Evolution of Approach

(Editor’s Note: This article was published July 19, 2015. It’s part of the Uneven Efforts​ series.)

During the 19th century, the idea that mental illness could sometimes be treated spread from France to England and to the United States. That spurred the development of hospitals where the mentally ill could be provided refuge and, to some extent, treatment — a trend that eventually touched New Hampshire and Vermont.

The Brattleboro Retreat, founded in 1834 with an intended capacity of 400 patients, was Vermont’s first mental health care institution. Its care was patterned on a Quaker concept of moral treatment that included “meaningful work, cultural pursuits, wholesome nutrition and daily exercise,” according to the institution’s website.

In New Hampshire, an 1836 report ordered by the state Legislature counted 312 cases of mental illness among 194,000 residents. That prompted lawmakers to appropriate money to build a state Asylum for the Insane, which opened in the fall of 1842 and soon had 47 patients.

“Therapy consisted primarily in taking patients away from the stresses and worries of their environment,” providing for their physical needs and keeping them active in a “benign atmosphere,” according to a history by Paul Shagoury, former chief psychologist at New Hampshire Hospital.

As the country grew, so did the population of the institutions housing the mentally ill. And as they got bigger, according to historian Paul Starr, “mental hospitals shifted from therapeutic to custodial functions.”

In Vermont, overcrowding became a problem at the Brattleboro Retreat. A new facility in Waterbury, which became the Vermont State Hospital, opened in 1890. A turn-of-the-century census found 524 patients in the Waterbury facility, and 281 in Brattleboro. By 1936, the population of the state mental hospital in Waterbury reached 1,700. The patient population in Waterbury was still 1,240 in 1960, but had been reduced to 150 by 1984. In New Hampshire, the population of the “asylum” reached 1,200 in 1917. By 1955, the population of what was then called New Hampshire Hospital had grown to an all-time high of 2,700, and each psychiatrist at the hospital treated more than 250 patients, according to Shagoury.

Recently, some critics of current systems for providing mental health care have urged policy makers to reconsider the value of at least some aspects of the early mental institutions. In January the Journal of the American Medical Association published a paper by three University of Pennsylvania medical ethicists titled “Improving Long-term Psychiatric Care: Bring Back the Asylum.” They argued that deinstitutionalization was a misleading label for a movement in which psychiatric hospitals had been replaced by non-therapeutic institutions. Community treatment too often lacked adequate resources, the mentally ill too often ended up homeless and, they wrote, “most disturbingly, U.S. jails and prisons have become the nation’s largest mental health care facilities.”

“For persons with severe and treatment-resistant psychotic disorders, who are too unstable or unsafe for community-based treatment, the choice is between the prison-homelessness-acute hospitalization-prison cycle or long-term psychiatric institutionalization,” they argued. That made large-scale but modern institutions “a necessary but not sufficient component of a reformed spectrum of psychiatric services.”

That piece provoked heated exchanges among advocates for mental health care reform. Counterpoint , the quarterly newsletter of Vermont Psychiatric Survivors, devoted two full pages in the centerfold of its summer issue to summarize the positions of the authors of the JAMA piece and offer what the periodical characterized as “fierce rebuttals.”