Mental health on this study
RESEARCHERS, EDUCATORS, and clinicians have long acknowledged the transformative impact of the mid-20th century focus on interpersonal relations and relationships on nursing, in general, and psychiatric nursing, in particular (Lego 1999 and Reed, 1995). Today, the work of nursing is inextricably relationship-centered (Duffy and Hoskins (2003). Some of the most compelling theoretical and methodological work in the discipline encourages practitioners in current practice to consider ways in which biases from ethnocultural variations (Choi, 2002) or racism (Kendall and Hatton (2002), to name but a few, affect the construction and experience of therapeutic relationships.
But relationships are themselves embedded in particular environments. The construction of safe, healing environments has, of course, long been a benchmark of expert psychiatric nursing practice. In addition, psychiatric nurses have been remarkably adept at adapting such environments to meet the needs of cognitively impaired patients or the demands of insurance companies for the rapid assessment, stabilization, and discharge of individual patients. Still, such adaptations assume the stability of supportive, empathic, and therapeutic relationships. Little attention has been paid to wondering if such an assumption is valid, or to understanding the longer-term implications of the reciprocity between such relationships and the immediate, structural, and demand-laden context in which they occur.
This historical case study of the work of those involved in the day-to-day care of patients at the Friends Asylum in early 19th century Philadelphia suggests that the implications may be quite profound. The historical case study methods applied in this research uses the distance of time to enable a more analytic focus on the nature of complex changes not immediately apparent to contemporary historical actors (Gaddis, J.L., 2002. The Landscape of History: How Historians Map the Past, Oxford University Press, London and New York.Gaddis, 2002). This method requires that background exposition, historical data, and analytic arguments form a reasoned narrative that addresses and advances different aspects of the study’s central thesis (Iacovetta & Mitchinson, 1998).
This study draws its data from the daily diaries kept by the lay superintendents of the Asylum from 1814–1840 (hereafter SD). At the end of each day, these men wrote about their, their patients’, and their attendant staff’s work: that was done about the house and in the “family’s” farm and gardens. More importantly, they wrote, with unusual candor and extraordinary detail, about their patients and their patients’ actual words and behaviors. The Asylum’s lay superintendents also wrote about their and their attendant staff’s feelings: about the joys and the frustrations of working, day-to-day, with insane patients. These patients’ names have been changed in this study to protect their confidentiality. Still, both their words and that of their staff tell a story about how the small, incremental changes made to a therapeutic environment fundamentally changed the way staff thought about and implemented therapeutic relationships.
The friends asylum
The Friends Asylum, founded in Philadelphia in 1817, was the first institution in the United States solely for insane men and women, and was the model for many similar institutions established later in the 19th century (Grob, 1973). The Asylum practiced a then-innovative and new treatment: the “moral treatment” of the insane. Moral treatment held out to families the bold and very real promise of a cure if only they consigned their insane kin to the care and treatment of a new institution (Evans, 1839). There, a new kind of moral and disciplined environment, created by lay men and women, would stand in sharp contrast to the debilitating (although, moral treatment’s adherents were quick to state, not necessarily deliberate) associations of home that had first given rise to and then supported the insane’s deranged symptomatology (D’Antonio, 2001). Theoretically, an asylum’s quiet, secluded, and healthy country setting, its diverting opportunities, the soothing associations of gardens and walkways, and the “judicious kindness of others” would gently appeal to both the insane individual’s latent rationality and to his inherent capacity to find the road to his recovery and eventual cure (Tuke, 1813).
Work and the practice of moral treatment
In actual practice, moral treatment at the Friends Asylum in the early 19th century took the familiar and reframed it as therapeutic (D’Antonio, 1990). Every normal aspect of a sane person’s life became part of the armantarium of an insane patient’s treatment. The structured times an individual arose in the morning, took meals, and retired at night was at once a disciplined therapeutic strategy consciously planned to the instill the habits of orderliness and control lost to the ravages of insanity and a familiar routine harkening back to the idyllic rhythms of a domestic farm economy. During the longer, more productive, days of summer, staff and their patients arose at five, and enjoyed their supper at seven. In winter, they arose at seven and took supper at five. Dinner was always at noon, with a trumpet summoning men from the fields or workshops (The Friends Asylum, 1913).
Insane patients worked side-by-side with their attendant staff and the institution’s farmer, gardener, and domestic help within this routine to attend to the seemingly never ending cycle of daily, weekly, and seasonal chores both within and outside the house. The tenets of moral treatment cast this work as therapeutic. Cultivating potatoes or making new bed sheets, for example, distracted the morbidly preoccupied, soothed the violently agitated, and stimulated the dangerously depressed. This work was both meaningful and productive. It was also critically important. The Asylum’s domestic economy, in fact, depended upon the labor of both staff and patients together to care for sick patients, to put food on the table, and to cover chronic shortfalls on its shoestring budget (see especially SD 26 May 1823, 19 April 1827, and 29 April 1830).
Tags: Health study