A home away from home

Until the 19th century, people with mental illness were cared for by family members, who quietly attended to their needs in rural areas. But with the dawn of the Industrial Age, and its accompanying growth of crowded cities, many people feared people with mental illness were a threat to public safety.

That perceived threat provided the impetus for the creation of asylums to confine psychiatric patients. Consequently, by the second half of the century, many states had opened public psychiatric asylums. These sanctuaries ultimately became the hospitals for the poor, since the better-off patients could take refuge in the private philanthropic asylums, such as McLean Hospital in Massachusetts, which required patients to pay their own way.

The closing decades of the 19th century saw another shift in the care of mentally ill people: In response to the deteriorating conditions of the public hospitals, a number of physicians opened small, private asylums in their own homes for psychiatric patients. For the wealthy patient, hospitalization in a doctor's residence—a "home away from home"—was undoubtedly a welcome alternative to public care.

To some extent, the small private asylums resembled the early 19th-century hospitals promoted by two European reformers, Phillipe Pinel (1745–1826) and William Tuke (1732–1822). Critical of the harsh treatment of the mentally ill in Europe at the time, Pinel and Tuke advocated using a regular routine and a pleasant environment—or moral therapy as it was called—as tools for treating mental illness. The large public hospitals, facing financial constraints and a growing patient population, simply could not offer this type of attention to patients.

Psychotherapy emerges

For the most part, private asylums offered the treatments that were popular at that time. In the late 19th and early 20th centuries, most physicians held a somatic view of mental illness and assumed that a defect in the nervous system lay behind mental health problems. To correct the flawed nervous system, asylum doctors applied various treatments to patients' bodies, most often hydrotherapy, electrical stimulation and rest.

From 1890 to 1918, however, when the private hospitals were at the height of their popularity, medical thinking about the etiology of mental illness also began to change. A small number of physicians abandoned the somatic view of mental illness and adopted a more psychological understanding of the disease. Among them was Boris Sidis (1867–1923). Before obtaining his medical degree, Sidis had earned a PhD from Harvard University under the tutelage of William James (1842–1910). Sidis's psychological training distinguished him from other asylum doctors. He argued that consciousness itself, rather than the nervous system, was the "data" of psychology. Sidis also believed in the subconscious. In his treatment, Sidis hypnotized patients to gain access to memories buried in their subconscious. After he roused patients from the hypnotic trance, Sidis described their memories to them. Patients' awareness of their hidden memories, according to Sidis, eliminated all of their symptoms.

In 1910, Sidis opened a private asylum, the Sidis Psychotherapeutic Institute, on the Portsmouth, N.H., estate of a wealthy New Englander. Hoping for referrals from psychologically minded colleagues, he announced the opening of his hospital in the Psychological Bulletin and advertised it in the Journal of Abnormal Psychology, which he had founded. The ad noted that he would treat patients by "applying his special psychopathological and clinical methods of examination, observation and treatment."

Sidis touted the luxury of the asylum's accommodations and setting, even more than the availability of psychotherapy. "Beautiful grounds, private parks, rare trees, greenhouses, sun parlors, palatial rooms, luxuriously furnished private baths, private farm products," wrote Sidis in his brochure describing the institute. Moreover, he offered his patients the somatic treatments of hydrotherapy and electrical stimulation, as did his less psychologically minded colleagues. The emphasis on luxury combined with the availability of the popular somatic treatments, even in an institution created by an "advanced" thinker like Sidis, suggests that wealthy patients expected a traditional, medical approach to treatment.

Sidis's writings point to another reason for physicians' reluctance to adopt a psychological approach to psychiatric disorders. At the end of the 19th century, psychology was linked to the popular "mind cure movements," as William James called them, such as the Christian Science Church and the Emmanuel Movement. Mary Baker Eddy founded the Christian Science Church, which advocates prayer for healing disease. The Emmanuel Movement also had religious origins. Elwood Worcester started that movement, offering lectures for nervous patients. In an era when medical practitioners were struggling to establish a scientific footing for their treatments, doctors may have distanced themselves from any psychological therapy because of its link to treatment offered by the clergy, who had no medical training. Sidis addressed this issue in an article about his institute. "Psychotherapy … is diametrically opposed to the superstitious and anti-scientific practices of lay healers and non-medical practitioners. This point cannot be too strongly emphasized," he declared.

Rich vs. poor

As the Sidis Institute illustrates, life in the small, private asylums contrasted sharply with conditions in the late 19th-century public institutions. Patients at public hospitals were usually involuntarily committed, and they typically displayed violent or suicidal behavior before their hospitalization. The public hospitals were overcrowded and dirty, with bars on the windows. The staff was poorly paid and frequently treated patients harshly. Given these terrible conditions, well-to-do patients used their wealth to take shelter in a physician's home and escape the fate of the poor. Not surprisingly, the cost of a private hospitalization was steep. Sidis, for example, charged $50 to $100 and "upwards" a week ($50 would be equivalent to roughly $1,000 today). "Bills are payable in advance," he informed his prospective patients.

For their money, patients received personal, attentive care. Fanny Farmer (1857–1915), the noted cookbook author, stressed the importance of pampering patients to improve their health. Speaking to the staff at one institution, Farmer recommended that patients be given individual custard servings, rather than ladling the custard from a large, common bowl because patients want to feel that they are "being particularly looked out for."

Compared with the public hospitals, where the gender ratio was almost even, the small, private asylums, at least in New England, cared for many more women than men. There are two likely explanations for this gender difference. First, women were typically less aggressive than men and may have appeared to be more suitable patients for hospitalization in a doctor's home. It is possible, however, to view the psychiatric hospitalization from a different angle; in an era when most wealthy women's lives were largely confined to the domestic realm, an institution that advertised its comfortable, homey setting may have provided an acceptable, even fashionable, retreat from the world for well-to-do women. In any case, the differing ratio of women to men in the small, private asylums demonstrates that gender intersected with social class in the history of late 19th and early 20th century psychiatric care.

The small private asylums were quite successful for a number of years. There were only two in Massachusetts in 1879 and more than 20 by 1916. In addition, the asylums frequently started small and grew. The Newton Nervine asylum was a case in point. In 1892, N. Emmons Paine, a Boston University Medical School instructor, opened the Newton Nervine in his own home with four patients. Over the next 10 years, he added three buildings to accommodate a total of 21 patients. A reported increase in the number of mentally ill individuals over the course of the 19th century may have contributed to the success of the private asylums. "A good many people are beginning to realize that nervous diseases are alarmingly on the increase …. Nerves are the most ‘prominent' complaint of the 19th century," wrote one reporter in an 1887 issue of the Boston Globe.

After World War I, mental health treatment changed yet again. The growing recognition that baths and electricity were not curing psychiatric illness combined with the failure of autopsies of mentally ill individuals to demonstrate brain lesions raised question about somatic explanations of psychiatric illness. Psychotherapy, which may well have been a tough sell to both patients and medical professionals before the war, clearly overtook the somatic treatments. While private asylums for the wealthy did not completely disappear, psychotherapy, which clinicians could offer in their offices, became the new standard of care for America's well-to-do.

Ellen Holtzman, PsyD, is a psychologist in private practice in Wakefield, Mass. Katharine S. Milar, PhD, of Earlham College is historical editor for "Time Capsule."