Although few people are satisfied with the quality of mental health services in the US, it is still startling to find physicians and psychiatrists enthusiastically calling for a return to asylums. One might think that the grim history of confinement would have precluded such advocacy. Whether in popular imagination (think of The Snake Pit or One Flew Over the Cuckoo’s Nest), historical literature (Michel Foucault’s Madness and Civilization), or legislation (exemplified by the Americans with Disabilities Act), the asylum seemed to represent yesterday’s nightmare.
Nevertheless, last winter, The Journal of the American Medical Association ran an editorial titled in part “Bring Back the Asylum,”1 and a few weeks later, a New York Times Op-Ed piece endorsed it.2 In this same spirit, Massachusetts recently invested $300 million in a new mental hospital, the Worcester Recovery Center and Hospital. Are the failures of community services so extreme and beyond repair as to justify recreating asylums?
The bleak history of asylums is worth recalling. In the opening decades of the nineteenth century, widespread and exaggerated optimism about the ability of well-ordered institutions to cure insanity led state after state to build asylums. Initially, they were points of pride, with some claiming 100 percent cures, but within forty years, they deteriorated into custodial facilities. Untrained and unsupervised staff stood guard over patient populations that were predominantly composed of immigrants, many of them elderly. Periodic exposés documented gross overcrowding and mistreatment but did not lead to corrective action. Legislatures, content to rid the streets of troublesome individuals, kept their appropriations meager.3
During the first half of the twentieth century, state hospitals became more and more overcrowded and understaffed. In New York and Massachusetts, for example, they held patients far in excess of capacity. During 1925, there was an excess of 27 percent in New York and 14 percent in Massachusetts. On average, there was one physician for every 250 patients, so the institutions were almost entirely custodial.4 To make matters worse, they became a preferred site for human experimentation. Superintendents approved the research programs and patients had neither the capacity nor the opportunity to say no; to researchers’ delight, there was no effective oversight of the work. In World War II, mental hospitals were the setting for experiments with malaria and flu; patients were purposely infected with the diseases so that the efficacy of experimental drugs could be evaluated. Immediately after the war, the institutions were used for vitamin experiments. Researchers restricted patient diets to induce vitamin deficiencies so that they could investigate the adverse effects. What better way to learn that without vitamin B, patients developed lesions, physical infirmities, and neurological problems?
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