In a recent article entitled, “US: Care lacking at troubled Washington psychiatric hospital,” that appeared in many Northwest and national USA news sites and sources, the continuing troubles at Washington state’s Western State (psychiatric) Hospital were documented. Speaking as a psychiatrist that recognizes both the still present need for inpatient psychiatric beds and treatment, as well as the past history of state hospital abuses, I am again troubled by the travails of this hospital.
For the reader, I wish to add a little background. This hospital is very large, over 800 beds and serves a rather large if not huge area as big as some countries. It has had all kinds of troubles over the last several years. It almost lost its federal hospital accreditation a few years ago. Loss of such endorsement in the USA means that a hospital is not able to bill for services rendered to patients through the American-federal insurance entities of Medicare (for American elderly) and Medicaid (for the American poor, those on “welfare,” the derogatory term in the USA for aid to the poor).
The news detailed that this hospital will lose up to $53M in the coming financial year which runs from July 2018 until the end of June 2019. That, in turn, means that Washington State will have to make up that money to the hospital to keep it running. And for the wondering reader not well acquainted with the American health care system, such a public hospital can NOT close. Services of psychiatric care cannot stop for obvious reasons.
The article referenced above gives a good deal of the history behind this unfortunate development which I will not go into. I wish to give the reader some semblance of explanation of why this has happened. The reader will need to have a historical viewpoint. The problems of this hospital did not start a year or two back…They have been longstanding to say the least.
Like many state hospitals in the USA, Western is located out in the countryside, quite a distance, meaning usually up to a hundred or more miles from the nearest urban area. This means that the labor pool un its area, including its home city, has a quite small metropolitan area from which to draw employees for hire. And this state hospital like most, has to employ hundreds of health workers. My own state hospital of my employ has 1,200 employees!
As a corollary in our modern society that now is overwhelmingly city based with all the ‘amenities’ thereof, is a harder sell to prospective employees. Few persons want to uproot themselves and move to a much smaller city or town and give up the modern shopping centers and such.
Currently, salaries for the professional working class are moderately lower in state psychiatric hospital settings than comparable urban areas. For nurses, physicians, physician-psychiatrists, across the economic board. Western State Hospital has long had psychiatrist shortages and nurse shortages. A few years ago the hospital had to suddenly close wards totally a hundred beds or so. No psychiatrists to see the patients…The salary issues had prompted several, ?seven or so, to move themselves and their skills to a VA (Veteran’s Administration) hospital in another part of the state because the VA hospital pay was SO MUCH HIGHER. Western State could not compete.
Another issue that has hurt Western is that the hospital structure itself is housed in a building that is many decades old, some dating back to the late 1800’s. This circumstance is actually NOT all that unusual in the USA. Most of the American state hospitals originated in the state hospital building boom after 1870 or so. [My own state hospital’s main building just a connecting walkway away from the building I work in, was built in1875. It is a gorgeous building that fortunately has been masterfully maintained].
Washington state’s governor, Jay Inslee, has labored mightily for several years to help correct the situation. He has worked with the previously reluctant legislature to increase funding which still needs far more generosity on a permanent basis. Implicit in this last sentence is a hint. Psychiatric state hospitals in the USA have long been underfunded.
Worsening this chronic pattern has been that in the last 20 years or so since the first ‘recession’ of the dot com era’s origin in 1999, states’ tax intake has shrunk. With each wave of recession in the American economy, states in the federal union that is called the United States, have had to drastically tighten their budgets. Public healthcare including state psychiatric hospitals, highway construction funding, financial initiatives in public transit, and education have taken very significant hits.
The results have been the kinds of delayed consequences that are exemplified in Western State Hospital’s evolving plight resulting in its delayed de-accreditation. This slow train wreck in public state hospitals is developing at a number of other state psychiatric hospital systems. Few states are doing what it takes to rebuild, revamp and replaces their aging, falling down facilities. The solution in the majority of states especially in the Northeastern United States has been to close many facilities. This has had the predictable result of throwing hundreds of essential inpatient psychiatric beds into thin air. And this is where the huge increase in mentally ill came from that now occupy jails and are homeless on cities’ streets.
So another basis for the de-accreditation has been that the physical plant of Western is so old and faulty that buildings are not safe and are hazards to residents and employees’ well being.
Through the wonders of my trusty Google Search Bots, I was made aware of a book published by a regional university press. Upon linking to the press release for this book, I realized that in another less totally “connected” world in my past lifetime, I would have never known of this literary gem. This book, as fascinating and scholarly as it is, appealing to my personal historical interests and professional psychiatric mental health reform history, likely will have an undeserved narrow readership. But in my own literary zeal, I hope to support this author’s superb scholarship efforts in this field by calling attention to her wonderful book and read.
The book I am speaking of is “The Crusade for Forgotten Souls: Reforming Minnesota’s Mental Institutions, 1946-1954,” by Susan Bartlett Foote. This book is published by the University of Minne- otaPress, Minneapolis, MN, 20108.
There exist dozens of books in print on the history of mental health reform, state hospitals, asylums, and so on. Additionally, there are many out of print books to be had by the student of mental health reform, thanks to the incredible networked of bookshops and sellers on the Internet. I have long been a student and collector (to my wife’s everlasting anti-hoarding tendencies) of antique and historical tomes on psychiatry, mental health, and psychoanalysis. In past decades when I first had my interest kindled in this scholarly effort by two mentors. These two far-sighted supervisors and teachers cultivated the awareness in me that many surprising answers and relevant insights could be gleaned from the acquaintance of the historical efforts of predecessors in our field and any area of human endeavor and understanding for that manner. To fuel my collecting and voracious reading appetite, I relied on one publishing and book reseller business in New York City (natch, where else?) as the only source for my dogged blood hound collector impulses. That business still exists, but sadly I utilized them far less often as their range of books seems narrow to me these days. But they still “cover” the field of psychiatric writers that I can find nowhere else so my loyalty to them persist.
This book serves as a scholarly, historical prod to this reader of mental health reform history because it is a unique book. It is not dry documentation of events as some books in this arena can be. Any area of historical review and retelling for a contemporary audience runs the high risk of taking the easy route of simply cataloging events. At least some of the history textbooks of my youth were such tediously boring examples. Like many youths of that era, I could not understand why anyone would want to study history. What saved me was experiencing the teaching of history of other countries and cultures in schools overseas. I was awakened to the rich stories of the Middle East and of the British Empire in different schools. I returned to the US at the end of my high school years and dove into America political history in the only history course before university studies that hooked me. I focused on two area, the Civil War and the formation of the American system of government in the Revolutionary period. These interests prepared me for looking at my profession of psychiatry in a historical manner that afforded me a much deeper appreciation for even the most routine daily efforts in my work with patients and systems.
One of the first lessons that are highlighted in Ms. Foote’s book is the lost refrain that mental reform is not a new current of our time. Every generation of reformers seems to suffer initially from the realization that their efforts often have been duplicated in past eras. The helpful grace of this intellect and psyche warming circumstance is that any contemporaneous effort can be buttressed by learning from the directions of past efforts and their successes and failures.
Another lesson that is more sobering is that past reforms led to acclaimed successes that were much celebrated. Politicians, reformers, and those who implemented the changes bourne out of the results of the reforms felt early on that changes they had all worked so hard to accomplish would go a long way toward solving the problems that initiated the zeal of reform.
But the efforts did not lead to lasting change. In the state mental hospital orbits, reality overtook even the best of intentions.
Ms. Foote weaves a masterful story of a period of years in the pre-deinstitutionalization era, up to the early 1950’s. This makes for a truly engaging and fascinating read. Many different tides of motivations and ideologies are described. They range from social reformers of the 1800’s such as national figures like Dorothea Dix to a more intimate portrayal of local Minnesotan figures that were unknown to me. One of the other historical tributaries for the unique critical mass reached in Minnesota in the post-WWII years, was that of the singular religious community in the state, largely not existing elsewhere in this country except for the Quaker communities who pioneered mental health reform as early as the 1700’s.
One notable feature of Ms. Foote’s book helps stories of patients’ lives to come alive as few other books I have read. The second chapter has vignette life stories of several patients all ably researched from superb sources that the author read herself in unique local venues in Minnesota.
Only one other book I have seen rivals this book as far as an unusual source of person based history which I find to be the most interesting kind…That other book with such storytelling power is “The Lives They Left Behind: Suitcases from a State Hospital Attic,” by writer by
In my journey through my training centers becoming a psychiatrist, I was accidentally graced that my medical school and subsequent residency centers had medical libraries with superb historical collections. There are a number of other medical school libraries who have similar collections. At Michigan and then at Duke, I found myself spending empty hours reading histories of medicine and then psychiatry in the rarefied collections rooms. These left an indelible mark in my reading appetites that have lasted my entire professional life.
The past five decades of exposure and experience have faced me with the enormous shifts in practice models, the wrenching changes in mental health service delivery since the 1950’s, and continuing dilemmas posed by seductive national solutions that brought with them worsening problems. The overall shift in western mental health care has swung from outpatient care for the well-off seen by private practitioners, the subsequent mental health center movement for the general populace from the 1960’s through the 1980’s, and the even larger but mostly unseen segment of public inpatient psychiatric hospital care that dwarfed all other portions of the mental health care pie. This last “market” underwent the most severe changes of all. By the latter 1960’s the movement to close state psychiatric hospitals was underway fueled by the new sociologic analyses of authors like Erving Goffman and the emergence national awareness of the wretched, medieval conditions of state hospitals and wretched treatment of patients. Commitment laws came to be humanized with respect for patients’ rights to legal representation after the 1974 Supreme Court Wyatt vs. Stickney decision. De-institutionalization, the discharging of inpatients from state hospitals proceeded through the 1990’s, eventually emptying states’ psychiatric hospitals of roughly 4/5 of their beds, closing old hospitals in wholesale fashion.
Many figures played major roles in this profoundly important movement. R. D. Laing in the UK tried treating schizophrenic patients in more open, experimental settings. Typical of those times, whether in state hospitals or a number of private free-standing hospitals, patient governments were formed. Patients were encouraged and helped to make many personal and treatment decisions for themselves. The “therapeutic community” movement arose out of, and in parallel, grew from this non-authoritarian, more democratic hospital life. Hospitals were opened up to the community. Echoing rehabilitation practices of nearly a century before, patients were permitted to work and earn money. Social activities were begun with the return of art, dance, crafts, and musical pursuits.
One very influential source of the de-institutionalization movement in psychiatric hospital care came from Italy in the 1960’s. This piece of psychiatric history is little known in the USA.
The Italian psychiatrist who pioneered many of the components of radical change in public psychiatric hospitals was Dr. Franco Basaglia. His story is nothing short of fascinating. As is so often the case in the culture of Italian figures no matter what their field of endeavor, his crusade began to take shape in his younger years being exposed to different mass political movements and periods of social upheaval in Italy. He was born into the fascist periods of Italy before and through World War II. He absorbed radical social concepts from the communist and socialist movements of post-war Italy. These concepts guided him to become the effective psychiatric reformer that led to his national fame and regard. This kind of personal development would be viewed as heretical, treasonous and would prevent any achievement in this conservative America. But in Italy, Basaglia’s social-intellectual development made perfect sense.
Basaglia did all the things we think of radical in a wretched state hospital. He empowered patients, tore down fences, did away with tortuous physical treatment, had patients go into the community and so on. He did all this in a true backwater town on the northern border away from any and all big cities and centers of thought and social change. He worked for several years in isolation and obscurity. Then through a fascinating chain of fortuitous events, his efforts began to be noticed and the powerful beacons of the press and celebrity status quickly enveloped him, his work and his staff.
His efforts came quickly to be acclaimed and trumpeted nationally and internationally. His influence in Italy was far beyond that of any of America’s famous reformers such as Dorothea Dix, Nelly Bly, Erving Goffman, Laing and all the others. Italy responded with the national social change that has only been equaled in the Scandinavian countries, not France, nor the UK and especially not in the United States.
With a few years, a reform law was passed in Italy named after Basaglia. It set the national goal of the closure of ALL the public state psychiatric hospitals!
This was indeed fully accomplished, a feat that is beyond astounding in the annals of national social change. For several decades now in Italy, there have been no mass hospitalizations of the chronically mentally ill. There do not seem to be hundreds of thousands of “CMI” (chronically mentally ill) persons everywhere on the streets of Italy. Somehow Italy with all its frequent political crises, changes in governments, scandals, raucous politics and all the other tumult that seems par for the national life of Italy, has done what other western societies cannot care pretty well for the nation’s mentally ill.
I would refer the reader who might be interested in the history of Dr. Franco Basaglia and the “reformation” of Italy’s national mental health de-institutionalization and revolution to the writings of Prof. John Foot of the University of Bristol in England. His book, The Man Who Closed the Asylums: Franco Basaglia and the Revolution in Mental Health Care is well worth the read. An online article published in VERSO, “Closing the Asylums,” gives readers a worthy overview into Dr. Basaglia, the times and his accomplishments.
Realizing what Basaglia accomplished forty years ago leaves this student of psychiatry, its history, and observer of our current national crises, sad for where we have been trapped by our own hobbling prejudices, resistance to social change and pattern of quickie formulas that led to the all too familiar conundrum of “unintended consequences,” and bigger and more complex messes with each year in mental health care delivery.
A somewhat new trend has been emerging over the last 1-2 years and is becoming more of a force in mental health reform. That trend is the efforts of private and state-private psychiatric care systems to try to preserve and add psychiatric inpatient beds in their areas. The efforts testify to the need for more psych inpatient beds almost everywhere. They are also confirmation of the huge national mistake that has been made in the previous 40 years or so nationally to close inpatient state hospital psychiatric beds.
I will first set the stage, reviewing some of the factors leading to a national inpatient bed shortage. Second, I will discuss two recent differing state systems’ efforts to add or preserve inpatient psychiatric services. One is a novel success story that bears study, and the other is a looming failure that illustrates some of the factors that persist that impede this kind of mental health care system delivery. Lastly, I will conclude this lengthy piece, reviewing why the national loss of inpatient beds happened, contrasting what occurred in the public arena, which is so well known, with what happened in the private psychiatric treatment bed world. Continue reading “New Psych Beds Still Needed Nationwide; Two Differing Solutions”
At times I like and choose to highlight short advocacy pieces that are opinion pieces written regionally that are so eloquent I feel they are worth sharing. They also serve as crystal clear reminders that mental health reform issues are really quite universal in our country.
One such piece was just published in The Buffalo News just today, August 30, 2017, still during the continuing agonizing events of Hurricane Harvey down in Houston Texas. This is a Wednesday as I write this and it has been raining in the Houston now for 5=6 days straight with over 50 inches all told having fallen in many areas, covering now up to 50 counties. It is dawning upon all of us, and without a doubt that domestically this may be not only one of the “defining issues” of the Trump Presidency but likely one of the “dominating” social issues of his tenure. The initial help efforts have been monumentally large, fast in onset and heartening to all who witness the “citizen” led and self-initiated efforts portrayed on the news outlets.
The infrastructure costs and time to repair will be higher than anything this nation has ever seen and will clearly take years. This is an incredibly sobering realization for this country which is many ways been spared because of its temperate climate the magnitude of many natural disasters that seem to inflict cruel pain and hardship on poorer regions of the world such as Bangladesh’s almost annual massive floods, displacing up to a million people during its monsoon season. I mention this because it is also happening there this very week also.
But there is another thread that I wish to emphasize in this post as no doubt many other citizen writers/bloggers and most of the national media will discuss and likely also argue over for a few weeks. That is the national physical infrastructure that has been neglected and minimally maintained in most parts of the country for a number of years if not decades. Urban plumbing, water systems, waste treatment capabilities and plants, water resources, roads, highways, airports, and bridges have come to be on the minds of governments at local, state and national levels.