Through the millennia before civilizations grew sufficiently debonair to decide that mad people must be routed off city streets and hustled into prisonlike asylums, where the fashionably “sane” often could pay a few coins to come and see them howl and beg and writhe and pull at their chains, the demarcations between normal and aberrant behavior were more ambiguously drawn, and with far less fear and loathing. An archetypal figure stood between the normative community or tribe and the misfit at its margins. Sometimes the figure magically drew the misfit’s fevered mental pain into himself, in a healing way. Sometimes the figure was the misfit, healing the tribe.
A typical name for that figure, drawn from seventeenth-century Cossacks who intruded into the herding societies of eastern Siberia, is shaman.1 The descriptor’s variants—schamane, saman, babalawo, sheripiari, magi, wu, baal shem, prophet, and hundreds of others—date from the earliest sentient tribes and ethnic groups, however separated by oceans, mountains, or distance. The terms denote those who can achieve excited, trancelike states and who claim access to an invisible realm of mystical presences powerful enough to intervene in the affairs of men.
Such charismatic figures in history are plentiful. Socrates hallucinated. He heard at least one disembodied voice, which he affectionately called “my daemon.” He valued it. It gave him wise advice—advice that invariably warned him away from some contemplated action, as opposed to suggesting one. He went so far as to speak of “divine madness.”
In one famous formulation, citing the work of ethnologists, the French philosopher Michel Foucault proposed that it is possible to recognize primitive societies’ different attitudes toward madness. The key is to examine the status assigned a given community’s members in each of several essential groupings: labor and economic production; family and sexuality; language and speech; and “ludic,” or lighthearted, activities: games and festivals. Not every tribal member would fit comfortably into all these categories, yet “madness has always been excluded,” Foucault wrote.2 Those defined as “mad” (retroactively, by modern social researchers) were simply unable to fit in. They couldn’t or wouldn’t work, were celibate, spoke incomprehensibly, or posed a danger or disruption during festivals. The society’s attitude toward them might or might not have been based on fear or the impulse to punish. It might have been based on reverence. “Depending on the case, [the madman] is given a religious, magical, ludic or pathological status,” Foucault wrote. The role of madness in society is to reveal the limit between the Same and the Other, he says, and through this to reveal the truth in both of them.
Both the benevolent Greeks and their conquerors, the crueler and more bloodthirsty Romans, seem generally to have understood that madness was indeed an aberration, often a punishment from the gods, and not a divine state. It was most notably the Greek physician Hippocrates (about 460–377 BC) who initiated the glacial movement of thought away from supernatural beings as deliverers of insanity. His replacement theory, an imbalance of the four bodily “humours” (blood, phlegm, and black and yellow biles), was hardly more productive, though it held sway in the practices of some doctors for two thousand years.
Psychiatric researchers have increasingly agreed that while the causes of insanity resist definitive diagnosis, its severity can be correlated with degrees of stress. Among the most common stimulants of human stress (other than childhood life within dysfunctional families) has been urban living, especially since the Industrial Age. This correlation has convinced leading investigators such as E. Fuller Torrey that the intensity of urban living largely accounts for the acute rise in indicators of schizophrenia and related diseases. Torrey has described this rise as a “plague.”* The science and medical journalist Robert Whitaker, for differing reasons, has described it as an “epidemic.”†
Among the earliest of cities is London. Its origins trace to AD 50. By the Middle Ages its merchants, growing plump on the bounties of a vigorous sea trade, had firmly transplanted the ancient “guild system”—economic alliances of tradesmen and companies—within its rapidly growing borders. By 1600, its population had reached two hundred thousand people, a twentyfold increase in fifty years. By the beginning of the nineteenth century, London surpassed Paris and then Constantinople as Europe’s largest city. All of this was good news for just about everybody except the dispossessed and the mentally ill, two populations that often seemed one and the same.
One might ask: Why did people then, and people today, continue to live in cities if the effects on sanity are so toxic? In 1969, the French-born biochemist René Dubos won the Pulitzer Prize for his book So Human an Animal, in which he postulated that humankind’s essential nature has not significantly changed since the Stone Age. A key component of human nature is adaptability, and herein lies trouble: “The greatest dangers of overpopulation [which dangers include stress] come paradoxically from the fact that human beings can make adjustments to almost anything.”3 Based on this ability, Dubos asserted, “modern man could readily return to primitive life, and indeed he does to some extent whenever he needs to.” But that is far from the greatest penalty for human adaptability. In a provocative passage near the end of his book, Dubos declares:
Most of man’s problems in the modern world arise from the constant… exposure to the stimuli of urban and industrial civilization… the physiological disturbances associated with sudden changes in ways of life, the estrangement from… the natural cycles under which human evolution took place, the emotional trauma and the paradoxical solitude in congested cities, the monotony, boredom… in brief all the environmental conditions that undisciplined technology creates.4
If all this is true, early London, with its crooked streets and foul gutters, its cheek-by-jowl living conditions among poor immigrants from mutually incomprehensible language systems, its ambient diseases and long unlit winter nights in which thieves and cutthroats preyed—this early London was a petri dish for human stress. And madness.
This London had little time for either mad people or shamans—one and the same, to those who bothered to think at all about them. They got in the way, they contributed nothing, their speech and behavior were incomprehensible—the damned demons inside their heads, like as not!—and they very often stank.
To paraphrase Ebenezer Scrooge: “Are there no madhouses?”
Well, yes.
The flagship accommodation was Bedlam.
“Bedlam” was the vernacular name assigned to the first and most infamous madhouse of them all. The institution has occupied four sites since its origin in 1247 as a small religious sanctuary, the Priory of St. Mary of Bethlehem, near Bishopsgate. “Bethlehem” was quickly contracted in usage to “Bethlem,” and, later, to “Bedlam.” In time the retreat was converted into a hospital, more or less. It functioned mainly as an almshouse. Around 1403, the hospital began to accept a handful of “lunaticks” for care, and employed a few monks to look after and try to cure them. The monks were happy to oblige, and they set about beating their charges. (They probably believed that they were striking at the evil spirits.) The inmates fared better than their brethren in Spain, where Torquemada and his legions of the Inquisition were piously burning them alive.
A sewer that preexisted Bethlem’s construction drew in more and more of London’s growing waste until it overflowed. The sewer couldn’t be fixed, and so Bethlem moved from the fetid grounds as soon as it was able, which was after 420 years. Over that time, its lineage of administrators dumped some three thousand corpses of former patients into the soft rank ground. Finally, in 1676, the facilities were relocated a short distance west to some newly constructed buildings in Moorfields. In 1547, King Henry VIII seized control of Bethlem and granted the City of London a charter to administer the desolate cluster of buildings as a sanctuary for the insane.
Moorfields epitomized the rebuilding of London after the Great Fire of 1666—outside its walls. Its dark and sinister interior came to symbolize something quite the reverse. The architect was one Robert Hooke, a contemporary of Christopher Wren. Hooke designed it specifically as a mental institution—the first such building in Britain. Two stories tall, with accommodations for 120 patients, it loomed grand and imposing: “a long, single-pile building with an elaborate central block connected by flanking wings to two pavilions,” in the description of one architectural scholar.5
Two heavy stone gargoyles, one atop each interior entrance gate, mocked any possible doubt about the business inside. The fiends were carved by the Danish sculptor Caius Gabriel Cibber. One, staring out in lifeless vacuity, was called Melancholy Madness. The other, a grimacing man-beast raising a chained arm, was called Raving. Past the gates, in the cells along the impervious stone corridors, the tumultuous “Bedlam” of folklore reached its awful zenith.
For a long period, the City of London Court of Aldermen chose Bedlam’s supervisors on a patronage basis from the same mercantile society that recoiled at the sight of the mad. The supervisors—unable to imagine any sort of mandate for mollycoddling these wretches—hired their cell-keepers from the same societal sublevels as those of many “patients” themselves. The keepers, delighted to have control over a mass of humanity even more godforsaken than they, took pains—as it were—to make sure that everyone within screaming range could tell the difference.
Now the beating began in earnest. The poor, uneducated, and embittered jailers unleashed levels and varieties of cruelty both physical and psychological upon their “patients” that have not been surpassed in history. Not quite, anyway. Added to this misery was the administration’s lack of interest in sanitation or upkeep, either structural or human. The roof sagged and later caved in; human waste glutted the drains. The cruelty was occasionally leavened by scientific inquiry. The first experiment in blood transfusion as therapy occurred at Bethlem in 1667. The donor was a sheep.6
More importantly, the Bedlam keepers created a dark, enduring paradigm. Even as the asylum became infamous through the city, then the kingdom, and then throughout Europe and the American colonies for the beating, shackling, taunting, starving, hygienic neglect, and even the occasional murdering of the people on the other side of the bars—even as these depravities sickened the pious (some, at least) and caused the timorously decent to turn away—these tactics were being adopted with varying degrees of intensity in the newer asylums including the York Lunatic Asylum, built in 1777.
“Charitable” asylums were opened in the eighteenth century in eight English towns: Norwich (1713); London (1751); Manchester (1766); Newcastle (1767); York (1777); Liverpool (1792); Leicester (1794); and Hereford (1797). The ninth opened in Exeter in 1801.
The abuses continued.
And there were no shamans to intervene. Not for miles, not for decades and centuries. No schamanes, no samans, no babalawos, no sheripiaris, no magi, no wu, no baal shems. Just jailers with glittering eyes and truncheons in their hands; just bars and piss-soaked bedding and dry food scraps and chains bolted to cold stone walls. No healing here, no higher ecstasy. Just pain and ever-deepening psychosis. And for most, no exit, save death.
Here was the true dawn of the epoch in which no one cared about crazy people. The epoch, as we will see, has not ended.
Bethlem patients were “treated,” occasionally and haphazardly—and always, of course, by physicians with no grasp of how the brain worked. More often they were punished. Treatment and punishment could be hard to tell apart. So could the sane and the insane: depressives and drunks and the homeless poor languished among the true psychotics, as did, for instance, wives who talked back to their husbands. Administrators did try to keep the “criminally insane” sequestered from the others. Bethlem inmates who made trouble were doused in icy water or strapped inside chairs that spun rapidly, or both. These procedures were popular partly because they delivered a double benefit: they also answered as therapy. Some inmates (to use a more accurate term than “patients”) were chained to walls—sometimes for months, occasionally for years, their ankles and wrists festering with gangrene. One inmate, named James Norris, remained enshackled for fourteen years. They were stripped of clothing, kept alive on subsistence levels of food and water, and they screamed into the darkness for mercy and release. Women incarcerated there were often raped by their keepers; at least one was impregnated twice, and miscarried.
To give credit where it is due, Bethlem pioneered in the use of antipsychotic medication—that is, if you define opium, morphine, murky tonics and cathartics, or laxatives as “antipsychotic medication.”
In 1818 a former patient at Bethlem at Moorfields, Owen Metcalf, unspooled to an investigative Parliamentary Select Committee a long string of abuses. In one instance, “[a] patient named Harris, for the trifling offence of wanting to remain in his room a little longer one morning than usual, was dragged by Blackburn [keeper manager], assisted by Allen, the basement keeper, from No. 18, to Blackburn’s room, and there beaten by them unmercifully; when he came out his head was streaming with blood, and Allen in his civil way wished him good morning.”7
A new apothecary named John Haslam arrived at Bethlem in 1795. Haslam fancied himself an expert in matters of the deranged mind, and he published several monographs on the subject. He professed to know exactly how to cure mental illness. First, he believed, the patients’ wills had to be broken. So Haslam obligingly beat a lot of them bloody. Or bloodier.
Funding was always a source of concern to those who ran the institutions, as it is today. Societies and governments have never favored spending money to sustain their mad people. The mad don’t vote; the mad don’t do anything to generate wealth. Many don’t even know who they are. Why toss good money at them, beyond the costs of keeping them alive? (This attitude largely explains the urine-saturated straw bedding.) In England the pauperized insane—those who had not been caught and thrown into prison—depended on the Poor Law, a scattershot welfare system that provided subsistence-level food and shelter for those wandering the streets, or at least a portion of them.
As public institutions governed by the City of London, Bethlem and its imitators could not even require admission fees from prospective patients. And indeed, Bethlem Moorfields did not habitually turn away the indigent insane, though waiting lists soon developed. The administrators were virtually obliged to be artful.
Their most benign strategy was to negotiate discreetly with, say, a wealthy family that wanted to rid its household of an inconvenient relative. After all, the masters of Bethlem were part of the elite society they dickered with. The Monros, a high-bourgeois family of Londoners with Scottish origins, supplied four generations of shrewd physician-administrators at Bethlem; well-connected and deeply scheming men. James, the first, arrived in 1728, and he immediately banned medical students from the premises, no doubt on the theory that they would see more than was healthy for the management. He began the family’s cultivation of the wealthy. And he turned madness into a spectator sport.
Visitors had occasionally handed over a bit of coin, even to the monks back in the Priory days, for the pleasure of watching their fellow human beings jabber, cavort, fight, howl, copulate, and otherwise act out primal impulses.
The grounds around Bedlam’s walls afforded far more expansive views. Visitors were not only welcomed but encouraged, at a price. Sometimes they arrived by the horse-drawn busload, wearing waistcoats and top hats or twirling parasols, fashionable promenaders at the Ascot of lunacy. They paid a penny; later, two, and no exceptions. The ladies and gentlemen—and their children—were allowed to mingle with the entertainment, and to scoff and jest in the inmates’ faces.
In 1815, the City of London moved Bethlem asylum again, to a new building in St. George’s Fields in Southwark. Moorfields had fallen into physical decay surpassing even that of the old sewage-besotted Priory. The last Monro to administer Bedlam, Edward Thomas, assumed control the following year. Edward was forced to resign in 1852, after the Lunacy Commission was shocked to find that he, too, lacked human respect for his patients.
The late eighteenth century saw the formation of the first movement to rebuke the Bedlam template for dealing with society’s “lunaticks” and “mad” people. (Not until 1930, 683 years after its founding, was Bethlem’s theater of sanctioned state depravity reestablished as Bethlem Royal Hospital, and its era of modern professionalism launched.) As this movement spread through western Europe and the United States, its principles became known as “moral treatment.” Some psychiatric scholars maintain that it remains the most effective of all history’s treatments for the mentally ill.
Moral care took shape as a concept almost simultaneously in the minds of two men who did not know each other. One was a French doctor; the other, a British Quaker businessman.
The doctor was a Parisian named Philippe Pinel, a smallish country doctor with a hunger for ideas that caught the temper of the Enlightenment. In 1773, Pinel enrolled at the University of Montpellier, France’s oldest medical academy and the source of medical science’s freshest thought. There, he encountered refinements on an ancient concept known as “vitalism.”
Vitalism’s tenets would be largely refuted by advances in biophysical understandings of how the mind and the body interacted. Genetic theory would virtually extinguish what remained. Yet vitalism’s core tenets—the necessity of balance between mind and body; the power of nature to heal all sorts of human diseases—led Pinel to a historic approach toward the mentally ill.
It took a rather convincing demonstration of mass psychosis—the French Revolution—to supply Philippe Pinel with the entrée he needed to put that approach into practice.
Pinel was living the modest life of a medical journalist and translator when the French Revolution swept the country with its antiaristocratic ideals. The new government, aware of his interest in the insane, appointed him in 1793 as physician-in-chief of the infamous Bicêtre Hospital for men. This converted orphanage, later a prison, was classic in its casual barbarity. Its jailers habitually kept patients confined in shackles, often for the better part of their lives. The chains were bolted to the walls so tightly that those confined by them were obliged to sleep standing up.
Pinel commenced his reforms at once. He mandated improvement in the quality of food, ordered regular replacement of the feces-and-urine-besotted straw that served as beds, and created exercise regimens for the inmates.8
The reform that secured Pinel’s place in history was a decision to strike off the shackles of forty-nine Bicêtre inmates. The idea might have originated with the doctor’s assistant, one Jean-Baptiste Pussin, though it is entirely consistent with Pinel’s vision. The directive shocked even the revolutionary Paris Commune, which summoned Pinel to justify it at a hearing. Yet the directive almost immediately justified itself: not one of the newly unchained men bolted from his cell and ran out on a violent spree.
At about the time Pinel was pioneering his reforms in France, a sixtyish Yorkshire coffee merchant named William Tuke III was mourning the death of a fellow Quaker, a young woman named Hannah Mills. Mills had expired in the darkness of York Lunatic Asylum, built in 1777 in Tuke’s hometown of York, the medieval walled city in northern England.
Quakerism, the Society of Friends, had originated in Britain the century before, one of many restless Christian groups to break with the Church of England over perceived false doctrine and overweening Puritanism. The Friends gathered adherents to their tenets of pacifism, philanthropy, and social justice. They began to emigrate from England and the Netherlands to America, where William Penn would found a great city, and where the Society of Friends would leave a great legacy of stewardship toward the mentally ill.
Hannah Mills’s death stunned and galvanized Tuke. A recent widow, Mills had been admitted to York Asylum less than two months before her passing—probably for depression caused by her husband’s death. Whatever was wrong with her, York Asylum deepened it. The young widow lasted forty-five days. Her death was recorded on April 29, 1790. Whether she was a suicide, or perhaps a victim of lethal abuse, or both, has not been documented.
William Tuke was incredulous that the asylum administrators refused to offer an explanation for the woman’s abrupt passing. Tuke did not fulminate or try to run the York Asylum out of business. That was not the Quaker way. Instead, he commissioned his own asylum and opened it in 1796.
He did not call it an asylum. Nor did he or his family refer to those who stayed there as “lunatics.” Tuke designed the facility in collaboration with a London architect named John Bevans. Bevans shared Tuke’s hopeful but mistaken belief, nearly identical to Pinel’s, that an open, healthful environment and respectful treatment by caretakers could lead, virtually of themselves, to the restoration of an afflicted mind.
York’s architecture—a compact, homey three-story brick building—and its placement atop a hill offering views of woods, meadows, and streams, were central to Tuke’s therapeutic vision.9 So was the personal stewardship of the patients administered by him and his kindhearted wife and sons. So were the hearty, healthful meals the Tukes provided.
William Tuke’s York Retreat was a success, if one discounts the matter of curing mental illness. Tuke never lost his conviction that the “lunatic” condition could be cured. Nor did he ever lose his determination to penetrate the secretive walls of York Asylum, which he believed iniquitous. He pursued this goal for twenty-three years. Eventually he found an ally in the town magistrate, Godfrey Higgins. In 1813, Higgins learned that a man whom he himself had decreed to be “insane” and sentenced to York had managed to get word out that he was being mistreated. Higgins decided to investigate. He used his authority under common law to command entry. What he saw—and heard, and smelled—there repelled him:
When the door was opened, I went into the passage and found four cells… in a very horrid and filthy situation. The straw appeared to be almost saturated with urine and excrement… the walls were daubed with excrement… I then went upstairs and [the keeper] showed me a room… the size of which he told me was twelve feet by seven feet and ten inches, and in there were thirteen women.10
Tuke’s fellow Quakers, meanwhile, had seen their humane influence flow westward across the Atlantic. America’s first incorporated hospital of any kind, Philadelphia Hospital, opened its doors to patients in the prerevolutionary year of 1753. Its cofounders were Dr. Thomas Bond, a Quaker, and Benjamin Franklin. It accommodated a handful of insane patients in a few basement rooms.
Dr. Benjamin Rush, a signer of the Declaration of Independence and one of several figures celebrated as “the father of American psychiatry,” joined the medical staff in 1783 and served until his death in 1813. Rush was the first man of science in this country to publicly reject the idea that insanity was caused by demons or witches. In the spirit of Pinel, he joined the argument against the use of those shackles. An eyewitness to the steady expansion of cities on the eastern seaboard, he also was the first American to identify stress as a powerful contributor to madness, if not its cause.
Philadelphia Hospital retained one noxious legacy of Bedlam: it charged visitors a shilling apiece to visit the hospital basement on Sunday afternoons and gape at the thrashing, screeching crazy people inside. This practice disgusted the newly arrived Quakers and stirred them to action. As William Tuke had in York, they financed and built their own sanctuary for the insane. The Friends Asylum for the Relief of Persons Deprived of the Use of Their Reason opened in Philadelphia in 1813, the young nation’s first private psychiatric hospital. Moral treatment had established a beachhead in America.
It spread outward from Philadelphia. One of its most prestigious havens was the State Hospital, opened in 1833 as the first state-financed sanctuary, in Worcester, Massachusetts.
The hospital’s first commission chairman, the future education visionary Horace Mann, supervised the planning stages. Mann got involved in creating the hospital in part because he subscribed to the growing concern that madness was rising rampantly in the young nation. One of his first acts as commission chairman was to oversee a committee that took a census of mad people, the first such survey in Massachusetts. The committee declared that at least five hundred mentally ill people were without protection.11
Worcester State’s first superintendent was Dr. Samuel Woodward, who at six feet six inches literally towered some thirteen inches above his countrymen of average height. Once the people of Worcester recovered from their first sight of him, they were won over by his kindness and gentle nature. He greeted each arriving patient personally. If they had been transported from another asylum or prison, he would use his own large hands to free theirs from confinement. He assured the forty-two hundred citizens of Worcester that the new sanctuary posed no danger to them, and that “the law of kindness” was an essential tool in restoring the mad to sanity.
Woodward’s thirteen-year stewardship was marked by a combination of his extreme personal decency, his excusable yet limiting innocence of neurobiology, and by the nature and volume of patients that came to his asylum. He rejected any notion that “madness” was a factor of low character or evidence of internal demons. He sought to reamplify the humane credos of Pinel and Tuke. On the other hand he was attracted to the new pseudoscience of phrenology, the belief that human behavior could be anticipated—and manipulated—by a study of the brain’s physical features. A century later, of course, phrenology was among the baseless theories summoned to justify some of the most immoral treatment the world has ever witnessed.
The urgency that spurred the proliferation of asylums in this period was prompted by fear. Doctors, city fathers, and ordinary citizens throughout America came to believe with Horace Mann that madness was on the rise. Woodward shared this perception. As had others, they blamed city life, still a new experience in much of the new nation. “Insanity,” summarized one Massachusetts psychiatrist in a paper presented in 1851, “is then a part of the price which we pay for civilization.”12
Yet perhaps people, including the founders of Worcester, did not pay enough attention to the most plausible source of “epidemic” concerns: the phenomenal rise in the American population as a whole. Immigration and new births had already increased the number of United States citizens from 9.5 million in 1820 to 13 million in 1833. The population boom found its way into America’s young cities. As they grew, it began to seem as though their streets were unaccountably filling up with “mad” people. The fact was, they were filling up with people, and the mad among them, by virtue of their concentration, were more visible than ever before.
Whatever the cause, the nation’s first generation of public asylums such as Worcester was soon overwhelmed. Before Worcester’s inaugural year ended, Samuel Woodward had yielded to a heartbreaking necessity: set aside his law of kindness and discharge as many nonviolent patients, and even some with criminal pasts, as he could to make room for newer, more violent ones—“the lunatics and furiously mad,” as the term of art had it. These were the kinds of patients the state was sending to the facility from jails and prisons; and Worcester, a state-financed institution, had no choice but to accept them. In fact, Massachusetts law required that all dangerous “lunatics” already in jail be transferred to Worcester. This practical but unforeseen necessity soon began to erode Worcester’s agenda of moral treatment therapy, diminishing the time and space its practitioners needed to do their work. Here was an ominous regression toward the asylum as jail: the very condition that moral treatment had been designed to extinguish.
Still, largely through Woodward’s efforts, his asylum’s national reputation as a “model” of its kind held up. Goodwill persisted among the city fathers—but was now modified by a fear for public safety.
In 1836, state appropriations funded two new wings, bringing the maximum patient capacity to 229. Still the numbers of applicants—and supplicants—surged higher. Overcrowding, another curse of the older days, continued.
Five years later, reinforcement of a different kind arrived.
It arrived in the person of a tiny, sickly woman of devout Unitarian faith, her dark hair parted severely in the middle and tied in a bun behind, which made her ears stick out, and the resolve of a Rottweiler with its teeth sunk into flesh. Dorothea Dix was on the case.
Dix had lived in the town of Worcester during her childhood. She had lived in a lot of New England places: Hampden, Maine, where she was born (later a part of Massachusetts); then Barnard, Vermont, after her boozy father and migraine-addled mother had fled from Hampden and the path of British infantry in the War of 1812. Then Boston, where she ran a private school; then to the industrialized fogs of England—perhaps not the ideal destination for a four-year sojourn to recover from what is now known as tuberculosis. The disease would recur through her long life and make her an invalid. Yet the overcrowded, sickly, and anxious hordes of London factory workers contributed to one of her most firm beliefs, which until then only Benjamin Rush was known to share: that urban turmoil correlated with vulnerability to insanity. In this, she anticipated René Dubos by eighty years.
In England Dix had been swept into a cohort of British reformers, many of them Quaker, who introduced her to the madhouse netherworld. Dix came home bristling with the determination to be of use to such incarcerated souls. One day in March 1841, she volunteered to teach Sunday school to some women confined at the East Cambridge (Massachusetts) jail. Afterward, a jailer escorted her around the facility. As she gazed into the cells she heard a scream and demanded to see the source. The jailer reluctantly escorted her to a heavy locked door. He opened it and the chilly air inside blew a heavy stench into their faces. The scream had come from within a group of huddling, half-naked “lunatics” who had been encaged in the hovel for years—in the company of convicted violent criminals, as was still common. She asked the jailer how this could be. He comfortably (and, as things turned out, famously) assured the small lady that she should not bother herself; the insane could not feel heat or cold.
That encounter settled her life’s course.
Against the warnings of friends who were aware of her health problems, Dorothea Dix embarked upon an eighteen-month itinerary that took her to jails and asylums throughout Massachusetts, barging past guards to interview patient-inmates and their keepers. At the end of her journey, she was convinced that the moral treatment asylums were in fact benefiting patients, but that the jailing of excess “mad” people was rampant and their plight an affront to humanity. She returned to Worcester and in 1843 joined forces with Woodward, Mann, and a well-born reformer named Samuel Gridley Howe to inspire or shame the legislature into action. (Howe had run for and won a seat in the state House of Representatives as a Whig just so he could speak for Dix from the inside.)13 In January she prepared a “Memorial to the Legislature of Massachusetts” (women were not allowed to address the legislature in person back then; they had to submit their thoughts in writing). Her words ring in the pantheon of American oratory—or as oratory-that-might-have-been.
I come to place before the Legislature of Massachusetts the condition of the miserable, the desolate, the outcast. I come as the advocate of helpless, forgotten, insane, idiotic men and women; of beings sunk to a condition from which the most unconcerned would start with real horror; of beings wretched in our prisons, and more wretched in our almshouses. I… arrest and fix attention upon a subject only the more strongly pressing in its claims because it is revolting and disgusting in its details.14
Mann, Howe, and the others were thrilled. Representative Samuel Gridley Howe introduced the Memorial in the legislature. It was sent to the Committee on Public Charitable Institutions, then shaped into a bill by committee chairman Howe. After debates and modifications, the bill passed both houses, and Samuel Woodward was granted authority to build new housing at the asylum for 150 patients.
Dorothea Dix expanded her inspection tours to the entire country, and then to Europe, traveling thirty thousand miles by some estimates, via railroad, steamship, stagecoach, and buggy, and whatever else was available, which was not much. She cultivated the friendship and support of President Fillmore and the great Massachusetts senator Charles Sumner. She gave speeches, cajoled legislators, and talked wealthy people into funding asylum building and improvement. She took a detour through the Civil War to serve as superintendent of the Army of Nurses for the Union (where she and her nurses also treated wounded Confederates, including many from the five thousand lying maimed at Gettysburg). And then she went to work for the insane again.
She is credited with direct roles in the founding of thirty-two asylums by 1880, including the New Jersey State Lunatic Asylum at Trenton in 1848. She died in her guest apartment there in July 1887 at age eighty-five. She was having tea.
Even as Dorothea Dix’s reputation and accomplishments grew through the 1840s and 1850s, Worcester’s prestige declined. Another baleful law, that of diminishing returns, was beginning to catch up with the asylum and all those that shared its Enlightenment-fired ideals. America’s population kept swelling: to seventeen million in 1840, then to twenty-three million by 1860, near the outbreak of the Civil War. This growth and other factors, evident even at the outset of moral care in America, kept on pushing against the founders’ idealism. There were simply too many more patients, too many more criminals, and too many other kinds of hard cases among those patients. More time was needed for administrative duties and less time for supervisors’ personal visitation; less time for healthful activities; less space—far less space—per patient than the early dreamers had deemed necessary. The righteous fervor and dedication of the early supervisors and staff and caretakers inevitably cooled with their replacements, and the replacements of those replacements.
Samuel B. Woodward died in Northampton, Massachusetts, in 1850, at age sixty-three. Fully twenty-three years elapsed between his death and the next—and last—effort to rejuvenate his generation’s vision: twenty-three years of policy wars, scrambles for space; the replacement of passion with bureaucracy and systemized procedure. The times also brought societal changes that imposed tough choices unforeseen a half-century earlier—necessities of segregation, for instance: not just racially, but segregation of the violent from the nonviolent, pauper from affluent, immigrant from native-born. A new breed of less idealistic staff members took these distinctions as criteria for the amount of kindness and attention they were willing to confer.
A national air of pessimism was enveloping the mental health world—certainly on the question of whether insanity could be widely cured. Still, in 1873, Massachusetts pushed ahead to finance construction of a new and larger replacement for Worcester State Hospital. The cost exceeded $1 million. Its administration building virtually announced that moral treatment was here to stay. The signal proved false.
Kirkbride Hall was the new Worcester asylum’s most prominent structure, crowned by a high Gothic clock tower that could be seen well beyond the borders of the city of 146,000. The tower soared above the five granite stories of the administration hall. It overlooked the nearby Lake Quinsigamond, with its eight graceful islands, to the east, and pointed heavenward in the manner of a church steeple.
It was named for its designer, the physician-turned-architectural-planner Thomas Kirkbride, who in 1840 had become superintendent of the Pennsylvania Hospital for the Insane. A Quaker like William Tuke, Kirkbride fastened on the Yorkshireman’s espousal of a harmonious environment. He devoured Tuke’s 1815 book Practical Hints on the Construction and Economy of Pauper Lunatic Asylums, and later published his own similar and influential treatise. He created concepts for siting, landscaping, and building design that found nationwide favor and determined the general look of insane asylums for the rest of the nineteenth century.
Kirkbride asylums were designed as antidungeons, ornate and elegant, incorporating features from the Queen Anne, Second Empire, and Gothic Revival styles: spires and cupolas and gabled roofs, and construction from fine timber or heavy stone. (Kirkbride provided the essential interior plans for his buildings, but construction and landscaping were jobbed out to a number of artisans around the country.)
No one expressed the vision of an ideal physical layout with greater lyricism or tenderness than Kirkbride himself:
Great care should be taken in locating the building, that every possible advantage may be derived from the views and scenery adjacent, and especially as seen from the parlors and other rooms occupied during the day. The prevailing winds of summer and the genial influence of the sun’s rays at all seasons, may also be made to minister to the comfort of the inmates, and the grounds immediately adjacent to the hospital should have a gradual descent in all directions, to secure a good surface drainage.15
Few asylum-building committees cared to deviate from the master’s vision: besides its utilitarian logic, a domed or spired “Kirkbride” on the edge of town (never inside!) lent an aura of elegance to the whole area. More than a few thoughtful observers, though, detected something quite apart from elegance: an indefinable brooding, an opaque heaviness, less elegant than Gothic. Others who were more informed about prevailing trends in mental health care could see even beyond the Gothic, into a gathering void. Kirkbride had meant to endorse and enhance moral treatment with his buildings, but he was enhancing a phantom. In post–Civil War America, urban industry, not the rural cycles, dictated the pace of life. Philosophies of care were changing as well, in sync with the times. Psychiatrists had grown impatient with the notion of therapy that led to cure; they’d seen precious little empirical evidence. What role was left to them, then?
It was the role of custodianship: basic supervisory care and feeding of those unfortunates whose reason was maimed by fate, yet who lived on.
This shrunken agenda for moral treatment began to lose its moorings even as the number of public and private asylums, a great many of them “Kirkbrides,” swelled to nearly three hundred over the decades.
The horrid systematic cruelty of Bedlam never returned. Not completely. But it never completely went away, either. This fact is documented by almost weekly news accounts from the human disposal systems that our large urban prisons and hospitals have become.
Time has not been kind to the old moral care asylums’ appearance. Broken windows and support beams left unrepaired, lawns and flower beds unmanicured, damaged furniture on the inside unreplaced—all this left the mansions exposed in their decrepitude.
Increasingly, these asylums were simply abandoned as larger, centralized (and impersonal) hospitals were built to warehouse the mentally ill. The elderly insane especially suffered the transition, as supervisors nudged reluctant families to accept them back into the home. When families refused, these people stayed in the system but endured the usual indignity of indifference, magnified by contempt and revulsion.
Some asylums burned down; some were (and continue to be) demolished for newer facilities or housing developments or shopping malls. A surprising number of them remain standing on their patches of prairie, but under conditions of decrepitude and debasement that conjure images of the inmates at Bedlam, helpless before the smirks and taunts of strolling visitors. In an inversion that would have devastated the Kirkbrides and Woodwards and Manns and Dixes, and the Tukes and Pinels before them, the remains of these buildings now represent not hope but evil. Mass-marketed commercial evil.
Many have been purchased by entrepreneurs attuned to the American appetite for the macabre, especially in the computer-generated forms of garroting, throat-slashing, and torture. These businessmen and -women, rejoicing in the caricature presented by the old sanctuaries, have made it pay: by refurbishing the cells and apartments with stage-set spooks and sorcerers and sinister scientists with bloody smocks, and splashing fake blood on the walls. The classic sanctuaries for haunted human beings are thus transformed into haunted houses. They draw attraction-seeking Americans who travel great distances, stand in line, sometimes for hours, and pay dearly for tickets that allow them to step inside and squeal as computerized mad scientists perform bloody atrocities upon shrieking “inmates” strapped to their beds. “These are the places where physicians cut into their brains with ice picks and robbed them of their personalities,” exults one attraction website. “They are places where they were raped, medicated, abused, murdered.”16
No definitive theories have explained why this haunted attractions boom (or “BOO-oom,” as TV news websites merrily put it) has become, by some calculations, a billion-dollar business. America Haunts, a trade association, estimates that there are twelve hundred large-scale, for-profit haunted attractions in the United States, not to mention another three thousand haunted houses that open for the Halloween season.
Some suggest that the haunted-house experience offers a cathartic release in our anxiety-saturated times. (A kind of therapy, as it were.) Some say it offers just another roadside attraction.
As for shamans, they have persisted, counter to all expectation. Persisted, and proliferated. The contemporary urban world has seen a resurgence in the number of self-described shamans and of shamanistic thought, expressed partly in the New Age revolution of the 1970s. And the affinities between their ecstasies, and epiphanies, remain as strong as ever—as often acknowledged by the believers themselves. Except that the believers seldom if ever describe their experiences as mental illness.
The author and self-described shaman Paul Levy has recalled insisting to psychiatrists years ago, regarding his involuntary hospitalization after an “ecstatic” episode, that he had simply been trying to express the “good news” of what was being revealed to him about the nature of reality: “I tried to explain to the psychiatrists that I WAS sick,” Levy wrote, “but just not in the way they were imagining. I had a creative, psychological illness, which is to say that my seeming madness was an expression of my creative self.”
He was not clinically ill, Levy insisted; he was “perturbed,” suffering from a “shamanic illness”—in trauma from recalling the abuse he had endured at the hands of his “desperately sick, sociopathic father.” His father had connected Levy “as a link in a chain to an unbroken lineage of violence… extending far back in time and throughout space.”
Thus his “seeming madness,” Levy insisted, “was an expression of my creative self, alchemically transforming an underlying perturbance in the field of consciousness so as to heal itself.”17
These insistences from Paul Levy, and what I’ve learned about shamanism in general, have put me in mind of my son Kevin.
Like Levy, Kevin refused—as I’ve said—to define himself as mentally ill. He had a condition; that was as far as he would go. I have thought, as well, of the time in the schoolyard in which Kevin admonished the burly ice-hockey athlete for striking the tall young girl—and did not draw a challenge of fisticuffs himself from the bully. I thought of other such moments. Nothing really dramatic or revelatory, but moments in which (in retrospect) Kevin conferred a measure of peace, even laughter, upon a situation, armed only with directness, honesty, and his crooked grin.
I don’t believe in shamanism as an extrasensory phenomenon. I don’t believe that shamans have, or ever have had, a connection to the divine.
But if I did believe…
Are you listening, Kevin?