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Dorothea Dix

Crusader for patients with mental illness

Strickler, Jeff, DHA, RN; Farmer, Tracey, MSN, RN

doi: 10.1097/01.NURSE.0000549724.14939.d8
Feature: Pioneers in Nursing

Prepare to be inspired by this 19th century nursing icon.

At UNC Hospitals Hillsborough Campus in Chapel Hill, N.C., Jeff Strickler is vice president and Tracey Farmer is a clinical nurse education specialist.

The authors have disclosed no financial relationships related to this article.



“If I am cold, they are cold; if I am weary, they are distressed; if I am alone, they are abandoned.”

Dorothea Dix1

DOROTHEA DIX WAS NEVER formally trained as a nurse, but she was instrumental in shaping the future of the profession—especially in mental health. Dorothea Lynde Dix was born April 4, 1802, in Hampden, Maine, to a chronically ill mother and a father who was an alcoholic, which led to her feeling abandoned by her parents during childhood.2,3 She left home at age 12 to live and study in Boston with her wealthy grandmother. Her extended family in Boston was considered upper class, which gave Dix access to many prominent acquaintances such as Ralph Waldo Emerson, one of the most influential thinkers of the day.2,4

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In the beginning

Dix became a teacher in 1821 and started an elementary school for girls in her grandmother's home.5 In 1824, she published a popular guide for schoolteachers, Conversations on Common Things, or Guide to Knowledge: With Questions.4 In 1831, she founded a secondary school within her own home.

Despite her teaching success, she suffered from frequent episodes of “malaise,” which eventually interfered with her ability to function.4 Today, her illnesses would be recognized as clinical depression, which may have provided the impetus for her interest in advocacy for people with mental illness.3,5,6

As was traditional at the time for those with means, Dorothea's physician suggested she travel abroad for treatment and convalescence. In England, she was hosted by William Rathbone, a politician and social reformer.4,6 Her convalescence was an influential time in Dix's life. She overcame her “malaise” and thought it a direct result of her environmental surroundings and the compassionate care she received. This experience formed the framework for her ideas surrounding care of those with mental illness.6

During her time in England, Dix met and was influenced by English prison reformer Elizabeth Fry. She was also acquainted with an influential Quaker reformer, Samuel Tuke, whose family had established the renowned York Retreat for the treatment of those with mental illness and promoted the use of “moral therapy” to ameliorate or cure mental illness. Dix also adopted this mindset.4,6,7

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Heeding a call to action

Dix returned to the US upon the death of her grandmother in 1837. A few years later, a young clergyman asked Dix to begin a Sunday school class in the East Cambridge Jail in Massachusetts. While at the prison, she witnessed prisoners with mental illness treated inhumanely. Many were unclothed and housed in darkness without heat or sanitation. Some were chained and flogged. A shocked Dix voiced her concerns to the jailer, who told her, “lunatics cannot feel the cold.”7

For the next 2 years, Dix toured jailhouses, almshouses, and poorhouses in New England to collect data from her direct observations of patients with mental illness.4,6,8 On Dix's many tours, she witnessed patients with mental illness housed alongside criminals in similarly deplorable conditions. Dix shared the Unitarian view that prisoners who committed crimes could achieve moral perfection through optimal environmental influences.8 She believed removing bad environmental influences would give prisoners time to reflect on their crimes and cure them of their mental illness.8 Dix also believed that intellectual and social stimulation should be part of the treatment.2

Dix found that many prisoners had a mental illness. She began conducting research that focused on two distinct problems: care of those convicted of a crime, and care of people with mental illness.9 Her work improved standards of care for those with mental illness in the US and Canada and initiated the systematic recording of observations to elicit support for humane treatment.9 She lobbied federal and state governments for better conditions for prisoners and those with a mental illness by compiling manuscripts of her “objective data” and, in a time when only men held elected office, found legislators sympathetic to her cause to present to state legislatures.8 In 1843, Dix submitted a report documenting her findings to the Massachusetts state legislature.

Dix successfully lobbied state governments to build and pay for mental asylums, and her efforts led to a bill enlarging the state mental institution in Worcester.8 She then moved to Rhode Island and later to New York to continue her work on prison and mental health reform. In 1845, she published Remarks on Prisons and Prison Discipline in the United States to advocate for continued reform.5

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Wartime leadership

In 1861, at the start of the Civil War, Dix was appointed superintendent of the female nurses of the Union Army.2 In this capacity, she recruited 3,214 women for an all-volunteer corps of nurses and organized hospitals for wounded soldiers.9-11 She was ill-suited for administration and had great difficulty with the post, primarily because she was challenging the contemporary convention of medical care as a woman working in what was then considered a man's field.5 At this time, nurses were not recognized as having military rank but were given the power to organize hospitals to care for soldiers, appoint nurses, and regulate donated supplies.9

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Enduring legacy

After the Civil War, Dix spent her remaining years continuing her work to improve the plight of people with mental illness before retiring at age 82. She died on July 17, 1887 at age 85 and was interred in the Mount Auburn Cemetery in Cambridge.5,12

Dix is recognized as a pioneer for her achievements in mental health advocacy and mental asylum reform. She relentlessly lobbied for humane conditions for prisoners and those with a mental illness.2,7,8 Dix criticized those with opposing views, arguing that their data were subjective while her data were objective and used firsthand accounts.8 Ironically, Dix never involved herself in the movement to abolish slavery or women's rights matters, although she embodied achievement for women by demonstrating success in social activism and reform.13

By 1880, Dix was responsible for creating 32 of the 123 mental hospitals existing in the US at that time.2 As a tireless patient advocate who surveyed the needs of inmates with mental illness and prisoners, she used objective data to compel legislators to action—a model that resonates today.

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    13. Howe DW. Making the American Self: Jonathan Edwards to Abraham Lincoln. Cambridge, MA: Harvard University Press; 1997.
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