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A brief outline of the classical psychiatric hospital as a custodial, total, and closed institution is offered against the background of changing conceptions of mental illness, developed after the establishment of psychiatry as a medical specialty at the end of the eighteenth and beginning of the twentieth century. The historical development shows a trajectory fraught with ethical dilemmas associated with an ethics of coercion and control. The psychiatric hospital as a place of conﬁnement and therapeutic milieu has lost much of its medical justiﬁcation. The ethics of personal, interpersonal, and institutional relations is emphasized.
Institutionalization (forced or voluntary) has been associated with the practice of psychiatry since its beginnings. It has served as a form of social control of deviant, aberrant, or undesirable behaviors, as an observational ﬁeld, and as an adjunct to treatment of mental disorder. Sociologically, the mental hospital – although undergoing changes in its evolution – can be compared to other types of institutions serving custodial functions, like jails and asylums. Critics have underscored the ethical and legal problems associated with its existence, and a strong deinstitutionalization movement during the twentieth century has led to a reduction in its medical usefulness in the context of the intervention armamentarium of contemporary psychiatry. This research paper highlights some historical dimensions and proposes arguments for the ethical analysis of the institutions associated with the practice of psychiatry, including personal, interpersonal, and organizational dimensions.
History And Context
Throughout human history, poverty, crime, madness, religious calling, political dissent, and other human features have made it necessary to build or to adapt special places for isolation and retirement. Under various names, these institutions have served different goals: protection of society, protection of self-harm, invisibility of degrading conditions, philanthropy, and religious devotion. Their existence dates back to the Middle Ages and they can be said to be a constant of all known societies.
Long before psychiatry was established as a medical or scientiﬁc discipline, mental disorder existed in society. Prior to the establishment of the asylum or madhouse as an institution, mentally deranged persons had to be handled by family and relatives. The important historical fact is that the emergence of custodial institutions was a societal response to different kinds of challenges: poverty, crime, madness, and dissent. These conditions were probably not properly distinguished until the advent of professional psychiatry and the constitution of mental illness as a separate condition belonging to the realm of medicine and not a matter of philanthropy, punishment, or social protection. Many almshouses or strong-houses for “distracted persons” established in Europe and America had only custodial functions and served various purposes, hiding what was unpleasant to see or suffer, protecting the community and serving religion, among them.
The asylum and the madhouse in all its different conﬁgurations ﬁrst started their role as places for “moral treatment” during the eighteenth and nineteenth centuries. Legend has it that Philippe Pinel released insane people from their chains and Benedict Morel, among many alienists of the eighteenth and nineteenth century, advocated some form of therapy for degeneration, insanity, and madness, along with similar institutions at both sides of the Atlantic (Rothman 1971). In England, the Quaker Tuke family is credited as being one its early proponents (the York Retreat). The idea behind was that if society could cause maladies of the soul, then isolation could prove beneﬁcial. In addition, the order and regimentation of living conditions could help deranged people to gain access to civilized and ordered lives. At some point in time, work was added as a means of helping people regain self-esteem and pride. Since proven means of treatment were unavailable, nonexistent, or inefﬁcient, the therapeutic goal was not the prime concern of those institutions. In many countries, they were established or administered by religious orders and private entrepreneurs, the State coming afterwards as guardian and protector. Laws of public health and the recognition that mental health is a right of citizens made the asylum a place where humanity could be restored to afﬂicted citizens.
The modern mental hospital, as studied thoroughly during the twentieth century, was expected to develop into a “therapeutic community” or “small society” (Caudill 1958). However, as Goffman (1961) showed in a series of seminal analyses, the mental hospital is one type of “total institution.” Like prisons and monasteries, these are institutions where no aspect of life is beyond surveillance or control. Separate spaces for work, relax, or social interactions do not exist. Authority decides what can be done, in what form, and when. The rites of passage of entering one such institution is associated with humiliation and degradation. In some cases, like jails and mental hospitals, being or having been an inmate becomes a stigma.
Moral analysis of total and closed institutions must consider that, however isolated they may be, and whatever means are used to prevent external inﬂuences, be they physical or social, they do not exist in isolation from the major society. Inmates bring with them their former personal roles, rapidly changed into sick and patient roles. Their behavior is thus a mixture of the ways in which they present themselves in everyday life and in the new environment. Staff members and medical personnel (doctors and nurses) build “role groups,” whose cohesion depends on the overall atmosphere of the institution. They retain contacts to the outside world because they usually do not live in the facilities and have personal and family lives independent from their work at the institution.
Investigating such institutions in the past has led to research techniques which involve deception and thus are subject to criticism from an ethical point of view. The classical studies of David Rosenhan (1973), William Caudill (1958), Erving Goffman (1961), and many others disclosed how difﬁcult it is to escape the “labeling process” associated with being admitted to such an institution. “Being sane in insane places” is almost a utopia, since the mere fact of being diagnosed as a mental patient starts a “patient career,” a vital trajectory difﬁcult to hide and which, in retrospect, leads to a reinterpretation of previous and current life. The deleterious effects of conﬁnement, sometimes with people not friendly or unknown, or from another social milieu, can be a disruptive experience.
Moral Careers Of Inmates And Staff
The relations between physicians, nurses, administrators, support personnel, and inmates are a privileged ﬁeld for sociological and moral analysis. Norms and practices that are taken for granted in the world outside the institution mutate within its environment. Such is the case regarding respect for people, considering their needs and inclinations, and refraining from exercising undue control or restraint. “Informed restraint” is seldom practiced under conditions of vertical organization of life, with people in the role of keepers and guardians and people in the role of sick persons. The literature on the asylum and its social or therapeutic role is rich in descriptions of abuses and neglect (Robinson 1974).
As a social laboratory for exploring normal and abnormal adjustments to isolation and control, the mental hospital – reformulated as a therapeutic community or maintaining its feature of a custodial asylum – constitutes a privileged place for the analysis of moral conduct. It also ensures prolonged observation of people and in this regard was a valuable aid in the diagnosis and categorization of chronic mental pathology. Ethical dilemmas are reﬂected in the use of power by institution authorities, in the limits imposed to humans under extreme conditions, and in the observance of rules in everyday behavior, in the presentation and disguise of the self, and in the ways to adapt. Most deinstitutionalization movements during the twentieth century were grounded on the notion that the therapeutic and rehabilitation goals were rarely achieved and that closing such institutions could be an accepted form of social reinsertion in the community. Halfway houses and protection by community mental health centers seemed to build a viable alternative to the asylum or classic mental hospital. These solutions, however, are also fraught with moral dilemmas and do not prevent exploitation of discapacitated or handicapped individuals by economic interests.
The Ethics Of Forced Institutionalization
There exist many reasons for internation into a mental hospital. Traditional justiﬁcations include the following:
(a) Private harm, in preventing, for instance, that suicidal persons may attempt against their own life or neglect essential measures of self-care.
(b) Public harm, deﬁned by police or interested parties; this is not restricted to physical harm, since it may also involve disclosure of State secrets in time of war or turmoil.
(c) Legal considerations, rooted in the conviction that the public must be protected from offense to the sensibilities affected by deviant behavior, to hidden or overt dangers associated with violence and aggression, or to crimes committed under altered states of consciousness.
(d) Personal welfare, considering that some conditions merit close observation and appropriate treatment that can only be performed under conditions of conﬁnement.
One important ethical consideration pertains to the authority or power of those entitled to make decisions on behalf of others. If mental illness is a medical condition, the medical profession claims to have the right to initiate a process of involuntary use of conﬁnement. Human rights movements and advocates for the self-determination of persons have tended to rely on legal constraints to medical authority. Thus, the ethical dilemma of who cares for whom may adopt the form of a collision between professional powers. As in other spheres of treatment, the principles of “best interest” and “surrogate decision making” or “substituted judgment” are relevant. In order for the best interest principle to be relevant, the vital trajectory of the person affected by the decision must be known or assumed. For substituted judgment, the relative or the mentor must have full identiﬁcation with the needs, expectations, and wishes of the person to be affected by the measure of reclusion.
The mental hospital as a system of participants, procedures, products, and social processes has its own dynamics. It affects both the climate in which activities are performed and the relations between the persons involved (essentially, inmates, administrators, technical and medical staff, and relatives). Any administrative procedure must be examined in light of the purported aims of the institution. The use of individual therapies, be they physical or psychological in nature, cannot be considered in isolation from the overall climate and ethical tone of the whole. Technical expertise, as the historical record shows, has oscillated greatly, with periods in which occupational therapy was the landmark and times where “open” wards and freedom of movement were preferred to restraint and isolation. Since the advent of neuroleptic treatments in the 1950s, much has been changed in the way experts consider the need for physical isolation or control of undesirable symptomatology. The participation of “patients” in collective decision making has resulted in a forced “democratization” of the healing process without altering profoundly that idea of a custodial institution, irrespective of the fact that it seems to produce a sentiment of shared authority that may or may not collide with entrenched ideologies of psychiatry as a profession. The incorporation of social scientists, psychologists, anthropologists, and social workers is a clear demonstration that mental illness is a form of life and a social identity heavily dependent upon social labeling processes, stigmatization, and discrimination. The social ethics of the whole institution must be coherent with this conception, beyond the purely medical or organic deﬁnition of mental disorder.
Other Forms Of Psychiatric Hospitalization And Therapeutic Milieu
The classical psychiatric institution lost much of its prestige and justiﬁcation when other forms of treatment came into use. Neuroleptics and other pharmaceutical products greatly helped to relieve patients from severe symptomatology and to lead normal lives. Closer integration with medicine led to general hospital psychiatry and psychosomatic units, with psychiatric departments becoming part of general hospitals. Partial hospitalization, with day-care hospitals or voluntary hospitalization during the night or for a few days, along with community mental health centers and other forms of therapeutic environments have displaced the emphasis on large institutions for chronic patients.
In the chain of services for the mentally ill, the custodial institution has lost some of its medical justiﬁcation. Deinstitutionalization in different parts of the world (e.g., Lolas 2010), aimed at reducing the burden of being conﬁned to a total institution and supported by the moral argument that they produce more harm than relief, has fostered ethical reﬂection on the goals and outcomes of institutions that, according to some critics, are more self-serving than therapeutic. It is still an open question if these closed and protected environments will completely disappear, for there is always need for custody in aging populations that become afﬂicted by some form of mental derangement, criminal cases where insanity is used as an alternative to imprisonment, and the situation of homeless individuals who sometimes have no other alternative for a decent quality of life. Contemporary textbooks of psychiatry rarely address the issue as it was the case in former times. The ethics of coercion, however, remains both a legal and a medical dilemma that all professionals need to face (Taylor 2014).
Ethical dilemmas posed by custodial institutions like prisons, mental hospitals, and monasteries have been present in history since ancient times. The mental hospital is developed as one means of controlling madness, insanity, alienation, poverty, crime, and political dissent. Long after its medical justiﬁcation seems superseded by criticism in the twentieth century and an emphasis on deinstitutionalization was evident, the ethics of coercion remains a legal and medical problem, as well as the ethics of interpersonal and organizational relations within the institutions, partially replaced by mental health centers, partial hospitalization, and pharmacological treatment of serious psychiatric conditions.
- Caudill, W. A. (1958). The psychiatric hospital as a small society. Cambridge, MA: Harvard University Press.
- Goffman, E. (1961). Asylums. Essays on the social situation of mental patients and other inmates. New York: Doubleday.
- Lolas, F. (2010). Psychiatry and human rights in Latin America. Ethical dilemmas and the future. International Review of Psychiatry, 24, 325–329.
- Robinson, D. N. (1974). Harm, offense, and nuisance. Some ﬁrst steps in the establishment of an ethics of treatment. American Psychologist, 29, 233–238.
- Rosenhan, D. (1973). On being sane in insane places. Science, 179(4070), 250–258.
- Rothman, D. J. (1971). The discovery of the asylum. Social order and disorder in the New Republic. Boston: Little, Brown.
- Taylor, B. (2014). The last asylum: A memoir of madness in our times. London: Penguin.
- Sadock, B. J., Sadock, V. A., & Ruiz, P. (Eds.). (2009). Kaplan and Sadock’s comprehensive textbook of psychiatry. Philadelphia: Lippincott, Williams & Wilkins.
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