Psychiatric institutions in Europe, nineteenth and twentieth century

The modern asylum, an institutional model based on the isolation of the mentally ill, was born at the turn of the eighteenth and nineteenth centuries. The asylum model became widely established during the nineteenth century (asylums multiplied and treated increasingly large populations). However, it prompted sharp criticism from its very beginnings. The search for alternatives to the asylum began during the nineteenth century, and accelerated due to the disruption caused by the two global conflicts. The need for internment continued to be questioned during the 1950s and 1960s, within a context of profound transformations in the psychiatric field. Reforms were implemented in most Western countries to develop the treatment of mental illness beyond the walls of asylums, with contrasting results depending on the space in question.

View of the Sainte-Anne Mental Asylum in Paris, 1877. Source : Wikimedia Commons
Summary

The great European confinement: general expansion, varying temporalities

The modern asylum was born in Europe at the turn of the eighteenth and nineteenth centuries through the combination of a body of knowledge, a treatment method, and an institutional model. The “moral treatment” of Philippe Pinel (1745-1826), based on the belief that madness is curable, sought to use the amount of reason still present in each individual. It translated into the development of models for institutional life, such as that of the York “retreat” founded by William Tuke (1732-1822). The asylum was designed as a “healing machine,” a curative instrument that used a single measure—isolation—to achieve both a humanitarian and a security objective.

Each country had its major figure and founding law, with that of France (1838) becoming a model that partly inspired that of the United Kingdom (1845) and Belgium (1850). The mental asylum spread massively across Europe: in 1878 there were 104 establishments for mental patients in France, and in 1899 there were 279 in Germany. For all that, this should not obscure the disparities between national situations. In Spain, modern establishments for the insane appeared only in the 1850s, while in Italy the structuring of the psychiatric profession and the founding of new institutions did not occur until the second half of the nineteenth century, with national legislation being adopted only in 1904. Russia was even further behind. While some countries adopted a homogeneous and unified model, others organized psychiatric assistance in a more decentralized fashion (Switzerland), or relied heavily on charitable and religious organizations (Sweden, Portugal, the Netherlands, etc.). Knowledge and institutional models circulated on a European scale, following a logic that was equal parts emulation and competition between nations. Foreign trips to observe the practices of neighbors became a common practice. The attention of European psychiatrists also turned to the colonies, as demonstrated by the Congress of Tunis held in 1912.

The populations treated in asylums increased exponentially from the middle of the century, with the number rising in France from 10,000 patients in 1840 to over 60,000 in 1900. Asylums grew ever larger and took on gigantic proportions, often surpassing 1,000 patients (as at Clermont in the Oise department, which for a long time was Europe’s largest institution for the mentally ill).

Multi-faceted crisis and a search for alternatives

Asylums were victims of their own success, and soon faced persistent congestion.

The rate of recovery was low everywhere, while recurring scandals involving arbitrary confinement and abusive internment fueled criticism of the institution and its doctors. The Evere affair sparked intense protest of medical practices in Belgium in 1871-1872, and the abuses of the “trade in lunacy” were singled out in Victorian England. While Belgian law and English law were changed in 1873 and 1889 to exert better control over mental institutions, none of the attempts to reform the French 1838 law proved successful.

This multi-faceted crisis nevertheless promoted a diversification in institutional practices and structures, and led to the opening of special areas within institutions for epileptics and alcoholics, as well as agricultural colonies for convalescents. Still, the history of madness continued to take place beyond the walls of asylums. In 1857, Scotland implemented a boarding-out system that allowed mental patients to be placed with families, who were compensated for taking them in. In the Flemish Belgian town of Geel, a key anti-model was developed based on the treatment of mental patients “outside the walls,” amid the city's inhabitants.

The quest to replace asylums intensified at the end of the century, as demonstrated by the opening of “family colonies” by the Seine department in France. In 1911 the German psychiatrist Gustav Kolb (1870-1938) established a free service in Erlangen offering treatment outside of an asylum.

Transformations accelerated by the wars

Traditional asylum nevertheless remained the predominant model on the European scale, and underwent major changes only after the upheaval of the two global conflicts. In France, the specific circumstances of the First World War allowed for experimentation with alternative solutions for confinement. Reflections on how to transform the asylum model developed during the interwar period, while treatment practices were transformed by the arrival of “shock therapy.” In the 1920s a number of European institutions offered treatment beyond the asylum: the Tavistock Clinic opened in London in 1920, the Service libre de prophylaxie mentale (Free service for mental prophylaxis) was founded by Édouard Toulouse (1865-1947) in Paris in 1922, and the Afdeeling voor Zeenuw-en Geesteszieken appeared in Amsterdam. While these initiatives remained in the minority, they nevertheless attest to an aspiration for a change in paradigm, which was symbolized in France by the substitution of the term “psychiatric hospital” for that of “asylum” in 1937.

The Second World War was also a key moment of reflection on the asylum model’s limits. Challenges to this model were of particular importance in Germany due to the crimes committed against the mentally ill under the Third Reich. In France, “l'hécatombe des fous” (“massacre of the insane”) resulted in 40,000 patients killed by starvation in hospitals and sparked radical questioning of asylum structures, especially as the improvised “liberation” of some patients who successfully readapted to the outside world—within a context of exodus—led psychiatrists to put the need for confinement into perspective.

Dehospitalization and its limits

Psychiatric hospitals underwent transformations during the 1950s and 1960s, especially due to the introduction of the first neuroleptic drugs, such as chlorpromazine. The use of these new medicinal substances lowered patients’ level of agitation, and reduced the length of stay within the institution. The 1960s also saw the diversification of therapeutical practices, which went hand in hand with the arrival of new professions in European psychiatric institutions (psychologists, ergotherapists, social workers). While there was increasing criticism from supporters of antipsychiatry, who saw the psychiatric hospital as a pathogenic site, a new wind of reform swept through European psychiatry, one that turned on opening the psychiatric space to the outside.

This desire for reform was present on both sides of the Iron Curtain, as demonstrated by the “Rodewisch Theses,” an ambitious reform program formulated in 1963 by psychiatrists in the GDR. In Western countries, this reform movement led to a process of psychiatric dehospitalization. The circular of 15 March 1960, which divided French asylums in different sectors, reflects this change of paradigm. In the FRG, an investigative commission established by the Bundestag in 1975 recommended restructuring most psychiatric hospitals. The process took a more radical form in Italy, where law 180 in 1978 banned new admissions in psychiatric hospitals, and led to their gradual closing. These reforms sought to develop the treatment of patients outside of the hospital, with varying results depending on the space in question. In France, the development of alternative structures came later, and hospitals remained at the heart of the psychiatric system. Paradoxically, the dehospitalization process, whose limits have been shown by recent research, has not challenged the hospital-centered approach of the psychiatric care system.

Translated by Arby Gharibian

To quote from this article

Fanny Le bonhomme , Anatole Le bras , « Psychiatric institutions in Europe, nineteenth and twentieth century », Encyclopédie d'histoire numérique de l'Europe [online], ISSN 2677-6588, published on 21/10/21, consulted on 27/01/2023. Permalink : https://ehne.fr/en/node/14132

Bibliography

Coldefy, Magali, “L’évolution des dispositifs de soins psychiatriques en Allemagne, Angleterre, France et Italie : similitudes et divergences,” Questions d’économie de la santé, IRDES 180 (2012).

Freeman, Hugh, Gijswijt-Hofstra, Marijke, Oosterhuis, Harry, Vijselaar, Joost (eds.), Psychiatric Cultures Compared. Psychiatry and Mental Health Care in the Twentieth Century: Comparisons and Approaches (Amsterdam: Amsterdam University Press, 2005).

Klein, Alexandre, Guillemain, Hervé, Thifault, Marie-Claude (eds.), La fin de l’asile ? Histoire de la déshospitalisation psychiatrique dans l’espace francophone au xxe siècle (Rennes: PUR, 2018).

Porter, Roy, Wright, David (eds.), The Confinement of the Insane: International Perspectives, 1800-1965 (Cambridge: Cambridge University Press, 2003).

Postel, Jacques, Quétel, Claude (eds.), Nouvelle Histoire de la psychiatrie (Paris: Dunod, 1994).

/sites/default/files/styles/opengraph/public/institutions%20psychiatriques.jpg?itok=oI04aMaw