Two rules usually govern whether someone should be placed in a psychiatric hospital: if someone is an immediate threat to harm themselves, or to harm other people. If neither of these two criteria are met, then the patient may benefit from outpatient care. If there is uncertainty as to the extent of a patient's danger to themselves or others, they are typically placed in a hospital for safety reasons.
In the United Kingdom the Middlesex County Court Judges pressured the UK Government resulting in an Act of Parliament - The Madhouse Act 1828, allowing the building of purpose-built asylums, the first of which the 1st Middlesex County Asylum was at Hanwell in West London and opened its doors in late 1831. (Src. Museums of Madness, Andrew T. Scull, Penguin 1979)
Initially these early asylums were little more than repositories for the mentally ill – removing them from mainstream society in the same manner as a jail would for criminals. Conditions were often extremely poor and serious treatment was not yet an option.
Unlike medieval Christian physicians who relied on demonological explanations for mental illness, medieval Muslim physicians and psychologists relied mostly on clinical observations. They made significant advances to psychiatry and were the first to provide psychotherapy and moral treatment for mentally ill patients, in addition to other forms of treatment such as baths, drug medication, music therapy and occupational therapy. In the 10th century, the Persian physician Muhammad ibn Zakarīya Rāzi (Rhazes) combined psychological methods and physiological explanations to provide treatment to mentally ill patients. His contemporary, the Arab physician Najab ud-din Muhammad, first described a number of mental illnesses such as agitated depression, neurosis, and sexual impotence (Nafkhae Malikholia), psychosis (Kutrib), and mania (Dual-Kulb).
In the 11th century, another Persian physician Avicenna recognized 'physiological psychology' in the treatment of illnesses involving emotions, and developed a system for associating changes in the pulse rate with inner feelings, which is seen as a percursor to the word association test developed by Carl Jung in the 19th century. Avicenna was also an early pioneer of neuropsychiatry, and first described a number of neuropsychiatric conditions such as hallucination, insomnia, mania, nightmare, melancholia, dementia, epilepsy, paralysis, stroke, vertigo and tremor.
Bethlem Royal Hospital (Bedlam) was the first known psychiatric hospital in Europe, founded in London in 1547. It soon became infamous for its treatment of the insane, and in the eighteenth century outsiders would pay a penny to come and watch their patients as a form of entertainment. In 1700 it is recorded that the "lunatics" were called "patients" for the first time, and within twenty years separate wards for the "curable" and "incurable" patients had been established. The institution was still a coercive and brutal regime when William Battie criticized its practices in his treatise in 1785. By 1815 thousands of visitors were still being permitted in to view the "unfortunates" as they were by then called.
The Hartford Retreat (now the Institute of Living at Hartford Hospital) and McLean Hospital also set the tone for the United States' history of relatively humane private psychiatric facilities. The Quakers of the mid-Atlantic states, particularly Pennsylvania, also offered dignified treatment that was among the most progressive in the world. The transition to state hospitals and "state schools", however, brought with them many abuses that shocked operators of private American psychiatric hospitals. Reformers, such as American Dorothea Dix began to advocate a more humane and progressive attitude towards the mentally ill. Some were motivated by a so-called Christian Duty to mentally ill citizens. In the United States, for example, numerous states established state mental health systems paid for by taxpayer money (and often money from the relatives of those institutionalized inside them). These centralized institutions were often linked with loose governmental bodies, though oversight and quality consequently varied. They were generally geographically isolated as well, located away from urban areas because the land was cheap and there was less political opposition. Many state hospitals in the United States were built in the 1850s and 1860s on the Kirkbride Plan, an architectural style meant to have curative effect. States made large outlays on architecture that often resembled the palaces of Europe, although operating funding for ongoing programs was more scarce. Many patients objected to transfers from private hospitals to state facilities. Some Brattleboro Retreat patients tried to hide when state officials arrived to transfer them to the new Waterbury State Hospital. This decline in patient census led to the collapse of many private institutions, which still accepted indigent patients even when state reimbursement for private hospitals dropped in the face of rising state hospital costs.
In 1817 a William Ellis was appointed as superintendent to the newly built West Riding Pauper Asylum at Wakefield. A Methodist, he too had strong religious convictions and with his wife as matron they put into action those things they had learnt from the Sculcoates Refuge in Hull which was run on a similar model as the York Retreat. After 13 years their reputation had become such, that they were then invited to run the newly built first pauper asylum in Middlesex called the Hanwell Asylum. Accepting the posts, the asylum opened in May 1831. Here the Ellis's introduced their own brand of humane treatment and 'moral therapy' combined with 'therapeutic employment'. As its initial capacity was for 450 patients it was already the largest asylum in the country and subject to even more building soon after. Therefore, the immediate and continuing success of humane therapy working on such a large scale, encouraged its adoption at other asylums. In recognition of all this work he received a knighthood. He continued to develop therapeutic treatments for mental disorders and always with moral treatment as the guiding principle.
In Lincoln, Lincolnshire, England, Robert Gardiner Hill with the support of Edward Parker Charlesworth, developed a mode of treatment that suited 'all types' of patients, where by the reliance on mechanical restraints and coercion could be made obsolete altogether, a situation he finally achieved in 1838.
By the following year of 1839 Sergeant John Adams and Dr. John Conolly was so impressed by the work of Hill, that they immediately introduced the method into their Hanwell Asylum, which was by then the largest in the kingdom. The greater size required Hill's system to be developed and refined. This was necessary as it was beyond Conolly to be able to supervise each attendant as closely as Hill had done. Even so, he bid a pair of extra soft slippers made so that he could walk around the building at night without his foot falls warning the attendance of his imminent approach. By September 1839, mechanical restraint was no longer required for any patient. For years, this day was remembered at the Hanwell asylum by a celebration on its anniversary. Hanwell also was a very accomplished communicator and wrote and lectured widely about his work in mental health.
By such means these and others, more effective treatment methods gradually took hold in different countries, and attitudes towards the treatment of the mentally ill began to drastically improve during the mid-19th century. Courts began to administer involuntary commitments with a greater eye towards medical justification.
From 1942 to 1947, conscientious objectors in the US assigned to psychiatric hospitals under Civilian Public Service exposed abuses throughout the psychiatric care system and were instrumental in reforms of the 1940s and 1950s. The CPS reformers were especially active at the Byberry Hospital in Philadelphia where four Friends initiated The Attendant magazine as a way to communicate ideas and promote reform. This periodical later became the The Psychiatric Aide, a professional journal for mental health workers. On May 6, 1946, Life Magazine printed an exposé of the mental healthcare system based on the reports of COs. Another effort of CPS, namely the Mental Hygiene Project, became the National Mental Health Foundation. Initially skeptical about the value of Civilian Public Service, Eleanor Roosevelt, impressed by the changes introduced by COs in the mental health system, became a sponsor of the National Mental Health Foundation and actively inspired other prominent citizens including Owen J. Roberts, Pearl Buck and Harry Emerson Fosdick to join her in advancing the organization's objectives of reform and humane treatment of patients.
These usually consist of anyone aged under 18.
In the UK long-term care facilities are now being replaced with smaller secure units (some within the hospitals listed above). Modern buildings, modern security and being locally sited to help with reintegration into society once medication has stabilized the condition are often features of such units. An example of this is the Three Bridges Unit, in the grounds of Hanwell Asylum in West London and the John Munroe Hospital in Staffordshire. However these modern units have the goal of treatment and rehabilitation back into society within a short time-frame (two or three years) and not all forensic patients' treatment can meet this criterion, so the large hospitals mentioned above often retain this role.
Some anti-psychiatry activists have advocated for the abolition of long-term hospitals for the criminally insane, including on the grounds that those judged not guilty by reason of insanity should not then be indefinitely confined with potentially less legal rights, or on the converse grounds that insanity is not a coherent concept and so should not be a basis for different treatment.
To see lists of individual establishment: view the categorical index for Psychiatric hospitals; which appears at the very bottom of this article.