From Asylum to Community: Mental Health Policy in Modern America
434
From Asylum to Community: Mental Health Policy in Modern America
434Hardcover
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Product Details
| ISBN-13: | 9780691631264 |
|---|---|
| Publisher: | Princeton University Press |
| Publication date: | 04/19/2016 |
| Series: | Princeton Legacy Library , #1217 |
| Pages: | 434 |
| Product dimensions: | 6.10(w) x 9.30(h) x 1.10(d) |
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From Asylum to Community
Mental Health Policy in Modern America
By Gerald N. Grob
PRINCETON UNIVERSITY PRESS
Copyright © 1991 Princeton University PressAll rights reserved.
ISBN: 978-0-691-04790-4
CHAPTER 1
The Lessons of War, 1941–1945
World War II marked a watershed in the history of mental health policy and the evolution of American psychiatry. Many psychiatrists who served in the military came to some novel conclusions. They found that neuro-psychiatric disorders were a more serious problem than had previously been recognized, that environmental stress associated with combat contributed to mental maladjustment, and that early and purposeful treatment in noninstitutional settings produced favorable outcomes. These beliefs became the basis for the claims after 1945 that early identification of symptoms and treatment in community settings could prevent the onset of more serious mental illnesses and thus obviate prolonged institutionalization. The war reshaped psychiatry by attracting into the specialty a significant number of young physicians whose outlook was molded by their wartime experiences and who were attracted by psychodynamic and psychoanalytic concepts. After 1945 many of them assumed leadership positions within the specialty and attempted to forge new community-oriented policies that broke with the traditional consensus on the need for prolonged hospitalization of mentally ill persons. In a sense World War II inaugurated several decades of ferment that eventually led to a profound transformation in mental health policy.
* * *
Public policies, more often than not, are evolutionary in nature; only rarely do they emerge in some novel form following a cataclysmic event. Mental health policies were no exception: the changes that occurred during and after World War II were linked to earlier trends. The change in the composition of the patient populations of mental hospitals after 1890 was of major significance. Throughout the nineteenth century, patient populations were made up largely of acute cases institutionalized for less than a year. With the exception of such institutions as the Willard Asylum for the Insane in New York State (founded with the express purpose of caring only for chronic cases), the bulk of patients were discharged in twelve months or less. Some elderly persons with marked behavioral signs were institutionalized for longer periods and often remained until they died, but the majority of such cases were sent to almshouses, which served as surrogate old-age homes.
Between 1890 and 1940, however, the proportion of long-term chronic patients increased dramatically. By 1923 more than half of all patients had been institutionalized for five years or more. Many were individuals over sixty-five suffering from conditions associated with aging; others manifested behavioral symptoms that were probably of known somatic origins (e.g., paresis, a tertiary stage of syphilis). The changes in the demographic characteristics of the patient population—often stimulated by the adoption of new public welfare policies—had a marked influence on the structure and function of mental hospitals. Simply put, twentieth-century mental hospitals became institutions that provided long-term custodial care for an overwhelmingly chronic population whose behavioral disorders were often related to an underlying somatic pathology. The presence of so many of these patients contributed to the depressing internal atmosphere characteristic of many public hospitals. Physicians, and especially nurses and attendants, were generally unable to maintain high morale and enthusiasm, given the tragic condition and often bizarre behavior of their patients. Indeed, the character of the patient population contributed to the disruptive forces that were always present; conflict and disorganization lay directly below the surface at many institutions.
As mental hospitals changed, their links with psychiatry became more tenuous. Trained as physicians, psychiatrists clearly preferred a therapeutic rather than a custodial role, and the institutional context in which they traditionally practiced was hardly conducive to the pursuit of the former. The rise of modern "scientific" medicine in the late nineteenth century appeared to accentuate the seeming "backwardness" of psychiatry. Under such circumstances it was understandable that twentieth-century psychiatrists attempted to redefine concepts of mental diseases and therapeutic interventions, as well as the very context in which they practiced. In so doing they implicitly posited a conflict between the traditional mental hospital (which provided custodial care for large numbers of chronic patients) and the imperatives of modern psychiatry.
Receptivity toward innovation was perhaps best illustrated by subtle modifications in psychiatric models of disease. Generally speaking, the traditional model was based on the assumption that there was a sharp distinction between health and disease. The presence of mental disease was indicated by dramatic behavioral and somatic signs that fundamentally deviated from the prior "normal" behavior of that individual. By the turn of the century, however, such representative figures as Sigmund Freud in Europe and Adolf Meyer and William Alanson White in the United States were already challenging this paradigm. They, as well as others, began to argue that behavior occurred along a continuum that commenced with the normal and concluded with the abnormal. Such an approach elevated the significance of the life history and prior experiences of the individual, thereby blurring the demarcation between health and disease. Some who entered the specialty in the interwar years were attracted by psychodynamic or psychoanalytic psychiatry and after 1945 disseminated its virtues among younger colleagues. Psychodynamic psychiatry, wrote John C. Whitehorn, Meyer's successor at Johns Hopkins, emphasized "the study of the 'genetic-dynamic' development of one's personality." Sickness and health, insisted Karl A. Menninger, was "a scale in the successfulness of an individual-environment adaptation." At one end was "health, happiness, success, achievement, and the like, and at the other end misery, failure, crime, delirium, and so forth."
Admittedly, psychodynamic psychiatry did not necessarily reject either the conventional belief that mental disease was a somatic illness or somatic therapies; eclecticism, not consistency, was often characteristic of the specialty. Nevertheless, the implications of psychodynamic psychiatry were striking. If there was a continuum from the normal to the abnormal, then the possibility existed that before the process had run its course outpatient psychiatric interventions could alter the outcome. Hence early treatment in community facilities might prevent the onset of the severe mental diseases that had previously required institutionalization. By the 1920s and 1930s signs of modest change were already evident: some psychiatrists were affiliated with child guidance clinics; some were involved with the mental hygiene movement, which had emerged during the first decade of the twentieth century; and some attempted to apply psychoanalytic principles to the practice of psychiatry. The majority of psychiatrists, however, still clung to their traditional base in mental hospitals.
Before 1940 the new psychodynamic psychiatry grew at a slow pace. The specialty was for the most part preoccupied with the severe mental illnesses and identified with traditional mental hospitals. Most state-hospital psychiatrists had little or no interest in psychoanalytic theory and tended to emphasize somatic therapies in conjunction with such directive methods as suggestion, reassurance, advice, and reproof. The preoccupation with institutions was evident in the work of the Mental Hospital Survey Committee, created in 1936 by the APA, U.S. Public Health Service (PHS), and other medical organizations. Under the direction of Samuel W. Hamilton, a prominent psychiatrist, the committee launched a multiyear study of mental hospitals. In an exhaustive survey of mental hospitals published in 1941, Hamilton and his co-workers offered a series of conclusions that were neither striking nor innovative. Their recommendations were traditional and did not in any way suggest that alternatives to mental hospitals be considered. They called simply for higher levels of financial support, greater psychiatric autonomy, and the appointment to hospital boards of disinterested individuals concerned solely with the public good.
* * *
The stability of mental health policy in 1940 was only superficial. The new psychodynamic psychiatry had yet to modify the preoccupation with severe mental illnesses, and the sporadic efforts to create outpatient or general hospital psychiatric facilities were still in their infancy. Nor had the full consequences of the gradual weakening of the links between mental hospitals and psychiatrists been realized. Finally, prewar psychodynamic and psychoanalytic thinking still tended to ignore the influence of broad environmental factors on personality; the prevailing emphasis was on individual and family relationships.
World War II, however, proved a critical catalyst. During that conflict, mental hospitals, which had already been injured by the ravages of the Great Depression of the 1930s, deteriorated still further as other priorities were established. Even as the war drew to a close, revelations of decrepit conditions within hospitals had begun to create an atmosphere in which noninstitutional alternatives would be seriously considered. Equally significant, wartime experiences seemed to provide conclusive evidence that the principles of psychodynamic psychiatry, when linked with new policies and institutions, had the possibility of revolutionizing the ways in which society perceived and dealt with the mentally ill.
Like other public facilities, mental hospitals had been hard hit by the Great Depression of the 1930s. Staff-patient ratios decreased; new construction came to a halt; and normal maintenance was deferred. Under normal circumstances the return of better times might have enabled hospitals to recoup lost ground, just as they had after previous economic crises. The national emergency engendered by the outbreak of a global conflict, however, created more pressing priorities, and the deferred needs of mental hospitals were largely ignored. The rise in the number of patients in state institutions from 410,000 in 1940 to nearly 446,000 in 1946, for example, was not matched by a commensurate expansion of physical facilities. Consequently the excess of population over capacity, according to federal statistics, rose from 9.8 to 16.3 percent. Such data may have even underestimated the magnitude of the problem. An independent study in 1946 estimated that overcrowding ranged from 20 to 74 percent.
Even more significant was the decline in the quality of internal institutional environments during the war years. The induction of large numbers of physicians and staff into the armed forces created acute shortages. By late 1943 New York, which operated the nation's largest hospital system, reported vacancy rates of 31 percent for physicians and 32 percent for ward employees. The consequences of staff shortages throughout the nation were dramatic: restraint of patients became more common; hygienic conditions deteriorated; individualized attention, medical and occupational therapy, and supervised recreation all suffered. Patient care, complained the superintendent of Pilgrim State Hospital in New York in late 1942, "is not what it was a year ago." Replacements for those inducted into the military were "of an inferior grade," and he was forced to employ individuals drawn "from the welfare rolls in New York City and ... these people are not the type to make good employees." Although such problems were by no means new, there is little doubt that the war exacerbated their impact.
Peacetime failed to bring any immediate improvements. The demobilization of the armed forces and the transition from war to peace took precedence. Few state governments made an effort to deal with nearly a decade and a half of neglect of their mental hospitals. In 1947, for example, there were 12 to 30 patients for each attendant, 176 patients for each nurse, and 250 to 500 patients per psychiatrist. APA standards, by contrast, called for one attendant for every 6 to 8 patients, a nurse for every 4 to 40 patients, and a psychiatrist for every 30 to 200 patients (the variation in the ratios depended on the nature of the patient population at each institution).
* * *
Crowding of patients, staff shortages, and inadequate facilities and budgets were endemic problems of state mental hospital systems. With variations among states and regions, they had persisted for nearly a century. Indeed, to define problems in such terms was also to identify solutions. Crowding and inadequate facilities could be eliminated through the expansion of existing facilities or the construction of new ones; staff shortages could be alleviated through the employment of additional personnel; meager budgets would disappear with the infusion of new resources. The resolution of existing difficulties, in other words, left intact the basic policy of caring for and treating the mentally ill in traditional public mental hospitals.
The psychiatric experiences of World War II, however, led unerringly to a fundamentally different kind of analysis. By the mid-1940s the wisdom of equating mental illnesses with mental hospitals had become a subject for debate rather than an unquestioned proposition. The psychiatric "lessons" of the war, insisted some, suggested an alternative model based on early identification of individuals who were at high risk or whose mental illness was of recent origin, followed by prompt treatment in outpatient or inpatient community settings. In effect, World War II provided psychodynamically oriented psychiatrists (as well as those trained or influenced by Meyer) with an unparalleled opportunity to test new approaches. Out of their encounter with war and the lessons they drew came the outlines of a new paradigm that in the postwar era would prove a potent force for innovation.
On the eve of war there were no indications that psychiatry was on the verge of fundamental change. Although a number of psychiatrists had taken an active part in the military during World War I, their experiences were largely forgotten in the intervening two decades. The outbreak of hostilities in the late summer of 1939 found psychiatrists—much like their compatriots—unprepared for mobilization or war. As early as 1938 the trustees of the William Alanson White Psychiatric Foundation had urged members of the specialty to offer their services to the nation in the impending crisis. In 1939 the Southern Psychiatric Association and, to a lesser extent, the APA added their support. But few responded to these calls at this time.
By the autumn of 1940, however, a number of psychiatrists had become involved in the effort to strengthen the nation's defenses in the event of war. Their initial involvement was with the Selective Service System. The rapid buildup of the armed forces required some mechanism that would assist in identifying in advance individuals unqualified for military service because of neuropsychiatric problems (which at that time included homosexuality). Not only was the induction of such individuals costly in terms of time and money, but it threatened to impair military effectiveness and efficiency. Even before the end of the year, such figures as Harry Stack Sullivan, Winfred Overholser (superintendent of St. Elizabeths Hospital in the District of Columbia), and others were assisting officials of the Selective Service System in setting up procedures to identify individuals ill-suited for the rigors of military life.
The assumption underlying screening, of course, was that knowledge of personality and background could assist in predicting disposition to mental disorders. Indeed, in the emotion-laden atmosphere of the early days of the war, organizations such as the National Committee for Mental Hygiene (NCMH) as well as individuals were speaking in language that implied a sharp expansion in the specialty's boundaries. Not only could psychiatry screen out the unfit and rehabilitate battlefield psychological casualties, but it could also provide indispensable assistance in maintaining military and civilian morale, coping with the dislocations of war, and furthering the social cohesion so vital for the preservation of mental health.
(Continues...)
Excerpted from From Asylum to Community by Gerald N. Grob. Copyright © 1991 Princeton University Press. Excerpted by permission of PRINCETON UNIVERSITY PRESS.
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Table of Contents
- FrontMatter, pg. i
- Contents, pg. vii
- Illustrations, pg. ix
- Tables, pg. xi
- Preface, pg. xiii
- Abbreviations Used in Text, pg. xvii
- Prologue, pg. 1
- CHAPTER ONE. The Lessons of War, 1941-1945, pg. 5
- CHAPTER TWO. The Reorganization of Psychiatry, pg. 24
- CHAPTER THREE. Origins of Federal Intervention, pg. 44
- CHAPTER FOUR. Mental Hospitals under Siege, pg. 70
- CHAPTER FIVE. The Mental Health Professions: Conflict and Consensus, pg. 93
- CHAPTER SIX. Care and Treatment: Changing Views, pg. 124
- CHAPTER SEVEN. Changing State Policy, pg. 157
- CHAPTER EIGHT. A National Campaign: The Joint Commission on Mental Illness and Health, pg. 181
- CHAPTER NINE. From Advocacy to Policy, pg. 209
- CHAPTER TEN. From Institution to Community, pg. 239
- CHAPTER ELEVEN. Challenges to Psychiatric Legitimacy, pg. 273
- Epilogue, pg. 302
- Notes, pg. 305
- Selected Sources, pg. 375
- Index, pg. 393