“Healthy Avenues of the Mind”: Psychological Theory Building and the Influence of Religion During the Era of Moral Treatment

Moral treatment was the first established form of psychiatric care in the United States. Originating in Europe, it was practiced from approximately 1815 to 1875. Little-known today, American moral treatment involved a heavy reliance on psychological forms of treatment, a remarkable degree of humanism and optimism about the treatability of the most severe mental illnesses, and a notable prescience about the impact of the “milieu” on patients (1, 2). The writings of the practitioners of moral treatment warrant reexamination for the light they shed on pre-Freudian concepts of the ego. In addition, their work has noteworthy parallels with some of our latest neurobiological discoveries, since these psychiatrists firmly believed that their psychological interventions led to organic changes in brain matter, although they lacked the methods to validate this. Today, of course, there is a growing body of neurobiological evidence demonstrating that psychological events have the ability to measurably alter the brain both functionally and anatomically (3, 4).

Two related areas concerning moral treatment are the particular focus of this article. The first is the influence of Protestant thinking on psychiatric theory building during this period. The second is the emergence of early psychiatric theories concerning the functioning of the “self.” Delineating these two topics requires distinguishing which concepts about the self evolved out of the existing religious framework and which had their evolutionary roots elsewhere. The American Journal of Insanity and the annual reports of asylum superintendents—the main outlets for psychiatric ideas of the period—provide the basis for this discussion.

HISTORICAL BACKGROUND

The rise of moral treatment coincided with the sweeping national Protestant revival known as the Second Great Awakening (1780–1830) (2, pp. 48–50). Defined as a shift from predestinarianism to the doctrine of free will (5, 6), it disputed the Calvinist belief in man's depraved nature. By its emphasis on good works and community volunteerism as a means toward salvation, this movement expanded beyond theological borders to become an influential social force (5, 6). During this period, Protestant religious worship was an unquestioned part of everyday life, and belief in man's perfectibility was pervasive (5, 6). Although individual asylum superintendents certainly had varying degrees of religiosity, they had a uniform respect for the power of Protestant faith and practice.

The superintendents also drew extensive inspiration from European Enlightenment authors such as Philippe Pinel, John Locke, Etienne Bonnot de Condillac, Franz Joseph Gall, Johan Christoph Spurzheim, George Combe, Pierre Cabanis, and Antoine Louis Claude Destutt de Tracy (1, pp. 55–83). As a result, their writings display a special, and at times peculiar, fusion of Enlightenment philosophy with American Protestant piety. In conceptualizing mental illness, determining where it was localized and its cause, and describing how and why it progressed, American superintendents relied heavily on a combination of Gall's phrenology and faculty psychology, reformulations of Gall's concepts by the Scottish Common Sense School of Thomas Reid and Dugald Stewart, Locke's and Condillac's epistemology of associationism and sensationalism, and further refinements of their philosophies by the nineteenth-century philosophical school of the French Ideologues—especially Cabanis and de Tracy. From Gall's phrenological faculty model came the belief in physically rooted brain faculties such as will, passion, reason, intellect, and animal instincts. Locke's and Condillac's theories of sensationalism and associationism were deeply influential for many asylum superintendents, but the materialistic viewpoint and rejection of innate endowment were not acceptable to all. Certain parts of Locke's and Condillac's thought—such as the proposition that schemata of sensations formed clusters of associations, which then formed ideas—were assimilated alongside the phrenological and faculty models into their own (somewhat ill-defined) synthetic model. Thus, it was an accepted credo among American superintendents that the brain consisted of distinct faculties, which were formed and fed by associations (envisioned variously as subunits of faculties or as interconnections between faculties), which in turn were fed by sensations (envisioned as subunits of associations). The Scottish Common Sense School of Reid and Stewart upheld this mechanistic model but differed sharply from the Lockean school on the matter of the faculties' starting point. The former adhered to the idea of God-given innate faculties that functioned according to natural laws, while the Lockean view of the mind as a tabula rasa rejected innate functions (7, pp. 14–23). American superintendents' ideas tended to fall somewhere between these two positions. Most demurred on the question of the absolute origin of faculties and were in agreement with some features of the Lockean model.

However, if moral treatment was a child of humanism, Protestant ethics, and empiricism, it was perhaps above all a response to the dire treatments for mental illness that had preceded it. Until the first decades of the nineteenth century, therapies such as bleeding, cathartics, and ice baths—or worse, punishment, imprisonment, and neglect—were common measures used for the mentally ill. Rather than envisaging mental illness as demonic possession or a form of debasement, the pioneers of moral treatment viewed it as a physical illness. They saw it as a phenomenon that changed a person's behavior through physical changes in the brain, rather than as something that debased his or her humanity.

The moral treatment asylums that sprang up in the 1820s and 1830s in the United States were modeled on already existing European facilities, with special regard for the English Yorkshire Retreat, founded by William Tuke, a Quaker. Although American asylums varied according to local geographic and economic constraints, all of them subscribed to a common set of approaches. Each provided occupational therapy and amusements designed to distract patients from their irrational and unhealthy preoccupations, a structured agricultural life built around Christian virtues of self-discipline and work, and a kind and respectful approach to patients, inspired by Protestant ethics (1, pp. 114–144).

The superintendents' assertions concerning the pathophysiology of mental illness provide a foundation for examining the role religion played in furthering their thinking. The writings display a synthesis between the phrenology/faculty model on the one hand and the associationist/sensationalist model on the other. Horace Buttolph, superintendent of the New Jersey State Lunatic Asylum at Trenton and editor of the American Journal of Insanity, like many of his colleagues, frequently presented his readers with expositions on pathophysiology. He wrote,

By perceiving personality and behavioral phenomena as arising from specific faculties, a high level of therapeutic confidence was possible in matters of both etiology and intervention. In the same report Buttolph wrote,

Superintendents postulated that disease affected one or a few faculties at a time, while many other faculties remained in their healthy state. Monomania, a common diagnosis of the period, described patients who had delusions of primarily one kind (e.g., persecutory). “The varieties of monomania,” Buttolph noted, “may be as numerous as the individual faculties of the mind” (9, p. 26).

The belief that certain faculties remained relatively healthy despite illness was frequently reiterated and formed the basis of one major avenue of treatment: treatment directed toward the healthy faculty. The assumption was that such treatment was readily processed by the healthy faculty precisely because it was healthy and able to recognize healthy input.

Samuel B. Woodward, superintendent of the State Lunatic Hospital at Worcester, in Massachusetts, wrote,

The faculties that remained intact during bouts of insanity were thought to be dormant but able to be reawakened by the right kind of therapy. This consisted of offering harmonious associations and sensations of various kinds aimed at awakening the faculties of mind that were still healthy.

RELIGION'S ROLE IN MORAL TREATMENT

We can now turn to the primary topic of this essay: the role religious ideas played in psychiatric practices and in the emergence of nascent definitions of the self. Because religion had such a pervasive social influence, one must distinguish how much of its impact on moral treatment was incidental and how much was a deliberate element of patient care.

Many superintendents had definite opinions about the dangers of exposing their patients to “too much” religion, about the benefits of regular worship, and about the propensity of certain disorders to produce excessive preoccupation with religious themes. They were openly opposed to the popular fiery sermons common throughout this revivalist period, regarding them as potentially harmful mental influences (11, p. 107; 12, pp. 122–123). Privately, superintendents were a religiously devout group (a substantial subset were Quakers, and the rest were members of other Protestant denominations). Nevertheless, they unanimously adhered to the belief that the brain's soundness depended on moderation. Describing the unhealthy imbalances of the brain in terms of overexcitement and torpidity, they maintained that overzealous study of any subject—whether business, literature, or religion—was frequently the cause of many cases of insanity (13, p. 49; 14, pp. 23–25). This view notwithstanding, they routinely hired chaplains to live on the asylum grounds, or they provided patients the opportunity to attend services in a nearby church. Chaplains preaching to the mentally ill were warned by superintendents to adopt an unprejudiced stance. They should avoid, wrote Pliny Earle, one of the most prominent asylum superintendents of his day, “all denunciations and the weightier terrors of the law, all speculative and much controverted points, and all purely sectarian or denominational dogmas or doctrines” (15, p. 24). The Editors of the American Journal of Insanity cited the verse of the British poet William Cowper as a standard for the tone to be employed: “Cowper,” they wrote, “himself for a long time insane, has described a preacher suitable for such a station: `Simple, grave, sincere;/In doctrine incorrupt; in language plain,/And plain in manner; decent, solemn, chaste'” (12, p. 121).

In order to serve effectively, chaplains for the mentally ill were urged to learn about the then-new scientific models of mental illness: phrenology, faculty psychology, and associationism. They should have, wrote the Editors of the American Journal of Insanity in 1845, “a good knowledge of Anatomy and Physiology, and of those writings that teach the dependence of mental phenomena upon the organization [of the brain], and understand how often the former [mental phenomena] are deranged and the whole moral character changed by slight disorder of the latter” (12, p. 123).

Emphasis was often placed on patients attending worship with the same regularity as before they became ill. Superintendents placed great importance on environmental influences, and the environment felt to be most conducive to health was, as the historian Nancy Tomes has pointed out, one that was orderly and regimented (16). Church attendance fitted this specification perfectly. John S. Butler, the superintendent of the Hartford Retreat in Connecticut after 1842, observed that religious worship in the asylum “calls to mind, doubtless, the period when they [patients] were accustomed to worship God in his sanctuary; and kindles up once more, a desire to return, to renew again their acts of worship” (17, p. 11).

Superintendents emphasized the capacity of religious worship to inspire self-control and rational behavior. It was frequently noted that agitated patients suddenly calmed down when they were allowed to attend services (17–20). T.S. Kirkbride, superintendent of the Pennsylvania Hospital for the Insane from 1844 to 1883 and another of the most prominent psychiatrists of his day, wrote,

And Samuel Woodward, whose observations tended to be more passionate, noted, “By our whole moral treatment, as well as by our religious services, we try to inculcate all of that which is rational” (10, p. 41). Religious services were also used as a reward system. Amariah Brigham, superintendent of the Hartford Retreat until 1842 and co-Editor of the American Journal of Insanity, for instance, had “no doubt that these services are beneficial to our patients. Permission to attend them is solicited by nearly all, and many are induced to exercise their self-control in order to enjoy this privilege” (21, p. 24).

Exposing the patient to what was rational and compatible with Christian truth was considered to be a psychological or physiological intervention (the two terms having quite similar meanings at this juncture). This was so because the superintendents' firm belief in environmental determinism gave scientific legitimacy to the application of an external influence. The benefits of religious teaching were thought to have a direct effect on the physiology of the brain by strengthening a particular faculty. There was consensus among American superintendents, driven in part by religious pressures, that mental illness should be understood in strictly physical terms (1, pp. 13, 14, 58, 64–71, 86, 87). Illness resided in the organic matter of the brain and did not affect the ethereal mind. Although the mind-brain duality was an accepted premise, fears of materialist encroachments on the mind lingered, and the concept of the mind's inviolability needed constant reaffirming. John P. Gray, the devoutly religious co-Editor of the American Journal of Insanity and superintendent of the State Lunatic Asylum at Utica, was emphatic on this point. “Disease is what we have to deal with. Not disease of the mind, for the mind, the spiritual principle, the immortal being cannot be the subject of disease” (22, p. 385). Elsewhere he wrote, “If the mind is a material substance, a secretion of the brain, as bile is a secretion of the liver, then the sublime faith of the Christian religion is of little consequence to man and they who work for the advancement of medical science truly labor in vain” (22, p. 390).

Other superintendents agreed with Gray. They differed from him only in that they defined the faculties of brain so as to include faculties of religious receptivity and moral volition, which they felt could become diseased just like any other faculty (1, pp. 73–83). Thus, they underscored the mind's immortality but assigned the ability to distinguish right and wrong to a function of the brain that was directed by natural laws and could be disrupted by a breach of these laws (1, pp. 73–83). The contentious question of which human characteristics should be attributed to the mind and which to the brain was left unresolved. Most superintendents of the 1840s, 1850s, and 1860s (in contrast to Gray) remained vague and apprehensive about the issue. While the brain—not the mind—was viewed as the basis of illness, conflations of mind and brain continued to surface. It seems, however, that this confusion provided fertile ground for theory building. Horace Mann, one of the trustees of the State Lunatic Hospital at Worcester, noted,

A variant of the mind-brain concern was Brigham's notion that “in most cases, as observation demonstrates, even in old cases there is but slight disease of the brain, and often but a small part of this organ. If it was not so, the disease would soon terminate in death, for extensive or severe disease of the brain soon proves fatal” (24, p. 14).

Thus, while seeming to embrace the dictum “the brain is the organ of the mind,” American superintendents at times confused the two. Although they proposed that the brain was what was diseased, there were wistful comments that the mind still needed saving or at least a great deal of attention. These unresolved ambiguities, however, stimulated discussion about the nature of selfhood, as we shall see further on.

The highest sphere in what Horace Buttolph had referred to as the “region of sentiment” was the faculty of religious receptivity. This faculty was seen as having special characteristics, making it often capable of both withstanding illness and hastening the improvement of the other faculties. This at least partial hardiness was viewed as providing an avenue for treatment. “No man has any right to question the existence, in the minds of the great majority of lunatics, of a susceptibility to religion,” J. S. Butler wrote, citing Dr. Jacobi, the superintendent of the Prussian Sieburg Asylum. “It is important and of unequivocally beneficial influence,” he continued, “not to allow the impression of true piety to become extinguished in the minds of these patients, but on the contrary, to seize hold of even the faintest traces of religion, and to convert them, as much as possible, into agents in their recovery” (25, p. 19).

Many of these writers were able to embrace the contradictory view that the religious faculty could both resist disease and be vulnerable to it. As Buttolph expressed it, the religious faculty contained “those higher feelings proper to man, [which] when disturbed by disease of the brain are diminished, perverted or increased in their natural strength according to the character of the diseased action” (8, p. 26).

Thomas H. Gallaudet, well-known for his pioneering work in the education of the deaf, also served as chaplain to the Hartford Retreat, working closely with the superintendents Amariah Brigham and John S. Butler from 1838 to 1850. He regularly wrote his observations in his “Chaplain's Report,” a commentary of a few pages appended to the superintendent's annual report. The tone of his comments closely echoed those of the superintendent but focused on the behavior of patients during religious services. Gallaudet argued, first, that the religious faculty was part of a larger system of faculties. Second, he contended that the religious faculty was often the one that remained healthy when other faculties were disturbed by delusions. “There are so many shades and degrees, too, of mental derangement,” he observed in 1842, “that not infrequently the mind which suffers from a delusion on some other topic, has perfectly clear perceptions of religious truth” (24, p. 35). And third, he believed that given the fact that the religious faculty so often remained intact, treatment directed toward it allowed it to have a curative effect on the other faculties.

How could treatment directed to a healthy faculty give it power to remedy the other disturbed faculties? “It is through the healthy avenues of the mind,” Woodward posited, “that religious truth is received and makes its impression upon the feelings” (26, p. 86). His understanding of this phenomenon was rooted in a belief in associationism. The physiological and epistemological model of this theory held that physical sensations formed associations in the mind and that complex matrices of associations formed ideas. The mind contained these clusters of associations, which were amenable to each other's influence. In this view, sensations were stimuli arising from the immediate environment, and a chapel service was one such stimulus (7, pp. 83–88, 95–99).

The superintendents thus juxtaposed two almost dichotomous schools of thought—phrenology/faculty psychology on the one hand and associationist/sensationist psychology on the other. From one school they derived support for their notion of constant, innately endowed faculties; from the other they borrowed a mechanical schema for how specific external stimuli might alter brain matter of a specific faculty. This juxtaposition linked the views that individuals possessed innately endowed qualities with views about how individuals were formed by the external flow of stimuli. Accordingly, these men filled their asylums with what they felt were salutary “sensations,” abiding by Brigham's advice that “a museum or collection of minerals, shells, pictures, specimens of ancient and modern art and curiosities of all sorts, should be connected with institutions for the insane” (27, p. 14).

Some superintendents went further, however, and wondered whether the nature of this link (between endowment and external flow) might contain important psychological clues about the particular makeup of specific patients. Their frequent observation of the calming effects of the hour of worship led some to wonder if there was a lesson to be learned not about religion but about psychology of the self. Their notion of “motives” provides some insight into this link. A motive was thought to be able to kindle the patient's willpower. It appealed to a central entity in the patient—what Pliny Earle called “self-consciousness” or the “I”—and was thought to induce persons to exert “control of themselves” (28, p. 16). The therapeutic approach that gave motives a central place marks the beginnings of a psychology of the self, one that envisions a self responding to motives for reasons that, in our terms, did not appear conscious.

Many superintendents spoke of motives that appeal to the self through intangible channels—channels that have a “higher purpose” and that give the self new “energy.” In one case report, Woodward wrote of a young woman “whose mind appeared perfectly demented; who talked incessantly” until he “proposed to her to attend chapel.” During the chapel service “she was perfectly silent and quiet for the hour,” but upon returning to her room “commenced talking again, and again continued it till the hour of the service in the afternoonShe ultimately recovered,” he stated, “and the first motive which was effectual to excite self-control, was the desire and determination not to disturb the religious exercises of the Sabbath. The benefit of one hour of self-control in such a case, from such a cause is incalculable” (13, p. 79; italics in the original). While the content of the motive—in this case, the religious exercise—is stressed, a greater emphasis is placed on the subjective feelings, “the desire and determination” of the patient. Whatever the motive may be, the important requisite is that it elicit the patient's desire and determination.

The distinction between religion as social intervention and as a catalyst for inner, psychological change is subtle but evident from Woodward's emphasis on self-control as the origin of the patient's ultimate recovery. Other superintendents gave similar examples. In fact, in much of this material, the process of gaining self-control in itself is the focus of the therapeutic effect. The implication is that an immediate, simple kind of self-control (the social requirements of attending chapel) can engender a more individual, autonomously driven type of self-control (the “incalculable” benefit leading to ultimate recovery).

Such a shift in emphasis is noteworthy given the fact that the explicit teachings of morality and religion were still viewed, because of environmental determinism's strong influence, as having a direct therapeutic and physiological effect by fortifying specific faculties (29). As I have noted, most asylum superintendents focused a great deal on the outward behavior of their patients. If patients acted with greater self-restraint, they were viewed as improving and they were rewarded. Accordingly, as they improved they were allowed to dine with the other patients, then with attendants, and in the last stage of recovery, with the superintendent and his family. Notwithstanding these practices, many of the superintendents' writings also proposed that internal changes took place as a result of a strong motive, and that this factor might be as important to recovery as visible behavioral changes. The interest in inducing self-control, for superintendents such as Woodward and Earle, was not merely to change the patient's behavior from “boisterous and destructive” to “perfectly quiet” but to catalyze the patient's own inner agencies of control. “It is rare,” Woodward observed, “that the paroxysm of excitement, with an insane man, is so great as to be beyond the power of control, if a motive sufficiently strong could be presented at the moment. This has often led me to remark, that no insane man is beyond the reach of a motive, if the motive is presented in the right time and the right manner” (19, p. 54).

Religious worship was often seen as the right motive. Why this was so was not explained, but perhaps because religion addressed human beings' higher qualities—“those higher consolations of a spiritual nature,” as Horace Mann (13, p. 4) put it—and had a mysterious connection to that which rendered their souls immortal, it was thought to be the only force able to appeal to the last vestiges of the self in someone undergoing the paroxysms of insanity. In Woodward's statement about the importance of the right motive, one detects a notion of self that is to some extent conceived of as active and central to the behavior of the person. Pliny Earle was explicit about presenting the right motive to those parts of the patient's mind that, despite insanity, may have retained their integrity. Like Woodward, he argued that stimulation of the healthy part of the mind was the best therapeutic method for reawakening the individual's “self-control” and “governing power,” that is, for awakening those central elements in the individual that are lost in mental derangement. For Earle, this stimulation was the equivalent of a motive. In 1866 he wrote,

In Earle's view, for the patient to begin to think and act rationally, it was necessary to awaken or “induce” the centers of “self-control, self-government or volition.” Simultaneously, however, the burden fell mainly on the superintendent, through his control of the environment of the asylum, to provide the right motive at “the right time” and in the “right manner.” And if Earle focused on secular pursuits, religion nevertheless continued to be the mainstay of most of these superintendents and administrators. “They [the board of trustees of the Asylum at Worcester] also requested funds for the erection of a chapel,” wrote Horace Mann in 1839, “where the religious feelings of the inmates might find some solace for their sufferings, a stimulus for their efforts at self-command.” And, Mann continued, “As might have been expected beforehand, religious motives have been found to give more energy to the thoughts and affections, than any others could have imparted” (13, p. 4).

These discussions of motives are also revealing for what they conclude about the relationship between self-consciousness and self-government. In 1866 Earle wrote from the Northampton asylum,

The sophistication of Earle's psychological thinking is appreciable despite the many ambiguities of this passage. Two ideas regarding motives appear interconnected. First, a motive was conceived of both as an external stimulus (similar to an incentive) and as an inner drive or intention. Second, Earle, like many of the other superintendents, seemed to believe in a self-conscious central entity that responded to such external stimulation by becoming active and capable of governing the more disrupted parts of the person's behavior and thinking.

The superintendents' fluency and fascination with religious dimensions provided a precursory framework for these sorts of psychological explanations of their patients' behavior. For example, the religious notion of the inviolability of the mind contributed to psychological concept building by emphasizing the importance of an intangible core self: what Earle called a “preserved self-consciousness” or the “I of their own being.” His suggestion was that this entity was a psychological structure (sharing many features with will) that under ideal circumstances achieved an organizing function. The “inviolable mind” concept conveyed an elevated status to preserved faculties, making them, as we saw in Earle's and Woodward's writings, the object of special and theoretically lively attention. This notion of the preservation of aspects of the self in the face of mental illness was all the more tenable because a parallel religious construct had existed all along.

CONCLUSIONS

It is worth pointing out that some of the superintendents' conclusions about an individual's central agency or core self echo concepts about the inherent organizing attributes of the ego put forth by ego psychologists a hundred years later (30–32). As early as the 1830s, superintendents theorized about a control-exerting agency—a “self-dominating power” (28, p. 16). They further argued that physicians and patients could strive to reestablish mental health by strengthening this agency. There are notable parallels between Heinz Hartmann's concept of the organizing role of the ego and Pliny Earle's 1866 view of the organizing function of the “I of their own being” (28). These coincidental resonances reveal the sophistication of psychological definitions that were attempted at such an early date.

Thus, while the theoretical observations of the superintendents may not have been sufficiently systematic to serve as landmarks to future clinicians, we can still admire the psychotherapeutic efforts of these men. They believed that the diseases they observed (predominantly the psychoses and severe mood disorders) were due to physiological changes, but they maintained that the content of the individual personality and psyche played a pivotal role in the arduous healing process. I have argued that in their writings and practice, religious concepts were productively intermingled with the beginnings of psychological concept building. It seems that awareness about states of the soul served as an important framework for these nascent observations about states of the mind. This claim invites closer examination of the biographies and complete writings of individual superintendents to understand better the religious and nonreligious influences that shaped their thinking.

Received Feb. 20, 1997; revision received Nov. 3, 1997; accepted Feb. 9, 1998. From the Payne Whitney Clinic, New York Hospital-Cornell Medical Center, New York. Address reprint requests to Dr. Taubes, Apt. 66, 884 West End Ave., New York, NY 10025-3514. The author thanks the staff of the Pennsylvania Hospital Archives and the Oskar Diethelm Library for their help in making materials available and George Makari, M.D., and Nathan Kravis, M.D., for their suggestions.