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In the early 19th century, the United States adopted new European ideas to create an institution that promised moral treatment to their patients illnesses. Over the years, into the 20th century, This moral treatment was built on the assumption that "those suffering from mental illness could find their way to recovery and an eventual cure if treated kindly and in ways that appealed to the parts of their minds that remained rational. It repudiated the use of harsh restraints and long periods of isolation that had been used to manage the most destructive behaviors of mentally ill individuals."

https://www.nursing.upenn.edu/nhhc/nurses-institutions-caring/history-of-psychiatric-hospitals/

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The history of psychiatric hospitals was once tied tightly to that of all American hospitals. Those who supported the creation of the first early-eighteenth-century public and private hospitals recognized that one important mission would be the care and treatment of those with severe symptoms of mental illnesses. Like most physically sick men and women, such individuals remained with their families and received treatment in their homes. Their communities showed significant tolerance for what they saw as strange thoughts and behaviors. But some such individuals seemed too violent or disruptive to remain at home or in their communities. In East Coast cities, both public almshouses and private hospitals set aside separate wards for the mentally ill. Private hospitals, in fact, depended on the money paid by wealthier families to care for their mentally ill husbands, wives, sons, and daughters to support their main charitable mission of caring for the physically sick poor.

But the opening decades of the nineteenth-century brought to the United States new European ideas about the care and treatment of the mentally ill. These ideas, soon to be called "moral treatment," promised a cure for mental illnesses to those who sought treatment in a very new kind of institution-an "asylum." The moral treatment of the insane was built on the assumption that those suffering from mental illness could find their way to recovery and an eventual cure if treated kindly and in ways that appealed to the parts of their minds that remained rational. It repudiated the use of harsh restraints and long periods of isolation that had been used to manage the most destructive behaviors of mentally ill individuals. It depended instead on specially constructed hospitals that provided quiet, secluded, and peaceful country settings; opportunities for meaningful work and recreation; a system of privileges and rewards for rational behaviors; and gentler kinds of restraints used for shorter periods.

Many of the more prestigious private hospitals tried to implement some parts of moral treatment on the wards that held mentally ill patients. But the Friends Asylum, established by Philadelphia's Quaker community in 1814, was the first institution specially built to implement the full program of moral treatment. The Friends Asylum remained unique in that it was run by a lay staff rather than by medical men and women. The private institutions that quickly followed, by contrast, chose physicians as administrators. But they all chose quiet and secluded sites for these new hospitals to which they would transfer their insane patients. Massachusetts General Hospital built the McLean Hospital outside of Boston in 1811; the New York Hospital built the Bloomingdale Insane Asylum in Morningside Heights in upper Manhattan in 1816; and the Pennsylvania Hospital established the Institute of the Pennsylvania Hospital across the river from the city in 1841. Thomas Kirkbride, the influential medical superintendent of the Institute of the Pennsylvania Hospital, developed what quickly became known as the "Kirkbride Plan" for how hospitals devoted to moral treatment should be built and organized. This plan, the prototype for many future private and public insane asylums, called for no more than 250 patients living in a building with a central core and long, rambling wings arranged to provide sunshine and fresh air as well as privacy and comfort.

With both the ideas and the structures established, reformers throughout the United States urged that the treatment available to those who could afford private care now be provided to poorer insane men and women. Dorothea Dix, a New England school teacher, became the most prominent voice and the most visible presence in this campaign. Dix travelled throughout the country in the 1850s and 1860s testifying in state after state about the plight of their mentally ill citizens and the cures that a newly created state asylum, built along the Kirkbride plan and practicing moral treatment, promised. By the 1870s virtually all states had one or more such asylums funded by state tax dollars.

By the 1890s, however, these institutions were all under siege. Economic considerations played a substantial role in this assault. Local governments could avoid the costs of caring for the elderly residents in almshouses or public hospitals by redefining what was then termed "senility" as a psychiatric problem and sending these men and women to state-supported asylums. Not surprisingly, the numbers of patients in the asylums grew exponentially, well beyond both available capacity and the willingness of states to provide the financial resources necessary to provide acceptable care. But therapeutic considerations also played a role. The promise of moral treatment confronted the reality that many patients, particularly if they experienced some form of dementia, either could not or did not respond when placed in an asylum environment.

The medical superintendents of asylums took such critiques seriously. Their most significant effort to improve the quality of the care of their patients was the establishment of nurses' training schools within their institutions. Nurses' training schools, first established in American general hospitals in the 1860s and 1870s, had already proved critical to the success of these particular hospitals, and asylum superintendents hoped they would do the same for their institutions. These administrators took an unusual step. Rather than following an accepted European model in which those who trained as nurses in psychiatric institutions sat for a separate credentialing exam and carried a different title, they insisted that all nurses who trained in their psychiatric institutions sit for the same exam as those who trained in general hospitals and carry the same title of "registered nurse." Leaders of the nascent American Nurses Association fought hard to prevent this, arguing that those who trained in asylums lacked the necessary medical, surgical, and obstetric experiences common to general-hospital-trained nurses. But they could not prevail politically. It would be decades before American nursing leaders had the necessary social and political weight to ensure that all training school graduates-irrespective of the site of their training-had comparable clinical and classroom experiences.

It is, at present, hard to assess the impact of nurses' training schools on the actual care of patients in psychiatric institutions. In some larger public institutions, the students worked only on particular wards. It does seem that they had a more substantive impact on the care of patients in much smaller and private psychiatric hospitals where they had more contact with more patients. Still, it may be that their most enduring contribution was opening the practice of professional nursing to men. Training schools in asylums, unlike those in general hospitals, actively welcomed men. Male students found places either in schools that also accepted women or in separate schools formed just for them.

Training schools for nurses, however, could not stop the assault on psychiatric asylums. The economic crisis of the 1930s drastically cut state appropriations, and World War II created acute shortages of personnel. Psychiatrists, themselves, began looking for other practice opportunities by more closely identifying with general, more reductionistic, medicine. Some established separate programs-often called "psychopathic hospitals"-within general hospitals to treat patients suffering from acute mental illnesses. Others turned to the early-twentieth-century's new Mental Hygiene Movement and created outpatient clinics and new forms of private practice focused on actively preventing the disorders that might result in a psychiatric hospitalization. And still others experimented with new forms of therapies that posited brain pathology as a cause of mental illness in the same way that medical doctors posited pathology in other body organs as the cause of physical symptoms: they tried insulin and electric shock therapies, psychosurgery, and different kinds of medications.

By the 1950s, the death knell for psychiatric asylums had sounded. A new system of nursing homes would meet the needs of vulnerable elders. A new medication, chlorpromazine, offered hopes of curing the most persistent and severe psychiatric symptoms. And a new system of mental health care, the community mental health system, would return those suffering from mental illnesses to their families and their communities.

Today, only a small number of the historic public and private psychiatric hospitals exist. Psychiatric care and treatment are now delivered through a web of services including crisis services, short-term and general-hospital-based acute psychiatric care units, and outpatient services ranging from twenty-four-hour assisted living environments to clinics and clinicians' offices offering a range of psychopharmacological and psychotherapeutic treatments. The quality and availability of these outpatient services vary widely, leading some historians and policy experts to wonder if "asylums," in the true sense of the word, might be still needed for the most vulnerable individuals who need supportive living environments.

Patricia D'Antonio is Carol E. Ware Professor in Mental Health Nursing, Chair, Department of Family and Community Health, Director, Barbara Bates Center for the Study of the History of Nursing, and Senior Fellow, Leonard Davis Institute of Health Economics.

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The history of psychiatric hospitals was once tied tightly to that of all American hospitals. Those who supported the creation of the first early-eighteenth-century public and private hospitals recognized that one important mission would be the care and treatment of those with severe symptoms of mental illnesses.

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Although psychiatric hospitals still exist, the dearth of long-term care options for the mentally ill in the U.S. is acute, the researchers say. State-run psychiatric facilities house 45,000 patients, less than a tenth of the number of patients they did in 1955.

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Why did so many psychiatric hospitals close?

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Why did so many psychiatric hospitals close?

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In the 1960s, laws were changed to limit the ability of state and local officials to admit people into mental health hospitals. This lead to budget cuts in both state and federal funding for mental health programs. As a result, states across the country began closing and downsizing their psychiatric hospitals.

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The equipment used in medical facilities in the 50s is extremely different to today. Such appliances include glass syringes and mercury thermometers. Mercury syringes were finally discontinued in the 1990s after being deemed too dangerous to handle since breaking the thermometer could easily lead to mercury poisoning.

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Once a doctor had gotten their degree and their license, they didn't need to re-license like today. So once a doctor got a job, they were only held accountable by their bosses, but if they ran the hospital themselves they could easily abuse their power.

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Mental health treatments today differ a lot from those of the 50s and 60s. Treatments now are much safer, there is very little risk involved and every treatment has been proved to work. The most common treatments are, Psychotherapy, Medication, Support Groups, Case Management, Hospitalization, and Self Help.

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Psychiatric hospitals in the 50s/60s to right now 

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Psychiatric hospitals in the 50s/60s to right now 

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The reasons for going to the psychiatric hospitals are the same from back then and now. For example depression and being gay or having special needs so that's one thing in common but people back then they expected to go in and never leave and now they want to get better and move on.

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Today, many mental health centers are located near parks, neighborhoods and homes, and looked much cleaner and safer than they did back then. These hospitals are most likely run by the state, and provide short term care due to high costs.

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What you'll learn to do: describe the treatment of mental health disorders over time

It was once believed that people with psychological disorders, or those exhibiting strange behavior, were possessed by demons. These people were forced to take part in exorcisms, were imprisoned, or executed. Later, asylums were built to house the mentally ill, but the patients received little to no treatment, and many of the methods used were cruel. Philippe Pinel and Dorothea Dix argued for more humane treatment of people with psychological disorders. In the mid-1960s, the deinstitutionalization movement gained support and asylums were closed, enabling people with mental illness to return home and receive treatment in their own communities. Some did go to their family homes, but many became homeless due to a lack of resources and support mechanisms.

Today, instead of asylums, there are psychiatric hospitals run by state governments and local community hospitals, with the emphasis on short-term stays. However, most people suffering from mental illness are not hospitalized. A person suffering symptoms could speak with a primary care physician, who most likely would refer him to someone who specializes in therapy. The person can receive outpatient mental health services from a variety of sources, including psychologists, psychiatrists, marriage and family therapists, school counselors, clinical social workers, and religious personnel. These therapy sessions would be covered through insurance, government funds, or private (self) pay.

Learning Objectives

Explain how people with psychological disorders have been treated throughout the ages and discuss deinstitutionalization

Describe the ways in which mental health services are delivered today, including the distinction between voluntary and involuntary treatment

For much of history, the mentally ill have been treated very poorly. It was believed that mental illness was caused by demonic possession, witchcraft, or an angry god (Szasz, 1960). For example, in medieval times, abnormal behaviors were viewed as a sign that a person was possessed by demons. If someone was considered to be possessed, there were several forms of treatment to release spirits from the individual. The most common treatment was exorcism, often conducted by priests or other religious figures: Incantations and prayers were said over the person's body, and she may have been given some medicinal drinks. Another form of treatment for extreme cases of mental illness was trephining: A small hole was made in the afflicted individual's skull to release spirits from the body. Most people treated in this manner died. In addition to exorcism and trephining, other practices involved execution or imprisonment of people with psychological disorders. Still others were left to be homeless beggars. Generally speaking, most people who exhibited strange behaviors were greatly misunderstood and treated cruelly. The prevailing theory of psychopathology in earlier history was the idea that mental illness was the result of demonic possession by either an evil spirit or an evil god because early beliefs incorrectly attributed all unexplainable phenomena to deities deemed either good or evil.

From the late 1400s to the late 1600s, a common belief perpetuated by some religious organizations was that some people made pacts with the devil and committed horrible acts, such as eating babies (Blumberg, 2007). These people were considered to be witches and were tried and condemned by courts-they were often burned at the stake. Worldwide, it is estimated that tens of thousands of mentally ill people were killed after being accused of being witches or under the influence of witchcraft (Hemphill, 1966)

By the 18th century, people who were considered odd and unusual were placed in asylums. Asylums were the first institutions created for the specific purpose of housing people with psychological disorders, but the focus was ostracizing them from society rather than treating their disorders. Often these people were kept in windowless dungeons, beaten, chained to their beds, and had little to no contact with caregivers.

In the late 1700s, a French physician, Philippe Pinel, argued for more humane treatment of the mentally ill. He suggested that they be unchained and talked to, and that's just what he did for patients at La Salpêtrière in Paris in 1795 (Figure 2). Patients benefited from this more humane treatment, and many were able to leave the hospital.

In the 19th century, Dorothea Dix led reform efforts for mental health care in the United States. She investigated how those who are mentally ill and poor were cared for, and she discovered an underfunded and unregulated system that perpetuated abuse of this population (Tiffany, 1891). Horrified by her findings, Dix began lobbying various state legislatures and the U.S. Congress for change (Tiffany, 1891). Her efforts led to the creation of the first mental asylums in the United States.

Despite reformers' efforts, however, a typical asylum was filthy, offered very little treatment, and often kept people for decades. At Willard Psychiatric Center in upstate New York, for example, one treatment was to submerge patients in cold baths for long periods of time. Electroshock treatment was also used, and the way the treatment was administered often broke patients' backs; in 1943, doctors at Willard administered 1,443 shock treatments (Willard Psychiatric Center, 2009). (Electroshock is now called electroconvulsive treatment, and the therapy is still used, but with safeguards and under anesthesia. A brief application of electric stimulus is used to produce a generalized seizure. Controversy continues over its effectiveness versus the side effects.) Many of the wards and rooms were so cold that a glass of water would be frozen by morning (Willard Psychiatric Center, 2009). Willard's doors were not closed until 1995. Conditions like these remained commonplace until well into the 20th century.

Starting in 1954 and gaining popularity in the 1960s, antipsychotic medications were introduced. These proved a tremendous help in controlling the symptoms of certain psychological disorders, such as psychosis. Psychosis was a common diagnosis of individuals in mental hospitals, and it was often evidenced by symptoms like hallucinations and delusions, indicating a loss of contact with reality. Then in 1963, Congress passed and John F. Kennedy signed the Mental Retardation Facilities and Community Mental Health Centers Construction Act, which provided federal support and funding for community mental health centers (National Institutes of Health, 2013). This legislation changed how mental health services were delivered in the United States. It started the process of deinstitutionalization, the closing of large asylums, by providing for people to stay in their communities and be treated locally. In 1955, there were 558,239 severely mentally ill patients institutionalized at public hospitals (Torrey, 1997). By 1994, by percentage of the population, there were 92% fewer hospitalized individuals (Torrey, 1997).

Before we explore the various approaches to therapy used today, let's begin our study of therapy by looking at how many people experience mental illness and how many receive treatment. According to the U.S. Department of Health and Human Services (2013), 19% of U.S. adults experienced mental illness in 2012. For teens (ages 13-18), the rate is similar to that of adults, and for children ages 8-15, current estimates suggest that 13% experience mental illness in a given year (National Institute of Mental Health [NIMH], n.d.-a). In 2016, the number was slightly lower with 18.53% of adults reporting that they suffered from a mental illness (see Mental Health America for more statistics).

With many different treatment options available, approximately how many people receive mental health treatment per year? According to the Substance Abuse and Mental Health Services Administration (SAMHSA), in 2008, 13.4% of adults received treatment for a mental health issue (NIMH, n.d.-b). These percentages, shown in Figure 4, reflect the number of adults who received care in inpatient and outpatient settings and/or used prescription medication for psychological disorders. The "2016 State of Mental Health in America" report showed that 57% of adults with mental illnesses do not receive any treatment. Stigmas about mental illness, cost, insurance concerns, awareness, and accessibility are all contributing factors as to why more do not receive treatment (MHA).

Children and adolescents also receive mental health services. The Centers for Disease Control and Prevention's National Health and Nutrition Examination Survey (NHANES) found that approximately half (50.6%) of children with mental disorders had received treatment for their disorder within the past year (NIMH, n.d.-c). However, there were some differences between treatment rates by category of disorder (Figure 5). For example, children with anxiety disorders were least likely to have received treatment in the past year, while children with ADHD or a conduct disorder were more likely to receive treatment. Can you think of some possible reasons for these differences in receiving treatment?

Considering the many forms of treatment for mental health disorders available today, how did these forms of treatment emerge? Let's take a look at the history of mental health treatment from the past (with some questionable approaches in light of modern understanding of mental illness) to where we are today.

Mental Health Treatment Today

Today, there are community mental health centers across the nation. They are located in neighborhoods near the homes of clients, and they provide large numbers of people with mental health services of various kinds and for many kinds of problems. Unfortunately, part of what occurred with deinstitutionalization was that those released from institutions were supposed to go to newly created centers, but the system was not set up effectively. Centers were underfunded, staff was not trained to handle severe illnesses such as schizophrenia, there was high staff burnout, and no provision was made for the other services people needed, such as housing, food, and job training. Without these supports, those people released under deinstitutionalization often ended up homeless. Even today, a large portion of the homeless population is considered to be mentally ill (Figure 6). Statistics show that 26% of homeless adults living in shelters experience mental illness (U.S. Department of Housing and Urban Development [HUD], 2011).

Another group of the mentally ill population is involved in the corrections system. According to a 2006 special report by the Bureau of Justice Statistics (BJS), approximately 705,600 mentally ill adults were incarcerated in the state prison system, and another 78,800 were incarcerated in the federal prison system. A further 479,000 were in local jails. According to the study, "people with mental illnesses are overrepresented in probation and parole populations at estimated rates ranging from two to four times the general population" (Prins & Draper, 2009, p. 23). The Treatment Advocacy Center reported that the growing number of mentally ill inmates has placed a burden on the correctional system (Torrey et al., 2014).

Today, instead of asylums, there are psychiatric hospitals run by state governments and local community hospitals focused on short-term care. In all types of hospitals, the emphasis is on short-term stays, with the average length of stay being less than two weeks and often only several days. This is partly due to the very high cost of psychiatric hospitalization, which can be about $800 to $1000 per night (Stensland, Watson, & Grazier, 2012). Therefore, insurance coverage often limits the length of time a person can be hospitalized for treatment. Usually individuals are hospitalized only if they are an imminent threat to themselves or others.

Most people suffering from mental illnesses are not hospitalized. If someone is feeling very depressed, complains of hearing voices, or feels anxious all the time, he or she might seek psychological treatment. A friend, spouse, or parent might refer someone for treatment. The individual might go see his primary care physician first and then be referred to a mental health practitioner.

Some people seek treatment because they are involved with the state's child protective services-that is, their children have been removed from their care due to abuse or neglect. The parents might be referred to psychiatric or substance abuse facilities and the children would likely receive treatment for trauma. If the parents are interested in and capable of becoming better parents, the goal of treatment might be family reunification. For other children whose parents are unable to change-for example, the parent or parents who are heavily addicted to drugs and refuse to enter treatment-the goal of therapy might be to help the children adjust to foster care and/or adoption (Figure 7).

Some people seek therapy because the criminal justice system referred them or required them to go. For some individuals, for example, attending weekly counseling sessions might be a condition of parole. If an individual is mandated to attend therapy, she is seeking services involuntarily. Involuntary treatment refers to therapy that is not the individual's choice. Other individuals might voluntarily seek treatment. Voluntary treatment means the person chooses to attend therapy to obtain relief from symptoms.

Psychological treatment can occur in a variety of places. An individual might go to a community mental health center or a practitioner in private or community practice. A child might see a school counselor, school psychologist, or school social worker. An incarcerated person might receive group therapy in prison. There are many different types of treatment providers, and licensing requirements vary from state to state. Besides psychologists and psychiatrists, there are clinical social workers, marriage and family therapists, and trained religious personnel who also perform counseling and therapy.

A range of funding sources pay for mental health treatment: health insurance, government, and private pay. In the past, even when people had health insurance, the coverage would not always pay for mental health services. This changed with the Mental Health Parity and Addiction Equity Act of 2008, which requires group health plans and insurers to make sure there is parity of mental health services (U.S. Department of Labor, n.d.). This means that co-pays, total number of visits, and deductibles for mental health and substance abuse treatment need to be equal to and cannot be more restrictive or harsher than those for physical illnesses and medical/surgical problems.

Finding treatment sources is also not always easy: there may be limited options, especially in rural areas and low-income urban areas; waiting lists; poor quality of care available for indigent patients; and financial obstacles such as co-pays, deductibles, and time off from work. Over 85% of the l,669 federally designated mental health professional shortage areas are rural; often primary care physicians and law enforcement are the first-line mental health providers (Ivey, Scheffler, & Zazzali, 1998), although they do not have the specialized training of a mental health professional, who often would be better equipped to provide care. Availability, accessibility, and acceptability (the stigma attached to mental illness) are all problems in rural areas. Approximately two-thirds of those with symptoms receive no care at all (U.S. Department of Health and Human Services, 2005; Wagenfeld, Murray, Mohatt, & DeBruiynb, 1994). At the end of 2013, the U.S. Department of Agriculture announced an investment of $50 million to help improve access and treatment for mental health problems as part of the Obama administration's effort to strengthen rural communities.

Think It Over

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It was once believed that people with psychological disorders, or those exhibiting strange behavior, were possessed by demons. These people were forced to take part in exorcisms, were imprisoned, or executed. Later, asylums were built to house the mentally ill, but the patients received little to no treatment, and many of the methods used were cruel.

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Psychiatric Hospitals in the 50s/60s to right now {Buildings}

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Psychiatric Hospitals in the 50s/60s to right now {Buildings}

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In the past the buildings were all ruined and looked nasty and didn't look like you wanted to be there but now they look more inviting and more pleasant.

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Medical professional's Accountability now 

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Medical professional's Accountability now 

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For a medical professional to practice medicine today they first need to be granted a Licence to practice medicine and surgery, and then must continue to get re-licensed every set amount of time. Only reserved powers can certify and give licenses.

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During the 1950s, 1 in 3 families admitted a family member to a Asylum. Most patients expected to never leave. The highest recorded number of patients was about 560,000. There were rumors of experiments, treatments were inhumane, and the buildings were rarely clean.

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Many unauthorized experiments took place at Asylums. Some had positive results but many had gruesome endings. Many patients were killed due to these wild experiments.  Two experiments that showed results were the Ice Pick Lobotomy and Electro Shock Therapy. New drugs were tested on patients like Opium and Thorazine.

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Back in the 50's and 60's mental asylums and hospitals had much harsher and cruel conditions than they have today. Many hospitals back then weren't taken care of, due to either lack of funding, or irresponsibility. Although many hospitals had harsh conditions, Some had peaceful, quiet and secluded conditions that provided activity and recreation for their patients.

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-The institutes that we have today are a lot safer and a lot more pleasant.
-Treatments are more humane.
-Specific Therapy and Group Therapy are used now.
-There are Antipsychotic and Antidepressant medications being used today.

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Psychiatric hospitals in the 50s/60s to Right now {Treatment}

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Psychiatric hospitals in the 50s/60s to Right now {Treatment}

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In the 50s/60s were much more violent and scary then they are today. Today they do more therapy and group stuff rather then just you and the doctor. Back then they used more abusive things.