A Brief History of Mental Health Legislation

For centuries, religious or spiritual explanations have determined the way in which people with mental disorders have been treated in many societies. During the Middle Ages, people in European countries often viewed mental problems as having supernatural causes associated with demonic or divine possession. The early 17th century saw the rise of secular explanations of madness as a physical state. Between 1600 and 1700 increasing numbers of poor people with mental disorders were confined in public jails, workhouses, poorhouses, general hospitals and private asylums across Europe and what is now North America. Many early medical explanations of madness did not encourage compassion or tolerance but implied that this impaired physical state was self-inflicted through an excess of passion, so justifying punishment.

It is thought that during the first part of the 18th century the dominant view of mentally disturbed people was as incurable subhumans and this was used to justify the poor living conditions and the use of physical restraints in places of confinement.

The Humane Movement.

The pressure for reform of these institutions coincided with the rise in humanitarian concerns in the 18th century, and many institutions introduced moral treatment programmes). The success of humane and moral treatment led to the building of many asylums in European countries and the USA.

Philippe Pinel c/- wikipedia

Philippe Pinel (20 April 1745 – 25 October 1826) was a French physician who was instrumental in the development of a more humane psychological approach to the custody and care of psychiatric patients, referred to today as moral therapy. He also made notable contributions to the classification of mental disorders and has been described by some as "the father of modern psychiatry".

Dr. Philippe Pinel at the Salpêtrière, 1795 by Tony Robert-Fleury. Pinel ordering the removal of chains from patients at the Paris Asylum for insane women. c/- wikipedia

However, most of these large public institutions were unable to replicate the success of the dedicated pioneers of moral treatment. Financial constraints, large numbers of patients and the lack of cost-effective alternatives to moral therapy meant that these state mental hospitals quickly became custodial institutions.

The 20th century saw a change in emphasis from custody and protection to the care and treatment of people with mental disorders and the development of a more humane approach.

However, the laws and legislation covering commitment of people to these institutions tended to also reflect a paternalistic approach and left most of the power and authority to those doctors in charge of these institutions, with little oversight and consideration of the individual’s wishes and desires.

Not unsurprisingly with such unlimited power and authority there were many famous cases of people, many of whom were women, being unfairly and unreasonably committed.

After the Second World War the human rights movement expanded and focused attention on gross violations of basic human rights, including violations against people with mental disorders.

Research showed that mental asylums had little therapeutic impact and that they sometimes exacerbated mental disability. Internationally, there was an increased awareness of the poor living conditions and inadequate treatment and care available in many asylums and of the necessity for governments to protect the rights of people with mental disorders.

The discrediting of mental asylums on humanitarian grounds led to a review of both public laws and policies. 

Deinstitutionalization

Many countries and jurisdictions developed specific mental health legislation for the first time and these laws incorporated principles such as instilling certain rights for patients and opportunities for independent reviews of decisions.

A process of reducing the number of chronic patients in state mental hospitals, the downsizing and closing of some hospitals, and the development of community mental health services as alternatives, began to occur, a process known as “deinstitutionalization”.

This period also coincided with the discovery and development of many of the first biological treatments for major psychiatric conditions, including lithium for Bipolar Disorder, the first antipsychotics and tricyclic antidepressants.

Some have argued that deinstitutionalization did not really occur out of a public change in attitude and approach but rather as a result of there being less need for beds in institutions as many individuals now had access to treatments which could at least in part restore some function and autonomy to them.