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Amongst the most neglected groups in the USA are the chronic mentally ill. A substantial number are homeless, psychotic, physically ill, and unable to fend for themselves. They cannot organize politically, and have few advocates.
According to Sisti and colleagues, in 1955, 550,000 chronic mentally ill people lived in state hospitals; today, with a marked increase in the population of the US, only 45,000 chronically mentally ill people reside in state hospitals. Sisti and colleagues estimate that this is a decrease of 95% (1). The state mental hospital is becoming extinct.
Psychiatry as a specialty was born in hospitals for the mentally ill in the early 1800s. Later in the century it was believed that the beauty of the asylum itself was a major part of the treatment of mental illness (2). In the early 1900’s, state hospitals were built with beautiful entrances, and soaring lobbies, in beautifully landscaped park-like settings. The hospitals were self sufficient: patients grew their own vegetables, cared for farm animals, and produced much of the clothing and implements they used. Almost every state in the country had a state hospital for the mentally ill, and most had many. The hospitals were mammoth in size and built in rural areas. Obtaining support to have a hospital built was a political and financial triumph for a community. The increase in civic pride that came with the construction of one of these hospitals in a particular area may be analogous to the excitement that surrounds the construction of a major sports stadium in contemporary life. For many who lived in rural America in the late nineteeth and early twentieth century, the state hospital may have been the largest building ever seen. The hospitals issued picture postcards, and collections of these postcards continue to be displayed at current meetings of the American Psychiatric Association.
In the second and third decades of the 20th century there was great demand for state psychiatric hospital beds; the hospitals became severely overcrowded. The care of the patients declined greatly along with the state hospital’s reputation. The unkempt state of the patients and the poor care they received increased the fear and stigma of the hospitals and of mental illness. Fear of state mental hospitals was common among the general public; people dreaded the possibility that they or their relatives might have to be confined there.
Several influences came together to insure the decline of the state hospital system. First, there was an intellectual argument against state hospitals. Foucault, an influential French critic, argued that asylums served no role in treating patients and were a holdover from earlier centuries in Europe in which the Church housed the mentally ill as a means to generate income from real estate holdings. Goffman, an American sociologist, believed that the institutions that housed the mentally ill were in many ways responsible for creating the mental illness (3).
Reflecting the growing distaste for state mental hospitals was the development of the landmark Community Mental Health Services legislation under President Kennedy. As described by Torrey, this legislation largely ignored state hospitals and the patients who lived there. Although community mental health centers were intended to allow for patients to be released from hospitals and cared for in the community, there were no representatives from state hospitals involved in the creation of the legislation. The community mental health centers were developed and designed by people who had no experience caring for the types of patients housed in the state hospitals (4). It seems that the status of the state hospital had declined to such an extent that it was assumed that anyone involved with state hospitals could not have anything useful to contribute.
Before the Kennedy Community Mental Health Centers act, care for the mentally ill was funded by the states. The passage of the act created federally funded community mental health centers. This change in the funding stream from the states to the federal government created a major financial incentive for the states to discharge the patients from the state hospitals to the community mental health centers. States were eager to relieve themselves of the financial burden of the state hospital system. But the community mental health centers failed to address the needs of the seriously mentally ill discharged state hospital patient.
The development of psychopharmacology in the late 1950’s created a sense of optimism about the ability of medications to cure or alleviate mental illness. The medications helped but were often accompanied by intolerable side effects. Also, many patients were left with disabling symptoms that could not be helped with medication Often patients refused to take their medications.
Media contributed to the low regard in which the state hospitals and their patients were held. The movie, The Snake Pit, led to this term becoming a synonym for appalling mental health residential care. The book and movie, One Flew over The Cuckoo’s Nest, supported this view.
The state hospital has succumbed to the wrecking ball of real estate developers; there are no mourners. The chronically mentally ill are housed in jails. Prisons for criminals are unsuited for the care of the severely mentally ill. Thought must be given to the optimal care for these individuals and the financial resources must be found to insure that it is provided.
References
1) Sisti, D.A., Segal A.G. and Emanuel, EJ. Improving long term psychiatric care: Bring back the asylum. JAMA. 2015 313:243-244.
2) Shorter, E. A History of Psychiatry Wiley: New York. 1997. PP 1-68.
3) Sacks, O. Asylum, Introductory essay to Payne, C. Asylum: Inside The Closed World of State Mental Hospitals. MIT Press Books:Cambridge, Mass. 2009.
4) Torrey, E.F. American Psychosis: How the Federal Government Destroyed the Mental Illness Treatment System. Oxford University Press. Oxford. 2014.
Copyright: Stuart L. Kaplan, M.D., 2015.
Stuart L. Kaplan, M.D., is the author of Your Child Does Not Have Bipolar Disorder: How Bad Science and Good Public Relations Created the Diagnosis. Available at Amazon.com.
Picture credit: Norristown State Hospital Postcard, Wikimedia Commons, Smccphotog.
