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]

Pondering This Play by Martha Wade Steketee

“I never dreamed I’d have a now of my own that looked this good.”

It is 1922. Prohibition has a three year track record, and U.S. women enjoy their second year of the right to vote. One of the most popular songs in America is Al Jolson’s version of “Toot Toot Tootsie (Good-Bye)”. Silent film stars Mary Pickford and Douglas Fairbanks celebrate their second anniversary and the League of Nations (the precursor to the United Nations) celebrates its third. U.S. women comprise less the 25 percent of the work force and of those women who work, approximately 25 percent are in white collar jobs, 25 percent are in manufacturing jobs, less than 20 percent work as domestic servants, and most of the balance work in agriculture. Women begin to don the haircut called the “bob” sported by actress Colleen Moore in the 1920 silent film “Dinty. This year the Radium Dial Company continues its recently relocated business in a town named Ottawa, Illinois, about 80 miles southwest of Chicago. And in 1922, Catherine Wolfe Donohue begins a new job at this company located in her home town, just blocks from her home.

The work at Radium Dial involves painting luminous numbers on watch and clock faces for pennies a “dial”. The material Catherine and her colleagues use to paint constantly glowing timepiece dial face numbers is laced with a valuable newly discovered ore called radium. This element was tested for scientific purposes, used during the World War in airmen’s and soldiers’ timepieces and asserted to have medicinal, therapeutic and cosmetic uses. The women of Radium Dial ingest this new compound while doing their work, painting the dials, pointing their paintbrushes between their lips, breathing the radium-filled dust, and sitting near the completed dial faces stacked beside them at their work stations.

And for Catherine, this was her way into a new life, this new American woman, this independence. As dramatized by playwright Melanie Marnich in “These Shining Lives”, Catherine revels in the sensations of working after her first day of work “I walked home that night in the dark. A girl walks differently when she’s making money. I thought to myself, ten years ago a girl like me couldn’t even vote let alone make this kind of money. Couldn’t do better than her father and just as good as her husband. Couldn’t even smoke ... But now? I never dreamed I’d have a now of my own that looked this good.”

This real tale of freedom and independence for Catherine and hundreds of women like her in Illinois, New York, New Jersey, and elsewhere quickly becomes a story of corporate ignorance, malfeasance, and ultimate responsibility. Legal actions brought by women in a New Jersey radium dial company result in settlements in the 1920s, and the women of Ottawa continue their work. In 1925, the U.S. Department of Labor orders a general survey of all radium plants to investigate radium effects on occupational diseases including the newly identified “radium necrosis”, and the women of Ottawa continue their work. Medical opinion during the 1920s is divided on the effects of radium on the human body and the women of Ottawa continue their work. A Public Health Service conference in December 1928 considers the problem of safeguarding workers in industries using radium, and the women of Ottawa continue their work. And by 1937 the Radium Dial Company stops its work in Ottawa, only to continue it in New York State

In 1922 our dramatized Catherine Donohue is in awe of the “now” that is possible. Sixteen years later, the dramatized and well-documented Catherine testifies on behalf of herself and other dying former Radium Dial employees as “Ottawa’s Living Dead.” This play is their story of humor and independence. And so much more.

SOURCES

“All Radium Plants in Federal Inquiry: Labor Department States Search to Discover the Cause of “Radium Necrosis”, Hears of No Other Cases, New Occupational Disease Would Affect the Workmen’s Compensation Law”, New York Times June 21, 1925.

“Important Events of the 1920s”
http://www.enotes.com/1920-american-decades-about/important-events [accessed 12/2/2008]

Kovarik, Bill (2002). “The Radium Girls”, originally published as Chapter Eight of Mass Media and Environmental Conflict.
http://www.runet.edu/~wkovarik/envhist/radium.html [accessed 12/2/2008]

The Louise Brooks Society, Louis Brooks Chronology.
http://www.pandorasbox.com/bio/chronology.html [accessed 12/2/2008]

“75 Experts Meet On Radium Disease: Washington Conference Urges Surgeon General to Name a Board of Inquire, Would Codify Safeguards, Watch Company Official Says Use of Steel Stylus Instead of Brush Obviates Ill Effects” December 21, 1928

“The Story of Radium: Madame Curie’s Discovery Followed Years of Striving – How America Took The Lead”, New York Times May 15, 1921.

“Woman Tells of ‘Living Death’ at Radium Quiz: Former Watch Painter Faints; Halts Hearing”. Chicago Daily Tribune, February 11, 1938.

- Martha Wade Steketee (dramaturg)

From the Director

We are now in the midst of the second week of rehearsals and learning more and more about this play and the women who populate it with each and every rehearsal. We are looking forward to a field trip to the Northwestern libraries where Catherine Wolf Donahue's papers are stored. We hear that there are journal entries, a scrap book made by her family, and letters between her doctor and husband that have survived.

The images we have found of the women of Radium Dial and others in the play have been inspirational and we are anxious to read Catherine in her own words. As the play's story becomes clearer to all of us working on it, I am in awe of the women who inspired this story, what they stood for, and how much they sacrificed in the name of justice. I know I speak for the cast and designers when I say that we cannot wait to share this pivotal story from our nation's history. See you in January! - Rachel Walshe (director)