Dorothea Dix and the Trade in Lunacy

Dorothea Dix, Harvard University Houghton Library

Dorothea Dix was a leading US and international mental health reformer. She knew how to wield her quill pen and do her own reporting to advocate for positive changes. We still have a lot to learn from her.

Starting in 1830 with her investigative reporting on the deplorable conditions of inmates at a Cambridge, Massachusetts jail, Dorothea Dix quickly spread her mental health advocacy efforts with inspections of prisons and insane asylums throughout Massachusetts and other states, then internationally to England and Scotland (petitioning Queen Victoria for reforms), France, Italy (petitioning Pope Pius IX), and Turkey (trying unsuccessfully to meet with and petition Florence Nightingale at the end of the Crimean War).

After Dix’s controversial stint as Superintendent of Women Nurses for the Union Army during the American Civil War, she again took up her mental health reform efforts extending them to the Far West, visiting California, up through Oregon, to Washington Territory. Remarking on the natural beauty of Washington, including snow-capped Mt. Rainier, she described in a letter to her British Quaker reform friends, the Rathbones of Liverpool, that she was favorably impressed by the Pacific Northwest’s “humane and liberal” prisons and insane asylums. She attributed their excellence to how newly settled the area was, a newness that allowed for more progressive thinking than in either European or the American East Coast cities.

Dix was involved with political debates raging in England and Scotland where local parishes used the contract system, paying for their insane poor to live and work in private, for-profit insane asylums. Many of the asylum proprietors cut costs and increased their profits by shackling patients inside unheated rooms and depriving them of food and medical care. Known as the “trade in lunacy,” once the truths of the trade were uncovered, the practice was a source of widespread moral outrage and calls for reform.

In America, there were claims that treatment of insane incurable paupers in state-run insane asylums was a more humane approach. Proponents claimed it would save money in the long run, given economies of scale and since patients could avoid being sent to higher-cost jails and prisons.
Early reports from institutions such as the Worcester Insane Asylum claimed high success rates of “curing” patients of their insanity, by citing high patient discharge rates. What they failed to mention were the equally high rates of readmission of these patients to the same or similar institutions within short periods of time. Once forced to face these statistics, proponents of insane asylums, including Dorothea Dix, began to point to “seasonable care,” meaning that successful treatment and cure rates occurred when patients were identified early in their illness and were provided with appropriate treatment at insane asylums. Early in their illness was typically defined as treatment within the first year of onset of their symptoms.

Public and private debates in America were raging as to whether paupers–insane or not–brought on their own plights through immoral acts such as intemperance, specifically in terms of alcohol consumption, and the duty of the state to care for such people. Calvinist work ethics and conceptions of sin and salvation colored these debates. Women with children “out of wedlock” and prostitutes were labeled as sinners and as undeserving poor. Leading reformers such as Dorothea Dix declared that the duty of society was the same whether insanity or destitution resulted from “a life of sin or pure misfortune.”

Sources:

Dorothea Lynde Dix, Asylum, Prison, and Poorhouse: The Writings and Reform Work of Dorothea Dix in Illinois (Carbondale, Ill.: Southern Illinois University Press, 1999).

Thomas J. Brown, Dorothea Dix: New England Reformer, Harvard Historical Studies ; v. 127 (Cambridge, Mass.: Harvard University Press, 1998).
Dix, Asylum, Prison, and Poorhouse.

Legislative Assembly of the Territory of Washington, “An Act Relating to the Support of the Poor.”

Tamonud Modak, Siddharth Sarkar, and Rajesh Sagar, “Dorothea Dix: A Proponent of Humane Treatment of Mentally Ill,” Journal of Mental Health and Human Behaviour 21, no. 1 (2016): 69, https://doi.org/10.4103/0971-8990.182088.

Dorothea Dix, “‘I Tell What I Have Seen’—The Reports of Asylum Reformer Dorothea Dix,” American Journal of Public Health 96, no. 4 (April 1, 2006): 622–24, https://doi.org/10.2105/AJPH.96.4.622.

Dorothea Lynde Dix, The Lady and the President: The Letters of Dorothea Dix & Millard Fillmore (Lexington: University Press of Kentucky, 1975).

The Long View

This, unfortunately, is the season for despair for far too many people in our country. We have the recent health policy and population health news that, for the third year in a row, life expectancy in the United States is going down. Our overall life expectancy began to stagnate in the 1980s, then decline for certain groups, and more recently to decline more broadly. (see: “‘There’s something terribly wrong’: Americans are dying young at alarming rates” by Joel Achenbach, The Washington Post, November 26, 2019)

And, as researchers point out, this decline cannot be blamed solely on the opioid epidemic. Neither can it be blamed on Democrats or Republicans. Diseases and deaths of despair in our country are something we are all responsible for, what we all can do something about.

History teaches us to take a long view. History training, in the words of one of my favorite contemporary British historians, David Hitchcock, is also “empathy training among other things.”

Recently, I have had the pleasure of immersing myself in the oral history interviews I have conducted with a variety of people working and living at the intersection of homelessness and health in Seattle-King County. You can view the names and photographs of the people I have interviewed so far for my Skid Road project, as well as a few videos, here.

As an antidote to despair, I offer you an excerpt from my interview with one of my mentors, the social worker and civic engagement teacher Nancy Amidei. This interview was conducted on June 16, 2015 at Jack Straw Cultural Center in Seattle. This was her response to my question of what gives her hope for the future:

“I’m old enough to be able to say that when I graduated from college, there was no Medicare, there was no Medicaid, there was no Head Start, there was no WIC [Women, Infants, and Children] program. Food stamps was a pilot demonstration project in seven counties. What else? Oh, school lunch was only in the schools that could afford it, only the rich schools. There was no senior nutrition program. There was no American with Disabilities Act. There was no Civil Rights Act. There was no Voting Rights Act. Oh, there were no women in professional sports because there was no Title IX.

So, if I had to guess, I think all of those things passed within maybe twenty years from when I graduated. Well, if you had lived through that kind of change and you’ve seen that happen–and most of that is stuff that helps people who are not rich, who are not powerful. Food stamp recipients are not rich and powerful. Welfare moms are not rich and powerful. We can do things in this country, and you don’t have to be rich and powerful to make it happen. But you do have to vote, and you do have to pay attention to who’s in office. You do have to pay attention to the candidates. And you do have to speak up.”

Homelessness Started Two Years Ago

Richmond, Virginia 1986. Covering up Homelessness

An important news update brought to you by President Trump: Homelessness started two years ago in our country and it is the fault of liberal states, of liberal people in sanctuary cities such as Los Angeles, San Fransisco, and New York. And Seattle. Oh yes, and our president claims that it is the fault of homeless people themselves. “They like living that way.”

“We’ve never had this in our lives,” he said in a FOX news interview with Tucker Carlson last week. When asked by Carlson what we should do about it Trump responded, “Take the (homeless) people and do something.” Presumably by that, he means clear homeless people away, dispose of them out of sight. Perhaps in detention centers along the US-Mexican border. Or behind rows of doors from torn-down affordable urban housing as in the photograph above from my hometown of Richmond, Virginia. I took that photograph in 1986 on my way to my work as a nurse with homeless people.

Trump pointed to his clearing out of homeless people in Washington, DC when he moved into the White House. He claims he told people that he had leaders of the world coming to see him, the President of the United States, and “they can’t be looking at that” referring to visible poverty and homelessness in our nation’s capital.

That this revisionist history, these lies, would be laughably absurd in a different context, a different time—perhaps sometime in our hopefully brighter future—is one thing. But that wistful and wishful thinking only highlights the current dangers in this rhetoric. People believe what Trump and Carlson say. People act on what Trump and Carlson say. “Take the (homeless) people and do something” leads to vigilantism and physical attacks (and killings) against people who are or who “look homeless.”

Let the Light In

Doorway Community Cafe

“Is there still a will in this country to make things better?” Ben Danielson, MD, director of the Seattle Children’s Odessa Brown Clinic asked this question a few days ago in a nursing course I co-teach. His question resonates with me as I firmly believe that we all have the responsibility to leave things better than we found them. It is all too easy to complain bitterly about a situation we find distasteful but not work to improve things.

That is why I am grateful for our interprofessional Doorway Project team, youth serving agencies, and the young people in Seattle who are working to bring the dream of a community cafe to reality. The photo above shows the iterative design rendering of the cafe space, along with Seattle sunshine coming through the imagined (and real) skylights from our pop-up cafe event this past week. The sticky notes have additions from participants. Their suggestions include such as a rooftop community garden, music, a small shower—and stuffed animals to hug.

Our Doorway team is tasked with the lofty goal of ending youth homelessness in Seattle’s University District. We’re doing this by working with young people who are “experts by experience”—and with the wider community—to design a community cafe space where everyone is welcome. And where young people are valued for who they are and for what they bring to the table: music, artwork, poetry, storytelling, and more.

Dr. Danielson admonished our students in class this week to “not be shy about stealing good ideas,” pointing out that things we think of as innovative have usually been done before. For the Doorway Community Cafe we are building on the model of the Merge Cafe in Auckland, New Zealand, as well as the Open Door Cafe in Edinburgh, Scotland. The work of our students and young people from the community on the Doorway Project gives me hope for the future.

Creating Community

Pop Brixton, London

What do old shipping containers have to do with creating community? They can be re-purposed to provide sturdy protection for indoor gathering spaces, such as one I visited this past week in London.

Pop Brixton is an indoor-outdoor community space in the heart of the ethnically diverse south London neighborhood of Brixton (of David Bowie and Eddy Grant/”Electric Avenue” fame). Built of shipping containers on a previously empty, unused city lot full of concrete rubble, Pop Brixton is an incubator for community pop-up cafes, music and art events, an alternative school, a shared office/workspace (Impact Hub Brixton), a community garden, and even a community/people’s refrigerator named Freddie.  

“Freddie” the People’s Fridge

One of the Pop Brixton design features that struck me as being most effective was its central dining hall space with large, communal tables. This space was winterized when I visited, being enclosed and well-heated with portable gas heaters. Local artists (along with children from the neighborhood) designed and made the colorful banners hanging overhead, as well as the cleverly-constructed “fireplace” at the heart of the communal space. The fireplace is made of a plywood frame/”flames” with orange paper and lights—shown below in the two photographs. There were a few people sitting around engrossed with the solo glow of their smartphones, but the vast majority of people were talking and interacting in positive ways. 

Upstairs on the second floor (wheelchair accessible), was a lovely open seating area for quieter, more contemplative places for conversations (or nursing babies), surrounded by plants and more banners. 

Out back on the ground floor is the community garden (near Freddie the Fridge), the school, and the office-sharing/community-building space of Impact HUB Brixton. All of the small businesses housed in Pop Brixton are independent, with the majority being owned/operated by local community members. They actively promote social enterprises as well as having a Community Investment Scheme where all members donate at least one hour each week to use their time and skills to support local causes. 

One of the local agencies they support is Skye Alexandra House, a semi-residential home for vulnerable women aged 16-18 who have suffered abuse, imprisonment, prostitution, or disruptive foster care experiences. Pop Brixton supports their “Inspiring Butterflies” program, “a series of workshops that focus on personal development, life skills, awareness of sexual exploitation and domestic violence, bullying, money management, performing arts and enterprise.”

Pop Brixton is inspiring and welcoming and truly is a place where people make (positive, community-building) things happen. Out of boxes. 

Loneliness Kills

Living on my own in the kingdom of loneliness for over three months has made me more aware of the pernicious effects of loneliness on health and wellbeing. It does not surprise me that the U.K now has a Minister of Loneliness, and that Prime Minister Theresa May has recently released a loneliness policy report: “A Connected Society: A Strategy for Tackling Loneliness—Laying the Foundations for Change” (October 15, 2018). May calls loneliness a “great public health challenge” and plans to have GPs within the NHS to be able to refer patients to community programs geared to ease loneliness.

Yesterday, I visited a long-standing (36 years) community cafe in Edinburgh that has been successfully combating loneliness among the elderly and people living with mental health challenges Located near the Royal Edinburgh Hospital, a long-standing mental health facility in the Morningside area of the city, the Open Door Cafe is a most welcoming place. From the high school student volunteer, Hamish, who greeted me and served me a great cuppa’ and scone, to the friendly regular customer/patrons who shared their stories with me, this was a place that warmed my heart. It also gives me hope that we can open the community Doorway Cafe in the University District of Seattle along similar lines. They use a pay-it-forward model and also have a robust group of volunteers to keep the place sustainable. In addition, they receive some funding from the NHS.

It also warms my heart to have discovered that the Open Door cafe was founded by an Edinburgh nurse, Peggy Hunter, all the way back in 1982. She said, “I have a dream to turn loneliness into fellowship, isolation into recognition…” and she has done just that. 

I love their statement on their website in which they succinctly describe their cafe championing of diversity: “Of course, many people who use our services have a variety of support needs, so you may find having a cuppa is a different experience to that of your usual coffee shop. Can you open your mind to share some space with someone who is different from you?”

How the Poor (and Homeless) Die

Homeless encampment, Edinburgh cemetery

A powerful and classic (yet too little known) social justice writing by George Orwell is his autobiographical essay “How the Poor Die.” It should be required reading for all nursing and other health science students as it eloquently describes the experience of death and dying for poor and homeless people. Although the essay is based on his experiences, first as a poor patient on a public ward of a Paris hospital in 1929, and then back in England and Scotland (Glasgow) towards the end of WWII, there are echoes of truths in his observations that are relevant today. 

One of the most poignant parts of the essay describes “old numero 57” (patients were numbered, not named) lying—and dying—on a cot in the open ward next to Orwell. He writes, “They are treated like animals. They die alone, their organs already marked for a bottle in the museum, their bodies designated for dissection.” 

Orwell’s essay came back to me yesterday as I went in search of pauper’s grave sites in Edinburgh. From my research, it seems that there are thousands upon thousands of pauper’s graves in many of the town’s oldest remaining church cemeteries—such as St Cuthbert’s just below the Edinburgh Castle. They are buried in communal ( or, rather “mass”?) graves that are, of course, unmarked, and typically located in the now grassy central parts of the cemetery as shown in this photograph I took yesterday. There are older laws banning the grazing of sheep or cattle on these churchyard fields; current laws are posted banning all animals, including dogs (except for certified service animals). 

St Cuthbert churchyard

Edinburgh is infamous for its early to mid nineteenth century grave robbers, body snatchers, or “resurrection men” who dug up recently buried bodies of people and sold them to surgeons of the University of Edinburgh Medical School for their anatomy dissection. And then there were the body snatchers (and complicit surgeons) who took it even further, murdering poor and homeless men and women on the streets and in flophouses. People who died in poor/workhouses and public insane asylums and whose families did not claim (and pay for) their bodies were sold by the Overseers of the Poor to the medical schools for dissection. Is it any wonder that poor and homeless people have a well-founded fear of public hospitals and related institutions?