Stephen Garton

Seeking Refuge: Why Asylum Facilities Might Still be Relevant for Mental Health Care Services Today

This article reassesses the history of mental asylums in New South Wales, arguing that far from being 'cemeteries for the still breathing,' Victorian and Edwardian asylums served multiple purposes, providing genuinely therapeutic conditions for many patients, while warehousing chronic incurables and those without networks of support. Mental asylums in nineteenth century New South Wales rarely resorted to measures of restraint and seclusion and had a notable record of high rates of recovery and low rates of readmission. The marked institutional decline of the twentieth century that eventually prompted critics from many quarters to demand the closure of large asylums represented more a loss of faith in institutionalisation and the desire of psychiatrists to achieve higher status and more lucrative remuneration treating new middle class populations of neurotics than inherent flaws in the asylum ideal itself. Thus deinstitutionalisation policies were built on a fundamentally revisionist history that failed to consider the reality of care in these institutions, an insight that opens up opportunities to rethink the role and function of refuge in contemporary mental health policy.

Asylums have had a bad press. Generations of reformers have condemned mental asylums as oppressive, contrary to the dictates of humane care and incapable of providing adequate treatment that might effect recovery. At first asylums were not sufficiently asylum-like, too much like prisons or workhouses. From the early twentieth century, however, the asylum ideal itself became the object of condemnation. Patients had to be freed from large custodial institutions in order to advance the cause of mental health care. And by the end of the last century reformers had largely succeeded. We now inhabit a world of community-based care, psychiatric clinics, acute care and crisis facilities for those suffering psychiatric disorders, where patients are no longer inmates but consumers of a range of health services. These transformations in treatment policies suggest that mental health care reform is inextricably linked to the practice of history. Reform gains impetus from the construction of historical narratives—the past was far from perfect and that unhappy past is the reason why change is essential. Each wave of reform has worked to rewrite narratives to explain and justify itself. But how might we assess reform efforts if those historical narratives justifying change are themselves flawed? If there are problems in the history does that throw up awkward questions about the reforms replacing that past?

Historians have given formal shape and substance to these popular perceptions. The great blossoming of asylum history in the post World War II period coincided with a newfound confidence of psychiatrists in the capacity of medical treatments, mainly psychotropic drugs, to finally empty asylums. Criticism also emerged from other quarters. New radical movements emerged which condemned psychiatry as a form of social control. What united psychiatrist and antipsychiatrist alike, however, was an aversion to the Victorian moral therapy asylum and this in turn helped shape the history of psychiatry being written after World War II. For example Erving Goffman's acclaimed 1961 analysis of mental hospitals as oppressive 'total institutions,' which reconstructed patients as compliant institutionalised inmates, had a profound effect on major revisionist historians of the asylum such as Andrew Scull and David Rothman.¹ The thrust of the modern historiography of the asylum, revisionist and Whig, has generally been to depict moral treatment as an ideology divorced from the reality of asylum life. For Andrew Scull the asylum was a utopia, the reality was that these institutions were 'cemeteries for the still breathing.'² Even those historians more sympathetic to the aspirations of early moral reformers, such as Kathleen Jones, Anne Digby, and Gerald Grob, generally conceded that the hopes of reformers were stillborn, and Victorian asylums lapsed into custodialism where control and discipline was paramount and patients were 'not subjects to be treated but objects to be managed.'³ Similarly Ruth Caplan depicts nineteenth century moral treatment as a 'cult of curability,' suggesting that it was more based on faith than fact.⁴

The historical narrative that has been constructed about the asylum is largely an ideological one, built upon the views of asylum superintendents and reformers who bemoaned the fate of moral therapy and condemned the overcrowding and accumulation of chronic patients, and on the universally unfavourable assessments of mental hospitals that pervaded late-twentieth-century discourses on mental health. But was the reality as bleak as it has been depicted? Despite the wealth of historical analysis of lunacy, historians, with a few exceptions, have rarely ventured beyond the superintendent's office into the wards.⁵ There is some excellent work on forms of committal, patterns of admission, and the social characteristics of inmates, which throws important light on the complex relationship between families, localities, dislocation, poverty, and incarceration but even these social histories rarely come to grips with the therapeutic regimen of asylums.⁶ The excellent work that does elucidate everyday life in institutions usually comes in the form of histories of particular asylums (although even here the view from the superintendant's office often dominates) and thus larger patterns are sometimes lost in the focus on the particular.⁷ It is important to get beyond the annual report and, to use the parlance of contemporary public policy, look at the outcomes. How successful was moral therapy in the Victorian asylum? And if there are objective measures of success why did these indicators enter a period of sharp decline in the twentieth century justifying the policies of deinstitutionalisation that sought to dismantle the Victorian asylum?

The argument proceeds in three parts. First I attempt to provide a brief survey of some of the key reform movements in Britain, Australia, and North America since the eighteenth century. Obviously this is an introductory sketch, which like all brief overviews will simplify and reduce complexity and difference in the pursuit of generalisation and conciseness. Secondly the argument will focus on the actual treatments offered to patients in asylums in late-nineteenth and early-twentieth-century New South Wales. The aim here is to assess the evidence concerning treatment and its efficacy. In essence I argue that there is evidence to suggest that for many patients treatment regimens were comparatively humane, and more importantly effective. Finally I explore the evidence for the serious deterioration in conditions in mental hospitals in New South Wales from the 1920s onwards. Why did indicators of therapeutic success fall sharply in this period? What does this deterioration tell us about the abject state of mental hospitals by the second half of the twentieth century? My argument is that asylum treatment in the right context could be relatively effective and historians need to recover this therapeutic efficacy as part of a broader understanding of the social history of insanity. If the asylum was effective at a particular point in time, if institutionalisation was not inherently custodial, then this does raise interesting questions about the narratives that have supported deinstitutionalisation and community treatment. This is not a plea for reopening these institutions, which would be absurd—they are of a time and place now gone. But I would suggest that it is worthwhile reviving the classical ideal of asylum—a place of genuine refuge from the world—as one part of a larger comprehensive mental health care system. This argument is offered as a modest contribution to a larger effort, evident in some contemporary scholarship, to reclaim a rightful place for notions of refuge, asylum, and haven in contemporary mental health policy.⁸

Two centuries of mental health reform

In the late–eighteenth and early–nineteenth centuries a wave of reformers, inspired by evangelical and enlightenment ideas about the importance of moral and physical environments in shaping each individual, condemned the state of lunatic asylums in Britain, Europe, and North America. Benjamin Rush and Dorothea Dix in America, Daniel Tuke and William Wilberforce in Britain, Phillipe Pinel in France, and many other like-minded reformers in these and other parts of the world have claimed a large place in the history of lunacy as the instigators of a more humane attitude towards the insane.⁹ In 1815, when William Wilberforce toured the infamous Bethlem Asylum for the Insane in London he uncovered atrocities and inhumane forms of treatment beyond his imagining, none more abject than William Norris, chained by the neck to a wall for fifteen years and yet, miraculously after such treatment, according to Wilberforce, sane. This spurred efforts by Wilberforce and like-minded evangelical, Quaker, and humanitarian reformers to create a new form of asylum for those afflicted with mental unease, places where patients could be uplifted and restored through a regimen of moral reform, religious instruction, fresh air, exercise, and useful labour. These new asylums were to be places for the practice of moral therapy rather than mere confinement.¹⁰

These were noble sentiments and throughout the nineteenth century they caught the imagination of doctors and reformers on both sides of the Atlantic, the wider British imperial world, and beyond. The spread of asylums modelled on the new principles of moral therapy was extensive. Large grand Victorian edifices, commonly with pavilion wards, extensive and well landscaped grounds, airing and exercise courts, farms and gardens, and ha-ha walls to disguise the fact that patients were still locked away from the outside world, dotted the institutional landscape of Britain, Europe, North America, Latin America, South Africa, Australia, and New Zealand. Even the language of lunacy began to change—therapy rather than confinement, disease rather than depravity, doctors rather than turnkeys.¹¹ These magnificent buildings often remain a glorious part of our architectural heritage, although these days many are used for other purposes—universities, museums, art schools, and sought-after apartments.

Yet within a few generations of their founding the moral therapy asylums favoured by the great lunacy reformers of the early–nineteenth century were themselves the subject of harsh criticism. Overcrowding, the accumulation of chronic incurables, patient brutalisation and ill treatment, and declining government and philanthropic support were all cited as factors in the erosion of the asylum ideal. These institutions had become places of incarceration rather than cure.¹²

If we were to take a broad overview of mental health reform over the last hundred years one way we might characterise the twentieth century would be to see it as a period of prolonged effort to escape the clutches of the asylum. The steps in this slow and inexorable effort to take doctors and patients out of large institutions of incarceration were incremental. In the first decade of the twentieth century prominent Australian psychiatrists, such as Eric Sinclair, Inspector-General of the Insane in New South Wales, sought to persuade politicians to allow the admission of voluntary patients into new style admission wards and clinics. In Sinclair's view the great failure in lunacy law was that medical certification, the Victorian safeguard against wrongful incarceration, ensured that patients remained untreated until their condition worsened to such an extent that by the time they were admitted to an asylum they were incurable.

The solution for Sinclair was early treatment, outside the confines of a traditional asylum. The earlier a patient could be treated the greater the likelihood of cure. Mental illness he believed should be seen like any other disease, with patients free to seek treatment whenever they felt the need. To overcome the fear of permanent incarceration patients should be admitted on a voluntary basis, free to discharge themselves when they felt inclined (unless of course psychiatrists considered them a threat requiring certification). Equally important, new types of treatment facilities—out-patient and in-patient clinics in public hospitals and special admission wards in mental hospitals, separate from the back wards for incurables—would be more therapeutic and encourage voluntary patients to seek treatment free of the anxiety of incarceration. These arguments made headway. By the interwar years New South Wales, like other Australian states, had a range of clinical and voluntary mental hospital treatment facilities.¹³

Despite these reforms, mental hospitals remained significant institutions of incarceration with 100 in every 100,000 of the population confined in an institution, although by the 1940s over a third of all patients were now voluntary. There was also a significant growth in patients seeking out-patient and clinical care with over 200 a year being treated in the Mental Ward at the Darlinghurst Reception House and the new mental clinic at Royal Prince Alfred Hospital.¹⁴

Streaming voluntary patients out of the old mental hospital system, however, did little to address the needs of the chronic incurables left in these grand edifices. Certainly doctors continued to search for a cure for serious mental afflictions, although as we shall see (below) the history of such experiments as malarial therapy in the 1920s, cardizol and insulin coma therapy in the 1930s, electro-convulsive therapy of the 1940s and psychosurgery in the 1950s, suggests that inmates of back wards were seen more as guinea pigs than patients in increasingly desperate attempts to prove that there was a role for psychiatrists in the treatment of psychosis. Finally, however, the great psychotropic drug revolution of the late 1950s offered psychiatrists, really for the first time, hope that there were medical therapies available that might alleviate, though rarely cure, the worst effects of psychotic episodes, enabling patients, provided they maintained their medicinal regimen, to live outside the incurable wards of old.¹⁵

The hopes raised by the psychotropic drugs of the 1950s and 1960s created a context for unprecedented psychiatric criticism of the old mental hospitals. In 1955 Allan Stoller, medical officer in the Victorian Department of Mental Hygiene conducted an extensive report on Australian mental health care and found that mental hospitals suffered 'from mass overcrowding, with a general level of custodial care with little active treatment.'¹⁶ This influential report lead to increased government funding of mental health care but the 1961 Royal Commission into Callan Park, instigated by public criticisms of conditions by the then superintendent, Dr Harry Bailey (who gained posthumous infamy for his involvement in deep sleep therapy at Chelmsford Hospital), revealed that little improvement had been achieved; Callan Park Mental Hospital was a disgrace—run down, decrepit, a place of incarceration rather than treatment. The sensational headlines and accompanying photographs proclaimed mental hospitals as 'concentration camps,' graphically depicting the horror of the traditional asylum.¹⁷ This institutional form of treatment was irrevocably damaged in the eyes of both the medical profession and the public. Asylums, the critics proclaimed, inevitably declined into custodialism and ill treatment. They were inhumane and unsuited to the needs of modern mental health care. These were institutions that could not be reformed. They were rotten at the very core. The only solution was to abandon them. As prominent psychiatrist Cunningham Dax argued, the problem was that the link between mental hospitals and 'the penal system had never been broken.'¹⁸

Ironically, just as psychiatrists came to see that they needed to abandon mental hospitals as sites of professional practice a series of radical political movements emerged condemning psychiatry as a form of social control oriented towards cementing professional power and prestige at the expense of patients. Radical antipsychiatry movements, student radicals and later feminist and gay activists, were united in their condemnation of psychiatry as a form of state-sanctioned repression of those who lived outside narrowly defined norms of middle-class life. In 1969 such critiques were brought home forcibly to Australian psychiatrists when radicals picketed the historic joint American Psychiatric Association/Royal Australian and New Zealand College of Psychiatrists conference in San Francisco.¹⁹ In the face of such widespread criticism psychiatrists sought to further distance themselves from the taint of custodialism.

Disquiet with asylum incarceration on all sides drove reform. Australian psychiatrists began to trumpet the virtues of community treatment. In the 1960s Australian governments began to pass legislation creating categories such as the temporary patient or facilitating legal representation for those recommended for admission to protect patients from unnecessary or lengthy incarceration. Governments began to build more clinics and open more outpatient facilities in general hospitals for psychiatric patients. By the late 1970s the median length of stay in a mental hospital admission ward had fallen by 50 percent. There were active efforts to reduce the importance of mental hospital treatment and minimise the stay for those admitted to such institutions. In the 1980s and 1990s this trend culminated in the active closure of many older mental hospitals. These were irredeemable institutions, remnants of a troubled and blinkered past. New developments in the way we understand mental illness and great advances in psychiatric treatment enabled patients to be freed from incarceration. Patients were no longer inmates of an asylum but people with an illness like any other that could be treated without resort to confinement.

What was required was a sustained effort to undo the wrongs of the past, freeing patients from incarceration and enabling them to return to the community where they could be treated humanely, like a person with any other illness. All round Australia governments began to investigate the ways in which they could implement community treatment for the mentally afflicted.²⁰ In New South Wales the comprehensive 1983 Richmond Report on mental health declared definitively that all the old mental hospitals needed to be closed and community treatment instituted. And, over the next two decades, successive governments sought to implement the thrust of the Richmond Report.²¹ The age of the grand Victorian mental asylum was over.

Treatments and their efficacy

Was the traditional mental hospital, as conceived and implemented in the nineteenth century, intrinsically or inevitably custodial, more geared to being part of a penal system than a medical service, as popular and official opinion of the late–twentieth century would have us believe? Exploring this question involves tracking back over the history of asylums to investigate just how they worked in practice. Some of this involves understanding how the moral therapy movement that sustained the asylum ideal in nineteenth-century Australia, operated in specific institutional contexts and the consequences of these practices for patients.

Moral therapy was late coming to the Australian colonies. The ideas were there from the mid–nineteenth century; prominent moral reformers and medical practitioners such as politician Henry Parkes, Dr R.W. Willson (Catholic Bishop of Hobart) and Dr Francis Campbell (superintendent of the Tarban Creek Asylum) condemned the antiquated buildings (often old convict factories) that housed lunatics in cramped and poorly ventilated quarters, advocating instead proper purpose-built institutions designed along the lines of the latest theories of moral therapy.²² James Barnet, the NSW Colonial Architect, declared that in the 1860s he had seen 'such sights as he hoped never to see again ... rats running over patients, the gutters were stinking, the closets overflowing and everything was in a fearful condition.'²³ Few thought this was satisfactory. Lack of funding inhibited immediate reform but momentum was building. In 1868 the cause of lunacy reform in New South Wales received a significant boost when the Parkes Government appointed visiting naval surgeon Frederic Norton Manning as superintendent of Tarban Creek Asylum. Manning accepted on condition that he spend a year investigating the best systems of lunacy treatment around the world. He returned a firm proponent of the moral therapy approach and began to undertake significant reforms at Tarban Creek, improving conditions for inmates and adding wards to reduce overcrowding.²⁴

His work impressed authorities and in 1876 he was appointed Inspector (later Inspector-General) of the Insane with responsibility for all the colony's lunatic asylums. In this position he engaged in a significant campaign of reform persuading parliament to increase the vote for asylums. As a consequence he was able to establish a third major asylum in Sydney at Rozelle, built on the latest Kirkbride moral therapy principles. The new Callan Park Hospital and Gladesville Hospital (the renamed Tarban Creek) became the major admission hospitals for lunatics in New South Wales, while Parramatta Asylum focused more on the criminally insane, inebriates, and the aged and infirm. The internal reforms were equally significant. Manning, in the mainstream of moral therapy ideas, advocated pleasant uplifting surroundings, useful labour, good diet, rest, religious instruction, education, fresh air, and regular entertainment. By the mid 1880s Henry Parkes remarked with satisfaction that the colony's asylums were now 'palaces.'²⁵ One has to allow for typical political bombast in such claims but the evidence of improvement appears significant in comparison to Barnet's dire observations twenty years earlier.

Callan Park and Gladesville each had extensive farms for employing inmates in therapeutic labour and supplying the institution with fresh produce. The number of wards had been expanded and light, ventilation, and sewerage systems upgraded. Workshops were built to provide more useful employment. Manning was a great believer that animals cultivated higher sympathies in patients and all the asylums, in addition to farm animals, had kangaroos, koalas, peacocks, goats, parrots, emus, and cockatoos as pets to engage the interest of patients. Sports were also encouraged and patients regularly played tennis, cricket, soccer, bowls, and coits. They were also taken out for Sunday afternoon cruises on the Parramatta River using the Lunacy Department ferry, The Lucinda. Indoor amusements were also a feature of asylum life—concerts, theatrical performances, minstrel shows, music hall entertainments, and dances were an integral part of the regular institutional routine.²⁶

All of this sounds like a considerable improvement in the lives of inmates of the colony's lunatic asylums. But of course as historians we have to be sceptical of accounts of asylums in New South Wales that draw heavily on the views of those who sought to promote the virtues of asylum treatment. We have to be wary of romanticising moral therapy. The existence of peacocks and picnics does not necessarily undermine representations of asylums as overcrowded, institutional, and custodial in operation. And of course all the dances and musical performances in the world did not prevent a steady accumulation of chronic patients, overcrowding, and routines geared more to discipline than cure. The point here, however, is less that asylums were benign and enlightened and more that this is evidence that doctors, like Manning, were very committed to improving conditions, making institutions more effective, and of course trumpeting these successes. This, as we shall see later, is a critical issue in understanding the rise and fall of the asylum in New South Wales.

In this context, however, it is critical to move beyond attacking or defending the asylum. What we need is some relatively objective evidence by which to assess the achievements of these reforms. What are some of the measures that we could investigate? Three for which we have evidence are recovery rates, readmission rates, and the use of restraints such as straight jackets. Each goes to the heart of the historical narrative that overturned asylums—mental hospitals were institutions of permanent incarceration marked by high levels of punishment and restraint. Were nineteenth-century mental asylums the progenitors of the modern mental hospital, graphically depicted in films such as One Flew over the Cuckoo's Nest (1975)—places of brutal repression, punishment, and ruthless suppression of any deviant behaviour with no attention given to therapy?

The historical evidence for New South Wales suggests otherwise. The use and interpretation of recovery and discharge statistics, however, requires some caution. Does discharge mean recovery? It may not in every case but certainly official statistics differentiated between those discharged as 'recovered' and those 'relieved,' the latter being patients considered to be still suffering some mental affliction but sufficiently harmless to be released to families willing to take them home. A further problem is how to represent the rate of recovery. There was certainly considerable discussion of this problem at the time. Frederic Norton Manning believed that discharges (recovered and relieved) should be expressed as a percentage of the number of patients admitted each year on the grounds that most such discharges occurred in the first year of confinement and the inevitable accumulation of chronic incurable patients would distort the effectiveness of psychiatrists in effecting cure if discharges were a percentage of the total patient population.²⁷ There are merits and drawbacks in either approach. The key is to be consistent and here we will adopt Manning's preferred method for representing recovery rates because it does reveal an important aspect of the experience of admission to a colonial asylum.

In the 1880s, of those admitted each year, between 40 and 45% of patients were discharged as recovered and a further 5% relieved each year.²⁸ In other words nearly one in two patients admitted each year were likely to be discharged before the end of their first year in the hospital. By the 1930s, however, these rates had deteriorated considerably. In that decade only just over a quarter of men admitted in any year were discharged recovered and just under a third of women; 10–15% of patients were discharged as relieved.²⁹ More patients were being returned home when still suffering a mental affliction and the numbers recovered fell significantly. Overall discharges were down by 10%.

Another interesting dimension to the history of mental asylums in New South Wales is the evidence on readmissions. In the late–nineteenth century less than 10% of patients had been admitted to a mental hospital before. By the 1930s the readmission rate had risen to 15% and by the 1970s was 60%. A significant proportion of patients admitted to late-nineteenth-century institutions recovered and recovered to an extent that meant that they never re-entered the mental hospital system. By the end of the twentieth century mental hospital facilities had become a 'revolving door' where patients left a mental health care facility and returned to that or some similar facility again and again.³⁰

The patterns in the use of restraints like straightjackets, leather-muffs, and padded cells are equally revealing. In the 1880s less than 1% of patients were placed in restraint each year.³¹ And commonly this restraint consisted of seclusion in a room for four to eight hours a day or the use of muffs to restrain the hands and prevent self-harm for three or four days. Straightjackets and more extreme contraptions such as the Utica-crib were rarely used. By the 1930s, however, 20% of patients were under some form of restraint during the year, often for longer periods of time, many for twenty-four hours a day for months on end, some for 365 days in the year. And these patients were far more likely to be in straightjackets.³² The epidemic of straightjacket use was such that in 1931 Charles Hogg, the inspector-general, had to issue a directive to all superintendents warning them to ensure that the devices were taken off at regular intervals to check for bedsores.³³ There were other indicators of institutional decline. Accidents increased, from 20 fatal and 83 nonfatal in the 1880s to 40 fatal in the 1930s. Non-fatal accidents were not reported in that decade but in the decade before 1920 they amounted to 334, so one can assume that they were higher again in the 1930s. Suicides also increased from 9 to 63 between these decades—far outstripping the proportional increase in the patient population.³⁴

All the evidence suggests that there was a severe deterioration in the conditions in New South Wales mental hospitals between the 1880s and the 1930s. Many of the depictions of the horrors of incarceration that motivated advocates of deinstitutionalisation would appear to have far more validity in relation to the 1930s than the 1880s. Contrary to the popular and official discourse of the late–twentieth century the colonial asylum of the late–nineteenth century seems to have been relatively humane, with high rates of recovery, low rates of readmission, and little recourse to restraint. Things were dramatically worse by the 1930s. Psychiatrists, journalists, and popular writers rightly condemned the state of asylums in Australia, and elsewhere, inculcating a deeply ingrained popular antipathy to psychiatric incarceration that nurtured the emergence of deinstitutionalisation polices decades later. The more immediate question, however, is what caused this measurable decline in the effectiveness of the asylum?

The Decline of the Asylum

There are a number of possible explanations for this evident institutional deterioration, and it is worthwhile exploring some of these in detail. Three commonly cited reasons of particular note are overcrowding, failure to build new facilities to keep up with demand, and inadequate provision of medical services for patients. Let's take them in turn. In the 1880s there was evidence of overcrowding. Despite the best efforts of moral therapy reformers to ensure favourable conditions in asylums, on average there were 200 more patients than designated beds in the 1880s, meaning that some patients were forced to sleep on mattresses on the floor. By the 1930s, however, there were around 1400 excess patients, a dramatic increase.³⁵ Chronic overcrowding accelerated despite the opening of new mental hospitals. In the 1880s there were four main institutions (Callan Park, Gladesville, Parramatta, and Newcastle) but by the 1930s new hospitals had been opened at Goulburn, Rydalmere, Peat and Milson Islands, Stockton, Morriset, and Orange, while new wards had been built at Gladesville and Callan Park. The building program failed to keep pace with demand and overcrowding worsened.

Staffing problems also increased. In the 1880s less than 50 nurses, attendants, kitchen, and grounds staff resigned each year by the 1930s that had increased to over 400, suggesting rising levels of frustration and discontent, and for patients a higher proportion of new and inexperienced staff. Similarly throughout the 1920s and 1930s there were continual complaints by inspector-generals about the difficulty of attracting medical staff to asylums. As a consequence hospitals and wards for the chronic patients (those considered incurable) were no longer able to maintain permanent medical staff. Instead they were forced to roster local doctors to visit patients on a weekly basis to monitor general health and wellbeing.³⁶ These patients received almost no regular psychiatric attention let alone treatment.

An important consideration here is whether these factors are causes or consequences? On balance they seem to be symptoms of a system in crisis, unable to keep pace with the growth in the demand for mental health services. But is this sufficient explanation? When we examine the figures on the proportion of the population certified as insane the picture becomes more complicated. In the 1880s the rate of admission was between 55 and 60 persons per 100,000 of the population. By the 1930s the rate of certified patients remained at around 60 per 100,000.³⁷ What had changed was the emergence of new patient populations by the interwar years. In the 1880s patients had to be certified to receive psychiatric treatment in a hospital for the insane. By the 1930s the long campaign by doctors to allow voluntary admissions, treating patients in the early stages of their illness when they believed they were more curable, had largely succeeded. By 1939 while there were 1669 certified patients in mental hospitals there were 1077 voluntary patients representing a dramatic escalation in the patient population, and its proportion of the general population.³⁸

The emergence of a sizeable voluntary patient population gives a clue as to one of the fundamental causes of the steady deterioration in conditions in mental hospitals. By the early–twentieth century Australian psychiatrists were becoming concerned at the accumulation of chronic patients in mental hospitals. One factor underpinning this concern was anxiety about the professional standing of psychiatrists. Working in a mental hospital was different. Doctors were salaried public servants not private practitioners and honorary visiting staff in public hospitals. More importantly the central involvement of police in the admission of patients and the fact that patients were compulsorily confined suggested that mental hospital doctors were more custodians of the unfortunate than proper medical practitioners on a par with their colleagues in other branches of medicine. As a consequence psychiatry was widely seen as a low status area of specialisation best avoided by doctors of ambition and aspirations to high professional status. The mental hospital service undoubtedly attracted humane and skilled medical practitioners passionately interested in the treatment of mental illness but it also had a high proportion of doctors who had no other career options; those from modest social backgrounds, and a number of women who began to graduate in medicine in the early twentieth century, who lacked the resources or connections to start private practices.³⁹

The steady accumulation of chronic patients also promoted speculation about the causes of these incurable conditions. Hereditary predisposition was an obvious and unsurprising answer. Thus psychiatrists were prominent in the emergence of the eugenics movement both here and overseas. The argument that many of the major social ills of the day—crime, poverty, delinquency and mental illness—were the result of hereditary deficiencies passed from generation to generation caught the imagination of a wide range of scientists and professionals in the late–nineteenth and early–twentieth centuries. Heredity seemed to explain why some patients recovered while others did not. Psychiatrists were excited by this idea because it suggested that those suffering hereditary deficiencies should be screened out of mental hospitals into separate institutions, leaving mental hospital doctors free to concentrate their energies on the curable patients who succumbed to problems arising out of their social environment such as stress, anxiety, and grief or other discernible physical conditions that might cause mental symptoms (infections, toxins, diseased organs), deemed treatable conditions.⁴⁰

In 1913 Eric Sinclair, Inspector General of the Insane, argued that mental defective should be streamed out of the mental hospital system into 'separate residential colonies ... entailing life-long care' under the control of a separate Board.⁴¹ The response of the Lunacy Department was to operate particular mental hospitals exclusively for mental defectives (Peat and Milson Island, Stockton, Morriset, Newcastle) and to admit those at major metropolitan hospitals into separate wards. The thrust of mental hospital policy was to classify patients more carefully than ever before into curable and incurable wards, with a corresponding decline in medical and nursing resources allocated to the latter.⁴²

A further development along these lines was to press for voluntary treatment facilities. The reasoning behind this campaign was clear. As Eric Sinclair also argued 'the progress of medical science as regards mental disease tends to deal more largely with cases at their beginning and take more care of the curable than the incurable.'⁴³ For Sinclair and like-minded psychiatrists in Australia and overseas the stumbling block to effective treatment was the requirement for medical certification. Patients had to wait until their condition was sufficiently serious to warrant certification before they could receive expert treatment. But, as Sinclair and others argued, patients were most curable in the earliest stages of their illness. For Sinclair lunacy law was more concerned with 'legal requirements than the medical,' and, rather, he believed that mental illness should be treated like any other illness. Furthermore most psychiatrists believed that the main obstacle to seeking early intervention in mental illness was the fear of permanent incarceration. Thus if patients no longer feared compulsory confinement they would seek out medical attention as soon as they felt sick and not be forced to wait until they were beyond help. Thus voluntary admission became a key to increasing the proportion of curable patients in the asylum population. And to effect cure such patients had to be streamed into special admission wards, psychiatric clinics, and out-patient facilities at general hospitals. Thus psychiatry could claim its rightful place as a legitimate medical practice, free of the stigma of custodialism.⁴⁴

Progress was slow. The first mental ward was not opened until 1908 and voluntary admissions were not possible until 1915 but, as we have seen, by 1939 voluntary patients were more than a third of the mental hospital population. And from the late 1930s new treatment options, out-patient clinics, and wards in public hospitals, opened up opportunities for psychiatric care outside of the mental hospital system altogether.⁴⁵

At the same time a thriving private practice market in mental and nervous diseases began to emerge. The increasing interest in nervous diseases and the growth of a sizeable colonial middle class interested in seeking treatment for such conditions offered the prospect of lucrative Macquarie Street, Collins Street, and Wickham Terrace style practices for those with expertise in these fields. There had been a thriving 'quack' trade in cures for nervous debility for many years but by the late–nineteenth and early–twentieth centuries doctors sensed that there was a respectable market in this area and new approaches and therapies offered them the tools to distinguish themselves from quacks. The interest in treatments such as psychotherapy, hypnotism, suggestion, Weir-Mitchell rest cures, and psychoanalysis (Freud sent a paper to the 1909 Australasian Medical Congress as did Jung) opened up new professional opportunities for doctors. And psychiatrists began to leave the mental hospitals in significant numbers to enter private practice. In the 1880s one or two psychiatrists in mental hospitals had small private consultancy arrangements or operated private facilities for a few patients. By the 1970s there were 3000 psychiatrists in private practice in Australia, far more than in the public sector.⁴⁶

In other words over the course of the early–twentieth century psychiatrists pressed hard for reforms in the mental hospital system that freed them from the constraints of practice in the large mental hospitals of the Victorian era. Curable and incurable patients were differentiated ever more sharply, with significantly different levels of medical support. New treatment facilities emerged that offered doctors and patients therapeutic contexts outside the old mental hospital system. And increasingly doctors left the mental hospitals to establish lucrative private practices. In other words a series of deliberate decisions and policies led to a significant decline in conditions for patients, especially certified patients, left in the old mental hospitals. Doctors increasingly saw the patients in these back wards and hospitals for incurables as suffering hereditary conditions, deserving of humane care but for whom active medical therapy was largely useless. Of course there was an earnest effort to find treatments for the worst mental afflictions. But many of these experiments were ethically dubious, suggesting that chronic patients were seen less as human beings deserving of civilised care, as they had been by Frederick Norton Manning, and more as subjects for experimentation. For example the first four patients subjected to malarial therapy in 1925 died. In the early 1940s, when ECT was first introduced in New South Wales, no muscle relaxants were used, and 25 percent of patients suffered severe injuries in the course of this treatment.⁴⁷ Mostly patients in these sectors of the mental health system languished as doctors and governments turned their attention to improving facilities for the curable. Psychiatrists had lost the faith of their nineteenth-century forbears in the capacity of the asylum to cure. The rot had set in and the old mental hospitals went into serious decline promoting the scandalous revelations of 'concentration camp' like conditions in the 1960s and 1970s.

Reconsidering the asylum ideal

I'm not the first to suggest that the horrors of the mental hospital system were not endemic and inherent but in fact a product of specific changes in policy and practice emerging in the interwar years. Albert Deutsch, in his classic 1937 account of the crisis in the American hospital system The Mentally Ill in America, was alarmed at the deterioration in treatment conditions for the mentally ill between the wars and saw this neglect as in part a deliberate decision by the medical profession to turn away from asylums as places for active psychiatric treatment.⁴⁸ His voice, however, was drowned out by the wealth of psychiatric opinion that saw the mental hospital ideal as intrinsically flawed; the only humane solution being to flee the system and try to treat people to prevent their admission to these institutions. As I have tried to suggest above there was a crisis in mental health care beginning just before World War I and accelerating through the interwar and post World War II period. Mental hospitals were deliberately run down and resources diverted to other treatment systems. But asylums were not always this bad. In their colonial heyday they were relatively well-resourced, well-maintained institutions that had an excellent record of success in the effective treatment of mental conditions. Few patients were ever restrained. Almost half of all new admissions recovered within the year and a significant proportion of patients admitted to moral therapy asylums in late–nineteenth century recovered to an extent that meant that they never re-entered the mental hospital system again. A century later many patients went in and out of treatment facilities on a regular basis never free of mental health service support.

Colonial psychiatrists, like Frederic Norton Manning, believed in moral therapy. They were of the view that a healthy environment, occupation, moral uplift, active medical and nursing care, and genteel amusement were effective forms of therapy that produced excellent results. They acknowledged that there would be an accumulation of incurables each year but even for these patients an uplifting hospital environment had therapeutic benefits and there was little need to resort to restraint or confinement to maintain order and discipline in the institution. Conditions for patients in mental hospitals, except those in the admission and voluntary wards, had worsened dramatically by the interwar years. Doctors no longer believed in the therapeutic effects of the hospital environment and thus it was neglected. This created the conditions for a sustained assault on the mental hospital system by the end of the twentieth century. The Asylum ideal was finally put to rest.

We now live in an era of community treatment. But recent critics have pointed to flaws in this system. Poorly resourced community facilities, insufficient community support services, and the growth of inadequately regulated hostels and homes for the mentally afflicted run by private operators, some of whom resort to high drug dosages to ensure peace in the household, have led to what is known as the revolving door syndrome.⁴⁹ The mentally afflicted receive short-term psychiatric care in medical facilities and are released as quickly as possible to community facilities where they are sustained by therapeutic drugs and under-resourced social welfare systems. The strain is serious and they frequently return to psychiatric facilities for short-term crisis care. In and out of treatment facilities they go. In addition there is an increasing proportion of inmates suffering mental afflictions held in prisons, reformatories, geriatric homes, and hostels for the homeless. The problem of mental illness is being shifted around the social welfare and criminal justice system.⁵⁰

This is a far from satisfactory state of affairs. And there is no single answer or policy solution. But reflection on the history of the mental asylum suggests that far from asylums being the source of the problem they may offer guidance on one possible solution. This is not a plea to return to the old asylum system, given the cost of such institutions that is hardly feasible. But it seems possible that the therapeutic effectiveness of the Victorian asylum was in part a product of the fact that they provided respite from the stresses of everyday life precipitating mental collapse. Asylums were havens from a stressful world and patients, with care and support, were given the time to recover their senses and return revived and strengthened to the outside world. The classical ideal of the asylum as a place of temporary refuge from the world is a valuable one. It worked for a considerable proportion of patients admitted to the late-nineteenth-century mental hospitals when doctors and nurses were committed to making this system work. It failed when doctors and nurses no longer supported this ideal. But the capacity for some patients to undergo sustained treatment in a caring environment for a month or more, even a year, rather than a few days or weeks, might have significant therapeutic benefits. It might reduce the risk of readmission. It might be one strategy in a much larger armoury of policies and practices to deal with the problem of mental illness that is worth reviving. History far from condemning the asylum might just be on its side.

University of Sydney

Notes

^1.� Erving Goffman, Asylums: Essays on the Social Situation of Mental Patients and Other Inmates (Harmondsworth: Penguin, 1961). See David Rothman, The Discovery of the Asylum: Social Order and Disorder in the New Republic (Boston: Little Brown, 1971) and Andrew Scull, The Most Solitary of Afflictions: Madness and Society in Britain 1700–1900 (New Haven: Yale University Press, 1993).

^2.� Andrew Scull, "Asylums: Utopias and realities" in Asylum in the Community, edited by Dylan Tomlinson and John Carrier (London: Routledge, 1996), 7–17.

^3.� Anne Digby, Madness, Morality and Medicine: A Study of the York Retreat, 1796–1914 (Cambridge: Cambridge University Press, 1985), 56. See also Kathleen Jones, A History of Mental Health Services (London: Routledge and Kegan Paul, 1972) and Gerald N. Grob, Mental Illness and American Society, 1875–1940 (Princeton NJ: Princeton University Press, 1983).

^4.� Ruth B. Caplan, Psychiatry and Community in Nineteenth-Century America (New York: Basic Books, 1969), 92.

^5.� See for example Lindsay Prior, "The appeal to Madness in Ireland" in Asylum in the Community, edited by Dylan Tomlinson and John Carrier (London: Routledge, 1996), 67–90. I made a few tentative forays into this area myself many years ago and this article tries to build on that earlier work and give it a much sharper analytical edge. See Stephen Garton, Medicine and Madness: A Social History of Insanity in NSW 1880–1940 (Kensington: NSW University Press, 1988).

^6.� See for example Mark Finnane, Insanity and the Insane in post-famine Ireland (London: Croom Helm, 1981) and R.W. Fox, So Far Disordered in Mind: Insanity in California, 1870–1930 (Berkeley: University of California Press, 1978).

^7.� For noteworthy asylum histories that do analyse institutional life with considerable insight see the classic study of York Asylum by Digby (see note 3) and Elizabeth Malcolm, Swift's Hospital: A History of St Patrick's Hospital Dublin, 1746–1989 (Dublin: Gill and Macmillan, 1989). For an earlier period see Michael McDonald, Mystical Bedlam: Madness, Anxiety and Healing in Seventeenth Century England (Cambridge: Cambridge University Press, 1982).

^8.� See Dylan Tomlinson and John Carrier (eds), Asylum in the Community (London: Routledge, 1996).

^9.� In addition to some of the classic accounts already cited, such as those of Jones, Grob, Scull, Rothman, Digby, and Finnane, see Michel Foucault, Madness and Civilisation: A History of the Insanity in the Age of Reason, translated by Robert Hurley (New York: Random House, 1971) and Robert Castel, The Regulation of Madness: The Origins of Incarceration in France (Berkeley: University of California Press, 1988).

^10.� For specific analyses of Wilberforce and the wider evangelical and Quaker reform movements see Scull, 83–125. See also F.K. Brown, Fathers of the Victorians: The Age of Wilberforce (Cambridge: Cambridge University Press, 1961).

^11.� The global reach of these principles is evident in such collections as Roy Porter and David Wright, eds, The Confinement of the Insane: International Perspectives, 1800–1965 (Cambridge: Cambridge University Press, 2003), which covers England, Ireland, Switzerland, Canada, Australia, South Africa, Germany, USA, France, Japan, Argentina, Mexico, India, and Nigeria.

^12.� On the decline of the asylum and the growing pessimism of reformers see Grob, 7–30; Scull, 267–333; Joseph Melling and Bill Forsythe, eds, Insanity, Institutions and Society, 1800–1914: A Social History of Madness in Comparative Perspective (London: Routledge, 1999); and Ellen Dwyer, Homes for the Mad:Life Inside Two Nineteenth-Century Asylums (New Brunswick NJ: Rutgers University Press, 1987).

^13.� For a general overview of these developments see Garton, Medicine and Madness, 76–85.

^14.� Garton, Medicine and Madness, 86–92.

^15.� For an overview of some of these trends see Stephen Garton, "Changing Minds" in Ann Curthoys, A.W. Martin, and Tim Rowse, eds, Australians from 1939 (Sydney: Fairfax, Syme & Weldon Associates, 1987), 343–55 and Milton Lewis, Managing Madness: Psychiatry and Society in Australia 1788–1980 (Canberra: AGPS Press, 1988), 49–61.

^16.� Allan Stoller and K.W. Arscott, Report on Mental Health Facilities and Needs of Australia (Canberra: AGPS, 1955), 52–4.

^17.� See "Report of the Hon. Mr Justice McClemens, Royal Commissioner appointed to inquire into certain matters affecting Callan Park Mental Hospital," NSW Parliamentary Papers 4 (1961–2): 673–99.

^18.� Cunningham Dax, "The Social Incentives in Mental Hospital Treatment," Medical Journal of Australia 1 (1955), 20.

^19.� See Garton, "Changing Minds," 350–2. See also Lewis, 63–5; Joy Damousi, Freud in the Antipodes: A Cultural History of Psychoanalysis in Australia (Kensington: UNSW Press, 2005), 281–304; Nick Crossley, Contesting Psychiatry: Social Movements in Mental Health (New York: Routledge, 2006); and D.G. Cooper, Psychiatry and Anti-psychiatry (London: Paladin, 1970).

^20.� Some historians have argued that the process of decarceration began much earlier. For example see Andrew Scull, Decarceration—Community Treatment and the Deviant: A Radical View (New Jersey: Prentice Hall, 1977). For the impact in Australia see Lewis, 75–98 and Damousi, 256–80.

^21.� See David Richmond, Report on Mental Health Services in NSW, 6 vols, (Sydney: NSW Government Printer, 1983).

^22.� For an overview of these early developments see Garton, Medicine and Madness, 17–23; John Bostock, The Dawn of Australian Psychiatry: An Account of Measures Taken for the Care of Mental Invalids from the Time of the first Fleet, 1788, to the year 1850 (Glebe: Australian Medical Publishing co., 1968); C.J. Cummins, The Administration of Lunacy and Idiocy in New South Wales, 1788–1855 (Sydney: Department of Public Health, 1967); D.I. McDonald, "Gladesville Hospital: The Formative Years, 1838–1850," Journal of the Royal Australian Historical Society 51, (December 1965): 273–95; Catharine Coleborne, Reading Madness: Gender and Difference in the Colonial Asylum in Victoria, Australia, 1848–1888 (Perth: Network Books, 2007), 13–37; and Lewis, 1–33

^23.�Sydney Morning Herald, 23 April 1883.

^24.� For an overview of Manning's career and significance see D.I. McDonald, "Frederick Norton Manning, 1839–1903," Journal of the Royal Australian Historical Society 58 (September 1972): 190–201.

^25.� Speech by Sir Henry Parkes 1 September 1885, quoted in G.A. Tucker, Lunacy in Many Lands (Sydney: Government Printer, 1887), 1559.

^26.� See Garton, Medicine and Madness, 160–8.

^27.� NSW Inspector-General of the Insane, Annual Report, 1887 (Sydney: NSW Government Printer, 1887), 8.

^28.� Figures compiled from NSW Inspector-General of the Insane, Annual Reports, 1880–9.

^29.� Figures from NSW Inspector-General of Mental Hospitals, Annual Reports, 1930–9.

^30.� For readmission rates see Inspector-General of the Insane, Annual Reports, 1880–1940. For figures on readmission in the 1970s see Garton, "Changing Minds," 354.

^31.� NSW Inspector-General of the Insane, Annual Report, 1884, 10.

^32.� Callan Park Hospital Medical Journals 1900–1940, State Records NSW, 3/7045–7053 and Gladesville Hospital Medical Journals, 1900–1940, State Records NSW, 8/2327—2339.

^33.� Inspector-General of Mental Hospitals Circular, 17 August 1931, Inspector-General of Mental Hospitals Correspondence, State Records NSW, 12/3469.

^34.� These figures come from the Inspector-General Annual Reports. For a general overview of these patterns of treatment, admission, discharge, and institutional care see Garton, Medicine and Madness, 168–81.

^35.� Inspector-General of the Insane, Annual Reports, 1880–1940.

^36.�Ibid.

^37.�Ibid.

^38.�Ibid.

^39.� See Garton, Medicine and Madness, 74–85 and "Changing Minds," 343–55.

^40.� For an overview of the importance of hereditarian and eugenic ideas in Australia see Martin Crotty, John Germov, and Grant Rodwell, eds, "A Race for a Place": Eugenics, Darwinism and Social Thought and Practice in Australia, Proceedings of the History and Sociology of Eugenics Conference, University of Newcastle, 2000 and Diana Wyndham, Eugenics in Australia: Striving for National Fitness (London: Galton Institute, 2002). See also Stephen Garton, "Sound Minds and Healthy Bodies: Reconsidering Eugenics in Australia 1914–1940" Australian Historical Studies 26, no. 103 (1994): 163–81 and Mary Cawte, "Craniometry and Eugenics in Australia: R.J.A. Berry and the Quest for Social Efficiency" Australian Historical Studies 22, no. 86 (1986): 35–53.

^41.� Inspector-General of Mental Hospitals, Annual Report, 1913, 4.

^42.� See Stephen Garton, "Bad or Mad? Developments in Incarceration in NSW 1880–1920," in What Rough Beast? The State and Social Order in Australian History, edited by Sydney Labour History Group (Sydney: Allen and Unwin, 1982), 89–110.

^43.� Evidence of Eric Sinclair, "Royal Commission of Inquiry into the Administration of the Mental Hospital and the Reception House for the Insane at Darlinghurst," NSW Parliamentary Papers 1 (1913), 640.

^44.� See Garton, Medicine and Madness, 53–64.

^45.�Ibid., 76–92.

^46.� See Damousi, 31–53.

^47.� See Garton, Medicine and Madness, 168–70.

^48.� Albert Deutsch, The Mentally Ill in America: A History of Their Care and Treatment Since Colonial Times, 2^nd ed. (1937; New York: Columbia University Press, 1965), 443–57.

^49.� See for example Peter Tyrer and Francis Creed, eds, Community Psychiatry in Action: Analysis and Prospects (New York: Cambridge University Press, 1995); Psychiatrists Working Group, She Won't Be Right Mate!: Impact of Managed Care on Australian Psychiatry and the Australian Community (Camberwell: Psychiatrists Working Group, 1997); and Rael Jean Isaac and Virginia C. Armat, Madness in the Streets: How Psychiatry and the Law Abandoned the Mentally Ill (New York: Free Press, 1990).

^50.� For example see Olav Nielssen, "Prevalence of Psychoses on Reception to Male Prisons in NSW," Australian and New Zealand Journal of Psychiatry 39, no. 6 (2005): 453–59.

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