During the 19th century, mental health disorders were not recognized as treatable conditions. They were perceived as a sign of madness, warranting imprisonment in merciless conditions. One woman set out to change such perceptions: Dorothea Lynde Dix.

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Dorothea Dix was instrumental in changing perceptions of mental illness for the better.
Image credit: The National Library of Medicine

Born in Maine in 1802, Dix was instrumental in the establishment of humane mental healthcare services in the United States.

Dix - a teacher and nurse during the American Civil War - tirelessly campaigned for the fair treatment of patients with mental health disorders, after being appalled by the conditions in which they were confined.

"I proceed, Gentlemen, briefly to call your attention to the present state of Insane Persons confined within this Commonwealth, in cages, stalls, pens! Chained, naked, beaten with rods, and lashed into obedience," wrote Dix in a Memorial to the Legislature of Massachusetts in 1843.

In the years that followed, Dix traveled to hundreds of prisons and workhouses across the U.S., documenting the inhumane treatment that people with mental illness received and reporting her findings to state legislatures.

Her work not only resulted in the establishment of 32 mental health hospitals in a wealth of U.S. states, but it also helped to change people's perceptions of mental illness.

"Through her work, she shed light on the abuse and neglect of those with mental illness, which helped change perceptions and policy approaches of state, national, and international leaders to establish more humane treatment approaches," Paolo del Vecchio, director of the Center for Mental Health Services at the Substance Abuse and Mental Health Services Administration, told Medical News Today.

For our fifth and final article in a series celebrating female role models in medicine, we look at Dix's incredible life and career.

How did her steadfast lobbying for mental healthcare reform more than 200 years ago help to shape today's treatment for patients with mental illness? What challenges remain for mental healthcare?

An unhappy childhood

Dix's childhood was not a happy one; her father was an abusive alcoholic, and her mother struggled with mental illness. At the age of 12, Dix ran away from her home in Maine to live with her wealthy grandmother in Boston, MA.

Despite a lack of formal education, Dix was clearly a smart and ambitious woman, as she went on to establish a career as a schoolteacher. In 1821, at the age of 19, she opened a school for young girls in her grandmother's mansion.

In the years that followed, Dix penned a number of children's books and short stories and, in 1831, she opened a school for underprivileged children, which she ran from her own home.

However, these achievements were not easy; Dix often suffered from bouts of illness, including severe cough and fatigue, which eventually ended her career as a teacher.

Archives suggest that her physical illness took its toll on her mental health, causing her to become depressed. Her mental illness, however, would later become a driving force in her desire to change mental healthcare in the U.S. for the better.

Inspired by her own mental illness

In the mid-1830s, Dix traveled to Europe in the hope of finding a cure for her ongoing illness.

During her time in England, she met with social reformers Elizabeth Fry and Samuel Tuke. Fry had helped to pass new legislation in the United Kingdom to make the treatment of prisoners more humane, while Tuke founded England's York Retreat for the mentally ill.

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Dix was appalled by the treatment of patients with mental illness.

Evidence suggests that Dix's own experience of mental illness, as well as the work of these social reformers, helped to inspire her to make changes to mental healthcare in the U.S.

"Perhaps her own struggles helped make her a more compassionate advocate for people who had been diagnosed as mentally unstable or insane," wrote historian Manon S. Parry in a paper published in 2006. "Certainly her ill health ended her teaching career and brought her into a new circle of contacts."

In 1841, Dix volunteered to teach a Sunday School for female inmates at a jail in East Cambridge, MA. Here, she witnessed the suffering of women with mental illness. They were chained to beds, starved, and abused - punished as if they were criminals.

Horrified by this maltreatment, Dix began visiting jails and workhouses across Massachusetts and documenting her findings.

The rise of mental healthcare

In 1843, these findings were presented in a Memorial to the Legislature of Massachusetts.

As part of the Memorial, Dix asked for the funds to introduce reform for the care of patients with mental illness in Massachusetts' only state mental hospital - Worcester Insane Asylum. Her request was approved.

"This memorial reveals how Dix worked within the conventions of her time to carve a role for herself in public life and draw attention to the horrendous treatment of the mentally ill in prisons, almshouses for the poor, and asylums," writes Parry.

"Ideals of femininity characterized women as having a special responsibility to the most vulnerable members of society, and a moral authority superior to men's. At the same time, women were supposed to be protected from images and experiences of suffering and degradation."

"Dix was able to use her vivid and upsetting descriptions to powerful effect, damning the existence of these abuses and shaming political leaders into taking action on her behalf, and on behalf of the 'inmates' of these institutions."

Manon S. Parry

Following her success in Massachusetts, Dix took her campaign for mental healthcare reform to other states.

A significant point in Dix's crusade was the Bill for the Benefit of the Indigent Insane, which was put before Congress in 1854. The bill proposed legislation to provide federal land and funding for the development of new mental institutions.

While the bill was passed by both houses of Congress, it was vetoed by President Franklin Pierce, who stated that the issue of social welfare should be the responsibility of each individual state, rather than that of the federal government.

Though disappointed by this decision, Dix continued to make progress at a state level. Between 1843 and 1880, she helped to establish 32 new mental hospitals across the U.S. - including in New York, Indiana, Illinois, Rhode Island, and Tennessee - and she aided in improving the care of many more.

From 'lazy and worthless' to 'sick and human'

When it comes today's care for patients with mental health disorders, we have undoubtedly come a long way since the 1800s.

Today, there are more than 6,100 mental health outpatient facilities and more than 800 psychiatric facilities in the U.S., compared with just 123 mental hospitals in 1880.

"Dix was one of our nation's first champions for healthcare as a basic right and that we have a societal and public responsibility to care for those vulnerable citizens among us," del Vecchio told MNT.

Furthermore, she helped to change the way that patients with mental illness are perceived.

As psychiatrist Dr. Fuller Torrey, executive director of the Stanley Medical Research Institute, told us, "She changed the perception from being lazy and worthless to being sick and human."

Still, there is much more to be achieved in the field of mental health, and experts believe that we can learn a great deal from inspirational figures such as Dix.

'We need more champions like Dix'

According to the National Alliance on Mental Illness, around 1 in 5 adults in the U.S. experience some form of mental health disorder in any given year.

The rate of mental illness is even higher for inmates in prison or jail - a report from the U.S. Department of Justice found that more than half of these individuals have a mental health disorder.

Statistics show that around 56 percent of patients with mental illness in the U.S. do not receive treatment.

There is also a severe shortage of mental health professionals. In fact, Mental Health America report that in states with the lowest workforce, there is only one mental health professional - including psychiatrists, psychologists, and social workers - for every 1,000 people.

Stigma surrounding mental illness also remains a problem. The American Psychological Association state that only 25 percent of adults with symptoms of mental illness believe that people will be caring and sympathetic toward them.

Moving forward, del Vecchio believes that we can build a better world for people with mental illness by following in Dix's footsteps.

"Today, we need more champions like Dorothea Dix to provide leadership to change attitudes and policies to enable all Americans with mental illness to recover and live full, productive lives in our communities.

Dix is a role model to others who want to reform how people with serious mental illness are treated. She provides an example of how dedicated individuals can help change society for the better."

Paolo del Vecchio