Moral treatment | Quakers & Mental Health

Moral treatment

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Introduction to Moral Treatment

Moral treatment was the main way that the Asylum treated patients. As an 1825 history of the Asylum explained, “Although the use of drugs and medicaments is allowed, in almost every case, to be indispensible, less weight is attached to it in the Friends’ Asylum, than to moral treatment” (Waln 15). The Asylum implemented moral treatment, which involved almost every aspect of the patients' lives, by treating the patients as much like rational beings as possible, and “inspir[ing] their troubled minds, on every dawn of intellect, and in every moment of calmness… with consoling evidence, that they were indeed regarded as men and brethren” (Waln 4). Treating the patients like rational beings meant using restraint only as a last resort, to ensure the safety of the patient and those around him or her, not as a punishment. Under moral treatment, the superintendent and keepers treated the patients as individuals, and helped them to try to regain control of themselves. Some important facets of moral treatment at the Asylum were connections with the community, religious oversight, and occupational therapy.

"[Moral treatment] leads many to struggle to conceal and overcome their morbid propensities; and, at least, materially assists them in confining their deviations, within such bounds, as do not make them obnoxious to the family."
~Samuel Tuke, Description of the Retreat, 1813

The Cruel Side of Moral Treatment

Moral treatment was widely believed to be kinder than other types of treatment available to the mentally ill because it limited the use of physical restraint and did not condone corporal punsishment. Although moral treatment at the Asylum was non-violent and focused on getting the patients to try to take control of their lives again, some of moral treatment’s manifestations could be cruel. For some examples of the cruel side of moral treatment, see the stories of Nathan Y. and Abraham S. in the Case Studies.

Moral Treatment and Self-Discipline

The Quaker founders of the Retreat and the Asylum defended and explained their use of moral treatment by arguing its efficacy. Moral treatment was not good because it was less violent, they wrote, it was good because it made the mentally ill "conform for the good of the community" (Godlee 75). Scholar Fiona Godlee maintained that this focus on changing the outward behaviors of the patients to make them less obnoxious to the community contradicts Quaker faith and practice. Quakers are supposed to focus on the importance of inward changes of heart and making one’s behavior match one's inner life. For Godlee, moral treatment’s focus on the comfort of other people, as opposed to the cure of the patients, made moral treatment seem deeply un-Quaker. Historian Anne Digby countered that Quakers have always placed great importance on self-control, and she argued that moral treatment's coercive tactics would have seemed like a natural and familiar way to help mentally ill Quakers regain that self-control (68). The tension between these two viewpoints mirrors the tensions developing in American Quakerism, which would eventually lead to the Hicksite-Orthodox Schism.

Early Usage of Physical Restraints and Seclusion

Moral treatment was the primary form of treatment at Friends Asylum until the 1850s. Utilizing the methods fundamental to moral treatment, the Asylum treated its patients with kind, gentle, yet disciplined means with the hope that their patients’ sanity would be restored. Despite this commitment to humane forms of treatment, patients were still subjected to physical restraints and periods of seclusion, highlighting a clear internal contradiction within the practice of moral treatment. The juxtaposition of restraints and seclusion with the Asylum’s commitment to kindness and compassion was a challenge that the Asylum never found a direct solution to until the 1850s when the institution transitioned to a medical model.

Theoretically, moral treatment rejected the physical control of one person by another, and it emphasized gentler forms of social controls, constructed around an idealized vision of a “family united in the bonds of love, [rather] than of a receptacle for lunatics.”1,2 In practice, physical restraints were seen as “necessary evil” and were used to prevent patients from being destructive or noisy, and they were sometimes used to prevent the patient from running away.3,4 Patients who were deemed “harmless,” “quiet,” or “convalescent” were housed in the upper stories of the building; patients who were “violent,” “noisy,” and “incurable” were housed in the lower stories of the building.5 The separation was to keep the noisy patients from disturbing the quiet patients and the Asylum staff who lived in the upper stories of the building. Whenever patients were especially violent or noisy, they would be put in a “solitary chamber,” sometimes combined with physical restraints, in order to calm them down or to punish them.6 When restrained in the solitary chamber, the patient was “confined in a strait waistcoat, and in a recumbent posture, by means of broad leathern belts crossing his breast and legs, with straps affixed, which encircle his wrists and ankles.”7 Sometimes threatening patients with physical restraint or seclusion was enough to restore the patient’s self-control. Isaac Bonsall wrote that Hannah Jones “had been so frequent in the expression of ‘I wish I could go home, I wish I had stayed with my father and died there, etc.’ that my wife threatened to put the straight jacket on her if she would not be quiet.”8

Physical restraints and seclusion were used at different rates depending on the superintendent and physicians. Isaac Bonsall, the Asylum’s first superintendent from 1817-1823, did not hesitate to use restraints whenever patients were destructive or noisy, as in the case of Hannah Jones. By contrast, Thomas Kirkbride, resident physician at Friends Asylum in 1832 and later resident physician at Pennsylvania Hospital in Philadelphia, frequently expressed abhorrence towards the use of physical restraint, writing that he “never saw it in use without a feeling of mortification, nor without asking himself whether it was really necessary.”9

Common restraints used included handstraps, bedstraps, and the straight waist jacket. The reasons for using restraints were categorized as physical or behavioral. Physical reasons included destroying property, attempting suicide, eloping (or elopement attempts), and attacking others.10 Oftentimes, restraints were used as punishments for these behaviors. Behavioral reasons included “improper conduct,” being “noisy,” being “excited,” or “threaten[ing] others.”11 Although restraints were often necessary to ensure the safety of the patients and the Asylum staff, they were occasionally interpreted as a form of social control and abuse of power in which patients were deprived of their freedom, though the true thoughts of the patients are difficult to discern because of the lack of information in the archival records

1. D’Antonio, Patricia. Founding Friends: Families, Staff, and Patients at the Friends Asylum in Early Nineteenth-Century Philadelphia. Lehigh University Press, 2006, p. 131.

2. Annual Reports, 1826 Box 1, Friends Hospital Records, Quaker and Special Collections, Haverford College, Haverford, Pennsylvania.

3. Tomes, Nancy. A Generous Confidence: Thomas Story Kirkbride and the Art of Asylum-Keeping, 1840-1883. Cambridge etc.: Cambridge University Press, 1984, p. 198.

4. D’Antonio, Founding Friends, p. 59.

5. Annual Reports, 1826.

6. Annual Reports, 1826.

7. Annual Reports, 1826.

8. Superintendent Daybook Vol. 1, 1817-1820 Item 61, June 14, 1817, Friends Hospital Records, Quaker and Special Collections, Haverford College, Haverford, Pennsylvania.

9. Tomes, A Generous Confidence, p. 198.

10. D’Antonio, Founding Friends, p. 205.

11. D’Antonio, Founding Friends, p. 205.

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