In last month’s column, I discussed how 19th century psychiatrists began recognizing the possibility that a mental disorder might affect only one facet of an individual’s personality (volition), leaving others relatively untouched. This included moral sensibilities, which many came to believe could be corrupted by inherited defects of the nervous system or brain injury.
The excerpt below is from an article by A. B. Richardson published in 1890 in the American Journal of Insanity.1 Richardson was the superintendent of the Athens Asylum for the Insane in Ohio. The Athens Asylum, built in 1874, was one of a number of facilities designed according to the notions of the asylum director Thomas Kirkbride (1809-1883). Kirkbride’s treatise on hospital design—On the Construction, Organization, and General Arrangements of Hospitals for the Insane, first published in 1854—provided the inspiration throughout the United States for the construction and management of asylums as carefully structured retreats [For more on Kirkbride and the buildings inspired by his plans, visit http://www.kirkbridebuildings.com.]
Like Kirkbride and numerous other alienists during the 19th century, Richardson understood the asylum as a total treatment institution, one whose very architecture and daily rhythms were seen as the keys to its therapeutic effect. As he put in an 1888 article, “In less mystifying terms, if there is in any insane person, any function of the brain that is normal in activity, if there is any direction in which there is healthy action, we must seize upon this and from it start lines of activity by such an adjustment of environment, such an impress from other intelligences as will bring still other centres of activity into normal action. . . . The superintendent is the active agent who must prepare every mold, and adjust the degree and relative force of every influence.”2
Here, in the conclusion to his 1890 discussion about extending psychiatric care to lawbreakers and moral outcasts, Richardson highlights the importance of both material structures and structured activity in treatment. His statement stands as a pithy summary of the 19th century alienist idea of therapy as a form of “management.”
. . . Diseased morals are as properly the field for our work as diseased intellect or a diseased brain which in fact in the broad sense the former discloses as surely as the latter.
The moral treatment of insanity is most important, and when more perversion is the chief evidence of disease, I still believe a hospital for the insane the proper place for its treatment. To make the most of its possibilities it is necessary to follow principles that are well founded, and that variations in the moral sense are dependent upon structural variations, and that our treatment of diseased morals, or in other words, of defective and perverted moral capacity, should be based upon the well-established facts of physiology and anatomy, I claim to be correct practice. We place splints upon a fractured bone because we desire to control and limit its functional activity. We prescribe quiet and a darkened room in hypersensitive conditions of the special senses, to regulate and restrain their functional activity. Likewise we should properly adjust the social surroundings in one whose morals are diseased, and who, because of the imperfect development of his brain, or because of brain disease, is unable to estimate properly his social responsibilities and duties. Modifications in structure follow, or at least accompany regulation and restraints of function, and in this manner permanent variations in the moral power, in the moral propensities of the individual, may be established. When it is recognized that moral responsibility bears a fixed relation to structural development, and must change with changes in structure, our social organizations will be upon a more certain and more substantial basis. The principles of ethics can then be enunciated in more exact terms. It will be the law, because scientifically correct, that every individual has a relative responsibility which is determined by his peculiarities of structure, and when the rights of others are in any manner jeopardized by defective or impaired functional capacity, external substitutes will supplement this deficiency on rational lines of action. The individual will be placed under treatment instead of sent for punishment. Protection and rational modification will be the end sought, not revenge or the infliction of a penalty. Repulsive traits and unpleasant qualities should not prevent us from showing justice. If disease or defect is the cause of moral obliquity, no hideous feature of the disorder should allow an unjust prejudice to control us. We must strive to attain that plane of thought which is so far removed from improper influence as will enable us to judge every action solely as an index of the condition of the organ from which it has its origin. While conceding the influence of motive properly educated, while according to volition the full authority which it can justly claim, let us remember that our brother is powerless to re-arrange the structural elements from which his moral nature is evolved. External influences must direct him. We must be his guides toward the clearer path. While showing mercy and pointing out whatever is possible in extentuation we must also indicate the direction in which improvement must be made, and show wherein the error has arisen.1(pp368-369)
1. Richardson AB. Perversions of the moral sense in insanity. Am J Insanity. 1890;46:363-369.
2. Richardson AB. Tact in the management of the insane. Am J Insanity. 1888;45:16.