On This Day … 15 May [2022]

Events

  • 1817 – Opening of the first private mental health hospital in the United States, the Asylum for the Relief of Persons Deprived of the Use of Their Reason (now Friends Hospital, Philadelphia, Pennsylvania).

Friends Hospital (Philadelphia)

Friends Hospital is a psychiatric hospital located in Philadelphia, Pennsylvania, United States.

Founded in 1813 by Quakers as The Asylum for the Relief of Persons Deprived of the Use of Their Reason, the institution was later renamed the Frankford Asylum for the Insane. It was the first private mental hospital in the nation, and is the oldest such institution with a continuous history of operation. Its campus, which dates to its founding, is a National Historic Landmark.

Friends Hospital is accredited by the Joint Commission on Accreditation of Healthcare Organisations and licensed by the Commonwealth of Pennsylvania.

What is Friends Hospital (Philadelphia)?

Introduction

Friends Hospital is a psychiatric hospital located in Philadelphia, Pennsylvania, United States.

Founded in 1813 by Quakers as The Asylum for the Relief of Persons Deprived of the Use of Their Reason, the institution was later renamed the Frankford Asylum for the Insane. It was the first private mental hospital in the nation, and is the oldest such institution with a continuous history of operation. Its campus, which dates to its founding, is a National Historic Landmark.

Friends Hospital is accredited by the Joint Commission on Accreditation of Healthcare Organisations and licensed by the Commonwealth of Pennsylvania.

Brief History

The Quakers established Friends Hospital in 1813, drawing on a belief that all persons could live a “moral, ordered existence if treated with kindness, dignity, and respect”, despite disabilities. The influential minister Thomas Scattergood decried what he considered the harsh conditions faced by patients in mental asylums; Scattergood instead called for the “moral treatment” of patients. This model served as an inspiration for the establishment of the Friends Asylum for Persons Deprived of the Use of Their Reason; it was the nation’s first privately run psychiatric hospital.

Mission

The 1813 mission statement of the hospital was “To provide for the suitable accommodation of persons who are or may be deprived of the use of their reason, and the maintenance of an asylum for their reception, which is intended to furnish, besides requisite medical aid, such tender, sympathetic attention as may soothe their agitated minds, and under the Divine Blessing, facilitate their recovery.”

Services

Adolescent Programmes

  • A dedicated treatment program specifically design for young people 13-17 years of age.
  • 24 bed acute care psychiatric unit with separate wings for male and female patients (12 for males, 12 for females).
  • Private bedrooms with unit access to an enclosed outside courtyard.
  • Treatment of all major psychiatric disorders and co-occurring substance issues.
  • Holistic and patient centred approach, including regular group and family therapy, as well as individual therapy when indicated.
  • Individualised treatment, wellness and safety and discharge plans.
  • Academic support including an educational assessment and daily education instruction provide by a certified teacher.

Adult Programmes

  • Dedicated Adult Units offering a rand of programming design for the varied needs of patients ages 18 to 65.
  • Private patient bedrooms with unit access to an enclosed outside courtyard.
  • Treatment for all major psychiatric disorders and co-occurring substance issues.
  • Recovery-oriented approach emphasizing each patient’s own support systems, strength and community connections in collaboration in professional treatment.
  • Individualised treatment, wellness, and safety, and discharge plans.

Older Adult Programmes

  • A dedicated treatment programme specifically design for older adults.
  • Private patient bedrooms with unit access to an enclosed outside courtyard.
  • Treatment for all major psychiatric disorders, including behavioural symptoms related to dementia.
  • Treatment for co-occurring substance issues.
  • Holistic and patient centred approach, including regular group and family therapy, as well as individual therapy when indicated.
  • Age sensitive, individualised treatment, wellness, and safety, and discharge plans.

Greystone Programme at Friends Hospital Located on the grounds of the Friends Hospital, the Greystone Programme is a long-term community residence designed to meet the special needs for individuals with severe and persistent mental illnesses. Consisting of two houses, Greystone House and Hillside House, the program is dedicated to helping its residents move toward recovery, greater independence, and an enhanced quality of life. The Greystone Program emphasizes the development of skills of daily living, socialisation, purposeful activity, and recovery enables residents to realize their dignity, worth and highest individual potential. Many residents have chosen to make the Greystone Programme their permanent home while other will successfully transition to a less structured environment.

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Who was Philippe Pinel?

Introduction

Philippe Pinel (20 April 1745 to 25 October 1826) was a French physician, precursor of psychiatry and incidentally a zoologist.

He was instrumental in the development of a more humane psychological approach to the custody and care of psychiatric patients, referred to today as moral therapy. He worked for the abolition of the shackling of mental patients by chains and, more generally, for the humanisation of their treatment. He also made notable contributions to the classification of mental disorders and has been described by some as “the father of modern psychiatry”.

After the French Revolution, Dr. Pinel changed the way we look at the crazy (or “aliénés”, “alienated” in English) by claiming that they can be understood and cured. An 1809 description of a case that Pinel recorded in the second edition of his textbook on insanity is regarded by some as the earliest evidence for the existence of the form of mental disorder later known as dementia praecox or schizophrenia, although Emil Kraepelin is generally accredited with its first conceptualisation.

“Father of modern psychiatry”, he was credited with the first classification of mental illnesses. He had a great influence on psychiatry and the treatment of the alienated in Europe and the United States.

Early Life

Pinel was born in Jonquières, the South of France, in the modern department of Tarn. He was the son and nephew of physicians. After receiving a degree from the faculty of medicine in Toulouse, he studied an additional four years at the Faculty of Medicine of Montpellier. He arrived in Paris in 1778.

He spent fifteen years earning his living as a writer, translator, and editor because the restrictive regulations of the old regime prevented him from practicing medicine in Paris. The faculty did not recognize a degree from a provincial university like Toulouse. He failed twice in a competition which would have awarded him funds to continue his studies. In the second competition, the jury stressed his ‘painful’ mediocrity in all areas of medical knowledge, an assessment seemingly so grossly incompatible with his later intellectual accomplishments that political motives have been suggested. Discouraged, Pinel considered emigrating to America. In 1784 he became editor of the medical journal the Gazette de santé, a four-page weekly. He was also known among natural scientists as a regular contributor to the Journal de physique. He studied mathematics, translated medical works into French, and undertook botanical expeditions.

At about this time he began to develop an intense interest in the study of mental illness. The incentive was a personal one. A friend had developed a ‘nervous melancholy’ that had ‘degenerated into mania’ and resulted in suicide. What Pinel regarded as an unnecessary tragedy due to gross mismanagement seems to have haunted him. It led him to seek employment at one of the best-known private sanatoria for the treatment of insanity in Paris. He remained there for five years prior to the Revolution, gathering observations on insanity and beginning to formulate his views on its nature and treatment.

Pinel was an Ideologue, a disciple of the abbé de Condillac. He was also a clinician who believed that medical truth was derived from clinical experience. Hippocrates was his model.

During the 1780s, Pinel was invited to join the salon of Madame Helvétius. He was in sympathy with the French Revolution. After the revolution, friends he had met at Madame Helvétius’ salon came to power. In August 1793 Pinel was appointed “physician of the infirmeries” at Bicêtre Hospital. At the time it housed about four thousand imprisoned men – criminals, petty offenders, syphilitics, pensioners and about two hundred mental patients. Pinel’s patrons hoped that his appointment would lead to therapeutic initiatives. His experience at the private sanatoria made him a good candidate for the job.

The Bicêtre and Salpêtrière

Soon after his appointment to Bicêtre Hospital, Pinel became interested in the seventh ward where 200 mentally ill men were housed. He asked for a report on these inmates. A few days later, he received a table with comments from the “governor” Jean-Baptiste Pussin. In the 1770s Pussin had been successfully treated for scrofula at Bicêtre; and, following a familiar pattern, he was eventually recruited, along with his wife, Marguerite Jubline, on to the staff of the hospice.

Appreciating Pussin’s outstanding talent, Pinel virtually apprenticed himself to that unschooled but experienced custodian of the insane. His purpose in doing this was to “enrich the medical theory of mental illness with all the insights that the empirical approach affords”. What he observed was a strict nonviolent, nonmedical management of mental patients that came to be called moral treatment or moral management, though psychological might be a more accurate term.

Although Pinel always gave Pussin the credit he deserved, a legend grew up about Pinel single-handedly liberating the insane from their chains at Bicetre. This legend has been commemorated in paintings and prints, and has lived on for 200 years and is repeated in textbooks. In fact, it was Pussin who removed the iron shackles (but sometimes using straitjackets) at Bicêtre in 1797, after Pinel had left for the Salpêtrière. Pinel did remove the chains from patients at the Salpêtrière three years later, after Pussin joined him there. There is some suggestion that the Bicetre myth was actually deliberately fabricated by Pinel’s son, Dr Scipion Pinel, along with Pinel’s foremost pupil, Dr Esquirol. The argument is that they were ‘solidists’, which meant then something akin to biological psychiatry with a focus on brain disease, and were embarrassed by Pinel’s focus on psychological processes. In addition, unlike Philippe, they were both royalists.

While at Bicêtre, Pinel did away with bleeding, purging, and blistering in favour of a therapy that involved close contact with and careful observation of patients. Pinel visited each patient, often several times a day, and took careful notes over two years. He engaged them in lengthy conversations. His objective was to assemble a detailed case history and a natural history of the patient’s illness.

In 1795, Pinel became chief physician of the Hospice de la Salpêtrière, a post that he retained for the rest of his life. The Salpêtrière was, at the time, like a large village, with seven thousand elderly indigent and ailing women, an entrenched bureaucracy, a teeming market and huge infirmaries. Pinel missed Pussin and in 1802 secured his transfer to the Salpêtrière. It has also been noted that a Catholic nursing order actually undertook most of the day to day care and understanding of the patients at Salpêtrière, and there were sometimes power struggles between Pinel and the nurses.

Pinel created an inoculation clinic in his service at the Salpêtrière in 1799, and the first vaccination in Paris was given there in April 1800.

In 1795 Pinel had also been appointed as a professor of medical pathology, a chair that he held for twenty years. He was briefly dismissed from this position in 1822, with ten other professors, suspected of political liberalism, but reinstated as an honorary professor shortly thereafter.

A statue in honour of Pinel now stands outside the Salpêtrière.

Publications

In 1794 Pinel made public his essay ‘Memoir on Madness’, recently called a fundamental text of modern psychiatry. In it Pinel makes the case for the careful psychological study of individuals over time, points out that insanity is not always continuous, and calls for more humanitarian asylum practices.

In 1798 Pinel published an authoritative classification of diseases in his Nosographie philosophique ou méthode de l’analyse appliquée à la médecine. Although he is properly considered one of the founders of psychiatry, this book also establishes him as the last great nosologist of the eighteenth century. While the Nosographie appears completely dated today, it was so popular in its time that it went through six editions between its initial publication and 1818. Pinel based his nosology on ideas of William Cullen, employing the same biologically-inspired terminology of ‘genera’ and ‘species’ of disorder. Pinel’s classification of mental disorder simplified Cullen’s ‘neuroses’ down to four basic types of mental disorder: melancholia, mania (insanity), dementia, and idiotism. Later editions added forms of ‘partial insanity’ where only that of feelings which seem to be affected rather than reasoning ability.

The first mental derangement is called melancholia. The symptoms are described as “taciturnity, a thoughtful pensive air, gloomy suspicions, and a love of solitude.” It is noted that Tiberius and Louis XI were subjected to this temperament. Louis was characterised by the imbalance between the state of bitterness and passion, gloom, love of solitude, and the embarrassment of artistic talents. However, Louis and Tiberius were similar in that they both were deceitful and planned a delusional trip to military sites. Eventually both were exiled, one to the Isle of Rhodes and the other to a province of Belgium. People with melancholia are often immersed with one idea that their whole attention is fixated on. On one hand they stay reserved for many years, withholding friendships and affection while on the other, there are some who make reasonable judgment and overcome the gloomy state.  Melancholia can also express itself in polar opposite forms. The first is distinguished by an exalted sense of self-importance and unrealistic expectations such as attaining riches and power. The second form is marked by deep despair and great depression.  Overall individuals with melancholia generally do not display acts of violence, though they may find it wildly fanciful. Depression and anxiety occurs habitually as well as frequent moroseness of character.  Pinel remarks that melancholia can be explained by drunkenness, abnormalities in the structure of the skull, trauma in the skull, conditions of the skin, various psychological causes such as household disasters and religious extremism, and in women, menstruation and menopause. 

The second mental derangement is called mania without delirium. It is described as madness independent of a disorder that impairs the intellectual faculties. The symptoms are described as perverse and disobedient.  An instance where this type of species of mental derangement occurs where a mechanic, who was confined at the Asylum de Bicetre, experienced violent outbursts of maniacal fury. The paroxysms consisted of a burning sensation located in the abdominal area that was accompanied by constipation and thirst. The symptom spread to the chest, neck, and face area. When it reached the temples, the pulsation of the arteries increased in those areas. The brain was affected to some length but nonetheless, the patient was able to reason and cohere to his ideas. One time the mechanic experienced furious paroxysm at his own house where he warned his wife to flee to avoid death. He also experienced the same periodical fury at the asylum where he plotted against the governor.  The specific character of mania without delirium is that it can either be perpetual or sporadic. However, there was no reasonable change in the cognitive functions of the brain; only pervasive thoughts of fury and a blind tendency to acts of violence.

The third mental derangement is called mania with delirium. It is mainly characterised by indulgence and fury, and affects cognitive functions. Sometimes it may be distinguished by a carefree, gay humour that can venture off path in incoherent and absurd suggestions. Other times it can be distinguished by prideful and imaginary claims to grandeur. Prisoners of this species are highly delusional. For example, they would proclaim having fought an important battle, or witness the prophet Mohammad conjuring wrath in the name of the Almighty. Some declaim ceaselessly with no evidence of things seen or heard while others saw illusions of objects in various forms and colours. Delirium sometimes persists with some degree of frenzied uproar for a period of years, but it can also be constant and the paroxysm of fury repeat at different intervals. The specific character of mania with delirium is the same as mania without delirium in the sense that it can either be continued or cyclical with regular or irregular paroxysms. It is marked by strong nervous excitement, accompanied by a deficit of one or more of the functions of the cognitive abilities with feelings of liveliness, depression or fury.

The fourth mental derangement is called dementia, or otherwise known as the abolition of thinking. The characteristics include thoughtlessness, extreme incorrectness, and wild abnormalities. For instance, a man who had been educated on the ancient nobility was marching on about the beginning of the revolution. He moved restlessly about the house, talking endlessly and shouting passionately on insignificant reasons. Dementia is usually accompanied by raging and rebellious movement, by a quick succession of ideas formed in the mind, and by passionate feelings that are felt and forgotten without attributing it to objects.  Those who are in captive of dementia have lost their memory, even those attributed to their loved ones. Their only memory consists of those in the past. They forget instantaneously things in the present – seen heard or done. Many are irrational because the ideas do not flow coherently.  The characteristic properties of dementia are that there is no judgment value and the ideas are spontaneous with no connection.  The specific character of dementia contains a rapid progression or continual succession of isolated ideas, forgetfulness of previous condition, repetitive acts of exaggeration, decreased responsiveness to external influence, and complete lack of judgement.

The fifth and last mental derangement is called idiotism, or otherwise known as “obliteration of the intellectual faculties and affections.”  This disorder is derived from a variety of causes, such as extravagant and debilitating delight, alcohol abuse, deep sorrow, diligent study, aggressive blows to the head, tumours in the brain, and loss of consciousness due to blockage in vein or artery. Idiotism embodies a variety of forms. One such form is called Cretinism, which is a kind of idiotism that is relative to personal abnormalities. It is well known in the Valais and in parts of Switzerland.   Most people who belong in this group are either deficient in speech or limited to the inarticulate utterances of sounds. Their expressions are emotionless, senses are dazed and motions are mechanical. Idiots also constitute the largest number of patients at hospitals. Individuals who have acute responsiveness can experience a violent shock to the extreme that all the activities of the brain can either be arrested in an action or eradicated completely. Unexpected happiness and exaggerated fear may likely occur as a result of a violent shock.  As mentioned previously, idiotism is the most common among hospital patients and is incurable. At the Bicetre asylum, these patients constitute one fourth of the entire population. Many die after a few days of arrival, having been reduced to states of stupor and weakness. However, some who recover with the progressive regeneration of their strength also regain their intellectual capabilities. Many of the young people that have remained in the state of idiotism for several months or years are attacked by a spasm of active mania between twenty and thirty days.  The specific character of idiotism includes partial or complete extermination of the intellect and affections, apathy, disconnected, inarticulate sounds or impairment of speech, and nonsensical outbursts of passion.

In his book Traité médico-philosophique sur l’aliénation mentale; ou la manie, published in 1801, Pinel discusses his psychologically oriented approach. This book was translated into English by D.D. Davis as a Treatise on Insanity in 1806, although Davis substituted Pinel’s introduction for his own, leaving out among other things Pinel’s strong praise for Alexander Crichton. Pinel’s book had an enormous influence on both French and Anglo-American psychiatrists during the nineteenth century. He meant by alienation that the patient feels like a stranger (alienus) to the world of the ‘sane’. A sympathetic therapist living in that world might be able to journey into the patient’s experience, understand the ‘alienated’, their language, and possibly lead them back into society.

In 1802 Pinel published La Médecine Clinique which was based on his experiences at the Salpêtrière and in which he extended his previous book on classification and disease.

Pinel was elected to the Académie des Sciences in 1804 and was a member of the Académie de Médecine from its founding in 1820. He died in Paris on 25 October 1826.

Clinical Approach

Psychological Understanding

The central and ubiquitous theme of Pinel’s approach to aetiology (causation) and treatment was “moral,” meaning the emotional or the psychological not ethical. He observed and documented the subtleties and nuances of human experience and behaviour, conceiving of people as social animals with imagination.

Pinel noted, for example, that:

“being held in esteem, having honor, dignity, wealth, fame, which though they may be factitious, always distressing and rarely fully satisfied, often give way to the overturning of reason”.

He spoke of avarice, pride, friendship, bigotry, the desire for reputation, for conquest, and vanity. He noted that a state of love could turn to fury and desperation, and that sudden severe reversals in life, such as “from the pleasure of success to an overwhelming idea of failure, from a dignified state—or the belief that one occupies one—to a state of disgrace and being forgotten” can cause mania or ‘mental alienation’. He identified other predisposing psychosocial factors such as an unhappy love affair, domestic grief, devotion to a cause carried to the point of fanaticism, religious fear, the events of the revolution, violent and unhappy passions, exalted ambitions of glory, financial reverses, religious ecstasy, and outbursts of patriotic fervour.

Treatments

Pinel developed specific practical techniques, rather than general concepts and assumptions. He engaged in therapeutic conversations to dissuade patients from delusions. He offered benevolent support and encouragement, although patients who persistently resisted or caused trouble might be threatened with incarceration or punishment if they were not able to control themselves.

Pinel argued that psychological intervention must be tailored to each individual rather than be based solely on the diagnostic category, and that it must be grounded in an understanding of the person’s own perspective and history. He noted that “the treatment of insanity (l’aliénation mentale) without considering the differentiating characteristics of the patients [la distinction des espèces] has been at times superfluous, rarely useful, and often harmful”, describing the partial or complete failures of some psychological approaches, as well as the harm that the usual cruel and harsh treatments caused to patients before they came to his hospital. He saw improvement as often resulting from natural forces within the patient, an improvement that treatment could at best facilitate and at worst interfere with.

Pinel’s approach to medical treatments has been described as ambiguous, complex, and ambivalent. He insisted that psychological techniques should always be tried first, for example:

“even where a violent and destructive maniac could be calmed by a single dose of an antispasmodic [he referred to opium], observation teaches that in a great number of cases, one can obtain a sure and permanent cure by the sole method of expectation, leaving the insane man to his tumultuous excitement… …and [furthermore] seeing, again and again, the unexpected resources of nature left to itself or wisely guided, has rendered me more and more cautious with regard to the use of medications, which I no longer employ—except when the insufficiencies of psychological means have been proven.”

For those cases regarded as psychologically incurable, Pinel would employ baths, showers, opium, camphor and other antispasmodics, as well as vesicants, cauterisation, and bloodletting in certain limited cases only. He also recommended the use of laxatives for the prevention of nervous excitement and relapse.

Pinel often traced mental states to physiological states of the body, and in fact could be said to have practiced psychosomatic medicine. In general, Pinel traced organic causes to the gastrointestinal system and peripheral nervous system more often than to brain dysfunction. This was consistent with his rarely finding gross brain pathology in his post-mortem examinations of psychiatric patients, and his view that such findings that were reported could be correlational rather than causative

Management

Pinel was concerned with a balance between control by authority and individual liberty. He believed in “the art of subjugating and taming the insane” and the effectiveness of “a type of apparatus of fear, of firm and consistent opposition to their dominating and stubbornly held ideas”, but that it must be proportional and motivated only by a desire to keep order and to bring people back to themselves. The straitjacket and a period of seclusion were the only sanctioned punishments. Based on his observations, he believed that those who were considered most dangerous and carried away by their ideas had often been made so by the blows and bad treatment they had received, and that it could be ameliorated by providing space, kindness, consolation, hope, and humour.

Because of the dangers and frustrations that attendants experienced in their work, Pinel put great emphasis on the selection and supervision of attendants in order to establish a custodial setting dedicated to norms of constraint and liberty that would facilitate psychological work. He recommended that recovered patients be employed, arguing that “They are the ones who are most likely to refrain from all inhumane treatment, who will not strike even in retaliation, who can stand up to pleading, menaces, repetitive complaining, etc. and retain their inflexible firmness.” Pinel also emphasized the necessity for leadership that was “thoughtful, philanthropic, courageous, physically imposing, and inventive in the development of manoeuvres or tactics to distract, mollify, and impress” and “devoted to the concept of order without violence”, so that patients are “led most often with kindness, but always with an inflexible firmness.” He noted that his ex-patient and superintendent Pussin had showed him the way in this regard, and had also often been better placed to work with patients and develop techniques due to his greater experience and detailed knowledge of the patients as individuals.

Moral Judgements

Pinel generally expressed warm feelings and respect for his patients, as exemplified by: “I cannot but give enthusiastic witness to their moral qualities. Never, except in romances, have I seen spouses more worthy to be cherished, more tender fathers, passionate lovers, purer or more magnanimous patriots, than I have seen in hospitals for the insane, in their intervals of reasonableness and calm; a man of sensibility may go there any day and take pleasure in scenes of compassion and tenderness”. He argued that otherwise positive character traits could cause a person to be vulnerable to the distressing vicissitudes of life, for example “those persons endowed with a warmth of imagination and a depth of sensitivity, who are capable of experiencing powerful and intense emotions, [since it is they] who are most predisposed to mania”.

Pinel distanced himself from religious views, and in fact considered that excessive religiosity could be harmful.

However, he sometimes took a moral stance himself as to what he considered to be mentally healthy and socially appropriate. Moreover, he sometimes showed a condemnatory tone toward what he considered personal failings or vice, for example noting in 1809: “On one side one sees families which thrive over a course of many years, in the bosom of order and concord, on the other one sees many others, especially in the lower social classes, who offend the eye with the repulsive picture of debauchery, arguments, and shameful distress!”. He goes on to describe this as the most prolific source of alienation needing treatment, adding that while some such examples were a credit to the human race many others are “a disgrace to humanity!”

Influence

Pinel is generally seen as the physician who more than any other transformed the concept of ‘the mad’ into that of patients needing care and understanding, establishing a field that would eventually be called psychiatry. His legacy included improvement of asylum conditions; broadly psychosocial (incl. milieu) therapeutic approaches; history-taking; nosography (the science of the description of syndromes); broadly-numerical assessments of courses of illness and treatment responses; and a record of clinical teaching.

Pinel’s actions took place in the context of the Enlightenment, and a number of others were also reforming asylums along humanitarian lines. For example, Vincenzo Chiarugi, in the 1780s in Italy, removed metal chains from patients but did not enjoy the same renown bestowed on the more explicitly humanitarian Pinel who was so visible from late 18th century revolutionary France. In France, Joseph D’Aquin in Chambéry permitted patients to move about freely and published a book in 1791 urging humanitarian reforms, dedicating the second edition in 1804 to Pinel. The movement as a whole become known as moral treatment or moral management, and influenced asylum development and psychological approaches throughout the Western world.

Pinel’s most important contribution may have been the observation and conviction that there could be sanity and rationality even in cases that seemed on the surface impossible to understand, and that this could appear for periods in response to surrounding events (and not just because of such things as the phase of the moon, a still common assumption and the origin of the term lunatic). The influential philosopher Hegel praised Pinel for this approach.

The right psychical treatment therefore keeps in view the truth that insanity is not an abstract loss of reason (neither in the point of intelligence nor of will and its responsibility), but only derangement, only a contradiction in a still subsisting reason; – just as physical disease is not an abstract, i.e. mere and total, loss of health (if it were that, it would be death), but a contradiction in it. This humane treatment, no less benevolent than reasonable (the services of Pinel towards which deserve the highest acknowledgement), presupposes the patient’s rationality, and in that assumption has the sound basis for dealing with him on this side – just as in the case of bodily disease the physician bases his treatment on the vitality which as such still contains health.

Pinel also started a trend for diagnosing forms of insanity that seemed to occur ‘without delerium’ (confusion, delusions or hallucinations). Pinel called this Manie sans délire, folie raisonnante or folie lucide raisonnante. He described cases who seemed to be overwhelmed by instinctive furious passions but still seemed sane. This was influential in leading to the concept of moral insanity, which became an accepted diagnosis through the second half of the 19th century. Pinel’s main psychiatric heir, Esquirol, built on Pinel’s work and popularised various concepts of monomania.

However, Pinel was also criticised and rejected in some quarters. A new generation favoured pathological anatomy, seeking to locate mental disorders in brain lesions. Pinel undertook comparisons of skull sizes, and considered possible physiological substrates, but he was criticised for his emphasis on psychology and the social environment. Opponents were bolstered by the discovery of tertiary syphilis as the cause of some mental disorder. Pinel’s humanitarian achievements were emphasized and mythologised instead.

With increasing industrialisation, asylums generally became overcrowded, misused, isolated and run-down. The moral treatment principles were often neglected along with the patients. There was recurrent debate over the use of psychological-social oppression even if some physical forces were removed. By the mid-19th century in England, the Alleged Lunatics’ Friend Society was proclaiming the moral treatment approach was achieved “by mildness and coaxing, and by solitary confinement”, treating people like children without rights to make their own decisions.

Similarly in the mid-20th century, Foucault’s influential book, Madness and Civilisation: A History of Insanity in the Age of Reason, also known as History of Madness, focused on Pinel, along with Tuke, as the driving force behind a shift from physical to mental oppression. Foucault argued that the approach simply meant that patients were ignored and verbally isolated, and were worse off than before. They were made to see madness in others and then in themselves until they felt guilt and remorse. The doctor, despite his lack of medical knowledge about the underlying processes, had all powers of authority, and defined insanity. Foucault also suggested that a focus on the rights of patients at Bicetre was partly due to revolutionary concerns that it housed and chained victims of arbitrary or political power, or alternatively that it might be enabling refuge for anti-revolutionary suspects, as well as just ‘the mad’.

Scull argues that the “…manipulations and ambiguous ‘kindness’ of Tuke and Pinel…” may nevertheless have been preferable to the harsh coercion and physical “treatments” of previous generations, though he does recognise its “…less benevolent aspects and its latent potential … for deterioration into a repressive form….” Some have criticised the process of deinstitutionalisation that took place in the 20th century and called for a return to Pinel’s approach, so as not to underestimate the needs that mentally ill people might have for protection and care.

What is the Maudsley Hospital?

Introduction

The Maudsley Hospital is a British psychiatric hospital in south London.

The Maudsley is the largest mental health training institution in the UK. It is part of South London and Maudsley NHS Foundation Trust, and works in partnership with the Institute of Psychiatry, King’s College London. The hospital was one of the originating institutions in producing the Maudsley Prescribing Guidelines. It is part of the King’s Health Partners academic health science centre and the National Institute for Health Research (NIHR) Biomedical Research Centre for Mental Health.

Brief History

Early History

The Maudsley story dates from 1907, when once leading Victorian psychiatrist Henry Maudsley offered London County Council £30,000 (apparently earned from lucrative private practice in the West End) to help found a new mental hospital that would be exclusively for early and acute cases rather than chronic cases, have an out-patients’ clinic and provide for teaching and research. Maudsley’s associate Frederick Walker Mott had proposed the original idea and he conducted the negotiations, with Maudsley remaining anonymous until the offer was accepted. Mott, a neuropathologist, had been influenced by a visit to Emil Kraepelin’s psychiatric clinic with attached postgraduate teaching facilities in Munich, Germany. The Council agreed to contribute half the building costs – eventually rising to £70,000 – and then covered the running costs which were almost twice as high per bed as the large asylums. The hospital also incorporated the Central Pathological Laboratory, transferred from Claybury Hospital, run by Mott. Construction of the hospital was completed in 1915. An Act of Parliament had to be obtained, that year, to allow the institution to accept voluntary patients without needing to certify them as insane.

However, before it could open, the building was requisitioned to treat war veterans. After the war it was returned to the control of London County Council and it finally opened as the Maudsley Hospital in February 1923. The first superintendent was psychiatrist Edward Mapother, while Frederick Golla took over the running of the pathology lab from Mott. Both were more sceptical of the Kraepelinian categories of diagnosis, and took a more pragmatic and eclectic view on causation and treatment. Psychiatrist Mary Barkas worked here between 1923 and 1927 in the children’s department established by William Dawson.

In the interwar period the Maudsley Hospital engaged in widespread experimentation with animal hormones, both in small doses to rectify supposed deficits and in overdoses as a shock therapy. Numerous psychoactive drugs and procedures were tried out, in what has been described as ‘unconstrained experimentation’. One of those involved, as a trainee and then junior doctor, was the controversial William Sargant. The hospital’s nursing staff comprised a matron, assistant matron, six sisters and 19 staff nurses with at least three years general hospital training, supported by 23 probationers and 12 male nurses. It had a good reputation for training nurses and some applicants even travelled overseas to train there. A report (held at Bethlem’s Archives & Museum) from a nurse who trained at the Maudsley shows some of the work of a new trainee: “Apart from observation and simple treatment, nurses are trained in special investigations and therapy. They carry out many of the routine psychometric tests, help as technicians in the ward laboratories, and are instructors in occupational therapy”.

The Maudsley Hospital Medical School was established in 1924 and eventually became a well-respected teaching centre. In 1932, Mapother described it as “the main postgraduate school of mental medicine in England.” The Maudsley Hospital had initially struggled to secure funding from the Medical Research Council, and, to undertake further research and develop the Medical School, but a substantial grant was obtained in 1938 from American charity the Rockefeller Foundation. Originally, there was no provision for the treatment of children and the rapid growth in this patient population was unforeseen. A child guidance clinic was set up under the directorship of Dr William Moodie, the deputy medical superintendent, in 1928. The late 1920s and 1930s saw a rapid growth in the number of patients treated: this growth led to an ongoing building programme including a secure unit, completed in 1931, and an out-patients department, completed in 1933.

Links with Eugenic Research

Both Mapother and then deputy Aubrey Lewis supported involuntary eugenic sterilisation, unequivocally recommending it to the Brock Committee in 1932. Lewis was a member of the Eugenics Society and a 1934 chapter he authored is “remarkable for its total admiration for the German work and workers”. With the spread of National Socialist (Nazi) laws in Germany from 1933, however, they decried the Nazi conflation of therapy and punishment, a move partly attributed to political and funding expediency. The Maudsley maintained its links with Germany, taking on both pro-Nazis and Jewish emigres through fellowships provided by the Commonwealth Fund and, after 1935, large scale funds from the American Rockefeller Foundation. Eliot Slater continued to visit Munich through the 1930s and contributed to academic festivities honouring Nazi eugenicist Ernst Rudin. During this time, Maudsley psychiatry developed a distinctive combination of practical experimentation and intellectual scepticism. Influential psychiatrist Aubrey Lewis became clinical director of the Maudsley in 1936.

At the outbreak of the Second World War, and with the threat of air-raids, the Maudsley Hospital closed and staff dispersed to two locations: a temporary hospital at Mill Hill School in north London and Belmont Hospital in Sutton, Surrey. Staff returned to the Maudsley site in 1945 and three years later the Maudsley joined up with the Bethlem Royal Hospital to become partners in the newly established National Health Service (NHS).

Post-War

In the 1960s a group from the Maudsley Hospital attacked the use of lithium for mood disorders. The head, Aubrey Lewis, called it “dangerous nonsense”, and colleagues published that it was therapeutically ineffective. Their objections have recently been described as ‘poorly grounded’ and having steered practitioners away from a beneficial agent. In 1999, the Maudsley Hospital became part of the South London and Maudsley NHS Foundation Trust (“SLaM”), along with the Bethlem Royal Hospital.

Services

The trust manages one of the UK’s few biomedical research centres specialising in mental health. The centre, managed in partnership with the Institute of Psychiatry, King’s College London, is based on the Maudsley Hospital campus and funded by the NIHR.

Media

In 2013 South London and Maudsley NHS Foundation Trust (‘SLaM’) took part in a Channel 4 observational documentary entitled Bedlam. The final programme, “Breakdown”, focused on older adults, including those admitted to the Older Adults Ward at Maudsley Hospital.

What is Institutional Syndrome?

Introduction

In clinical and abnormal psychology, institutionalisation or institutional syndrome refers to deficits or disabilities in social and life skills, which develop after a person has spent a long period living in psychiatric hospitals, prisons or other remote institutions.

In other words, individuals in institutions may be deprived (whether unintentionally or not) of independence and of responsibility, to the point that once they return to “outside life” they are often unable to manage many of its demands; it has also been argued that institutionalised individuals become psychologically more prone to mental health problems.

The term institutionalisation can also be used to describe the process of committing an individual to a mental hospital or prison, or to describe institutional syndrome; thus the phrase “X is institutionalised” may mean either that X has been placed in an institution or that X is suffering the psychological effects of having been in an institution for an extended period of time.

Background

In Europe and North America, the trend of putting the mentally ill into mental hospitals began as early as the 17th century, and hospitals often focused more on “restraining” or controlling inmates than on curing them, although hospital conditions improved somewhat with movements for human treatment, such as moral management. By the mid-20th century, overcrowding in institutions, the failure of institutional treatment to cure most mental illnesses, and the advent of drugs such as Thorazine prompted many hospitals to begin discharging patients in large numbers, in the beginning of the deinstitutionalisation movement (the process of gradually moving people from inpatient care in mental hospitals, to outpatient care).

Deinstitutionalisation did not always result in better treatment, however, and in many ways it helped reveal some of the shortcomings of institutional care, as discharged patients were often unable to take care of themselves, and many ended up homeless or in jail. In other words, many of these patients had become “institutionalised” and were unable to adjust to independent living. One of the first studies to address the issue of institutionalisation directly was British psychiatrist Russell Barton’s 1959 book Institutional Neurosis, which claimed that many symptoms of mental illness (specifically, psychosis) were not physical brain defects as once thought, but were consequences of institutions’ “stripping” (a term probably first used in this context by Erving Goffman) away the “psychological crutches” of their patients.

Since the middle of the 20th century, the problem of institutionalisation has been one of the motivating factors for the increasing popularity of deinstitutionalisation and the growth of community mental health services, since some mental healthcare providers believe that institutional care may create as many problems as it solves.

Romanian children who suffered from severe neglect at a young age were adopted by families. Research reveals that the post-institutional syndrome occurring in these children gave rise to symptoms of autistic behaviour. Studies done on eight Romanian adoptees living in the Netherlands revealed that about one third of the children exhibited behavioural and communication problems resembling that of autism.

Issues for Discharged Patients

Individuals who suffer from institutional syndrome can face several kinds of difficulties upon returning to the community. The lack of independence and responsibility for patients within institutions, along with the ‘depressing’ and ‘dehumanising’ environment, can make it difficult for patients to live and work independently. Furthermore, the experience of being in an institution may often have exacerbated individuals’ illness: proponents of labelling theory claim that individuals who are socially “labelled” as mentally ill suffer stigmatisation and alienation that lead to psychological damage and a lessening of self-esteem, and thus that being placed in a mental health institution can actually cause individuals to become more mentally ill.

What is Bethlem Royal Hospital?

Introduction

Bethlem Royal Hospital, also known as St Mary Bethlehem, Bethlehem Hospital and Bedlam, is a psychiatric hospital in London. Its famous history has inspired several horror books, films and TV series, most notably Bedlam, a 1946 film with Boris Karloff.

Bethlem Royal Hospital Main Building.

The hospital is closely associated with King’s College London and, in partnership with the Institute of Psychiatry, Psychology and Neuroscience, is a major centre for psychiatric research. It is part of the King’s Health Partners academic health science centre and the NIHR Biomedical Research Centre for Mental Health.

Originally the hospital was near Bishopsgate just outside the walls of the City of London. It moved a short distance to Moorfields in 1676, and then to St George’s Fields in Southwark in 1815, before moving to its current location in Monks Orchard in 1930.

The word “bedlam”, meaning uproar and confusion, is derived from the hospital’s nickname. Although the hospital became a modern psychiatric facility, historically it was representative of the worst excesses of asylums in the era of lunacy reform.

1247 to 1633

Foundation

The hospital was founded in 1247 as the Priory of the New Order of our Lady of Bethlehem in the city of London during the reign of Henry III. It was established by the Bishop-elect of Bethlehem, the Italian Goffredo de Prefetti, following a donation of personal property by the London alderman and former sheriff, Simon FitzMary. The original location was in the parish of St Botolph, Bishopsgate’s ward, just beyond London’s wall and where the south-east corner of Liverpool Street Station now stands. Bethlem was not initially intended as a hospital, in the clinical sense, much less as a specialist institution for the insane, but as a centre for the collection of alms to support the Crusader Church and to link England to the Holy Land.

De Prefetti’s need to generate income for the Crusader Church and restore the financial fortunes of his see had been occasioned by two misfortunes: his bishopric had suffered significant losses following the destructive conquest of Bethlehem by the Khwarazmian Turks in 1244, and his immediate predecessor had further impoverished his cathedral chapter through the alienation of a considerable amount of its property. The priory, obedient to the Church of Bethlehem, would also house the poor and, if they visited, provide hospitality to the bishop, canons and brothers of Bethlehem. Thus, Bethlem became a hospital, in medieval usage, “an institution supported by charity or taxes for the care of the needy”. The subordination of the priory’s religious order to the bishops of Bethlehem was further underlined in the foundational charter, which stipulated that the prior, canons and inmates were to wear a star upon their cloaks and capes to symbolise their obedience to the church of Bethlehem.

Politics and Patronage

During the thirteenth and fourteenth centuries, with its activities underwritten by episcopal and papal indulgences, the hospital’s role as a centre for alms collection persisted, but its linkage to the Order of Bethlehem increasingly unravelled, putting its purpose and patronage in doubt. In 1346 the master of Bethlem, a position at that time granted to the most senior of London’s Bethlemite brethren, applied to the city authorities seeking protection; thereafter metropolitan office-holders claimed power to oversee the appointment of masters and demanded in return an annual payment of 40 shillings. It is doubtful whether the city really provided substantial protection and much less that the mastership fell within their patronage but, dating from the 1346 petition, it played a role in the management of Bethlem’s finances. By this time the Bethlehemite bishops had relocated to Clamecy, France, under the surety of the Avignon papacy. This was significant as, throughout the reign of Edward III (1327-1377), the English monarchy had extended its patronage over ecclesiastical positions through the seizure of priories under the control of non-English religious houses. As a dependent house of the Order of Saint Bethlehem in Clamecy, Bethlem was vulnerable to seizure by the crown and this occurred in the 1370s when Edward III took control. The purpose of this appropriation was, in the context of the Hundred Years’ War between France and England, to prevent funds raised by the hospital from enriching the French monarchy via the papal court. After this event the masters of the hospital, semi-autonomous figures in charge of its day-to-day management, were normally crown appointees and it became an increasingly secularised institution. The memory of its foundation became muddied and muddled; in 1381 the royal candidate for the post of master claimed that from its beginnings it had been superintended by an order of knights and he confused its founder, Goffredo de Prefetti, with the Frankish crusader, Godfrey de Bouillon. The removal of the last symbolic link to the Bethlehemites was confirmed in 1403 when it was reported that master and inmates no longer wore the star of Bethlehem

In 1546 the Lord Mayor of London, Sir John Gresham, petitioned the crown to grant Bethlem to the city. This petition was partially successful and Henry VIII reluctantly ceded to the City of London “the custody, order and governance” of the hospital and of its “occupants and revenues”. This charter came into effect in 1547. The crown retained possession of the hospital while its administration fell to the city authorities. Following a brief interval when it was placed under the management of the governors of Christ’s Hospital, from 1557 it was administered by the governors of Bridewell, a prototype house of correction at Blackfriars. Having been thus one of the few metropolitan hospitals to have survived the dissolution of the monasteries physically intact, this joint administration continued, not without interference by both the crown and city, until incorporation into the National Health Service in 1948.

From Bethlem to Bedlam

It is unknown when Bethlem, or Bedlam, began to specialise in the care and control of the insane, but it has been frequently asserted that Bethlem was first used for the insane from 1377. This date is derived from the unsubstantiated conjecture of the Reverend Edward Geoffrey O’Donoghue, chaplain to the hospital, who published a monograph on its history in 1914. While it is possible that Bethlem was receiving the insane during the late fourteenth century, the first definitive record of their presence in the hospital is in the details of a visitation of the Charity Commissioners in 1403. This recorded that amongst other patients there were six male inmates who were “mente capti”, a Latin term indicating insanity. The report of the visitation also noted the presence of four pairs of manacles, 11 chains, six locks and two pairs of stocks but it is not clear if any or all of these items were for the restraint of the inmates. While mechanical restraint and solitary confinement are likely to have been used for those regarded as dangerous, little else is known of the actual treatment of the insane for much of the medieval period. The presence of a small number of insane patients in 1403 marks Bethlem’s gradual transition from a diminutive general hospital into a specialist institution for the confinement of the insane. This process was largely completed by 1460.

From the fourteenth century, Bethlem had been referred to colloquially as “Bedleheem”, “Bedleem” or “Bedlam”. Initially “Bedlam” was an informal name but from approximately the Jacobean era the word entered everyday speech to signify a state of madness, chaos, and the irrational nature of the world. This development was partly due to Bedlam’s staging in several plays of the Jacobean and Caroline periods, including The Honest Whore, Part I (1604); Northward Ho (1607); The Duchess of Malfi (1612); The Pilgrim (c. 1621); and The Changeling (1622). This dramatic interest in Bedlam is also evident in references to it in early seventeenth-century plays such as Epicœne, or The Silent Woman (1609), Bartholomew Fair (1614), and A New Way to Pay Old Debts (c. 1625). The appropriation of Bedlam as a theatrical locale for the depiction of madness probably owes no little debt to the establishment in 1576 in nearby Moorfields of The Curtain and The Theatre, two of the main London playhouses; it may also have been coincident with that other theatricalisation of madness as charitable object, the commencement of public visiting at Bethlem.

Management

The position of master was a sinecure largely regarded by its occupants as means of profiting at the expense of the poor in their charge. The appointment of the masters, later known as keepers, had lain within the patronage of the crown until 1547. Thereafter the city, through the Court of Aldermen, took control and, as with the King’s appointees, the office was used to reward loyal servants and friends. Compared to the masters placed by the monarch, those who gained the position through the city were of much more modest status. In 1561 the Lord Mayor succeeded in having his former porter, Richard Munnes, a draper by trade, appointed to the position. The sole qualification of his successor in 1565, a man by the name of Edward Rest, appears to have been his occupation as a grocer. Rest died in 1571, at which point the keepership passed on to John Mell in 1576, known for his abuse of “the governors, those who gave money to the poor, and the poor themselves.” The Bridewell Governors largely interpreted the role of keeper as that of a house manager and this is clearly reflected in the occupations of most appointees as they tended to be inn-keepers, victualers or brewers and the like. When patients were sent to Bethlem by the Governors of the Bridewell the keeper was paid from hospital funds. For the remainder, keepers were paid either by the families and friends of inmates or by the parish authorities. It is possible that keepers negotiated their fees for these latter categories of patients.

John Mell’s death in 1579 left the keepership open for the long-term keeper Roland Sleford, a London cloth-maker, who left his post in 1598, apparently of his own volition, after a 19-year tenure. Two months later, the Bridewell Governors, who had until then shown little interest in the management of Bethlem beyond the appointment of keepers, conducted an inspection of the hospital and a census of its inhabitants for the first time in over 40 years. Their purpose was “to view and p[er]use the defaultes and want of rep[ar]ac[i]ons”. They found that during the period of Sleford’s keepership the hospital buildings had fallen into a deplorable condition with the roof caving in and the kitchen sink blocked, and reported that “…it is not fitt for anye man to dwell in wch was left by the Keeper for that it is so loathsomly filthely kept not fit for any man to come into the house”.

The committee of inspection found 21 inmates with only two having been admitted during the previous 12 months. Of the remainder, six at least had been resident for a minimum of eight years and one inmate had been there for around 25 years. Three were from outside London, six were charitable cases paid for out of the hospital’s resources, one was supported by a parochial authority, and the rest were provided for by family, friends, benefactors or, in one instance, out of their own funds. The reason for the Governors’ new-found interest in Bethlem is unknown but it may have been connected to the increased scrutiny the hospital was coming under with the passing of poor law legislation in 1598 and to the decision by the Governors to increase hospital revenues by opening it up to general visitors as a spectacle. After this inspection, the Governors initiated some repairs and visited the hospital at more frequent intervals. During one such visit in 1607 they ordered the purchase of clothing and eating vessels for the inmates, presumably indicating the lack of such basic items.

Helkiah Crooke

At the bidding of James VI and I, Helkiah Crooke (1576-1648) was appointed keeper-physician in 1619. As a Cambridge graduate, the author of an enormously successful English language book of anatomy entitled Microcosmographia: a Description of the Body of Man (1615) and a member of the medical department of the royal household, he was clearly of higher social status than his city-appointed predecessors (his father was a noted preacher, and his elder brother Thomas was created a baronet). Crooke had successfully ousted the previous keeper, the layman Thomas Jenner, after a campaign in which he had castigated his rival for being “unskilful in the practice of medicine”. While this may appear to provide evidence of the early recognition by the Governors that the inmates of Bethlem required medical care, the formal conditions of Crooke’s appointment did not detail any required medical duties. Indeed, the Board of Governors continued to refer to the inmates as “the poore” or “prisoners” and their first designation as patients appears to have been by the Privy Council in 1630.

From 1619, Crooke unsuccessfully campaigned through petition to the king for Bethlem to become an independent institution from the Bridewell, a move that while likely meant to serve both monarchial and personal interest would bring him into conflict with the Bridewell Governors. Following a pattern of management laid down by early office-holders, his tenure as keeper was distinguished by his irregular attendance at the hospital and the avid appropriation of its funds as his own. Such were the depredations of his regime that an inspection by the Governors in 1631 reported that the patients were “likely to starve”. Charges against his conduct were brought before the Governors in 1632. Crooke’s royal favour having dissolved with the death of James I, Charles I instigated an investigation against him in the same year. This established his absenteeism and embezzlement of hospital resources and charged him with failing to pursue “any endeavour for the curing of the distracted persons”. It also revealed that charitable goods and hospital-purchased foodstuffs intended for patients had been typically misappropriated by the hospital steward, either for his own use or to be sold to the inmates. If patients lacked resources to trade with the steward they often went hungry. These findings resulted in the dismissal in disgrace of Crooke, the last of the old-style keepers, along with his steward on 24 May 1633.

Conditions

In 1632 it was recorded that the old house of Bethlem had “below stairs a parlour, a kitchen, two larders, a long entry throughout the house, and 21 rooms wherein the poor distracted people lie, and above the stairs eight rooms more for servants and the poor to lie in”. It is likely that this arrangement was not significantly different in the sixteenth century. Although inmates, if deemed dangerous or disturbing, were chained up or locked up, Bethlem was an otherwise open building with its inhabitants at liberty to roam around its confines and possibly the local neighbourhood. The neighbouring inhabitants would have been quite familiar with the condition of the hospital as in the 1560s, and probably for some considerable time before that, those who lacked a lavatory in their own homes had to walk through “the west end of the long house of Bethlem” to access the rear of the hospital and reach the “common Jacques”. Typically the hospital appears to have been a receptacle for the very disturbed and troublesome and this fact lends some credence to accounts such as that provided by Donald Lupton in the 1630s who described the “cryings, screechings, roarings, brawlings, shaking of chaines, swearings, frettings, chaffings” that he observed.

Bethlem had been built over a sewer that served both the hospital and its precinct. This common drain regularly blocked, resulting in overflows of waste at the entrance of the hospital. The 1598 visitation by the Governors had observed that the hospital was “filthely kept”, but the Governors rarely made any reference to the need for staff to clean the hospital. The level of hygiene reflected the inadequate water supply, which, until its replacement in 1657, consisted of a single wooden cistern in the back yard from which water had to be laboriously transported by bucket. In the same yard since at least the early seventeenth century there was a “washhouse” to clean patients’ clothes and bedclothes and in 1669 a drying room for clothes was added. Patients, if capable, were permitted to use the “house of easement”, of which there were two at most, but more frequently “piss-pots” were used in their cells. Unsurprisingly, inmates left to brood in their cells with their own excreta were, on occasion, liable to throw such “filth & Excrem[en]t” into the hospital yard or onto staff and visitors. Lack of facilities combined with patient incontinence and prevalent conceptions of the mad as animalistic and dirty, fit to be kept on a bed of straw, appear to have promoted an acceptance of hospital squalor. However, this was an age with very different standards of public and personal hygiene when people typically were quite willing to urinate or defecate in the street or even in their own fireplaces.

For much of the seventeenth century the dietary provision for patients appears to have been inadequate. This was especially so during Crooke’s regime, when inspection found several patients suffering from starvation. Corrupt staff practices were evidently a significant factor in patient malnourishment and similar abuses were noted in the 1650s and 1670s. The Governors failed to manage the supply of victuals, relying on “gifts in kind” for basic provisions, and the resources available to the steward to purchase foodstuffs was dependent upon the goodwill of the keeper. Patients were fed twice a day on a “lowering diet” (an intentionally reduced and plain diet) consisting of bread, meat, oatmeal, butter, cheese and generous amounts of beer. It is likely that daily meals alternated between meat and dairy products, almost entirely lacking in fruit or vegetables. That the portions appear to have been inadequate also likely reflected contemporary humoral theory that justified rationing the diet of the mad, the avoidance of rich foods, and a therapeutics of depletion and purgation to restore the body to balance and restrain the spirits.

1634 to 1791

Medical Regime

The year 1634 is typically interpreted as denoting the divide between the mediaeval and early modern administration of Bethlem. It marked the end of the day-to-day management by an old-style keeper-physician and its replacement by a three-tiered medical regime composed of a non-resident physician, a visiting surgeon and an apothecary, a model adopted from the royal hospitals. The medical staff were elected by the Court of Governors and, in a bid to prevent profiteering at the expense of patients that had reached its apogee in Crooke’s era, they were all eventually salaried with limited responsibility for the financial affairs of the hospital. Personal connections, interests and occasionally royal favour were pivotal factors in the appointment of physicians, but by the measure of the times appointees were well qualified as almost all were Oxbridge graduates and a significant number were either candidates or fellows of the College of Physicians. Although the posts were strongly contested, nepotistic appointment practices played a significant role. The election of James Monro as physician in 1728 marked the beginning of a 125-year Monro family dynasty extending through four generations of fathers and sons. Family influence was also significant in the appointment of surgeons but absent in that of apothecaries.

The office of physician was largely an honorary and charitable one with only a nominal salary. As with most hospital posts, attendance was required only intermittently and the greater portion of the income was derived from private practice. Bethlem physicians, maximising their association with the hospital, typically earned their coin in the lucrative “trade in lunacy” with many acting as visiting physicians to, presiding over, or even, as with the Monros and their predecessor Thomas Allen, establishing their own mad-houses. Initially both surgeons and apothecaries were also without salary and their hospital income was solely dependent upon their presentation of bills for attendance to the Court of Governors. This system was frequently abused and the bills presented were often deemed exorbitant by the Board of Governors. The problem of financial exploitation was partly rectified in 1676, when surgeons received a salary, and from the mid-eighteenth century elected apothecaries were likewise salaried and normally resident within the hospital. Dating from this latter change, the vast majority of medical responsibilities within the institution were undertaken by the sole resident medical officer, the apothecary, owing to the relatively irregular attendance of the physician and surgeon.

The medical regime, being married to a depletive or antiphlogistic physic until the early nineteenth century, had a reputation for conservatism that was neither unearned nor, given the questionable benefit of some therapeutic innovations, necessarily ill-conceived in every instance. Bathing was introduced in the 1680s at a time when hydrotherapy was enjoying a recrudescence in popularity. “Cold bathing”, opined John Monro, Bethlem physician for 40 years from 1751, “has in general an excellent effect”; and remained much in vogue as a treatment throughout the eighteenth century. By the early nineteenth century, bathing was routine for all patients of sufficient hardiness from summer “to the setting-in of the cold weather”. Spring signalled recourse to the traditional armamentarium; from then until the end of summer Bethlem’s “Mad Physick” reigned supreme as all patients, barring those deemed incurable, could expect to be bled and blistered and then dosed with emetics and purgatives. Indiscriminately applied, these curative measures were administered with the most cursory physical examination, if any, and with sufficient excess to risk not only health but also life. Such was the violence of the standard medical course, “involving voiding of the bowels, vomiting, scarification, sores and bruises,” that patients were regularly discharged or refused admission if they were deemed unfit to survive the physical onslaught.

The reigning medical ethos was the subject of public debate in the mid-eighteenth century when a paper war erupted between John Monro and his rival William Battie, physician to the reformist St Luke’s Asylum of London, founded in 1751. The Bethlem Governors, who had presided over the only public asylum in Britain until the early eighteenth century, looked upon St Luke’s as an upstart institution and Battie, formerly a Governor at Bethlem, as traitorous. In 1758 Battie published his Treatise on Madness which castigated Bethlem as archaic and outmoded, uncaring of its patients and founded upon a despairing medical system whose therapeutic transactions were both injudicious and unnecessarily violent. In contrast, Battie presented St Luke’s as a progressive and innovative hospital, oriented towards the possibility of cure and scientific in approach. Monro responded promptly, publishing Remarks on Dr. Battie’s Treatise on Madness in the same year.

Bethlem Rebuilt at Moorfields

Although Bethlem had been enlarged by 1667 to accommodate 59 patients, the Court of Governors of Bethlem and Bridewell observed at the start of 1674 that “the Hospitall House of Bethlem is very olde, weake & ruinous and to[o] small and streight for keepeing the greater numb[e]r of lunaticks therein att p[re]sent”. With the increasing demand for admission and the inadequate and dilapidated state of the building it was decided to rebuild the hospital in Moorfields, just north of the city proper and one of the largest open spaces in London. The architect chosen for the new hospital, which was built rapidly and at great expense between 1675 and 1676, was the natural philosopher and City Surveyor Robert Hooke. He constructed an edifice that was monumental in scale at over 500 feet (150 m) wide and some 40 feet (12 m) deep.[n 8] The surrounding walls were some 680 feet (210 m) long and 70 feet (21 m) deep while the south face at the rear was effectively screened by a 714-foot (218 m) stretch of London’s ancient wall projecting westward from nearby Moorgate. At the rear and containing the courtyards where patients exercised and took the air, the walls rose to 14 feet (4.3 m) high. The front walls were only 8 feet (2.4 m) high but this was deemed sufficient as it was determined that “Lunatikes… are not to [be] permitted to walk in the yard to be situate[d] betweene the said intended new Building and the Wall aforesaid.” It was also hoped that by keeping these walls relatively low the splendour of the new building would not be overly obscured. This concern to maximise the building’s visibility led to the addition of six gated openings 10 feet (3.0 m) wide which punctuated the front wall at regular intervals, enabling views of the façade. Functioning as both advertisement and warning of what lay within, the stone pillars enclosing the entrance gates were capped by the figures of “Melancholy” and “Raving Madness” carved in Portland stone by the Danish-born sculptor Caius Gabriel Cibber.

At the instigation of the Bridewell Governors and to make a grander architectural statement of “charitable munificence”, the hospital was designed as a single- rather than double-pile building, accommodating initially 120 patients. Having cells and chambers on only one side of the building facilitated the dimensions of the great galleries, essentially long and capacious corridors, 13 feet (4.0 m) high and 16 feet (4.9 m) wide, which ran the length of both floors to a total span of 1,179 feet (359 m). Such was their scale that Roger L’Estrange remarked in a 1676 text eulogising the new Bethlem that their “Vast Length … wearies the travelling eyes’ of Strangers”. The galleries were constructed more for public display than for the care of patients as, at least initially, inmates were prohibited from them lest “such persons that come to see the said Lunatickes may goe in Danger of their Lives”.

The architectural design of the new Bethlem was primarily intended to project an image of the hospital and its governors consonant with contemporary notions of charity and benevolence. In an era prior to the state funding of hospitals and with patient fees covering only a portion of costs, such self-advertisement was necessary to win the donations, subscriptions and patronage essential for the institution’s survival. This was particularly the case in raising funds to pay for major projects of expansion such as the rebuilding project at Moorfields or the addition of the Incurables Division in 1725-1739 with accommodation for more than 100 patients. These highly visible acts of civic commitment could also serve to advance the claims to social status or political advantage of its Governors and supporters. However, while consideration of patients’ needs may have been distinctly secondary, they were not absent. For instance, both the placement of the hospital in the open space of Moorfields and the form of the building with its large cells and well-lit galleries had been chosen to provide “health and Aire” in accordance with the miasmatic theory of disease causation.

It was London’s first major charitable building since the Savoy Hospital (1505-1517) and one of only a handful of public buildings then constructed in the aftermath of the Great Fire of London (1666). It would be regarded, during this period at least, as one of the “Prime Ornaments of the City … and a noble Monument to Charity”. Not least due to the increase in visitor numbers that the new building allowed, the hospital’s fame and latterly infamy grew and this magnificently expanded Bethlem shaped English and international depictions of madness and its treatment.

Public Visiting

Visits by friends and relatives were allowed and it was expected that the family and friends of poor inmates would bring food and other essentials for their survival. Bethlem was and is best known for the fact that it also allowed public and casual visitors with no connection to the inmates. This display of madness as public show has often been considered the most scandalous feature of the historical Bedlam.

On the basis of circumstantial evidence, it is speculated that the Bridewell Governors may have decided as early as 1598 to allow public visitors as means of raising hospital income. The only other reference to visiting in the sixteenth-century is provided in a comment in Thomas More’s 1522 treatise The Four Last Things, where he observed that “thou shalt in Bedleem see one laugh at the knocking of his head against a post”. As More occupied a variety of official positions that might have occasioned his calling to the hospital and as he lived nearby, his visit provides no compelling evidence that public visitation was widespread during the sixteenth century. The first apparently definitive documentation of public visiting derives from a 1610 record which details Lord Percy’s payment of 10 shillings for the privilege of rambling through the hospital to view its deranged denizens. It was also at this time, and perhaps not coincidentally, that Bedlam was first used as a stage setting with the publication of The Honest Whore, Part I, in 1604.

Evidence that the number of visitors rose following the move to Moorfields is provided in the observation by the Bridewell Governors in 1681 of “the greate quantity of persons that come daily to see the said Lunatickes”. Eight years later the English merchant and author, Thomas Tryon, remarked disapprovingly of the “Swarms of People” that descended upon Bethlem during public holidays. In the mid-eighteenth-century a journalist of a topical periodical noted that at one time during Easter Week “one hundred people at least” were to be found visiting Bethlem’s inmates. Evidently Bethlem was a popular attraction, yet there is no credible basis to calculate the annual number of visitors. The claim, still sometimes made, that Bethlem received 96,000 visitors annually is speculative in the extreme. Nevertheless, it has been established that the pattern of visiting was highly seasonal and concentrated around holiday periods. As Sunday visiting was severely curtailed in 1650 and banned seven years later, the peak periods became Christmas, Easter and Whitsun.

The Governors actively sought out “people of note and quallitie” – the educated, wealthy and well-bred – as visitors. The limited evidence would suggest that the Governors enjoyed some success in attracting such visitors of “quality”. In this elite and idealised model of charity and moral benevolence the necessity of spectacle, the showing of the mad so as to excite compassion, was a central component in the elicitation of donations, benefactions and legacies. Nor was the practice of showing the poor and unfortunate to potential donators exclusive to Bethlem as similar spectacles of misfortune were performed for public visitors to the Foundling Hospital and Magdalen Hospital for Penitent Prostitutes. The donations expected of visitors to Bethlem – there never was an official fee – probably grew out of the monastic custom of alms giving to the poor. While a substantial proportion of such monies undoubtedly found their way into the hands of staff rather than the hospital poors’ box, Bethlem profited considerably from such charity, collecting on average between £300 and £350 annually from the 1720s until the curtailment of visiting in 1770. Thereafter the poors’ box monies declined to about £20 or £30 per year.

Aside from its fund-raising function, the spectacle of Bethlem offered moral instruction for visiting strangers. For the “educated” observer Bedlam’s theatre of the disturbed might operate as a cautionary tale providing a deterrent example of the dangers of immorality and vice. The mad on display functioned as a moral exemplum of what might happen if the passions and appetites were allowed to dethrone reason. As one mid-eighteenth-century correspondent commented: “[there is no] better lesson [to] be taught us in any part of the globe than in this school of misery. Here we may see the mighty reasoners of the earth, below even the insects that crawl upon it; and from so humbling a sight we may learn to moderate our pride, and to keep those passions within bounds, which if too much indulged, would drive reason from her seat, and level us with the wretches of this unhappy mansion”.

Whether “persons of quality” or not, the primary allure for visiting strangers was neither moral edification nor the duty of charity but its entertainment value. In Roy Porter’s memorable phrase, what drew them “was the frisson of the freakshow”, where Bethlem was “a rare Diversion” to cheer and amuse. It became one of a series of destinations on the London tourist trail which included such sights as the Tower, the Zoo, Bartholomew Fair, London Bridge and Whitehall. Curiosity about Bethlem’s attractions, its “remarkable characters”, including figures such as Nathaniel Lee, the dramatist, and Oliver Cromwell’s porter, Daniel, was, at least until the end of the eighteenth-century, quite a respectable motive for visiting.

From 1770 free public access ended with the introduction of a system whereby visitors required a ticket signed by a Governor. Visiting subjected Bethlem’s patients to many abuses, including being poked with sticks by visitors or otherwise taunted, given drinks and physically assaulted or sexually harassed, but its curtailment removed an important element of public oversight. In the period thereafter, with staff practices less open to public scrutiny, the worst patient abuses occurred.

1791 to 1900

Despite its palatial pretensions, by the end of the eighteenth century Bethlem was suffering physical deterioration with uneven floors, buckling walls and a leaking roof. It resembled “a crazy carcass with no wall still vertical – a veritable Hogarthian auto-satire”. The financial cost of maintaining the Moorfields building was onerous and the capacity of the Governors to meet these demands was stymied by shortfalls in Bethlem’s income in the 1780s occasioned by the bankruptcy of its treasurer; further monetary strains were imposed in the following decade by inflationary wage and provision costs in the context of the Revolutionary wars with France. In 1791, Bethlem’s Surveyor, Henry Holland, presented a report to the Governors detailing an extensive list of the building’s deficiencies including structural defects and uncleanliness and estimated that repairs would take five years to complete at a cost of £8,660: only a fraction of this sum was allocated and by the end of the decade it was clear that the problem had been largely unaddressed. Holland’s successor to the post of Surveyor, James Lewis, was charged in 1799 with compiling a new report on the building’s condition. Presenting his findings to the Governors the following year, Lewis declared the building “incurable” and opined that further investment in anything other than essential repairs would be financially imprudent. He was, however, careful to insulate the Governors from any criticism concerning Bethlem’s physical dilapidation as, rather than decrying either Hooke’s design or the structural impact of additions, he castigated the slipshod nature of its rapid construction. Lewis observed that it had been partly built on land called “the Town Ditch”, a receptacle for rubbish, and this provided little support for a building whose span extended to over 500 feet (150 m). He also noted that the brickwork was not on any foundation but laid “on the surface of the soil, a few inches below the present floor”, while the walls, overburdened by the weight of the roofs, were “neither sound, upright nor level”.

Bethlem Rebuilt at St George’s Fields

While the logic of Lewis’s report was clear, the Court of Governors, facing continuing financial difficulties, only resolved in 1803 behind the project of rebuilding on a new site, and a fund-raising drive was initiated in 1804. In the interim, attempts were made to rehouse patients at local hospitals and admissions to Bethlem, sections of which were deemed uninhabitable, were significantly curtailed such that the patient population fell from 266 in 1800 to 119 in 1814. Financial obstacles to the proposed move remained significant. A national press campaign to solicit donations from the public was launched in 1805. Parliament was successfully lobbied to provide £10,000 for the fund under an agreement whereby the Bethlem Governors would provide permanent accommodation for any lunatic soldiers or sailors of the French Wars. Early interest in relocating the hospital to a site at Gossey Fields had to be abandoned due to financial constraints and stipulations in the lease for Moorfields that precluded its resale. Instead, the Governors engaged in protracted negotiations with the City to swap the Moorfields site for another municipally owned location at St. George’s Fields in Southwark, south of the Thames. The swap was concluded in 1810 and provided the Governors with a 12 acres (4.9 ha; 0.019 sq mi) site in a swamp-like, impoverished, highly populated, and industrialised area where the Dog and Duck tavern and St George’s Spa had been.

A competition was held to design the new hospital at Southwark in which the noted Bethlem patient James Tilly Matthews was an unsuccessful entrant. The Governors elected to give James Lewis the task. Incorporating the best elements from the three winning competition designs, he produced a building in the neoclassical style that, while drawing heavily on Hooke’s original plan, eschewed the ornament of its predecessor. Completed after three years in 1815, it was constructed during the first wave of county asylum building in England under the County Asylum Act (“Wynn’s Act”) of 1808.] Extending to 580 feet (180 m) in length, the new hospital, which ran alongside the Lambeth Road, consisted of a central block with two wings of three storeys on either side.[186] Female patients occupied the west wing and males the east; as at Moorfields, the cells were located off galleries that traversed each wing. Each gallery contained only one toilet, a sink and cold baths. Incontinent patients were kept on beds of straw in cells in the basement gallery; this space also contained rooms with fireplaces for attendants. A wing for the criminally insane – a legal category newly minted in the wake of the trial of a delusional James Hadfield for attempted regicide – was completed in 1816. This addition, which housed 45 men and 15 women, was wholly financed by the state.

The first 122 patients arrived in August 1815 having been transported to their new residence by a convoy of Hackney coaches. Problems with the building were soon noted as the steam heating did not function properly, the basement galleries were damp and the windows of the upper storeys were unglazed “so that the sleeping cells were either exposed to the full blast of cold air or were completely darkened”. Although glass was placed in the windows in 1816, the Governors initially supported their decision to leave them unglazed on the basis that it provided ventilation and so prevented the build-up of “the disagreable effluvias peculiar to all madhouses”. Faced with increased admissions and overcrowding, new buildings, designed by the architect Sydney Smirke, were added from the 1830s. The wing for criminal lunatics was increased to accommodate a further 30 men while additions to the east and west wings, extending the building’s façade, provided space for an additional 166 inmates and a dome was added to the hospital chapel. At the end of this period of expansion Bethlem had a capacity for 364 patients.

1815-1816 Parliamentary Inquiry

The late eighteenth and early nineteenth centuries are typically seen as decisive in the emergence of new attitudes towards the management and treatment of the insane. Increasingly, the emphasis shifted from the external control of the mad through physical restraint and coercion to their moral management whereby self-discipline would be inculcated through a system of reward and punishment. For proponents of lunacy reform, the Quaker-run York Retreat, founded in 1796, functioned as an exemplar of this new approach that would seek to re-socialise and re-educate the mad. Bethlem, embroiled in scandal from 1814 over its inmate conditions, would come to symbolise its antithesis.

Through newspaper reports initially and then evidence given to the 1815 Parliamentary Committee on Madhouses, the state of inmate care in Bethlem was chiefly publicised by Edward Wakefield, a Quaker land agent and leading advocate of lunacy reform. He visited Bethlem several times during the late spring and early summer of 1814. His inspections were of the old hospital at the Moorfields site, which was then in a state of disrepair; much of it was uninhabitable and the patient population had been significantly reduced. Contrary to the tenets of moral treatment, Wakefield found that the patients in the galleries were not classified in any logical manner as both highly disturbed and quiescent patients were mixed together indiscriminately. Later, when reporting on the chained and naked state of many patients, Wakefield sought to describe their conditions in such a way as to maximise the horror of the scene while decrying the apparently bestial treatment of inmates and the thuggish nature of the asylum keepers. Wakefield’s account focused on one patient in particular, James Norris, an American marine reported to be 55 years of age who had been detained in Bethlem since 01 February 1800. Housed in the incurable wing of the hospital, Norris had been continuously restrained for about a decade in a harness apparatus which severely restricted his movement. Wakefield stated that:

… a stout iron ring was riveted about his neck, from which a short chain passed to a ring made to slide upwards and downwards on an upright massive iron bar, more than six feet high, inserted into the wall. Round his body a strong iron bar about two inches wide was riveted; on each side of the bar was a circular projection, which being fashioned to and enclosing each of his arms, pinioned them close to his sides. This waist bar was secured by two similar iron bars which, passing over his shoulders, were riveted to the waist both before and behind. The iron ring about his neck was connected to the bars on his shoulders by a double link. From each of these bars another short chain passed to the ring on the upright bar … He had remained thus encaged and chained more than twelve years.

Wakefield’s revelations, combined with earlier reports about patient maltreatment at the York Asylum, helped to prompt a renewed campaign for national lunacy reform and the establishment of an 1815 House of Commons Select Committee on Madhouses, which examined the conditions under which the insane were confined in county asylums, private madhouses, charitable asylums and in the lunatic wards of Poor-Law workhouses.

In June 1816 Thomas Monro, Principal Physician, resigned as a result of scandal when he was accused of ‘wanting in humanity’ towards his patients.

Dr T.B. Hyslop came to the hospital in 1888 and rose to be physician in charge, bringing the hospital into the 20th century and retiring in 1911.

1930 to the Present

In 1930, the hospital moved to the suburbs of Croydon, on the site of Monks Orchard House between Eden Park, Beckenham, West Wickham and Shirley. The old hospital and its grounds were bought by Lord Rothermere and presented to the London County Council for use as a park; the central part of the building was retained and became home to the Imperial War Museum in 1936. The hospital was absorbed into the National Health Service in 1948.

750th Anniversary and “Reclaim Bedlam” Campaign

In 1997 the hospital started planning celebrations of its 750th anniversary. The service user’s perspective was not to be included, however, and members of the psychiatric survivors movement saw nothing to celebrate in either the original Bedlam or in the current practices of mental health professionals towards those in need of care. A campaign called “Reclaim Bedlam” was launched by Pete Shaughnessy, supported by hundreds of patients and ex-patients and widely reported in the media. A sit-in was held outside the earlier Bedlam site at the Imperial War Museum. The historian Roy Porter called the Bethlem Hospital “a symbol for man’s inhumanity to man, for callousness and cruelty.”

Recent Developments

In 1997, the Bethlem Gallery was established to showcase the work of artists that have experienced mental distress.

In 1999, Bethlem Royal Hospital became part of the South London and Maudsley NHS Foundation Trust (“SLaM”), along with the Maudsley Hospital in Camberwell, and the merger of mental health services in Lambeth and Lewisham took place.

In 2001, SLaM sought planning permission for an expanded Medium Secure Unit and extensive works to improve security, much of which would be on Metropolitan Open Land. Local residents’ groups organised mass meetings to oppose the application, with accusations that it was unfair that most patients could be from inner London areas and were, therefore, not locals and that drug use was rife in and around the hospital. Bromley Council refused the application, with Croydon Council also objecting. However the Office of the Deputy Prime Minister overturned the decision in 2003 and development started. The 89-bed, £33.5m unit (River House) opened in February 2008. It is the most significant development on the site since the hospital opened in 1930.

Fatal Restraints

Olaseni Lewis (known as Seni; aged 23) died in 2010 at Bethlem Royal Hospital after police subjected him to prolonged restraint of a type known to be dangerous. Neither police nor medical staff intervened when Lewis became unresponsive. At coroner’s inquest, the jury found many failures by both police and medical staff which played a part in Lewis’s death. They said “The excessive force, pain compliance techniques and multiple mechanical restraints were disproportionate and unreasonable. On the balance of probability, this contributed to the cause of death.” Ajibola Lewis, Olaseni Lewis’s mother, claimed a nurse at Maudsley hospital where Lewis had been earlier warned against allowing his transfer to Bethlem. “She said to me, ‘Look, don’t let him go to the Bethlem, don’t let him go there’,” his mother said. A doctor later persuaded her to take her son to Bethlem hospital. She was concerned about the conditions there. “It was a mess,” she told the court, “It was very confused, a lot of activity, a lot of shouting. I was not happy; I was confused.”

Police were trained to view Lewis’s behaviour as a medical emergency, but the jury found police failed to act on this. The jury found that “The police failed to follow their training, which requires them to place an unresponsive person into the recovery position and if necessary administer life support. On the balance of probability this also contributed to the cause of death.” A doctor did not act when Lewis became unresponsive while his heart rate dramatically slowed.

The Independent Police Complaints Commission first cleared officers over the death, but following pressure from the family, they scrapped the conclusions and started a new inquiry. The IPCC was planning disciplinary action against some of the police officers involved. Deborah Coles of the charity Inquest, who has supported the Lewis family throughout their campaign, said the jury had reached the most damning possible conclusions on the actions of police and medics. “This was a most horrific death. Eleven police officers were involved in holding down a terrified young man until his complete collapse, legs and hands bound in limb restraints, while mental health staff stood by. Officers knew the dangers of this restraint but chose to go against clear, unequivocal training. Evidence heard at this inquest begs the question of how racial stereotyping informed Seni’s brutal treatment.”

A disciplinary hearing conducted by the Metropolitan Police found the officers had not committed misconduct. The hearing was criticised by the family because it was held behind closed doors with neither press nor public scrutiny.

In 2014, Chris Brennan (aged 15) died of asphyxiation while at Bethlem hospital after repeated self-harming. The coroner found lack of proper risk assessment and lack of a care plan contributed to his death. The hospital claimed staffing problems and low morale were factors. Lessons were learned and the adolescent unit where Brennan died was assessed as good in 2016.

In November 2017, a bill was debated in the House of Commons that would require psychiatric hospitals to give more detailed information about how and when restraints are used. This bill is referred to as “Seni’s law”. In November 2018, the bill received Royal Assent as the Mental Health Units (Use of Force) Act 2018.

Facilities

The hospital includes specialist services such as the National Psychosis Unit.

Other services include the Bethlem Adolescent Unit, which provides care and treatment for young people aged 12-18 from across the UK.

The hospital has an occupational therapy department, which has its own art gallery, the Bethlem Gallery, displaying work of current and former patients.

The Bethlem Museum of the Mind features exhibits about the history of Bethlem Royal Hospital and the history of mental healthcare and treatment. It features a permanent collection of art created by some of its patients, as well as changing exhibitions.

Media

In 2013, the South London and Maudsley NHS Foundation Trust (SLaM) took part in a Channel 4 observational documentary, Bedlam. Staff and patients spent two years working with television company The Garden Productions. The four-part series started on 31 October.

The first programme, Anxiety, followed patients through the 18-bed Anxiety and Disorders Residential Unit. This national unit treats the most anxious people in the country – the top 1% – and claims a success rate of three in four patients.

The next programme was called Crisis; cameras were allowed in Lambeth Hospital’s Triage ward for the first time. In a postcode with the highest rates of psychosis in Europe, this is the Accident and Emergency of mental health, where patients are at their most unwell.

The third programme, Psychosis, films a community mental health team. South London and Maudsley NHS Foundation Trust provides support for more than 35,000 people with mental health problems.

The final programme, Breakdown, focuses on older adults, including the inpatient ward for people over 65 with mental health problems at Maudsley Hospital.

Notable Patients

  • Richard Dadd – artist.
  • John Frith – would-be assailant of King George III.
  • Mary Frith – also known as “Moll Cutpurse” or “The Roaring Girl”, released from Bedlam in 1644 according to Bridewell records.
  • Daniel M’Naghten – catalyst for the creation of the M’Naghten Rules (criteria for the defence of insanity in the British legal system) after the shooting of Edward Drummond.
  • Jonathan Martin – set fire to York Minster.
  • William Chester Minor – surgeon who was committed for murder; best known for being one of the largest contributors to the Oxford English Dictionary.
  • James Hadfield – would-be assassin of King George III.
  • Margaret Nicholson – would-be assassin of King George III.
  • Edward Oxford – tried for high treason after the attempted assassination of Queen Victoria and Prince Albert.
  • Augustus Welby Northmore Pugin (1812-1852) – English architect, best known for his work on the Houses of Parliament as well as many churches; in the last year of his life he suffered a breakdown, possibly due to hyperthyroidism, and was for a short period confined in Bethlem.
  • Hannah Snell (1723-1792) – a woman cross-dressing as a male soldier; spent the last six months of her life in Bethlem.
  • Bannister Truelock – conspirator who plotted to assassinate George III.
  • Louis Wain – artist.

Stacey Dooley: Back on the Psych Ward (2021)

Introduction

Stacey Dooley returns to Springfield Hospital to work with the team again, looking after patients over six months as they battle through the pandemic.

Refer to Stacey Dooley: On the Psych Ward (2020).

Outline

Mental health across society has worsened since the pandemic began. Stacey Dooley returns to Springfield Hospital, and over six months, including the second nationwide lockdown, works with the team to experience first-hand how the pandemic is impacting patients in crisis. Stacey assists staff as they treat a wide range of mental health conditions and takes part in the tough decisions necessary to keep patients safe.

Stacey meets Coral, who is brought into Springfield by the police one night after attempting to take her life. Coral tells Stacey and the team about her long-running battle with anxiety and depression, which she attempts to self-medicate by drinking alcohol.

The pandemic has seen a rise in suicidal behaviour, especially amongst young people. Stacey meets Oskar, a 20-year-old university student whose struggle with intense suicidal thoughts brings him into the hospital in crisis.

For those with pre-existing mental health conditions, waiting lists and delays to treatment caused by the pandemic are pushing them to breaking point. Suziee is diagnosed with emotionally unstable personality disorder, which causes extreme highs and lows to her moods. But with her therapy now cancelled, she is struggling to cope on her own and turns to the hospital for help.

Stacey also gets to know 21-year-old Ali, an inpatient at Springfield, which is home to the only inpatient unit of its kind in the country for those with severe obsessive compulsive disorder (OCD). Since childhood, Ali’s OCD rituals have changed from repetitive tapping during stressful exams and blinking to keep her parents safe in the car to extreme bathroom routines. For severe OCD cases like Ali’s, this ward is her last chance at beating this devastating condition, and over the months Stacey sees a dramatic change in Ali’s obsessions.

Production & Filming Details

  • Presenter(s):
    • Stacey Dooley.
  • Director(s):
    • Erica Jenkin.
    • Katie Rice.
  • Producer(s):
    • Gabi Adams … assistant producer.
    • Carla Grande … producer.
    • Erica Jenkin … producer.
    • Katie Rice … producer.
    • Brian Woods … producer.
  • Writer(s):
  • Music:
    • Alexander Parsons.
  • Cinematography:
  • Editor(s):
    • Paddy Garrick.
  • Production:
    • True Vision.
  • Distributor(s):
    • BBC Three (2021) (UK) (video).
  • Release Date: 13 April 2021 (Internet).
  • Running Time: 59 minutes.
  • Rating: TV-MA.
  • Country: UK.
  • Language: English.

What is a Mental Health Trust (UK)?

Introduction

A mental health trust provides health and social care services for people with mental health disorders in England.

There are 54 mental health trusts. They are commissioned and funded by clinical commissioning groups (CCG).

Patients usually access the services of mental health trusts through their general practitioner (GP; primary care medical doctor) or via a stay in hospital. Most of the services are for people who live in the region, although there may be specialist services for the whole of the UK or services that accept national referrals. Mental Health Trusts may or may not provide inpatient psychiatric hospital services themselves (they may form part of a general hospital run by a hospital trust). The various trusts work together and with local authorities and voluntary organisations to provide care.

Services

Services provided by mental health trusts vary but typically include:

  • Counselling sessions – one-to-one or in a group.
  • Courses – such as on how to deal with stress, anger, and bereavement. Courses may also be available for carers of those with mental health disorders.
  • Resources – such as leaflets and books on mental health issues.
  • Psychotherapy – treatment sessions with a therapist. Commonly cognitive behavioural therapy.
  • Family support – providing support to the family, friends, and carers of those with a mental health problem.
  • Community drug and alcohol clinics – helping people to cope with addiction.
  • Community mental health houses – supported housing to help people live in the community.
  • Day hospitals and day centres – short-term outpatient sessions with a psychiatrist, clinical psychologist or other mental health professional, and drop-in centres for peer support and therapeutic activities.

If more specialist hospital treatment is required, Mental Health Trusts will help with rehabilitation back into the community (social inclusion). Trusts may operate community mental health teams, which may include Crisis Resolution and Home Treatment, assertive outreach and early intervention services.

The Mental Health Act 1983, Mental Health Act 2007 and Mental Capacity Act 2005 cover the rights, assessment and treatment of people diagnosed with a mental disorder who are judged as requiring to be detained (“sectioned”) or treated against their will. A mental health trust will typically have a Mental Health Act team responsible for ensuring that the Act is administered correctly, including to protect the rights of inpatients, or of service users in the community who may now be under community treatment orders. The Care Quality Commission is the body with overall national responsibility for inspecting and regulating the operation of the mental health act by the regional trusts.

Capacity

According to the British Medical Association (BMA) the number of beds for psychiatric patients was reduced by 44% between 2001 and 2017. An average of 726 mental health patients were placed in institutions away from their home area in 2016.

Children of school age are normally treated through Child and Adolescent Mental Health Services (CAMHS), usually organised by local government area. Young people who become psychiatric in-patients frequently are treated in adult wards due to lack of beds in wards that are suitable for people of their ages. Young people frequently stay in hospital wards when they are fit for discharge because the mental health support facilities they need are not available where they live.

List of MHTs
These are the mental health trusts in the NHS in England in 2017 (note that many have NHS Foundation Trust status – a type of trust that has more independence from government):

  • 2gether NHS Foundation Trust.
  • 5 Boroughs Partnership NHS Foundation Trust.
  • Avon and Wiltshire Mental Health Partnership NHS Trust.
  • Barnet, Enfield and Haringey Mental Health NHS Trust.
  • Berkshire Healthcare NHS Foundation Trust.
  • Birmingham and Solihull Mental Health NHS Foundation Trust.
  • Bradford District Care Trust.
  • Cambridgeshire and Peterborough NHS Foundation Trust.
  • Camden and Islington NHS Foundation Trust.
  • Central and North West London NHS Foundation Trust.
  • Cheshire and Wirral Partnership NHS Foundation Trust.
  • Cornwall Partnership NHS Foundation Trust.
  • Coventry and Warwickshire Partnership NHS Trust.
  • Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust.
  • Derbyshire Healthcare NHS Foundation Trust.
  • Devon Partnership NHS Trust.
  • Dorset HealthCare University NHS Foundation Trust.
  • Dudley and Walsall Mental Health Partnership NHS Trust.
  • East London NHS Foundation Trust.
  • Greater Manchester Mental Health NHS Foundation Trust.
  • Humber NHS Foundation Trust.
  • Isle of Wight NHS Trust.
  • Kent and Medway NHS and Social Care Partnership Trust.
  • Lancashire Care NHS Foundation Trust.
  • Leeds and York Partnership NHS Foundation Trust.
  • Leicestershire Partnership NHS Trust.
  • Lincolnshire Partnership NHS Foundation Trust.
  • Mersey Care NHS Trust.
  • Norfolk and Suffolk NHS Foundation Trust.
  • North East London NHS Foundation Trust.
  • North Essex Partnership University NHS Foundation Trust.
  • North Staffordshire Combined Healthcare NHS Trust.
  • Northamptonshire Healthcare NHS Foundation Trust.
  • North Cumbria Integrated Care NHS Foundation Trust.
  • Nottinghamshire Healthcare NHS Trust.
  • Oxford Health NHS Foundation Trust.
  • Oxleas NHS Foundation Trust.
  • Pennine Care NHS Foundation Trust.
  • Rotherham Doncaster and South Humber NHS Foundation Trust.
  • Sheffield Health & Social Care NHS Foundation Trust.
  • Somerset Partnership NHS Foundation Trust.
  • South Essex Partnership University NHS Foundation Trust.
  • South London and Maudsley NHS Foundation Trust.
  • South Staffordshire and Shropshire Healthcare NHS Foundation Trust.
  • South West London and St George’s Mental Health NHS Trust.
  • South West Yorkshire Partnership NHS Foundation Trust.
  • Southern Health NHS Foundation Trust.
  • Surrey and Borders Partnership NHS Foundation Trust.
  • Sussex Partnership NHS Foundation Trust.
  • Tavistock and Portman NHS Foundation Trust.
  • Tees, Esk and Wear Valleys NHS Trust.
  • West London NHS Trust.
  • Worcestershire Health and Care NHS Trust.

What is the Eastern State Hospital (Virginia)?

Introduction

Eastern State Hospital is a psychiatric hospital in Williamsburg, Virginia. Built in 1773, it was the first public facility in the present-day United States constructed solely for the care and treatment of the mentally ill. The original building had burned but was reconstructed in 1985.

Francis Fauquier and the Enlightenment

Eastern State Hospital traces its foundation to a speech by Francis Fauquier, Royal Governor of the colony of Virginia, on 06 November 1766. At the House of Burgesses’ first meeting since the Stamp Act and Virginia Resolves, Fauquier primarily discussed the relationship between the Mother Country and these colonists, and expressed optimism for their future. His speech also unexpectedly addressed the mentally ill, as follows:

“It is expedient I should also recommend to your Consideration and Humanity a poor unhappy set of People who are deprived of their senses and wander about the Country, terrifying the Rest of their fellow creatures. A legal Confinement, and proper Provision, ought to be appointed for these miserable Objects, who cannot help themselves. Every civilized Country has an Hospital for these People, where they are confined, maintained and attended by able Physicians, to endeavor to restore to them their lost reason.”

About a year later, on 11 April 1767, Governor Fauquier addressed the same issue before the next House of Burgesses, thus:

“There is a subject which gives me concern, on which I shall particularly address myself to you, as it is your peculiar province to provide means for the subsistence of the poor of any kind. The subject I mean is the case of the poor lunatics. I find on your journals that it was Resolved, That an hospital be erected for the reception of persons who are so unhappy as to be deprived of their reason; And that it was Ordered, that the Committee of Propositions and Grievances do prepare and bring in a bill pursuant to the above resolution. But I do not find that any thing more was done in it. It was a measure which I think could offend no party, and which I was in hopes humanity would have dictated to every man, as soon as he was made acquainted with the call for it. It also concerns me much on another account; for as the case now stands, I am as it were compelled to the daily commission of an illegal act, by confining without my authority, a poor lunatic, who, if set at liberty, would be mischievous to society; and I would choose to be bound by, and observant of, the laws of the country. As I think this is a point of some importance to the ease and comfort of the whole community, as well as a point of charity to the unhappy objects, I shall again recommend it to you at your next meeting; when I hope, after mature reflection, it will be found to be more worth your attention than it has been in this.”

Governor Fauquier’s benevolent and bold expressions did eventually lead to the establishment of the Eastern State Hospital, although he died 03 March 1768, before it was built. His compassion and humanitarian care for those who needed it the most, made it easier for his ideas to be developed and a facility built.

Fauquier’s concern probably rested in Enlightenment principles, which were so widespread throughout the time. The 18th century was a time for rejecting superstitions and religions, and substituting science and logical reasoning. The philosophers David Hume and Voltaire were studying and investigating the worth of human life, which would ultimately alter perceptions of the mentally ill. During this time in London, insane people were viewed and used for as entertainment and comical relief. The Bethlehem Royal Hospital (sometimes called Bedlam) attracted many tourists and even held frequent parades of inmates. Enlightenment attitudes encouraged more sensitivity towards the mentally ill, rather than treating them as outcasts and fools. Some started to believe that being mentally ill was, in fact, an illness of the mind, much like a physical disease or sickness, and that these mental illnesses were also treatable.

Before Governor Fauquier’s speeches, a person who was mentally ill was not diagnosed by a doctor, but rather judged by 12 citizens, much like a jury, to be either a criminal, lunatic or Idiot. Most classified as lunatic were placed in the Public Gaol in Williamsburg. Taxpayers probably appreciated the hospital idea only if they had a family member or close friend who was mentally ill. The only hospital where mentally ill patients were sometimes taken before Eastern State Hospital was built, was the Pennsylvania Hospital, a Quaker institution in Philadelphia. Until a campaign by Benjamin Rush in 1792 to establish a separate treatment wing, mentally ill patients were kept in the basement and out of the way of regular patients who needed medical assistance.

Percival Goodhouse was is thought to be one of the first patients admitted to the Eastern State Hospital after its opening on 12 October 1773.

Civil War and Decline

In 1841, Dr. John Galt was appointed superintendent of the hospital, with roughly 125 patients (then called “inmates”) at the time. Dr. Galt introduced Moral treatment practices, a school of thought which viewed those with mental illness as deserving of respect and dignity rather than punishment for their behaviour. Galt provided his patients with talk therapy and occupational therapy, and argued for in-house research. He decreased the use of physical restraints, even going an entire year without using them, relying instead on calming drugs (including laudanum), and also proposed deinstitutionalizing patients in favour of community-based care, though this proposal was repeatedly rejected. As the head of the hospital, Galt was successful in pressing for admission for enslaved people with mental illness, and taught the enslaved people owned by the hospital to provide talk therapy alongside nurses and aides. Although he claimed to treat patients equally regardless of their race, Galt did not publish racial breakdowns of his patients.

When the Civil War came to Williamsburg, the hospital found itself alternately on one side of the lines and then the other. On 06 May 1862, Union troops captured the asylum. Two weeks later, on 17 or 18 May, Dr. Galt died of an overdose of laudanum, though it is unclear whether this was intentional or accidental. When the hospital was captured, Union soldiers found that the 252 patients had been locked in without food or supplies by the fleeing white employees. Somersett Moore was the only non-African American employee to return following the capture, and he gave the keys to release the patients to the occupying men.

In the following decades, the increasingly crowded hospital saw a regression in methodology as science was increasingly viewed as an ineffective means of dealing with mental illness. During this era of custodial care, the goal became not to cure patients, but to provide a comfortable environment for them, separate from society. On 07 June 1885, the original 1773 hospital burned to the ground due to a fire that had started in the building’s newly added electrical wiring, a consequence of the great expansion of facilities at this time.

Restoration

By 1935 Eastern State Hospital housed some 2,000 patients with no more land for expansion. The restoration of Colonial Williamsburg and development of the Williamsburg Inn resulted in the facility being at the centre of a thriving tourist trade. The hospital’s location and space issues made a move necessary. Between 1937 and 1968, all of Eastern State’s patients were moved to a new facility on the outskirts of Williamsburg, Virginia, where it continues to operate today.

In 1985, the original hospital was reconstructed on its excavated foundations by the Colonial Williamsburg Foundation.

Mexico: The Abandoned (2013)

Introduction

Today, over 10% of the global population suffers from mental health problems. Three decades of collaboration between scientists and Buddhist scholars have revealed techniques that allow us to develop our mental well-being and improve the impact we have on our planet.

Part of the Dispatches documentary series (see below).

Outline

Ade Adepitan, Daniel Bogado and former hospital patients gain access to Mexico’s psychiatric institutions to secretly film the horrific and inhumane conditions endured by thousands of men and women.

Dispatches

Dispatches is a British current affairs documentary programme on Channel 4, first broadcast on 30 October 1987. The programme covers issues about British society, politics, health, religion, international current affairs and the environment, and often features a mole inside organisations under journalistic investigation.

Production & Filming Details

  • Director(s):
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  • Release Date: 25 October 2013.
  • Running Time: 25 minutes.
  • Rating: Unknown.
  • Country: UK.
  • Language: English.

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