Note to readers: This is a companion piece to the first of Awais Aftab, MD's interview series, Conversations in Critical Psychiatry: Allen Frances, MD. We thank both Dr Aftab and Dr Frances for their contributions.
Dr Frances is Professor Emeritus and former Chair, Department of Psychiatry, Duke University; Chair, DSM-IV Task Force; and author of Saving Normal and Essentials of Psychiatric Diagnosis.
My career is ending on a sour note. It is hard to be complacent when 600,000 people who should be our patients are instead languishing as prisoners or sleeping on streets. County jails are now the biggest providers of psychiatric care for people suffering from severe mental illness. And our patients do particularly poorly in jail—enduring long stays, frequently in crazy-making solitary confinement and often targeted for physical and sexual abuse. I have seen long rows of cells, in each of which is a desperate mentally ill occupant who has smeared excrement all over the walls and windows.
We have no excuse for collectively failing the patients who need us most. It is easy enough for each of us to blame the system—the government neglect, professional association passivity, and advocacy groups’ loss of mission—but I also blame myself for having done far too little, far too late. We are all part of the system and must take personal responsibility for its miserable performance.
We won’t be able to correct this horrible mess without understanding its history. The mental hospitals established by the states in the 19th century had the best of intentions and the worst of consequences. Their goal was the humane treatment of the mentally ill following the principles promulgated by the father of modern psychiatry, Phillipe Pinel. These asylums were meant to be places of peaceful rural retreat, providing safety and a meaningful life for psychiatric patients who had no place in the rapidly growing cities. The hospitals were self-contained communities, much more civilized and welcoming that the chaotic urban environments. There were workshops and surrounding farms that allowed patients to learn skills and feel productive. Hospital directors, staff, and families lived on the grounds and broke bread with the patients. The architecture of the buildings was usually strikingly beautiful, and they were surrounded by lovely bucolic settings.
The 20th century witnessed a rapid and thorough degradation of the system, with cattle-car overcrowding and system-wide patient neglect. Professionalizing the staff depersonalized the care. Growing cities surrounded and swallowed up hospital grounds, restricting patients to endless days in ugly, packed, stench-filled wards. Unions resented job competition from unpaid or low paid patients and pressured to have workshops closed. The well-meaning asylums had degenerated into dreadful snake pits.
My first experience in psychiatry occurred 55 years ago as a medical student in one of these state hospitals. It was degrading and disgusting—an overwhelming smell of urine, neglected patients screaming and posturing, a demoralized and disengaged staff, disappearing doctors.
The “deinstitionalization” movement meant to correct this chaos arose from a strange combination: public outrage; a new model of community psychiatry; the discovery of powerful new drugs; Kennedy family guilt; and state government greed. Three books were especially influential. The Snake Pit, a semi-autobiographical 1946 novel by Mary Jane Ward (made into an acclaimed 1948 movie), vividly presented a first-hand account of the sufferings of terrorized patients.1The Myth of Mental Illness, written in 1961 by libertarian psychiatrist Tom Szasz, made the moral and legal argument that patients are citizens with civil rights that must be respected.2 Published in the same year, sociologist Erving Goffman’s Asylums revealed that total institutionalization made patients much sicker and more dependent than they would be in any less crazy-making environment.3
Community psychiatry envisioned an attractive alternative life for the mentally ill—symptoms stabilized by the new antipsychotic meds, living independently in the community, re-socialized and working productively. John Kennedy’s exposure to his sister’s mental illness motivated him to support a comprehensive mental health bill that provided funding for community health centers (CMHCs) throughout the United States. State governments were all too eager to close the enormous mental hospitals that were usually their biggest budget line item.
Deinstitutionalization was an ugly business. Patients who had been in hospital for decades were often dumped on the street with just one week’s warning. A man was admitted to my acute inpatient unit the day after he had been discharged from the state hospital that had been his home and business for 22 years. He had achieved great status and relative affluence washing staff member’s cars. Now, without any transition or support, he was disconsolate and could not picture making a new life for himself. A few days later, I had to cut him down after he had hung himself in the bathroom.
CMHCs eventually did live up to expectations and were a thrilling place to work. We saw many of our patients flourish, away from the toxic state hospital environment. Seemingly chronic symptoms were reduced via a happy combination of the new meds, rehab, and socialization. By the 1970s, the United States was the pioneer and world leader in deinstitionalization and community psychiatry.
The author reports no conflicts of interest concerning the subject matter of this article.
1. Ward MJ. The Snake Pit. New York: Random House; 1946.
2. Szasz TS. The Myth of Mental Illness. New York: Random House; 1961.
3. Goffman E. Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. New York: Doubleday; 1961.
4. Fuller D, Sinclair E, Gelled J, et al: Going, Going, Gone: Trends and Consequences of Eliminating State Psychiatric Hospital Beds, Report of Treatment Advocacy Group. June 2016. https://www.treatmentadvocacycenter.org/going-going-gone. Accessed May 15, 2019.