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For most of U.S. history up to the time of the Community Mental Health Act of 1963, the mentally ill were generally warehoused in state and local mental institutions on a long-term basis. Most had been involuntarily committed by orders from courts or physicians, and the discharge rate was very low. Before the 1950s and 1960s, there were few effective treatments for mental illnesses like depression, anxiety disorders and schizophrenia, which were commonly considered incurable. Only with the psycho-pharmacological revolution in recent decades and new anti-depressant and anti-psychotic medications has it been possible for the severely mentally ill to be treated on an outpatient basis through community mental health centers. Of course, as the old state hospitals have emptied many of the mentally ill have ended up homeless, since they are unable to hold maintain regular employment or continue on a medication regimen without supervision. According to present-day state laws, involuntary commitment to mental institutions can only apply to those judged to be a danger to themselves and others, and therapeutic practice no prefers short-term stays whenever possible. This has led to a problem of psychiatric wards being filled with patents repeatedly sent to these facilities for short stays instead of long-term commitment to state hospitals. Even worse, jails and other punitive facilities are increasingly being used as warehousing facilities in the same way as they state hospitals back during the 'snake pit' days before 1960.
In the early modern era, with the growth of commercial towns in North America and Western Europe, the authorities gradually become aware of the problem of large numbers of paupers, vagrants and mentally ill persons who could not be cared for by their families and local communities. Of course, society had always been aware of mental illness, even if the causes was thought to be demon possession, although for the most part deranged individuals who were not a danger to others were not confined. From the 17th Century until well into the 20th Century, governments set up almshouses, poorhouses and workhouses that confined the elderly poor, the disabled, orphans and the mentally ill in the same institution, although in social welfare policy there was always a distinction between those who were physically and mentally capable of working and those who were not. In 1752, the Pennsylvania Hospital opened up a ward for the mentally ill in the basement, although the treatments were either nonexistent or ineffective -- if not positively harmful. From the very start, most mental institutions in America were basically places of long-term confinement and warehousing for individuals who could not be treated or cured, and were unable to care for themselves (Levine, 1981, p. 15).
In 1833, Horace Mann recommended that Massachusetts establish the first hospital decided to care for the mentally ill, which opened at Worcester. At that time, physicians were still optimistic that the majority of the mentally ill could be cured, thus "removing them from the welfare rolls and saving the state money in the long run" (Levine, p. 17). In reality, of course, the new state hospitals continued the role of custodial care, with commitments often lasting for life, due to the lack of effective diagnosis and treatment of mental illness. America in the 1830s was undergoing a capitalist revolution, with the decline of the old aristocracy and its paternalist culture in many parts of the country, at least outside the slaveholding Southern states. This new society was more urban, industrialized and competitive, with a new capitalist class coming to power. At the same time, abolitionism, women's rights and prison reform also became important for the first time in American history: indeed, they all had their origins in the same era. Many people at the time believed that mental illness was increasing as the old agrarian society was overturned and "communities badly rent by social and economic change" (Levine, p. 19). Not for the last time would many social observers associate the rise of mental illness with the pressures and strains of urban, industrial civilization.
Dr. Samuel Woodward, the first superintendent of the Worcester State Hospital, was a religious and humanitarian man who generally shared the liberal ideology of progress that was common during this period. He truly believed that the majority of the mentally ill could be cured with kind and humane treatment, and also in the "perfectibility of people" in general (Levine, p. 20). Yet long experience was to prove that the early optimism was not justified and that many of those judged to be insane could not be cured. By 1875, discharge rates from state hospitals had fallen to 30%, falling to 20% by the 1920s and often the 5%. By the 1890s, most psychiatrists like Dr. Pliny Earle had concluded that insanity was incurable, and accepted the fact that the main purpose of state hospitals would be confinement and warehousing for life. Most of their inmates were poor, immigrants and members of minority groups, although blacks were almost always confined in segregated and inferior facilities. Destitute and impoverished immigrants, crowded into slums, certainly produced a large number on mentally ill persons, and by the late-19th Century made up about 75% of the patients in many state hospitals, which basically served the poor mentally ill and provided no real treatments (Levine, p. 22). Attendants in these hospitals were poorly paid and trained, and they were chronically understaffed, so much so that in New York City common criminals were assigned to work as attendants.
Needless to say, these giant warehouses were far removed from the reformist dreams of Dorothea Dix, who more than any other individual was responsible for creating the system of state hospitals in the United States. She had also been motivated by religious and humanitarian concerns, and was "dedicated, determined, in not fanatical" in her efforts to establish mental hospitals in every state. Dix was clearly a transformational leader who did not know how to take "no" for an answer, which has always been true of most successful reformers in history, but given the limited knowledge of the time, she had no idea which treatments -- if any -- would be effective for mental illness. Her main concern was to "remove the insane from jails, almshouses, and workhouses, where they were kept in abominable conditions." Moreover, in the 19th Century and well into the 20th, "commitment laws were lax" and often required only the signature of a physician to have a person confined for life in a mental institution (Levine, p. 24). State hospitals developed a reputation for confining the impoverished and dangerous, and "negative attitudes associated with welfare were associated with mental hospitals" (Levine, p. 26). State and local administrators were most often concerned with limited budgets, efficiency and cost-per-patient ratios than with therapy and treatment. Another reason for low discharge rates was the fact that many inmates in state hospitals were put to work on farms and other enterprises in order to save money for the state and local governments. Dr. Earle's hospital never went over-budget and always earned a profit, which made it well-admired by the businessmen and managers who really ran the state government. Since Earle maintained that the mentally ill could not be treated or cured in any event, it made sense that as many of them as possible worked to pay for their keep. County farms, almshouses and infirmaries also continued well into the 20th Century, and in many cases the elderly and disabled mentally ill simply had nowhere else to go (Levine, p.29).
Before the 1950s and 1960s, the federal government had little or no influence over mental health care policy, which was almost entirely the concern of state and local governments. In 1854, for instance, President Franklin Pierce vetoed a bill for federal funding for state hospitals on the grounds that this was not the responsibility of the national government (Levine, p. 31). Under the provisions of the original Social Security Act of 1935, federal payments could not be made to patients in state hospitals and other institutions, although this changed in the 1950s and 1960s. From the 1830s to the 1960s, then, the state hospital "continued to be the mainstay of the mental health system," funded mainly by state and local governments. About the only exception to this was the Veterans Administration that was forced to establish mental health care facilities for the large number of psychiatric casualties from both world wards -- conditions then known as shell shock, combat psychosis or combat fatigue but today classified as Post-Traumatic Stress syndrome (PTSD). Even though new treatments appeared in the 1930s, such as lobotomies, insulin shock and electric shock -- which turned out to be mostly ineffective -- these did not change the basic nature of the system. When deinstitutionalization began in the 1960s, the elderly mentally ill were among the first to be effected, although most were transferred to nursing homes that received Medicaid and Medicare payments from the state and federal governments. Indeed, this new policy created as many problems…[continue]
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