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THE BIG MENTAL HOSPITAL IS OBSOLETE

STATEMENT AT PUBLIC HEARING
NEW YORK STATE SENATE COMMITTEE ON PUBLIC HEALTH (SEN. METCALF, CHMN.)
2 P.M., TUESDAY, JANUARY 28, 1958
SENATE CHAMBER, THE CAPITOL, ALBANY
by
MIKE GORMAN, Washington, D, C,
Executive Director, NATIONAL COMMITTEE AGAINST MENTAL ILLNESS

Senator Metcalf and members of. the Committee:

"Indeed, we live in a strange world, and it has been said that
the standard of civilization of a country may be judged by the num-
ber of mental hospital beds per 1,000 of the population, the United
States of America being in the lead, ourselves, France and the
Scandinavian countries following hard at their heels, Is there no
better solution for looking after the deviants and helpless in our
society than the long-term mental hospital?,..The other day an In-
fectious Diseases Hospital closed down and was put up for sale, not
for lack of staff, but for lack of patients, Perhaps those who are
coming after us will regard the period through which we are now
passing in psychiatry as the mental hospital era, and maybe at the
Annual meeting of the Royal Medico-Psychological Association in 2056,
a coach trip will be arranged to pay a visit to the last of the big
custodial care long-term mental hospitals before it is finally con-

verted into a holiday camp!"
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The author of the above words is Dr, T, P, Rees, father of the
Open Hospital and for more than 20 years, superintendent of the
famous Warlingham Park Hospital near London, Warlingham Park is
one of 29 mental hospitals which serve the southwest region of London,
There are five and one-half million people in this region, but the
capacity of the average mental hospital is less than 2,000 beds,
After touring a number of these superb hospitals, I asked Dr. Rees
how he and the other superintendents had succeeded in holding their
size down,

"We just refused to allow them to build any additional wings on
hospitals which had reached the size of 2,000 beds," Dr. Rees told me,
"When more beds were needed, we suggested additional small hospitals
in nearby communities,"

In America, the resistance to the big mental hospital has been
less successful, In an attack on the big mental hospital at the
Ninth Mental Hospital Institute of the American Psychiatric Associa-
tion last year, Dr. Harry Solomon, President of the American Psychia-
tric Association, talked nostalgically of the futile efforts of the
medical superintendents of the 19th Century to keep their institu-
tions small and close to the heart of the community’

"As we all know, the hospitals increased in size to 400 to 600
to 800 and finally as high a number as 15,000,,.I maintain that the
present system is already outmoded, that its inheritance from the
1820's and 1830s and subsequent decades must be viewed with great
suspicion and new ways developed to meet the challenges,"

At the same Institute, Dr, Me Srop Tarumianz who, as chairman of

the Central Inspection Board of the American Psychiatric Association
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has studied state mental hospitals more closely than any psychiatrist
in this country, called for "a master plan for a revolutionary change
in the structure of the care and treatment of the mentally il1", Dr,
Tarumianz proposed small hospitals of 100 to 500 bed capacity for
“individual, intensive, coordinated treatment", .

Testifying before this very committee in 1956, Dr. Daniel Blain,
Medical Director of the American Psychiatric Association, stated that
“we are now faced with the stark reality of our failure, many years
ago, to shift from a policy of custodial care for the mentally ill to
active programs of treatment, training and research, We are 30 years
behind in translating scientific advances into action in our state
hospitals,"

The most impressively documented and authoritative attack on the
big mental hospital came in a 1953 report issued by the Expert
Committee on Mental Health of the World Health Organization,

"The committee is convinced that it is, in general, undesirable
to build new psychiatric hospitals for more than 1,000 patients,"
the report stated . "It is well known, of course, that many hospitals
exist which far exceed this size, and in a later section some sugges-
tions are made of the manner in which the harmful effects of such
institutions can be mitigated, It is essential, however, that every-
thing should be done to discourage the building of more hospitals of
this type. Indeed, the figure of 1,000 patients which the committee
puts forward is, in the opinion of a majority of its members, not
put forward as representing the optimum size; it is put forward as a
size which should on no account be exceeded, From the point of view

of therapeutic efficiency, these members of the committee hold that
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a better size would be somewhere between 300 and 1,000 beds, The
committee is well aware of many arguments put forward in favour of
very much larger units, These arguments are frequently based on
the supposed reduction in the cost per patient per day obtainable
in a larger unit. It appears, however, that the widespread belief
in the economy of very large hospitals is probably unfounded,

“Recent studies have suggested that from a point of view of
financial exonomy the optimum capacity for hospitals probably lies
between 250 and 400 beds, Smaller establishments are expensive be-
cause of their lower average percentage of occupants and the diffi-
culty of amortizing technical equipment which is not in full use,
Above 400 beds, the cost per bed begins to increase Slowly and reaches
rather high figures above 800 beds. The reason is probably uncon-
trollable wastage, lack of responsibility on the part of too large a
staff, unnecessary buying, and an industrial type of mechanization
which is inevitable in very large hospitals; one must add to these
the impossibility of sustained personal contact between the director
and hundreds of hospital workers,"

I am not unaware that there are present problems of mental hospital
Overcrowding. In his message to the legislature, Governor Harriman
reported that the New York mental hospitals were overcrowded by about
19,000 patients. While this overcrowding continues, some new beds
will have to be constructed. However, I do insist, with all the
emphasis at my command, that these beds should not be tacked on to
already overcrowded institutions. For example, Creedmoor Hospital
out on Long Island now has 6,200 patients. According to a statement
made by its superintendent at the Ninth Mental Hospital Institute,
new construction under way and additional construction now in the

planning stage will add about 5,000 more patients to its present load.
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It will then become the fourth hospital on Long Island in the 10,000
patient range. I say this is monstrous and anti-therapeutic. Recent
figures show that Creedmoor is presently unable to provide adequate
staff for its current patient population; what happens when 5 ,000
more patients are added?

I am also critical of the rigidity and inflexibility of the
New York mental hospital building program. It is not geared to an
era of new treatments and new concepts. For example, the advent of
the tranquilizing drugs has meant a drop of 500 patients a year over
the past two years. This is actually a drop of 6,000 beds in hospital
construction because the mental hospital population had been increasing
at an annual rate of 2,500 patients in the immediate years preceding
the advent of the drugs. So we don't need 6,000 beds that were con-
sidered absolutely necessary in 1954 when the new bond issue for
building went into effect.

In a letter to the editor of "Better Homes and Gardens" relative
to the article by Mr. Maisel, Dr. Paul Hoch, Commissioner of the
Department of Mental Hygiene, points out that if the patient popula-
tion continues to decrease at the rate of about 500 patients a year,
it will take 43 years to eliminate present overcrowding. This is
rank casuistry. First of all, it presupposes a freezing of new
knowledge and new techniques in the treatment of mental illness.
Secondly, it is the very kind of specious argument which kept build-
ing bed upon bed at Pilgrim State Hospital until today, with its
14,000 bed capacity, it is an ironic monument to Dr. Charles Pilgrin,
who in his day fought the big mental hospital.

Then there is the hoary argument about replacing the "obsolete"

bed. The Oxford English dictionary defines obsolete as: "That is
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no longer practiced or used; discarded; out of date", How many
times do you keep replacing this so-called obsolete bed? When do
you reach the point when you abandon it as "out of date",

The World Health Organization report quoted above also critizes
mental hospitals today as being built to last too long, As it points
out: "Many countries will be burdened for a long time to come with
large obsolete hospitals built years ago to fit a conception of the
role of the mental hospital which is now completely rejected".

The report admits that even the small community hospitals which
it recommends will probably be obsolete in 20 or 30 years time, It
therefore proposes that mental hospitals be built with easily move-
able interior construction, Using this standard, I defy anyone to
move anything in the interior of some of the New York monoliths,

But what do we do with the present big mental hospitals in New
York State? Until they can be abandoned, or reduced to manageable
size, it is vitally necessary that the Department of Mental Hygiene
pay some heed to the recommendations of the World Health Organiza-
tion Expert Committee for a breaking-up of these large hospitals
into independent services of from 400 to 700 patients, each with its
own medical director and its own medical staff, Each of these units
should be complete in that it includes patients of all clinical
types, of both sexes and it should have its own admission and treat-
ment facilities, This language is very elear and it does not mean
the token breaking-up of a hospital into an intensive treatment
unit and a scattering of additional buildings for all other patients
not under active treatment.

Fundamentally, New York must develop an entirely new attitude
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toward the large mental hospital, Apart from all other con-
Siderations, it must take off its blinders and realize what pro-
fessional medical organizations have been telling it for a number of
years -~ that it cannot staff these large hospitals located in re-
mote areas of the state, In 1956, testifying before this committee,
I pointed out that New York was actually losing ground in recruiting
psychiatric staff for its mental hospitals, Recently the American
Psychiatric Association released a report which confirmed the testi-
mony at the 1956 hearing, According to that report, New York is 3lst
among the states in the number of full-time employees per 100
patients, It is 16th in number of physicians per 100 patients, 47th
in psychologists, 8th in registered nurses, 32nd in attendants and
22nd in social workers, In practically all these categories, it is
far below the neighboring states of New Jersey and Connecticut,

What is the answer, then, to this dilemma? Two years ago, speak-
ing to the First Annual Conference of Community Mental Health Boards
in Syracuse, I proposed that the New York Department of Mental Hygiene
concentrate upon the development of small mental hospitals scattered
in scores of communities throughout the state, These small mental
hospitals could serve as the nuclei for a complex of mental health
services in the area, After visiting a number of English mental hos-
pitals, Dr. Robert C, Hunt, then Assistant Commissioner of the De-
partment of Mental Hygiene and now superintendent of Hudson River
State Hospital, pointed out that in these English community mental
hospitals "the staffs think of themselves as operating a complete
battery of mental health services in which the hospital is just a

type of treatment to be used when there are special indications",
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In the article referred to, Dr, Hunt noted that there are half a
dozen mental hospitals in Britain which are well in advance of the
best practices in this country.

In Canada, Dr. Humphrey Osmond, Superintendent of the Saskatchewan
‘Hospital, is leading a growing movement against the big hospital. In
a very thoughtful article in a recent issue of "Mental Hospitals",

Dr. Osmond attacked the big mental hospitals as anti-therapeutic and
frightening to patients who are already insecure, Dr. Osmond has de-_
veloped the Saskatchewan plan, which will consist of a series of small
regional mental hospitals serving an area of over 250,000 square miles
in that province,

The psychiatric unit in the general hospital is also a key ele-
ment in reducing the need for big mental hospitals, At the 1956
hearing of this committee, Dr, Paul Lemkau, then Director of the New
York City Community Mental Health Board, proposed that New York State
make a far greater effort to hospitalize thousands of acutely mentally
ill patients in general hospitals instead of waiting until they become
chronically ill and must be committed to state mental hospitals, Dr,
Lemkau pointed out that the present ceiling. on matching funds under
the Community Mental Health Services Act does not allow sufficient
funds for the development of psychiatric units in general hospitals; he
proposed that these units be exempted from the present ceiling. This
proposal is certainly worthy of further investigation by this
committee,

In essence, what we are pleading for is a complete change in
New York*s attitude toward the mental hospital, In the City of
Amsterdam this past summer I met a remarkable psychiatrist who, since

1930, has devoted himself to making the large mental hospital obsolete.
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In that city of one million people, he has developed thirteen full-
time regional psychiatric teams who handle most of the mental illness
in the city. His name is Dr, Arne Querido and he argues most eloquently
that too many psychiatrists hunt for diagnosable symptoms to prove the
need for hospitalization; he and his co-workers look for specific
strengths in the patient, his family, his aeighbors and his job, which
can keep him out of the hospital, |

"I should like to defend the thesis that in the last analysis the
cure or the adaptation of the mentally disturbed can only be accom-
plished in society, and that a successful stay in society is the only
real test of any therapeutic endeavor," Dr, Querido remarked recently,
“Of course, circumstances may compel seeking the desired change in the
patient by means of a stay in the hospital, and technical considera-
tions may require observation or treatment by an in-patient arrange-
ment. But I think it can be said that any removal of a mentally dis-
turbed patient from his social background implies the sidestepping of
the nucleus of the problem."

This type of preventive effort cannot be accomplished cheaply. It
requires highly trained manpower and expensive community resources, I
therefore want to make it clear, Mr, Chairman, that I am proposing no
cuts or savings in the state’s expenditures for the mentally ill. On
the contrary, Any money saved from the building program should go into
these expanded community mental health services, and much more addi-
tional money should be appropriated for these purposes,

Psychiatric research offers one strong possibility in that it is
an investment in the eventual acquisition of new treatment techniques,

As a number of witnesses pointed out at the 1956 hearings of this
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committee, New York is spending a disproportionately small sum on
psychiatric research, New York is still spending less than $3 million
a year in this area, only a fraction of the staggering $195 million
annual budget of the New York Department of Mental Hygiene, As a
starter, New York should immediately double the sums available for
psychiatric research,

As brought out in the recent American Psychiatric Association
survey of manpower, the weakest link in the New York system is the
lack of trained psychiatric personnel, At the 1956 hearing, Dr. Hoch
promised that "an extensive training program" would be organized,
Outside of the development of some graduate training for hospital
physicians conducted at the Downstate and Syracuse branches of the
State University, those of us who follow the New York program rather
closely have seen little evidence so far of a greatly expanded train-
ing program,

At the 1956 hearing, Dr, Blain commended the graduate training
program of the New York Department but called for "a much more com-

prehensive plan" involving three key elements:

1. A doubling or tripling of the state psychiatric resi-
dency program over the next six years, There has
been very little change in the psychiatric residency

program since Dr, Blain testified,

2. The development of an administrative scheme whereby
the medical schools are given key responsibility for
the administration of the training programs in the
State hospitals, This works beautifully in England,

where each of the 14 medical schools is assigned a
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group of mental hospitals for whose training and
other services it is responsible, New York State

nas not yet moved in this direction,

3. Subsidies to the ten medical schools of New York
State for an expansion of faculty, staff and con-
sultants to handle this training job. I see no
evidence that this proposal is being acted on in

any way.

The education of the general practitioner in psychiatric skills
is moving very slowly, if at all, in New York State, At the 1956
hearing Dr, Richard P, Bellaire, President of the New York Academy of
General Practice, presented a whole series of recommendations to en-
list the general practitioner in the handling of mental illness, He
urged the increased use of the general practitioner in both the state
mental nospital and the community clinic, and he proposed that the
Department of Meatal Hygiene set up standard procedures for the follow-up
of discharged patients, particularly those on maintenance doses of the
tranquilizing drugs. Dr. Bellaire testified that the New York State
Academy of General Practice had formed a Committee on Mental Health
under tne chairmanship of Dr, Carl Alden of Adams, and he pointed out
that this Committee was “eager" to tackle the problem, This was a
most important proposal and I wonder why immediate steps were not
undertaken to sit down with the general practitioners of the state
and develop a joint attack on mental illness?

In its testimony at the 1956 hearing, the National Committee

Against Mental Illness proposed a minimum starting sum of $1,500,000
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for the employment and training of general practitioners in the New
York system, There is no evidence that this proposal has been taken
very seriously.

In discussing community mental health services, we must not for-
get the role of the community in keeping patients from returning to
the state mental hospital, In Mr. Maisel‘s article, the point was
made that few states have developed a standard policy of distributing
maintenance dosages of the tranquilizing drugs to discharged patients
who cannot afford them, This is a most serious indictment, for it
seems pointless to treat and bring some of these patients up to a
point of reasonable adjustment, only to see the whole expensive effort
fail because of financial inability to continue on the drugs,

As far as I have been able to ascertain, New York State has not
yet developed any plan for the financing of maintenance drugs to dis-
charged patients. If anyone doubts the need for such a policy, I re-
spectfully commend to him the enormous volume of letters I received
from all parts of the country after I had mailed out the Maisel article,

The problem is being attacked in a number of ways. In several
States, fees are being paid by the Department of Mental Health to
general practitioners willing to take over drug administration to dis-
charged patients. Governor George Leader of Pennsylvania writes me
that, in several of that state's institutions, the family doctor is
brought into the hospital and a cooperative arrangement worked out
with him at the point when the patient is ready to be released,

Governor Goodwin Knight of California writes that “in the 1957-58
fiscal year budget we initiated three aftercare clinics in three of

our state hospitals to furnish the aftercare to which you refer,
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This program will be expanded to include all hospitals as tax moneys
become available for this purpose,"

In Oklahoma, the local mental health associations have taken
the responsibility of providing drugs for discharged mental patients,

I am appealing here, not for a perfectly devised maintenance
drug plan here in New York, but for an end to the apparent indifference
to any plan suggested, I would like to see the same kind of open-
mindedness which characterized a recent letter on the Oregon mental
hospital system which I received from Governor Robert D, Holmes:

"I would like to see the program dispense with more buildings
and beds, and increase the professional staff and drug supplies, but
this attitude is not as generally acceptable as I wish it were,"
Governor Holmes wrote, ",,..1I agree that in the end it is very poor
economy for the state not to finance an expanded treatment program
for patients able to be released from our mental institutions, but
not completely cured, or who need maintenance drug dosages,"

Space does not permit a discussion of many of the additional
comaunity resources which must be used, If these are not used, then
New York will one day face a mental hospital building need which
will break its financial back,

In sum, Mr, Chairman, I am not proposing a reduction, but rather
an increase in appropriations for the New York Department of Mental
Hygiene, However, I am proposing a basic change in orientation -- a
gradual transfer of the responsibility for psychiatric services from
the big mental hospital to the community general hospital, the family
physician and other community resources, This is a program which
will take a number of years to implement, but it is the only en-
lightened one for the citizens of New York,

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