demonological

Psychiatric hospital

A psychiatric hospital (previously called insane asylum, mental hospital; or derogatorily looney bin, nut house or Funny Farm) is a hospital specializing in the treatment of serious mental illness, usually for relatively long-term inpatients.

Two rules usually govern whether someone should be placed in a psychiatric hospital: if someone is an immediate threat to harm themselves, or to harm other people. If neither of these two criteria are met, then the patient may benefit from outpatient care. If there is uncertainty as to the extent of a patient's danger to themselves or others, they are typically placed in a hospital for safety reasons.

History

Cities

As the number of people living in cities increased, there became an increasingly large population of mentally ill people. Generally speaking, in rural areas the mentally ill had been able to rely on local support of the people around them, or managed to simply go unnoticed amongst 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 a nuisance. This led to the building of the early asylums.

In the United Kingdom the Middlesex County Court Judges pressured the UK Government resulting in an Act of Parliament - The Madhouse Act 1828, allowing the building of purpose-built asylums, the first of which the 1st Middlesex County Asylum was at Hanwell in West London and opened its doors in late 1831. (Src. Museums of Madness, Andrew T. Scull, Penguin 1979)

Initially these early asylums 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.

By region

Middle East

Unlike medieval Christian physicians who relied on demonological explanations for mental illness, medieval Muslim physicians and psychologists relied mostly on clinical observations. They made significant advances to psychiatry and were the first to provide psychotherapy and moral treatment for mentally ill patients, in addition to other forms of treatment such as baths, drug medication, music therapy and occupational therapy. In the 10th century, the Persian physician Muhammad ibn Zakarīya Rāzi (Rhazes) combined psychological methods and physiological explanations to provide treatment to mentally ill patients. His contemporary, the Arab physician Najab ud-din Muhammad, first described a number of mental illnesses such as agitated depression, neurosis, and sexual impotence (Nafkhae Malikholia), psychosis (Kutrib), and mania (Dual-Kulb).

In the 11th century, another Persian physician Avicenna recognized 'physiological psychology' in the treatment of illnesses involving emotions, and developed a system for associating changes in the pulse rate with inner feelings, which is seen as a percursor to the word association test developed by Carl Jung in the 19th century. Avicenna was also an early pioneer of neuropsychiatry, and first described a number of neuropsychiatric conditions such as hallucination, insomnia, mania, nightmare, melancholia, dementia, epilepsy, paralysis, stroke, vertigo and tremor.

Continental Europe

Phillipe Pinel (1793) is often credited as being the first in Europe to introduce more humane methods into the treatment of the mentally ill (which came to be known as moral treatment) as the superintendent of the Asylum de Bicêtre in Paris. A hospital employee of Asylum de Bicêtre, Jean-Baptiste 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. Vincenzo Chiarugi in Italy may have banned chains before this time.

Bethlem Royal Hospital

Bethlem Royal Hospital (Bedlam) was the first known psychiatric hospital in Europe, founded in London in 1547. It soon became infamous for its treatment of the insane, and in the eighteenth century outsiders would pay a penny to come and watch their patients as a form of entertainment. 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. The institution was still a coercive and brutal regime when William Battie criticized its practices in his treatise in 1785. By 1815 thousands of visitors were still being permitted in to view the "unfortunates" as they were by then called.

United States

Progress in treatment was also occurring in the United States, often ahead of similar advances in Europe. This was especially true in tolerant New England and particularly one institution in Brattleboro, Vermont. In 1834, Anna Marsh established the prestigious Brattleboro Retreat to offer "merciful, ethical, and scientific care" to the mentally ill. Originally named the Vermont Asylum for the Insane, the hospital pioneered the application of "moral treatment" based on clean living, patient empowerment, and therapeutic farm work. The hospital grew into a large research facility complete with these world firsts: a patient-produced newspaper, hospital swimming pool, bowling alley, gymnasium, theater, chapel, patient choir, patient sports leagues, outing club, dairy farm, and patient-run companies. Marsh endowed the Brattleboro Retreat in memory of her late physician husband. The vision she expressed in her will would come to impact around the world. Today it stands as a member of the Ivy League Hospitals. The original hospital building was the Marsh home, which still stands among the large riverside campus.

The Hartford Retreat (now the Institute of Living at Hartford Hospital) and McLean Hospital also set the tone for the United States' history of relatively humane private psychiatric facilities. The Quakers of the mid-Atlantic states, particularly Pennsylvania, also offered dignified treatment that was among the most progressive in the world. The transition to state hospitals and "state schools", however, brought with them many abuses that shocked operators of private American psychiatric hospitals. Reformers, such as American Dorothea Dix began to advocate a more humane and progressive attitude towards the mentally ill. Some were motivated by a so-called Christian Duty to mentally ill citizens. 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 institutionalized inside them). These centralized institutions were often linked with loose governmental bodies, though oversight 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. States made large outlays on architecture that often resembled the palaces of Europe, although operating funding for ongoing programs was more scarce. Many patients objected to transfers from private hospitals to state facilities. Some Brattleboro Retreat patients tried to hide when state officials arrived to transfer them to the new Waterbury State Hospital. This decline in patient census led to the collapse of many private institutions, which still accepted indigent patients even when state reimbursement for private hospitals dropped in the face of rising state hospital costs.

United Kingdom

Around the same time as Pussin and Pinel, the Quakers, particularly William Tuke, pioneered an enlightened approach (moral treatment) in England at the York Retreat. The Retreat was not a psychiatric hospital, and in fact the medical approaches of the day were abandoned in favor of understanding, hope, moral responsibility and occupational therapy. The Brattleboro Retreat and the former Hartford Retreat were named after it.

In 1817 a William Ellis was appointed as superintendent to the newly built West Riding Pauper Asylum at Wakefield. A Methodist, he too had strong religious convictions and with his wife as matron they put into action those things they had learnt from the Sculcoates Refuge in Hull which was run on a similar model as the York Retreat. After 13 years their reputation had become such, that they were then invited to run the newly built first pauper asylum in Middlesex called the Hanwell Asylum. Accepting the posts, the asylum opened in May 1831. Here the Ellis's introduced their own brand of humane treatment and 'moral therapy' combined with 'therapeutic employment'. As its initial capacity was for 450 patients it was already the largest asylum in the country and subject to even more building soon after. Therefore, the immediate and continuing success of humane therapy working on such a large scale, encouraged its adoption at other asylums. In recognition of all this work he received a knighthood. He continued to develop therapeutic treatments for mental disorders and always with moral treatment as the guiding principle.

In Lincoln, Lincolnshire, England, Robert Gardiner Hill with the support of Edward Parker Charlesworth, developed a mode of treatment that suited 'all types' of patients, where by the reliance on mechanical restraints and coercion could be made obsolete altogether, a situation he finally achieved in 1838.

By the following year of 1839 Sergeant John Adams and Dr. John Conolly was so impressed by the work of Hill, that they immediately introduced the method into their Hanwell Asylum, which was by then the largest in the kingdom. The greater size required Hill's system to be developed and refined. This was necessary as it was beyond Conolly to be able to supervise each attendant as closely as Hill had done. Even so, he bid a pair of extra soft slippers made so that he could walk around the building at night without his foot falls warning the attendance of his imminent approach. By September 1839, mechanical restraint was no longer required for any patient. For years, this day was remembered at the Hanwell asylum by a celebration on its anniversary. Hanwell also was a very accomplished communicator and wrote and lectured widely about his work in mental health.

By such means these and others, more effective treatment methods gradually took hold in different countries, and attitudes towards the treatment of the mentally ill began to drastically improve during the mid-19th century. Courts began to administer involuntary commitments with a greater eye towards medical justification.

Ineffective treatments

This provided a fruitful environment for the popularity of quick-fix solutions, like the eugenic compulsory sterilization programs undertaken in over 30 U.S. states (and, later, in Germany), which allowed institutions to discharge patients while still claiming to be serving the public interest. These new treatments of mental illness – which is 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 US 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 May 6, 1946, Life Magazine printed an exposé of the mental healthcare system based on the reports of COs. Another effort of CPS, namely the Mental Hygiene Project, became the National Mental Health Foundation. Initially skeptical 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.

Radical medicine

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 the hundreds from the 1930s to the 1950s, and were ultimately replaced via the advent of modern psychotropic medications.

Drugs

By the mid-1950s, the first psychiatric medications became available for the treatment of mental illness, such as chlorpromazine, which revolutionized 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.

Political device

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). It is thought Dr. Hans Asperger was involved in the T-4 program in Nazi state hospitals throughout Germany and Austria in the time when he discovered Asperger's syndrome, a developmental disability in the Autistic spectrum.

Types

There are a number of different types of modern psychiatric hospitals, but all of them house people with mental illnesses.

Crisis stabilization

One type is the crisis stabilization unit, which is in effect an emergency room for mental disorders. Laws in many jurisdictions providing for involuntary commitment require a commitment order issued by a judge within a short time (often 72 hours) of the patient's entry to the unit.

Open units

Open units are psychiatric units that are less secure than crisis stabilization 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 physically unlocked, other open units still use locked entrances and exits. This is to keep patients from escaping, which may be described as "leaving impulsively," or leaving without being discharged from the unit.

Medium-term

Another type of psychiatric hospital is a medium term, which provides 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 begin 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 consist of anyone aged under 18.

Long term care facilities

In the UK long-term care facilities are now being replaced with smaller secure units (some within the hospitals listed above). Modern buildings, modern security and being locally sited to help with reintegration into society once medication has stabilized the condition are often features of such units. An example of this is the Three Bridges Unit, in the grounds of Hanwell Asylum in West London and the John Munroe Hospital in Staffordshire. However these modern units have the goal of treatment and rehabilitation back into society within a short time-frame (two or three years) and not all forensic patients' treatment can meet this criterion, so the large hospitals mentioned above often retain this role.

Halfway houses

One type of institution for the mentally ill is a community-based halfway house. These houses provide assisted living for patients with mental illnesses 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 some localities fail to provide sufficient funding for them, such provision being seen as costly.

Used as a form of prison

In some countries the mental institution may be used for the incarceration of political prisoners, as a form of punishment (see Psikhushka). In the United States, more so in the past than now (although it still happens) a 72 hour hold would be placed on a person by police when that person had committed no crime, but the police still wanted to take action against that person.

Anti-psychiatry objections

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

Michael Foucault is widely known for his comprehensive critique of the use and abuse of the mental hospital system in Discipline and Punish. Erving Goffman coined the term 'Total Institution' for places which took over and confined a person's whole life. The anti-psychiatry movement coming to the fore in the 1960s oppose many of the practices, conditions, or existence of mental hospitals. The Consumer/Survivor Movement has often objected to or campaigned against conditions in mental hospitals or their use, voluntarily or involuntarily.

Some anti-psychiatry activists have advocated for the abolition of long-term hospitals for the criminally insane, including on the grounds that those judged not guilty by reason of insanity should not then be indefinitely confined with potentially less legal rights, or on the converse grounds that insanity is not a coherent concept and so should not be a basis for different treatment.