One of the most well-known incidents in the history of psychiatry, indeed perhaps the founding moment of modern psychiatry, is the freeing of the insane from their chains by Pinel as part of the general reform in treatment of the mentally ill. The moral treatment opened the door for humane conditions to become normal and rehabilitation or at least stabilization to be pursued. These goals led to the establishment of large state hospitals in the United States, hospitals primarily concerned with keeping and treating the mentally ill. Stagnation in the methods of treatment and increasing numbers of inmates led to a perception that these places of refuge had become little more than warehouses for the mentally ill or, worse still, prisons for those committed against their will who were in fact not unwell. Dissatisfaction grew and along with it came increasing calls for the emptying of the asylums, calls justified by their no longer functioning as shelters for the insane but as prison with gentler fetters but prisons all the same.
George Paulson's Closing the Asylums: Causes and Consequences of the Deinstitutionalization Movement takes up the history of what happened as these large state hospitals were closed, mainly in the post-World War II period and especially after the 1960s, and their residents were shifted to independent living, community care facilities, nursing homes, as well as the streets and prisons. Paulson, a retired neurologist, takes up the story of two state hospitals where he worked during his career and uses his observations in those institutions to consider the causes and consequences of closing similar facilities around the country.
Paulson's account is praiseworthy for its attention to the varied, interrelated causes of deinstituionalization. Some of these are well-known such as the development of effective medication for some previously untreatable disorders, legal emancipation and recognition of patients' rights in the wake of civil right movements, and a shift in societal attitudes about mental illness. However, Paulson also points out important elements that are sometimes overlooked, including the shift in research funding from state hospitals to research universities, the creation and expansion of nursing homes, urbanization and the resulting revaluation of property set aside for large hospital grounds, new disciplines of counseling psychology and social work, and even changes in legal requirements for paying residents for work in hospitals and union competition for those jobs. He is equally generous in considering consequences, including homelessness, increasing number of incarcerated ill, drug abuse, and a dearth of medical care for the most vulnerable. Paulson names the increased but often unclear cost of caring for those who would have been in the asylums, inconsistent monitoring of outpatient care, and inadequate support for mental illness as lingering problems that are a result of deinstitutionalization that can be addressed but must first be acknowledged. Though these negative consequences tend to dominate the narrative, Paulson is careful to point out that there were benefits to closing the asylums. Replacing a system of involuntary care with one that is maximally voluntary, increasing community agencies and services, reducing the length of hospital stays, increased legal protection for the mentally ill, development of new professions, and the reintegration of psychiatry and neurology are among the beneficial results he praises.
The main weakness of the book is that Paulson does little to weigh the significance of his causes against one another. He repeatedly claims that it is difficult to see exactly what role each of his respective causes played and uses this claim to justify his reluctance to make claims about their relative importance. While this is true, it seems that at least a little more could have been done to evaluate the importance, even if it was a cautious evaluation. Anyone familiar with the complexity of the case would sympathize with the difficulty of such judgments, but surely one purpose of careful consideration of the complexity is to find perspective by which to assess causes. He acknowledges his limitations as an amateur historian and his hesitation here may be one example of where it makes a difference. On the other hand, this same amateur status allows him to speak freely about his experiences and offer a personal account of the challenges presented by deinstitutionalization. Paulson's care for the plight of the mentally ill, his appreciation of the importance of bygone institutions, and his willingness to put his firsthand perspective to work might have been masked by professional training as a historian but instead remain as the chief rewards of reading his book. There are no grand theories here and often there is not a clearly unified account of causes or even a distinction between causes and consequences, but he gives the reader a close-up account of an important set of events in the history of psychiatry. Furthermore, the reader is given plenty of reason to rethink the current structures of care for the mentally ill and provocation to see it improved. Closing the Asylums delivers a wealth of considerations about causes and consequences of deinstitutionalization, but what to make of these considerations is left largely up to the reader. It is an outsider's defense of the importance of psychiatric medicine and clear reminder that closing the "warehouses" for the mentally ill did not usher in an unqualified golden age of psychiatric care.
© 2013 Dennis Trinkle
Dennis Trinkle II is a Ph. D. candidate in philosophy at the University of Wisconsin - Madison. He specializes in philosophy of mind, psychology, and psychiatry. At present, he is working on a dissertation about the nature of mental disorders.