Were State Psychiatric Hospitals Better 100 Years Ago?

A fundamental intellectual tenet of mine is that to have a comprehensive and ‘honest with oneself’ grasp of historical and social long term processes, history of the subject being studied should be included. George Santayana’ famous quote that those who ignore history are ‘doomed’ to repeat, seems to hold more and more power of truth the older I become.

The history modern mental health care began in almshouses, shelters for the developmentally disabled and intellectually disabled, earliest perhaps by the Quakers of the early 1700’s in Pennsylvania. Theirs was an extraordinary (and still is) ethos of charity, helping those in need and one of the original origins of the philosophy of “non-violence,” embodied in conscientious objects in our wars and taking on the needs of the shunned, ‘repugnant,’ disabled persons who frightened the average person. It is no new concept that state hospitals were built intentionally out of the ‘boondocks,’ the countryside, away from towns so delicate sensibilities of citizens were not disturbed by the sight of unpredictable persons, that in reality before the era of modern treatment in the middle half of the 1900’s NO ONE really understood beyond crude empirical approaches, i.e., “we do not know how but this medicine works on hallucinations so let’s give it for that.”

There are many, many articles, books, some films from the earliest days of the then miraculous, wondrous Brownie 8 movie camera, that record the abysmal conditions of many state psychiatric hospitals in the Western world and the US, Latin America, Scandinavia, Europe and a few other regions and countries where modest efforts at housing the chronically mentally ill occurred. For instance, it is not well known that the famous country singer, Johnny Cash, established and supported an orphanage for children in Jamaica and did so very quietly as a true philanthropist.

If it were not for Google’s miraculous search bots, I would never have come across or read the article to which I wish wholeheartedly to refer the reader. It is from this week’s edition of the English newspaper, The Daily Mail. In the usual British brutal journalistic tradition it has simply ghastly title: “EXCLUSIVE: Chained to their beds with no heat or water, and left to lie in their own excrement: How the 19th century mentally ill were sent to hide away in grisly insane asylums and categorized as ‘idiots’, ‘imbeciles’ or ‘lunatics,’

This article itself is based on what appears to be a singularly striking book with lots of old pictures of life and patients in state psychiatric hospitals in Scotland and England, entitled, ” Lunatics, Imbeciles, and Idiots: A History of Insanity in Nineteenth Century Britain & Ireland, by Kathryn Burtinshaw and Dr. John Burt.

The title really does set the tone for part of the impact of the article that really “rattles your doors,” as a former mentor of mine would say to us green, novice psychiatric trainees.

If you follow the URL link to this article itself in the Daily Mail I think that if you look at the pictures with a discriminating eye from some hints from me, some surprised may ensue for you.

I struggled with myself and thought of just going ahead and lifting the pictures from the article and publishing them here in this post. But that would be being a ‘bad boy’ of me, and against all kinds of information and copyright law. And for all I know, Rupert Murdoch owns this paper and I sure do not want him suing me!

1. But I will summarize the points I think you should look for and grasp. A note of disclaimer: my observations partly come from my teenage experience of a few years serving on a border kibbutz in Israel, near Hadera, Rishon LeZion and other almost legendary kibbutzim and moshavim north of Jerusalem and part of the defense perimeter in the sixties before the War of 1967 when the Israelis survived the collective Arab League attacks and took position of the West Bank. As a “kibbutznik,” half my day was spent in going to high school and the other half of the day was spent in working on the farm and training in the high school Army, kind of like the ROTC but one helluva lot more serious and truly the real thing.

Anyway, the kibbutzim and moshavim were “collective farms,” and most everything was shared. These collectives were in a sense workable socialism or Communism in workable, fair terms. Everything was flat in the governance, there were no Stalins or such. Everybody including the elementary school children worked according to their abilities. It was loads of fun for an American teen. State hospitals for decades since the late 1800’s functioned as socialistic (oh my!) as islands of socialism/communal settlements and self-governing bodies. It worked incredibly well in my view. Patients in states hospital used to work every weekday if they were able, responsible and trustworthy enough on all manner of the farm, raising and shearing sheep, having cows and large dairy farms, large truck vegetable farms that not only fed the whole hospital but were welcome edible merchandise in the local towns where state hospitals were located. “Work placements,” as they were called were HIGHLY COVETED by patients and were rewards that helped humanely shape improved behavior in many a patient before the era of medicines.

2. One will also notice that patients often were dressed in formal clothes. Whether this was intentional propaganda in those days to make state hospital like look as good as the rest of the proper Victorian era, I do not know. But except for pictures in many other collections of state hospital life that I have seen which show the extremely violent patients for which there were few and dreadful management options such as canvas wraps, strait jackets etc. But nowadays and for as long as I have frequented state psychiatric hospitals, NO ONE of the patients anywhere in any state has clothes as nice as those depicted routinely in the piece of pictorial history.

3. And the darker side of those days is fairly and openly depicted as well. The posters and almost “playbills” that call mental patients “imbeciles,” and “lunatics,” jar our modern sensibilities and are a reminder of the tenor of those times.

4. The one notable phenomenon from the olden days of psychiatry that is surprisingly absent from this article is that o the standard bugaboo of electroconvulsive therapy. And for those who have never seen a picture of it, or the movie Snake Pit, which forever burned into the modern western consciousness the then very frightening phenomenon of ECT. Of course, ECT went on to be the focus of every anti-mental health and anti-psychiatry advocacy group since at least the 1950’s spearheaded by L. Ron Hubbard and the Church of Scientology. ECT “mills,” as they rightly called in the 1940’s and 1950’s represented the reality that in the era of the discovery of psychiatric medications, we had nothing but ECT; so, everyone who was really very seriously psychotically ill received ECT. Granted there were certainly dishonest psychiatric practitioners who continued this after the data clearly showed ECT worked best in psychotic depression and less well in other conditions except for full blown supremely violent and dangerous mania that responded then and now to nothing else.

5. The pictures in this article from the Daily Mail seemed to show at first glance, ECT, but actually does not. It is showing the forced feeding of a patient who as the articles explains, was likely psychotically delusional about food and that  thought all food was poisoned, and would not eat. Unless heroic measures were instituted, these patients died period. They are still with us and not all that uncommon. In the last five to six years I have had a half dozen of these patients and they are not anorexics, which most of us now regard as a unique combination of psychiatric disordered brain systems and truly aberrant endocrine disorders of the appetite and satiety mechanisms of the common behavior of eating. The picture in the article shows the patient with a feeding tube down his nose, not so unusual as this is often is used in patients with gastric bleeds etc. But there is a bottle way up in the air, frozen in space hanging from an almost indiscernible set of wires suspending it above the patient.

6. Another feature that is absent from modern state  psychiatric hospitals is that it was very common for staff to live on designated floors in the massive state hospital building and be available to the patients more than the modern 8 hour shift routine. Staff became quite close to patients and many staff often had favorites. Sometimes of course this led to human nature showing itself through sexual abuse as some staff would  take advantage of relatively defenseless staff. But nonetheless, the kinds of closeness  that histories depict almost in all state hospitals, where present employees proudly show pictures of the their ancestors generations ago who were heads of farming programs, members of the hospital’s laundry and sewing and cooking departments or manly members of the hospital’s own fire brigade. Much of that is lost even though in many ways it was quite paternalistic, but again those were the tenor of the times.

7. The article  frankly takes head on the horrific abuses of the state hospitals especially in the hundred and some years from the early to mid 1800’s to the 1960’s. Tales of patients in England and Scotland being in true bondage, restraints or boarded or bricked up in tiny areas with almost no care at all, make for truly sickening reading.

8. Finally the last part of this era of pre-modern psychiatry talks of the rather useless diagnostic debate that emerged in the later 1800’s concerning the differences among lunatic, imbeciles, idiots. The supposed differences I do not think are even worth detailing in this article. But it presaged and illustrated the emergence of the “alienist” psychiatrist. This sort scary name, almost implying that psychiatrists studied creatures from outer space, doing psychiatry’s “image” no good at all was very misleading to say the least. Psychiatry had evolved into a descriptive discipline and not very scientific except when it came to correlating the effects, say of syphilis, with psychosis and the many neurological deficits syphilis caused.

Psychiatrists typically had hundreds of patients. They became descriptors of psychopathology. They would interview and/or observe patients and obsessively write down descriptions of odd behaviors and the psychotic language of patients. Then they would ponder these and follow the scientific ethos of the 1800’s and attempt to classify the pathology they observed and recorded, similar to all the natural scientists of the day, discovering new species of insects, mammals, amphibians, bacteria all under the growing rubric of controversial evolution.

Many psychiatrists tried to construct diagnostic systems of psychopathology and most of them until the turn of the 1900’s were nothing short of ridiculous. Only the true disciplined thinkers in psychiatry in biological psychiatry such as Eugen Bleuler, Emil Kraeplin, Adolph Meyer and others constructed systems of diagnostic that helped spur research and were in turn confirmed in one arena or another as biological psychiatry began to be able to start to construct tenuous bridges between behaviors and brain functioning.

As an aside the other realm of psychiatry and psychology that of interpersonal work such as cognitive therapy, interpersonal work, group therapy, psychoanalysis, etc., were not practiced nor useful in the state hospital setting as Freud himself asserted at the turn of the century.

So, I still ponder and wonder and roll all this past history juxtaposed against the present state of the present day state psychiatric hospital.

To attempt an answer to the question I posed in my title I will take two positions.

First, in the ‘old days,’ the discharge was roughly 50%, almost the same as it is nowadays. We still struggle mightily and I MEAN mightily at all levels of mental health services and research with the nearly half of patient population who respond poorly and negligibly to almost everything we have in our planetarium. So from the point of view, the state hospitals of decades ago were in many ways as good as our modern centers of treatment delivery. But they were indeed better if you think what it would mean to patients to be able to get out of the hospital and the stifling, boring confines of units on a frequent if not daily basis. The civil rights advocates yelled the highest battlements and fought like legal tigers against patients being able to work (oh my God, I guess that is a sin to work…). All that was based on some instance of true exploitation of patients for the profit of the hospital or the director or some greedy SOB somewhere. I have heard such advocate even before I went into psychiatry and medical school in the 1960’s compare having state hospital patients work to the exploitative, cruel work gangs at Parchman Prison supposedly the most brutal jail in this country. And last time I heard anything about Parchman, things are not much better but I hope I am wrong.

So we had a sociological advocacy movement by a new kind of lawyer class who established a new norm and standard with unintended consequences that in my old fashioned view were very  wrong.

This class of legal advocated in my simplistic view evolved into the ACLU and like organizations. And surprise, this veteran psychiatrist thinks that has been a very very good thing.

The other side of my answer to this vexing and troubling question of the comparative efficacy [effectiveness of treatment] of older and more modern state hospitals, si that our new types of treatment have indeed helped restore better non-institutional lives to hundreds of thousands of persons with mental illness. BUT we have thrown the baby out with the bathwater in our zeal to move away from the collective model of treatment in large communities-institutions with the DOZENS of treatment approaches that smaller psychiatric units which were supposed to the SAVIOR and replacements for banishing the state hospitals into the dustbin of history. Smaller units cannot aggregate physical therapy, occupational therapy, specialized and different groups therapies, psychodrama, group family therapy, specialized units for the violent and the horrific self abusers-cutters-inserters of foreign objects-swallowers, rapid cyclers, assaulters. Private psychiatric units in general hospitals, and even the smaller regional state sponsored short term crisis units simply cannot handle these extraordinary individuals.

So it is a mixed bag and an enormous task for states that have slashed state psychiatric inpatient beds, closed hospitals unwisely [though many closures were forced on states since the hospitals were literally falling down].

Now the penurious state dominated by the ethos and political ideologies of deferring these kinds of needs for decades are now having to face the music. They must drastically expand again their inpatient statewide systems and construct community-based housing and comprehensive treatment and supervisory systems mostly never seen before.

So, in summary, we have made progress but population growth, failure of outpatient systems and trans-institutionalization from hospital to emergency rooms and jails have obliterated much of the mental health service delivery systems that worked up to a point. As Dr. Harold Carmel MD, formerly of Duke University Psychiatry said prophetically almost ten  years ago, “it will take 10 years to get to where we were 10 years ago.

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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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