Tuesday, July 21, 2015

Bring back the asylum: A critical analysis of the call for a "return to 'modern' institutionalization methods"

By Cassandra Evans

Cassandra Evans is a Ph.D. student in Disability Studies at Stony Brook University. She studies mental disabilities and ethics surrounding treatment, services, and access for individuals with mental disabilities. She is currently examining the history of institutions in Suffolk County, Long Island (New York) and what shape the “way forward” from institutionalization will take in the new millennium.

This post is a shorter version of a talk Cassandra gave at the Society for Disability Studies’ national conference in Atlanta, Georgia, June 11, 2015.

In early June, 2015, I visited Pilgrim Psychiatric Center in Brentwood, New York, (Suffolk County, Long Island). As I drove onto the Pilgrim campus, I felt as if I could be entering any of the other scores of institutions around the country—the pictures I’ve seen all look so similar and convey the same eeriness: high rise brick buildings with plain numbers on them, grass growing up all around, broken and barred windows, some areas with trash heaps on the grounds and graffiti on the walls. The names were different, but during their official operations, the treatments and results were similar—many individuals stayed longer than they ever wanted, many died and few were “cured.”

This photo shows a brick high-rise institutional building with a 
gravel road leading away from its parking lot, green grass and 
fresh tire tracks nearby.  Toward the front of the building several 
cars are parked outside the front of the building at the bottom 
floor of this 10- or 12-story, double-winged ward.  “Building 82” 
at Pilgrim Psychiatric Center in Brentwood, New York, is still 
home to many individuals with psychiatric disabilities.  Though 
three out of four institutions in Suffolk County, Long Island were 
closed and their residents deinstitutionalized, others with more 
severe  disabilities or who were more geriatric ended up here.

Photo by Cassandra Evans
While there, I saw pictures and news clippings in the museum that demonstrated how, in the era when institutions were being built and filled—toward the late 1800s and early 1900s until about the 1950s, consensus was that these facilities and the treatments inside of them were “state-of-the-art.” Text describing the 1938 LIFE Eisenstaedt photo essay noted that the pictures are “showing the dark world of the insane and what scientists are doing to lead them back to the light of reason” (Long Island Psychiatric Museum, 2015). While that rhetoric was common then, I wonder if it is similar ableist thinking, this need to normalize that still prevails today, driving new calls to “bring back the asylum.”

It was a recent ethical argument on this topic in the Journal of American Medical Association (JAMA) that prompted me to visit the Long Island Psychiatric Museum. This article, “Improving long-term psychiatric care: bring back the asylum,” by Sisti, Segal and Emanuel (2015) made major waves in both academic and lay literature. In it, the authors argue that because of “transinstitutionalization”—the failure of deinstitutionalization to guarantee appropriate placements for former residents of these homes—the “way forward” for severe psychiatric patients is a return back to the asylum (Sisti et al, 2015).


This photo shows the outside of “Building 93” at Kings Park 
Psychiatric Center, originally called “Kings Park State 
Asylum” in Kings Park, New York.  There is an ominous 
darkness to the background sky of this 13-plus, story brick 
building, with a sky of grey clouds, dead grass, and bare
trees all around the abandoned surroundings.  This 
asylum was completely closed in 1996, but many buildings
 like “Building 93” remain on the property unused and
withering. As I neared the turn off for the Pilgrim Psychiatric 
Center, I had visions of a scene in the film Kings Park: Studies 
from an American Mental InstitutionThe decaying buildings 
of Kings Park Psychiatric Center or “Kings Park State Asylum,” 
as it was originally christened in 1896, sit some 11 miles to the 
north of the facility I would enter this day, and looks almost 
identical to the hundreds of Goffman-esque and Foucaldian 
brick wards built on Pilgrim’s campus. 

Photo by Rick Jones
While I am not categorically opposed to in-patient treatment for many health needs, and I do agree that the streets, emergency rooms, and jails or prisons are not safe nor appropriate places for people with mental disabilities, I argue that prudence and caution must guide newer service delivery decisions as well as humane and person-centered care. We must also remember that some individuals do in fact choose to be homeless and are quite happy doing so. Asylums, prisons, and streets are not the only answers—community-based mental health services have yet to be fully actualized. And, if, in some cases, a long-term institution is necessary, I wonder, how do we guarantee its benevolence and efficacy? The consumer/survivor/ex-patient/mad or “c/s/x/m community,” as its often described today, and their families deserve an answer to this question.


This black and white postcard, dated Oct. 4, 1964, found 
in the Long Island Psychiatric Museum, touts Pilgrim 
State Hospital’s own infamy: “largest in the world.” 
The photo showcases another high-rise brick building of 
at least 10-to 12-stories with turrets and hundreds of 
uniformly shaped small windows. LIFE Magazine 
clippings at the Museum also described Pilgrim as,  
“A city of the insane.  It grows every day.” 

Photo of the postcard by Cassandra Evans, 
taken at Long Island Psychiatric Museum, June 2015
We must also consider the possibility for non-medical motives for institutionalization. Some have argued large asylums were not only part of the medical system, but were also integral parts of local economies. While Pilgrim’s claim to being the “largest in the world” was true—no institution was physically larger nor housed more patients than Pilgrim—it was also grand in terms of job creation. As Liat Ben-Moshe argues, housing bodies in institutions like these historically (and in present day) created thousands of jobs (2011). Citing Russell’s logic of “handicapitalism,” Ben-Moshe calls our attention to the risks of making the “unproductive” or non-working bodies lucrative when we place them in institutional beds—whether that means jails, nursing homes, psychiatric centers or group homes. The four large institutions built in the late 19th century to mid 20th century in Long Island, in fact, brought the region thousands of jobs, fostered an entire economy based on psychiatric “care,” and created what are now the numerous towns in the area. As institutions in cities like New York became overcrowded, states looked to rural areas to create “work farms” or silos to warehouse patients. Thus, an entire industry was designed, built, and sustained around mental disabilities for decades.


This graphic is a Google map of Western Suffolk County in Long Island, 
showing major interstates and parkways and the proximity of four of Long 
Island’s asylums with their names and numbers in terms of chronological 
appearance in Suffolk County, written at each site:  1.  Kings County 
Asylum in Kings Park, New York; 2. Central Islip State Hospital in 
Central Islip, New York; 3. Pilgrim State Hospital in Brentwood, New York;
4. Edgewood State Hospital in Deer Park, New York. All sit within a 12- to 
15-mile radius. New York State built four large psychiatric hospitals in western 
Suffolk County between 1885 and 1942, housing anywhere between 20,000 to 
40,000 patients at one time between the four of them.  Pilgrim State remains the 
last functional institution of the four today, and now has about 300 individuals 
who live on campus long-term.
As I looked at black and white photos of men in straightjackets, I also thought of the “O and O” or “R and R” that James Trent writes about in Inventing the Feeble Mind (1994). These “work farms” were supposed to promote “Oxygen and Occupation” or “Rest and Relaxation.” The proposed philosophy behind institutionalization of both mental patients and “the feeble minded” through the end of the 19th and early 20th centuries touted outdoor experiences, fresh air, and acres of open land. The design of these rural farms (all over the country) would allow for shipping family members with serious mental disabilities off to safer, more controlled environments in picturesque areas where they could be a part of pastoral life—planting and tending crops, milking cows, sewing, and cooking country meals. While some of these activities did become part of some patients’ days, we now know, in the case of the individuals in psychiatric hospitals, they were still subjected to prolonged and significant physical restraints, experimental lobotomy surgeries, shock treatments, hydrotherapy, insulin, isolation, and testing of Thorazine. In addition, as Trent notes, “the feeble-minded” were commonly sterilized at their “work farms” (1994).

This black and white 1938 photograph was part of a series in an expose 
about a day in the life of “residents” at a number of asylums in the 
United States—Ohio, Pennsylvania and New York were featured. 
In this scene, six men in Pilgrim State Hospital are confined to 
straightjackets.  They sit in front of a brick wall with a barred 
window next to them.  Three of six of the men are sitting looking 
blankly into the camera.  One is standing in the corner with his mouth 
wide open—either yawning or yelling.  Two others are seen sitting 
looking away from the camera.  Each straightjacket has wide and 
bolding number on it, such as “4-2” or “I-8” in what looks like 
some form of identifying the patients. This photo is also found 
in the 1938 LIFE Magazine expose on “state-of-the-art” treatments. 

Photo by Alfred Eisenstaedt
I looked at the expansive grounds surrounding this particular parcel of land (at its height 1000 acres), and wondered how many of its 10,000 to 16,000 residents (the largest number of patients varies depending on the source) were actually participating in the “O & O” or “R & R” the institutions touted and for which the state or their families paid.

Sisti, Segal and Emanuel describe the asylum as a place of “retreat and security; shelter” (2015). They point to Worcester Recovery Center and Hospital in Massachusetts as a new, model asylum. It has electronic health records, 320 private rooms for “patients with chronic, serious mental illness,” and a fully integrated health system as a possible model for reform (244). They note that centers like this one are more desirable than the default treatment centers of nursing homes, jails, and prisons.

Coincidentally, Pilgrim Psychiatric Center, the last remaining institution of the four original asylums in Suffolk County, houses only about 300 long-term psychiatric patients now—about the same number for which Worcester was built. Pilgrim’s registry shrunk from a capacity of between 11,000 and 16,000 to a mere 300. The hospital says there are no longer direct admits and its goal is to only have patients stay for a maximum of six months of treatment, then discharge. However, currently, because there are still residual residents who have spent their entire lives in institutions, “the official average is eight years and one-third months” (Kalvin, 2015).


This photo (taken inside the Long Island Psychiatric Museum in color) 
shows a brown, wooden chair with leather arm straps, a leather waist 
strap, and a cranium-sized wooden box at the top of the chair that 
appears to fit over a human head—also equipped with leather restraint 
straps.  In the seat of the chair is a large round hole with a metal or tin 
pot underneath it, presumably to collect waste while an individual is 
restrained for long periods of time.  In the left side of the photograph, 
directly next to the chair, appears a portion of a beige-colored 
straightjacket—possibly just an arm or the groin straps—hanging 
from a pole right next to the chair. This chair was designed in the United 
States by physician Benjamin Rush, who is sometimes referred to 
as the grandfather of psychiatry.  Rush’s “tranquilizing” chair was 
considered state-of-the-art from the early 1800s through early 
1900s for subduing “insane” patients with chronic hallucinations 
and outbursts. LIPM notes that name later evolved into the “coercion chair.

Photo by Cassandra Evans
Of course there are far more than 300 people in Suffolk County, Long Island that need long-term care. While I agree, YES (emphatically), neither streets nor jail are proper places for long-term care (in some cases, it could be argued that those spaces may actually make recovery or community re-integration less likely when prison staff are not properly trained or equipped to be mental health providers), we must interrogate what it means for an asylum-like hospital to be a “safe haven,” or a “refuge.” The question of how long “long-term” is bears pondering as well. In order to be truly “patient-centered,” perhaps there is a way forward that includes the c/s/x/m community in designing these havens, asking these questions and providing answers.

Additionally, when Sisti, et al dismiss community-based mental health services as failures while admitting they were never well-funded, they leave more stones unturned. Further inquiry is needed to answer how community-based mental health services can become more effective and well-funded. Do parents and professionals still prefer asylums because they are more convenient and cost-effective? And, finally, it is worth noting that some individuals will continue to choose the streets as alternatives to asylums, prisons, or community care centers.

In the end, there were no self-identified c/s/x/m on my tour of the asylum—only two nurses who had lived on the Pilgrim campus attending nursing school and a couple who was taking the tour with their baby as “urban adventurers.” The nurses were celebrating their 40th anniversary of graduating from nursing school and the urban adventurer couple was trying to visit as many asylums across the country as they could. The baby was could not tell me why he was there, but he was screaming loudly, restrained in his chair, crying, and acting like he wanted to get out.

REFERENCES

Ben-Moshe, L. (2011). Disabling incarceration: connecting disability to divergent confinement in the USA. Critical Sociology doi: 10.1177/0896920511430864.

Foucault, M. (1965). Madness and civilization: a history of insanity in the age of reason. New York: Random House.

Foucault, M. (1977). Discipline and Punish: The Birth of the Prison. Translated by Alan Sheridan, London: Allen Lane, Penguin. First published in French as Surveiller et punir, Gallimard, Paris, 1975.

Goffman, E. (1961). Asylums; essays on the social situation of mental patients and other inmates. Garden City, N.Y.: Anchor Books.

Kalvin, S. (2015, June 3). Volunteer museum tour operator and employee of Pilgrim Psychiatric Center. In person interview at Long Island Psychiatric Museum.

Kings Park: stories from an American mental institution [Motion picture]. (2011) Wildlight Productions (Lucy Winer).

Merriam-Webster Dictionary (2015, June 2). Retrieved from http://www.merriam-webster.com/dictionary/asylum.

Montross, C. (2015, February 18). The Modern Asylum. The New York Times. Retrieved from http://www.nytimes.com/2015/02/18/opinion/the-modern-asylum.html?_r=0.

Russell, M. (1998). Beyond ramps: disability at the end of he social contract—a warning from an uppity crip. Monroe, ME: Common Courage Press.

Sisti, D.A., Segal, A.G., Emanuel, E. J. (2015). Improving long-term psychiatric care: bring back the asylum. Journal of American Medical Association, 313(3): 243-244.

Trent, J. (1994). Inventing the feeble mind: a history of mental retardation in the United States. Berkeley: University of California Press.

Want to cite this post?

Evans, C. (2015). Bring back the asylum: A critical analysis of the call for a "return to 'modern' institutionalization methods". The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2015/07/bring-back-asylum-critical-analysis-of.html

1 comment:

Mark Sherry said...

Thanks for this. I'd read the Tweets during SDS, but this gives me a much clearer sense of your presentation Cassandra.

All the best,
Mark Sherry