moral treatment—1800’s to 1910. Am J Occup Ther 1971; 25(5):223-5.
12. Charland LC. Benevolent theory: moral treatment at the York Retreat. Hist Psychiatry 2007; 18(1):61-80.
13. Porter R. Was there a moral therapy in eighteenth century psychiatry? Lychnos Lardomshist Samf Arsb 1981-1982; 12-26.
14. Tuke S. Description of the Retreat, an Institution near York, for Insane Persons of the Society of Friends (Abridged). Philadelphia: Kimber and Conrad; 1814.
15. Great Britain. Parliament. House of Commons. Committee Appointed to Consider of Provision Being Made for the Better Regulation of Madhouses in England. ‘First Report from the Committee on the State of Madhouses’. London, 1815.
16. Pinel P. Medico-Philosophical Treatise on Mental Alienation Second Edition, Entirely Reworked and Extensively Expanded (1809). Hoboken: Wiley-Blackwell; 2008.
17. Weiner DB. Betrayal! The 1806 English Translation of Pinel’s Traité médico-philosophique sur l’aliénation mentale ou la manie. Gesnerus. 2000; 57(1-2):42-50.
18. North RL. Benjamin Rush, MD: assassin or beloved healer? Bayl Univ Med Cent Proc 2000; 13(1):45-9.
19. Roberts AR, Kurtz LF. Historical perspectives on the care and treatment of the mentally ill. J Soc Welf Fam Law 1987; 14(4):5.
20. Sederer L. Moral therapy and the problem of morale. Am J Psych 1997; 134(3):267-72.
21. Grob GN. Abuse in American mental hospitals in historical perspective: myth and reality’, Int. J. Law Psychiatr. 1980; 3(3):295-310.
22. Blandford GF. Insanity. In: Stedman TL (Ed.) Twentieth Century Practice vol. 12; New York: William Wood; 1897.
23. Earle P. History, Description, and Statistics of the Bloomingdale Asylum for the Insane. New York: Egbert, Hovey & King; 1848.
24. Digby A. Madness, Morality and Medicine: A Study of the York Retreat, 1796-1914, London: Cambridge University Press; 1985.
25. Leuret F. On the Moral Treatment of Insanity, Chapter III. Paris: Chez J-B. Bailliere; 1840: 29-33.
26. Conolly J. The Treatment of the Insane without Restraint. London: Smith, Elder & Co; 1856.
27. Rush B. Medical inquiries and observations, upon the diseases of the mind. Philadelphia: Kimber & Richardson; 1812.
28. Foucault M. Madness and Civilization. A History of Insanity in the Age of Reason. Vintage Books, 1988. New York: Random House; 1961.
29. Colaizzi J. Seclusion and restraint: a historical perspective. J Psychosoc Nurs Ment Health Serv 2005; 43(2):31-7.
30. Kuosmanen L, Makkonen P, Lehtila H, Salminen H. Seclusion experienced by mental health professionals. J Psychiatr Ment Health Nurs 2015; 22(5):333-6.
31. Anon. The statistics of insanity being a decennial report of Bethlem Hospital from 1846 to 1855 inclusive. Br For Med Chir Rev 1858; 21(41):33-63.
32. Hurd HM. The Institutional Care of the Insane in the United States and Canada. Baltimore: Johns Hopkins University Press; 1916.
33. Eaton DB. Despotism in lunatic asylums. N Am Rev 1881; 132:263-75.
34. Conolly J. An Inquiry Concerning the Indications of Insanity, With Suggestions for the Better Protection and Care of the Insane. London: John Taylor; 1830: 18.
35. Klaf FS, Hamilton JC. Schizophrenia. J Ment Sci 1961; 107:819-27.
36. Barstow AC. Butler Hospital for the Insane, Fortieth Annual Report of the Board of Trustees. Providence: Angell & Co; 1884.
37. Chu EMY, van Santen J, Harbishettar V. Views from an asylum: a retrospective case note analysis of a nineteenth century asylum. Soc Psychiatry Psychiatr Epidemiol 2018; 53(10):1141-7.
38. Ober KP. The pre-Flexnerian reports: Mark Twain's criticism of medicine. Ann Int Med 1997; 126(2):157-63.
39. Viets HR. Note from Samuel Tuke to New York Hospital (1811). Am J Psychiatr 1922; 78:425-32.
40. Burrows GM. Commentaries on the Causes, Forms, Symptoms, and Treatment, Moral and Medical, of Insanity. London: Underwood; 1828.
41. Crothers TD. Inebriate criminals. Alienist Neurologist 1882; 3:66-84.
42. Arlidge JT. On the State of Lunacy and the Legal Provision for the Insane. London: John Churchill; 1859.
43. Earle P. The curability of insanity. A statistical study. Earle P. The curability of insanity. A statistical study. Am J Psychiatry 1885; 151:112-24.
44. Prichard JC. A Treatise on Insanity and Other Disorders Affecting the Mind. Chapter 10 “The Statistics of Insanity.” London: Sherwood, Gilbert and Piper; 1835.
45. MacGill S. On Lunatic Asylums: A Discourse Delivered on 2d August, 1810, Previous to Laying the Foundation Stone of the Glasgow Lunatic Asylum. Glasgow: James Hedderwick & Co; 1810.
46. Anderson LL, Lakin KC, Mangan TW, Prouty RW. State institutions: thirty years of depopulation and closure. Ment Retard 1998; 36(6):431-43.