Washington University School of Medicine
St. Louis, Missouri
The image of Phillipe Pinel removing the chains from “lunatics” in a Paris asylum at the end of the 18th century can be seen as a symbol for the beginning of the era of “modern” rehabilitation for mentally ill patients. Pinel may or may not have actually gone around striking shackles off of people, but the painting as a representation of enlightenment and reformation marks the beginning of a coherent, organized movement in the treatment of people with mental illness.
The reform movement coalesced with the notion of “moral treatment, ” typified as a model community in which the mentally ill could relearn life skills in an atmosphere free of tension and chaos. This process was compared to child-rearing, based on the belief that patients could develop behavioral self-control through a corrective relationship with a benign authority figure. In the mid-1800s, this model appeared to be very successful, accounting for a high discharge rate and low rates of readmission. However, the “treatment” relied to a significant extent on the personal charisma and skill of the asylum superintendent, who often established a personal relationship with each patient under his care. The number of patients requiring hospitalization increased dramatically at the beginning of the 20th century, with a corresponding increase in the cases with severe psychiatric disorders (see Ref. 1 for a