Psychiatric hospital

A psychiatric hospital (also called at various places and times, mental hospital, mental ward, asylum or sanitarium) is a hospital specializing in the treatment of persons with mental illness. Psychiatric wards differ only in that they are a unit of a larger hospital.

Background

Psychiatric hospitals or wards have a number of differences from other medical facilities. First, they often have elaborate procedures to prevent patient suicide. Second, they attempt to reduce the amount of sensory stimulation that patients receive. Contrary to popular belief, psychiatric hospitals are generally quiet, even boring places. Third, psychiatric hospitals often try to provide as normal an environment as possible. For example, unlike most other hospitals, many or most patients in psychiatric hospitals wear everyday clothes rather than patient examination garments.

In the United States, psychiatric hospitals in the past were often set up as separate institutions with funding and administrations separate from those of general health care. Since the development of psychotropic drug therapies in the 1950s, there has been an increasing move towards integration of psychiatric treatment within the general health sector. Psychiatric wards in general hospitals and various outpatient commitment programs are replacing the old asylums worldwide.

In the United Kingdom during the late 18th, 19th and early 20th centuries, county authorities were expected to provide their own asylums, for the care or incarceration of the insane. Private institutions had existed before this, and provided the only care available. Throughout this period, private institutions continued to exist and be founded for so called idiots and imbeciles, who were usually those who today would be said to have mental retardation or learning disabilities. The county asylum structure was nationalised in 1948, when the institutions were absorbed into to the National Health service. As in the U.S. and worldwide, most psychiatric hospitals have been replaced by Care in the Community and psychiatric wards in general hospitals.

It was only until relatively recently that incarceration was mandatory for all with considerable mental health problems. Today, secure and medium-secure units care for those who require more support or supervision.

Today, in both countries, if a patient had been admitted to the hospital on a voluntary basis, the patient is often allowed to check him or herself out of the hospital against medical advice. In most jurisdictions, to leave requires at least a day's notice. This is so in the event a doctor decides the patient would still present a danger to self or others, there is time to commence involuntary commitment procedures.

Efforts have often been made to improve mental health care. Nevertheless, many problems remain in those countries where free health care is not available or where funding is limited. This especially affects those with little money to pay for expensive facilities. Limited funding of hospitals can lead to a lack of adequate staff and resources which can lead to the use of restraints and medication for punishment rather than treatment. Procedural deficiencies such as a lack of documentation for involuntary treatment and other serious deficiencies remain all too common in some countries.

Types of psychiatric hospitals

There are a number of different types of modern psychiatric hospitals or wards.

Crisis stabilization

One type is the crisis stabilisation unit, which is in effect an emergency room for mental disorders. Because involuntary commitment laws in many jurisdictions require a judge to issue a commitment order within a short time (often 72 hours) of the patient's entry to the unit and because moving a severely ill mental patient can be extremely dangerous, especially as the patient may try to harm himself/herself or others, many of these stabilisation units have conference rooms which are used as courtrooms for emergency commitment procedures.

Open units

Open units are psychiatric units that are less secure than crisis stabilisation units. They are not used for acutely suicidal persons; the focus in these units is to make life as normal as possible for patients while continuing treatment to the point where they can be discharged. However, patients are usually still not allowed to hold their own medications in their rooms, because of the risk of an impulsive overdose. While some open units are still physically unlocked, other open units still use locked entrances and exits. This is to keep patients from leaving impulsively or without being discharged from the unit.

Medium-term

Another type of psychiatric hospital is a medium term. It is care lasting several weeks. Most drugs used for psychiatric purposes take several weeks to take effect and the main purpose of these hospitals is to watch over the patient while the drugs taken have their expected effect and the patient can be discharged.

Juvenile wards

Juvenile wards are sections of psychiatric hospitals or psychiatric wards set aside for children and/or adolescents with mental illness.

These usually consists of anyone aged 18 and younger.

Geriatric wards

Geriatric wards are designed to help treat older adult patients. The staff of these wards are specially trained to deal with older patients.

Hospitals for prisoners with mental illness

Another type of psychiatric hospital is designed for long-term care, a combination hospital and prison for the "criminally insane," typically for people with a psychotic illness who have committed serious crimes. In the United States, these are generally operated by the state government and exist in a few centralised locations. In the UK, the hospitals are run by the government in conjunction with the NHS; the best-known British institution of this type is Broadmoor Hospital in Berkshire. In most cases, persons within these hospitals have been charged with serious crimes and have been found not guilty by reason of insanity. As a result, in addition to precautions to prevent suicide, there are also precautions against escape (such as those found in a prison). The treatment of persons within such institutions has been a subject of long-standing debate, because a patient will often spend more time in the hospital than they would have spent in prison. However, the severely mentally ill often get much worse in standard prisons, and are usually targets of an even greater than normal amount of abuse from the rest of the prison population. Also, it is felt that if a severe mental illness causes someone to commit a crime, locking them up without treating the illness is both a violation of their civil rights and serves simply to put them back on the street, where the same untreated illness will often drive them to commit another crime, beginning the cycle anew.

Halfway houses

One final type of mental institution, that is not a hospital, is a community-based halfway house. These houses provide assisted living for mental patients for an extended period of time. These institutions are considered to be one of the most important parts of a mental health system by many psychiatrists, although many localities fail to provide sufficient funding for them.

Used as a form of prison

In some countries the mental institution may be (or may be argued, at least by some, to be) used for the incarceration of political prisoners, as a form of oppression (see Psikhushka). Only a small minority of people would argue that this is the case in every country, every hospital, or with respect to every patient.

Anti-psychiatry objections to mental hospitals

Some observers, notably psychiatrist Dr. Thomas Szasz, have objected to calling mental hospitals "hospitals" (see anti-psychiatry). Lawrence Stevens has described mental hospitals as "jails."

In particular, anti-psychiatry activists have advocated for the abolition of long-term hospitals for the criminally insane on the grounds that the insanity defence should not be permitted, and those confined to such institutions should be incarcerated in a regular prison instead, others on the grounds that the inmates' confinement to these "hospitals" punishes them for crimes of which they have been judged not guilty, and others on various other grounds.

History of psychiatric hospitals

The history of psychiatric hospitals is linked heavily with social and scientific attitudes towards mental health, and the attitudes towards those afflicted with mental illness, both of which have changed greatly over the past centuries.

File:HogarthBedlam.png

Scene of Bethlem Hospital from the final plate of William Hogarth's A Rake's Progress.

As the number of people living in cities increased, there became an increasingly large population of urban mentally ill. Generally speaking, in rural areas the mentally ill had been able to rely on local charity and support, or managed to simply "blend in" with the rest of the population. However, under the demands of larger cities they faced a higher degree of difficulty and had a much greater chance of causing disruption or simply being noticed. This led to the building of the early asylums which were little more than repositories for the mentally ill – removing them from mainstream society in the same manner as a jail would for criminals. Conditions were often extremely poor and serious treatment was not yet an option. The first known psychiatric hospital, Bethlem Royal Hospital (Bedlam), was founded in London in 1247 and by 1403, had begun accepting "lunatics". It soon became infamous for its harsh treatment of the insane, and in the 18th century would allow visitors to pay a penny to observe their patients as a form of "freak show". In 1700 it is recorded that the "lunatics" were called "patients" for the first time, and within twenty years separate wards for the "curable" and "incurable" patients had been established, representing the beginning of a clear shift in the attitude towards mental illness towards a disease of some form.

Phillipe Pinel (1793) is often credited as being the first to introduce humane methods into the treatment of the mentally ill as the superintendent of the Asylum de Bicêtre in Paris. However, this is a mistake. The credit should actually go to a hospital employee of Asylum de Bicêtre, Jean-Baptiste Pussin. Pussin was actually the first one to remove patient restraints. Pussin influenced Pinel and they both served to spread reforms such as categorising the disorders, as well as observing and talking to patients as methods of cure. At much the same time William Tuke was pioneering a more enlightened approach to the treatment of the mentally ill in England. These ideas gradually took hold in different countries, and in the United States attitudes towards the treatment of the mentally ill began to drastically improve during the mid-19th century.

Reformers, such as Dorothea Dix in the U.S., began to advocate a more humane and progressive attitude towards the mentally ill. In the United States, for example, numerous states established state mental health systems paid for by taxpayer money (and often money from the relatives of those institutionalised inside them). These centralised institutions were often linked with loose governmental bodies, though in general oversight was not high and quality consequently varied. They were generally geographically isolated as well, located away from urban areas because the land was cheap and there was less political opposition. Many state hospitals in the United States were built in the 1850s and 1860s on the Kirkbride Plan, an architectural style meant to have curative effect.

While many of those in state hospitals were voluntarily admitted, many more were involuntarily committed by courts. For this reason, state hospital patients were usually from the lower class, as the mentally ill from families with money often had enough private care to avoid being labelled a public menace.

In the United States, state hospitals in some places began to overflow by the beginning of the 20th century. As state populations increased, so did the number of mentally ill and so did the cost of housing them in centralised institutions. During wartime, state mental hospitals became even more overburdened, often serving as hospitals for returning servicemen as well as for their regular clientele. The incentive to discharge patients was high, yet there were still no adequate treatments or therapies for the mentally ill.

This provided a fruitful environment for the popularity of quick-fix solutions, like the eugenic compulsory sterilisation programs undertaken in over 30 U.S. states (and, later, in Nazi Germany), which allowed institutions to discharge patients while still claiming to be serving the public interest. These new treatments of mental illness – which was now seen as a "defect", and likely a hereditary one – were seen less as therapeutic for the individual patient than as preventative for the society as a whole.

From 1942 to 1947, conscientious objectors in the United States assigned to psychiatric hospitals under Civilian Public Service exposed abuses throughout the psychiatric care system and were instrumental in reforms of the 1940s and 1950s. The CPS reformers were especially active at the Byberry Hospital in Philadelphia where four Friends initiated The Attendant magazine as a way to communicate ideas and promote reform. This periodical later became the The Psychiatric Aide, a professional journal for mental health workers. On 1946-05-06 Life Magazine printed an exposé of the mental healthcare system based on the reports of COs. Another effort of CPS, Mental Hygiene Project became the National Mental Health Foundation. Initially sceptical about the value of Civilian Public Service, Eleanor Roosevelt, impressed by the changes introduced by COs in the mental health system, became a sponsor of the National Mental Health Foundation and actively inspired other prominent citizens including Owen J. Roberts, Pearl Buck and Harry Emerson Fosdick to join her in advancing the organization's objectives of reform and humane treatment of patients.

By the mid-1940s, treatment of the mentally ill took a new turn, with the advent of electroconvulsive therapy (ECT) and insulin shock therapy, and the use of frontal lobotomy. In modern times, insulin shock therapy and lobotomies are viewed as being almost as barbaric as the Bedlam "treatments", though in their own context they were seen as the first options which produced any noticeable effect on their patients. ECT is still used in the West, but it is seen as a last resort for treatment of mood disorders, and is administered much more safely than in the past. Elsewhere, particularly in India, reports have surfaced that ECT is enjoying increased use, as a cost-effective alternative to drug treatment. The effect of a lobotomy on an overly excitable patient often allowed them to be discharged to their homes, which was seen by administrators (and often guardians) as a preferable solution than institutionalisation. Lobotomies were performed in great numbers from the 1930s to the 1950s. At the time, these new therapies became a horrific part of popular understanding of the mental hospital, helping their popularity very little, to say the least.

By the mid-1950s, the first psychiatric drugs became available for the treatment of mental illness, such as thorazine, which revolutionised psychiatric care and provided new ways for many of the severely mentally ill to return to normal society. Newly developed antidepressants were used to treat cases of depression, and the introduction of muscle relaxants allowed ECT to be used in a modified form for the treatment of severe depression and a few other disorders. The use of Psychosurgery was narrowed to a very small number of people for specific indications. New treatments led to reductions in the number of patients in mental hospitals.

In the early 1960s in U.S., amid public images of mental hospitals as sites for horror movies, a deinstitutionalisation movement caught hold in many states. At the time, mental hospitals were viewed as the least desirable solution to the problem of mental illness, both from a humane point of view and an economic one. California, for example, began to scale back its large mental health system in favour of community-based care, whereby smaller clinics would provide care. Although many facilities were emptied, outpatient services proved severely inadequate, a disaster according to some, which has only recently been addressed with the enactment of the California Mental Health Services Act.

The negative stereotypes (and an undercurrent belief that patients were "entitled to think what they wanted", rather than accept societal norms) continued to promulgate, however, and went even further in the backlash against social welfare policies in the 1980s, which lead to massive deinstitutionalisation and funding cuts. These changes led to the closing of many mental hospitals and the further reliance on local community care. Many former patients, instead of reintegrating successfully into society or receiving community treatment, simply wound up as homeless persons.

A similar movement took place in the UK, in which "Care in the Community" came to take the place of most mental hospitals.

In some nations, mental hospitals were used as sites for the stifling of political dissidence or even genocide. Under Nazi Germany, a euthanasia program began which resulted in the killings of tens of thousands of the mentally ill housed in state institutions, and the killing techniques perfected at these sites became later implemented in the Holocaust (see T-4 Euthanasia Program). In the Soviet Union, dissidents were often put into asylums and kept on a variety of destabilising medications, with the hope of not simply removing them from society, but making them unreliable in the eyes of others (see Psikhushka). In the case of Zhores Medvedev, the ire of officials was aroused by manuscripts that had been published (without his permission) in the West and a book, Biology and the Cult of Personality, which was an attack on Lysenkoism.

The attitudes in these cases – that the mentally ill were a scourge and needed to be eliminated, and that the line between 'patient' and 'prisoner' is incredibly blurry – have their precedents in the history of mental hospitals, though were taken to extremes by totalitarian regimes.

Synonyms

Psychiatric hospitals are heirs to a colourful legacy of alternative monikers, many of which predate the advent of facilities concerned with medically oriented rehabilitation, e.g., bedlam, booby hatch, funny farm, haha hotel, happy hotel, laughing academy, giggle academy, koo-koo hut, wacky shack, loony bin, mad house, nut house, puzzle factory, sanitarium, and others.

External links

Antipsychiatry.org - 'Is Involuntary Commitment for "Mental Illness" a Violation of Substantive Due Process?' Lawrence Stevens, J.D.
BBC.co.uk - 'Mental hospital wards "dire"', BBC (July, 7, 2000)
ElPeecho.com - 'Pennhurst Information' (re: Spring City, Pennsylvania 'school' for the 'mentally retarded')