History of Institutionalization/Treatment

The Age of Asylums

Institutions for the mentally ill were established beginning in the 14th century. These facilities, or asylums, were opened in Florence, Spain, Belgium, and England. One of the most renowned was St. Mary of Bethlehem, located outside London -- better known as Bedlam (Figure 6). Mental patients were first accepted in 1403, and by 1547 it was totally devoted to the care of the insane. This asylum was well known for the brutal treatment of the insane. Bedlam was later used as a term to refer to all asylums.

Figure 6. "Bethlehem Asylum 'Bedlam' one of the first asylums (1403)." Courtesy of the National Library of Medicine.

William Battie, whose name gave origin to the word "batty", also advocated the use of "therapeutic" asylums in his Treatise on Madness in 1758.^[33] Many of the mentally ill were being treated in prisons or other inappropriate institutions. Asylums, however, continued to be known for their dehumanizing conditions. In the 18th century, an asylum in Newcastle, England, housed both sexes together tethered in chains in a dungeon-like atmosphere. In 1845, Esquirol reported on the inhumane aspects of the asylum environment: "If the patient's violence is extreme, he is fastened onto his bed and his movements are brought under control with a straitjacket....How many manic patients have become paralyzed through being fastened too long on their bed or in an armchair." Treatments included agents such as opium or camphor mixed with vinegar. In more extreme cases moxa, a flaming pitch applied to the head, was used.^[34] Esquirol also suggested that: "You can, if you wish, substitute for an iron heated in the fire, an iron heated in boiling water." In England as well as in the United States, patients would be placed on display on Sunday for the curious to view.

Generally, however, throughout the 18th and 19th centuries, a humane and compassionate approach to the mentally ill was advocated. Pinel, after assuming his role as a superintendent of a French asylum in 1793, removed the insane from their chains. He developed a "moral treatment" for the mentally ill, which included a kindly but firm disposition toward the patients. Groups, such as the Quakers, also advocated an attitude of kindness toward the mentally ill.

Benjamin Rush (Figure 7), often called the father of American Psychiatry -- one of the signers of the Declaration of Independence -- championed a variety of progressive causes including the abolition of slavery, alleviation of excessive hardship for prisoners, and the need to overcome discriminatory practices against the Indians. It was his advocacy for humane treatment of the mentally ill, however, that was to gain him international acclaim. He oversaw the care of the mentally ill at the Pennsylvania Hospital in Philadelphia and stressed the physical as well as environmental basis of psychiatric disorders. He also promoted sympathetic listening as a way of enhancing the treatment process -- "...catch the patient's eye and look him out of countenance. Be always dignified. Never laugh at or with them. Be truthful. Meet them with respect. Act kindly towards them in their presence. If these measures fail, coercion is necessary. Tranquillizing chair...." (Figure 8). ^[35]

Figure 7. "Benjamin Rush, often called the father of American Psychiatry. His advocacy for humane treatment of the mentally ill gained him international acclaim." Courtesy of the National Library of Medicine.

In 1812, a year before his death, he published Medical Inquiries and Observations upon the Diseases of the Mind.^[35] For the ensuing 70 years, this treatise was to be the only psychiatric text in America^[36] Thus, moral treatment emphasized respect for the afflicted individual and reeducation in a conducive rather than punitive setting.

Figure 8. "Wooden chair called the tranquilizing chair designed by Benjamin Rush the founder of American psychiatry and a signer of the US Constitution, equipped with restraints, he called it 'the tranquilizer'." Courtesy of the National Library of Medicine.

Dorothea Dix was a major figure in the United States mental hygiene movement in the 19th century. She forcefully advocated for the establishment of more psychiatric hospitals. Since there were few large existing buildings comparable to those in Europe, she lobbied for the setting aside of over 12 million acres of wilderness for the mentally ill (Figure 9). She was unsuccessful in this endeavor, however. She helped to found many asylums, which reached 48 in number by 1861. Approximately 8500 patients were hospitalized at that time in which there were 27 million residents in the United States.

Figure 9. "State hospitals called 'lunatic asylums' were advocated by Dorothea Dix in the early 1800's for compassionate treatment of the mentally ill." Courtesy of the National Library of Medicine.

In Philadelphia in 1844, thirteen asylum directors formed the Association of Medical Superintendents of the American Institutions for the Insane. This was later called the American Medico-Psychological Association, which later became the American Psychiatric Association. The American Journal of Insanity was first published in the 19th century at the New York State Lunatic Asylum in Utica. This would later be called the American Journal of Psychiatry.^[36]

Stigma and Early Treatments

Witchcraft and demonic possession. Throughout history, the seriously mentally ill have often been viewed with suspicion, disgust, and fear. During the Middle Ages and Renaissance Period witchcraft and demonic possession were considered to be the root of emotional disturbances. Confession and exorcism were therefore advocated as the means for overcoming and expelling these malevolent influences. The range of individuals to which these treatments were applied included those with organic psychosis and dementia in addition to schizophrenics and other severely mentally ill.

Reginald Scot's^[37] depiction of witches clearly includes symptoms and characteristics of the mentally ill. These individuals are described as "Old, lame, bleare-eyed, pale, fowle and full of wrinkles...in whose drowsie minds the divell hath gotten a fine seat...leane and deformed, showing melancholie in their faces...doting, scolds, mad, divellish." Instruments of torture and other barbarous means of confession were employed to rid the individual of devilish influences. These methods often resulted in death.

Malleus Maleficarum (the Witches Hammer)^[38] written by the Dominican friars Jakob Sprenger and Heinrich Kramer in 1486 was a guidebook for the recognition, judgment, and punishment of those who practiced witchcraft. Although many of the suggested techniques were brutal and inhumane, it was considered to be the "bible" for dealing with demonic influences by both church and state throughout the 17th century

Physical intervention. Physical interventions included bloodletting with leeches, and induction of emesis to eliminate poisons from the body. Trepanation, or the boring of holes in the skull to release the evil elements was practiced as early as 10,000 BC,^[39] and was utilized widely in many cultures. Some treatments were designed to induce fear or intense psychical and physical discomfort. Spinning the patient until loss of consciousness occurred was thought to be helpful in rearranging the contents of the brain (Figure 10). At times, an unsuspecting victim was immersed into ice water in order to shock the system. Other techniques included therapy, insulin shock, frontal lobotomy as well as other crude neurosurgical procedures.

Figure 10. "A whirling chair and bed was one of the early treatments for mental disorders." Courtesy of the National Library of Medicine.

Treatments in the 20th Century

ECT. Convulsive therapy was introduced in 1934 by von Meduna^[40] He contended that patients rarely suffered from epilepsy and schizophrenia, although this observation was later called into question. He also noted that some patients improved after a spontaneous convulsion. He initially utilized intramuscular injections of camphor, but the technique did not reliably induce seizures. In 1938, the Italians Cerletti and Bini^[41] introduced electrically induced seizures. Early use of this procedure sometimes resulted in complications such as fractures due to inadequate anesthesia. Some patients also complained of memory difficulties; however; the exact extent and permanence of these deficits continues to be controversial. Unilateral ECT is considered to have less amnestic side effects compared with bilateral treatments. Despite the current safety and effectiveness of this treatment, especially in refractory patients, it is an often feared and maligned treatment. This is a result of the crude means of administration used by early practitioners, forced treatment prior to the institution of adequate patient rights, as well as ignorance concerning the safety and efficacy of the technique. Legislative initiatives and patient protests have therefore limited the application of this modality. In addition, there is insufficient evidence showing a significant positive clinical impact on the treatment of schizophrenia.

The advent of psychopharmacology. The discovery of the antipsychotic chlorpromazine by the French team of scientists Pierre Deniker, Henri Leborit, and Jean Delay in the early 1950s ushered in the psychopharmacologic era. Not only were these medications efficacious in alleviating some of the most disturbing positive symptoms of the psychotic patient, they helped to initiate the understanding of the neurobiological processes underlying these disorders. Other, so-called "typical" agents such as thioridazine, trifuloperazine, and haloperidol had different side-effect profiles but similar mechanisms of action. They also had problems with potentially serious side effects of tardive dyskinesia. Treatment was significantly advanced through the introduction of the "atypical" neuroleptic clozapine. This agent helped to alleviate negative symptoms such as social withdrawal and apathy as well as cognitive deficits. The side effects, including potentially life threatening agranulocytosis, limited the utility of the drug. Newer atypical agents include risperidal, olanzapine, quetiapine, and ziprasidone. Not only do these medications have an improved side-effect profile, but new clinical uses are being discovered that extend their utility. For example, olanzapine was approved as a mood stabilizing medication.

Modern psychological explanations of schizophrenia have at times ascribed blame for the onset or perpetuation of the disorder to either victim or caregiver. Some psychodynamic theories, for example, posited that the individual's early upbringing was a major force in the development of psychotic disorders. A school of family therapy fostered the idea of a "schizophrenogenic" mother as the primary disorganizing force leading to a psychotic break. Our more recent understanding of the biological basis of behavior has helped to place the schizophrenic disorder in a less stigmatized and more comprehensive and realistic light.

The era of deinstitutionalization. Beginning in the 1950s, a large exodus from US state hospitals began. Often termed "deinstitutionalization," this policy resulted in the transfer of patients and care from chronic inpatient services to community-based services. The movement was driven by several factors.^[42] First, modern scientific developments have allowed for an ever-widening group of previously refractory patients to live outside of the confines of the hospital walls. Second, financial pressures have resulted in decreased funding by state governments and greater reliance on federal support for community programs. Third, advocacy groups have successfully argued for the introduction of more humane and less restrictive environments. In 1950 there were 322 state hospitals in the United States serving 512,501 residents. By 1996, the census had dropped to 61,722 residents in 254 institutions.^[43,44]

In order to address some of the needs of the chronically and persistently mentally ill patient, a variety of services have been developed, including short-term general psychiatric units, day treatment programs, halfway houses, social and vocational rehabilitation services, and case management programs. Despite the array of services offered, critics of the current system have contended that there is a lack of a sufficient number, integration, or effectiveness of programs available. Thus the care of patients in the community has at times resulted in a lack of adequate care for a proportion of these individuals. Social problems such as homelessness and violence have at times been attributed to the deinstitutionalization process.^[45]

In response to these criticisms and problems, more active community interventions have been developed. For example, Assertive Community Treatment programs, or ACT programs, have been implemented.^[46] The model for the ACT program was developed in the 1970s by Arnold Marx, MD, Leonard Stein, MD, and Mary Ann Test, PhD, and based on an inpatient unit of Mendota State Hospital, Madison, Wisconsin.^[47] The programs are designed specifically to aggressively reach and intervene with difficult-to-treat individuals, such as recidivists and the homeless. Although the cost of the program can be high, it is often less than the costs incurred by the fragmented care of these difficult-to-treat patients.^[48] Not only are repeated hospitalizations more expensive in the long run, many schizophrenic individuals are inappropriately incarcerated for aggressive behavior manifested during a psychotic state. Court mandated outpatient treatment has also become an increasingly available option in many states as a means of enforcing treatment in potentially violent or self-injurious patients.

The rise of patient advocacy groups, such as the National Alliance for the Mentally Ill (NAMI) ( http://www.nami.org/), has provided a forceful clinical and legislative forum advocating for the rights of the patients and their families. In contrast to the passive role the patient has accepted in the past, the client is now newly empowered to participate actively in the clinical decision process. For example, patient advocacy groups have placed stabilized patients who have suffered from serious mental illnesses on inpatient psychiatric units. The role of these advocates is to help the patient deal with the illness as well as cope with the system of care providers. In this way they provide a bridge to wellness for the acutely ill individual. In addition, they help the care providers to understand the patient's perspective of the mental health system and suggest means of improving the delivery of care.

The Internet has also become a powerful force in helping patients and families to understand and cope with this disorder. Web sites offer chat rooms, personal histories, information about new treatments, as well as suggestions about how to cope with the disorder (eg, http://www.schizophrenia.com/). For example, NAMI is actively supporting the ACT programs and offers information and advice on its Web site about ways of organizing these programs. Coordinated political, media, and community activity is suggested. In addition the process of mobilization of mental health officials and resources is delineated.