In the world of mental illness, nostalgia is a bad thing
Anyone who comes across policy rhetoric proposing that we reinvest in large psychiatric institutions should pick up a copy of Judi Chamberlin's book On Our Own: Patient-Controlled Alternatives to the Mental Health System. Published in 1978, the book is dedicated
To my sisters and brothers in the mental patients' liberation movement and to all those who have suffered at the hands of institutional psychiatry for the past three hundred years.
You have to admire this book. It represents an authentic, hard-fought point of view that resonates today. The book is part memoir, part political analysis of mental illness on the eve of deinstitutionalization, plus a tour of mid-1970's community programs. It embodies the passion of a person who's been hurt, who has seen others suffer, and who hungers for reform.
For too long, mental patients have been faceless, voiceless people. We have been thought of, at worst, as subhuman monsters, or, at best, as pathetic cripples, who might be able to hold down meager jobs and eke out meager existences, given constant professional support.
The book also serves as a meditation on the dynamics of coercion, torture and humiliation disguised as medical care. This is a political document for a population oppressed throughout history. It is Viktor Frankl's Man's Search for Meaning, fine-tuned for people who have been identified as crazy, mad, infantilized, incapable of caring for themselves.
Putting people in detention facilities called mental hospitals is considered humane. Improving mental hospitals then becomes a matter of providing more treatment. It doesn't matter if the patients call it torture.
And lest we forget, torture it was, perpetuated by an industry that worked in obscurity and operated according to rules it created for itself. In the mid-1970s even E. Fuller Torrey questioned what was going on. Chamberlin quotes Torrey.
The very term [mental disease] itself is nonsensical, a semantic mistake. The two words cannot go together except metaphorically; you can no more have a mental "disease" than you can have a purple idea or a wise space.
Literally anything could be treated as a psychiatric symptom. Once that happened, people in asylums might do anything to you. Chamberlin relates the experiences of Leonard Frank, a psychiatric patient in the mid-1960s. Frank was involuntarily committed by his parents when they discovered he lost his job and started living off his savings. He had become interested in Orthodox Judaism – plus he grew a beard, studied the Bible and started following the dietary laws. These were all interpreted as mental illness symptoms. Years later, Frank published the medical records of his psychiatric hospitalization in an ex-patient's newsletter he founded. Chamberlin notes
The records show that the only "symptoms" the psychiatrists were able to find, "symptoms" that they used to justify administering to him against his will fifty insulin shock and thirty-five electric shock treatments were his vegetarianism, his beard, and his denial that he was mentally ill. … The record indicates that whenever Leonard was given a mental-status examination, he answered all the factual questions correctly; he was, in psychiatric terminology, "well-oriented." …It was considered progress that "he asked for a bowl of clam chowder soup and took some bread and used butter on it." His "delusions" – that he should be a vegetarian, wear a beard, and observe his religion – were enough for a court order of commitment, requested by the doctors on the grounds that he was "dangerous to himself and others under these circumstances." What danger? Whose delusions?
Chamberlin notes that institutional psychiatry was designed to dehumanize. Mental hospitals were "total institutions" that controlled every aspect of an inmate's life. Institutions not only controlled the type of treatment to which a person was subjected, but the coercive rules of the "therapeutic milieu" controlled nearly every other detail about an inmate's life. This included when and where the person ate or slept, what the person wore, when to use the bathroom, and whether the toilet in the bathroom was in full public view. Chamberlin points out how the effects of institutionalization reinforced pathology, piling on justification for further treatment.
A natural consequence of being subjected to such a regimen is a feeling of depersonalization. Feelings of depersonalization are frequently considered primary symptoms of mental illness. To complete the circle, psychiatrists usually attribute their patients' feelings of depersonalization to their internal state and not to conditions within mental institutions. The whole experience of mental hospitalization promotes weakness and dependency. Not only are the lives of patients controlled, but patients are constantly told that such control is for their own good, which they are unable to see because of their mental illness. Patients become unable to trust their own judgment, become indecisive, overly submissive to authority, frightened of the outside world.
This emphasis on dependency reinforced the tremendous power gulf within institutions.
Patients are seen as sick, untrustworthy, and needing constant supervision. Staff members are seen as competent, knowledgeable, natural leaders. These stereotypes are believed by large numbers of patients and staff members. Communication is difficult across this gulf. Staff members don't believe what patients tell them. Patients don't believe what other patients say. Patients begin to question their own perception of situations, including their very accurate perceptions that they are looked down on and spied on by the staff.
Chamberlin experienced mid-1960s psychiatry first-hand, spending five months as a patient in six mental hospitals, an experience that left her traumatized.
I had never thought of myself as a particularly strong person, but after hospitalization, I was convinced of my own worthlessness. I had been told that I could not exist outside an institution. I was terrified that people would find out that I was an ex-patient and look down on me as much as I looked down on myself…It was years before I allowed myself to feel anger at a system that had locked me up, denied me warm and meaningful contact with other human beings, drugged me, and so thoroughly confused me that I thought of this treatment as helpful.
On Our Own aimed to create an alternative future, with changed commitment laws, and increased constitutional guarantees for patients. Chamberlin sought to "end the demeaning and harmful psychiatric system and replace it with true asylums, places to which people can retreat to deal with the pain of their existence." She favored patient-controlled alternatives that emphasized people helping one another, where the gulf between "patient" and "staff" disappeared; but she also recognized the existence of difficult problems, particularly funding issues and opposition from professionals.
In the ensuing 35 years, parts of Chamberlin's vision have been realized. For one thing, the psychiatric hospital system has been pretty much wiped out, which is, on balance, a good thing. The institutional psychiatry of the past was certainly not optimal. I think that the people who compare numbers of lost mental hospital beds to numbers of contemporary jail mental health beds are operating from a misplaced sense of nostalgia and wishful thinking. Confinement, coercion and misery were as nasty then as now, and neither type of institution really works. There are good reasons why so many horror movies are set in mental institutions – and good reasons why today's hospitals are designed for brief stays and small populations.
Psychiatric jurisprudence has certainly improved. Fewer people are subject to coercive treatment just because their parents are worried. It may be harder for parents to get courts to act, but still, even in the old days parents did not really want their children harmed, which is what the system unfortunately offered. Parents then as now simply want their children to be safe and well. Of course we still have much work to do with respect to court-connected remedies and mandatory care. Many more people are losing their lives to suicide and violence than need to. Stopping suicide and violence is the bottom line for me, but these are always hard cases.
We are, of course, still working on the alternative institutions that Chamberlin envisioned. Chamberlin's book is a key piece in designing a future where the experience of mental illness comes out right.
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