History of Psychiatry: Moral Management Movement

16th October 2023

Successful non-pharmaceutical treatment of mental health disorders in the 1800s

Businessman, philanthropist and Quaker, William Tuke, founded the moral management movement, a humane and effective non-pharmaceutical approach to treating serious mental illness in the early 1800s. The focus was on practicality, self-discipline and positive human interactions, as well as attention to what were discerned to be spiritual needs of the individual.

French psychiatrist Philippe Pinel (1745-1826) was also involved with the development of the moral management mental health treatment approach.

What was Moral Management in Mental Health Treatment?

During the early part of this period of humanitarian reform, the use of moral management was a method of mental health or mental disorder treatment that focused on a patient's of social, individual, and occupational needs. During the 1800s, it became relatively widespread as a treatment approach that was as effective, or even more effective, than modern psychiatric practice. This approach, which stemmed largely from the work of William Tuke and Philippe Pinel, began in Europe during the late eighteenth century and in America during the early nineteenth century. Rees (1957) described the approach this way:

"The insane came to be regarded as normal people who had lost their reason as a result of having been exposed to severe psychological and social stress. These stresses were called the moral causes of insanity, and moral treatment aimed at relieving the patient by friendly association, discussion of his difficulties, and the daily pursuit of purposeful activity."

Therapy with moral management treatment consisted of social therapy, individual therapy, and occupational therapy (Carson, et al., 2000. pp. 306-307).

William Tuke and the Retreat in York, England

The founder of the moral management or moral treatment movement, William Tuke, became interested in humane treatment of the mentally ill when a member of The Society of Friends (Quakers) in York, England, Hannah Mills, was committed to the York Asylum (for the mentally ill). When members of The Friends attempted to visit her, they were denied permission, and shortly thereafter, the woman died, presumably of neglect or mistreatment.

As a result of this experience, Tuke saw the need for compassionate treatment of the mentally ill. Tuke presented his ideas to The Society of Friends members with which he was associated, and his ideas came to fruition with the establishment of the Retreat at York, originally designed to accommodate approximately 33 patients.

Prior to the establishment of the retreat, impetus to Tuke's mission was reinforced when he visited St. Luke's Hospital, endeavoring to obtain information for his prospective project. What he saw there (absolute neglect of patients) made him redouble his efforts, and the retreat was formed in 1792, opening its doors to its first patients in 1796. The History of York website accurately states that "the Retreat at York led the world in the humane treatment of the mentally ill," becoming a model for similar endeavors in Europe and the United States.

Moral Management and the Humane Treatment for Those with Mental Illness-----in the United States

The moral management movement founded in England by William Tuke, and independently in France by Pinel, took root in the United States. The first mental hospital in the United States exclusively for the purpose of treating the mentally ill opened in October 1773 in Colonial Williamsburg, Virginia.

Inhumane and harsh conditions were common both in mental asylums both here and throughout the world. However, around 1836, the moral management approach to mental health treatment became a prevailing system of mental health treatment in Europe and in the United States.

The official "Colonial Williamsburg" website under the heading "Public Hospital" chronicles the history of what became the Williamsburg "Public Hospital for Persons of Insane and Disordered Minds." It notes that the moral management approach to treating mental illness, which became the prevailing philosophical base for the methods of treatment at the Williamsburg Hospital, "emphasized kindness, firm but gentle encouragement to self-control, work therapy, and leisure activity." Hospital rooms became more comfortable, and by 1859, the hospital housed 300 patients.

Changes at the Williamsburg Public Hospital reflected the change in attitude from harsh conditions for the mentally ill towards a humane approach. The prevailing approach came to incorporate "the view that the mentally ill were innocent victims who required protection from society," or asylum (Zwelling, 1985, p. 30).

While the common term used for mental health facilities during that time period - "lunatic asylum" - might evoke images of long-term or permanent involuntary commitment under severe conditions, with the moral management approach in the 1800s, emphasis focused on rehabilitation with release, rather than permanent commitment.

Treatment regimens with the moral management approach to mental health treatment or rehabilitation were also changed. There were fewer physical restraints, more open wards, and opportunities to practice positive activities such as farming and carpentry. Social activities, some involving members of the opposite sex, were incorporated into the daily activities of the patients.

Moral treatment in asylums was actually part of a broader movement in which more humane treatment in hospitals of physical illnesses for the poor was being provided for patients (Luchins. 1991). For those with mental illness, a great deal of emphasis was placed on the patients’ moral and spiritual development, and on rehabilitation of their "character" as opposed to a focus on their physical or mental disorder itself; this may be because there was little in the way of effective treatment for these conditions at the time.

With the moral management approach to mental health treatment, the focus was on mental health treatment, and involved manual labor—vocational rehabilitation, social integration, and spiritual discussion, along with humane treatment.

Effectiveness of Moral Management Treatment and the History Surrounding It

Moral management achieved a high degree of effectiveness—all the more amazing because it was done without the benefit of the antipsychotic drugs used today, and because many of the patients were probably suffering from syphilis, the then-incurable disease of the central nervous system.

In the 20-year period between 1833 and 1853, Worcester State Hospital's discharge or success rate of patients who had been ill less than one year before admission was 71%. Even for patients with a longer pre-admission disorder, the discharge rate was 59% (Bockhoven, 1972).

BBC History, under the heading "William Tuke (1732-1822)," describes the development of the moral management mental health treatment that Tuke and Pinel pioneered this way:

Tuke was "appalled by what he saw" in the insane asylums of that time period. In the spring of 1792, he appealed to the Society of Friends or Quakers (Tuke was a Quaker) "to revolutionise the treatment of the insane." In 1796 he collected enough money to open theYork Retreat for the care of the mentally ill.

BBC continues, "This was the first of its kind in England, and pioneered new, more humane methods of treatment for the mentally ill." Inmates' chains were removed, more pleasant housing was provided, along with "decent food." A program involving therapeutic use of occupational tasks was also initiated. "Tuke's work was contemporary with similar groundbreaking work in France by Philippe Pinel, although the two acted independently of each other."

Professor of Psychology and Director of the Clinical Adult Psychology graduate program at Southern Illinois University, Andrew M. Pomerantz, PhD, describes the work of William Tuke thus: "Tuke opened up the York Retreat, a residential treatment center where the mentally ill would always be cared for with kindness, dignity, and decency."

Pomerantz states that by labeling the facility a "retreat" "suggests a fundamentally different approach" than what was being practiced during that time period. "Good food, exercise and friendly interactions with staff" were part of the atmosphere that contributed to the success of the moral management treatment approach.

In France, Pinel was similarly interested in "improving the conditions" of the mentally ill rather than "locking them away." The moral management approach as promulgated by William Tuke is described in this way: "Self-discipline became central to moral treatment, and asylum reformers of the time took Tuke’s approach as a model." (Science Museum's History of Medicine).

Moral treatment, Science Museum states, "became one of the most influential practices in European asylums of the 1800s," linking Tuke's approach of humane rehabilitational treatment for mental illness with Pinel.

References for History of Psychology - Moral Management

1. Bewley, T. Madness to Mental Illness. A History of the Royal College of Psychiatrists. Online archive 1, William Tuke (1732–1822). Royal College of Psychiatrists. Retrieved April 26, 2015 from http://www.rcpsych.ac.uk/pdf/online%20archive%201%20william%20tuke.pdf

2. Carson, R. C., Butcher, J., N., Mineka, S. (2000). Abnormal Psychology and Modern Life (11th Edition) . Boston: Allyn & Bacon. pp. 43-45.

3. Public Hospital. Colonial Williamsburg. Retrieved April 26, 2015 from http://www.history.org/almanack/places/hb/hbhos.cfm

4. Pomerantz, A. (2012). Clinical Psychology: Science, Practice, and Culture (third edition). Thousand Oaks, California: SAGE Publications, Inc.

5. The Retreat. History of York. Retrieved April 26, 2015 from http://www.historyofyork.org.uk/themes/georgian/the-retreat

6. Tuke, William (1732 - 1822). BBC History. Retrieved May 3, 2013 from http://www.bbc.co.uk/history/historic_figures/tuke_william.shtml

7. Tuke, William (1732-1822). Science Museum's History of Medicine. London, England. Retrieved May 4, 2013 from http://www.sciencemuseum.org.uk/broughttolife/people/williamtuke.aspx

Further Reading on Moral Management

Foerschner, A.M. (2010). The History of Mental Illness: From "Skull Drills" to "Happy Pills". Student Pulse. (off-site).

Moral Management. (2011, November). Everything About Psychology Blog. (off-site).

Pinel, P. A Treatise on Insanity. 1962. (1962). (off-site Amazon link).