From the asylum to the hospital, humanizing care

The Bois-de-Cery asylum opened its doors in 1873 in Prilly, on the outskirts of Lausanne. 151 years later, the institution, which has since become a psychiatric hospital, bears within itself all the societal, medical, and architectural changes that the history of psychiatry and its French-speaking part have known. Conversation with Aude Fauvel, Senior Lecturer in the History of Medicine, and Mikhaël Moreau, Research fellow, Institute of Humanities in Medicine (IHM). 

IN VIVO/ The mission of the asylum for the insane in the 19^th century was to cure or keep away from society “challenging” cases. Yet, it was common for people to spend their whole lives in prison. How is the asylum different from a prison? 
AUDE FAUVEL ET MIKHAËL MOREAU/ The word asylum has a very strong meaning: it is, originally, a facility where everyone can take refuge. The alienists – the psychiatrists of today – then held the power to give asylum to the destitute who did not belong in prison. These people are not considered criminals but patients who need a hand. We are already seeing a desire to humanize care. In the 19^th century, the word “asylum” had a very positive connotation, unlike the hospital.

But that’s in theory. If, at the time, Cery was supposed to be a care facility, in reality, people were placed there against their will. The internment of a person in Cery is, therefore, most often requested by an authority (judicial or administrative) or by the family. Until the 1930s, few people came to Cery voluntarily. In some instances, if you asked to be hospitalized for suicidal thoughts, for example, entry could be refused. The canton paid, above all, for interning indigent persons who were “disturbing”: those who caused disorder on the public road, for example, showed a behavior considered deviant or violated a social or moral order. And to help pay their expenses, the internees worked. If Cery was really a place of care, why not welcome everyone but only the “disruptors”? That’s when the confusion between asylum and prison took place. In the Cery asylum, one was not treated as they would elsewhere. 

IV/ And the buildings of Cery are very far from the city of Lausanne...
AF and MM/ Indeed, at the time, the city was considered a bad environment because it was chaotic. Following the wrong crowd was common, and factory work was harmful. Not to mention that alcohol was everywhere. So, there was this idea that people developed a mental disease because they lived in an unhealthy environment. To treat people, you had to isolate them (visiting rights were very restricted) and make them “go green.” Working in the countryside was supposed to help them. The concept of work was very important: it was common to have the sick working in the fields or at the factory to discipline them, keep them busy, and make them responsible. There were also other types of treatment, such as hydrotherapy, baths were considered in the 19th century as powerful healing tools. While Switzerland was not as radical as France or Germany, the shift between internment and confinement was gradual. Slowly, the asylum was seen as a kind of closed daycare, and the internees as people to keep watch over rather than care for.

IV/ What about public opinion?
AF et MM/ The general public saw that people sent to the asylum were those who posed problems, “undesirables” who disturbed the moral order, and represented “threats.” The way the asylum works and admits people (or not) has contributed to degrade the image of Cery and its patients. Initially, however, the alienists thought they could cure them, but it turned out that cures were less frequent than expected. And very often, internments lasted for years or even life. Cery had 375 patients in 1873, but by 1960, there were almost 800.

The Canton of Vaud was one of the first to legislate to allow and regulate the sterilization of mentally ill people in 1928. At the time, this was seen as a positive development. By sterilizing certain people called “mentally disabled,” the idea was that they could be released because they would not pass along their “defect.” This practice helped to empty Cery. However, it was disavowed in the 1960s by the surgeons of the cantonal hospital who performed the procedure and addressed the issue of patient consent. In general, more and more doctors were questioning the operation of the facility, arguing that they did not study medicine to end up as caretakers or sterilizers. They also believed that the way in which the orders for detention were taken was not medically justified. They were tired of working for an institution that was widely regarded as a dumping ground.

IV/ What about gender differences in the institution? Were men and women admitted for the same reasons?
AF et MM/ Statistically, in Cery, as in many other asylums, the patient population was mixed, with a slight increase in women from the 1960s to the 1980s. Unlike in prison, where women are an extreme minority with less than 10%. This suggests that historically, women have been institutionalized and men incarcerated. A certain “gender bias” in the diagnoses does occur. The man who was locked in the asylum was considered potentially dangerous; they were psychopaths, sexual perverts, and alcoholics. More generally, men who were interned were those who did not perform their duties as workers, fathers, or husbands. And foreigners, too. For example, there was a strong Italophobia in the Canton of Vaud in the 1950s-60s. Unmarried, unemployed, and self-employed women were more likely to be accused of being hysterical or schizophrenic.

IV/ In 1948, Cery became a “psychiatric and university hospital.” What were the major changes compared to asylum? How was the psychiatric discipline modernized?
AF et MM/ Although 1948 marked the year in which the institution officially changed its name, the process of change began in the 1930s with the development of new research and new therapeutic methods, such as shock therapy, but also with the first forms of psychotherapy. In the 1950s, new drugs and psychotherapeutic approaches emerged, which reassured the population and reduced the length of stay. Gradually, the way people looked at the disease and the sick evolved; it went from a living space to a place specialized in care. This was also the period when architectural transformations were carried out in order to improve hospital conditions but also the working conditions of the caregivers. A new clinic was built, allowing for more services but also smaller divisions. The dormitories gradually gave way to rooms with fewer patients. There was genuine interest in improving the image of the institution to make it more attractive and thus promote the recruitment of staff, which has long been a problematic issue, but also in encouraging the public to come for treatment: for the first time, in 1953, the ratio between forced and voluntary internment was reversed.

IV/ One of the key players in the history of the Cery Hospital was Christian Müller, who was appointed director in 1961. Tell us about him. 
AF et MM/ When Christian Müller took the helm, it was beneficial for Cery. He was able to find the right support and get funds to do great work. He transformed the hospital into a specialized acute care facility with a greater variety of treatments. There were fewer patients, but they were better treated. This transformation also relied on the development of alternatives, such as the establishment of a healthcare network around the hospital. In 1966, the Vaudois hospital plan decreed sectoring, and the canton was cut into four. Each sector had its own institution and extra-hospital and extra-hospital networks. For Christian Müller, the hospital was necessary but not sufficient in itself and had to be a link in the care chain, based on a broader system, open to the city and no longer isolated in the countryside. Not to mention the fact that the 1960s saw an increasingly rapid urbanization, a strong demographic growth, and Cery became overwhelmed.

Christian Müller was also very attentive to the public image of psychiatry and his hospital. He supported promotional campaigns and maintained constant media attention. He did not hesitate to call the editors when a newspaper article was not to his liking. At the same time, a social movement was emerging that denounced the asylum model as obsolete. Users’ associations were starting to organize themselves and to campaign for the rights of patients. In a period marked by the rise of so-called “anti-psychiatric” movements, the media showed a strong interest in psychiatry. Blockbusters such as One Flew Over the Cuckoo's Nest or Family Life were very popular. The psychiatrist from the canton of Vaud took advantage of this to publicize the reforms of “modern psychiatry” and show that the hospital was no longer the daycare center that was the asylum of old.

IV/ Is the reintegration of patients possible after a psychiatric hospitalization in Cery?
AF et MM/ New treatments allow patients to leave the hospital but the real challenge is to be able to reintegrate them. Before, people changed cantons, changed names and still had difficulty finding work. The stigma was extremely strong. Then, gradually, we saw the development of workshops and sheltered homes, structures that provided support and help with reintegration, whether it was professional, family, or social. The therapeutic link was also evolving: the doctor was no longer just a figure who allowed or did not allow the patient to leave the hospital, but he was supported by a multidisciplinary team of caregivers, social workers, etc., who helped, guided, and cared for patients.

Patient associations were born. For the first time, we heard the voices of sick people, which brought to the forefront the issue of their rights: the right to consent, for example, to treatment or access one’s medical record. Until the 1980s, it was believed that patients should not know their diagnosis for fear of self-stigmatization.

IV/ If previously the confinement guaranteed to the population some degree of security, with the opening of hospitals and the freedom enjoyed by patients, was the notion of danger reactivated in society?
AF et MM/ Architecturally, the change was indeed significant: from the 1873 building, only “Les Cèdres” remains today. The ultra-modern building that has just been inaugurated shows a real willingness to open up with the rest of the city. Let us recall that until the 1960s, the most important question in the hospital was: Who has the keys? As for the notion of danger, let us remember that in the vast majority of cases, detained patients are no more dangerous than the average population. In Switzerland, as elsewhere, violence is most often committed within one’s immediate circle.

Yet, for the past 20 years or so, we have seen a hardening of security issues, a focus on the question of the risk of re-offending that psychiatrists are confronting. 

IV/ How do you see the future of psychiatry and its place in society?
AF et MM/ Historians do not indulge in futurology, but we can observe a cyclicity in the history of psychiatry, particularly with regard to the stereotypes about mental illness that persist in the background of our social representations. There have always been more or less successful attempts to instrumentalize political parties in order to exclude and discredit people who are different. 

What we can remember from Cery and its history is the Swiss pragmatism and its eclectic side, which allowed greater flexibility and openness of mind than in other European contexts in particular. And in 2024, thanks to patient associations and social networks, mental health was now a subject that was widely discussed. People with mental illness are no longer considered “nuts.” People dare to ask for help and trust psychiatry, so much so that today, there are no ways to meet the demand. This massive demand for consultation is unprecedented in the history of psychiatry. And, for the first time in 150 years, a woman – Kerstin von Plessen– is at the head of the Department of Psychiatry. This is a strong signal: the feminization of psychiatry also marks a turning point in representations of mental health and care. We believe it is a positive sign for the future!