From Auctions to Moral Treatment

You are being auctioned off in Oregon because you are considered insane. There are no resources to pay for your cares since your family can’t do it and you don’t have property to sell. The territory wants you off their hands as quickly and cheaply as possible. So you and your care are going to the lowest bidder.

This was a practice that emerged from the organization of the Oregon Territory in 1843 at the fledgling Willamette River community of Champoeg. The new territory recognized that it would need to adopt laws to deal with people they considered mentally ill or, in their terms, “insane.” This was the first reference to mental illness in Oregon since the stories of Archibald Pelton and John Day.

In 1844, the law was passed, establishing auctioning off of people considered mad if there were no other resources. The judge in this situation would require that the person without resources “be brought before him and if satisfied that such person was indeed a lunatic shall cause him to be let out…to the lowest bidder, to be boarded and clothed for one year.” Auctioning off a person considered mad was disrespectful enough, but it would be doubly so in that the care would go to the lowest bidder.

The law regarding people who appeared to be mentally ill meant sending them to the probate courts who, in turn, were to direct the county sheriff to summon a jury of “twelve intelligent and impartial men” to investigate whether a person was “insane.” This term had an inclusive meaning and was applied to “every idiot, person not of sound mind, lunatic, or distracted person.” If the jury made the determination that the person was “insane” he or she would be assigned three guardians whose responsibility was to see that the person got adequate care. One can easily imagine the way a person, especially a woman, would have experienced being examined by a jury of all men, judged insane, and then assigned to guardians who were again assuredly all male.

As a frontier provision of protectiveness, guardians were at least charged with responsibility to assure the person’s safety and in doing so they were “directed to govern themselves according to the provisions of the laws for the relief of the poor.” If there was no property, the guardians were to ensure that the person received the relief due to paupers, maintained under the care of the overseers of the poor. This was the beginning of a comparatively progressive system. These provisions stand in contrast to those in other states; in New England, for instance, poorhouses were expected to “be ridding the town of a worthless population” and their overseers could fetter, shackle, or whip the “inmates.”

However, Oregon’s guardians did have the authority “to the extent necessary to confine or guard the individual if they believed it was necessary for the safety of the insane person, or the property of others.” This laid some of the legal ground work for the use of seclusion and restraint we have now.

Troubled Oregonians also contended with the absence of a specific definition of madness. Without a clearer picture of “insanity,” the jury’s decision would be based on the 12 “impartial” men’s ideas and their ill-informed understanding of mental disturbances. Their beliefs about the nature of madness included things like demon possession, moral deviance, blood poisoning, masturbation, extreme religious frenzy, and more.

The definitions were unclear enough that in a largely misogynistic culture, the standard was applied to women who were traumatized by domestic violence. Some had taken action, like Charity Lamb, a mother of six, who finally took an axe over her abusive husband’s head. She was the first woman convicted of murder in Oregon, but after serving time in jail, she was considered mentally ill and spent the last 15 years of her life in the first state mental asylum.

In 1862, the Oregon legislature passed its first civil commitment statute, which defined the standard for forced hospitalization. A county judge could order this if it found a person “by reason of insanity or idiocy, as the case may be, is suffering from neglect, exposure, or is otherwise unsafe to be at large, or is suffering under mental derangement.” One or more “competent” physicians would examine the person and then certify under oath that “person or persons are insane or idiotic.” The court would order the person’s hospitalization. The law also stipulated that no persons could be committed if a “friend” could or would take responsibility for the care of the person. There are some similarities to the earlier process but with a different definition of “insanity” and the inclusion of physicians in the procedure.

About this time, an influential man in the history of Oregon mental health came to Portland named John Hawthorne. He had grown up on a family farm in Mercer County, Pennsylvania and began work in medicine as an apprentice to a local doctor. He appears to have attended medical school at Louisville, Kentucky. He came west, first to the Sacramento area, set up a medical practice there, ran successfully for the state legislature, and successfully invested in gold mines. After choosing not to seek re-election, he moved to Portland in 1857 and began his work with services to people who were on the county “poor farm.” Hawthorne soon saw that many people were paupers because they had been adjudicated as “insane.” He started to understand them with empathy.

During his time working with the poor, he bought property east of the growing town and used it to operate another poor farm, where he saw the same kind of people. He continued to practice surgery along with another physician. They were two of the first doctors to use anesthesia in their work. He also got involved with other civic projects such as helping finance the first bridge over the Willamette River, and he was elected to the city council. It was about this time that people had begun to recognize there must be something better than sending people as paupers to poorhouses.

Many people believed to be “insane” were unable to care for themselves; most, if they had families, could no longer take care of them. Hawthorne and others advocated for a safe place for these people, which eventually took the form of an asylum. Hawthorne and his partner, a doctor named A. M. Loryea, had opened such a place in 1861, which they called the Oregon State Insane and Idiotic Asylum. At first it served only private patients. However, Hawthorne and Loryea had learned of the “moral treatment” model through their involvement with Association of Medical Superintendents of American Institutions for the Insane. They then submitted a proposal based on that model to the state and received a contract in 1862. What became known as the Hawthorne Asylum was opened that year. The asylum represented a radical change in thinking and fundamental principles, which served as a model for modern state hospitals and other psychiatric and residential programs.

With the public contract in place, they admitted 35 people. The “Report of the Visiting Physician of the Oregon Hospital for the Insane for 1867-68” stated that the root cause for most patients’ admissions was self-abuse. A range of diagnoses were reported as “acute mania, dementia, epilepsy/epileptic mania, general paralysis (of the insane), idiocy, monomania and recurrent mania.” About half of the patients were considered to have ongoing or recurrent mania. The asylum became very costly during this time and later was estimated to be anywhere between one-third and 60% of the entire state budget.

By 1863, there were 63 patients, and by 1881, there were 327, representing a five-fold increase in per capita incidence of major mental health problems. State records show that 95% of the patients were paid for with public funds. About 75% were males, most were white, and three times as many were foreign-born compared to native Oregonians. People were admitted from all areas of the state with a very small number of patients from nearby territories.

Moral Treatment

Moral treatment was developed during the late 1700s by William Tuke (1732-1822) and his grandson Samuel Tuke (1784-1857), who had founded a private mental institution in England outside York called The Retreat. Moral treatment already included a “non-restraint” policy, one of William’s principles. But it wasn’t until Samuel unified all of the principles into a system by outlining them in his book A Description of the Retreat that moral treatment was popularized. A fundamental principle was that people judged to be insane were to be treated humanely, the same way as ordinary people.

The Tukes believed that patients benefited from being in a natural peaceful setting and by exercising their minds with books and music. They were expected to dine at the table, make polite conversation over tea, and do regular chores. The role of the “alienist” (psychiatrist) was to encourage rational behavior. The system relied on rules and constant supervision, enforced by simple rewards and punishments. Physical restraints could be used to modify behavior only if used sparingly, but not as punishments, only deterrents. In traditional asylums, patients were mixed together in the same ward, but the Tukes tailored treatment to each person and housed those with similar conditions together. A movement based on this in the United States was soon led by Dorothea Dix and others, who eventually founded the Friends Hospital in Pennsylvania. This facility still exists.

The Hawthorne asylum was in keeping with the principles of moral treatment—a quiet, relatively small place away from the stresses of everyday life. The asylum, originally sited in what is now downtown Portland, was moved east to a quieter area across the Willamette River. Hawthorne stated that his hospital’s goal was “permanent recovery” in as short a time as possible—something that hasn’t been the goal of treatment in state hospitals or even most community mental health programs since. The patients in the Hawthorne asylum were healthy: he reported no “general sickness…and what did occur was of a very mild form.” He attributed this to the “healthfulness of the location,” which included pure spring water, the thorough ventilation of the building, and making exercise outdoors available for patients whenever the weather permitted. He also pointed to various kinds of activities such as “stereoscopic views, swings, horizontal bars, checkers, cards,” and the grove of trees on the premises.

Residents ate in a common dining room, were served a variety of fresh and salted meats, fruit, vegetables, and bread, along with coffee and tea. Several acres were set aside for exercise and recreation. Women were able to work at sewing and knitting and were responsible for a great deal of the clothing used at the hospital. Men were able to work on the hospital’s farm and garden. Consistent with the principles of moral treatment, there was a regular schedule of physical and mental activities like planting trees, tending to gardens, and generally being in touch with nature. Indoors, there were private rooms and quiet sitting areas for conversation and relaxation. Restraints were avoided at all costs. These were the ingredients that led people to recovering their lives and the belief that each individual had inherent worth and goodness. Consistent with the principles of respect for the patients, Loryea and his family lived on the grounds, something that continued into the modern Dean Brooks era at Oregon State Hospital.

Hawthorne reported to the Oregon legislature in 1870 that his work was based “more on a feeling of humanity than the hope of reward.” He restated that his goal was “to aid in the restoration of health and reason to those placed under my charge.” In a later report, he stated that “to turn these people away without money, employment or any way of reaching their homes is to expose them to the danger of relapse to their former mental condition.” Still later, he said that the objective for such programs should be “permanent recovery” in as short a time as possible.

To our skeptical eyes, it is reasonable to ask whether these statements are just marketing for fundraising purposes. Some held similar suspicions at the time. Some argued that the ”treatment” was only serving to make the doctors rich. However, this was investigated, and none of these allegations were proven to be true.

In contrast, a view was provided by visiting physician, J. S. Giltner, who praised the facilities as “being clean and well maintained, while also maintaining a balanced diet for the patients and areas for them to have some physical exercise within the hospital grounds.” To add to Hawthorne’s credibility, he made a tour of similar places in the east.

An even greater affirmation came from Dorothea Dix, the great reformer of the conditions in state institutions in the US and Europe, who visited the Hawthorne asylum twice. Her background and experience as a nurse led her to challenge the way people were being treated in the US compared to elsewhere in the world. Dix was one of the earliest outside advocates for persons who were considered “mentally ill.” After seeing the Hawthorne facility though, she praised the institution for its enlightened approach to serving patients. She saw it as a model for the rest of the nation. She donated 100 books, 160 lithographic prints, stereoscopic pictures, and other articles of benefit to the patients. Other donations she made included a large number of magazines, including Harper’s Weekly, and many newspapers. If Dorothea Dix had any misgivings about the hospital it was that the number of patients grew over the commonly accepted size of 250 to about 327. This made many of the therapeutic characteristics of moral treatment extremely challenging.

Mary Pexton

The main physician responsible for the operation of the Hawthorne asylum was a man named John Kenworthy. His wife was Mary Pexton. Pexton contributed at the ground level to the lives of residents in the Hawthorne Asylum. She and others have remained mostly unknown, but they made Hawthorne’s dream come true.

Pexton had been involved in the earliest of mental health reforms. She began her career as a teacher at private schools in New England. Significantly for her later work with people who ended up in asylums and state hospitals was her commitment to “Remembering the lessons my parents taught me—at nineteen I wrote that I would use the torch of reasons and truth to light the pathways of mankind.” Soon she was employed by the state “lunatic asylum” in Utica, New York. She was influenced greatly by the pioneering advocacy work of Dorothea Dix and the “moral treatment” used by the Quakers. She was especially concerned with banning the use of chains, physical punishment, and dungeons.

Under the first director of the Utica asylum, Amariah Brigham, Pexton was immediately drawn to this way of working.  She soon met her mentor there, Samuel Shantz. They both believed, in her words, that “the mind, just like other parts of the body, must be exercised, nourished and regularly rested in order to function properly, and if it is overtaxed—it will fail.”

She brought this philosophy to the Hawthorne facility shortly after it opened, having just finished several years working in a miserable institution in Minnesota. She knew first-hand what the opposite model looked like. After making every effort to change the Minnesota asylum, which had been taken over by a medical director who did not believe that patients could be cured, she left to take a position as Matron at the Vallejo Orphan’s Home in the San Francisco area. It was there that she met John Kenworthy, whom she described as “quiet, calm and gentle of disposition.”

Pextonand Kenworthy relocated from California to work with Hawthorne. Kenworthy became Hawthorne’s “steward and general manager,” and they both spent 20 years working in Portland. In those days, staff actually lived in the same building as the patients and, in fact, Pexton and Kenworthy were married in the institution itself. All three believed in the same moral treatment model that Pexton first practiced in Utica. As a key staff person she helped establish a variety of innovative features of the program. These were described by J. S. Giltner in the “Visiting Physician Report,” in which he observed that patients indeed received this kind of “moral treatment.”

Pexton’s story is too little known but deserves recognition. She made a major contribution to the earliest Oregon movement toward progressive reform.

The Birth of the Oregon State Hospital

Less than 10 years after opening of the Hawthorne Asylum, it was becoming clear that the surge in people who were in need of services and support was going to overwhelm the size of the Hawthorne Asylum. Governor George Woods was the major advocate for planning a new facility, which become the Oregon State Hospital. He told the legislature that much work was needed in humanitarian interests to build a permanent facility for treatment that would permanently stop the earlier practices “of hawking these unfortunates…subject to the lowest bidder.” He said that what Hawthorne and Loryea did in Oregon was in remarkable contrast to how most people with major mental health challenges had been treated until then. He reminded the legislators that, at their direction, he had contracted with Hawthorne in 1862 for “the keeping, care, and medical treatment of the Insane and Idiotic of the State…” and that now the legislature, along with Loyrea, should begin planning suitable buildings in Salem for an institution.

In his 1870 message to the legislature, Woods went out of his way to comment on the way Hawthorne had fulfilled his duties. It is worth quoting Woods at length here: “l should do Dr. Hawthorne a serious injustice, were I not to say that he has faithfully carried out his contract with the State, and complied with all its requirements in letter and in spirit. Too much cannot be said in his praise. The medical treatment of the patients, I have reason to believe has been as efficient and thorough as in any other Asylum in the United States; while their food and raiment, and all those surroundings which secure bodily comfort, have been all that anyone could desire. It would be difficult to place them in better hands.” In short, then, whether he used the word “moral treatment” or not, he was acknowledging that the moral treatment model was the basis for this next step.

Woods concluded his 1870 speech with a statement that everything should be done for those who were admitted to the state’s care so that, among other goals, they would be returned “to their friends again.” By 1883 the new Oregon Insane Asylum had opened and all of the people who remained at the Hawthorne asylum were transferred to the new state hospital in Salem.

I believe that all of Oregon’s governors should consider Woods’ work a precedent and make it their duty to take a direct interest in mental health services and to establish the goal of recovery.

Conclusion

What lessons are here? Hawthorne deserves to be remembered for how mental health leaders must ensure that people are respected for their dignity as human beings. The moral treatment model, nearly 250 years old, is almost unknown now in Oregon and elsewhere. But this history shows that in less than 25 years this state moved from 12 men deciding who was “insane” and seeing them auctioned off for their “care” to the lowest bidder to creating a safe place focused on recovery. The goal of the Hawthorne asylum was getting the people’s lives back as soon as possible. As in the recovery of Archibald Pelton and John Day, no medications were available, so it was not drugs that were responsible for recovery. It takes creative and courageous leaders like George Woods, John Hawthorne, Dorothea Dix, and Mary Pexton to make this kind of success a reality.