Contrarian Thoughts on the State Mental Hospital System: We Still Need Them

The state hospital system in this country began as an attempt in various of the early 13 colonies and later the early states as humane, for the most part, attempts to house the mentally ill. Williamsburg VA, now the site of Eastern Virginia State Hospital and a  similar facility established by the Quakers in Philadelphia were two of the earliest efforts. There was no effective treatment until the advent of ECT (electroconvulsive therapy in the 1940’s and 1050’s with its own then shortcomings and crude, barbaric techniques till refined later, and the advent of psychiatric medications starting with Thorazine, Valium Elavil etc., in the 1950’s.

By this time even the best efforts of Clifford Beers a man who had recurrent psychotic mental illness and wrote in the early 1900’s the first widely read autobiographical account of his onw psychosis which was a national sensation as it described basically for the first time for the public, the pain of being mentally ill, and Dorothea Dix the great crusader for the mentally ill the lattter half of the 1800’s, fell short of preventing the average state hospital from turning into a facility for containment, incarcertion, etc., of the mentally ill. The famous book ASYLUM was published in the fifties and cranked up the debate over “institutionalization” and debasing treatment of the patients in the average state hospital. This fueled, the movement to get patients out of state hospitals, then beginning to be thought of as cruel institutions and less as places of possible treatment or early rehabilitation. This book came on the national scene at the “right” time, caught the attention of the public, politicians, advocates and helped to state the partial dismantling of state hospitals nearly every where. Bed numbers were reduced from averages of a few thousand beds per hospital, as many state hospitals were indeed massive. Smaller was thought to be better and bed numbers through the second half of the 20th century over time came down to the hundreds. And this does not include the dozens of institutions that were outright closed, because of revelations of abuse, mistreatment, no treatment, subhuman conditions, and “warehousing.” The Comprehensive Mental Health Center Act of 1963 was enacted as one of the last major pieces of legislation of the JFK Presidency. Smaller treatment-oriented facilities were to be built all over the country by the hundreds, often to be linked up with major medical centers. One of the earliest community psychiatric hospitals so built was Marshall I. Pickens Hospital in Greenville SC next to Greenville Memorial Hospital. They both still exist today; GMH is the major teaching hospital because of its size and faculty, of the University of South Carolina at Columbia. The opening of Marshall Pickens Hospital was graced by the presence of no less than Hubert Humphrey in the early years of Lyndon Johnson’s administration after the assassination of President Kennedy.

However, like almost ALL  subsequent mental health reform efforts in this country, the remainder of the projected “community mental health resources” were not built save for the country by county outpatient mental health centers. The Vietnam War came along and funding for the projected mental health facilities was sucked into the giant bottomless vortex of the budget for Vietnam.

The national system limped along as the private sector began to pick the slack especially in university medical school hospitals as psychiatrist trained after WWII and through the 1960’s and 1970’s began to emerge in decent numbers. Private psychiatric national treatment chains like “NME,” National Medical Enterprises, and “Charter Hospitals,” and many other single private treatment centers emerge as the world of mental health treatment took off as more and avenues of treatment emerged, but mostly for the public with health insurance. The private system basically shrank or collapsed. In the 1980’s the highly regarded think tank did a study of the effectiveness of inpatient psychiatric and substance abuse treatment especially for alcoholism emerged and showed the startling results of treatment having a no better than chance, i.e., no better than 50% effectiveness no matter what treatment approach was used, and the recidivism, readmission rate was in the majority. IBM took this and shortly drastically revised its previously unlimited mental health and substance abuse health insurance coverage and limited inpatient coverage to basically in the more strict plans on ONE 30 day admission per lifetime. After that if one relapsed one often was fired. So the “free ride” as it were was over. All the other major insurers adopted versions of this approach of much strict approach of “managed care” of the MH/SA (mental health/substance abuse) benefits birthing the managed care industry that focused on psychiatry first. Hospitalizations over the course of the next decade of so changed or deteriorated in “crisis stabilization’ short-term stays of less than two weeks, then a week at most. Suicide rates after discharge DID go up though this is still disputed by the “vested parties,” i.e., the third party payors. Forced discharged were the norm when “your benefits were exhausted” or “denied” by the insurers. Revenues for inpatient psychiatry and later outpatient psychiatry decreased rapidly in the late 1980’s and 1990’s and trainees saw all this and stopped enrolling in psychiatry residencies in droves. By the early 2000’s less than 500 medical students were enrolling in psychiatry training programs compared to an average of 2500 annually just years before, and the predicted, but unheeded dire warnings of future practitioner shortages fell on deaf, disdainful ears almost everywhere. Patients and practitioners then found out who their friends were not in high places and how powerless we all were back then, a painful revelation.

I will refer the interested reader to superb and evenhanded book on the history of the state hospital movement in the country in anticipation (such an exciting word for such a dry topic), called: The Eclipse of the State Hospital: Policy, Stigma, and Organization by George W. Dowdall. I have it linked to its offering site on for further review. One can buyed used copies of it a reasonable price, but I doubt it is in any but the largest urban libraries in the country. Once again, I need to remind the reader I am not an “Amazon Associate” or “Affiliate” or whatever the term is for bloggers that get a commision for readers’ buying a copy of the referred book. As they say in the South, “I have no dog in this race.” But the next series of post in this blog will take a long look at the past and especially current status of state psychiatric hospitals all over the country. The current evolving circumstance of the state hospital system is now exactly opposite the vision the well intentioned reformists had 50 years ago and this bears informed understanding if one i to have a “handle” on the many dimensions of the near-constant din of crisis over mental health care in the Western World and this country.


Author: Frank

I am a older child, adult, geriatric teaching psychiatrist with over 30 years' practice experience in North Carolina, first at Duke as clnical teaching faculty, then in Western NC as a primary child psychiatry specialist. I have taught and supervised child psychiatrists and psychiatrists in training and many other mental health professionals and taught at two medical schools. I have served in many public and private practice settings. My primary interest is in observing and documenting the ongoing mental health reform efforts in the State of North Carolina and documenting its sucessess and failures at all levels. My favorite pastime among many others is spoofing my friends and kids with my deadpan sense of humor.

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