He believed asylums should be planned to encourage work, both physical and mental. To get away from the stress and turmoil of the city, an asylum should be erected out in the country where there was space for patients "to work, walk, and congregate. He called for plenty of large windows, one central building, separate buildings for the genders, and separate wings for wards" (Haller & Larsen, 2005, p. 262).
The Kirkbride asylum had a central administration building with a dome that was flanked by two wings of tiered wards. Residents were separated according to sex and the symptoms of their illnesses, with "excited patients" on the lower floors farther away from the administrative center. Well-behaved, more rational patients were placed on uppers floors closer to the administrative section. Fresh air, natural light, and scenic views of the park-like grounds were available to all wards.
Kirkbride asylums were designed to work in harmony with the principles of moral treatment. Space was allocated for a variety of wholesome patient activities (such as lectures and classes), amusements, and outdoor exercise. Kirkbride "envisioned moral treatment as a series of internal experiences" (p. 263) for a wide range of social classes. His first hospital -- Pennsylvania Hospital for the Insane -- opened in 1841 with a progressive program, board, and staff familiar with strategies such as "psychological persuasion, classification and separation by mental disorder, amusements, and physical labor" (p. 263).
In a poetic essay about the architecture of asylums, Krahn (2005) reminds us, "The mental hospital is a house built by society for such people, a training house to conquer their fear or refusal or confusion or forgetfulness. Foucault has described these architectural intentions in detail, how power is demonstrated and exerted by institutional architecture which rules out certain behaviors and encourages others" (p. 104). This was certainly true of Kirkbride asylums, for as Krahn puts it, "the quality of material and shaping of space clearly spoke about who was to be where, you could see there were many different classes of people, different things you were allowed to do or told not to do" (p. 106).
Kirkbride saw moral treatment as the best way to treat mental illness, but he also was highly innovative and eager to use the new, exciting technologies of the day in activities and amusements:
One of the more popular efforts to enlighten and educate patients to return to sanity was the scheduling of evening magic lantern slide exhibitions and lectures. They were intended by Kirkbride to persuade, control, and amuse. He believed that they encouraged patients to fight depression and sadness, thereby regaining the happy demeanor necessary for resuming their places in the social order. He also assumed that the slides were a rhetorically persuasive tool for convincing patients that hospital officials cared for them. If the hospital provided entertainment equal or better to that in the outside world, the patients would believe that its staff members sincerely desired to make them well" (Haller & Larsen, 2005, p. 264).
Magic lantern presentations were not new. What was new was the use of photography, which made the effect much more realistic; in fact, asylums were among the first to use photography in the treatment of patients. Shows could consist of slides from popular fiction, historical episodes, current themes and news, natural history, comedy, and education -- including social causes and religious movements. Magic lantern shows, in general, were very popular with American audiences during the 19th century (before movies). For mental patients they were ideal for safe and suitable entertainment and education and, according to Haller & Larsen (2005), reminded patients of their middle-class sensibilities. Moreover, Kirkbride was careful to debrief the patients afterwards so that they would not become confused and think the images they saw were reality. He helped them to understand that the magic lantern shows with their realistic 3-D images were cleverly wrought illusions (Haller & Larsen, 2005).
As one of America's first psychiatrists, Kirkbride claimed he could diagnose sixteen different mental disorders in patients just by looking at them and "could determine visually from patients' conduct their degrees of insanity and sanity... [Kirkbride and others psychiatrists at the time] assumed that their trained clinical gaze could provide them with sufficient evidence of the presence of pathology" (Haller & Larsen, 2005, p. 75). Psychiatry, needless to say, was very much in its infancy, and practitioners were eagerly trying everything they could think of to help their patients.
As the superintendent of the Philadelphia Hospital for the Insane, Kirkbride, more than anyone else, influenced how other asylums were built and operated. State governments paid for the building of the best-known and largest asylums. The buildings and surroundings, according to Kirkbride principles, were considered to be active participants in the treatment. The landscaping, for instance, with its natural beauty could calm a person's mind while at the same time it improved the appearance of the asylum itself. "Farmland served to make the asylum more self-sufficient by providing readily available food and other farm products at a minimal cost to the state" (Kirkbride Buildings - History web site, p. 1). The asylum was a place meant to seclude the patient from the hectic energy and disturbing influences in the city that may have caused or contributed to his or her illness. Sunlight and air were crucial to a cheerful atmosphere, and structured activity was an important component in the treatment. Curing the patients was the primary goal.
The doctors, of course, were not alone in the decision-making process. Running an asylum involved negotiations between the doctor and the family members who were paying for treatment. Suzuki (2006) argues that the family played a far more significant role than most researchers and historians have recognized. Families had considerable influence in deciding what treatments were appropriate. According to Suzuki, "the lay interpretation of madness" was a key determining factor in "diagnosis, treatment, and management practices" (cited in Smith, 2006, p. 919). Families nearly always tried at first to care for the person at home. Sometimes the police would order the family to place the patient in an open slatted cage at home to protect themselves and their neighbors from assault (Lanzoni, 2005, p. 500). When family members were no longer able to care for the person, they tended to choose institutions with more homelike environments. Suzuki speculates that moral treatment "may have originated in the family, to be subsequently adopted in the best-managed institutions..." (p. 920). Whether or not that is so, families were "authorities in their own right, who seek and coordinate asylum care, as well as make strategic decisions as to when to institutionalize their family members" (Lanzoni, 2005, p. 499).
It could not have been an easy decision to make. In his famous book Asylums, sociologist Erving Goffman points out that once a person went into an asylum, it was difficult to get out, so difficult that Goffman defined asylums as impermeable institutions (Curran, 2006). No matter how homelike and cheerful the place was, the person was still incarcerated. For this reason various scholars have labeled asylums inherently abusive because once the patient was declared legally to be incompetent, he or she was deprived of civil liberties and human rights.
Later in the 19th century the focus of asylum care shifted from moral treatment to custodial care. This was a direct result of social conditions (Lanzoni, 2005). The number of committed patients greatly increased and frequently overwhelmed doctors and staff, who were "overworked and lowly paid.." (McGovern, 1993, p. 669). Custodial care began to take precedence over therapeutic efforts and individualized attention. Urbanization with ever-greater numbers of people seems to have triggered the shift away from treatment. Moreover, the asylums were designed to house smaller numbers and became overcrowded. Lanzoni (2005) states, this "effectively lowered cure rates and promoted a pessimistic view of mental illness..." (p. 502). A larger number of chronic (incurable) patients were admitted than had been in earlier years. Thus, she concludes, "Overcrowding and poor care then were not an indictment of medical practice per se, but rather resulted from an array of social changes and commitment practices that resulted in high internment rates" (p. 503).
An example is the South Carolina public lunatic asylum, which moved from "the ideal of moral treatment to custodial care" (Lanzoni, 2005, p. 503). By 1899 the asylum in South Carolina had become known as the worst in the country.
Overcrowding, marginal recovery rates, high mortality rates, and a failure to provide even basic custodial care were the norm" (p. 504). Not surprisingly, poor black patients were disregarded, ignored, and neglected. Social changes compounded the deplorable conditions. After the civil war South Carolina was one of the poorest states and continually lacked funds to support the asylum. Plus, a huge increase of patients came when blacks were emancipated and allowed to enter the state asylum. The South Carolina asylum followed a pattern…