Psychiatry Interpersonal and Biological Processes
ISSN: 0033-2747 (Print) 1943-281X (Online) Journal homepage: http://www.tandfonline.com/loi/upsy20
Business as Usual—At the State Mental Hospital Martha R. Fowlkes To cite this article: Martha R. Fowlkes (1975) Business as Usual—At the State Mental Hospital, Psychiatry, 38:1, 55-64, DOI: 10.1080/00332747.1975.11023834 To link to this article: http://dx.doi.org/10.1080/00332747.1975.11023834
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Business as Usual-At the State Mental Hospitalt Martha R. Fowlkes*
D
ESPITE official policy and professional emphasis to the contrary, the custodial mental hospital continues to exist as a major form of state-provided mental health care. In this paper, one such institution, "New England State Hospital," 1 is described, and the various features of hospital organization that sustain a system of custodial care are discussed. Although the custodial hospital offers little to its patients, its persistent survival can be explained by the number of nonpatient vested interests that are well served by the state hospital, precisely in its existing custodial form. The case study of New England State Hospital suggests that reform of state mental institutions depends less on a programmatic formulation of· desired changes than on an understanding of the structured resistance to such changes. It is common knowledge that the custodial state mental hospital is obsolete. From a variety of sources-whether Wiseman's notorious and unsettling film Titticut Follies, Kesey's popular novel One Flew Over the Cuckoo's Nest, or the sociological studies of Goffman (1961), Dunham and Weinberg (1960), Belknap (1956), and others-comes overwhelming evidence of the failure of such institutions to provide personalized care or active rehabilitative treatment. In a major address in 1963, President Kennedy condemned the "cold mercy of custodial isolation" and urged an end to the practice of confining patients "in an institution to 1 The name of the hospital is a pseudonym. The author was Ii member of the social service department of New England State Hospital from the fall of 1970 to June 1971. Close contact has been maintained with the hospital since that time, and to the best of my knowledge the facts and interpretations contained in this paper remain valid.
wither away." Congress followed suit by enacting the Mental Retardation and Community Mental Health Centers Act in the same year. Certainly it would be impossible to find any authority in the field of mental health care who would have a kind word for the custodial care of the traditional largescale state mental hospital. Mental health professionals are everywhere being trained in new multidisciplinary approaches and community rehabilitation. Indeed, a growing number of psychiatrists, following the lead of Szasz (1961), are rejecting the notion of mental illness altogether and are openly critical of the utilization of conventional medical solutions for what they view as a nonmedical problem. Szasz notwithstanding, the real issue in the past decade has not been the abolition but the reform of the state mental hospital. In this connection custodial forms of care
* Martha R. Fowlkes (MA London School of Economics 65) is currently a lecturer in the Department of Sociology and Anthropology, Smith College, and a graduate student in sociology, University of Massachusetts, Amherst. t I appreciate the comments and advice of Fred A. Kramer, Department of Political Science, University of Massachusetts, and Ely Chinoy, Department of Sociology and Anthropology, Smith College. PSYCHIATRY, Vol. 38, February 1975
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MARTHA R. FOWLKES
have been conceptually, professionally, and time, one-third of whom are geriatric. Probofficially rejected. Yet in reality, the cus- ably two-thirds of all the hospital's patients todial institution lives on as a dominant, if are "chronic," that is, permanent or longnot the dominant, form of state-provided term residents or regular returnees to the mental health care. In spite of a noticeable hospital. New England State Hospital, which serves decline in the resident popUlation of the nation's state mental institutions in the last an area comprising several counties, is situdecade, there nonetheless remain over half . ated on hundreds of acres of state land in a a million residents in state facilities for the sparsely populated part of a small town. mentally disabled. To be sure, a few of these The original hospital building, which houses facilities have made the transformation from half of all the patients, is a gloomy, fortresscustodial to therapeutic and community- like structure with barred windows. Inside, oriented care,2 and most recently a series tiny rooms once intended for single occuof "right to treatment" lawsuits have at- pancy are now double bedrooms; beds are tempted to establish minimally acceptable also lined up in rows against the walls of guidelines for patient care and treatment in vast rooms originally meant for use as the state hospitals of a number of regions solariums and infirmaries. Furnishings are across the country.s There is little doubt, sparse, air is close, paint is peeling, and the however, that most state facilities continue urine and disinfectant smells of the decades essentially unaltered, maintaining dismally have soaked into walls and floors and mingle low standards of care and treatment, ob- to make a permanent stench. Within each livious to the brave new world of mental major residential unit, patients live in health care." In the following description of wards, each ward a segment of a hierarchical a state hospital I will attempt to indicate structure representing degrees of so-called why changes that seem obviously desirable wellness or illness. The traditional locked wards for those the hospital considers the seldom occur. worst of its patients are very much in eviNEW ENGLAND STATE HOSPITAL dence and contain provisions for restraints The .enduring custodial character of the and seclusion. Although occasional happenings of a senstate hospital is well exemplified by the case of New England State Hospital." Estab- sationalist nature are often associated with lished well over 100 years ago, the hospital mental hospitals, the true picture of hoshas in years past housed a peak popUlation pital life is relentlessly passive and inert. of up to 2000 patients. At present there are For patients on the back or locked wards, some 1000 patients resident at any given life means being locked in, locked up, or tied down. Life on these wards is literally • For a discussion of a somewhat fortuitous shift in a perpetual state of suspended animation. from custodial to therapeutic care at one state mental hospital, see Robert Clurman, "The Pa- Patients elsewhere in the hospital who are tients Can Walk Out Any Time at Bronx State less deteriorated, or who are more "manageMental Hospital," N.Y. Time8 Magazine, April 2, able" through the heavy use of drugs, have • 1972, pp. 14ff· • With regard to the impact of the "nght to more freedom and are seemingly more active treatment" lawsuits, Mechanic (1973). no.tes that in a physical sense. However, the quality their effect is likely to be more quantltative than qualitative: " ... standards referring to a humane of the activity is aimless and repetitive and physical and social environment are more amen- is prompted by no particular motivation or able to court action than those pertaining to inencouragement to do anything or go anydividualized treatment regimens" (p. 23) . . 'Foran evaluation of present conditions and where. People travel incessantly the same number of residents in state facilities for the mentally disabled, see the following articles in the route day after day; others stare vacantly N.Y. Times: " ... Hope for Neglected in Mental at (frequently unfocused) television picInstitutions," March 26, 1972, p. 35; "New Hope tures, or pace the floor, or rock ceaselessly for the Retarded ... ," June 11,1972, pp. Iff. 56
PSYCHIATRY, Vol. 38, February 1975
"
THE STATE MENTAL HOSPITAL
back and forth, or repeat gestures and phrases for hours on end, or sit, or sleep. Though many patients work regularly at jobs throughout the hospital (it is essential for the maintenance of the hospital that the patients do chores), futility is built into occupations that typically carry with them no pay or promotion or any real appreciation. 5 Occasional movies, dances, a few athletic events, and some sparsely available occupational therapy provide diversibns for those who wish to participate. But even those patients who make a relatively busy routine for themselves have no purpose to their busy-ness. They have simply settled into an essentially passive hospital life in a more active way than some others. Despite the dreariness of the living conditions and the rare instances of brutality, the single most outstanding fact about life in this mental hospital (and the one with the most consequence to patients) is that nothing ever happens. The people there as patients have no sense of being there for a purpose, as one would go to a general hospital, say, for an appendectomy and recovery period and then go back to rejoin the outside world. The longer the period of a patient's residence the greater the loss of time perspective. For some the passage of time seems to have become virtually meaningless, marking neither the accomplishment of individually significant tasks or routines in the short run, nor a steady progression toward the achievement of specified ends in the long run. In the mental hospital people just are, that is all, and the hospital is merely custodian of their existence. The prevailing custodial emphasis of New England State Hospital, however, is not necessarily the product, as is often popularly thought, of patients who are universally so disturbed or helpless as to make • The right of mental patients to receive pay and social security and other employment benefits in return for the work they do in the state hospitals is an issue that has been raised in the courts, both in conjunction with the "right to treatment" suits and separately. As yet, however, no such guidelines are in effect for the patients of New England State Hospital. PSYCHIATRY, Vol. 38, February 1975
the custodial approach inevitable. Rather, the custodial emphasis is sustained by quite specific and predominating features of hospital culture and organization. These same features also operate to make unlikely the introduction of change, or to make unlikely the possibility that change will be successful once introduced. THE ADMISSIONS PROCESS
The custodial process is set in motion by hospital admissions policies and procedures. Admission to the hospital occurs primarily as a technical-legal process. Persons are admitted indiscriminately, whether voluntary, physician-referred, or court-referred. The hospital administrators seldom exercise their prerogative to evaluate the qualitative need or reasons for admission, because they believe they might either offend referring parties or prompt a would-be patient to sue the hospital for dereliction of its duties. Either possibility could jeopardize good public relations. Because the hospital absorbs virtually all comers, outside doctors and agencies often have little sense of what the resources and facilities of the hospital actually are. One local doctor, believing that New England State Hospital performed electric shock treatments, had been referring patients to the hospital for that purpose for some time. The hospital admitted them all, though shock treatments have been discontinued for years. Lacking a clear sense of treatment goals and what it is trying to accomplish in general for its patients, the hospital does not find it necessary to formulate any meaningful criteria for admission over and above those required by law. In true "chicken and egg fashion," the lack of criteria for admission creates a highly diverse patient population, whose needs and problems are so varied that it becomes nearly impossible for the hospital to formulate overall treatment goals. Within the hospital are to be found alcoholics, drug addicts, persons being examined in connection with court charges, retarded and otherwise organically brain57
MARTHA R. FOWLKES
damaged persons, the elderly and infirm, persons undergoing marital or life adjustment or even post-operative crises, teen-age runaways, and finally, persons whose confusion, hallucinations, and disassociated speech obviously indicate a psychotic state. With this kind of admixture of patients, the easiest course for the hospital is to minimize the individuality and variety of patient problems, and to emphasize instead the lowest common denominators of patient needs-food, shelter, and sedation with drugs to ensure cooperative behavior. PROFESSIONAL MARGINALITY
Although active treatment and rehabilitation programs could be provided for even such a large and diverse patient population, in none of its ranks does the hospital have the professional competency to do so. All but one of the twenty-odd clinical doctors who staffed the various units of the hospital were foreign-born, foreign-trained, and unlicensed, and have little or no psychiatric training. These doctors, by their failure to meet prevailing medical standards and to pass the general medical examinations for foreign doctors, are legally unfit and incompetent to enter the mainstream of American medicine and to engage in private medical practice. Yet the state has permitted their indefinite practice. in the state mental hospitals. A recent state ruling that would require even these doctors to demonstrate some minimal competence in the basic sciences and English language has been predictably greeted with defensive, self-righteous outrage, by the older doctors especially, who stand to lose their undemanding, relatively well-paid (considering their lack of qualifications), housing-provided niche in the hospital hierarchy. Aside from their basic medical and psychiatric ineptitude, these doctors generally speak and understand English only poorly and are without the awareness of American culture and social life that would permit understanding of a patient's life situation or background. One doctor, for example, became very confused about why a newly aumitted patient was so worried about 58
money, when she had said her husband was a photographer. What the woman had actually said, however, was that her husband was on welfare. The doctors often view mentally disturbed behavior with the hostility and contempt that derive from their own unexamined cultural and class biases, and they may be quite patrician in their demeanor with patients. The professional qualifications of other staff members are comparably weak. Attendants need not even have a high school diploma to qualify for work. Licensed Practical Nurses far outnumber the better trained and educated Registered Nurses. As recently as the spring of 1971, about two-thirds of a social work staff of twenty had only a BA degree. The psychology department numbered more advanced degrees and professional credentials among its members, but the senior psychologist could always be counted on to offer extremely cynical commentary whenever discussion in meetings turned to possibilities for change in the hospital. He once wrote an article in his professional field on the impossibility of doing treatment with mental hospital patients! The patient, then, is a victim of the limited qualifications of the staff and receives only limited care at their hands. Doctors define their roles very narrowly to include only those functions which they are quite certain they can perform. Therefore, they will interview patients and register diagnoses for legal record-keeping purposes, but the interview is not meant to suggest a doctor-patient relationship, nor does the diagnosis imply a program of treatment. Social workers have traditionally been at the service of both the hospital record room and the doctors, for whom they are expected to gather odds and ends of facts, necessary to complete various patient records but usually socially and psychologically irrelevant. The nursing role is reduced to its most fundamental and traditional level-that is, simply taking care of people. A "good" patient is one who is easy to care for and have around. Such a patient also becomes a disPSYCHIATRY, Vol. 38, February 1975
THE STATE MENTAL HOSPITAL
play model of behavior for all other patients. For example, the head nurse on a ward called attention to a pitiful, severely retarded, docile, grinning young man. "He's so good," she said. "We wish all of our patients were like this." (Here, indeed, is proof of the nonfictional nature of Kesey's "Big Nurse," in One Flew Over the Cuckoo's Nest.) Of course, a more alert, more capable patient quickly learns to suppress those characteristics which might indicate a greater sense of self-interest and more potential for mental health lest he become a nuisance to the nursing staff. The regression and inertia of the custodial patient becomes the norm.
of encouragement for the well-trained nurse to use her talents in interesting and innovative ways. Similarly, although a new director of social service has been able to hire a number of professionally trained social workers, they can have little impact in a system where their talents are not put to maximum use nor their skills respected. The idea that a social worker might take an active clinical and diagnostic role was greeted with derisive laughter by doctors and psychologists alike in one meeting. The doctors jealously guard their authority, knowing possibly how little they are respected by other staff members, who frequently make disparaging remarks about them. They also display great resistance to shared professional contributions to patient care, as the following indicates (the reference is to an experimental admissions screening program begun by the social service department and is taken from a letter written by one of the hospital doctors to the local paper) :
THE MEDICAL MODEL Particularly in the context of a staff of poorly qualified physicians, the heirarchical organization of personnel along the lines of the medical model-according to which the doctor not only is in charge but also has unquestioned and unquestionable authority-further fragments and minimizes patient care. Echoing the unimaginative ap- [Social workers] spend six months or so in an office next to the admissions room eagerly awaitproach of the doctors to whom they are ing the proper time to pounce upon the ... pasubordinate, personnel in all other depart- tient with a barrage of prepared social questions, ments also function within narrow limits, becoming oblivious for an hour or more of his performing mostly of-the-moment compart- medical and mental needs. And after the pamentalized tasks. There is little communi- tient is thus traumatized ... the patient is thus cation or interrelationship between the released to the doctor. various departments. As there is no comprehensive treatment program for an individual Schools of social work everywhere will patient, there is little incentive for one de- surely be astonished by this news that a partment to have any interest in or knowl- patient's mental and medical needs are edge of what another department might be entirely unrelated to his social self! doing on a patient's behalf. Doctors someLEADERSHIP AS PUBLIC RELATIONS times discharge patients without informing The hospital administrators themselves or consulting any of the other professionals do not lead; they simply oversee the status involved. The doctors are at the top of a status quo. Although the superintendent and his hierarchy that ranks all other jobs as two assistants are licensed doctors and beneath the doctors' in importance and trained psychiatrists, they assumed a conprestige. It is the job of the nonphysician sultant role, rather than an ongoing active staff simply to complement the "expertise" clinical role, in the hospital. All three men of the doctors, rather than to make integral are in their sixties and obviously have a contributions of their own to patient care. vested interest in maintaining their good It is not only lack of money which prevents standing with the state department of menavailable job blocs for additional registered tal health until the time· of their retirement. nurses from being filled; it is also the lack They take no issue with the hospital as PSYCHIATRY, Vol. 38, February 1975
59
MARTHA R. FOWLKES
custodial facility and have no aspirations for it to be otherwise. Nor do they judge it possible to alter the custodial emphasis. There is great administrative sensitivity to how the hospital appears to the public, and the administrators seem to be primarily concerned with promoting good public relations rather than patient care per se. When a group of. concerned citizens requested a tour of the· hospital, the supervisor ordered all patients normally kept in restraint or seclusion to be released for the period of the visit. Fresh paint on the normally dingy walls of the ward heralded a guided tour for the visiting committee of the state mental health association, who had come to evaluate hospital conditions. Outside donation of clothes is no longer permitted, lest the community think the hospital is not meeting patient needs. Official statements emphasize the hospital as residential rather than treatment facility and call attention to the improvement of current living conditions over those of the past. When a controversy arose over the numbers of unlicensed physicians in state mental hospitals, the supervisor of New England State Hospital skillfully diverted attention from the real issue of the quality of patient care by threatening that the hospital might have to close and neglect its patients if he lost his staff of doctors through their mere inability to pass exams. Not long afterward the local paper printed a full-page-complete-with-pictures report of progress, comfort, and dedication at New England State Hospital. The hospital and the semi-rural communities and small urban areas that it serves coexist peacefully. Local people seem to regard the hospital as meeting their needs in a suitably benign and low-keyed manner. They note with appreciation, for example, the recreational use they are permitted of a parcel of hospital land. As volunteers and participants in local mental health organizations, they are gratified to assist the much touted, well-intentioned work of the hospital. During the debate about accreditation of doctors, local public response was supportive of the hospital generally and 60
sympathetic specifically to the doctors, who were clearly seen as underdogs. From the administrative point of view, the duty of the hospital is to be the waiting receptacle for anyone who comes its way by whatever route. Patients are to be duly admitted, processed, housed, and maintained. Discharge has no specified qualitative meaning. Patients leave when the length of stay required by the admitting paper is up, or a voluntary patient decides to leave, or a family takes a relative home in its custody. The overriding concern of the administrators with regard to any or all parts of this cycle is to comply with all legal requirements and to avoid scandal. Some social workers have attempted to gain placement elsewhere for long-term patients who no longer require hospitalization. Many relatives of such patients, however, have clearly stated their wish that their patient-kin remain where they are. The administration is reluctant to intervene lest the hospital become a target of the families' anger. RESISTANCE TO CHANGE
The administrators have only a passive acceptance of change. Although staff members are not particularly encouraged to try out new ideas or programs, they are usually given indifferent permission to do so on their own motivation. Any changes, of course, require that the formal authority of the doctors and administration is left intact and legal requirements are not interfered with. But attempts to individualize and humanize the system of patient care are outside the scope of the official definition of patient care. While such efforts may be tolerated, therefore, they are not facilitated by any structural changes which would ensure the shllred concern and communication necessary for those efforts to be permanently successful. The experimental admissions program, undertaken in 1971 by the social service department, is a case in point. It was an attempt to replace previous automatic, rubber-stamped procedures with support, advice, and, if possible, referral elsewhere for the person seeking admission. For those PSYCmATRY, Vol. 38, February 1975
THE STATE MENTAL HOSPITAL
finally admitted, the intention was to emphasize helpful involvement with both patient and family from the beginning, and to collect information pertinent to eventual diagnosis and treatment. It quickly became clear that screening patients had little meaning, when most doctors and hospital administrators had no real interest in formulating specific guidelines for admission and did not wish to hear social service suggestions in that regard. There was also nowhere to go with painstakingly gathered data, when doctors were unresponsive to its use for their understanding or diagnosis of a patient. Significantly, the program was openly welcomed only by the one clinical doctor who happened to be a fully trained psychiatrist. Like the experimental admissions program, other efforts to broaden the scope of patient care invariably have an idiosyncratic base rather than a structural one and consequently meet with similarly qualified success. The years since 1971 have seen the introduction of a program of behavioral modification on one of the back wards, the provision of in-hospital legal services, and the establishment of an incentive community to aid in the resocialization of 60 chronic patients. In none of these cases, however, was the change suggested or initiated by either the hospital administrators or medical staff, and in two of the three instances, the impetus for change originated outside the hospital altogether, with professionals who wished to establish training opportunities for students. In the face of varying degrees of official indifference, the continued existence of such programs rests mainly on the amount of time and energy that a few individuals are able to give to them. Even the most dedicated individual efforts, however, are not sufficient to do the job these programs were intended to do, for they exist at arm's length from the ongoing system of patient care; they leave untouched the core structure of custodial care, ,,,,hich tends by its very functioning to weaken the objectives of the new programs. The behavioral modification program, for PSYCHIATRY. Vol. 38, February 1975
example, does not involve the ward personnel, who continue to carry out their duties in routine custodial fashion. Thus, the behavioral modification approach receives none of the reinforcement or follow-through necessary to build its effectiveness. In the case of the legal services program, insofar as patients know of its availability, they find their way to legal advice on their own. Only rarely has a staff member referred a patient to the service, and then only with regard to a purely private matter. While not prohibited from doing so, patients are not encouraged by physicians, social workers, or other staff to use the legal service to seek clarification of the legal terms of their own admission and commitment to and discharge from the hospital. It is far too soon to make any general statement about the long-range success of the incentive community in preparing patients for, and placing them in, living and work settings outside of the hospital. Undoubtedly the incentive community (which receives its own federal funds) actually benefits in many ways by its almost total isolation from the rest of the patient and staff community. But to some degree the potential of the incentive community depends on the potential of the patients referred for participation from the regular hospital wards. Referrals are supposed to reflect a qualitative evaluation of a patient's readiness and capacity to accept the increased responsibility entailed by the resocialization process. The consulting psychologist for the incentive community mentions the problem of inappropriate referrals-patients who are shuttled off into the incentive community less because of their ability to participate than because it is a convenient way to reduce the census population of a given ward. Once again signs of the familiar pattern of cross-purposes at work! EXPECTATIONS OF PATIENT FAMILIES
Patients and patient families are hardly in a position to offer any criticism of the hospital as it is. For persons with limited ability to pay, New England State Hos61
MARTHA R. FOWLKES
pital, costing less than $15 a day, is the only care available. Frequently lacking the knowledge with which to judge the quality of hospital care, families are reassured that the care at New England State Hospital is the only care possible. "Your boy is so sick, you'd better sign this paper so we can keep him here (another few weeks) (indefinitely)." I think here of the mother who mentioned that her daughter had been badly bruised in the hospital and said resignedly, "They told me she was hard to handle." The rigid medical diagnostic approach used by the hospital no doubt cOllveys the impression to families that mental illness is a sort of irreversible disease entity and leads to rather low expectations of what can be done for a patient in the first place. Thus if a patient has to make frequent return trips to the hospital, as many do, it is not because the hospital might have done a better job of treatment or aftercare planning. It is rather because mental illness is always there and prone to act up, and when it does, it is the accepted rule of the hospital to take care of the patient until symptoms abate. Families themselves often seek to relieve a host of family tensions by seeking admission for a family member whose behavior is particularly disturbed or disturbing. When they visit their patient-relative in the hospital, they are relieved to see that he or she is calmer or more "normal," the result usually of heavy doses of chlorpromazine or other drugs. Seldom are they concerned with the means used to bring about the change or with how durable or deep the change is. In any case, it is the patient who is expected to change. Hospitalization encourages a focus on the behavior of the patient alone, and spares other family members the need for consideration of their own interactive behavior with the patient and even possible contributions to his problems. Ex-patients whose behavior at home is not as compliant as a family might wish can be readmitted to the hospital as punishment. One woman came with the necessary papers to admit her ex-patient husband, who had evidently been having an affair with a neighbor. The 62
wife didn't like this at all and decided he "must be getting sick again"! There is no doubt that a more questioning and assertive group of families and patients could motivate the hospital to better safeguard patient interests. For example, a well-educated, once-affluent woman of professional background was admitted to the hospital by her relatives because it was inexpensive and geographically convenient for them. She challenged furiously everything about the hospital, from cleanliness to diagnosis to her own civil rights. Although her refusal to fit in easily with regular hospital routine made her a "problem" case in the eyes of the staff, the fact is that the level of hospital care rose to meet her needs and expectations. She was soon taken out of her restraints and moved to a more open ward, visited by an outside doctor and lawyer upon her request, and permitted to leave the hospital before her required length of stay was technically over. More important, she escaped being permanently committed, as her relatives had wished her to be, because the doctors in charge frankly admitted that she would raise too many objections, and it was unlikely that they could make the psychotic diagnosis "stick." CUSTODIAL CARE-WHO BENEFITS?
Now it is easy enough to postulate the kinds of changes needed if mental health care is actually to accomplish anything on behalf of its patients, in contrast to the custodial process discussed above. Much reform could take place within the existing hospital setting that would personalize patient care and facilitate treatment. Ideally the large-scale state institutions would be closed down altogether and replaced, say, by the less removed, more intimate, active settings of day-care centers, foster homes, half-way houses, psychiatric wards in general hospitals, and, of course, greatly expanded outpatient services in community mental health centers. Finally, even those persons whose disabilities are apparently permanent and who are consequently in need of ongoing custodial care surely deserve more cheerful, less stowed-away exPSYCHIATRY, Vol. 38, February 1975
THE STATE MENTAL HOSPITAL
istences. This utopian state of affairs, of course, presupposes an underpinning of both widespread community concern and generous financial support. But all that this is really saying is that patient interests ought to be central to mental health care. Indeed, if they were, custodial institutions such as New England Stat,s HORpital would long ago have ceased to exist. The explanation for their continued survival, as well as their resistance to change, is to be found in the many vested interests of nonpatient persons and groups, which are well served by the state mental hospital, precisely in its existing custodial form. From a sociological point of view, a New England State Hospital is quite functional-for everyone but its patients (cf. Gans, 1971). The interests served by each custodial facility as an individual institution are manifest in the very organization of the hospital itself as it has been discussed here: (1) For the community and region, a large state hospital that admits all comers creates the illusion that all local mental health care needs are being met, thus eliminating the need for the tedious and unwelcome business of local planning and spending for mental health care. (2) For the small town especially, a large-scale custodial mental institution offers employment to many people. As a service, the hospital creates no jarring discrepancy between itself and the often traditional character of other community institutions (education, politics, and the like). (3) For hospital administrators, the safest route to status, job security, and pensions lies in the maintenance of the status quo and the promotion of good public r~lations. (4) For poorly qualified, even incompetent professionals, otherwise unavailable jobs exist to which are attached income security, benefits, and at least hospitaldefined status and power. (5) For the hospital staff, custodial care is the easiest form of care. (6) For a family, the hospital acts as stabilizer when the behavior of one of its PSYCHIATRY, Vol. 38, February 1975
members has become annoying or burdensome. Furthermore, as part of an entire system of mental health care, the state institution undoubtedly receives continual support and reinforcement for its custodial operation from an even broader and more pervasive set of public and professional self-interests than those enumerated above: 6 (1) For the general hospital and the general public the state hospital conveniently eliminates the disturbed and disturbing from its midst. (2) For many outside psychiatrists and other clinical professionals, the hospital siphons off the least affluent and least attractive of the mentally disturbed, whom they would prefer not to serve anyway. (3) For a state department of mental health, the choice of hospital administrators is more easily made on a utilitarian basis of, say, seniority than on the more complicated and uncertain basis of suitability for implementing specific formulated goals for patient care. (4) For a state legislature, custodial care often appears to be the cheapest way, on a short-run, annual budget basis, of providing for a population doubly stigmatized by mental illness and lack of financial resources. (5) Finally, for a whole society, the public mental hospital reassuringly clarifies matters by officially separating "them" from "us." Persons on the "outside" thus come to develop a sense of their own comparative well-being and a conviction of the rightness and stability of their own ways of life. The apparent contradiction of the continuing existence of a New England State Hospital in an era dedicated to mental health reform is, thus, more easily understood. For the successful outcome of any decision to supersede custodial care with 8 Additional support for these concluding points may be found variously in the following writings: Cumming and Cumming (1957); Hollingshead and Redlich (1958), see especially Part 4; Coles (1964) ; Cumming (1967); Scheff (1967), see especially articles by Mechanic and Szasz.
MARTHA R. FOWLKES
'genuinely therapeutic help is necessarily dependent on two further decisions: to shape mental health policy around the interests of patients, rather than the claims of nonpatients; to design mental health services that reflect, in their own organization and procedures, the increased humanity and involvement of all concerned, rather than considerations of mere expediency. In a time when many pressing social problems clamor
for attention and priority, it is perhaps not surprising that the public-legislators, taxpayers, and professionals alike-often chooses the path of least resistance in allowing the problem of mental health care to remain "out of sight, out of mind"-neatly packaged in the form of the custodial institution. 16 MASSASOIT ST. NORTHAMPTON, MASS. 01060
REFERENCES BELKNAP, I. Human Problems of a State Mental II ospital; McGram-HilI, 1956. COLES, R. "Psychiatrists and the Poor," Atlantic Monthly, July 1964, pp.102-106. CUMMING, E. "Allocation of Care to the Mentally Ill, American Style," in M. N. Zald (Ed.), Organizing for Community Welfare; Quadrangle Books, 1967. CUMMING, E., and CUMMING, J. Closed Ranks; Harvard Univ. Press, 1957. DUNHAM, H. W., and WEINBERG, S. K. The Culture of the State Mentalllospital; Wayne State Univ. Press, 1960. GANS, H. "The Uses of Poverty: The Poor Pay All," Social Policy (1971) 2(2) :20-24. GOFFMAN, E. Asylums; Doubleday, 1961.
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HOLLINGSHEAD, A. B., and REDLICH, F. C. Social Class and Mental Illness; Wiley, 1958. KENNEDY, J. F. Mental Illness and Mental Retardation, Presidential Message; Govt. Printing Office, 1963. KESEY, K. One Flew Over the Cuckoo's Nest; New Amer. Library, 1962. MECHANIC, D. "The Right to Treatment: Judicial Action and Social Change," paper presented at Conference on Right to Treatment, Dept. of Clin. Psychology, Univ. of Mass., Amherst, 1973. SCHEFF, T. J. Mental Illness and Social Processes; Harper & Row, 1967. SZASZ, T. J. The Myth of Mental Illness; Dell, 1961.
PSYCHIATRY, VoL 38, February 1975
ISSN: 0033-2747 (Print) 1943-281X (Online) Journal homepage: http://www.tandfonline.com/loi/upsy20
Business as Usual—At the State Mental Hospital Martha R. Fowlkes To cite this article: Martha R. Fowlkes (1975) Business as Usual—At the State Mental Hospital, Psychiatry, 38:1, 55-64, DOI: 10.1080/00332747.1975.11023834 To link to this article: http://dx.doi.org/10.1080/00332747.1975.11023834
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Business as Usual-At the State Mental Hospitalt Martha R. Fowlkes*
D
ESPITE official policy and professional emphasis to the contrary, the custodial mental hospital continues to exist as a major form of state-provided mental health care. In this paper, one such institution, "New England State Hospital," 1 is described, and the various features of hospital organization that sustain a system of custodial care are discussed. Although the custodial hospital offers little to its patients, its persistent survival can be explained by the number of nonpatient vested interests that are well served by the state hospital, precisely in its existing custodial form. The case study of New England State Hospital suggests that reform of state mental institutions depends less on a programmatic formulation of· desired changes than on an understanding of the structured resistance to such changes. It is common knowledge that the custodial state mental hospital is obsolete. From a variety of sources-whether Wiseman's notorious and unsettling film Titticut Follies, Kesey's popular novel One Flew Over the Cuckoo's Nest, or the sociological studies of Goffman (1961), Dunham and Weinberg (1960), Belknap (1956), and others-comes overwhelming evidence of the failure of such institutions to provide personalized care or active rehabilitative treatment. In a major address in 1963, President Kennedy condemned the "cold mercy of custodial isolation" and urged an end to the practice of confining patients "in an institution to 1 The name of the hospital is a pseudonym. The author was Ii member of the social service department of New England State Hospital from the fall of 1970 to June 1971. Close contact has been maintained with the hospital since that time, and to the best of my knowledge the facts and interpretations contained in this paper remain valid.
wither away." Congress followed suit by enacting the Mental Retardation and Community Mental Health Centers Act in the same year. Certainly it would be impossible to find any authority in the field of mental health care who would have a kind word for the custodial care of the traditional largescale state mental hospital. Mental health professionals are everywhere being trained in new multidisciplinary approaches and community rehabilitation. Indeed, a growing number of psychiatrists, following the lead of Szasz (1961), are rejecting the notion of mental illness altogether and are openly critical of the utilization of conventional medical solutions for what they view as a nonmedical problem. Szasz notwithstanding, the real issue in the past decade has not been the abolition but the reform of the state mental hospital. In this connection custodial forms of care
* Martha R. Fowlkes (MA London School of Economics 65) is currently a lecturer in the Department of Sociology and Anthropology, Smith College, and a graduate student in sociology, University of Massachusetts, Amherst. t I appreciate the comments and advice of Fred A. Kramer, Department of Political Science, University of Massachusetts, and Ely Chinoy, Department of Sociology and Anthropology, Smith College. PSYCHIATRY, Vol. 38, February 1975
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MARTHA R. FOWLKES
have been conceptually, professionally, and time, one-third of whom are geriatric. Probofficially rejected. Yet in reality, the cus- ably two-thirds of all the hospital's patients todial institution lives on as a dominant, if are "chronic," that is, permanent or longnot the dominant, form of state-provided term residents or regular returnees to the mental health care. In spite of a noticeable hospital. New England State Hospital, which serves decline in the resident popUlation of the nation's state mental institutions in the last an area comprising several counties, is situdecade, there nonetheless remain over half . ated on hundreds of acres of state land in a a million residents in state facilities for the sparsely populated part of a small town. mentally disabled. To be sure, a few of these The original hospital building, which houses facilities have made the transformation from half of all the patients, is a gloomy, fortresscustodial to therapeutic and community- like structure with barred windows. Inside, oriented care,2 and most recently a series tiny rooms once intended for single occuof "right to treatment" lawsuits have at- pancy are now double bedrooms; beds are tempted to establish minimally acceptable also lined up in rows against the walls of guidelines for patient care and treatment in vast rooms originally meant for use as the state hospitals of a number of regions solariums and infirmaries. Furnishings are across the country.s There is little doubt, sparse, air is close, paint is peeling, and the however, that most state facilities continue urine and disinfectant smells of the decades essentially unaltered, maintaining dismally have soaked into walls and floors and mingle low standards of care and treatment, ob- to make a permanent stench. Within each livious to the brave new world of mental major residential unit, patients live in health care." In the following description of wards, each ward a segment of a hierarchical a state hospital I will attempt to indicate structure representing degrees of so-called why changes that seem obviously desirable wellness or illness. The traditional locked wards for those the hospital considers the seldom occur. worst of its patients are very much in eviNEW ENGLAND STATE HOSPITAL dence and contain provisions for restraints The .enduring custodial character of the and seclusion. Although occasional happenings of a senstate hospital is well exemplified by the case of New England State Hospital." Estab- sationalist nature are often associated with lished well over 100 years ago, the hospital mental hospitals, the true picture of hoshas in years past housed a peak popUlation pital life is relentlessly passive and inert. of up to 2000 patients. At present there are For patients on the back or locked wards, some 1000 patients resident at any given life means being locked in, locked up, or tied down. Life on these wards is literally • For a discussion of a somewhat fortuitous shift in a perpetual state of suspended animation. from custodial to therapeutic care at one state mental hospital, see Robert Clurman, "The Pa- Patients elsewhere in the hospital who are tients Can Walk Out Any Time at Bronx State less deteriorated, or who are more "manageMental Hospital," N.Y. Time8 Magazine, April 2, able" through the heavy use of drugs, have • 1972, pp. 14ff· • With regard to the impact of the "nght to more freedom and are seemingly more active treatment" lawsuits, Mechanic (1973). no.tes that in a physical sense. However, the quality their effect is likely to be more quantltative than qualitative: " ... standards referring to a humane of the activity is aimless and repetitive and physical and social environment are more amen- is prompted by no particular motivation or able to court action than those pertaining to inencouragement to do anything or go anydividualized treatment regimens" (p. 23) . . 'Foran evaluation of present conditions and where. People travel incessantly the same number of residents in state facilities for the mentally disabled, see the following articles in the route day after day; others stare vacantly N.Y. Times: " ... Hope for Neglected in Mental at (frequently unfocused) television picInstitutions," March 26, 1972, p. 35; "New Hope tures, or pace the floor, or rock ceaselessly for the Retarded ... ," June 11,1972, pp. Iff. 56
PSYCHIATRY, Vol. 38, February 1975
"
THE STATE MENTAL HOSPITAL
back and forth, or repeat gestures and phrases for hours on end, or sit, or sleep. Though many patients work regularly at jobs throughout the hospital (it is essential for the maintenance of the hospital that the patients do chores), futility is built into occupations that typically carry with them no pay or promotion or any real appreciation. 5 Occasional movies, dances, a few athletic events, and some sparsely available occupational therapy provide diversibns for those who wish to participate. But even those patients who make a relatively busy routine for themselves have no purpose to their busy-ness. They have simply settled into an essentially passive hospital life in a more active way than some others. Despite the dreariness of the living conditions and the rare instances of brutality, the single most outstanding fact about life in this mental hospital (and the one with the most consequence to patients) is that nothing ever happens. The people there as patients have no sense of being there for a purpose, as one would go to a general hospital, say, for an appendectomy and recovery period and then go back to rejoin the outside world. The longer the period of a patient's residence the greater the loss of time perspective. For some the passage of time seems to have become virtually meaningless, marking neither the accomplishment of individually significant tasks or routines in the short run, nor a steady progression toward the achievement of specified ends in the long run. In the mental hospital people just are, that is all, and the hospital is merely custodian of their existence. The prevailing custodial emphasis of New England State Hospital, however, is not necessarily the product, as is often popularly thought, of patients who are universally so disturbed or helpless as to make • The right of mental patients to receive pay and social security and other employment benefits in return for the work they do in the state hospitals is an issue that has been raised in the courts, both in conjunction with the "right to treatment" suits and separately. As yet, however, no such guidelines are in effect for the patients of New England State Hospital. PSYCHIATRY, Vol. 38, February 1975
the custodial approach inevitable. Rather, the custodial emphasis is sustained by quite specific and predominating features of hospital culture and organization. These same features also operate to make unlikely the introduction of change, or to make unlikely the possibility that change will be successful once introduced. THE ADMISSIONS PROCESS
The custodial process is set in motion by hospital admissions policies and procedures. Admission to the hospital occurs primarily as a technical-legal process. Persons are admitted indiscriminately, whether voluntary, physician-referred, or court-referred. The hospital administrators seldom exercise their prerogative to evaluate the qualitative need or reasons for admission, because they believe they might either offend referring parties or prompt a would-be patient to sue the hospital for dereliction of its duties. Either possibility could jeopardize good public relations. Because the hospital absorbs virtually all comers, outside doctors and agencies often have little sense of what the resources and facilities of the hospital actually are. One local doctor, believing that New England State Hospital performed electric shock treatments, had been referring patients to the hospital for that purpose for some time. The hospital admitted them all, though shock treatments have been discontinued for years. Lacking a clear sense of treatment goals and what it is trying to accomplish in general for its patients, the hospital does not find it necessary to formulate any meaningful criteria for admission over and above those required by law. In true "chicken and egg fashion," the lack of criteria for admission creates a highly diverse patient population, whose needs and problems are so varied that it becomes nearly impossible for the hospital to formulate overall treatment goals. Within the hospital are to be found alcoholics, drug addicts, persons being examined in connection with court charges, retarded and otherwise organically brain57
MARTHA R. FOWLKES
damaged persons, the elderly and infirm, persons undergoing marital or life adjustment or even post-operative crises, teen-age runaways, and finally, persons whose confusion, hallucinations, and disassociated speech obviously indicate a psychotic state. With this kind of admixture of patients, the easiest course for the hospital is to minimize the individuality and variety of patient problems, and to emphasize instead the lowest common denominators of patient needs-food, shelter, and sedation with drugs to ensure cooperative behavior. PROFESSIONAL MARGINALITY
Although active treatment and rehabilitation programs could be provided for even such a large and diverse patient population, in none of its ranks does the hospital have the professional competency to do so. All but one of the twenty-odd clinical doctors who staffed the various units of the hospital were foreign-born, foreign-trained, and unlicensed, and have little or no psychiatric training. These doctors, by their failure to meet prevailing medical standards and to pass the general medical examinations for foreign doctors, are legally unfit and incompetent to enter the mainstream of American medicine and to engage in private medical practice. Yet the state has permitted their indefinite practice. in the state mental hospitals. A recent state ruling that would require even these doctors to demonstrate some minimal competence in the basic sciences and English language has been predictably greeted with defensive, self-righteous outrage, by the older doctors especially, who stand to lose their undemanding, relatively well-paid (considering their lack of qualifications), housing-provided niche in the hospital hierarchy. Aside from their basic medical and psychiatric ineptitude, these doctors generally speak and understand English only poorly and are without the awareness of American culture and social life that would permit understanding of a patient's life situation or background. One doctor, for example, became very confused about why a newly aumitted patient was so worried about 58
money, when she had said her husband was a photographer. What the woman had actually said, however, was that her husband was on welfare. The doctors often view mentally disturbed behavior with the hostility and contempt that derive from their own unexamined cultural and class biases, and they may be quite patrician in their demeanor with patients. The professional qualifications of other staff members are comparably weak. Attendants need not even have a high school diploma to qualify for work. Licensed Practical Nurses far outnumber the better trained and educated Registered Nurses. As recently as the spring of 1971, about two-thirds of a social work staff of twenty had only a BA degree. The psychology department numbered more advanced degrees and professional credentials among its members, but the senior psychologist could always be counted on to offer extremely cynical commentary whenever discussion in meetings turned to possibilities for change in the hospital. He once wrote an article in his professional field on the impossibility of doing treatment with mental hospital patients! The patient, then, is a victim of the limited qualifications of the staff and receives only limited care at their hands. Doctors define their roles very narrowly to include only those functions which they are quite certain they can perform. Therefore, they will interview patients and register diagnoses for legal record-keeping purposes, but the interview is not meant to suggest a doctor-patient relationship, nor does the diagnosis imply a program of treatment. Social workers have traditionally been at the service of both the hospital record room and the doctors, for whom they are expected to gather odds and ends of facts, necessary to complete various patient records but usually socially and psychologically irrelevant. The nursing role is reduced to its most fundamental and traditional level-that is, simply taking care of people. A "good" patient is one who is easy to care for and have around. Such a patient also becomes a disPSYCHIATRY, Vol. 38, February 1975
THE STATE MENTAL HOSPITAL
play model of behavior for all other patients. For example, the head nurse on a ward called attention to a pitiful, severely retarded, docile, grinning young man. "He's so good," she said. "We wish all of our patients were like this." (Here, indeed, is proof of the nonfictional nature of Kesey's "Big Nurse," in One Flew Over the Cuckoo's Nest.) Of course, a more alert, more capable patient quickly learns to suppress those characteristics which might indicate a greater sense of self-interest and more potential for mental health lest he become a nuisance to the nursing staff. The regression and inertia of the custodial patient becomes the norm.
of encouragement for the well-trained nurse to use her talents in interesting and innovative ways. Similarly, although a new director of social service has been able to hire a number of professionally trained social workers, they can have little impact in a system where their talents are not put to maximum use nor their skills respected. The idea that a social worker might take an active clinical and diagnostic role was greeted with derisive laughter by doctors and psychologists alike in one meeting. The doctors jealously guard their authority, knowing possibly how little they are respected by other staff members, who frequently make disparaging remarks about them. They also display great resistance to shared professional contributions to patient care, as the following indicates (the reference is to an experimental admissions screening program begun by the social service department and is taken from a letter written by one of the hospital doctors to the local paper) :
THE MEDICAL MODEL Particularly in the context of a staff of poorly qualified physicians, the heirarchical organization of personnel along the lines of the medical model-according to which the doctor not only is in charge but also has unquestioned and unquestionable authority-further fragments and minimizes patient care. Echoing the unimaginative ap- [Social workers] spend six months or so in an office next to the admissions room eagerly awaitproach of the doctors to whom they are ing the proper time to pounce upon the ... pasubordinate, personnel in all other depart- tient with a barrage of prepared social questions, ments also function within narrow limits, becoming oblivious for an hour or more of his performing mostly of-the-moment compart- medical and mental needs. And after the pamentalized tasks. There is little communi- tient is thus traumatized ... the patient is thus cation or interrelationship between the released to the doctor. various departments. As there is no comprehensive treatment program for an individual Schools of social work everywhere will patient, there is little incentive for one de- surely be astonished by this news that a partment to have any interest in or knowl- patient's mental and medical needs are edge of what another department might be entirely unrelated to his social self! doing on a patient's behalf. Doctors someLEADERSHIP AS PUBLIC RELATIONS times discharge patients without informing The hospital administrators themselves or consulting any of the other professionals do not lead; they simply oversee the status involved. The doctors are at the top of a status quo. Although the superintendent and his hierarchy that ranks all other jobs as two assistants are licensed doctors and beneath the doctors' in importance and trained psychiatrists, they assumed a conprestige. It is the job of the nonphysician sultant role, rather than an ongoing active staff simply to complement the "expertise" clinical role, in the hospital. All three men of the doctors, rather than to make integral are in their sixties and obviously have a contributions of their own to patient care. vested interest in maintaining their good It is not only lack of money which prevents standing with the state department of menavailable job blocs for additional registered tal health until the time· of their retirement. nurses from being filled; it is also the lack They take no issue with the hospital as PSYCHIATRY, Vol. 38, February 1975
59
MARTHA R. FOWLKES
custodial facility and have no aspirations for it to be otherwise. Nor do they judge it possible to alter the custodial emphasis. There is great administrative sensitivity to how the hospital appears to the public, and the administrators seem to be primarily concerned with promoting good public relations rather than patient care per se. When a group of. concerned citizens requested a tour of the· hospital, the supervisor ordered all patients normally kept in restraint or seclusion to be released for the period of the visit. Fresh paint on the normally dingy walls of the ward heralded a guided tour for the visiting committee of the state mental health association, who had come to evaluate hospital conditions. Outside donation of clothes is no longer permitted, lest the community think the hospital is not meeting patient needs. Official statements emphasize the hospital as residential rather than treatment facility and call attention to the improvement of current living conditions over those of the past. When a controversy arose over the numbers of unlicensed physicians in state mental hospitals, the supervisor of New England State Hospital skillfully diverted attention from the real issue of the quality of patient care by threatening that the hospital might have to close and neglect its patients if he lost his staff of doctors through their mere inability to pass exams. Not long afterward the local paper printed a full-page-complete-with-pictures report of progress, comfort, and dedication at New England State Hospital. The hospital and the semi-rural communities and small urban areas that it serves coexist peacefully. Local people seem to regard the hospital as meeting their needs in a suitably benign and low-keyed manner. They note with appreciation, for example, the recreational use they are permitted of a parcel of hospital land. As volunteers and participants in local mental health organizations, they are gratified to assist the much touted, well-intentioned work of the hospital. During the debate about accreditation of doctors, local public response was supportive of the hospital generally and 60
sympathetic specifically to the doctors, who were clearly seen as underdogs. From the administrative point of view, the duty of the hospital is to be the waiting receptacle for anyone who comes its way by whatever route. Patients are to be duly admitted, processed, housed, and maintained. Discharge has no specified qualitative meaning. Patients leave when the length of stay required by the admitting paper is up, or a voluntary patient decides to leave, or a family takes a relative home in its custody. The overriding concern of the administrators with regard to any or all parts of this cycle is to comply with all legal requirements and to avoid scandal. Some social workers have attempted to gain placement elsewhere for long-term patients who no longer require hospitalization. Many relatives of such patients, however, have clearly stated their wish that their patient-kin remain where they are. The administration is reluctant to intervene lest the hospital become a target of the families' anger. RESISTANCE TO CHANGE
The administrators have only a passive acceptance of change. Although staff members are not particularly encouraged to try out new ideas or programs, they are usually given indifferent permission to do so on their own motivation. Any changes, of course, require that the formal authority of the doctors and administration is left intact and legal requirements are not interfered with. But attempts to individualize and humanize the system of patient care are outside the scope of the official definition of patient care. While such efforts may be tolerated, therefore, they are not facilitated by any structural changes which would ensure the shllred concern and communication necessary for those efforts to be permanently successful. The experimental admissions program, undertaken in 1971 by the social service department, is a case in point. It was an attempt to replace previous automatic, rubber-stamped procedures with support, advice, and, if possible, referral elsewhere for the person seeking admission. For those PSYCmATRY, Vol. 38, February 1975
THE STATE MENTAL HOSPITAL
finally admitted, the intention was to emphasize helpful involvement with both patient and family from the beginning, and to collect information pertinent to eventual diagnosis and treatment. It quickly became clear that screening patients had little meaning, when most doctors and hospital administrators had no real interest in formulating specific guidelines for admission and did not wish to hear social service suggestions in that regard. There was also nowhere to go with painstakingly gathered data, when doctors were unresponsive to its use for their understanding or diagnosis of a patient. Significantly, the program was openly welcomed only by the one clinical doctor who happened to be a fully trained psychiatrist. Like the experimental admissions program, other efforts to broaden the scope of patient care invariably have an idiosyncratic base rather than a structural one and consequently meet with similarly qualified success. The years since 1971 have seen the introduction of a program of behavioral modification on one of the back wards, the provision of in-hospital legal services, and the establishment of an incentive community to aid in the resocialization of 60 chronic patients. In none of these cases, however, was the change suggested or initiated by either the hospital administrators or medical staff, and in two of the three instances, the impetus for change originated outside the hospital altogether, with professionals who wished to establish training opportunities for students. In the face of varying degrees of official indifference, the continued existence of such programs rests mainly on the amount of time and energy that a few individuals are able to give to them. Even the most dedicated individual efforts, however, are not sufficient to do the job these programs were intended to do, for they exist at arm's length from the ongoing system of patient care; they leave untouched the core structure of custodial care, ,,,,hich tends by its very functioning to weaken the objectives of the new programs. The behavioral modification program, for PSYCHIATRY. Vol. 38, February 1975
example, does not involve the ward personnel, who continue to carry out their duties in routine custodial fashion. Thus, the behavioral modification approach receives none of the reinforcement or follow-through necessary to build its effectiveness. In the case of the legal services program, insofar as patients know of its availability, they find their way to legal advice on their own. Only rarely has a staff member referred a patient to the service, and then only with regard to a purely private matter. While not prohibited from doing so, patients are not encouraged by physicians, social workers, or other staff to use the legal service to seek clarification of the legal terms of their own admission and commitment to and discharge from the hospital. It is far too soon to make any general statement about the long-range success of the incentive community in preparing patients for, and placing them in, living and work settings outside of the hospital. Undoubtedly the incentive community (which receives its own federal funds) actually benefits in many ways by its almost total isolation from the rest of the patient and staff community. But to some degree the potential of the incentive community depends on the potential of the patients referred for participation from the regular hospital wards. Referrals are supposed to reflect a qualitative evaluation of a patient's readiness and capacity to accept the increased responsibility entailed by the resocialization process. The consulting psychologist for the incentive community mentions the problem of inappropriate referrals-patients who are shuttled off into the incentive community less because of their ability to participate than because it is a convenient way to reduce the census population of a given ward. Once again signs of the familiar pattern of cross-purposes at work! EXPECTATIONS OF PATIENT FAMILIES
Patients and patient families are hardly in a position to offer any criticism of the hospital as it is. For persons with limited ability to pay, New England State Hos61
MARTHA R. FOWLKES
pital, costing less than $15 a day, is the only care available. Frequently lacking the knowledge with which to judge the quality of hospital care, families are reassured that the care at New England State Hospital is the only care possible. "Your boy is so sick, you'd better sign this paper so we can keep him here (another few weeks) (indefinitely)." I think here of the mother who mentioned that her daughter had been badly bruised in the hospital and said resignedly, "They told me she was hard to handle." The rigid medical diagnostic approach used by the hospital no doubt cOllveys the impression to families that mental illness is a sort of irreversible disease entity and leads to rather low expectations of what can be done for a patient in the first place. Thus if a patient has to make frequent return trips to the hospital, as many do, it is not because the hospital might have done a better job of treatment or aftercare planning. It is rather because mental illness is always there and prone to act up, and when it does, it is the accepted rule of the hospital to take care of the patient until symptoms abate. Families themselves often seek to relieve a host of family tensions by seeking admission for a family member whose behavior is particularly disturbed or disturbing. When they visit their patient-relative in the hospital, they are relieved to see that he or she is calmer or more "normal," the result usually of heavy doses of chlorpromazine or other drugs. Seldom are they concerned with the means used to bring about the change or with how durable or deep the change is. In any case, it is the patient who is expected to change. Hospitalization encourages a focus on the behavior of the patient alone, and spares other family members the need for consideration of their own interactive behavior with the patient and even possible contributions to his problems. Ex-patients whose behavior at home is not as compliant as a family might wish can be readmitted to the hospital as punishment. One woman came with the necessary papers to admit her ex-patient husband, who had evidently been having an affair with a neighbor. The 62
wife didn't like this at all and decided he "must be getting sick again"! There is no doubt that a more questioning and assertive group of families and patients could motivate the hospital to better safeguard patient interests. For example, a well-educated, once-affluent woman of professional background was admitted to the hospital by her relatives because it was inexpensive and geographically convenient for them. She challenged furiously everything about the hospital, from cleanliness to diagnosis to her own civil rights. Although her refusal to fit in easily with regular hospital routine made her a "problem" case in the eyes of the staff, the fact is that the level of hospital care rose to meet her needs and expectations. She was soon taken out of her restraints and moved to a more open ward, visited by an outside doctor and lawyer upon her request, and permitted to leave the hospital before her required length of stay was technically over. More important, she escaped being permanently committed, as her relatives had wished her to be, because the doctors in charge frankly admitted that she would raise too many objections, and it was unlikely that they could make the psychotic diagnosis "stick." CUSTODIAL CARE-WHO BENEFITS?
Now it is easy enough to postulate the kinds of changes needed if mental health care is actually to accomplish anything on behalf of its patients, in contrast to the custodial process discussed above. Much reform could take place within the existing hospital setting that would personalize patient care and facilitate treatment. Ideally the large-scale state institutions would be closed down altogether and replaced, say, by the less removed, more intimate, active settings of day-care centers, foster homes, half-way houses, psychiatric wards in general hospitals, and, of course, greatly expanded outpatient services in community mental health centers. Finally, even those persons whose disabilities are apparently permanent and who are consequently in need of ongoing custodial care surely deserve more cheerful, less stowed-away exPSYCHIATRY, Vol. 38, February 1975
THE STATE MENTAL HOSPITAL
istences. This utopian state of affairs, of course, presupposes an underpinning of both widespread community concern and generous financial support. But all that this is really saying is that patient interests ought to be central to mental health care. Indeed, if they were, custodial institutions such as New England Stat,s HORpital would long ago have ceased to exist. The explanation for their continued survival, as well as their resistance to change, is to be found in the many vested interests of nonpatient persons and groups, which are well served by the state mental hospital, precisely in its existing custodial form. From a sociological point of view, a New England State Hospital is quite functional-for everyone but its patients (cf. Gans, 1971). The interests served by each custodial facility as an individual institution are manifest in the very organization of the hospital itself as it has been discussed here: (1) For the community and region, a large state hospital that admits all comers creates the illusion that all local mental health care needs are being met, thus eliminating the need for the tedious and unwelcome business of local planning and spending for mental health care. (2) For the small town especially, a large-scale custodial mental institution offers employment to many people. As a service, the hospital creates no jarring discrepancy between itself and the often traditional character of other community institutions (education, politics, and the like). (3) For hospital administrators, the safest route to status, job security, and pensions lies in the maintenance of the status quo and the promotion of good public r~lations. (4) For poorly qualified, even incompetent professionals, otherwise unavailable jobs exist to which are attached income security, benefits, and at least hospitaldefined status and power. (5) For the hospital staff, custodial care is the easiest form of care. (6) For a family, the hospital acts as stabilizer when the behavior of one of its PSYCHIATRY, Vol. 38, February 1975
members has become annoying or burdensome. Furthermore, as part of an entire system of mental health care, the state institution undoubtedly receives continual support and reinforcement for its custodial operation from an even broader and more pervasive set of public and professional self-interests than those enumerated above: 6 (1) For the general hospital and the general public the state hospital conveniently eliminates the disturbed and disturbing from its midst. (2) For many outside psychiatrists and other clinical professionals, the hospital siphons off the least affluent and least attractive of the mentally disturbed, whom they would prefer not to serve anyway. (3) For a state department of mental health, the choice of hospital administrators is more easily made on a utilitarian basis of, say, seniority than on the more complicated and uncertain basis of suitability for implementing specific formulated goals for patient care. (4) For a state legislature, custodial care often appears to be the cheapest way, on a short-run, annual budget basis, of providing for a population doubly stigmatized by mental illness and lack of financial resources. (5) Finally, for a whole society, the public mental hospital reassuringly clarifies matters by officially separating "them" from "us." Persons on the "outside" thus come to develop a sense of their own comparative well-being and a conviction of the rightness and stability of their own ways of life. The apparent contradiction of the continuing existence of a New England State Hospital in an era dedicated to mental health reform is, thus, more easily understood. For the successful outcome of any decision to supersede custodial care with 8 Additional support for these concluding points may be found variously in the following writings: Cumming and Cumming (1957); Hollingshead and Redlich (1958), see especially Part 4; Coles (1964) ; Cumming (1967); Scheff (1967), see especially articles by Mechanic and Szasz.
MARTHA R. FOWLKES
'genuinely therapeutic help is necessarily dependent on two further decisions: to shape mental health policy around the interests of patients, rather than the claims of nonpatients; to design mental health services that reflect, in their own organization and procedures, the increased humanity and involvement of all concerned, rather than considerations of mere expediency. In a time when many pressing social problems clamor
for attention and priority, it is perhaps not surprising that the public-legislators, taxpayers, and professionals alike-often chooses the path of least resistance in allowing the problem of mental health care to remain "out of sight, out of mind"-neatly packaged in the form of the custodial institution. 16 MASSASOIT ST. NORTHAMPTON, MASS. 01060
REFERENCES BELKNAP, I. Human Problems of a State Mental II ospital; McGram-HilI, 1956. COLES, R. "Psychiatrists and the Poor," Atlantic Monthly, July 1964, pp.102-106. CUMMING, E. "Allocation of Care to the Mentally Ill, American Style," in M. N. Zald (Ed.), Organizing for Community Welfare; Quadrangle Books, 1967. CUMMING, E., and CUMMING, J. Closed Ranks; Harvard Univ. Press, 1957. DUNHAM, H. W., and WEINBERG, S. K. The Culture of the State Mentalllospital; Wayne State Univ. Press, 1960. GANS, H. "The Uses of Poverty: The Poor Pay All," Social Policy (1971) 2(2) :20-24. GOFFMAN, E. Asylums; Doubleday, 1961.
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HOLLINGSHEAD, A. B., and REDLICH, F. C. Social Class and Mental Illness; Wiley, 1958. KENNEDY, J. F. Mental Illness and Mental Retardation, Presidential Message; Govt. Printing Office, 1963. KESEY, K. One Flew Over the Cuckoo's Nest; New Amer. Library, 1962. MECHANIC, D. "The Right to Treatment: Judicial Action and Social Change," paper presented at Conference on Right to Treatment, Dept. of Clin. Psychology, Univ. of Mass., Amherst, 1973. SCHEFF, T. J. Mental Illness and Social Processes; Harper & Row, 1967. SZASZ, T. J. The Myth of Mental Illness; Dell, 1961.
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