Many years ago, along with several other psychiatric aides, I participated in tackling a youth who hadn’t followed his behavior management “treatment plan,” and forced him into a seclusion room. I was new to the field and did as I was told. But the violence of the act left me upset and perplexed.
The psychiatric hospital where this took place had been founded by Mennonites—a religious order with a strong pacifistic tradition. How was I to square the violent restraint and isolation of a vulnerable patient with the values supposedly espoused by the hospital at its founding?
Naively, I asked the psychiatrist in charge what to make of the situation. The psychiatrist told me a story: One farmer visited another, hoping to buy a mule to do some work around the farm. The seller described a good animal—obedient to commands, strong, and healthy. This sounded good to the buyer, so he paid the farmer and began hitching the animal up to leave. However, the mule wouldn’t obey his commands. The seller walked up and whipped the mule… and it started moving. The seller explained that the animal was obedient—once you got its attention.
To that psychiatrist, the patient who hadn’t followed his “treatment plan” was a disobedient animal, and cruel punishment was simply what was required to get his attention—after which he would presumably follow his treatment plan.
But this left me even more confused. I didn’t believe that this kind of violence was an ethical method of getting a person’s attention, nor that blind obedience was the most important element of psychiatric treatment. How could a Mennonite hospital have ended up with values like this?
To answer that question, a history of the intersection of Mennonite values with the medical model is in order.
The Mennonites originated during a period of unrest and wars in Switzerland and the Netherlands. They were considered part of the “Radical Reformation,” a movement now 500 years old which placed a high value on nonviolence and pacifism. While there were others, a village Catholic priest, Menno Simons, began to articulate an understanding of the Christian faith that love for one’s neighbors and as an expression of that non-violence and pacifism. Some of the early leaders began to question compulsory military service. Another controversial belief was that infants should not be baptized and wait until they were old enough to know what becoming a Christian actually meant. While this may sound innocuous enough to us today, in a wider sense it called into question loyalty to and membership in the state and the church.
These beliefs led to persecution and the martyrdom of thousands of Mennonites. Unable to safely practice their spiritual views, many moved their families to parts of Poland and Germany. In 1787, the Russian emperor, Catherine the Great, promised them freedom of religion. Thus, when they found themselves unwelcome in Poland and Germany, many of them moved to what they called South Russia, now known as Ukraine.
Although it took decades after they had presumably begun to recognize there were people who were considered “mentally disturbed” in their closed Russian villages, in 1910 they started their own psychiatric hospital, Bethania. It was modeled after a Protestant facility established in 1867 in Germany, Bethel-in-Bielefeld, known for its commitment to healing and care and later for its resistance to growing antisemitism in Germany. In this spirit, the Mennonite’s Bethania served more than just their own: By 1925, half of the patients were Russians, Germans, and many from nearby Jewish communities. This facility was taken over by the Russian government in 1925 and closed in 1927 to make way for a power dam.
However, the influence of Bethania’s spirit extended to Canada and the United States when Mennonites continued immigrating there and finally again acknowledged there were individuals who they viewed as “mentally disturbed.” One of these persons was a minister who was facing deportation. A social worker, Henry Wiebe, who had a farm in Vineland, Ontario, agreed to take in the minister and cared for him. It turned out that Wiebe was already familiar with the philosophy of hope and care for people with mental health problems, having worked at Bethania for three years.
Whether he recognized it or not, this farm had similarities to what the Quakers had created in Philadelphia in 1814—asylums that implemented “moral treatment,” which was a therapeutic approach that called for humane, respectful treatment for all who came in contact with an individual there. An observer noted that “the whole spirit of this hospital is in the tradition of a genuine, warm Christian family in contrast to the harshness of a huge institution of a provincial mental institution. The patients carry on quite a normal life, not living under lock and key, daily working on the farm, eating and worshipping together…It is this type of custom which builds a real sense of security more valuable than [the] most highly developed scientific therapy.” The very first patient recovered, avoided deportation, and returned to his family. Wiebe began taking in more people, naming his farm-turned-hospital “Bethesda” after Bethania.
Mennonites’ next encounters with mental health soon came about during World War II. Hundreds of pacifist Mennonite young men and women, conscientious objectors to war, were assigned to work in understaffed state and provincial hospitals in the US and Canada. Knowing virtually nothing about these “asylums,” they were shocked. They witnessed the monotony of life there. They saw the dehumanization and contempt for the patients. They saw frequent assaults by staff on patients and patients on patients. They saw frequent use of mechanical restraints, segregation, and discrimination. They saw hospitals like Philadelphia State Hospital, with 6,000 patients but only 200 staff. They saw beatings. They saw hospitals where the staff carried blackjacks. They saw children crammed into fire traps a hundred years old. They saw murders.
They provided much of the tragic material in interviews for Albert Maisel’s highly influential Life Magazine article, “Bedlam, 1946, Most US Mental Hospitals are a Shame and Disgrace.” These stories paralleled those in the now better known 1948 classic by Albert Deutsch, The Shame of the States. As with Maisel’s article in Life, Deutsch’s main goal was to bring to the public an understanding that the patients confined in state hospitals who deserved humane and caring lives when they were getting absolutely none.
As the young men and women returned to their home communities, they began to express a desire to do something with their experiences. A group of them entered into discussions with other church leaders to consider a future of caring in contrast to what they had seen in state hospitals. They established psychiatric hospitals in California, Kansas, Indiana, Maryland, Pennsylvania, Ontario (Canada), and even in the Chaco of Paraguay. They made common cause with an existing relief organization, Mennonite Central Committee and, I would say fatefully, with mental health professionals.
This was a pivotal moment. What all previous Mennonite efforts had in common was that they were not based on the medical model. Yet, something happened then to conflict with nearly 500 years based on bedrock values of non-violence and humane care. How did the change in models lead to the seclusion and violent restraint illustrated in the story beginning this blog?
It is not really surprising that their psychiatric facilities were hospitals, rather than something more like that of a Quaker moral treatment program. Virtually none of the returning conscientious objectors had ever heard of the Quaker non-medical model of care.
The leaders in establishing the hospitals were almost all laymen. The few psychiatrists were all very much mainline in training and practice. Given the medical model’s credibility and authority to them, there was not an understanding that in important ways it differed radically from traditional Mennonite articles of faith. To those who planned and established the Mennonite psychiatric hospitals, this aspect of the likely use of force likely didn’t occur to them. To the degree that some anticipated a psychiatric hospital would make use of coercion, the violence of seclusion and restraint would be justified as therapeutic.
The medical model at that time used damaging “treatments” which included electroshock, insulin shock, hydrotherapy, and “security rooms.” But the prevailing notion was that these treatments were more humane, more appropriate, more sophisticated than what had come before—that these treatments would ease suffering, even if by inflicting it temporarily. In the same way, when psychiatric medications were introduced in the 1950s, the assumption was that they held great promise and were then used in such a way that some of the previous treatments (insulin shock therapy, for instance), were eliminated. Yet the use of physical violence continues, electroshock continues, drugs with powerful harms continue, and all while rates of “mental illness” continue to skyrocket.
What to take from this:
The medical model is powerful. Mennonite efforts began operating from a non-medical paradigm in Ukraine and Canada. They found ways to care compassionately. In World War II, their moral convictions led over a thousand Mennonite to speak out and challenge the evils in state hospitals.
Following those experiences, though, they brought the ideas of psychiatry back to their home communities. They provided church leaders with information that led to the establishment of seven psychiatric hospitals, which then led to adopting the medical model, as was the convention after World War II. That marked the beginning of a transition to that model.
The transition included the adoption of a range of services: drugs, shock treatment, and behavior management for adolescents. From there it was a natural acceptance of consequences like seclusion and restraint. It contradicted 500 years of the Mennonite tradition of non-violence and humane concerns, but when questioned about why the use of violence and force was acceptable, there was a ready answer, consistent with the medical model rather than a kind of moral therapy they had used.
Despite being established by Mennonites, for whom nonviolence was central to their creed for hundreds of years, the medical model made violence acceptable, even considered to be appropriate “treatment.”
A hospital by definition is based on the medical model. Given their susceptibility to ignoring humane concerns and allowing violent practice as the “standard of care,” they must be monitored constantly to ensure the safety of residents. I would adapt the words of John Philpot Curran to say that the price of freedom from violence in the medical model is eternal vigilance. Maybe it would be better to abandon the medical model and move on to a paradigm of humane care.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
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