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The asylum movement

Despite such pioneering efforts, in the early years of the nineteenth century many mentally ill people received no care and lived as vagrants or as inmates of workhouses and gaols. Also, there was public concern in England about the welfare of those in care, following reports of scandalously low standards in some private madhouses. This concern led to the County Asylum Act of 1808, which provided for the building of mental hospitals in each of the English counties. Unfortunately, little was done by the county authorities, and in 1845 it was necessary to enact the Lunatics Act, which required the building of an asylum in every county.

At first the new asylums provided good treatment in spacious surroundings. Moral management was championed, especially by members of the Nonrestraint Movement, which had started with the work of Gardiner Hill at the Lincoln Asylum in 1837 and was developed further by John Conolly at the Middlesex County Asylum, Hanwell. In 1856, Conolly published a significant book, ' The treatment of the insane without mechanical restraints'.

Unfortunately, these liberal steps were soon followed by a new restrictive approach. Increasing public intolerance led to the transfer of more and more patients from the community and prisons to the new asylums. Initial optimism about the curability of psychiatric disorder dissipated, as the limitations of moral treatment became apparent. More gloomy views about organic and hereditary causes prevailed. By the 1850s, the problems of overcrowded asylums were evident. Attempts were made to house patients with chronic illness in less restrictive and more domestic surroundings in detached annexes or houses in the grounds of the asylum.

Other hospitals returned patients to the community either by boarding them out with a family (a form of care which was practiced most successfully at Gheel in Belgium ) or by returning them to workhouses. The Lunacy Commissioners, whose role was to oversee the care of the mentally ill, were concerned that these arrangements could lead to abuse, and were opposed to them. Nevertheless, nineteenth-century asylums, even when overcrowded, provided a standard of care for the mentally ill that was lacking elsewhere. Thus the mentally ill were protected from exploitation, and were provided with shelter, food, and general health care. These benefits were counterbalanced by the disadvantages of loss of personal choice and autonomy, and of a monotonous and overprotective regimen that could lead to institutionalism.

Under the increasing pressures of overcrowding and staff shortages, there was less and less time for moral management. Again, a custodial approach was adopted. This change to custodial care was endorsed by the Lunacy Act 1890, which imposed restrictions on discharge from hospital. These custodial arrangements continued into the twentieth century, and their legacy is still seen in the size and structure of the large Victorian hospitals in which most psychiatry was practiced until recently.

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