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

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David Evers

Keywords

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

Abstract

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.

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