Asylums, Optimism, and Moral Treatment: Was Victorian mental health care as cruel as we believe?

Article by Kerry Lindeque

When we picture Victorian-era asylums and mental illness images of brutal treatment, inadequate living conditions and physical punishment come to mind. But this was not always the case. In the early 1800s, attitude towards care of the mentally ill shifted away from security and containment and towards a system that ‘aimed to treat people with mental illness like rational beings’. The so-called moral treatment system would forever change the face of psychiatry but was it really the forward-thinking, compassionate approach its proponents claimed? And why, after just a century of implementation, did it fall back into decline? 

The rise of moral treatment has numerous origins. In England it can be closely linked to the Quaker movement who saw the brutal conditions of asylums – where the use of irritant chemicals, beating, starvation and physical restraints were common – as morally reprehensible. More broadly, the moral treatment approach has strong links to the Age of Enlightenment and the increased belief in humanity’s rational capabilities. Philippe Pinel and Harriet Martineau were among the campaigners who saw that a patient’s capacity for reason, if combined with positive environmental and interpersonal factors, could lead to significant improvement in a sufferers’ mental health. The successful treatment of King George III’s ‘madness’, as well as the decline in superstitious beliefs regarding mental illness, were among other factors which popularised Pinel and Martineau’s rational, compassionate approach to treating mental illness. 

One of the greatest successes of the moral treatment movement was the reform of the 19th century asylum system. Because of the approach’s belief that environmental factors were vital in restoring a patients’ mental health, a new wave of mental institutions focused on rehabilitation and recovery were opening their doors, one of the first being Hanwell Mental Asylum in West London. Under the leadership of physiatrist John Connolly, the use physical restraints were banned in 1839 and treatment of patients was, as expressed by a visiting Justice, done “with uniform kindness and forbearance”. Because of the small populations of these new asylums, the care of patients was able to be personalised and consequently recovery rates were impressive. By the mid-1800s optimism around asylums and treatment of mental illness was at an all time high. 

But moral treatment, for all its assertions of being an empathetic, forward-thinking system, had its opponents. Critics of the system included the Alleged Lunatics’ Friend Society (ALFS), a 19th century advocacy group of former asylum patients and their supporters, who argued that the approach treated the mentally ill as though they were children. Psychiatrists and nurses would neglect to inform patients of their rights or give them choice concerning their treatment, instead using rules, constant supervision and solitary confinement to reduce the mentally ill to, as former asylum patient John Thomas Perceval described it, a “milk sop existence in society”. 

The practice of moral treatment in asylums, however, was not to last long. Industrialisation and rapid population growth meant that the small, rural institutions in which the use of this method functioned best were no longer a viable option for treating the mentally ill. Asylums faced worsening conditions and understaffing which resulted in increasing reliance on restraints, padded cells, and sedatives to manage patients. Even Hanwell, once a shining beacon of hope for moral mental health treatment, sank into decline and disrepair. As one inspector who visited the institution in 1893 commented: “It would be astonishing to find any cures ever made there”. Combined with the diminishing belief in the significance of environmental factors on mental health, the decline in optimism surrounding asylums and mental health care meant that moral treatment fell into disuse by the 20th century. 

While it is important to acknowledge the often-patronising nature of moral treatment, historians today recognise that the system made a far superior alternative to the brutal physical treatment of asylum patients that had come before it. Moral treatment had a significant impact on how we treat mental health today, opening the doors to the creation of occupational therapy and Soteria houses. Its most important contribution, certainly, was fighting the dehumanisation of the mentally ill – by recognising the rationality of sufferers and the power of compassion in helping them, moral treatment changed the face of mental health care forever.