American social reformer
Dorothea Dix was a renowned social reformer and vocal advocate for the humane treatment of people with psychiatric disabilities. During her lifetime, Dix traveled extensively throughout the United States and abroad, visiting jails and almshouses to document the inhumane treatment of those with mental illness. She used these notes and observations to fight for the use of “moral treatment” in their care. Her reports regarding the treatment of those with severe mental illness were presented in numerous state legislatures, leading to the creation or enlargement of many hospitals designed specifically for the needs of this group. Dix believed that it was important to provide a place that focused specifically on assisting people with mental illness. She felt that the current system of care, one that focused on trying to address the needs of many disparate populations, including orphans, criminals, and paupers, was not specialized to adequately address of all these issues. Dix believed that a therapeutic setting, focusing on recovery, without restraint or confinement of patients, would be most helpful in restoring mental health.
Dix rose to prominence after submitting a petition to the Massachusetts General Court, titled the Memorial to the Legislature of Massachusetts, which documented the horrific conditions of people with mental illness living in confinement throughout the state. As a result, Massachusetts enlarged its state mental hospital to provide specialized treatment to low-income individuals with psychiatric disabilities. As an outcome of her successful efforts in Massachusetts, Dix became involved in conducting surveys and inspections of almshouses and prisons in other states, and she lobbied other legislatures to enact similar reform legislation. She played an instrumental role in the creation of 32 mental hospitals and became nationally known for her reform efforts.
Although Dorothea Dix was progressive in her views about psychiatric disability and specialized treatment for people with mental illness, she did not embrace reform in many other areas. As a woman, she did not feel that it was appropriate to engage in public speaking herself. So instead of addressing legislative bodies and other groups, she wrote speeches that were read on her behalf by prominent men who supported her efforts to create mental health care facilities. In addition, unlike many reformers and activists of the 1800s, she was not an abolitionist, and she maintained close ties with prominent slaveholder families. Some historians have argued that she was more effective in her advocacy of humane treatment for the mentally ill because she followed the strict social conventions of the time. She presented herself as a reluctant activist moved to action by the plight of people with mental illness. However, her conservative views in many areas have made her less appealing as a role model for subsequent generations that have rejected many of her beliefs.
Dix was born on April 4, 1802, in Hampden, Maine, a small village on the Massachusetts frontier. During her youth, there was significant tension within her family, particularly between her parents and grandparents. Dorothea’s father lacked much of the ambition and drive that had characterized her grandfather’s success. In addition, her father married a woman that his parents felt was beneath him. At age 12, Dix ran away from her parents and went to live with her grandmother in Boston. At 14, she moved in with the family of a prominent physician and became semi-independent from her family. While living with this family, Dix opened a private school. She continued to teach for the next 20 years, in various locations, at her grandmother’s home and at the Female Monitorial School, and she also provided private tutoring. In addition, she published a number of books for children, including her most famous Conversations on Common Things.
Dix’s focus on social reform was in part influenced by her strong commitment to the Unitarian faith. In the early 1820s, Dix began attending sermons every Sunday and Thursday, and focused her life increasingly around church lectures, sermons, and humanitarian projects. Dix seemed particularly influenced by the church’s emphasis on the poor and unfortunate and its efforts to create a more socially just community. Dix regularly attended a Unitarian church led by William Ellery Channing, and over time developed a personal relationship with the pastor. Dix began tutoring his children and eventually began to accompany the family on summer trips and on a lengthy journey to the Caribbean.
During the late 1820s and the early 1830s, Dix developed significant health problems, including a chronic respiratory condition. In the winter of 1836, she experienced an episode of severe depression. Seeking rest and a change of scenery, she sailed for England in the spring. However, upon her arrival, her symptoms worsened and she became bedridden and despondent. Dix was taken in by a Unitarian philanthropist, William Rathbone II, and his wife, who were acquainted with William Ellery Channing. During her stay with the Rathbones, Dix continued to experience severe symptoms of depression, in addition to an episode of pneumonia. She consulted with William Rathbone and Oxford physicians regarding her symptoms. Dix was often confined to her room by chronic fatigue; however, she enjoyed frequent visits from the Rathbone family. Dix convalesced in England for a year and a half and, as she became stronger, she socialized increasingly with the numerous guests that visited the Rathbones. Through these interactions, Dix was probably exposed to the “reform movement of moral treatment” that was becoming increasingly popular in Europe. Upon receiving news of her grandmother’s death, she returned to New England in the summer of 1837.
Dix’s philosophy regarding treatment reform for individuals with mental illness was strongly influenced by the moral treatment movement. Originating at the York Retreat in England, this treatment focused on encouraging patients to use self-control instead of using physical and mechanical restraints. The York Retreat was a private hospital in which seven staff cared for 30 patients. Patients were expected to take part in daily activities, such as reading, writing, sewing, socializing, and gardening. Work also was considered an essential part of developing selfcontrol. Exercise, warm baths, and a generous diet were believed to be important to calm and reassure patients. Privileges were granted to individuals who behaved in a desirable manner. This new philosophy emphasized that patients could be rehabilitated and cured, particularly if early treatment was provided.
During the nineteenth century, public hospitals provided treatment only for low-income individuals and those who had exhausted their financial resources. Hospitals were viewed as the option of last resort and were associated with moral degeneracy and poverty. In addition, hospitals exposed patients to contagious, infectious diseases such as sepsis. In general, families cared for members with physical and/or mental illnesses at home. The asylum movement sought to change the role of hospitals in American society. The movement focused on creating institutions that would provide specialized care in pleasant, homelike environments. The asylum movement subscribed to the belief that the increasing complexity, dislocation, and urbanization of American life had detrimental effects on people’s physical and mental health. Asylums provided safe havens where people could recover from these effects.
Moral treatment in the asylums used a system of incentives and punishments to treat mental illness. Asylum staff developed an individualized regimen of various activities for each patient that included grooming, exercising, meeting with the physician, dining, recreation, educational activities, and some work activities. The regimen was changed as an individual’s symptoms improved or declined. Individuals were discharged from the asylum when they no longer experienced symptoms of mental illness, exercised sufficient control over undesirable impulses, and demonstrated a determination to lead a productive life. Asylum superintendents would often send inquiries in the years following discharge to former patients to see how they were doing. Generally, hospital stays lasted a number of months while, for a smaller number of people, hospitalizations occurred for a period of years.
When Dorothea Dix returned to Boston, she met Samuel Gridley Howe, who encouraged her interest in humanitarian work at a local prison. Together, they worked on strategies to bring more public attention to the situation of people with severe mental illness. Dix began visiting jails and almshouses in Massachusetts, documenting what she found throughout the state. During her visits, she conducted a census of each institution’s inmates with mental illness, documented their general condition, and intervened in particularly dire situations to alleviate suffering. She noted the availability of religious instruction and literature. Howe, who had recently been elected to the state legislature, encouraged Dix to summarize her findings in a petition to the legislature. Dix completed her petition, Memorial to the Legislature of Massachusetts, including the names and dates of the various places she had visited, for the opening session of the legislature, where it was presented on January 19, 1843.
In her Memorial to the Legislature of Massachusetts, Dix detailed graphic portraits of men and women living in filth; she described people living in “cages, closets, stalls, and pens!” who had been beaten and whipped. She gave case examples of individuals kept isolated in dark cellars, naked, and covered in human excrement. Many confined individuals had no clothing, heat, or furniture. Through the Memorial, Dix recommended legislative action to create asylums for those with severe mental illness. She advocated separating them from criminals, asserting that those with mental illness needed care, not punishment, and that by confining them in prisons, their conditions only worsened.
A pamphlet of the Memorial also was circulated throughout the state, causing considerable controversy, as some of the institutions included in her petition disputed her findings. However, a few prominent politicians and attorneys spoke out in her defense. As a result, Dix became increasingly influential and met with many legislators in an effort to lobby her cause. In the spring of 1843, the Massachusetts legislature allocated funds to greatly expand the State Mental Hospital at Worcester. Dix conducted similar investigations and engaged in lobbying efforts in other states, including New York, New Jersey, Pennsylvania, Kentucky, Illinois, Tennessee, Louisiana, Mississippi, North Carolina, Alabama, and Maryland. Her advice and assistance often was sought by state politicians because she was viewed as an objective outsider who could assess the plight of people with mental illness and provide guidance regarding legislation to address these concerns.
By the late 1840s, Dix focused on developing a national plan to address the treatment of people with mental illness. She created a federal memorial in which she described the plight of those with mental illness in various towns and villages throughout America. She argued that mental illness was increasing, and that other countries were experiencing similar problems. She focused on the potential for treatment to cure some individuals, and its ability to make those individuals whose conditions were thought to be “incurable” comfortable and socially useful. Her petition led to a bill proposing a federal land grant for 12,225,000 acres to be set aside as a public endowment. The income from this land was to be used to provide services for people with mental illness, as well as those who were blind, deaf, and mute. From 1848 to 1854, Dix continued to lobby for her plan, and the legislation was successfully passed by both the U.S. House and Senate. President Franklin Pierce, however, vetoed the bill and ended Dix’s pursuit of securing funding for current and future state programs to address the needs of the people with mental illness. In a written defense of his action, Pierce stated that he did not want to establish a precedent in which the federal government was responsible for funding state programs.
Discouraged by the failure of her effort to provide a national endowment for treatment of mental illness, Dix returned to Europe. She traveled extensively to many countries, including England, Scotland, France, Austria, Italy, Greece, Turkey, Russia, Sweden, Denmark, Holland, Belgium, and Germany. During her two years there, Dix visited prisons and almshouses, again documenting her findings and advocating for reform.
When Dix returned to the United States, she continued to lobby and advocate on behalf of her cause. Within a few years of her return, the Civil War began. She was appointed superintendent of United States Army Nurses by President Abraham Lincoln. In this position, however, Dix was often in conflict with the Army Medical Bureau. She had difficulty adjusting to the bureaucracy and organizational structure of the military establishment. Since her previous work had been conducted more autonomously, she faced constant challenges to her authority. With Dix’s reserved and distant manner, in addition to her unorthodox ways, many critics emerged, leading to a decline in her public image.
After the war, Dix again returned to advocacy work for people with psychiatric disabilities. However, she was disappointed to see that mental hospitals had become overcrowded, understaffed, and run down. Most of the facilities lacked adequate funding to provide the type of treatment originally envisioned by those advocating moral treatment. Many rural communities where asylums were located objected to funding treatment for predominately urban populations. In addition, the economic depression of 1857 and postwar depressions further depleted hospital funds. Asylum facilities were also strained by the huge influx of immigrants, who had few financial resources. These facilities became merely custodians of people with mental illness, not the therapeutic, tranquil environments for which she had fought.
Dorothea Dix died in 1887, at the age of 79. She is buried in Mount Auburn Cemetery in Cambridge, Massachusetts.
Activism; Depression; Institutionalization and Segregation; Mental Health; Psychiatry.
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