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The Honest Strap or the Hidden Cell, How Asylums Argued Over Which Coercion to Admit
In Brief
- The English abolition of mechanical restraint did not abolish coercion: seclusion took its place and, according to J. T. Arlidge, was harder to supervise than the strap.
- On both sides of the Atlantic, the legitimacy of restraint came to rest on registers that counted it, from Wisconsin's daily figures to Tuke's weekly journal.
- Crowding and the plea of economy undermined non-restraint and rational restraint alike, leaving force in the hands of unsupervised attendants.
- An 1886 American treatise judged the strap less harmful than sedative doses; a much later Supreme Court opinion reversed that hierarchy in favour of antipsychotic drugs.
Main authors
The history of psychiatric restraint is often told as a story of liberation: chains struck off, straitjackets abandoned, doors unlocked. The texts gathered here tell a more uneasy story. None of their authors, whether physician, nurse or manual writer, claims that the care of the mentally ill can do without force altogether [1, 2]. What they disagree about is the form force should take and, above all, whether it should be seen. In the 19th century this disagreement hardened into a transatlantic contrast: England professed absolute non-restraint, while American superintendents, who considered themselves no less humane, held that some restraining appliance remained necessary in certain cases [3].
Read closely, that contrast is less a quarrel between cruelty and kindness than a dispute over what an institution could admit to. The strap is visible, countable and easy to condemn; the locked single room and the sedative dose are quieter, and therefore harder to supervise [4, 5]. Each doctrine had a blind spot that its critics, often its own practitioners, were able to name. Nor did the question disappear with the asylum era: when a far later American court weighed the forced administration of antipsychotic drugs, it reasoned by comparing them with the very restraints and seclusion that the old superintendents had argued over [6, 7]. The long life of the quarrel suggests that what was at stake was never only the patient's body, but the institution's willingness to own the force it used.
A Necessary Evil, the Premise Both Camps Shared
The moral grammar of restraint appears fully formed in M. Allen's essay on the classification of what he calls the insane: restraint is an evil accepted only to avoid a greater one, justified by absolute necessity and harmful as soon as it outlasts that necessity . The argument is clinical as much as ethical. Prolonged restraint, Allen holds, aggravates the very states it is meant to contain, hardening fury and strengthening the resolve of the suicidal . Its corollary is demanding: whenever a patient behaves better with more liberty, the institution must accept risk, loss and expense rather than return to the strap . Restraint is framed as a debt the institution carries, not as a tool it owns.
This premise did not oppose confinement; it presupposed it. John Haslam treats confinement as always necessary in cases of insanity and as something to be imposed as early as possible, by which he means removal from home [8]. The household, in his account, is the place where the patient still feels himself master, where servants no longer obey and where the mere idea of being restrained is a constant irritant . He observes that patients described by their families as violent often grow calm once admitted, and relapse when returned home [9]. The asylum, in this reasoning, is itself the primary restraint, one that works by changing the patient's world rather than by binding his limbs.
The same logic extends from therapy to public safety. An American medical treatise of 1886 presents the treatment of fixed persecutory delusions as chiefly a matter of the safety and comfort of society, and calls seclusion in an asylum the only safe course when the patient's hostility can shift unpredictably from one person to another [10]. Here the word seclusion designates not a room but the institution as a whole. The vocabulary reveals a slippage that runs through the entire debate: the coercion that removes a person from the world is rarely counted as restraint at all; only the coercion applied within the walls is.
At the level of the ward, the premise became a rule of conduct. William D. Granger's manual for nurses asks attendants to use only necessary force, without malice, and to be able to demonstrate as much if a patient is injured . It forbids struggling with a violent patient alone, except to prevent homicide, suicide, serious injury or fire . The manual is revealing in what it takes for granted: force belongs to the attendant's ordinary work, and its legitimacy depends on its being justifiable after the fact. Already the question is less whether to coerce than how to account for coercion.
Two Doctrines, the Strap That Can Be Counted and the Room That Cannot
A Popular Science Monthly article of 1901 sets out the transatlantic contrast in conciliatory terms. American psychiatrists such as Todd, Woodward, Butler and Ray, it argues, pursued the same humane principles independently while the controversy over non-restraint was being fought abroad . The difference it records is one of degree: absolute non-restraint was more favoured in England, while American institutions held that a restraining appliance was still necessary in some instances . The framing is defensive. It insists that keeping the strap was not a lapse in humanity but a considered clinical judgment.
The American position found its strongest argument in measurement. Charles Dudley Warner, describing the county asylums of Wisconsin, presents them as homes rather than prisons, where inmates work under the watch of attendants and where remarkably little restraint is needed once a serious effort is made to do without it [11]. Significantly, his evidence is a count: about one person in a thousand in restraint or seclusion on any given day . Restraint, on this model, is a measurable exception whose rarity is proved by the register. Warner also folds restraint and seclusion into a single figure, declining the very distinction on which the English doctrine relied.
The English answer was a register too. Daniel Hack Tuke describes a regime in which no continued coercion is permitted, and in which the name of every patient under restraint or in seclusion, together with the means used, is entered weekly in a journal [12]. For Tuke, such records multiply the safeguards against restraint born of the cruelty, idleness or caprice of attendants . The convergence with Warner is striking: on both sides of the Atlantic, the legitimacy of force came to depend less on its form than on its being written down.
Yet J. T. Arlidge, a critic of English asylum practice from within, identifies the weakness of non-restraint precisely where the register is weakest. Once mechanical restraint had been set aside, he observes, seclusion in a special chamber or in the patient's own room partly took its place and was frequently abused . His explanation turns on supervision: seclusion is harder to control than an instrument, because the single room is always close at hand, a troublesome patient can be pushed into it with ease, and released just as easily when the superintendent's step is heard . The strap leaves a trace on the body and in the book; the door leaves none. Here the thesis of a simple transatlantic accusation needs nuance: the sharpest charge that non-restraint hid its force behind a door comes not from an American rival but from an English physician.
The American side had its own blind spot, and the 1886 treatise names it with comparable candour. Objectionable as mechanical restraint is, its authors argue, it does less harm than the continued use of large doses of sedatives to keep patients quiet enough to stay at home . The comparison targets domestic practice rather than English asylums, but it sets out a hierarchy of coercions in which the visible device is preferred to the invisible chemical one. Tuke, for his part, records a general movement toward granting as much freedom as safety allows and attaching less importance to walls and enclosures [13]. Both doctrines claimed to minimise force; each relied on a form of force that the other could more easily see.
What Doctrine Could Not Govern, Numbers, Economy and the Attendant's Hand
The quarrel between doctrines assumed an institution capable of applying them. Arlidge doubts that such an institution existed. A single medical officer surrounded by several hundred patients, he asks, cannot follow each case through its changing conditions or exercise vigilant superintendence [14]. He concedes that one man might administer thousands as a governor, provided he has enough subordinates, but holds that the real question is how to cure the largest number of new cases, which alone would keep costs down over time [15]. Non-restraint, which depends on constant and attentive staff, was precisely the regime most exposed to the effects of scale.
Arlidge traces scale back to economy. Huge asylums, like the detention of the mentally ill in workhouses, are justified by the plea of economy, and the larger they grow, the more their means of cure shrink [16]. Quoting a superintendent, he describes asylums receiving the paralysed, the aged and the troublesome, and sliding from hospitals for recovery into mere auxiliaries of the workhouse [17]. In the workhouses themselves, he finds no exercise, no supervision and the means of coercion entrusted to unfit attendants, producing the most shocking abuse of restraint and cruel seclusion [18]. Doctrine had little purchase where no one was charged with carrying it out.
American sources describe the same mechanism. The 1886 treatise depicts the State shutting behind the same locked doors and barred windows people of every social rank and every condition, from those it calls the criminal insane to patients with acute illness [19]. A Popular Science Monthly article of 1893 argues that a state care act, generous in intention, filled the hospitals with patients for whom nothing could be done medically, made classification nearly impossible and forced recent and suicidal cases to live alongside chronic and violent ones [20]. The crowding that undermined non-restraint in England undermined rational restraint in America just as surely: neither doctrine could function on a ward where patients could not be separated.
Clifford Whittingham Beers, writing as a former patient, gives this structural failure a human face. In the wards he knew, the patients spared abuse were those who needed care least; the violent were beaten for their violence, the helpless for their helplessness, and a restless newcomer to the violent ward was often assaulted on the first day [21]. He stresses that he endured such treatment in two private institutions before reaching a state hospital, and concludes that brutality was general [22]. His testimony cuts across the doctrinal quarrel. Whether the official regime allowed the strap or forbade it, force escaped the register through the attendant's hand, and the question of which coercion to admit, posed at the level of policy, was being settled unrecorded at the level of the ward.
The Dose as Successor, From the Asylum to the Courtroom
The 1886 preference for the strap over the sedative is overturned in a much later American judgment. In Washington v. Harper, Justice Anthony Kennedy argued that physical restraints are effective only in the short term, can cause serious physical harm to a resisting inmate and expose staff to injury, and that neither restraints nor seclusion had been shown to be acceptable substitutes for antipsychotic drugs, whether in medical effectiveness or in their cost to limited prison resources . The hierarchy has been reversed. Where the physicians of the 1880s ranked the visible device above the dose, the Court treats the dose as both the more effective and the more economical option.
Kennedy framed the matter as an accommodation between an inmate's liberty interest in avoiding forced medication and the State's interest in reducing the danger that a serious mental disorder poses to the patient and to others . The vocabulary is that of constitutional law, but the structure of the argument is the older essayist's: force justified as the lesser evil, weighed against a greater danger . What has changed is the instrument. Coercion now passes through the bloodstream rather than through straps or doors, and its visibility depends on procedure rather than on anything an observer could see on the ward.
John Paul Stevens, writing separately, put his finger on the ambiguity the old superintendents had known. By focusing on the risk an inmate poses to other people and to property, he argued, the policy allowed the State to invoke either its protective parens patriae authority or its police authority to override a prisoner's refusal of psychotropic drugs, leaving no basis for the claim that medication must serve the prisoner's own medical interest [23]. He added that a criminal conviction does not entitle the State to declare a person mentally ill and commit him involuntarily to a mental hospital [24]. Across roughly a century, the objection echoes the 1886 suspicion of sedatives used to keep patients quiet: the dose may serve order while presenting itself as care .
This confusion of therapeutic and penal authority had been diagnosed earlier from within psychiatry itself. Bernard Glueck observed that people were sent to hospitals for the sake of their recovery while the law continued to treat them as persons charged with crime, obstructing the very care it claimed to provide [25]. James Vance May saw no reason why people with mental disease should be supervised like criminals, and hoped that a largely lay movement might persuade legislators to provide treatment for those he calls defective delinquents instead of merely locking them up [26, 27]. The quarrel over the strap and the cell thus widens into a quarrel over jurisdiction: whether coercion is exercised as medicine or as punishment determines which of its forms can be openly admitted.
Across these texts, the opposition between non-restraint and rational restraint appears less as a contest between humanity and harshness than as a disagreement about which forms of force an institution could see and answer for. The English doctrine abolished the visible instrument and watched coercion reappear in a room that closed without leaving a trace ; the American doctrine kept the instrument and warned against the dose that silenced without showing . Both turned to registers as proof of their restraint , and both foundered on the crowding and economy that left force in unsupervised hands . When a court, far later, preferred the drug to the strap, it restaged the same debate with the hierarchy reversed and the old ambiguity between care and control intact .
The quarrel also belongs to a wider reflection on legitimate force. Bertrand Russell hoped that well-designed institutions would reduce the need for actual coercion even though government must keep the power to use it [28]; the anarchist Voltairine de Cleyre held that all action by the State, even when benevolent, rests in the end on a club, a gun or a prison [29]; and the prosecution at Nuremberg, in a wholly different context, defended the principle that coercion is legitimate only when held by the state and exercised in obedience to law [30]. The asylum debate sits between these positions. Its most durable lesson may be that the least visible coercion is not necessarily the mildest, and that an institution of care is measured less by whether it uses force than by whether it is prepared to name it, record it and answer for it.
