Journal of Mental Health and Human Behaviour

: 2016  |  Volume : 21  |  Issue : 1  |  Page : 69--71

Dorothea dix: A proponent of humane treatment of mentally ill

Tamonud Modak, Siddharth Sarkar, Rajesh Sagar 
 Department of Psychiatry and National Drug Dependence Treatment Centre, All Institute of Medical Sciences, New Delhi, India

Correspondence Address:
Siddharth Sarkar
Department of Psychiatry and National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029


The work of early pioneers like Dorothea Dix was instrumental in the establishment of institutions dedicated especially for the care of the mentally ill. Originally from the United States, she became acquainted with the idea of humane treatment of the mentally ill during her visit to England. After her return to the United States, she conducted a statewide investigation of care for the insane poor in Massachusetts and began to extensively lobby for reforms and establishment of more state-funded institutions for the care of mentally ill. Her efforts led to setting up of several mental health institutions, which became the cornerstone of care of psychiatrically ill, and for training of mental health care providers. Though subsequently, the hegemony of the institutions was challenged, and the era of deinstitutionalization was ushered in, the work of Dorothea Dix is important as it vouched for humane care of patients with mental illnesses.

How to cite this article:
Modak T, Sarkar S, Sagar R. Dorothea dix: A proponent of humane treatment of mentally ill.J Mental Health Hum Behav 2016;21:69-71

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Modak T, Sarkar S, Sagar R. Dorothea dix: A proponent of humane treatment of mentally ill. J Mental Health Hum Behav [serial online] 2016 [cited 2021 May 15 ];21:69-71
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 Life of Dorothea Dix

Dorothea Lynde Dix was born in Maine, in 1802 to alcoholic parents and an abusive father, and was brought up by her wealthy grandmother.[1] Initially, a school teacher by profession, Dix traveled to England in 1836 for a medical problem. There, she came into contact with prominent members of the lunacy reform movement in Britain who vouched for the humane treatment of the “mentally ill.” Upon returning to the United States Dix took upon herself the work of establishing mental hospitals across the country. She conducted a statewide investigation of care for the insane poor in Massachusetts and began to extensively lobby for reforms and establishment of more state “asylums.” Dix was influential in establishing “asylums” in Worcester, New Jersey, Louisiana, Illinois, North Carolina and Pennsylvania.[2] The culmination of her work was the bill for the benefit of the indigent insane which set aside federal land for the establishment of mental hospitals. Although passed by both houses of the congress it was vetoed by President Franklin in 1854. Dix continued her work conducting investigations of madhouses in Scotland and Nova Scotia. During the civil war, she supervised nurses for the confederate army. Following the war, she resumed her crusade to improve the care of prisoners, the disabled, and the mentally ill to which she dedicated the rest of her life. She passed away in 1887 at Cambridge, Massachusetts.[3]

The work of Dix in the nineteenth century brought into public attention the poor conditions suffered by the “insane.” Throughout much of the nineteenth century “asylums” continued to be established across much of the world, and Government provided care of these disadvantaged sections of society. These institutions became the “birthplaces of psychiatry” and were instrumental in the training of many early stalwarts of the field. We look into the rise of these institutions and the subsequent deinstitutionalization movement and the subsequent transformation into the modern psychiatric hospital.

 Early Days: the Growth of the Institution

The “Bimaristans” of the medieval Islamic world were the world's first establishments for the care of the “insane.”[4] However, with decline of the Muslim empire, such institutions also disappeared. In the medieval era, little attention was paid to the needs and care of the mentally ill. A few towns housed them in towers (popularly known as Narrentürme or fool's towers). One notable exception was The Priory of Saint Mary of Bethlehem, founded in 1247 which later became famous Bedlam.[5] Even then, services for those with mental disorders were limited and insufficient for the population they served.

This began to change in the late 17th century, with the rise privately run asylums initially established for the care of affected nobility. A number of famous psychiatric institutions including, St Luke's Hospital, psychiatric wards at the Guy's hospital and “asylums” in York, Leicester, Manchester and Liverpool were established.[6] These private “madhouses” proliferated on an unprecedented scale in the late eighteenth and early nineteenth century perhaps fueled by lack of state response, ignorance by the medical community and vested interests. Conditions in establishments were varied but mostly poor. There was a routine use of bars, chains, and handcuffs for restraining, and the inmates lived in filthy conditions.[7]

Public mental asylums began to be established in Britain after the passing of the 1808 County Asylums Act. Public outcry against the prevailing conditions at madhouses led to Parliamentary Committees to investigate these “madhouses.” In 1828, Commissioners in Lunacy were appointed to license and supervise private asylums. The 1845 Lunacy act, created the Lunacy Commission to focus on lunacy legislation reform in Britain.[8]

For most of the nineteenth and early twentieth century, the “asylum” remained the primary and sometimes the only method of dealing with the mentally ill. Such mental health institutions were able to provide some care to those who had mental health issues. Furthermore, these kept mentally ill patients off the streets. However, custodial nature of the institutions made them akin to jails, with limited treatment options being available. Patients were “committed” to these institutions by physicians and law enforcement authorities. Conditions in these institutions were deplorable, and the physical treatments could be considered abusive by today's standards. Patients were placed in strait-jackets, neglected, isolated from other people, or forced to endure primitive electroshock therapy, insulin coma, or (in some cases) lobotomy.[9]

While these institutions were considered the birthplace of psychiatry, the powerful and negative association of mental illness with “asylums” impacts psychiatry even today. Asylums became notorious for poor living conditions, lack of hygiene, overcrowding, ill-treatment, and abuse of patients; many patients starved to death. The public opinion toward institutions was marred by negative publicity through the media reports.

 Social, Cultural, and Political Context of the Deinstitutionalization

The mental health institutions did serve a purpose though their excesses were being gradually recognized. The idea of deinstitutionalization was propounded which referred to is the process of closure or downsizing of large psychiatric hospitals and the establishment of alternative services in the community. A key event in the rise of deinstitutionalization was Goffman's seminal work: Asylums: Essays on the Social Situation of Mental Patients and Other Inmates.[10] Goffman's concept of the “total institution” and “mortification of self” highlighted the sociological harm undergone by the patients. He perceived psychiatric hospitals as similar to prisons and argued that patients were subjected to restriction of freedom, suffered from the stigma of being a psychiatric patient and had their normal social roles taken away. At around the same time, availability of the first anti-psychotic medication chlorpromazine offered an option of alternative care in community. The thought of 1960's began to question the institution system and the field of psychiatry itself.[11] In 1963, President Kennedy passed the Community Mental Health Centers Act, restructuring services were provided at these institutions and who performed those services. Prominent members such as Thomas Szasz, George Alexander, and Erving Goffman began to lobby against involuntary psychiatric intervention. The concept of deinstitutionalization defined as the process of downsizing and closing large hospitals accompanied by the establishment of alternative community-based mental health services gained momentum.[12] As a result of the process of deinstitutionalization, many long-term hospitalized patients then were discharged into the community. The benefits of deinstitutionalization include independence and a better quality of life, reduction in psychotropic medication needs, and increased socialization and adaptability to change. Discharged patients reported better satisfaction with their living conditions and had acquired friends and confidants. In addition, they gained domestic and community living skills, although no change was found in the patients' clinical state or in their problems of social behavior.[13]

The process of deinstitutionalization was not without its set of problems. The individuals released from these institutions were often homeless, isolated, and victimized. Some individuals released from institutions deteriorated had episodes of violence, were reinstitutionalized, and some lost their lives.[14]

In modern psychiatry, the concept of “institutionalization” goes beyond the physical institution itself and is displayed in terms of policy and legal framework in terms of clinical responsibility and paternalism or understood as patients' response to institutional care. Institutional organization and clinical responsibility aim to provide a structured and safe environment to facilitate the treatment process and to help monitor patients.[15] The work of Dorothea Dix was responsible for an epoch development in the field of psychiatry: The birth of institutional care and government efforts for the care of mentally ill. While there has been a move toward the greater community involvement of patients, it must be borne in mind that perhaps such a blanket approach may not be in the best interests of all. While effort must be made, toward as much community rehabilitation as reasonably possible, clinicians must be aware that sometimes, structured care might be more useful.

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