Ms. Megan Hart of the Kansas Public Radio Station KCUR and the group Heartland Health Monitor partner KHI News Service has been following and chronicling the long sad story of the Osawatomie State Hospital in Kansas for quite some time now, nearly two years or perhaps longer, that this writer has been aware. Ms. Hart’s latest article, “Osawatomie State Hospital: A Leading Light for Mental Health Care Slowly Dims.” published July 25, 2016 documents very ably both the issues of this state hospital, its parent state, and the social vise that all too many such state hospitals more or less find themselves facing in this time of hoped for reform.This piece of American state hospital history is in many ways not unique to the fascinating and very checkered social history of the American state psychiatric hospital for public inpatient care of the seriously and chronically mentally ill.
Basically, like most state hospitals started in this country in the 1800’s, the hospital was started to have an organized place to house the “insane,” “lunatics,” and “imbeciles,” or the mentally retarded/intellectually disabled that always make up certain constant percentages of any population. It was thought or rationalized by the late 1800’s that building state hospitals out in the pleasant countryside, had salutary and calming effects on those populations and constituted the ethos of the concept of “moral treatment,” promulgated by the early advocates for the mentally ill such as Dorothea Dix, the champion crusader for the seriously psychiatrically ill. As most readers in this field know, only a few humane settings for these impaired populations existed in this country of anywhere for that matter, with the exception of the early hospitals created and staffed by the Quakers in Pennsylvania and Virginia in the 1700’s in America. But the stigma of mental illness and impairment and the centuries old prejudice toward these populations was perhaps the unspoken driving force for the placement of state hospitals out in the “boondocks,” in the 1800’s, to remove these scary, feared persons and social castoffs from the ‘delicate’ sensibilities of the Victorian era one can easily suppose. On the other hand, there were great perhaps unintended benefits of locating state public psychiatric institutions away from major population centers, afforded and actually forced them to become environmentally, agriculturally and ‘industrially’ self-sufficient. In my mind, given my adolescent history of years in Israel through the experience of having a father who was an internationally sought after specialist mining engineer, and having spent a year on an Israeli border kibbutz, I looked at those years of the state hospitals in the countryside of this nation, as being “kibbutzim for the mentally ill,” and saw it as a good thing. And that aspect of employing the majority of patients who could work and do useful tasks, was indeed healthful and healing in its own way. Patients worked in gardens, large scale truck farms, animal husbandry with herds of everything from cattle to pigs to chickens to sheep and more. Fruit orchards where climates of location permitted were cultivated as well. So the patients and staff all shared the benefits of “useful” [a la our modern children’s favorite character, Thomas the [Useful Engine] Train], jobs, an occupied day which was far better than being herded in hallways, locked units, in restraints etc. The benefits were many. State hospitals often were almost or entirely self-sufficient communities, producing their own food, fiber, leather, and clothing, Trades were taught and learned from animal husbandry and all the usual skills of agriculture, lumbering and woodworking, production of cloth, wool, and tailoring of clothing, and many other trades. Of course, not all patients could have “work placements,” as they were still called in the 1970’s when VA hospitals still employed patients, one remnant of those previous state hospital patient care practices.
But then the idea and ideology that patients were being exploited, as they were often not paid, came to the fore and the use of patients in work settings was seen by the anti-institutional movement as akin to being on a prison “chain gang.” And who knows, perhaps some of it was abusive, forced, involuntary, etc. And it was uncomfortably close in perceptual valence to easily being metaphorically amalgamated with slavery in the plantations, the kiss of social approbrium in this country with its history of slavery and racism. So in the mid to later 1900’s the opportunity of patients to be outside, to work, to be usefully occupied, to learn a trade [keeping in mind that such activity and involvement might be the ONLY vocational experience/education any might receive in their entire lives,…came to disappear.
Nowadays in almost all state hospitals, except very progressive ones who truly have many phases of gradual “step-down” levels of care, not much education in the community such as at a local community college, on site in the hospital in remedial education programs, English as a Second Language (ESL) programs, exist anymore. And it is a huge shame and waste of opportunity and human capital. So what do patients do? They go to groups and medication education programs which while helpful and very much needed, are boring after you have cycled through the same material a couple of times…
In my state hospital, there are interesting historical remnants of the ?”good ol’ days,” in that at one side of the campus a short walk from the patient buildings, are the pastures, silos, and barns of the old farm. The hospital has an extensive system of underground TUNNELS, that are in near perfect condition, built of arched hand made brick, with beautiful arched ceilings over 14 feet high, and wide enough to accommodate two horse wide wagons of the late 1800’s hauling, fuel, and all kinds of produce from the outlying farming and husbandry sites of the vast campus of over 7000 acres! They go for a few miles in all directions from the main patient care buildings. And make for great spelunking and caving as this son of a mining engineer and mother-geologist has experienced to the horror of the hospital administrators who have fears of ‘liability’ and other modern bureaucratic realities. One of the tunnels goes for nearly three miles underground, underneath the nearby interstate highway and surfaces in a field close to a typical highway motorist motel! What a juxtaposition of American culture! In my mind, the tunnels on/underneath the campus of my state hospital as I affectionately think of it and call it in my mind, is very much like the Metro in Washington DC, going off in all directions from a central station. And as the son of a mining engineer, it is truly an engineering marvel, and I wish my late father were here to see it. He would love it and tell me even more about it and its workmanship than I apprehend now.
Thankfully also in my state hospital, as I hope still exists in some or many others, is a phenomenon called “work therapy.” Patients who are functioning, on good behavior, progressing up the privilege or level system, are able to request this daily activity. They work in a certain place in the hospital, doing somewhat menial but very much needed tasks such as assembling medical gear, IV apparati and other medical field related articles that industries are kind enough to farm out to our population. And patients GET PAID for their work at minimum wage. And they love it. They can socialize and chat and relax and work. It is great stuff for them all. And like Thomas the Train, they can and do feel “useful.” [I have had a son and now young grandsons who are obsessed with Thomas the Train…Don’t ask me how many times I have watched ALL the episodes, bought all the engines for them endlessly over two generations, and seen and ridden on Thomas as one of his four permanent homes IS here in western North Carolina! So forgive the repetitive references to dear Thomas…]
Back to Osawatomie State Hospital. The article cited above provides one of the best single pieces of tracing the sad decline of a once very good state hospital, a process that has occurred many times before in such institutions. And now Osawatomie has been in serious trouble for some years. Ms. Hart like other current journalists documenting this process in our country as we haltingly try to transition from large institutional based care to community, smaller scale, closer to patients’ homes and families type care, shows how hard this has been. She rightly refers to the decades of legislative and financial (i.e., state budgetary scrimping) that has been much of the origin of the sins and abuses of the state hospitals as their characters reverted to the horrific almshouses and asylums of the earlier centuries, say in Dickinsonian England, a time and place I am thankful I apparently did not live in…
Osawatomie State Hospital did have one unique piece of history that I can attest to. It had the input of the Menningers from over at Topeka State Hospital, also a state psychiatric hospital in Kansas. TheMenningers were a storied family of three generations of revered and learned, humanitarian psychiatrists and all leaders in the field in their day. Sadly, the Menninger Institute, a venerated training center in psychiatry, closed in the early 2000’s, was in perilous financial troubles, and was thankfully bought by Baylor School of Medicine and moved to Houston. I have a sister who lives in Houston and the one time I visited Menninger’s residency program in Houston, it felt weird in comparison to the historical setting of the original training facility that was intimately associated with Topeka State Hospital that closed in 2003 itself. I also had a chance to work in North Carolina in the 1980’s with Walter Meninnger MD, the grandson as part of a forensic psychiatric team courtesy of a forensic psychiatrist supervisor at the time, who gave me the opportunity to work in his place with his famous colleague Dr. Menninger. It was an experience I have never forgotten.
In any case, Osawatomie State Hospital, and Kansas are struggling to revive, save and re-establish the quality of care at that historied facility. It is an effort being repeated all over the country. The reason is, like it or not, we still need public inpatient psychiatric beds by the thousands in this country, a reality not well accepted by the anti-institutional crowd. But their mission to transition to community-based care is the wise course. It is still largely untested. We have not had years of experience with the small-scale model. Nor have we had many many dozens of facilities that do this yet. And the expense of exporting the many specialties of psychosocial rehabilitation to most population centers in this country instead of the relatively isolated but large, “economically concentrated cost centers” known as state hospitals has yet to be appreciated and felt by our new revenue source averse legislators. It will cost enormous amounts of monies to supply all the services and disciplines to bring to bear upon smaller psychiatric treatment and rehabilitation centers. Nurses, psychiatrists, psychologists, counsellors, substance abuse specialists, educational specialists, work coaches, social therapy and community reintegration specialists, public health outreach workers who visit patients monthly and give them their depot antipsychotic injections, social workers, case managers, financial advisors and more readily (truly) available guardians, transporters-drivers to ensure appointment attendance not only for psychiatric care, but also just as importantly, dental and ongoing medical care, diabetic and dietary care workers, disability and rehabilitation workers and on and on. All this HAS to be “institutionalized,” put into place as THE routine standard of care to make this effort successful. If we decide again not to adequately fund this gargantuan budgetary effort, we will have a continuation of what we have now, a broken mental health system, the mentally ill and impaired shoved into places they do not belong or deserve, such as shelters, jails, and streets, costing our nation, even more money than we can imagine now.
So Osawatomie and other state hospitals in trouble, Western State in Washington state, Larned State Hospital, also in Kansas, all bear watching. Their fates will give us strong indications of where all this mental health reform stuff is going to end up. This writer can only hope that the politicos who are always yakking about “leadership,” will begin to exercize a lot of that “Vitamin L,” in a quarter that is not glamorous but very much needed. Their role models need to be Tim Murphy, Mike Coffman, Patrick Kennedy, Rosalyn Carter, Craige Deeds and all the others who have labored in these neglected vineyards now and in the recent modern past.