Mental Hospitals and the Mental Hygiene Movement in the United States I
- Author:
Dallas Pratt, M.D.
Staff Psychiatrist, National Mental Health Foundation I 1. The National Committee for Mental Hygiene:
Origins and Achievements
The mental hygiene movement in America was launched with the founding of the National Committee for Mental Hygiene in the first decade of the present century. The founder was Clifford Beers, a man whose knowledge of mental illness and its attendant problems came entirely out of his own experience as a patient in mental hospitals. The National Committee was designed to spearhead the reform of these institutions. The mixture of brutality and neglect which passed for ” care ” of the mentally ill at that time is unforgettably delineated in Beers’s autobiography: A Mind that Found Itself. Much was accomplished in the raising of standards in mental hospitals, and the National Committee turned gradually away from I the problems of institutional care, to concentrate more particularly on preventive psychiatry. Important research projects in schizophrenia and psychosomatic medicine have been sponsored. Even : more significant has been the impetus which the Committee has given to the establishment of child guidance clinics throughout the United States.
Although founded by a layman, the National Committee’s affairs are largely guided by psychia- < trists, and up to very recently it has attacked the problem of mental health chiefly through profes- ^ sional channels. For instance, a very competent survey of the condition of State Hospitals in 1937-9, was made available in print for professional readers. The findings did not disguise, the fact that serious deficiencies still existed. However, funds were apparently not available to the National Committee to undertake a comprehensive programme of public education and reform, and with the war the attention of the organization was absorbed by the needs of the armed forces and of psychiatric veterans. Two of its major activities were the promotion of psychiatric rehabilitation, and the operation of a PsycfiTatrrc~~’Tersonne 1 Placement Service. The latter primarily concerned itself with the placement of young psychiatrists returning from the services to civilian practice. Its finding was that there were twenty times as many positions open to doctors in State hospitals as there were applications for them, but that there were only half as many positions available in psychiatry outside of the State hospitals as there were applications.
Another achievement of the National Committee, again indicative of its concern about mental hospital conditions, was the major part it played, through its Medical Director, Dr George Stevenson, in the formulation and passage of the National Mental Health Act. This means that Federal Funds will be made available to the States, their political subdivisions, and to institutions and organizations, for broad mental health purposes. It is expected that the emphasis will be on research and the training. of psychiatric personnel, also to be furthered by the establishment under the Act of a Psychiatric Institute in Washington. Beyond the operation of this Institute, analogous perhaps to the Psychiatric Institute at the Maudsley Hospital, there is no thought of the Federal Government taking over any actual institution, so that this Act is in no way comparable with England’s National Health Service Act. It envisages no comprehensive mental health service for the community, and although the State Hospitals in the future will benefit from the increased supply of trained psychiatric personnel, and from the preventive aspects of intensified research, no immediate help is in sight from this source. 2. Trends in the American Psychiatric Association Turning now to a consideration of the attitude of the American Psychiatric Association (corresponding to the Royal Medico-Psychological Association) vis-a-vis the public mental hospitals, it is illuminating to notice the themes of the annual Presidential ?addresses since its founding in 1844. During its first seventy-five years of life, the Association was largely dominated by State Hospital superintendents, and the addresses reflected the interest in State Hospital problems. During the past twenty-five years, the interest and leadership gradually shifted to extra-muraLpsychiatry, largely under the stimulus of such men as Adolf Meyer, and of the psychoanalytical group, whose influence has steadily increased. Up to and through World War II the problems of the State Hospitals have been very much neglected, a fact which is noticeable not only from the tenor of the Presidential addresses, but also from the papers presented. The emphasis has shifted to research, child psychiatry, psychosomatic medicine and the relation of psychiatry to the other medical specialties, psychotherapy (particularly psychoanalysis), and war psychiatry. The shock therapies and psycho-surgery have, of course, received considerable attention, but by and large their application to State Hospitals does not appear to have been so much a matter of common practice as in England.
3. The New York State Investigation As an example of what was happening generally to the State Hospital systems, one may cite New York. Both in the United States and in England, this State is generally thought of as being among ‘the most advanced in the use of the shock therapies, yet the Commission appointed by Governor Dewey to investigate the New York State Hospital system reported in 1944: ” Only twelve out of twenty hospitals are now regularly using insulin shock therapy. Only five are using metrazol regularly and two of the institutions have never used electric shock therapy. Binghamton, Kings Park, and Utica have used electric shock only recently. One institution has never used any form of shock therapy… . Any such chaotic result cannot be entirely excused on the ground of lack of personnel “. This investigation had been started in 1943 following the outbreak of amoebic dysentery at one State Hospital; the Superintendent was retired, and the Commissioner of the Department of Mental Hygiene resigned. The Commission found that the Department of Mental Hygiene was inefficient and had failed to provide for curative rather than custodial care of patients. A new Commissioner was appointed. Various administrative changes were ‘undertaken, and a large sum of money was appropriated by the State for new building.
The deplorable conditions thus revealed in New York received considerable newspaper publicity, and in fact the concern aroused by reports in the Press probably induced the authorities to undertake the investigation. Two novels dealing with life in State Hospitals also appeared. The Snake Pit, by Mary Jane Ward, was a thinly disguised autobiographical account of the authoress’s experiences as a patient. It was later condensed in the Reader’s Digest, became a best seller, and is now being filmed. Ellen C. Philtine’s They Walk in Darkness was another but less successful attempt to describe State Hospital life; its authoress was the wife of a State Hospital psychiatrist. The authoress followed up her expose by organizing the People’s Committee for Mental Hygiene, a joint lay and professional organization which has continued to press for legislative reform of the New York State Hospitals. While it was obvious that a hospital system as decrepit as that revealed by the report of Governor Dewey’s Commission could not be reformed overnight, the People’s Committee has expressed continued dissatisfaction with the progress made. The Commissioner has made an effort to open up post-graduate training opportunities for State Hospital superintendents and physicians, but over-crowding, inadequate staffing, and lack of supplies are still unsolved problems.
4. The Contribution of Conscientious Objectors While the preoccupations of military psychiatry increasingly absorbed the attention of the professional organizations during the war years, interest in the plight of the State and Veterans’ Mental Hospitals began to develop from a most unexpected quarter. It was decided by the government that conscientious objectors who had been assigned to work camps under Civilian Public Service would be permitted to take alternate service as attendants in mental hospitals and in training schools for mental defectives. Attendants, both male and female, outnumber nurses on the staff of an American State Hospital by seven to one, and perform almost all the regular ward nursing functions. By the end of 1943, there were 2,000 pacifists and some of their wives working in 60 State Hospitals and Training Schools. These conscientious objectors, Quakers and members of other churches, were greatly concerned with the serious deficiencies of treatment which they found in State Hospital care, and the poorly paid, untrained, overworked attendant all too frequently resorted to the use of restraints and physical abuse in order to control the excessive number of patients. Physicians and superintendents in these institutions, however well-intentioned, could offer their patients little more than custodial care. The excellence of a few of these State Hospitals made the deterioration of the majority stand out in greater relief. The use of violence was perhaps the condition above all others which appalled the conscientious objectors, since the very basis of their pacifist philosophy was a belief in non-violent methods. One can comprehend the mental conflict engendered. The use of mechanical restraint,* and even surreptitious physical abuse of patients by attendants, are unfortunately far too prevalent in American mental hospitals. Nothing impressed the writer more during a recent tour of English mental hospitals than the apparent absence of such methods in those institutions.
(a) The Ohio Reform The first action taken by conscientious objectors towards reform in this field occurred in Ohio in 1943. A group of objectors working as attendants x at Cleveland State Hospital revealed the deplorable conditions existing in that institution to Walter Lerch, a reporter on the Cleveland Press, and to the Rev. Dores Sharpe of the Cleveland Baptist Association. Mr. Lerch wrote a series of articles exposing the situation at Cleveland State Hospital in forthright terms, and Dr Sharpe followed up this “needling” of the public conscience by organizing concerned groups of citizens into a popular movement for mental health reform, after which the Governor instituted an investigation; the findings largely corroborated the charges brought. The superintendent of the State Hospital resigned, and an outstanding psychiatrist, Dr. Frank F. Tallman, was appointed to the long vacant post of Commissioner of Mental Hygiene for Ohio. The Legislature appropriated seventeen million dollars for the Department of Mental Health. (b) The Veterans’” Administration Reform Another significant contribution was made in October, 1944, when a conscientious objector, named Robert Hegler, ran away from a Veterans’ Mental Hospital at Lyons, New Jersey, where he was serving as an attendant, and offered his diary for publication in the New York Journal American. Once again, people were shocked by eye-witness reports of physical abuse of the mentally ill. Several journalists took up the cudgels against the Veterans’ Administration, attacking not only the psychiatric hospitals but also the other Veterans’ facilities, and demanding a complete administrative house-cleaning. A Congressional investigation was initiated, and many of the allegations made by Robert Hegler against the Lyons Mental Hospitals were substantiated. When the clamour for reform spread from the lay press to such organs as the Journal of the American Medical Association, President Truman appointed General Omar Bradley as Veterans’ Administrator. The latter immediately instituted a complete reorganization of the Administration, and the hospitals have greatly improved their services. In addition to better in-patient care, the Administration has made a determined effort to provide out-patient psychiatric clinics in urban centres, and a programme of post-graduate psychiatric training is attracting scores of young psychiatrists. This training is concentrated in the centre at Winter General Hospital in Kansas, under the direction of Drs. Karl and William Menninger. By an ironic twist of fate, Robert Hegler was rewarded for his part in starting this chain of events by a two year prison term, for having taken absence without leave from his post at the hospital at Lyons. (c) The National Mental Health Foundation 1944 saw another and perhaps the most significant , contribution from the conscientious objector group. This time the protest against the status quo came from Pennsylvania, from four men?a writer, two lawyers and a mining engineer?who were working as attendants at Philadelphia State Hospital, at By berry. The Philadelphia Press had been parti- j cularly alive to the situation, and the Superintendent of the hospital had frankly stated to reporters that inadequate appropriations and lack of personnel made it impossible for him to provide decent care or treatment. The conscientious objectors referred to above were particularly struck by the low calibre type of attendant which the hospital was forced to employ, owing to their comparatively small com- i pensation and poor living conditions. They were moreover given no kind of training before taking up their duties. Physical abuse and the use of restraints were widespread. Accordingly, the four conscientious objectors: Edelstein, Barton, Hetzel and Steer, started to publish a magazine entitled The Attendant (since renamed The Psychiatric Aid). This contained material to aid the attendant, or the nurse, towards a more humane and therapeutic approach, presented in a popular fashion. A welldesigned format, illustrations and even a comic strip (illustrating various cardinal principles of good mental nursing) were and still are features of this periodical. The group also brought out a popularly 1/ written Handbook for Psychiatric Aides. 7 This group soon realized that the poorly paid, poorly trained attendant was only a symptom of progressive deterioration in many State Hospitals from long continued legislative neglect and lack of adequate appropriations. But this in turn reflected the apathy of the public, which?partly through a deep-seated fear of mental illness?took no responsibility to see that these institutions were properly looked after by their elected representatives.
The nation-wide prevalence of poor conditions was clearly indicated in the thousands of reports which the Byberry group collected from conscientious objector attendants, and from concerned nurses, social workers and physicians in State Hospitals and Institutions for Mental Defectives throughout the country. These reports (by far the most complete such file ever collected) formed the basis for the programme of public education which was undertaken as the second step in reform, the basic need being to arouse the public’s sense of responsibility.
Under the sponsorship of the National Committee for Mental Hygiene, and with a panel of professional advisors, the group launched the “National Mental Health Program”.^, The material from the file was such that it was bound to shock relatives of mental patients, and to alarm professional persons, particularly superintendents who might feel that they would be blamed for conditions of which, in fact, they were more the victims than the authors. However, the facts had been concealed from the public too long, and the resulting public apathy had always nullified any purely professional efforts towards reform, so that to bring the material to the attention of the widest possible audience in the most striking manner seemed necessary. Accordingly, the file was made available to Albert Maisel, along with actual photographs taken on the wards of State Hospitals. It was stipulated that he should in no case use the names of actual hospitals or persons, since the philosophy of the programme was to indict the system as a whole rather than to make scapegoats. Mr. Maisel wrote the article entitled ” Bedlam, 1946 which appeared in Life magazine in the spring of the year, and was later reprinted as the leading article in the Reader’s Digest. The total circulation of these two magazines is over thirteen million. The article, naturally, was written in a far more sensational way than for a scientific publication. There were several minor errors, but all the important facts were accurate and have never been challenged. While some of the worst institutions were described, the deplorable conditions depicted are unfortunately less the exception than the rule. Also, it may be assumed that much which is as bad if not worse has not been reported.
Life reported one of the largest reader-response correspondences in its experience, and there is no doubt that it has made millions of people aware of the tremendous mental health problem in their midst. The National Mental Health Program, by this time a distinct entity no longer under the sponsorship of the National Committee for Mental Hygiene, was incorporated in 1946 as the National Mental Health Foundation. Ex-Supreme Court Justice Owen Roberts accepted the Chairmanship, and the Society of Friends, aided by the other Peace Churches, was largely responsible for the financial support of the organization during 1946. Except for one psychiatrist (Dr Earl Bond) on the Board of Directors, and one (the writer) on the staff, the organization is entirely lay in its personnel. This is not only because it was felt that laymen are best able to prepare educational material for laymen (under professional guidance), but because the programme of the Foundation aims to educate the man in the street in the psychiatric needs of the community in the hope of joint lay and professional action. The Foundation seeks to represent the point of view of the layman (the citizen, the patient, the patient’s relative, the attendant) vis-a-vis those organizations which speak for the professional (the psychiatrist, the trained nurse, the social worker).
The reports on State Hospitals and Training Schools for Mental Defectives have also been made available to the public in a popularly written book: Out of Sight?Out of Mind, and in surveys of conditions in certain States (Pennsylvania, Iowa and New Jersey). 200,000 pieces of additional educational material have been circulated. Two full-time lawyers and their staff comprise the Foundation’s legal division, which has summarized the mental health laws of each of the forty-eight States, and has prepared new mental health legislation for Pennsylvania and Iowa.
As a corrective and constructive follow-up to the Life article, the Foundation has produced eight radio plays on mental hygiene?which have been heard on 200 radio stations in the United States and Canada?and is now producing thirteen more. Each of these fifteen-minute dramatizations are written by a professional writer on the staff of the Foundation, under the technical supervision of the staff psychiatrist. They dramatize various kinds of psychiatric services, or existing abuses with indications how these may be corrected by popular action, or misconceptions about mental illness? worked through in dramatic form to a more constructive point of view. The characters are sympathetically drawn, so that the listeners may identify themselves with them. The emphasis throughout is on positive action and constructive attitudes, with a consistent attempt to decrease the listener’s fear of mental illness and the mental hospital. Each play is produced in the studios of the National Broadcasting Company by professional actors, recorded on discs, and made available to local non-network radio stations under the sponsorship of local mental hygiene committees or other interested organizations.
In each State the Foundation seeks to work not directly but through the local mental hygiene organization, providing that organization is widely representative;’ the Foundation can make available its legal, educational and radio material, and the services of its speakers and field representatives. At the same time, it can act as a centre for the exchange of information between local groups. A basic principle in a programme of this kind is actual participation by the citizen in activities relating to mental health. One of the drawbacks of the Life article was the gruesome nature of the photographs which allowed readers to dissociate themselves from the problem: the patients depicted did not seem ” human ” ; the situations described seemed too xerrible to be “real”. Comparisons were frequently made between the scenes reproduced and photographs of German concentration camps. ” This can’t be happening in America.” In the radio plays described above, the process of identification, the empathy, is far greater?because it is an emotional rather than a conscious intellectual identification. Best of all is actual contact between the citizen and the mental patient, or the citizen and the psychiatric service. An example of this is the scheme whereby groups of University students of psychology, social work or allied subjects, work during the summer months as attendants in State Hospitals. There are Institutional Service Units now in operation in nine States, and the National Mental Health Foundation has promoted the plan wherever possible. The writer has tentatively explored the possibility of such students coming to work for a period of months, either in groups or singly, in British Mental Hospitals, and has drawn the attention of British psychiatrists to the success of the American venture.
The Foundation often arranges visits to mental hospitals, usually for specific lay organizations, or for State legislators, with two leaflets available: ” What to look for in a Mental Hospital “, and ” What to lodk for in a State Training School for the Feebleminded”. While an inquisitorial approach is not intended, it is expected that the superintendent and his staff” will be frank with the sincere citizen about the problems of an institution which, in a very real sense, is their joint responsibility.
Still another form of ” learning by doing ” which the Foundation has promoted is the setting up of volunteer service units in mental hospitals. These differ from the Institutional Service Units in that the volunteers, usually women, do not live in the hospital, but give certain hours each week to work in the occupational or recreational therapy departments of State Hospitals. The Foundation has stimulated the American Red Cross to set up such so-called ” Grey Lady ” units in New York, and recommend them throughout the States. A similar scheme was started by the Foundation in Pennsylvania, under the American Women’s Voluntary Services. It is essential that such groups meet three requirements: (1) They must be carefully selected ; (2) they must be closely disciplined by the sponsoring organization; and (3) they must be welcomed and receive basic training in the proper approach to mental patients by the staff of the hospital. Some of their activities have been: musical entertainment stressing patient participation, on the wards; organizing games on the wards for shut-in patients; library service; taking patients for walks; shopping service for patients; and assisting in occupational therapy. These volunteers not only supply needed services; they invariably become deeply interested in the problems of the hospital and promote better public relations between the hospital and the community.
5. New Activity in the Professional Organizations The emergence of lay organizations and the tremendous popular interest in the Press, have aroused the older professional organizations to new efforts in the field. The National Committee for Mental Hygiene has been organizing local mental health movements on a broad community basis in the Middle West, particularly in Ohio. Most significantly, the American Psychiatric Association has urged superintendents to reveal to the public the deficiencies of their hospitals?a recognition that lay support must be secured. It has also established the Psychiatric Foundation, which hopes to set up a much needed system of professional inspection and rating of mental hospitals? possibly analogous to the work done in the United Kingdom by the Board of Control. Finally, psychiatrists in the American Psychiatric Association have organized the Group for the Advancement of Psychiatry (nicknamed ” GAP “), which has been studying ways and means of reform.
6. The Present Phase: Laymen and Professionals co-operate One can, perhaps, discern three stages in the modern American mental hygiene movement. The first is one of lay protest, exposes in the Press, and the emergence of new non-professional organizations. The second phase sees new activity in these t latter organizations, as described above. The third stage has also been reached, and is marked by a rapprochement between the professional and lay organizations, and a replanning of their campaigns for funds, and of their individual objectives and respective spheres of activity. Agreement on the over-all mental health- programme for the nation is desirable, although each organization i may bring to this its own resources and its own emphasis. A joint meeting of representatives of the Menninger Foundation, the Psychiatric Foundation, the National Committee for Mental Hygiene, and the National Mental Health Foundation has taken place; and the last two organizations exchange representatives. The trend is towards co-operation, or, at the most, federation, but not towards organic unity. It is felt that each organization will be freer and better able to make a vigorous and original contribution if it preserves its own identity. Tangible results of the movement are to be seen in some States in the shape of re-organization of State Departments of Mental Health, formation of new citizen’s mental hygiene committees, additional appropriation by State Legislatures, and the creation of new psychiatric services. However, the surface has only been scratched, and the movement is hampered by lack of funds. Intangible results such as an increased interest and sense of responsibility of the public are hoped for, and are of primary importance. It will be of great interest to compare the developments of the coming years in the field of mental health in Britain and in the United States. In Britain the development of the mental health services is being planned from above, by the state, closely guided by professional advisors. In the United States, no nation-wide planning of this type is possible because of the Federal form of government. A truly national mental health programme will be only obtainable through public education, and this will be uniform only inasmuch as the organizations concerned can agree on joint objectives. The actual mental health services and reforms which finally emerge in each of the forty-eight States will in turn depend on the popular response to such education in each community. The excellence of such reforms will be proportionate to the sense of self-responsibility developed in the citizens, and to the communitywide participation therein of all groups, all classes, and all ages.
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