Psychiatric hospital

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

History
The history of psychiatric hospitals is linked heavily with social and scientific attitudes towards mentally retarded people, which have changed greatly over the past centuries.

Cities
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 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 England 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.

Bethlem Royal Hospital
Bethlem Royal Hospital (Bedlam) was the first known psychiatric hospital, founded in London in 1247 and by 1403, had begun accepting social outcasts, the "crazy people", "lunatics" and those who just couldn't stay hidden in society anymore. It soon became infamous for its cruel treatment of the insane, and in the 18th century would have outsiders pay a penny to come and watch their patients as a form of torturous 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. Mental illness was now no longer an affliction, but a disease, to be diagnosed and potentially cured.

Humane treatment
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. 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. At much the same time William Tuke was pioneering a more enlightened approach to the treatment of the mentally ill in England at the Retreat in York. This included not just humane treatment but moral therapy as well.

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 learn 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 development 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,  develop a mode of treatment that suited 'all types' of patients, where by the reliance on mechanical restraint and coercion could be made obsolete altogether, a situation he finally achieved in 1838.

By the following year of 1839 Serjeant John Adams and Dr. John Conolly were 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, had to do. 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. Yet by September 1839, all mechanical restraint were no longer required for any patient. For many years after, this day was remembered at the Hanwell asylum by celebration on the anniversary. He was a very accomplished communicator so wrote and lectured widely about his work in mental health and his fame ensure that his discoveries spread around the world.

By such means these and others, more effective treatment methods 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.

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 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 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 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.

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 great numbers from the 1930s to the 1950s.

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.

Deinstitutionalization
In the early 1960s in U.S., amid public images of mental hospitals as sites for - and possibly like - horror movies, a deinstitutionalization 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. Popular books and movies such as One Flew Over the Cuckoo's Nest and Zen and the Art of Motorcycle Maintenance painted very unflattering portraits of mental hospitals as torture chambers run by sadistic staff, contributing to the deinstitutionalization movement.

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.

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). 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.

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

Crisis stabilization
One type is the crisis stabilization unit, which is in effect an emergency room for mental disorders. 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.

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 still 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.

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.

Long term care facilities
In the UK, at least, long term care facilities are now being replaced with smaller secure units (some within the hospitals listed above). Modern buildings, modern security and locally sited to help with reintegration into society once medication has stabilized the condition. An example of this being the Three Bridges Unit, in the grounds of Hanwell Asylum in West London. 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 criteria, so the large hospitals mentioned above retain this role.

Halfway houses
One final type of institution for the mentally ill, that is not a hospital, is a community-based halfway house. These houses provide assisted living for patients with mental illnesses 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 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.