Recovery From Schizophrenia: Psychiatry And Political Economy

MADNESS AND THE INDUSTRIAL REVOLUTION 125become less frequent. The reasons, he believed, for the decline in recovery ratesincluded a failure to provide an adequate trial of moral treatment for manypatients. Latter-day psychiatric historians, however, have generally ignored DrRay and repeated Pliny Earle’s rather self-serving opinions as accurate. 108 Theyhave, thereby, buried important information—the course of functional psychosesin patients admitted to early nineteenth-century American hospitals was morebenign than in the hundred years that followed.THE DEMISE OF MORAL TREATMENTIt is possible, then, that the labor shortage in the first half of the nineteenthcentury in America influenced rehabilitative efforts for the insane and elevatedrecovery rates in psychosis. This notion, however, reverses some of the orthodoxexplanations for the demise of moral management in the latter part of thecentury. Thus, it was not so much that the failure of promises of curability ledlegislators to demand cost-cutting in the institutions; it may have been thediminished need for manpower that reduced the incentive to fund vigoroustreatment programs and caused a reduction in cure rates. It was not just a buildupof chronic patients and an increase in hospital size and overcrowding thatcaused the deteriorating institutional conditions; it was the decline inrehabilitative efforts that created the build-up of chronic patients. And the foreignpaupers who filled the asylums and so outraged the sensibilities of the psychiatristsand middle-class clientele—the Irish “clodhoppers” with their “filthy habits”—were not incurable because they had “scarcely an idea beyond that of…manualemployment,” as Isaac Ray claimed. 109 They were stuck because there was noemployment outside the hospital, and no longer any work therapy within thehospital. 110 (Inmates’ work had become too competitive to be tolerated by theunemployed beyond the institutions’ walls.) If funding cuts and overcrowdingwith chronic patients and paupers were the problems, then the affluent privatehospitals that selected more “recent” cases and excluded paupers—PennsylvaniaHospital, the Friends’ Asylum, McLean Hospital, Bloomingdale Asylum (whichexcluded paupers after 1857) and the Hartford Retreat (after 1866) 111 should haveexperienced few difficulties. As Table 5.3 shows, however, recovery ratesdeteriorated in these institutions also after 1870. Public and private asylums alikedeclined from curative to custodial institutions. 112Moral treatment reached its zenith in labor-starved, early nineteenth-centuryAmerica for two reasons. Firstly, given a demand for labor, moral managementwas a truly rehabilitative measure that could restore the maximum level offunctioning to the marginal psychotic patient. Secondly, as in contemporaryBritain, it legitimized the establishment of specialized institutions for confiningthe unemployable insane. With the inevitable disappearance of the labor shortage,the social-control functions of the institutions overcame their rehabilitativepurpose. Where environmental factors had previously been seen as important incausing psychosis, the emphasis now was on heredity. Prevailing concepts of