Big Box Mental Health: Institutions, Treatments, and Mental Illness

From our Dramaturg - Martha Wade Steketee

Eras of Mental Health Treatment in the United States

Urbanization in the United States disrupted extended family supports and the expectation that families would care for mentally ill relatives at home. Individual states built institutions, first called “asylums”, and eventually called “mental hospitals”. The Pennsylvania Hospital opened in Philadelphia in the mid 18th century and housing for patients with mental illness in the basement. At the same time, Colonial Virginia was the first “state” to build an asylum for mentally ill citizens (in its then capital Williamsburg). The mentally ill were also found in jails, almshouses, work houses, and other institutions.

By the time of the Revolutionary War, strains of four sectors of a ‘de facto’ mental health system were forged: general medical/primary care (Pennsylvania Hospital); specialty mental health care (Williamsburg asylum); home care; and human services (almshouse and work house).

The U.S. has had four reform movements in the area of institutional mental health: moral treatment (1800-1850), mental hygiene (1890-1920), community mental health (1955-1970), and community support (1975-present). The balance of this essay discusses each in turn.

Moral treatment was introduced as a reform in the late 19th century, imported from Europe. Reformers including Dorothea Dix and Horace Mann introduced the idea that mental illness could be treated in a controlled environment characterized by “moral” sensibilities. Mental illness was seen as temporary and not chronic and treatment was essentially humane. During this era many public and private asylums were constructed, with one in almost every state.

After the Civil War, professionals recognized the failures of the promise of early treatment, and asylums were built for untreatable, chronic patients. A mental hygiene reform movement began in the late 19th century to combine the emerging concepts of public health (at the time was referred to as “hygiene”), scientific medicine, and social progressivism. State Care Acts were passed between 1894 and World War I to centralize financial responsibility for the care of individuals with mental illness in every state government. State asylums were renamed mental hospitals. The mental hygienists believed in the principles of early treatment and expected to prevent chronic mental illness. To support this effort, they advocated for outpatient treatment to identify early cases of mental disorder and to follow discharged inpatients. The financial problems and overcrowding in the large centralized facilities deepened during the Depression and during World War II.

Enthusiasm for early intervention developed in WWII military health services led to a new mid-20th century reform: “community mental health”. Champions believed that long term institutional care in mental hospitals was neglectful, ineffective, and perhaps harmful. The new focus on community care and ‘deinstitutionalization” (encouraged by decreasing public dollars to support large institutions) led to dramatic declines in hospital stays and the discharge of many patients from hospital custodian care. The special needs of individuals with severe mental illness were not met with this strategy. Early treatment did not prevent disability.

A fourth reform era of “community support” started in 1975 and continues today. Rather than viewing and responding to chronic mental disorders as the object of neglect, this new reform movement focuses on acute treatment and prevention. Envisioned community support systems would address the social welfare needs of individuals with disabling mental illness. The vision is that individuals with mental illnesses can become citizens of their community if provided support and access to mainstream resources including housing and vocational training. Newer medications and new interventions (including “assertive community treatment” for schizophrenia) facilitate support and recovery in the community.

The current mental health system in the U.S. is a layered result of all these historical reform movements and ideologies, of financial incentives that affect availability of services, and of developments in care and treatments.

Source:
• 1999 “Firsts Surgeon General’s Report on Mental Health”, accessed at www.surgeongeneral.gov/library/mentalhealth/toc.html


Selected Timeline of Mental Health Treatment Technologies

1752 The Quakers in Philadelphia are the first in America to make an organized effort to care for the mentally ill. The newly-opened Pennsylvania Hospital in Philadelphia provided rooms in the basement complete with shackles attached to the walls to house a small number of mentally ill patients
1886 Sigmund Freud opens in private practice in Vienna
1896 The first psychological clinic is developed at the University of Pennsylvania marking the birth of clinical psychology.
1917 World War I brings with it a need to screen and classify military recruits. One of the tests is Robert Woodworth's Psychoneurotic Inventory, likely the first test to assess abnormal behavior.
1930s Drugs, electro-convulsive therapy, and surgery are used to treat people with schizophrenia and others with persistent mental illnesses.
1932 Sakel introduces insulin coma therapy as a treatment for schizophrenia. Also used to treat morphine withdrawal.
1934 Electroconvulsive therapy (ECT) introduced by von Meduna, a Hungarian physician, uses intramuscular injections of camphor. This does not reliably produce seizures, which he believed could ease schizophrenia.
1935 12 November. Neurologist Egas Moniz performs first brain surgery to treat mental illness in Portugal. He calls the procedure a "leucotomy."
1936 14 September. Walter Jackson Freeman modifies Moniz’s procedure, renames it the "lobotomy," and with his neurosurgeon partner James Watts performs the first ever prefrontal lobotomy in the United States. His patient is Alice Hood Hammatt, a housewife from Topeka, Kansas.
1938 After visiting a slaughterhouse and seeing animals knocked out by electric shock, Cerletti and Bini introduce electrically produced seizures. Inadequate anesthesia sometimes results in bone fractures, and patients complain of memory loss, and the process is considered more effective in treating depression than schizophrenia.
1942 Carl Rogers publishes 'Counseling and Psychotherapy' suggesting that respect and a non-judgmental approach to therapy is the foundation for effective treatment of mental health issues.
1945 Freeman begins experimenting with a new way of doing the lobotomy, after hearing about a doctor in Italy who accessed the brain through the eye-sockets.
1946 17 January. Walter Freeman performs the first transorbital lobotomy in the United States on a 29-year-old housewife named Sallie Ellen Ionesco in his Washington, D.C. office.
1954 Psychopharmacology hits the U.S. Thorazine was the biggest selling tranquilizer and manufacturers can't keep up with demand.
1955 More than 55,000 men, women and children in the U.S. undergo lobotomy.
1990s A new generation of anti-psychotic drugs is introduced. These drugs prove to be more effective in treating schizophrenia and have fewer side effects.


Sources:
• www.psychosurgery.org/about-lobotomy/
• www.britannica.com/EBchecked/topic/345502/lobotomy
• http://soundportraits.org/on-air/my_lobotomy/timeline.php
• www.npr.org/templates/story/story.php?storyId=5014576
• www.npr.org/templates/story/story.php?storyId=5014565
• www.eric.ed.gov/ERICDocs/data/ericdocs2sql/content_storage_01/0000019b/80/2f/33/9e.pdf [accessed 4/13/2009]
• www.mentalhelp.net/poc/view_doc.php?type=doc&id=8132&cn=91 [accessed 4/9/2009]
• www.pbs.org/wgbh/amex/nash/timeline/index.html [accessed 4/9/2009]
• www.experiencefestival.com/a/Timeline_of_Psychotherapy_history_-_Twentieth_century/id/2060196 [accessed 4/9/2009]