The Treatment of Insanity

Insanity in the 19th century

At the time the Worcester State Hospital was built, physicians believed insanity was a disease of the brain that was triggered by the violation of the “natural laws” of health. These laws required moderation in work, exercise, diet, and rest, and prohibited overindulgence and immoral behavior. The apparent rise in the number of lunatics in the 19th century was attributed to industrialization and urbanization, which separated human beings from nature and encouraged bad habits.

Nineteenth-century insanity is not directly equivalent to our definition of mental illness today. While some diagnoses have parallels, such as melancholia and depression, others – like hysteria and neurasthenia – do not have precise equivalents. Additionally, certain diseases and conditions that we would not consider mental illness, such as epilepsy, tertiary syphilis, and traumatic brain injury, were grouped under the label of insanity in the 19th century.

Change in Treatment

Historically, insanity had been considered untreatable. Some families of lunatics kept their ill relatives at home, while those without support ended up in jails or almshouses, or became homeless beggars. In the era of reform and optimism that emerged in the early 19th century, attitudes toward the insane changed. When an 1829 committee of the state legislature discovered lunatics living in dungeon-like conditions with filthy straw for bedding and rags for clothing, reformers were moved to act. The new lunatic hospital offered a humane and progressive solution to a growing crisis of public health.

A therapeutic environment

Under the principles of the new “moral treatment,” insanity was thought to be curable if patients were removed to a rural environment with clean air, scenic vistas, and a wholesome diet. Invigorated by the successes of their European peers, American physicians were incredibly optimistic about the potential of moral treatment, projecting a cure rate of 90% for patients who received prompt care in an asylum.

Asylum architects were influenced by popular romantic beliefs about the healing properties of nature. The asylum landscape was meant to emulate the appearance of a genteel garden or park, with winding paths, scenic vistas, and a variety of trees and vegetation.

Like the asylum landscape, the interiors of the hospital were designed to exert a therapeutic influence on patients. Administrators furnished the wards with carpets, potted plants, pianos, cages of songbirds, and illustrations of peaceful rural scenes.

The statistics published in the hospital’s annual report in the mid-19th century appeared to confirm the prediction that a large percentage of patients would be cured by its therapeutic environment. While later studies would call these statistics into question, at the time they served to reinforce physicians’ confidence in moral treatment and to win public support for the asylum.

Patient Profile

  • Most patients were working class. Wealthier families could choose to commit their relatives to the private McLean Asylum in Boston, or care for them at home.
  • While women and men were represented equally in the patient population, women tended to recover and obtain release more quickly.
  • African Americans were underrepresented in the hospital population relative to their numbers in the state, possibly reflecting racism in the allocation of public resources. Black patients were placed in separate wards.
  • Superintendent Dr. Samuel B. Woodward believed that Irish immigrants drove themselves insane by “indulgence of stimulating drink,” and that they were less likely to recover from insanity than their native-born counterparts.

Physicians claimed that the economic value of patients’ labor was secondary to its therapeutic role. However, the institution was dependent on patients’ labor. Male patients worked in agriculture, landscaping, and construction. Female patients were responsible for making bedding and clothes, operating the laundry, and housekeeping and food service. Physicians considered a patient’s ability to labor a measure of sanity.

The hospital’s grounds provided space for outdoor activities, including baseball and aerobics. Indoors, patients could visit the library, play games, and attend concerts, lectures, and tea parties. The asylum acquired magic lanterns, phonographs, radios, and film projectors. Nonetheless, life in the asylum was often monotonous, particularly in later decades when overcrowding and staff shortages imposed limits on patients’ freedom.

For its first few decades, the hospital enjoyed a reputation as a “model institution.” However, it was quickly overwhelmed by overcrowding and budgetary restraints. Fed by both native population growth and immigration, the patient population swelled past hospital capacity. The state limited the amount of resources the hospital could devote to either expansion or basic maintenance. As a result, the therapeutic mission of the hospital deteriorated.

The Late 19th Century

The late 19th century was characterized by growing pessimism. In The Curability of Insanity (1876), Pliny Earle, superintendent of the Northampton State Hospital, argued that insanity was not nearly as treatable as was once thought. Physicians became convinced that the insane were inherently defective. Large lunatic hospitals came to be viewed as wastes of taxpayer money. Patient accounts of abuse and neglect further soured public opinion against the asylum.

The 20th Century

Around the turn of the century, the hospital experienced a brief renaissance. Dr. Adolf Meyer directed the establishment of pathology and research laboratories. Over the next decades, researchers made many important discoveries. The hiring of social workers and establishment of community programs further helped to revitalize the hospital’s mission.

Nonetheless, by mid-century, the hospital faced a crisis. With the emergence of antipsychotic drugs and outpatient services, the public questioned the need for institutionalization. The 1960s and 70s witnessed the release of hundreds of thousands of patients. State hospitals were downsized or shuttered altogether. Today the Worcester Recovery Center and Hospital (formerly the Worcester State Hospital) holds the capacity for 320 patients, a small fraction of the 3,000 it held in 1955.

Specifics of Treatment

  • Heroic methods (18th-19th centuries)—bleeding, purging, and other measures intended to correct imbalances in the body that were thought to contribute to insanity.
  • Moral treatment (late 18th-19th centuries)—a holistic approach utilizing moderate labor, the enjoyment of nature, recreational activities, wholesome eating, and adequate rest.
  • Narcotics (19th-20th centuries), including chloral hydrate and morphine—intended to suppress symptoms of insanity and promote sleep. Some patients died of overdoses.
  • Hydrotherapy (19th-mid-20th centuries)—hot or cold baths, or wet towel wrap, intended to stimulate a depressed patient or relax an agitated one. Patients complained that staff often used hydrotherapy as a means of punishment and control.
  • Psychoanalysis (1890s-present)—based on the premise that mental illness is the result of unresolved psychological conflicts originating in childhood. By accessing the unconscious mind of the patient, the psychoanalyst seeks to identify these conflicts and resolve them.
  • Shock therapy (early 20th century-present)—the use of drugs, electricity, or fevers to induce comas or seizures. Electro-convulsive therapy (ECT), developed in the 1930s, gradually became the dominant method. While many associate ECT with the abuse of patients, famously depicted in “One Flew Over the Cuckoo’s Nest,” it is still used today as an effective treatment for depression and bipolar disorder.
  • Lobotomy (1930s-1960s)—a surgical procedure that severs connections to the frontal lobe. The procedure made patients more placid and manageable, but also caused negative personality and intellectual changes, permanent disability, and sometimes death.
  • Antipsychotics (1950s-present)—medicines that control symptoms of psychosis. While they revolutionized the treatment of major mental illness and brought relief to many, they also cause serious side effects.
  • Psychotherapy (20th century-present)—incorporates a broad range of techniques aimed at improving mental health through the guidance of a trained therapist. Psychotherapy may focus on restructuring negative mental patterns, improving communication with others, or developing new habits of behavior and thought.

2 thoughts on “The Treatment of Insanity

  1. In the early 70’s I bought wool strips the patients made from donated old wool clothing to make braded rugs. The strips were all cut to the same size, easy to work with and made beautiful rugs. Everyone needs to feel their work is valued and their work was, as I along with others were happy to have the wool perfectly precut at an affordable fee.

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    1. Thanks for your comment, Shane. The use of patient labor in state institutions has a long and controversial history. Patients were put to work making shoes, clothing, and furniture from the first year the Worcester State Hospital opened. This work was intended to be therapeutic as well as offset the costs of running the institution. In the mid-20th century, activists opposed what they saw as the exploitation of patients for their labor, and ultimately the practice was discontinued. This left many patients without a means to occupy themselves. Today we see the use of work in mental health treatment in occupational therapy, but it is not near the scale that it once was.

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