Prescribing Restraint: Patient Liberty and Movement in the Insane Asylum

Vesna Curlic explores the debates around patient liberty and restraint in asylum spaces

In 1890, an anonymous patient at Crichton Royal Hospital in Dumfries, Scotland wrote a piece for the institutional magazine, The New Moon, wherein he described his first impressions of the institution. He explained his idyllic routine, spending his mornings playing outdoor games or walking around the grounds, “viewing the romantic scenery of this historic district.” [1] In the afternoons, he might write a book or hone his professional skills or learn about science and art. Anyone except the dreariest souls, the patient states confidently, would be able to make themselves “if not at home, at least comfortable and happy here.”[2] This description of asylum life sounds deeply soothing. In fact, writing from the cramped quarters of COVID quarantine, this vision of the asylum sounds like a much more pleasant confinement than my own.

Psychiatric treatment in the late-nineteenth century asylum was governed by an enduring concept called ‘moral management,’ which tried to balance unwieldy patient populations in overly bureaucratic asylums with ideals of humane patient treatment. Using calming, domestic-inspired environments and a daily routine of work, exercise, recreation, and education, the asylum sought to control patient behaviour and return them to a rational state of mind.[3] As part of this system of treatment, asylum administrators (especially those in Scotland) sought to promote a sense of freedom among patients.[4] Despite these ideals, patients’ movement tended to be closely monitored and sometimes restricted as a part of their treatment. In addition to controlling their daily routines, patients’ hands and feet could be physically restrained in its most extreme forms. I find myself asking – how can we reconcile these restrictions with the ideals of patient liberty in the asylum?

The Crichton Royal Institution, Dumfries, Scotland. Transfer lithograph by Emil Ernst Friedrich Schenck. Credit: Wellcome Collection. Attribution 4.0 International (CC BY 4.0)

Open-Door System

At the end of the century, a radical new approach to patient liberty in the asylum was debated among psychiatric professionals. The open-door system was proposed as a modern and humane approach to asylum design, allowing patients more freedom to move around their living space. The system required that there were very few locked doors in the entire asylum and any symbols of prison-like confinement were eliminated. For example, the medical administrators at Crichton had done away with the high boundary walls in the early 1890s, which was then replaced by an open fence.[5] Psychiatric experts believed that the elimination of these symbols of confinement “resulted in an increase of tranquillity and contentment.”[6] The open door system was idealised as an enlightened psychiatric treatment.

Why then, did the open-door system face criticism? The answer lies, as many shattered ideals do, with practicality. Dr. Fredrick Needham, who later became a Commissioner in Lunacy, was a major critic of the open-door system’s potential for widespread use. He himself felt that this system would be a “Utopia in asylum life,” but worried about the practicalities of its implementation.[7] Needham’s main concern was about how the open-door system would work for different classes of patients. Late-nineteenth century asylums were largely organised by patients’ their social class, which essentially referred to their financial support (either privately supported or state-sponsored). Supporters of the open-door system admitted that it needed to be complemented with a strict schedule of work and recreation for patients, to keep them busy during the daylight hours and tired in the evening hours. In Needham’s view, the open-door system could only be used in asylums with pauper patient populations, as there was plenty of manual labour for those patients to do. For patients of the private class “whose education has been such as to have developed a strong- individuality and a habit of non-obedience,” it would be a challenge to find enough class-appropriate work to occupy them for the whole day.[8] Ultimately, the behaviours of insane people were deemed too unpredictable and class expectations forbade some patients from working sufficiently long hours to thrive in an open-door asylum. This discourse around the open-door system suggests that, while patient freedom was idealised, the practicality of patient management overruled these ideals in many asylum settings.

Liberty & Restraint

This uneven attitude towards patient liberty is further exemplified in the conversation surrounding physical restraint at the end of the century. We often think about the straitjacket as an inexorable part of the asylum landscape, but by the end of the nineteenth century, this had largely fallen out of fashion, having been deemed too cruel.[9] The straitjacket was replaced with other restraints, like padded gloves, which were thought to a “harmless and mild” method of restraint, much more in line with modern expectations of psychiatric treatment.[10] Despite these advancements in restraint technology, the use of mechanical restraints had nearly fallen out of practise entirely in the nineteenth century. Until, that is, a new cohort of doctors at the end of the century began advocating for them again.[11]

The debates around restraint are particularly interesting because both pro- and anti-restraint doctors saw themselves as holding the modern, enlightened position, while the opposition was deemed ignorant and uncritical. This debate played out at professional association meetings and in private correspondence, but the nature of this debate is captured nicely in a series of heated letters published in The Journal of Mental Science between two prominent Scottish psychiatric professionals. They summarised the major arguments about restraint in the psychiatric community, and in doing so, exposed the fact that convenience of patient management was often at odds with ideals of freedom.

This dispute began innocuously. Dr David Yellowlees, Physician-Superintendent at Gartnavel Royal Asylum, claimed at a 1889 meeting of the Medico-Psychological Association that “Restraint when dictated by harshness, irritation, or mere convenience is utterly wrong, but restraint when part of a well-considered plan of treatment, may, in special cases be perfectly wise or right.” Dr. Yellowlees went on to specify the particular cases when restraint was appropriate – he felt no hesitation in restraining a patient if they were suicidal or “in cases of extreme and exceptional violence.”[12] In addition to restraining a patient when they were a threat to themselves or others, Yellowlees also advocated for restraining patients if they might destroy asylum property or if they were extremely fidgety.[13] These were common reasonings for pro-restraint doctors. The destruction of asylum property was a particularly controversial reason, but pro-restraint doctors pointed to some patients’ obsessive, repetitive behaviours, which resulted in ruined clothing and bedsheets, and an increased cost to the asylum.[14]

Dr. Alexander Robertson, a professor of medicine at the University of Glasgow, found this perspective reprehensible. Responding with a biting letter, Robertson called Dr. Yellowlees “the leader in Scotland of a retrograde movement.”[15] Robertson argued that the ambiguous benefits of using restraint did not justify returning to the “cruellest … and darkest days” of the psychiatric profession.[16] He pointed out that when Gartnavel Royal Asylum was moved to its current location in 1843, the founders wrote a list of principles, including “employing no mechanical personal restraint in the treatment of the patients.”[17] Robertson found it ironic that a moral principal that was so clear to the asylum’s administrators fifty years ago was lost on modern doctors. Yellowlees’ opinion was unchanged. For Yellowlees and other pro-restraint doctors, the use of restraint was a modern, evidence-based form of treatment and the ability to prescribe restraint required expert training, which differentiated him from “cruel or unenlightened men in bygone days.”[18].

This debate demonstrates the contradictory and uneven attitudes in the psychiatric profession towards patient liberty, despite it being idealised in some rhetoric as an important part of psychiatric treatment. The open-door system, built on this idealisation of patient liberty, received criticism and was deemed too challenging to implement in most cases, while some doctors deemed the convenience of physical restraints more important than the moral imperative to give patients the bodily agency to move their limbs freely. I can’t help thinking about our anonymous patient from the beginning of this article. It’s clear that his experience was not universal. For reluctant patients, or patients with behaviours or illnesses deemed more challenging or inconvenient, the peaceful freedom to do as they please would certainly be restricted. As I find myself getting restless in my own health-imposed confinement, I think frequently of these patients. I think of the patients who were restless or agitated in the asylum while far away from all familiarity, and who had their freedom to move further restricted in response to this restlessness.

Vesna Curlic is currently undertaking her PhD at the University of Edinburgh. Her doctoral research considers immigration and public health in Britain in the late nineteenth and early twentieth centuries. She wrote her M.A. thesis on domesticity in British insane asylums.

 

References

[1] “My First Impressions of Crichton,” New Moon 47, no. 594 (November 1890): 1-2.

[2] “My First Impressions of Crichton,” New Moon, 1.

[3] Louise Hide, Gender and Class in English Asylums, 1890-1914 (London: Palgrave MacMillan, 2014), 91-93.

[4] Gillian Allmond, “Liberty and the Individual: The Colony Asylum in Scotland and England,” History of Psychiatry 28, no. 1 (2017): 30.

[5] Thirty-Fourth Annual Report of the Scottish Commissioners in Lunacy (1892), 52.

[6] Thirty-Fourth Annual Report of the Scottish Commissioners in Lunacy (1892), 52.

[7] Frederick Needham, “The ‘Open-Door’ System,” JMS  27, no. 118 (1881): 221.

[8] Frederick Needham, “The ‘Open-Door’ System,” JMS 27, no. 120 (1882): 557.

[9] Forty-Third Annual Report of the Scottish Commissioners in Lunacy (1901), xlix.

[10] Bethlem Royal Asylum Annual Report (1890), 49.

[11] Hide, Gender and Class, 132.

[12] Alex Robertson, “On the Use of Restraint in the Care of the Insane,” JMS 35, no. 151 (1889): 476.

[13] Robertson, “On the Use of Restraint in the Care of the Insane,” 476.

[14] Bethlem Royal Asylum Annual Report (1890), 49.

[15] David Yellowlees, “On the Use of Restraint in the Care of the Insane: To the Editors of ‘The Journal of Mental Science,’” JMS 35, no. 150 (1889): 287.

[16] Robertson, “On the Use of Restraint in the Care of the Insane,” 476.

[17] Robertson, “On the Use of Restraint in the Care of the Insane,” 477.

[18] Yellowlees, “To the Editors,” 478.

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