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Psychiatric hospital

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A psychiatric hospital (also called a mental hospital or asylum) is a hospital specializing in the treatment of persons with mental illness. Psychiatric wards differ only in that they are a unit of a larger hospital.

Psychiatric hospitals have a number of differences from other hospitals. First, they generally have elaborate procedures to prevent suicide by patients (for example, appliances with power cords are not allowed, and access to stairways and high, open windows is restricted). Second, they attempt to reduce the amount of sensory stimulation that the patients have. Contrary to popular belief, psychiatric hospitals are generally quiet, even boring places. Third, psychiatric hospitals often try to provide as normal an environment as possible. For example, unlike most other hospitals, many patients in psychiatric hospitals wear street clothes rather than examination patient garments.

Psychiatric hospitals in the past were often set up as separate institutions with funding and administrations separate from those of general health care. Since the development of effective therapies in the 1950s there has been an increasing move towards integration of psychiatric treatment within the general health sector. Psychiatric wards in general hospitals and various community based treatments are replacing the old asylums world wide.

If a patient had been admitted to the hospital on a voluntary basis, the patient is often allowed to check themselves out of the hospital Against Medical Advice. In most jurisdictions, to leave requires at least a day's notice. This is so in the event a doctor decides the patient would still present a danger to self or others that there is time to commence involuntary commitment procedures.

Since the 1960s, efforts have been made to improve mental health care. Nevertheless, many problems remain in those countries where free health care is not available or where funding is limited. This especially affects those with little money to pay for expensive facilities. Limited funding of hospitals can lead to a lack of adequate staff and resources which can lead to the use of restraints and medication for punishment rather than treatment. Procedural deficiencies such as a lack of documentation for involuntary treatment and other serious deficencies remain all too common in some countries.

Types of psychiatric hospitals

There are a number of different types of psychiatric hospitals or wards.

Crisis stabilization

One is the crisis stabilization unit, which is in effect an emergency room for mental disorders. Because involuntary commitment laws in many jurisdictions require a judge to issue a commitment order within a short time (often 72 hours) of the patient's entry to the unit and because moving a severely ill mental patient can be extremely dangerous, especially as the patient may try to harm himself/herself or others, many of these stabilization units have conference rooms which are used as courtrooms for emergency commitment procedures.

Open units

In some hospitals in the United States, there are often two distinct wards. The crisis stabilization ward is where all patients are initially placed. Usually, if the staff determines that the person is not a danger to self or others, the individual may be moved to an "open" unit. While the unit still may be locked, this type of unit is not as restrictive as the crisis stabilization unit. These open units try to make life as normal as possible for the patients. In these types of wards, a treatment team led by a doctor determines a plan of action for the patient. The staff watches the patient, and tries to help that patient to transition out of that particular ward into another environment as soon as possible. In most cases this can be back home to family, in others it is to a medium or long term care environment.

Medium-term

Another type of psychiatric hospital is used for medium term care lasting several weeks. Most drugs used for psychiatric purposes take several weeks to take effect and the main purpose of these hospitals is to watch over the patient while the drugs taken have their expected effect and the patient can be discharged.

Juvenile wards

Some psychiatric hospitals have a separate ward set aside for treating children that require hospitalization. These wards provide many of the services that those in the adult units receive, along with specialized educational services for children who may be absent from school due to the hospitalization.

Geriatric wards

Hospitals may have a specialized ward set aside for geriatric patients. These type of wards specilize in treating the older patient, and the conditions that may effect the minds of these patients.

Hospitals for prisoners with mental illness

One other type of psychiatric hospital is designed for long-term care: a combination hospital and prison for the "criminally insane": typically, people with a psychotic illness or personality disorder who have committed serious crimes. In the United States, these are generally operated by the state government and exist in a few centralized locations. In most cases, persons within these hospitals have been charged with serious crimes and have been found not guilty by reason of insanity. As a result, in addition to the precautions to prevent suicide there are also precautions against escape (such as are found in a prison). The treatment of persons within such institutions has been a subject of long-standing debate, because a patient will often spend more time in the hospital than they would have spent in jail. However, the severely mentally ill often get much worse in standard prisons, and are usually targets of an even greater than normal amount of abuse from the rest of the prison population. Also, it is felt that if a severe mental illness causes someone to commit a crime, locking them up without treating the illness is both a violation of their civil rights and serves simply to put them back on the street, where the same untreated illness will often drive them to commit another crime, beginning the cycle anew.

Half-way houses

One final type of mental institution which is not a hospital is a community-based half-way house which provides assisted living for mental patients for an extended period of time. These institutions are considered to be one of the most important parts of a mental health system by many psychiatrists, although many localities fail to provide sufficient funding for them.

Used as a form of prison

See Psikhushka

Anti-psychiatry objections to mental hospitals

Some observers, including Thomas Szasz, have objected to calling mental hospitals "hospitals" (see anti-psychiatry). Lawrence Stevens has described mental hospitals as "jails."

In particular, anti-psychiatry activists have advocated for the abolition of long-term hospitals for the criminally insane, on the grounds that the insanity defense should not be permitted and those confined to such institutions should be incarcerated in a regular prison instead, others on the grounds that the inmates' confinement to these "hospitals" punishes them for crimes of which they have been judged not guilty, and others on various other grounds.

History of psychiatric hospitals

The history of psychiatric hospitals is linked heavily with social and scientific attitudes towards mental health, and the attitudes of those afflicted with mental illness, both of which have changed greatly over the past centuries.

File:HogarthBedlam.png
Scene of Bethlem Hospital from Hogarth's A Rake's Progress.

As the number of people living in cities increased, there became an increasingly large population of urban mentally ill. Generally speaking, in rural areas the mentally ill had been able to rely on local charity and support, or managed to simply "blend in" with the rest of the population, however under the demands of larger cities they faced a higher degree of difficulty and had a much greater chance of causing disruption or simply being noticed. This led to the building of the early asylums which were little more than repositories for the mentally ill, removing them from mainstream society in the same manner as a jail would for criminals. Conditions were often extremely poor, and serious treatment was not yet an option. The first known psychiatric hospital, Bethlem Royal Hospital (Bedlam) was founded in London in 1247 and by 1403 had begun accepting "lunatics." It soon became (in)famous for its harsh treatment of the insane, and in the 18th century would allow visitors to pay a penny to observe their patients as a form of freak show. In 1700 it is recorded that the "lunatics" were called "patients" for the first time, and within twenty years separate wards for the "curable" and "incurable" patients had been established, representing the beginning of a clear shift in the attitude towards mental illness towards a disease of some form.

In 1793 Phillipe Pinel is credited as being the first to introduce humane methods into the treatment of the mentally ill as the superintendant of the Asylum de Bicêtre in Paris. He removed patient restraints and introduced categorising and separation as well as observation and talking to patients as methods of cure. At much the same time William Tuke was pioneering a more enlightened approach to the treatment of the mentally ill in England. These ideas gradually took hold in different countries and in the United States attitudes towards the treatment of the mentally ill began to drastically improve during the mid-19th century. Reformers, such as Dorothea Dix in the United States, began to advocate a more humane and progressive attitude towards the mentally ill. In the United States, for example, numerous states established state mental health systems paid for by taxpayer money (and often money from the relatives of those institutionalized inside them). These centralized institutions were often linked with loose governmental bodies, though in general oversight was not high and quality subsequently varied. They were generally geographically isolated as well, located away from urban areas (both because the land was cheap, and because there were less opposition to constructing such a hospital).

While many of those in state hospitals were voluntarily admitted, many more were involuntarily committed by courts. For this reason, state hospital patients were usually from the lower class, as the mentally ill from families with money often had enough private care to avoid being labeled a public menace.

In the United States, state hospitals in some places began to overflow by the beginning of the 20th century. As state populations increased, so did the amount of the mentally ill, and so did the cost of housing them in centralized institutions. During wartime, state mental hospitals became even more overburdened, often serving as hospitals for returning servicemen as well as for their regular clientelle. The incentive to discharge patients was high, however there were still no adequate treatments or therapies for the mentally ill.

Stockton State Hospital, in Stockton, California, was California's first state psychiatric hospital (picture ca. 1910).

This provided a fruitful environment for the popularity of quick-fix solutions, like the eugenic compulsory sterilization programs undertaken in over 30 US states (and, later, in Nazi Germany), which allowed institutions to discharge patients while still claiming to be serving the public interest. These new treatments of mental illness -- which was now seen as a "defect," and likely a hereditary one -- were seen less as therapeutic for the individual patient than as preventative for the society as a whole.

By the mid-1940s, treatment of the mentally ill became effective for the first time with the advent of electroshock (ECT) and insulin shock therapy, and the use of the lobotomy technique. In modern times, these early techniques are viewed as being almost as barbaric as the Bedlam "treatments," though in their own context they were seen as the first options which produced any noticeable effect on their patients. The effect of a lobotomy on an overly excitable patient often allowed them to be discharged to their homes, which was seen by administrators (and often guardians) as a preferable solution than institutionalization. Lobotomies were performed in great numbers from the 1930s to the 1950s. At the time, these new therapies became a horrific part of popular understanding of the mental hospital, helping their popularity very little, to say the least.

By the mid-1950s, the first psychiatric drugs became available for the treatment of mental illness, such as thorazine, which revolutionized psychiatric care and provided for the first time ways for many of the severely mentally ill to return to normal society. The newly discovered antidepressants helped with most cases of depression and the introduction of muscle relaxants allowed ECT to be used in a modified form for the treatment of severe depression and a few other disorders. Psychosurgery was refined and its use was narrowed to a very small number of people for specific indications. More effective treatments led to reductions in the number of patients in mental hospitals.

In the early 1960s USA, amid public images of mental hospitals as sites for horror movies, a deinstitutionalization movement caught hold in many states. California, for example, began to scale back its large mental health system in favor of community-based care, whereby smaller clinics would attempt to aid those suffering from early signs of mental illness before they got to the stage where they would be institutionalized in a mental hospital. At the time, mental hospitals were viewed as the least desirable solution to the problem of mental illness, both from a humane point of view and an economic one. The point of view continued to promulgate and went even further in the backlash against social welfare policies in the 1980s, which lead to massive deinstitutionalization and funding cuts. These changes lead to the closing of many mental hospitals and the further reliance on local community care.

In some nations, mental hospitals were used as sites for the stifling of political dissidence or even genocide. Under Nazi Germany, a euthanasia program began which resulted in the killings of tens of thousands mentally ill housed in state institutions, and the killing techniques perfected at these sites became later implemented in the Holocaust (see T-4 Euthanasia Program). In the Soviet Union, dissidents were often put into asylums and kept on a variety of destabilizing medications, with the hope of not simply removing them from society, but making them unreliable in the eyes of others (see Psikhushka). Both of the attitudes in these cases -- that the mentally ill were a scourge and needed to be eliminated, and that the line between 'patient' and 'prisoner' is incredibly blurry -- have their precedents in the history of mental hospitals, though were taken to extremes by totalitarian regimes.

Mental hospitals in film and television

Mental hospitals are often depicted as frightening places in fiction, where treatments are forced upon inmates by uncaring staff, or inmates themselves are either violently deranged or sinister. Although there have been cases of abuse of patients in real life, and some conditions do occasionally result in violent behavior, this stereotype of mental hospitals is misleading.

Some recent depictions of mental hospitals in fiction include:

See also

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