The Ins and Outs of 200 Years of Psychiatric Hospitals in the United States
Jeffrey L. Geller
Sarah Guzofski
Margo Lauterbach
In 1841, Dorothea Dix, then a 39-year-old former school mistress with a history of poor health and groping for a mission, visited the East Cambridge House of Corrections (Massachusetts) on March 28 to find therein a group of women obviously insane.1 Dix then traveled throughout Massachusetts examining the almshouses and jails, noting specifically the presence and condition of the insane. This resulted in her Memorial to the Legislature of Massachusetts in 1843:
Gentlemen … I proceed briefly to explain what has conducted me before you unsolicited and unsustained … I come to present the strong claims of suffering humanity. I come to place before the Legislature of Massachusetts the condition of the miserable, the desolate, the outcast. I come as the advocate of helpless, forgotten, insane, and idiotic men and women; of beings sunk to a condition from which the most unconcerned would start with real horror; of beings wretched in our prisons, and more wretched in our almshouses. And I cannot suppose it needful to employ earnest persuasion, or stubborn argument, in order to arrest and fix attention upon a subject only the more strongly pressing in its claims because it is revolting and disgusting in its details … The condition of human beings, reduced to the extremist states of degradation and misery, cannot be exhibited in softened language, or adorn a polished page.
I … call your attention to the present state of insane persons confined within this Commonwealth, in cages, closets, cellars, stalls, pens! Chained, naked, beaten with rods, and lashed into obedience.2
Dix then catalogued specific examples throughout the Commonwealth before indicating,
This state of things unquestionably retards the recovery of the few who do recover their reason under such circumstances, and may render those permanently insane who under other circumstances might have been restored to their right mind.2
Basically, Dix’s message provided two reasons to build and/or expand state hospitals: (a) it is the right/moral thing to do and (b) it will return those curable mentally ill to the rolls of taxpayer and remove them from public expense.
Before Dix began her campaign to elicit states’ support for the care and treatment of the insane, there had been the establishment of private psychiatric hospitals which met some of the states’ needs by having the state purchase hospital beds through various financial arrangements.3 With some exceptions—Kentucky (1824) and South Carolina (1828)—the earlier states of the United States had private hospitals before they had public ones (see Table 1.1).
States did respond to Dix’s plea—by 1845 she had traveled 10,000 miles, visited 18 state penitentiaries, 300 county jails and houses of correction, >500 almshouses, and had assisted in the establishment of 6 hospitals for the insane.1 But the state hospitals ran into their own financial difficulties as there were too many pauper cases and too few middle class paying patients. State hospitals even advertised to get paying patients including, in some instances, accepting slaves as payment.4
TABLE 1.1 OPENING DATES OF FIRST PRIVATE AND FIRST STATE HOSPITAL IN SELECTED STATES | |||||||||||||||||||||||||||
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Noting both prospective patients’ needs and the states’ struggling finances, Dix modified her approach, moving to the federal government for support. In 1848, Dix presented a Memorial to the US Congress requesting 5,000,000 acres (in later versions this was as high as 12,000,000 acres) of federal land, the income from which would be distributed to the states for support of the indigent insane.
Dix made some quite interesting points in her presentation to the legislature about the nature of insanity: the rate of insanity was increasing faster than population growth; many were not well informed about the “great and inadequate relieved distress of the insane;” “statesmen, politicians and merchants” were particularly susceptible to insanity; society was partly to blame because “little care is given in cultivating the moral affections in proportion with the intellectual development of the people;” and insanity, particularly in recently developed cases is curable, but to not treat it is to “condemn them [insane persons] to mental death.”5
Dix argued that society had obligations to this population. First, she stated, “Humanity requires that every insane person should receive the care appropriate to his condition, in which the integrity of the judgment is destroyed, and the reasoning faculties confused or prostrated.” Second, there was an obligation to “secure the public welfare” by protecting citizens from the “frequently manifested dangerous propensities of the insane.” Third, public welfare would benefit from the “restoration [of the insane] to usefulness as citizen ….”5
Dix believed that “under ordinary circumstances, and where there is no organic lesion of the brain, no disease is more manageable or more easily cured than insanity.” But to accomplish this, “special appliances” are required and because these are not readily obtainable or sustainable in families, towns, or cities there need to be hospitals.5
At the time Dix delivered her address there were, according to her, 20 state hospitals, several incorporated hospitals, and several small private establishments.5 Contemporary research by one of the authors (JLG) indicates that of psychiatric hospitals actually treating patients, there were 15 state hospitals; 2 county hospitals; 2 municipal hospitals; 6 larger private psychiatric hospitals; and at least 4 other facilities, which were the earliest examples of small psychiatric hospitals, many of which were opened and closed by the same psychiatrist, that is, depended upon him for the treatment of patients.3,6 These institutions, Dix asserted, could not meet the needs of the insane population of the United States. Dix also noted that the public hospitals were particularly stressed by the number of admissions represented by “uneducated foreigners.”5
Hospitals were a powerful tool in the fight against insanity: “under well-directed hospital care, recovery is the rule—incurable permanent insanity the exception.” And for those who could not be cured, hospitals would provide a “secure and comfortable” environment. For both classes of the insane, hospitals provided the opportunity for patients “to work under the direction of suitable attendants” such that they “recover from utter helplessness to a considerable degree of activity and capacity for various employments” (an early comment on hospital-initiated rehabilitation and recovery).5
Dix lobbied for her bill in Congress through four presidential administrations—Polk (1845 to 1849), Taylor (1849 to 1850), Fillmore (1850 to 1853), and Pierce (1853 to 1857) before it was passed by both houses of Congress. Pierce, however, vetoed the Bill in 1854, indicating:
I cannot but repeat what I have before expressed, that if the several States, many of which have already laid the foundation of munificent establishments of local beneficence, and nearly all of which are proceeding to establish them, shall be led to suppose, as they will be, should this bill become a law, that Congress is to make provision for such objects, the fountains of charity will be dried up at home, and the several States, instead of bestowing their own means on the social wants of their own people, may themselves, through the strong temptation, which appeals to States as to individuals, become humble suppliants for the bounty of the Federal Government, reversing their true relation to this Union.7
Interestingly enough, the medical profession favored Pierce’s position, not Dix’s. An editorial in the Boston Medical and Surgical Journal8 indicated, “asylums are now quite numerous in the States, and gradually increasing, and it seems legitimate to belong to them to provide for the unfortunate lunatics within their own jurisdiction” (p 25). Concern was expressed that if the federal government took responsibility for asylum-based care and treatment, “prodigious efforts would be made to empty local hospitals into the great national reservoir of insanity” (p 25). The Boston Medical and Surgical Journal editorialist thought the federal government should be responsible only for “soldiers and sailors who have lost their reason while in the service of their country” (p 26). Perhaps even more surprising, organized psychiatry of the era—the Association of Medical Superintendents of American Institution for the Insane (later to become the American Psychiatric Association)—entirely concurred.9
It took a nonpsychiatric physician, but one who had done assessments for the need for psychiatric hospitals and had run a small private facility of his own, Edward Jarvis,10 to most clearly articulate the 19th century position on the cost of care versus the cost of treatment. Jarvis explained,
A man of twenty years of age, if sane, has an average life of 39.48 years, while if insane he has but an average life of 21.31 years if not restored to health. The average time for restoring to health the insane who apply for treatment upon the early symptoms of disease is twenty-six weeks. At $4 per week, which was the average cost in the three State Lunatic Asylums in Massachusetts for the past year, this amounts to $104, to which is added $30 for each patient, for the cost of rent or interest on the value of the hospital, etc., for six months, making an average cost of $134 for restoration to health. If not restored to health, the family or State must be at an expense of $156 a year for 21.31 years, and must also lose the patient’s earnings for the 39.48 years which he would have made if well. The cost of the patient’s support is estimated at $2,121, while the loss of his future labor, if he becomes insane at twenty years of age, is estimated at $2,665.37, making a total loss of $4,786.37 if not cured; while, if cured in the average time of twenty-six weeks at a cost of $134, there will be a gain to the family or to the State of $4,652.10
Therefore, much of what defines the ensuing social history of the psychiatric hospital through the early years of the 21st century had been laid out by the mid-19th: What role should inpatient treatment play in the care of persons with mental illness? In terms of the public sector, what governmental entity should bear the cost for care and treatment of persons without financial resources who had serious mental illness? If the federal government became more active in this enterprise, would states attempt to cost shift this burden to the federal payor? Should there be separate hospitals for members of the armed forces and for veterans? What was the role of the private sector? What are the public safety functions of psychiatric hospitals—safety to the individual herself/himself and to society at large? Just how dangerous are persons with mental illness, the level and scope of dangerousness determining the magnitude of the number of inpatient psychiatric beds? And how do we balance cost benefit and humanitarian concerns where considering how most effectively we deal with the needs of persons with chronic mental illnesses?
As public psychiatric institutions grew in number and in size, and so too private facilities apparently grew in number (although how many closed in relationship to how many opened is not known) through the second half of the 19th century,3 the leaders of American psychiatry debated about the clinical methods of inpatient psychiatric treatment. Because all were superintendents of either public or private hospitals, they were quite familiar with the issues. Woodward11 noted how the insane were benefiting from hospitals’ abandonment of punitive treatments and adoption of beneficent ones.
Nichols12 commented on the decrease in the use of seclusion and restraint. Awl13 opined that a hospital’s reputation was dependent on its cures and discharges, while Ray14 complained that the distrust of hospitals was due to damning communication by patients to all too “willing ears.”
Nichols12 commented on the decrease in the use of seclusion and restraint. Awl13 opined that a hospital’s reputation was dependent on its cures and discharges, while Ray14 complained that the distrust of hospitals was due to damning communication by patients to all too “willing ears.”
Hospitals, it was noted, needed to be well constructed, for to do otherwise was false economy;15 were of necessity large, but better if they were small (250 patients in that era);16 and were overwhelmed by “the rising tide of indiscriminate lunacy pouring through the wards.”17 Contact with family during an episode of illness was a matter of debate: McFarland18 argued for treatment within the family when possible while Buttolph19 thought removal to a hospital separated the individual from the persons and place associated with the onset.
The use of biologic treatments in the hospital was also under consideration. Woodward11 expressed pleasure with the abandonment of the mechanical swing and bloodletting. Nichols12 remarked that sedation should not be used as a substitute for restraint while Everts warned against what he considered to be the general overuse of medication. Andrews (1893) proclaimed near the end of the century that “remedies are now employed to meet the symptoms of disease in a more rational manner than ever before.”
While paying attention to the clinical needs of patients, psychiatric leaders did not disregard issues of costs. Nichols16 warned how costly treatment is; Earle20 pointed out that expense did not necessarily correlate with quality; and Ray14 complained that all too often cost overrode all other considerations in the care and treatment of the insane.
As can be seen, just as with the social questions about psychiatric hospitals, the clinical questions for the ensuing century are pretty much set by the end of the 19th century. How well did the following generations deal with the roles, functions, and financing of psychiatric hospitals laid out by the pioneers of American psychiatric hospitals?
The Development of an Array of Types of Psychiatric Hospitals
The “mental hygiene” movement (1890 to 1950) followed the period of asylum-based care by expanding treatment into alternate psychiatric settings. The integration of psychiatry into general health care began as psychiatric hospitals and clinics focused on the scientific basis of mental illness and on prevention. Mental illness was thought to be a product of faulty environments or genetics, or both. Hence, there was a focus on child guidance clinics and on eugenics. Mental health service expanded to include new disciplines, social workers, and new locations, outpatient clinics.21
Despite these efforts, effective treatments for serious mental illness lagged behind, and persons with mental illness continued to suffer as outpatient treatment proved to be no more successful than the care previously received in asylums. This meant that asylums continued to play a key function, but budgetary demands and overcrowding impaired their efficacy. Persons with mental illness and the elderly were being treated ever more aggressively with insulin shock, electroconvulsive therapy, and psychosurgery in attempts to abate the scourge of insanity.22 Simultaneously, psychoanalysis flourished and psychiatrists began leaving asylums to care for “healthier” patients in private practice.23
General hospital psychiatric units date back to Benjamin Franklin and Benjamin Rush who, in 1783, founded the first of such units in the United States at the Pennsylvania Hospital.24 General hospital psychiatry, however, was largely dormant and did not reemerge until the 1930s. It flourished thereafter due to interweaving forces throughout the medical community. A scientific focus on psychiatry as part of the medical model for illness and the biopsychosocial approach to patients played key roles in this transformation. At its start though, the evolution of psychiatry in the general hospital was driven by the social and economic climate of the era. General hospitals were vulnerable to the rising costs of health care and particularly to unused beds. Moving the treatment of psychiatric patients into general hospitals allowed these hospitals to operate low-cost beds and permitted other medical disciplines to play a larger role in the treatment of those with mental illness. Conversely, psychiatrists could aid medical and surgical specialists as consultants in treating patients with psychosomatic illnesses. That this occurred when individuals with mental illness were beginning to be regarded as patients who had biopsychosocial illnesses warranting multidisciplinary treatment, rather than the “insane” or “lunatics” driven by sin and destined to be locked away in asylums, satisfactorily legitimized the economic argument.3 Simultaneously, there was a reform in psychiatric and general medical education, placing an
emphasis on research and disease prevention, whereby physicians began to focus on the patient and his or her psychology. Theories of psychopathology grew to reflect more dynamic interpretations of illness. These forces, however, did not reach most persons in need of psychiatric treatment. There remained a very significant cohort of undertreated mentally ill, symbolizing society’s continued underlying disregard for the psychological influences on diseases.25
emphasis on research and disease prevention, whereby physicians began to focus on the patient and his or her psychology. Theories of psychopathology grew to reflect more dynamic interpretations of illness. These forces, however, did not reach most persons in need of psychiatric treatment. There remained a very significant cohort of undertreated mentally ill, symbolizing society’s continued underlying disregard for the psychological influences on diseases.25
The first departments of psychiatry in general hospitals were supported by grants from the Rockefeller Foundation, led by Alan Gregg who was the director of the Rockefeller Foundation’s Medical Sciences Division. Massachusetts General Hospital (Boston, Massachusetts), Barnes Hospital (St. Louis, Missouri), Duke Hospital (Durham, North Carolina), and Billings Hospital (Chicago, Illinois) were some of the first grant recipients. Funding supported education and fellowships, research, psychoanalytic training, and direct patient care. It appears that Gregg’s selective funding for specific research was pivotal in the development of psychosomatic medicine in general hospitals.25 The Rockefeller Foundation gave approximately $11 million between 1931 and 1941 and created general hospital psychiatry units that to this day continue to make some of the most significant contributions within American academic medicine.25
By the early 1940s, approximately 40 inpatient psychiatry units existed in general hospitals in the United States. Post-World War II growth of general hospital psychiatry was fueled by the development of psychiatry units associated with both civilian and military hospitals. By 1952, 205 of the larger US hospitals had psychiatric inpatient units with at least 15 beds.26
Psychopathic hospitals were essentially clearinghouses; they would provide temporary treatment for patients with psychiatric illnesses.27 Psychopathic hospitals received patients with all mental disorders, focusing particularly on patients with acute-onset illnesses. Some of the earliest psychopathic hospitals were the Boston Psychopathic Hospital, Colorado Psychopathic Hospital, Syracuse Psychopathic Hospital, and the Neuropsychiatric Institute at the University of Michigan. Throughout the 1950s more autonomous psychiatric “institutes,” such as the institute at Michael Reese Hospital in Chicago, the Langley Porter Clinic in San Francisco, and the Psychiatric Institute at the University of Maryland, were built in direct proximity to general hospitals. These facilities were valuable teaching institutions and research facilities.
An example of a psychopathic hospital is the Boston Psychopathic Hospital, named in 1920, and formerly known as the Psychopathic Department of Boston State Hospital, which was founded in 1912. In 1924, the Boston Psychopathic Hospital had 110 beds and a relatively large staff that made up administrative, medical, psychology, laboratory (biochemical and pathology), research, outpatient, social service, occupational therapy, nursing, and clerical departments. The facility supported medical/surgical consultations, and x-ray and dental services. Patients were usually admitted for short periods of time, and disposition planning was based on diagnoses and disease acuity. Many cases came from general hospitals and patients were usually transferred soon after arrival to either state hospitals or discharged to outpatient psychiatric care.28 Services eventually expanded to include emergency services, child and adolescent units, and patients in the general community. As it became more of a community-based facility, the “Psycho” (as it was called) had its name changed to the Massachusetts Mental Health Center.
The veterans’ hospital system was established after World War I when veterans were entitled to health care benefits and compensation. By mid-1919, >3,200 veterans were receiving treatment in US Public Health Service hospitals that were overcrowded, far from patients’ homes, and incompatible with rehabilitation and long-term care. Civilian hospitals also cared for veterans, and there was a huge backlog of pending cases. A congressional study estimated there were 204,000 US soldiers who had been “wounded not mortally,” and uncounted legions who had tuberculosis and neuropsychiatric conditions.29 Individual states were unable to create policies to handle this need; hence the federal government became responsible for veterans’ health care. Congress, however, was unable to design a national program. Ultimately, the American Legion and the Veterans of Foreign Wars in 1919 served as lobbyists for veterans, supporting, against vocal opposition, the Public Health Service’s estimate that >30,000 hospital beds were needed for veterans, predominantly for psychiatry and tuberculosis. On his last day in office in 1921, President Woodrow Wilson signed into law a bill supporting $18.6 million for the establishment of hospitals for veterans.29
From 1921 to 1923, under Secretary Andrew Mellon, “consultants on hospitalization” approved the building of >6,000 beds in new veteran’s hospitals across the United States.29 From 1923 to 1945,
the Veterans Administration (or VA as of 1930) directed by General Frank T. Hines, saw considerable expansion of hospital beds. Following World War II, new construction led to a revamping of veterans hospitals whereby they were virtually reinvented and rebuilt, and many were affiliated with medical schools; teaching and research became an important focus.29 Although the VA hospital accounted for only a small percentage of the hospitalized population, trends in care shifted within the VA system toward inpatient care while elsewhere there was a diminution in use of inpatient beds. Between 1955 and 1975, the number of VA inpatient episodes increased by 143%, whereas state and county mental hospitals decreased by 37%.29
the Veterans Administration (or VA as of 1930) directed by General Frank T. Hines, saw considerable expansion of hospital beds. Following World War II, new construction led to a revamping of veterans hospitals whereby they were virtually reinvented and rebuilt, and many were affiliated with medical schools; teaching and research became an important focus.29 Although the VA hospital accounted for only a small percentage of the hospitalized population, trends in care shifted within the VA system toward inpatient care while elsewhere there was a diminution in use of inpatient beds. Between 1955 and 1975, the number of VA inpatient episodes increased by 143%, whereas state and county mental hospitals decreased by 37%.29
In contrast to public hospitals, private psychiatric hospitals are generally smaller (50 to 200 beds), more autonomous, with high staff-patient ratios, and offer comprehensive treatment modalities. Historically, private psychiatric hospitals have the potential to adapt to the social and economic changes within their respective communities, and if they cannot meet such demands, they are vulnerable to closure. Financial pressures have always threatened the existence and expansion of private psychiatric facilities.
In 1920, an era in which there was a plethora of psychiatric institutions to care for those with mental illness, most patients were in state hospitals; only 4% were treated in private psychiatric hospitals. Throughout the 1930s private facilities continued to open alongside psychopathic hospitals and general hospital psychiatry units. This expansion slowed down somewhat throughout the 1940s, limited by the high cost of expansion and an inability to afford private treatment. At the same time, the National Mental Health Act (1946) supported research and training in private psychiatric hospitals.
Throughout the 1950s, private psychiatric hospitals, although a small minority of the total number of all psychiatric facilities, admitted 25% to 40% of psychiatric patients annually.3 However, the public opinion of psychiatry post-World War II was not a favorable one. Crippled by financial strain, a shortage of psychiatrists, and staff dissatisfaction, private facilities fell into bankruptcy throughout the 1950s. Newly developed psychoactive medications offered more effective treatments, and may have fueled, in part, the rebound of the fragile private psychiatric hospitals throughout the 1960s. In 1970, state hospitals represented 91.8% of inpatient beds, general hospitals 5.0%, and private hospitals 3.2% of inpatient beds. By 1998, the total percentage of inpatient beds that belonged to state hospitals had decreased to 42.0% whereas the total percentage of inpatient beds for general hospitals and private hospitals both increased to 35.8% and 22.2%, respectively.
Related posts:
Psychosocial Approaches in Inpatient Psychiatry
Pharmacologic Approach to the Psychiatric Inpatient
Psychiatric Education on the Inpatient Unit
Hospital Treatment of Depression and Mania
The Patient with Borderline Personality Disorder
Evaluation and Management of Substance Use Disorders on the Inpatient Psychiatric Unit
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