Psychiatric hospital

This article is about modern psychiatric hospitals. For historical lunatic asylums, see history of psychiatric institutions.
Traverse City State Hospital, Traverse City, Michigan

Psychiatric hospitals, also known as mental hospitals and psychiatric wards ("psych" wards) when they are a sub-unit of a regular hospital, are hospitals or wards specializing in the treatment of serious mental disorders, such as clinical depression, schizophrenia, and bipolar disorder. Psychiatric hospitals vary widely in their size and grading. Some hospitals may specialize only in short-term or outpatient therapy for low-risk patients. Others may specialize in the temporary or permanent care of residents who, as a result of a psychological disorder, require routine assistance, treatment, or a specialized and controlled environment. Patients are often admitted on a voluntary basis, but people whom psychiatrists believe may pose a significant danger to themselves or others may be subject to involuntary commitment.[1]

Modern psychiatric hospitals evolved from, and eventually replaced the older lunatic asylums. The treatment of inmates in early lunatic asylums was sometimes brutal and focused on containment and restraint.[2][3] With successive waves of reform, and the introduction of effective evidence-based treatments, modern psychiatric hospitals provide a primary emphasis on treatment, and attempt where possible to help patients control their own lives in the outside world, with the use of a combination of psychiatric drugs and psychotherapy.

A crisis stabilization unit is in effect an emergency room for psychiatry, frequently dealing with suicidal, violent, or otherwise critical individuals. Open units are psychiatric units that are not as secure as crisis stabilization units. Another type of psychiatric hospital is medium term, which provides care lasting several weeks. In the United Kingdom, both crisis admissions and medium term care is usually provided on acute admissions wards. Juvenile or adolescent wards are sections of psychiatric hospitals or psychiatric wards set aside for children and/or adolescents with mental illness. Long-term care facilities have the goal of treatment and rehabilitation back into society within a short time-frame (two or three years). Another institution for the mentally ill is a community-based halfway house.

Critics such as American psychiatrist Thomas Szasz have insisted that psychiatric hospitals are like prisons, not hospitals, and that psychiatrists who subject others to coercion function as judges and jailers, not physicians.[4] The French historian Michel Foucault is widely known for his comprehensive critique of the use and abuse of the mental hospital system in Madness and Civilization. Franco Basaglia, a leading Italian psychiatrist who inspired and was the architect of the psychiatric reform in Italy, also defined the mental hospital as an oppressive, locked and total institution in which prison-like, punitive rules are applied.[5]

History

The York Retreat (c.1796) was built by William Tuke, a pioneer of moral treatment for the insane.

Modern psychiatric hospitals evolved from, and eventually replaced the older lunatic asylums. The development of the modern psychiatric hospital is also the story of the rise of organized, institutional psychiatry. The moral treatment and care of the mentally ill, as opposed to isolation, was first pioneered in the Islamic world by physicians whose treatment of mental patients was regarded as a religious obligation based on the Quranic verse Do not give the property with which God has entrusted you to the insane, but feed and clothe them with this property and speak kindly to them.[6] It greatly differed from the reigning view in which the insane were viewed as under the influence of the Devil therefore needing to be isolated from society. The first psychiatric hospital was built by the Muslims in Baghdad in 705 AD, under the leadership of the Umayyad Caliph Al-Walid ibn Abd al-Malik.[7] Others would rapidly follow, with some of the more famous ones being built in Cairo in 800 AD and in Damascus in 1270 AD. The physicians of the Islamic world would invent and use a variety of treatments, including occupational therapy, music therapy, as well as medication.[6]

Western Europe would adopt these views later on with the advances of physicians like Phillipe Pinel at the Bicêtre Hospital in France and William Tuke at the York Retreat in England. They advocated the viewing of mental illness as a disorder that required compassionate treatment that would aid in the rehabilitation of the victim. The arrival in the Western world of institutionalisation as a solution to the problem of madness was very much an event of the nineteenth century. The first public mental asylums were established in Britain; the passing of the 1808 County Asylums Act empowered magistrates to build rate-supported asylums in every county to house the many 'pauper lunatics'. Nine counties first applied, the first public asylum opening in 1812 in Nottinghamshire. In 1828, the newly appointed Commissioners in Lunacy were empowered to license and supervise private asylums. The Lunacy Act 1845 made the construction of asylums in every country compulsory with regular inspections on behalf of the Home Secretary. The Act required asylums to have written regulations and to have a resident physician.[8]

At the beginning of the nineteenth century there were a few thousand "sick people" housed in a variety of disparate institutions throughout England, but by 1900 that figure had grown to about 100,000. This growth coincided with the growth of alienism, later known as psychiatry, as a medical specialism.[9] The treatment of inmates in early lunatic asylums was sometimes very brutal and focused on containment and restraint.[2][3]

In the late 19th and early 20th centuries, terms such as "madness," "lunacy" or "insanity"—all of which assumed a unitary psychosis—were split into numerous "mental diseases," of which catatonia, melancholia and dementia praecox (modern day schizophrenia) were the most common in psychiatric institutions.[10]

In 1961 sociologist Erving Goffman described a theory[11][12] of the "total institution" and the process by which it takes efforts to maintain predictable and regular behavior on the part of both "guard" and "captor," suggesting that many of the features of such institutions serve the ritual function of ensuring that both classes of people know their function and social role, in other words of "institutionalizing" them. Asylums was a key text in the development of deinstitutionalization.[13]

With successive waves of reform, and the introduction of effective evidence-based treatments, modern psychiatric hospitals provide a primary emphasis on treatment, and attempt where possible to help patients control their own lives in the outside world, with the use of a combination of psychiatric drugs and psychotherapy.[14] These treatments can be involuntary. Involuntary treatments are among the many psychiatric practices which are questioned by the mental patient liberation movement. Most psychiatric hospitals now restrict internet access and any device that can take photos.[15]

Types

There are a number of different types of modern psychiatric hospitals, but all of them house people with mental illnesses of widely variable severity.

Crisis stabilization

Vienna's Narrenturm—German for "fools' tower"—was one of the earliest buildings specifically designed for mentally ill people. It was built in 1784.
Main article: Emergency psychiatry

The crisis stabilization unit is in effect an emergency room for psychiatry, frequently dealing with suicidal, violent, or otherwise critical individuals.

Open units

Open units are psychiatric units that are not as secure as crisis stabilization units. They are not used for acutely suicidal persons; the focus in these units is to make life as normal as possible for patients while continuing treatment to the point where they can be discharged. However, patients are usually still not allowed to hold their own medications in their rooms, because of the risk of an impulsive overdose. While some open units are physically unlocked, other open units still use locked entrances and exits depending on the type of patients admitted.

Medium-term

Another type of psychiatric hospital is medium term, which provides care lasting several weeks. Most drugs used for psychiatric purposes take several weeks to take effect, and the main purpose of these hospitals is to monitor the patient for the first few weeks of therapy to ensure the treatment is effective.

Juvenile wards

Juvenile wards are sections of psychiatric hospitals or psychiatric wards set aside for children and/or adolescents with mental illness. However, there are a number of institutions specializing only in the treatment of juveniles, particularly when dealing with drug abuse, self-harm, eating disorders, anxiety, depression or other mental illness.

Long-term care facilities

In the UK long-term care facilities are now being replaced with smaller secure units (some within the hospitals listed above). Modern buildings, modern security and being locally sited to help with reintegration into society once medication has stabilized the condition[16][17] are often features of such units. An example of this is the Three Bridges Unit, in the grounds of Hanwell Asylum in West London and the John Munroe Hospital in Staffordshire. However these modern units have the goal of treatment and rehabilitation back into society within a short time-frame (two or three years) and not all forensic patients' treatment can meet this criterion, so the large hospitals mentioned above often retain this role.

These hospitals provide stabilization and rehabilitation for those who are having difficulties such as depression, eating disorders, mental disorders, and so on.

Halfway houses

One type of institution for the mentally ill is a community-based halfway house. These facilities provide assisted living[18] for patients with mental illnesses for an extended period of time, and often aid in the transition to self-sufficiency. These institutions are considered to be one of the most important parts of a mental health system by many psychiatrists, although some localities lack sufficient funding.

Political imprisonment

In some countries the mental institution may be used in certain cases for the incarceration of political prisoners, as a form of punishment. A notable historical example was the use of punitive psychiatry in the Soviet Union[19] and China.[20]

Secure units

In the UK, criminal courts or the Home Secretary can refer people to what are known as psychiatric secure units, even though for many decades now, the term "criminally insane" is no longer legally or medically recognized. They are hospitals mostly run by the National Health Service, which undertake psychiatric assessments and can also provide treatment and accommodation in a safe, hospital environment where its patients can be prevented from harming themselves or others. They also run under clearly defined Home Office rules.

These secure hospital facilities are divided into three main categories and are referred to as High, Medium and Low Secure. Although it is a phrase often used by newspapers, there is no such classification as "Maximum Secure". Low Secure units are often referred to as "Local Secure" as patients are referred there frequently by local criminal courts for psychiatric assessment before sentencing.

Community hospital utilization

Community hospitals across the United States regularly see mental health discharges. A study of community hospital discharge data from 2003-2011 showed that mental health hospitalizations were increasing for both children (patients aged 0–17 years) and adults (patients aged 18–64). Compared to other hospital utilization, mental health discharges were the slowest increasing hospitalizations for children, but the most rapidly increasing hospitalizations for adults under 64.[21]

Some units have been opened in recent years with the specific purpose of providing Therapeutically Enhanced Treatment and so form a subcategory to the three main ones.

The general public are familiar with the names of the High Secure Hospitals due to the frequency that they are mentioned in the news reports about the people who are sent there. Those in England include, Ashworth Hospital in Merseyside;[22] Broadmoor Hospital in Crowthorne, Berkshire and Rampton Secure Hospital in Retford, Nottinghamshire and in Scotland is The State Hospital, Carstairs.[23] Northern Ireland and the Isle of Man have their own Medium and Low Secure units but use the mainland faculties for High Secure, which smaller Channel Islands also transfer their patients to as Out of Area Referrals under the Mental Health Act 1983.

Of the Medium Secure units, there are many more of these in number scattered throughout the UK. As of 2009 there were 27 women only units in England alone.[24] Irish units include those at prisons in Portlaise, Castelrea and Cork.

Criticism

American psychiatrist Thomas Szasz insisted that psychiatric hospitals are like prisons, not hospitals, and that psychiatrists who subject others to coercion function as judges and jailers, not physicians.[4]

The French historian Michel Foucault is widely known for his comprehensive critique of the use and abuse of the mental hospital system in Madness and Civilization. He argued that Tuke and Pinel's asylum was a symbolic recreation of the condition of a child under a bourgeois family. It was a microcosm symbolizing the massive structures of bourgeois society and its values: relations of Family-Children (paternal authority), Fault-Punishment (immediate justice), Madness-Disorder (social and moral order).[25][26]

Erving Goffman coined the term "Total Institution" for mental hospitals and similar places which took over and confined a person's whole life.[27]:150[28]:9 Goffman placed psychiatric hospitals in the same category as concentration camps, prisons, military organizations, orphanages, and monasteries.[29] In his book Asylums Goffman describes how the institutionalisation process socialises people into the role of a good patient, someone "dull, harmless and inconspicuous"; in turn, it reinforces notions of chronicity in severe mental illness.[30]

Franco Basaglia, a leading Italian psychiatrist who inspired and was the architect of the psychiatric reform in Italy, also defined the mental hospital as an oppressive, locked and total institution in which prison-like, punitive rules are applied, in order to gradually eliminate its own contents, and patients, doctors and nurses are all subjected (at different levels) to the same process of institutionalism.[5]

American psychiatrist Loren Mosher noticed that the psychiatric institution itself gave him master classes in the art of the "total institution": labeling, unnecessary dependency, the induction and perpetuation of powerlessness, the degradation ceremony, authoritarianism, and the primacy of institutional needs over those of the persons it was ostensibly there to serve-the patients.[31]

The anti-psychiatry movement coming to the fore in the 1960s has opposed many of the practices, conditions, or existence of mental hospitals. The psychiatric consumer/survivor movement has often objected to or campaigned against conditions in mental hospitals or their use, voluntarily or involuntarily. The mental patient liberation movement emphatically opposes involuntary treatment but generally does not have any issue with any psychiatric treatments that are consensual, provided that both parties are free to withdraw consent at any time.

Involuntary nature of psychiatric hospitalization

Some patients in psychiatric hospitals may remain confined until their psychiatrists consider them to no longer be dangerous, sometimes for the remainder of their lives. Some of the patients, while they are technically considered to be voluntary patients, have volunteered to be hospitalized in lieu of being subjected to penal actions by judicial systems. If they were to leave the hospital, they would be subject to imprisonment in a penal institution. In some cases, the conditions inside psychiatric hospitals are actually more unpleasant – more punishing – than the penal institutions they replace. Long term involuntary commitment requires legal proceedings, but individuals may be held for shorter periods of time, for observation, upon the opinion of two doctors, usually one of which is a psychiatrist. Hospitals must annually advise all committed patients of their right to a hearing on whether they can be released.

Additionally, a court-appointed psychiatrist must examine each patient annually. A full hearing is required at least every two years. Patients may also apply for release at any time and receive a full hearing on the application.[32] However, since patients may be isolated from the outside world, getting assistance in preparing for hearings may be difficult. The ability to contact a family member or lawyer, afforded to persons who are under arrest, may not be readily available to psychiatric patients. However patients may be afforded occasional opportunities to leave the institution temporarily, often accompanied by a visitor, and may be able to use this as an opportunity to leave permanently.

The National Institute of Mental Health shows that in 2008 13.4 percent of adults in the United States received treatment for a mental illness yet only 58.7 percent of adults with a serious mental illness (SMI) received treatment (NIMH, Mental Health Services and Treatment). Since the 1980s, state-run mental health facilities have been closing and a major reason for the closing is money. Facilities are closing and the number of mentally ill is not decreasing which is leaving no place for these patients to be seen.

A growing number of mentally ill individuals have been met by a shrinking number of beds to treat them in. The Treatment Advocacy Center put out a report with some startling numbers. In 1955 for every 100,000 US citizens there were 340 psychiatric hospital beds. In 2005 that number had diminished to 17 per 100,000. In a state by state evaluation Mississippi had the most beds available and Nevada and Arizona had the smallest number available at fewer than 6 beds per 100,000 citizens. Colorado has 16.9 per 100,000 citizens and according to the report is considered to have a “severe bed shortage”. It has now been determined that the US is over 95,000 beds short of reaching minimal standards for appropriate treatment.

Abuse and neglect

In the 1800s, patients in some psychiatric wards were regularly subject to cruelty, neglect and abuse. The staff were responsible for the majority of physical injury. Some examples of the abuse are still debated but here are some examples most people agree on today: Female and male patients were subjected to take baths in ice-cold water, others were roped and led outside and forced to exercise like cattle, doctors beat patients' heads into the wall for no reason, forced to sleep in tiny, unheated rooms, with thin slips and given no blankets, some were starved as "treatment".

In 1888, journalist, Nellie Bly, was approached by Joseph Pulitzer to write and expose about rumours of the cruelty and neglect at the Blackwells Island Insane Asylum. After renting a room at a boardinghouse, she acted crazy and was sent shortly after a quick examination. She found out that hospitals had very poor conditions and the food was stale and old, and the water tainted. When Pulitzer finally sent a lawyer to Blackwells, Nellie was released subsequently and wrote the story. The general public's reaction was outrage, and New York and five other states raised its public awareness by over $1,000,000.

See also

To see lists of individual establishments: view the categorical index for Psychiatric hospitals; which appears at the very bottom of this article.

References

  1. ↑ "White House Intruder Put in Mental Ward". New York Times. June 1, 1995.
  2. ↑ 2.0 2.1 Life Magazine
  3. ↑ 3.0 3.1 Life Magazine
  4. ↑ 4.0 4.1 Szasz, Thomas (2011). "The myth of mental illness: 50 years later" (PDF). The Psychiatrist 35: 179–182. doi:10.1192/pb.bp.110.031310. Retrieved 27 April 2012.
  5. ↑ 5.0 5.1 Tansella M. (November 1986). "Community psychiatry without mental hospitals—the Italian experience: a review". Journal of the Royal Society of Medicine 79 (11): 664–669. PMC 1290535. PMID 3795212.
  6. ↑ 6.0 6.1 Dennis O'Donnell. The Locked Ward: Memoirs of a Psychiatric Orderly. pg. 82.
  7. ↑ Psychiatry and the Palestinian Population. Psychiatric Bulletin,2002.
  8. ↑ Unsworth, Clive."Law and Lunacy in Psychiatry's 'Golden Age'", Oxford Journal of Legal Studies. Vol. 13, No. 4. (Winter, 1993), pp. 482.
  9. ↑ Porter, Roy (2006). Madmen: A Social History of Madhouses, Mad-Doctors & Lunatics. Tempus: p. 14.
  10. ↑ Yuhas, Daisy. "Throughout History, Defining Schizophrenia Has Remained a challenge". Scientific American Mind (March 2013). Retrieved 2 March 2013.
  11. ↑ Goffman, Erving (1961). Asylums: essays on the social situation of mental patients and other inmates. Anchor Books.
  12. ↑ "Extracts from Erving Goffman". A Middlesex University resource. Retrieved 8 November 2010.
  13. ↑ Mac Suibhne, Séamus (7 October 2009). "Asylums: Essays on the Social Situation of Mental Patients and other Inmates". BMJ 339: b4109. doi:10.1136/bmj.b4109.
  14. ↑ Surgeongeneral.gov
  15. ↑ Cqc.org.uk
  16. ↑ Medscape.com
  17. ↑ Hospital.com
  18. ↑ Vaslamatzis, G.; Katsouyanni, K.; Markidis, M. (1997). "The efficacy of a psychiatric halfway house: a study of hospital recidivism and global outcome measure". European Psychiatry 12 (2): 94–97. doi:10.1016/S0924-9338(97)89647-2.
  19. ↑ Matvejević, Predrag (2004). Between exile and asylum: an eastern epistolary. Central European University Press. p. 32. ISBN 963-9241-85-7.
  20. ↑ LaFraniere, Sharon; Levin, Dan (11 November 2010). "Assertive Chinese Held in Mental Wards". The New York Times. Retrieved 22 March 2012.
  21. ↑ Weiss AJ, Barrett ML, Andrews RM (July 2014). "Trends and Projections of U.S. Hospital Costs by Payer, 2003-2013". HCUP Statistical Brief #176. Rockville, MD: Agency for Healthcare Research and Quality.
  22. ↑ Official site, Accessed 2010-06-02
  23. ↑ Official site, Accessed 2010-06-02
  24. ↑ Georgie Parry‐Crooke (June 2009) My life: in safe hands?. Accessed 2010-06-02
  25. ↑ Deleuze and Guattari (1972) Anti-Oedipus p. 102
  26. ↑ Michel Foucault [1961] The History of Madness, Routledge 2006, pp.490–1, 507–8, 510–1
  27. ↑ Davidson, Larry; Rakfeldt, Jaak; Strauss, John (editors) (2010). The Roots of the Recovery Movement in Psychiatry: Lessons Learned. John Wiley and Sons. pp. 150. ISBN 88-464-5358-1.
  28. ↑ Wallace, Samuel (1971). Total Institutions. Transaction Publishers. p. 9. ISBN 88-464-5358-1.
  29. ↑ Weinstein R. (1982). "Goffman's Asylums and the Social Situation of Mental Patients" (PDF). Orthomolecular psychiatry 11 (N 4): 267–274.
  30. ↑ Lester H., Gask L. (May 2006). "Delivering medical care for patients with serious mental illness or promoting a collaborative model of recovery?". British Journal of Psychiatry 188 (5): 401–402. doi:10.1192/bjp.bp.105.015933. PMID 16648523.
  31. ↑ Mosher L.R. (March 1999). "Soteria and other alternatives to acute psychiatric hospitalization: a personal and professional review" (PDF). Journal of Nervous and Mental Disease 187 (3): 142–149. doi:10.1097/00005053-199903000-00003. PMID 10086470.
  32. ↑ "Involuntary Commitment Law". OLR Research Report. Oct 2, 2002.

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