The “Good Old Days” of Asylums

Asylums were originally intended to be comforting places of both isolation from society and environments where those with mental illness could receive treatment. A quick review of some of the photos taken at the time quickly apprises you of two different views; one lauding the “comfort” factor and the other a somewhat darker view.

Figure: Typical asylum layout w back wards

The photos I’ve seen show both beautifully decorated hallways with Christmas trimmings, comfortable furniture and supportive work areas turning out rustic furniture as well as providing food and vegetables for the patients. Of course, all of us have heard of the “back wards” but few of us have ever seen one. Here, away from the purported gaiety and the simple, tranquil life inherent in these “humane” programs lay the ugly side of institutions, a side easily forgotten in a tsunami of public relations efforts to promote a change in treatment.

True, those with mental illness were an incredible burden on both family and community when there was little to no treatment for it and, in some cases, where faulty diagnosis led to commitment. Change was needed and we saw the rise of super stars like Dorothea Dix who not only advocated for the mentally ill, but spent her later years living in an apartment in one of the institutions she had help raise public and government awareness to build.

Psychiatric hospitals began to mushroom around the country until they grew to the size of small towns, totally independent from the surrounding, very distant communities. They had rail heads to bring in supplies, a variety of specialized shops where patients manufactured and repaired clothing and shoes, supervised maintenance programs, furniture shops (the reed materials gathered from ponds on grounds), and even cemeteries and morgues in addition to operating rooms. The operating rooms weren’t the only place treatment was provided. In Holland, too, they were struggling to care for thousands of the mentally ill and it led to radical change in these institutions (http://bitly.com/2J7yGiU).

Hospitals in the United States also maintained isolation rooms as well as rooms for tubbing and chains on the walls to restrain overly aggressive patients who exhibited signs of being out of control. Needless to say, the treatments weren’t always as humane as we would like to think they were. The equivalent of fire hoses was used to “calm” patients as well as ice baths. Electroconvulsive shock therapy (ECT), first conceived in Europe, was liberally used and anyone who has seen “One Flew Over the Cuckoo’s Nest” will have some small idea what they must have been like in those settings.

The settings, therefore, weren’t exactly idyllic. I’ve spoken to old hands at now-closed psychiatric hospitals and the tales they told were quite revealing. Medical directors raping patients as a form of “therapy,” one CEO rode around on horseback with a shotgun, shooting pigeons from the roof peaks of the buildings and regular all-you-can-drink mandatory cocktail parties were held Friday evenings.

Tunnels beneath the grounds connected all the buildings and here rooms were rented out for wedding parties that came and music therapy groups were held. I never saw one musical instrument or even a photograph of a patient with a musical instrument. One “sewing therapy” group I saw consisted of women threading a needle through a bit of cloth, removing the thread and doing it all over again, endlessly for the entire day.

The hospitals were also places not only for the mentally ill, but for parents who wanted to drop off children with odd symptoms (seizure disorder for one), or husbands who wanted to rid themselves of unruly wives. Husbands could not only commit their wives, they could will their children to others and not the mother on their death.

Some patients spent much of their lives inside these asylums with no contact with the world around them or its changing culture. One institution I visited, before it too was torn down, had swings and seesaws in evidence because children as young as four years old were housed there. Once the children reached 18, they were sent to adult institutions.

The 60s were supposed to be a time of realization that change had to come to the treatment of the mentally ill and so began the ill-conceived and poorly monitored “deinstitutionalization” movement. Sharks, looking to fill empty boarding houses or hotels, quickly saw the gold they could stuff into their pockets and signed off to care for discharged patients.

These patients were then sent to single-family homes or dilapidated beach front hotels where they received little care and, perhaps, insufficient meals. Therapy was walking the streets all day until the door was unlocked for them to return after four o’clock. Medicine was, in too many instances, left on a kitchen table for patients to take themselves. Staff consisted of anyone willing to take a no-skills job with minimum pay.

Thus, was born the homeless-in-America wave. Patients had rights and they didn’t have to remain in these community residences. Lawyers saw the civil rights of their clients being violated and sued. States refused responsibility for these former patients and dumped them on local community resources where the patients were encouraged to apply for local welfare or Medicaid.

Some hospitals even used a form of discharge that is unquestionably unethical; leaving discharged patients at bus stations, hospital emergency rooms or giving them a plane ticket out of the country. Now a new crop of entrepreneurs popped up with their version of community mental health paid for by this new funding source. But the primary problems, lack of trained personnel, inadequate monitoring and greed still remained. New mental health fiefdoms were born.

The challenges remain for our society and, in particular, for the medical establishment charged with discovering more effective treatment of mental illness. Within this environment of challenge there is now a cry for a return to the asylum model in order to “prevent gun violence.” The logic here is shaky, or rather non-existent, as is the argument that grocery-store pornography causes school shooting violence. The blame game is in active mode now.

Assuredly, some of those who engage in violence may have a mental illness, but is warehousing them the answer? How effective is the treatment, whether in a hospital or the community, you must ask. How did they come to this moment in their lives is yet another question that must be answered. We still don’t have the answers. For those interested in the discourse, I recommend you read the NYT article by their editorial board: https://nyti.ms/2J4RrDz.