Who brought the reforms of moral therapy to the United States?

Hospital libraries, including ones designed for patient use, share a common history with hospitals in the evolution of health care delivery 1. The library as a component of the early “insane asylum” in the United States is well documented, and many had been established by the mid-nineteenth century. While these libraries certainly existed as a means of recreation for asylum patients, this historical communication will demonstrate they also served as a center for “bibliotherapy,” the use of reading as a means of healing.

Prior to the 1800s, the plight of the mentally ill was seen mostly through a lens of superstition. They were believed to be possessed by Satan or under punishment by God for their sins and were either hidden by their families or consigned to poorhouses or jails 2. In the early 1800s, a religious revival known as the “Second Great Awakening” swept the country and ushered in a series of social reforms such as women's rights, abolition, and a better understanding of mental illness 3. Insanity was for the first time seen as a condition that was physiological in nature and could be treated and often cured 4. The asylum was ideally a retreat where patients with mental illness could go to rest and recover. A significant portion of this recovery included “moral therapy,” which promoted activities such as gardening, woodworking, playing games, sewing, and reading in addition to medical care. It was within this moral therapy movement that bibliotherapy, using books and reading as a cure for mental and physical illness, first came to be 5.

Prominent Philadelphian Benjamin Rush was the first American physician to write about psychiatric care in his 1812 book, Medical Inquiries and Observations Upon the Diseases of the Mind. His thoughts stemmed from similar innovations that began in England, France, and Italy in the eighteenth century 6. While some of his recommendations, such as blood-letting, would be anathema today, he suggested having psychiatric patients engage in “amusements” such as reading. “In order to assist all the remedies that have been mentioned, it will be useful, as soon as our patients begin to discover any marks of the revival of mind, to oblige them to apply their eye to some simple and entertaining book,” offered Rush. He also encouraged copying manuscripts and reading to the illiterate listener, concluding that these tasks would fix the patient's mind on one subject and distract it from others that may be causing the condition. To facilitate this “mode of exciting and regulating the faculties and operations of the mind,” Rush suggested that patients be exposed to books of history, travel, and fiction and that these should “compose a part of…every public and private mad-house” 7.

Another prolific author of early nineteenth century psychiatry was John Minson Galt, superintendent of the Eastern Lunatic Asylum in Williamsburg, Virginia. In his 1846 textbook, he, like Rush, prescribed reading as an important therapy for his patients. He also went a step further, calling for the creation of libraries as a basic element in the many similar asylums that were being founded at that time 8. “And we,” he wrote in his 1843 annual report, “have felt the want of a regular library…so as to render this a valuable and regular additional agent in moral treatment” 9. In 1853, writing in the Journal of Psychological Medicine and Mental Pathology, Galt wrote that “To many patients, [reading] proves a source of agreeable feelings, during time which would otherwise be full of the tedium of ennui” 10.

In 1854, Thomas Story Kirkbride, physician and superintendent of the Pennsylvania Hospital for the Insane, wrote a prominent series of articles in the American Journal of Insanity. From these articles would come the “Kirkbride Plan” that would influence the design of both public and private asylums well into the twentieth century. The unique feature of a Kirkbride hospital was its staggered wings that allowed light and adequate cross-ventilation. Over thirty such Kirkbride hospitals were built in the United States, with a few still in use today 11. One of the amenities called for in these articles were libraries, one for male patients and one for female patients 12.

While most early practitioners of the moral therapy movement generally favored bibliotherapy, what the patients should read was open to a much wider interpretation. Rush called for patients to be exposed to fiction 7. He advised that reading novels would serve as a needed diversion to those suffering with mental illness. Not all, however, were in agreement. “Cheap novels and trashy newspapers [are] more a cause than a cure of insanity,” wrote Isaac Ray, superintendent of Butler Hospital in Providence, Rhode Island. He felt that reading was important, going so far as to lament that while the architectural elements of his new facility “fully answered his expectations, they were yet to have a library in place.” But he felt that the material read by patients should not “overly excite” the mind. In fact, a not-so-infrequent diagnosis for admission to an asylum in the mid-1800s was insanity caused by “reading novels” 13. “Travel books, histories and biographies” were recommended by Ray as well as by many of his peers 14, 15.

Another point of contention was whether or not the Bible should be included in an asylum library. Religious excitement was another common diagnosis found on admission records of patients labeled insane in the nineteenth century. Persons who adhered to Millerism or other “fundamental” or “non-Orthodox” religious beliefs (a label often applied then to anything outside of the Protestant church) were frequently labeled as lunatics and sent to asylums. As a result, the Bible was kept away from these patients “whose disease [might] lead them to make improper use of [the Scriptures],” wrote George Chandler of the New Hampshire Asylum. On the other hand, Galt said that the Bible was “the book most desired and read” by his patients. He considered the daily reading of consoling Psalms and New Testament passages a must for those patients suffering from melancholia 8.

By the late 1800s, the patient census of most US asylums had begun to rapidly outgrow the size of their facilities. Causal factors included the explosion of the population due to immigration. Hospital overcrowding quickly defeated the goals of calm, time-intensive moral therapy. Thus many asylums, much to the frustrations of institutional leadership, became more custodial in nature and less therapeutic 4. Among the activities that began to suffer with these changes was the general availability of patient reading programs.

Bibliotherapy, however, did not end. It simply moved from one of the moral therapies, usually overseen by an asylum superintendent (or a patient), to that of a special service maintained by trained staff. In 1904, E. Kathleen Jones, chief librarian at McLean's Hospital in Belmont, Massachusetts, first began practicing bibliotherapy with patients as part of her official duties 16. Today, bibliotherapy is commonly used in the cognitive behavioral therapy milieu. Librarians have not proliferated as practitioners of bibliography, most likely due to the special training and certification required to work with patients in a clinical setting 17.

Modern hospitals are now returning to some of the basic principles espoused by the moral therapists in the design of new facilities. A recent study at a Midwestern hospital found the decibel level at a bedside during the 7:00 a.m. shift change reached as high as 113 decibels, the equivalent of a jackhammer, hardly beneficial for rest and healing. Roger Ulrich, psychologist and professor of architecture at Texas A&M University states that “Research shows that even little touches [in new design] can have a substantial impact. Patients feel and do better if the hospital offers pleasant distractions such as soothing artwork on the walls, windows that offer views of nature, and places to visit such as gardens and lounges” 18. In addition to enhancing the hospital environment, bibliotherapy can play a role in holistic care.

In the fall of 2012, the Worcester Recovery Center and Hospital opened in Worcester, Massachusetts. This is the newest mental health hospital in the United States and will replace inpatient wards in aging buildings at other state facilities. The 428,000 square-foot campus, designed by architect Frank Pitts, would probably meet the approval of Rush, Galt, and the other moral therapists. Included in the design are 320 single patient rooms, outdoor courtyards, a gymnasium, a music room, a school, game rooms, and a large, bright patient library with books for pleasure reading and computer workstations 19.

Superintendents of early asylums recognized that reading was a healing activity for their patients. Some, such as Ray, attempted to be prescriptive about the types of books available. Others, such as Samuel Woodward, first superintendent of what is today the Worcester Recovery Center and Hospital, felt it did not matter. Whether patients read to relieve the tedium of everyday asylum life, to expand their knowledge of a subject, to pray, or to simply escape, early bibliotherapy was an essential part of treatment. Although bibliotherapy has evolved along with mental health care, its roots and connection with the library are very much intact.

References

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