THE INSTITUTIONALIZATION OF MENTAL HEALTH IN THE 19TH AND 20THCENTURIES IN MASSACHUSETTS
Institutionalization is commonly used to mean a procedure of creating something to become entrenched in an organization, society or social system as a well known norm or custom within that society. Institutionalization as a term is also used to refer to the act of entrusting of a person by a society to a certain institution for instance a mental institution. In such cases, it is used to describe both the treatment and damage which might be caused to the marginalized people by the corrupt or oppressive application of rigid systems of medical, legal or social controls by private or publicly owned organizations. It also describes the method of familiarizing someone to the life in the particular institution he is being taken to. The term mental health is used to illustrate the level of emotional or cognitive wellbeing or the lack of a mental illness. From the point of view of holism or positive psychology, mental health includes a person’s ability to be able to enjoy life and get a balance involving efforts to attain psychological flexibility and life activities.
Of paramount importance in preparation of the basics of new community oriented policies was changing the nature of the patient populace of the mental hospitals after the year 1890. between the year 1830 and 1880, the percentage of individuals with a long term care in the mental hospitals was a bit low in comparison to the unusual proportions between the year 1890 and the year 1950.Funding models played a major role in hindering the raise in this case. In broad-spectrum, State laws provided the principal funds essential for obtaining new sites and building, increasing, and refurbishing existing physical sites. Local communities, in contrast, were expected to disburse mental institutions a sum equivalent to the real cost of treatment and care of any patient admitted. Moreover, the system did not take for granted that every individual suffering from any mental illness will be taken care of in a government institution. Rules in general required that only individuals with mental illness and were dangerous needed to be referred to government mental institutions. Other patients who most probably could get assistance from curative interventions could be institutionalized but at the judgment of local administrators. The system, in a nutshell, consisted of a divided task. Therefore, for a greater part of the nineteenth century, a large proportion of individuals with mental sickness either lived in the community continuously otherwise was kept in civic almshouses. Families which had plenty of resources would entrust their family members to government institutions, given that they were ready to cater for the financial responsibility for their maintenance. In addition, governments had to compensate hospitals for the patients who lacked well-known legal residency, for example immigrants. The effect was a multicolored pattern (Grob, 1994b).
Separated task for individuals with mental sicknesses had considerable consequences. The system had a tendency to encourage rivalries and competition between related governmental powers. In many governments, the requirement that communities were economically legally responsible for their needy and impoverished insane residents created motivations for local administrators to maintain the needy in almshouses where they were lowly charged. Mental institution’s officials frequently faced constant pressure from societies to release patients, regardless of their state, so as to save funds. Local administrators rarely even tried to compel mental institutions to compensate the society for job done by patients, although such work was regularly well thought-out to be an element of a healing regimen. Sarcastically, separated monetary and government power had the illogical consequence of keeping people with lasting care requirements in mental institutions at relatively small numbers (Grob, 1973, 1983).
As the figure of people with long-standing care augmented, however, governments gradually began to re-evaluate their strategies. Disappointed by a method that segmented the states and the authorities (led by Massachusetts and New York) adopted laws that reassured local societies of any responsibility at all in taking care of persons with mental sicknesses. The supposition of the people, who preferred centralization was that home care, though cheap, was below standard and promoted dependency and chronicity. on the other hand, treatment and care in mental institutions, although very expensive at first, would be inexpensive at the end of the day since it would encourage the chances of recuperation for some patients and offer more humanitarian care for other patients (Grob, 1983).
Though the intention of government supposition of accountability was to make sure that people with mental sicknesses would get a better quality of treatment and care, the repercussions in real practice were very different. In short, local administrators found in the fresh laws a great chance to reallocate a number of their monetary responsibilities onto the government. The function of the laws was obvious, namely, to take away the care of citizens with enduring mental ill health from local authorities. However, local administrators went past the intention of the laws. Originally, 19th century almshouses (which used to be administered and supported by local states) served as some homes for the aged and senile without any monetary resources. The enactment of government care acts offered local administrators with an unanticipated chance. They further redefined senility according to psychiatric terms, consequently beginning to shift aged people away from local almshouses into government mental institutions. Humanitarian worries played a comparatively minor function in the development; economic reflections were of great importance (Grob, 1983).
In 1818, the first private hospital for the mentally challenged persons was initiated, referred to as the McLean Asylum in Boston. In 1833, the Worcester State Lunatic Asylum was founded.
Dorothea Dix, one of the 19th century major psychiatric reformers came from Massachusetts. She is notable remembered for her efforts in 1843 in her lobbying to the legislature of Massachusetts to improve the mental institutions in Massachusetts (Gollaher, 1995).
According to Upshur et, al (1997), from then, the mental health issues were better handled using an institutional approach. By 1875, six mental hospitals were already established handling more than 2,000 people while by 1910, these institutions did more than 13 inhabiting close to 10,000. It is in the mid 1950s when the state took full charge of the mental health institutions in Massachusetts.
Several remarkable reforms on the mental health whose efforts were to make better the mental institutions occurred in Massachusetts over the period. These reforms include in areas such as the;
- Psychopathic hospitals,
- Mental health movements,
- Mental health out patient’s clinics among others.
These reforms had a common objective in ensuring the mentally challenged persons were continuously managed in a better way as time went by (Rothman 1980)
Throughout the reforms, the mental institutions remained dominant in the public health institutions services, however the struggle for better services for the mentally ill patients was not deep rooted due the strain on the financial resources, overcrowding in the public healthcare institutions and certain clique of philosophers who proposed the mental health patients be put in jails instead of hospitals.
Specialized psychiatric services began to be offered in the general public hospitals at the beginning of 1900. A study by Epstein and Dow art (1993) revealed that the psychiatric units in the Cambridge Hospital took several years before it was fully established. A few psychiatric wards existed in the general hospitals of Massachusetts by 1960. There was a great increase in the participation by the private and public sector health providers in the mental health services between 10960s and 1970s and this was boosted by the rise in the growth of the private and public insurance coverage. A new law was effected in 1976 whereby all the private insurers were required to pay 60% of the medical bill for the mental health inpatients in Massachusetts, alternatively the private insurer was required to pay the same amount for the mental health patients just like for other medical problems in addition to a $500 annual mental health benefit for outpatients (Montgomery, McGuire, 1982)
For several decades, the mental health system in Massachusetts that had been controlled by the private sector was shifting towards specific public and private community based services. This was an indication of the response to the several financial, organizational and managerial concerns that were not expected during the inauguration of the mental health services in Massachusetts.
These changes are attributed to the availability of better medical care, changes in the statutes and participation by the communities through community services.
Governor Michael Dukakis started the Mental Health Action Project in 1985 and he clearly noted that in Massachusetts, institutionalization was not accompanied with community care that was adequate enough hence resulting to its failure.
Coupled with this sad reality, the government of Michael Dukakis focused on a strategic plan aiming at;
- Provision of support and emergency services to all the people within the state suffering from chronic mental sickness.
- Improvement of the quality of care provided to all patients in the public hospitals or in community based centers.
- Increase in the number of residential care and the alternative treatment opportunities
- Enhancing an improved management in the Department of Mental Health in Massachusetts.
This strategic plan was to be implemented within duration of five years and initial capital requirement was $151.2 million and the operating expenses were $110 million. These recommendations were passed in unison by the by the Massachusetts legislature thus leading to the passing of Chapter 599 of the Acts of 1986. This legislation increased the funding appropriation of the Department of Mental Health in Massachusetts. Local mental health facilities began to be improved using the private and public mental health providers and this resulted to reduced number of inpatients in the public general hospitals.
Since the 17th century, the care for the mentally challenged persons in Massachusetts had been left to the public sector. For over 200 years, the mentally challenged persons have been wholly taken care of by the towns from which they live through poor farms which are specially established or locally elected care takers for the poor. From the year 1830 to the year 1930, the commonwealth took over the responsibility of the mentally challenged persons with the construction of one farm and three schools for them.
In the 19th century, the commonwealth was very generous of building the schools and the farm with their designing done by well experienced architects. In spite the fact that the buildings done on the 20th century were not designed by well experienced architects, there is evidence of quality in them. The level of state sponsored hospitals in Massachusetts display the level of government involvement in the institutional development in the US. It is worth noting that Massachusetts, New York and Pennsylvania were along the first states to be in forefront for institutional reform as noted that the function of Massachusetts;
The Bay State had pioneered in nineteenth century welfare. Its policies had helped to legitimate the state mental hospital in the early part of the century. Massachusetts had also established the first Board of State Charities in 1863 and a State Board of Health six years later. The cultural and intellectual leadership of its citizens reinforced its political significance, and where Massachusetts led other states traditionally followed (Grob, 1983: pg 82).
The large and extensive building in the country side of Massachusetts is a clear indication of the system that existed in the 19th century. Since the inauguration of the Massachusetts State Hospital in the 1840, the institutions approach reached its peak in 1940s but immediately after then, there was intensified criticism for the institutional care.
The history of the general public offering aid to the mental patients resulted from the dynamics in the political/ social arena coupled with the progress in the scientific medical practices. It also includes the changes in the policies from the 18th century through 19th century where by initially there were no institutions and care was offered by the local community to the modern time where the federal government is closely involved.
The efforts to cater for the mentally challenged in Massachusetts began with the establishment of the Massachusetts General Hospital which had a psychiatric subdivision to cater for the mentally challenged in . This was catalyzed by many reformers who wanted the state government to play a crucial role in assisting the mental patients institutions. The first major policy was pushed in 1821 by Josian Quincy through the General Court who after analyzing the 1791 to 1820, i.e. the post revolutionary era requested the state to be concerned of the poor who included the mental patients since they were surviving on the mercy of the well wishers, but there was main action taken until 1852. In 1829, Horace Mann launched a campaign advocating for better treatment of the mentally ill patients who were being locked in jails and handled badly by severally being chained, this led a commission being formed to give reports on the statistics of the mental patients from all town within the commonwealth. The results of the committee proved to the legislature the essence of giving proper care to the leading to selection of three commissioners to find a site for construction of hospital for the mental patients. The results were the erection of the first mental asylum for the mental patients in Worcester, which was considered to be central geographical location in Massachusetts in 1832.
After ten years, the analyses of Mann were enlarged by Dorothea Dix who made it public that there were inadequate facilities in the mental hospital in Worcester which was highly overpopulated. Dix who was a national figure delivered a speech in 1843 to the legislature addressing the plight of the mental illness patients. Dix’s speech led to an immediate expansion of the Worcester hospital from the original 120 beds to 360 beds coupled with construction of two additional asylums for the mental illness patients. In her speech, she stated that;
I come to present the strong claims of suffering humanity. I come to place before the Legislature of Massachusetts the condition of the miserable, the desolate, the outcast. I come as the advocate of helpless, forgotten, insane, and idiotic men and women; of beings sunk to a condition from which the most unconcerned would start with real horror; of beings wretched in our prisons, and more wretched in our almshouses. And I cannot suppose it needful to employ earnest persuasion, or stubborn argument, in order to arrest and fix attention upon a subject only the more strongly pressing in its claims because it is revolting and disgusting in its details...I proceed gentlemen, briefly to call your attention to the present state of insane persons confined within this Commonwealth, in cages, closets, cellars, stalls, and pens! Chained, naked, beaten with rods and lashed into obedience (Dix 1843: pg 2).
Dix harsh words were followed by statistical data of a mentally ill patient who had been chained for 17 years in a tiny room in Lincoln, a woman losing her skin due to harsh conditions she experienced in Danvers, a wearily skeletal naked woman kept in a room without light and air under stairs in Newburyport, among other ugly incidences. She acknowledged the fact that those conditions were fruits of ignorance from the care givers who assumed that the mentally challenged patients did not have any sense of emotion. She further said that, “I do not know how it is argued that mad persons and idiots may be dealt with as if no spark of recollection ever lights up the mind. The observation and experience of those who have had charge of hospitals show opposite conclusions” (Dix 1843 pg 10)
In 1846, the legislature appointed more committees to investigate the welfare of the idiots’ asylum at Worcester was transformed to Massachusetts School for Idiotic and Feeble-Minded Youth and this displayed the initial step of the public involvement in providing care to the mentally challenged persons. The Massachusetts School for Idiotic and Feeble-Minded Youth under the manipulation of Theodore Lyman was transformed in to Massachusetts State Reform School and these were the first institutions to be operated by the government of Massachusetts.
The government of Massachusetts continued to assist in offering and building medical institutions for the next 30 years with additional 2 more institutions build namely the Nautical Reform School and Industrial School for girls, these institutions were ran by a board of trustees. In compliance with the 1836 state law and with the cooperation with three counties, Essex, Middlesex and Suffolk, more facilities were built for the mental patients.
As the system turned to be more complicated and large, the law making body formed a Massachusetts Board of State Charities whose responsibility was to coordinate these institutions, this was established in Chapter 240, Acts of 1863. According to Grob (1983), the objective was to collect data, establishment of issues and define issues but not mainly to act as regulator of these institutions. The chairman of Massachusetts Board of State Charities between 1865 and 1874 was Dr. Samuel Gridley Howe and in an annual conference in 1867, he said that;
The purpose of charity in New England has been to diminish the number of the helpless, to make them sounder, stronger, more hopeful and self-reliant. Justice, no less than mercy, has been in the thoughts of our people; a justice not satisfied with almsgiving, but seeking zealously to establish a So9~al condition in which alms would be less and less needed. Painful as the sights of woe in many of our charitable institutions must be, they are made more tolerable by the thought that in America—the home of the poor man—we are in the way to throw off and neutralize much of the misery handed down to us from older countries and less hopeful times.
This clearly indicates that the early reformers dedicated most of their energies to eradicate diseases which may have been mental or physical, crime and poverty. These reforms were mainly advocated for by the Massachusetts modern utopian philosopher. During Howe’s 16 years in the board, two additional hospitals were built in Danvers and Worcester.
State Board of Health and Board of State Charities and boards of other institutions that were self governing were merged by Chapter 291 of the Acts of 1879 and this brought together the public approach and the state approach in the issues of the mentally challenged persons. The other board of trustees of institutions included;
- State Reform School
- State Industrial School
- Inspectors of the State Primary School
- The State Almshouse
- State Workhouse
- The almshouses at Monson, Bridgewater and Tewksbury
The merging resulted to formation of a Board of Health, Lunacy, and Charity whose seven year era is remembered by the establishment of the 1884 Westborough Insane Hospital which utilized the Boys Reform School buildings.
The end of the Board of Health, Lunacy, and Charity is identified with changed attitude which clearly displayed the national dissatisfaction on the capability of the institutions to cure mental patients problem, change criminal and fight poverty. The boards’ inability to meet its responsibilities is attributed to its diverted attention to the many institutions. It is worth noting that it is in Massachusetts where control experiment on central management on efforts to increase accountability was carried out in the US due to the rich medical profession (Grob, 1983, pg 211). It is the 1884 analysis on in Legislation on Insanity in Massachusetts that marked the beginning of constructive legislation to protect the mentally ill patients.
Chapter 101 of the Acts of 1886 established the Board of Health which divided the roles played by the heterogeneous Board of Health, Lunacy, and Charities while Chapter 433 of the Acts of 1898 distinguished the Board of Charity and Insanity. Three new institutions were established between 1886 and 1896 under the direction of Board of Charity and Insanity, these institutions were;
- The 1889 the Massachusetts Hospital for Dipsomaniacs and Inebriates located at Foxborough
- The 1892 Medfield Insane Asylum for chronic mental illness at Medfield
- The 1899 Templeton Colony for persistent cases of retardation
In addition, the almshouses at Monson were turned to Massachusetts Hospital for Epileptics in 1895.
The initiation of these institutions clearly displays the dedication in the late 19th century to mental problems and the trust in the scientific medical application. Critical analysis was carried out patients whose illness arose from epileptics and alcoholism who could be easily cured. This led to separation between the chronic and less chronic patients and the chronic were to be kept in institutions which could make their lives better. The institution holding the chronic mental patients could were constructed in such a way that they could hold a maximum of 2000 patients and this was aimed to reduce the pressure in the future on these institutions.
The main responsibility of the Board of Insanity was to link the care for the mentally ill patients that began in the 1830s in the form of community care to the state care a goal achieved in 1900 while funds began to be received in 1904.
The historical development of mental health institutions in Massachusetts has been very diverse and these developments have had a great contribution to the nation. The mental hospital movement began in the 1800 with the first general hospital for the mentally challenged being built in the early 1900s; this further led to institutionalization in the postwar period and development of the community based centers for care.
Massachusetts was among the first states to recognize the need for better mental services to the mentally ill persons and this led to implementation of plans aimed at offering better medical care and housing. More than 225,000 people accessed medical aid between 1997 and 1999 after legislation of Chapter 203 of the Acts of 1996 that allowed more mental patients to access to medical aid.
Though the state has been serious in ensuring that it provides good medical care to the mental patients, while compared with other states, it is too much behind. A 1986 survey by the Public Citizen Health Research Group ranked the 41st state and this was noted as “painful downhill slide…in caring for those who cannot care for themselves” ((Torrey, Wolfe, 1986, pg 69). However, a survey carried out in 1990 showed that the state have improved its services since it was ranked in position 16. Though the state has greatly improved, this can be attributed to the models in the health institutions that have been developed in Western Massachusetts, Boston Worcester among other regions.
Though the mental health programs institutions in Massachusetts began in a slow motion, the state now boasts having the best mental health medical infrastructure with best performing hospitals. Programs aimed at improving better medical institutions to mental patients have been initiated to offer vocational training to the mental health experts.
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 Massachusetts State Hospitals Social history, retrieved on 12th, October, 2008, available at http://www.1856.org/socialhistory.html