Table Of ContentClosing the Asylums
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Closing the Asylums
Causes and Consequences of the
Deinstitutionalization Movement
GEORGE PAULSON, M.D.
Foreword by John C. Burnham
McFarland & Company, Inc., Publishers
Jefferson, North Carolina, and London
LIBRARYOFCONGRESSONLINECATALOGDATA
Paulson, George W., ¡930–
Closing the asylums : causes and consequences of the
deinstitutionalization movement / George Paulson ;
foreword by John C. Burnham.
p. cm.
Includes bibliographical references and index.
ISBN 978-0-7864-7098-3
softcover : acid free paper
¡. Deinstitutionalization—History—United States.
2. Hospitals, Psychiatric—History—United States.
3. Commitment of Mentally Ill—History—United States.
4. History, 19th century—United States. 5. History,
20th century—United States. 6. Mental Health Services—
History—United States. 7. Mentally Ill Persons—History—
United States. I. Title
362.2'10973—dc23
[DNLM: WM 27 AA1] 2012018469
BRITISHLIBRARYCATALOGUINGDATAAREAVAILABLE
© 2012 George Paulson. All rights reserved
No part of this book may be reproduced or transmitted in any form
or by any means, electronic or mechanical, i ncluding photocopying
or recording, or by any information storage and retrieval system,
without p ermission in writing from the publisher.
Front cover photograph: Buffalo State Psychiatric Hospital Ward,
Buffalo, New York (courtesy Clara Daly) www.wardnine.com
Manufactured in the United States of America
McFarland & Company, Inc., Publishers
Box 6¡¡, Je›erson, North Carolina 28640
www.mcfarlandpub.com
Table of Contents
Foreword by John C. Burnham 1
Preface 4
Introduction: Dorothea Dix Hospital and Hilltop, and Why I Care 8
1: Hilltop Asylum in Columbus, Ohio 29
2: Did DI Result from Attitudinal Change, and Did It
Reflect New Wisdom? 49
3: Building Obsolescence and Deinstitutionalization 89
4: Did Deinstitutionalization Reflect the Arrival of Successful
Medications, or Was Medication Only a New Chemical
Straitjacket? 102
5: Role of New Disciplines in Mental Hospitals 114
6: Urbanization, Loss of a Rural Location 129
7: Advances in Public Health and Public Attitudes 144
8: The Increase in Social and Community Resources and Their
Effect on Enhancing Freedom for the Patients 153
9: Legal Initiatives as a Major Factor in Change 160
10: Elimination from the Hospitals of the Physically Handicapped 180
11: Summary, with Consequences of Deinstitutionalization 182
Notes 201
Bibliography 205
Index 209
v
To all those in the past, and now,
who have struggled with mental illness
Foreword by John C. Burnham
In the middle of the twentieth century, the United States had a major
institution, the state hospital, to care for the most unfortunate people in
society. The institution had been developing for more than a hundred
years, and state hospitals were found everywhere in the country. In the
quarter of a century after 1960, the state hospitals were disestablished and
largely destroyed—a move that by any measure was radical. The result
was that several hundred thousand people were deinstitutionalized, that
is, removed or pushed out of the state hospitals. For some, the change was
welcome. For many others, however, usually the most vulnerable and help-
less, the experience was unfavorable for them and for their families—and
for society as well.
To a remarkable extent, people at that time and especially since have
ignored this truly revolutionary change. They seem to have accepted what
happened. Seldom in history has such a sudden shift, affecting so many
people and changing society in so many ways, occasioned so little public
comment or concern. A very large number of publications have dealt with
specific aspects of the process of deinstitutionalization of mentally disabled
people. But ordinary citizens and even responsible officials have simply
disregarded objections and criticisms. Today, legislators at all levels show
an amazing refusal to recognize any basic responsibility to provide for peo-
ple who are too disabled to function in society.
The way that Americans have come to deal with the very mentally ill
now is to deny their illnesses. A 2010 report tells us that there are more
seriously mentally ill people in prisons and jails than in hospitals. The
very ill are held responsible for their sicknesses rather than met with pity,
charity, concern, and care.
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FOREWORD BY JOHN C. BURNHAM
The professionals who deal with the mentally ill have had to adapt
to this social revolution. For years, psychiatrists have had surprisingly little
contact with imprisoned or institutionalized patients. Indeed, most psy-
chiatrists moved to outpatient settings that included few or no patients
who were very ill. Most basic care decisions about that group came to be
made by judges, lawyers, social workers, and others who had no medical
qualifications. The total result of all this change was a fundamentally
underfunded, demoralized, and dysfunctional mental health system. Yet
over the past decades, those who worked in that system simply did the
best that they could under circumstances that seemed beyond their control.
Often they were able to manage outcomes that were favorable or even
good.
This book is a remarkable report from someone who was both an
inside participant in the system and an outsider with a historian’s eye. The
author, George Paulson, M.D., trained and at various times served as a
neurologist in mental hospitals and outpatient clinics. His career has in
fact covered the time from the era of the great state hospitals through dein-
stitutionalization into the current era of adaptation. He therefore can pro-
vide a striking eyewitness report. Early on, for example, he was one of
those who recognized the tardive dyskinesia that patients developed who
were treated with the first major antipsychotic, chlorpromazine. Later on,
he studied the institutional changes in treatment venues as well as the
medical problems of mental deterioration in diseases of old age. He is now
consulting in an era in which the neurological and somatic elements in
mental diseases are of concern to both psychiatrists and neurologists. He
therefore speaks with the double authority of medical expert and partic-
ipant observer.
This book, however, also includes another voice: informed concern
from a historian’s point of view. Paulson has published not only many sci-
entific papers but also a number of historical works on medicine, on physi-
cians, and on institutions. He has earned a special expertise that he brings
to this book as he asks: What happened to a great American institution,
and why? And implicit in that questions is another inquiry: Where are we
now, and where do we go from here?
Paulson’s account of what actually happened in the care of very ill
mental patients is therefore doubly well informed. He makes a historian’s
survey of the literature, and to that he adds his thoughtful personal clinical
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Foreword by John C. Burnham
observation. The treatment is also remarkably dispassionate except for his
concern for the patients and his respect for people who attempted to do
the right thing. Where others might grow indignant, Paulson tries for
understanding. He makes his account easy to follow because he can draw
on the histories and specific experiences of two major hospitals, one in
North Carolina and one in Ohio—parallel, different, typical. And his
illustrative case histories of patients deepen the sense of how real different
kinds of problems were for those working and living in the system.
Paulson talks openly about the present and future as he uses both
past records and a lot of experience to convey an immense amount of wis-
dom. He is fully aware of the complexity of the factors that brought about
the radical change in caring for mentally disabled people. He shows how
first one causal element and then another operated, introducing each one,
then at some point giving a detailed consideration of it, and finally circling
around and coming back to the way it intersected with other factors. The
account is both straightforward and sophisticated. It will leave the reader
not only informed but also wiser. And in this account readers will also
learn a great deal about the viewpoints of patients as well as caregivers.
This book has two particularly important audiences. One is those
physicians and other professionals who work with very ill mental patients.
The other is people who want to know how their parents’, grandparents’,
and great-grandparents’ generations could have left us all to live in a world
in which practical brotherhood has so failed to protect terribly unfortunate
people who need, simultaneously, respect and care.
John C. Burnham is research professor of history at The Ohio State University and a past
president of the American Association for the History of Medicine. A Fulbright lecturer,
he is the author of Accident Prone: A History of Technology, Psychology and Misfits of the
Machine Age(2009), among other books.
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