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Book Review   |    
Jennifer Neuwalder
Psychiatric Services 2009; doi: 10.1176/appi.ps.60.8.1147
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by Carla Yanni; Minneapolis, University of Minnesota Press, 2007, 256 pages, $82.50

Dr. Neuwalder is affiliated with the Department of Psychiatry, University of Massachusetts, Worcester.

Carla Yanni's recent book, The Architecture of Madness, provides a lucid history of state asylums in the United States, from the 1770s through the late 19th century. An architectural historian by training, Yanni emphasizes the formal organization of asylums as built manifestations of the prevailing technological advances and moral hypotheses of their times. The scope of Yanni's scholarship is impressive, and her writing is accessible and clear. Her introduction explores socio-ideological contexts that underpinned "the architecture of madness." She qualifies her undertaking, emphasizing that most asylums were not designed by big-name architects and that she covers neither "inebriate asylums" nor "idiot asylums," which were distinct from asylums for the "curably insane." Her task was complicated by the fact that many of these buildings are in disrepair or have been torn down.

Chapter 1 begins with London's (in)famous Bethlem, the oldest psychiatric institution in Europe and the epitome of pre-Enlightenment, brutal approaches to madness. Yanni moves briskly into an overview of late-18th-century British and French institutions, modeled on the Enlightenment ideal of "moral treatment." She concludes with England's York Retreat, which ushered in a model of psychiatric hospitalization embraced by American "alienists," characterized by separation from society, a healthful environment, and avoidance of mechanical restraints. In chapter 2, the Linear Plan (or "the Kirkbride Plan") takes center stage. Linear Plan is a misnomer, because the design is more of a V shape, with the "center main" at the apex, which housed the superintendent, chapel, and public parlors. The wards, stepped back from either side of the center main, led literally to the "back wards," those reserved for the most treatment-refractory patients. Kirkbride's asylums, intended to house 250 patients, embodied principles of "environmental determinism," such as morally uplifting rural outdoor environments, with paths, gardens, vistas, light, ventilation, and views of natural beauty from all rooms.

Chapters 3 looks beyond Kirkbride to the Cottage Plan. As the 19th century progressed, the contiguous, often oppressively monolithic, linear-plan structures were replaced by smaller building units, in parallel with university campus design of the same era. Chapter 4 continues with the culmination of the Kirkbride Plan on a scale previously unimagined, with an officially sanctioned census of 650 that often exceeded 1,000. Each chapter is punctuated with photographs and architectural plans of individual buildings as well as master plans of hospital grounds. An appendix shows the plans of five asylums that are representative of different periods, and the shift in scale is dramatically apparent.

Yanni concludes with an overview of state psychiatric institutions' more recent past, including deinstitutionalization, the advent of the clubhouse model, and how we as a society remember asylums and the people who lived, and often died, within their walls. Yanni's work raises many questions worthy of future study: What do state psychiatric hospitals mean to society today? What solutions have contemporary architects found for the issues of containment and rehabilitation in an age that favors community psychiatry over long-term hospitalization? In the end, although the fashion of architecture may matter less than it did in the 19th century, the elusive potential of environmental determinism remains.

The reviewer reports no competing interests.

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