Mental Health Institutions

Mental Health Institutions. Before the Revolutionary War, most mentally ill persons in the colonies lived either with their families or in local alms houses.With urbanization, specialized institutions emerged to care for the dependent and ill. In 1752, the Pennsylvania Hospital in Philadelphia, the colonies' first general hospital, accepted insane patients. In 1773, the Virginia House of Burgesses established a freestanding “madhouse” in Williamsburg, modeled on London's Bethlem Royal Hospital (from whence the word “bedlam” derives). When the New York Hospital opened in 1791, it too made provision for “maniacs,” along with medical and surgical cases. Charity hospitals' decision to include lunatics manifested the Enlightenment view of insanity as a treatable affliction. Among the best‐known advocates of more active therapeutics was Benjamin Rush, a physician who developed a “tranquilizing chair” to soothe the agitated. Nonetheless, care generally remained harsh; hospitals relied on bleedings, purgings, and emetics to calm the disturbed and often locked in basement cells those considered dangerous.

In the 1820s, a very different regimen, known as “moral therapy,” appeared, first at private nonprofit institutions like the Friends' Asylum at Frankford, Pennsylvania (1817), and the McLean Asylum outside Boston (1818), and then at state‐funded institutions, like Massachusetts's Worcester State Hospital (1833). Inspired by the work of Philippe Pinel in France and William Tuke in England, advocates of moral therapy supported treatment of the insane by psychological methods, in particular a carefully constructed round of activities designed to stimulate patients' latent reason and capacity for self‐control. Specialized lunatic asylums in peaceful, rural areas became the preferred therapeutic setting. By the second half of the nineteenth century, most states and many major cities had at least one public psychiatric institution, while corporate and proprietary hospitals continued to serve the wealthy. As the number and size of state hospitals increased, however, overcrowded wards housed chronic cases: long‐term schizophrenics, the senile, paralytics, and epileptics. As a result, both the internal environment and the external image of the state asylums began to deteriorate. By 1900, hospital superintendents found themselves under bitter attack from other medical professionals (especially neurologists), ex‐patients, and state legislators.

By the early twentieth century, the most innovative psychiatric research was taking place in research institutes, laboratories, and private practice. Psychopathic hospitals, intended to provide acute care, opened in a number of major cities. A mental‐hygiene movement, aimed at promoting general mental health, emerged. Yet, in part because many psychiatrists were uninterested in the severely and chronically mentally ill, state hospital populations continued to grow. Underfunded and desperate for treatments that would control if not cure their patients, hospitals experimented with somatic therapies, including insulin shock, malarial fever, and lobotomies (surgical removal of part of the brain).

Staffing shortages during World War II further exacerbated this situation. During the 1940s and 1950s, however, new drug therapies and the increasing involvement of the federal government began to reshape mental health institutions. Two federal laws of 1946—the Mental Health Act and the Hill‐Burton Act—helped to fund the rebuilding of the public hospital system, the expansion of general hospitals (including psychiatric units), and the development of community services. The hope that antipsychotic drugs, like chlorpromazine, and antidepressants, like reserpine, would enable the long‐term mentally ill to return to their communities prompted state legislatures and mental‐health advocates to press for the downsizing of large psychiatric facilities. Mary Jane Ward's 1946 novel The Snake Pit, exposing the dreadful conditions in state mental institutions (made into a successful movie in 1948), intensified the pressures for reform.

During the 1950s and 1960s, as enthusiasm for community mental‐health centers swept the nation, new groups of mental health care consumers began to use them. Public institutions, however, continued to provide most of the inpatient care, especially for the severely impaired, although the average length of stay decreased. Some patients seemed caught in a “revolving door” syndrome, moving in and out of psychiatric facilities to little long‐term effect. Others, particularly those with a dual diagnosis of mental illness and substance abuse, lived marginal but highly visible lives in shelters and on city streets. During the 1970s and 1980s, a loose coalition of politicians, advocacy groups like the National Alliance for the Mentally Ill, and health‐care professionals pressured community mental‐health centers to refocus on the severely ill. The managed care movement of the 1990s increased the proliferation of halfway houses, supported‐care facilities, and other quasi‐independent residential facilities. As a result, the institutional landscape was highly diverse as the century ended, although the challenge of chronic mental illness remained.
See also Dix, Dorothea; Drugs, Illicit; Medicine; Menninger, Karl and William; Mental Retardation; Prisons and Penitentiaries; Psychology; Psychotherapy.

Bibliography

David Rothman , The Discovery of the Asylum, 1971.
Gerald Grob , The Mad among Us, 1974.
Nancy Tomes , A Generous Confidence: Thomas Story Kirkbride and the Art of Asylum Keeping, 1840–1883, 1984.
Ellen Dwyer , Homes for the Mad, 1987.
George Dowdall , The Eclipse of the State Mental Hospital, 1996.
Joel Braslow , Mental Ills and Bodily Cures, 1997.

Ellen Dwyer