Founding Friends: Families, Staff, and Patients at the Friends Asylum in Early Nineteenth-Century Philadelphia (review)

The history of the care and treatment of persons with severe mental illnesses has generally focused—with some notable exceptions—on policy at the macro level. Scholars have for the most part been concerned with public policy. For some the themes of social control and maintenance of social order have been central to their analysis. These scholars have tended to portray mental hospitals as monolithic institutions that served the needs of society and the medical profession rather than patients. In delineating institutions in such terms, they have frequently neglected their internal history in order to offer interpretations and generalizations that presumably illuminate the larger society. Certainly, this is true of such scholars as David Rothman, Andrew Scull, and the ubiquitous Michel Foucault.

More recently, historians have begun to turn their attention to the internal history of mental hospitals. In so doing, they have focused not simply on psychiatric thinking and practice, but on the role played by family, patients, nurses, and attendants. Founding Friends by Patricia D’Antonio is in this tradition.

The Friends Asylum for the Insane is among the oldest private hospitals in the United States. Founded by Philadelphia Quakers, the institution opened in 1817 and is still in existence. Fortunately, the institution’s superintendents—most of whom were laypersons—kept daily diaries. They wrote about their patients, the medical therapies prescribed by attending physicians, the moral (i.e., psychological and environmental) treatments, the behavior and responses of patients, the role of the attendant staff, as well as the involvement of families. In using this source, D’Antonio has provided a rich and revealing portrait of the inner working of one, albeit atypical, early nineteenth-century mental hospital.

Although created by men concerned with accommodating middle-class norms with Quaker religious beliefs, the Asylum took as its fundamental premise the enduring importance of traditional Quaker domesticity. Its structure and organization was designed to emulate an upright Quaker family. Physicians, for example, came to the institution to diagnose and treat, but only when asked; the internal regimen was directed by a male lay superintendent. Gender, however, played a significant if complex role. Moral (i.e., psychological and environmental) treatment represented a peculiar duality: cure/care, coercion/kindness, male/female. Yet, in practice, such dualisms tended to become conflated. Moreover, families continued to play an important role. They decided when it was necessary to send a distressed relative to the Asylum, and its members negotiated with the staff over their care and treatment. Nor were patients quiescent; they exercised power by negotiating with their families about their fate or even left the Asylum to return home.

The ideal of asylum life, of course, rarely approximated reality. The assumption that patients would exercise rationality within the framework of a harmonious family life proved unrealistic. Asylum managers and staff faced an ambivalent situation; they wanted to provide individualized treatment and yet maintain a disciplined environment. In the end, they could not balance the two. Under these circumstances, they followed the model that existed at virtually all other mental hospitals, where control was vested in individuals with medical training. Medical hegemony thus undermined the ideal of the Asylum as a family. The insane now became a group needing specialized treatment rather than individuals accountable for their behavior. The goal—even if often unattainable—was cure rather than care or support.

D’Antonio’s explanation of this shift is somewhat unique. Families that committed their difficult and troublesome members expected that the Asylum staff could recreate a family environment that would promote recovery. The irony, of course, was that the staff faced many of the same problems that had led the family to commit its member. Eventually, the tensions at the Asylum proved too great, and the result was the replacement of a family ideal by a more medicalized institution. Physicians, according to D’Antonio, did not...