Moral treatment

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Moral treatment or English moral management or moral treatment is a psychiatric treatment concept that was mainly spread from England to Western Europe at the end of the 18th century and was decisive here in the early 19th century. In England in 1794 the Quaker William Tuke (1732-1822) founded a private "madhouse" - a psychiatric facility - according to today's standards in York , which he gave the programmatic name " The Retreat " (seclusion, refuge). This form of moral treatment practiced there was later largely adopted by the attitude of psychics .

The practice of moral treatment initially also combined somatic ideas and treatment methods, such as regular meals, adequate rest, adequate sleep and medication. “Moral” refers to the Latin mores (= cult, custom, habit, custom, belief in the effectiveness of education, relaxation and human kindness). The terms “management” and “treatment” express the therapeutic optimism which first made psychiatry a science based on experience and which stands in contrast to the pure custody and exclusion character of the earlier institutions.

Origin and Spread

William Tuke

England

England is considered the country of origin of moral treatment. This type of treatment is related to English enlightenment morality .

The introduction of "moral management" is sometimes seen in the founding of St. Luke's Hospital in London by William Battie (1703–1776) in 1751, who designated such a house for the first time as a training center for medical students and instead of "care" (= Care, care) spoke of "cure" in the sense of therapy and not of custody. Battie took care of the abolition of the publicly distancing "mad look" that was common at the time, for example for socially critical caricaturists such as William Hogarth , romantic writers such as Samuel Richardson or satirical journalists, and replaced them with an institution of practical experience and intuition serving the education of students.

The moral treatment as a movement socializing the mentally ill was then carried by the religious convictions of the Quaker community in York under its founder William Tuke (1732-1822). William's grandson, Samuel Tuke (1784–1857), described this form of treatment in more detail in a book published in 1813. “Moral management” reached its peak under John Connolly (1794–1866) and the principle of non-violence and the renunciation of mechanical coercion ( no restraint ). In intellectual history, however, the moral treatment is also rooted in the Scottish school of common sense philosophy . This empirical stance subsequently led not only to a consistent avoidance of coercion, as demanded by the somatics , but also - especially in Germany - to the movement of the psychics , who advocated educational, not always non-violent aspects of treatment. There was no psychotherapy in the current sense at that time.

France and Italy

In France, the "traitement moral" was already carried out by Philippe Pinel (1745–1826), which he seems to have largely taken over from Jean-Baptiste Pussin . It was, however, a form of treatment that could be largely distinguished from "moral management" and which can only be compared to the moral treatment of the English style in certain respects. The "traitement moral" Pinels was more of an administrative character, was based on coercive treatment and retained the distinction between professional interests. The economic utilization of the sick for work is regulatory. The socially separating concept of the poor insane was therefore still appropriate. John Connolly's system didn't catch on until 60 years later. In Italy and France, the influence of England was directed more towards the teaching of William Cullen (1710–1790), as his pupils Pinel and Vincenzo Chiarugi (1759–1820). There are also misunderstandings between “traitement moral” and “moral treatment” because of the different meanings of “morality” in French and English. In France the psychological-subjective, in England more the communal aspect of this term is meant in accordance with the different meanings of sensus communis , see also the history of functional syndromes .

Germany and USA

Except in Western Europe, where the moral treatment was mainly widespread, it also came to Germany, where it was introduced by Johann Christian Reil in 1803 and also spread to the USA. However, Reil's rather liberal stance did not prevail in Prussia. There, from 1805 , the rather strict views of Johann Gottfried Langermann gained the upper hand. Stahl's idea of the idiopathic disturbance of the soul and Kant's moral philosophy of the passions to be mastered had an effect on the conception of mental illness as self-inflicted unreason, see also the concept of endogenous psychosis and the associated negative attitude towards subjectivity , the sensus communis and the sensualistic doctors like Johann August Unzer . The Prussian insane reform followed less the notions of the sensus communis, more common in France and England, in the sense of positive social responsibility for the insane, but was guided more by security thinking. Since psychics were numerically well represented in Germany , it should be pointed out that these are not necessarily psychologizing views, but very often moralizing ones, while in France with French moral as mentioned before the psychologizing point of view is meant. The moral treatment has now merged into social psychiatry and its diverse concepts. Even if the somatic treatment method largely dominated from about 1850 onwards, there have always been new practical approaches to renewing everyday psychiatric life in institutions.

Spiritual and cultural-historical basics

The moral treatment was originally determined by the religious beliefs of the Quaker community and by the acceptance of the wholesome influence of the community ( sensus communis ). The basic religious attitude can be felt by many representatives of “moral management” and can be related to the sensitivity in other countries after the religious wars that have ended there, cf. also pietism . However, it is also a child of the Enlightenment and as such a philanthropic attitude indirectly supported by the more secular »moral sciences«, as initially portrayed by John Locke (1632–1704) and Bernard Mandeville (1670–1733) and later by John Stuart Mill (1806-1843) was added. Locke and Mandeville were both doctors and therefore also dealt with mental health problems. Early scientific models were also important here, such as those used by Thomas Willis (1621–1675) and his doctrine of the "spiritus animales" (1667), Robert Whytt (1714–1766) and William Cullen (1710–1766). 1790) were available. Moral philosophical aspects of the English philosophy of the sensus communis and the Scottish school stood alongside the beginning scientific and natural philosophical considerations. Sometimes they went back to the rules for dealing with the mentally ill, as they were first formulated by the Roman encyclopedic author Aulus Cornelius Celsus in the 1st century AD.

The basic attitude of the Enlightenment towards the mentally suffering is expressed in the 5th book of the Enlightenment novel " Wilhelm Meisters Lehrjahre " by Johann Wolfgang von Goethe.

“Besides the physical,” said the clergyman, “… I find the means to cure madness very easy. It is the same thing that prevents healthy people from going insane. Arouse their self-activity, get them used to order, give them a concept that they have their being and fate in common with so many that the extraordinary talent, the greatest happiness and the greatest misfortune are only small deviations from the ordinary; so no madness will creep in, and when it is there it will gradually disappear again. I've given the old man's lessons, he teaches some of the children the harp, he helps out in the garden, and he's much more cheerful. He wishes to enjoy the coal that he plants and wishes to teach my son, to whom he gave the harp in the event of his death, very diligently, so that the boy might also need it. As a clergyman I try little to tell him about his wonderful scruples, but an active life brings about so many events that he must soon feel that any kind of doubt can only be lifted through effectiveness. I go to work gently; but if I can still take his beard and robe away from him, I have gained a great deal: for nothing brings us closer to madness than when we distinguish ourselves from others, and nothing maintains the common understanding so much as in the general sense many people to live with. How much is unfortunately not in our upbringing and in our civic institutions, whereby we prepare ourselves and our children to be mad. "

Methods

The following therapeutic measures were carried out: friendly individual care, occupational therapy, religious exercises, amusements, games, music-making, physical exercises, studies, recreation, gardening and agricultural work, with no physical means of restraint and physical violence.

Problem

The basis of moral treatment, especially in Germany, is the idea that mental illness is to be understood as misguided moral action and will. Since the moral treatment is ultimately mostly based on a more or less comprehensive system of social or at least group-specific norms, by definition it cannot agree with the ethical convictions of the patient to be treated, which are always individually and subjectively shaped . This is already supported by reasons of sociological differences and differentiations. This fundamental discrepancy is exacerbated by the fact of the social question and by the problem of the poor lunatic , but did not prevent the accusation of subjective guilt towards the patient, especially in Germany.

Since the treatment of the insane, from a moral point of view, assumes that the patient's lack of moral strength stands in the way of recovery, the essence of the treatment is necessarily based on the attempt to transfer medically or socially justifiable moral ideas to the patient. However, this requires a necessary adjustment on the part of the patient being treated. This adjustment in turn is brought about by different means, which, however, hardly have to be individually determined, but always have to be viewed as more or less compulsive , even if one speaks of renouncing physical means of coercion and physical violence. A spectacular healing success of moral treatment in England was the treatment of King George III. by Francis Willis , also using means of force to break the will of the king. Klaus Dörner therefore speaks of the attempt to internalize compulsion. Adaptation is a prerequisite for any education. Therefore, pedagogical ideas, as well as the principle of the family, have great weight within the concept of moral treatment. But moral-philosophical and theological ideas also flow into this concept. However, it should not be forgotten that an adult mentally ill person should no longer be considered a child. This gives rise to problems of independence or incapacitation .

Individual evidence

  1. a b Asmus Finzen : The Pinel pendulum. The dimension of the social in the age of biological psychiatry . 1st edition. Edition Das Narrenschiff im Psychiatrie-Verlag, Bonn 1998, ISBN 3-88414-287-9 ; (a)  The beginnings : p. 10 ff .; (b)  Constant renewals ?: p. 35
  2. a b c d e f g h Klaus Dörner : Citizens and Irre. On the social history and sociology of science in psychiatry . [1969] Fischer Taschenbuch, Bücher des Wissens, Frankfurt / M. 1975, ISBN 3-436-02101-6 ; (a) on taxation “moral management”: pp. 57, 92–94, 112, 249; (b) on taxation “traitement moral and moral treatment” pp. 64, 159 f .; (c) on taxonomy “Self-correction in Germany under the influence of Kant's philosophy”: pp. 207 ff., 244 f .; (d) on the district “Sensus communis”: pp. 206 f., 215; (e) Re. “subjective assignment of guilt”: p. 207; (f) Re. “Forced treatment of the king”: page 92; (g) Re. “Internalization of compulsion”: p. 96 ff .; (h) on district “incapacitation”: p. 210
  3. ^ Edward Shorter : A historical Dictionary of Psychiatry . 1st edition. Oxford University Press, New York 2005, ISBN 0-19-517668-5 , pp. 53, 180-181, 221; issuu.com ( Memento of the original from March 28, 2010 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / issuu.com
  4. a b Uwe Henrik Peters : Lexicon of Psychiatry, Psychotherapy, Medical Psychology . 6th edition. Urban & Fischer, Munich 2007, ISBN 978-3-437-15061-6 , p. 658, books.google.de
  5. ^ Samuel Tuke: Description of the Retreat, an Institution near York, for Insane Persons of the Society of Friends . York 1813
  6. ^ John Connolly : Treatment of the insane without mechanical restraint . 1st edition 1839, 2nd edition 1856, reprint 1973, German 1860
  7. a b Erwin H. Ackerknecht : Brief history of psychiatry . 3. Edition. Enke, Stuttgart 1985, ISBN 3-432-80043-6 , p. 60
  8. Johann Christian Reil : Rhapsodies about the application of the psychic spa method on mental disruptions . Halle, 1803, pages 26 and 49 f.
  9. GS Bockhoven: Moral Treatment in American Psychiatry . New York, Springer-Verlag 1963
  10. Hans-Georg Gadamer : Hermeneutics II. Truth and Method. Additions. Collected Works . JCB Mohr (Paul Siebeck), Tübingen 1990, Volume II, ISBN 3-16-146043-X ; Cape. 23. Problems of practical reason. On Stw. "Comparison of the modern term 'moral sciences' ( John Stuart Mill ) and the ancient tradition of human 'practice' including politics since antiquity ( Aristotle )": in particular page 320, paragraph 2, page 324 and Page 327 para. 2
  11. ^ Johann Wolfgang von Goethe : Wilhelm Meisters apprenticeship years . A novel. Berlin: from JF Unger (1795–1796) 5th book, 16th chapter. Reclam edition p. 361; Artemis commemorative edition p. 310 f .; Insel anniversary edition 4th volume, p. 400 f., Neue-religion.de